Chest X-ray Systematic Approach
Review areas

Key points

  • Apices - Pneumothorax?
  • Bones/soft-tissues - Fractures/density?
  • Cardiac shadow- Consolidation/mass?
  • Diaphragm - Pneumoperitoneum?
  • Edge of the image - Unexpected findings?

Mnemonic - ABCDE

After a systematic look at the whole chest X-ray, it is worth re-checking areas that may conceal important pathology.

It is always worth double checking for pneumothorax or pneumoperitoneum. In an OSCE/viva this is seen as good practice, and a mark may be granted for mentioning the absence of these entities.

A pneumothorax is most easily seen at the apices on a Posterior-Anterior (PA) X-ray. Pneumoperitoneum (free gas below the diaphragm) is only seen on a chest X-ray if acquired when the patient is positioned erect.

Other review areas include the soft-tissues and bones, the area behind the heart, and the edges of the image.

Review areas - Apices

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Review areas - Apices

  • There is a small pneumothorax on the right.
  • A pneumothorax is often a very subtle finding, and may only be seen on a second review of each lung apex.
  • You should also check the lung apices for tumours.

Review areas - Bones

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Review areas - Bones

  • Bone abnormalities can be very subtle on chest X-rays. Here the first right rib is destroyed by a metastatic bone lesion(?).
  • Compare this poorly defined area of increased soft tissue density with the normal first left rib (highlighted).

Review areas - Cardiac shadow

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Review areas - Cardiac shadow

  • The area behind the heart is too dense (red ring) and the left hemidiaphragm is not well-defined to the midline. This is evidence of consolidation affecting the left lower lobe.
  • There is also a reactive effusion (arrow).

Review areas - Diaphragm

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Review areas - Diaphragm

  • Check every chest X-ray for pneumoperitoneum (arrowheads).
  • Occasionally lung pathology is visible through the 'window' of the gastric bubble (asterisks), which is normal in this case.

Review areas - Edge of the image

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Review areas - Edge of the image

  • Well done if you noticed the small left pleural effusion (arrow).
  • Did you spot the missing right humerus?
  • This patient had a history of a previous malignant bone lesion of the right humerus which had been resected (red area). Note the surgical clips (white).

Page author: Salisbury NHS Foundation Trust UK (Read bio)

Last reviewed: February 2016