Chest X-ray Systematic Approach
The clinical question

Key points

  • Interpret chest X-rays only in view of the clinical setting
  • Treat the patient - not the X-ray!
  • When requesting a chest X-ray always provide specific clinical information

At first, many medical students think that X-rays give definitive answers, without reference to clinical features. Occasionally this may be the case, but ideally X-rays should be interpreted with full reference to the clinical scenario. Many X-ray diagnoses can only be made in the light of clinical information. Therefore, you must always provide specific clinical information whenever requesting a radiological investigation.

Often the findings will confirm the clinical suspicion, or the absence of a finding may be reassuring. An experienced clinician will often know the diagnosis before the X-ray is performed, but use the X-ray to determine extent or location of the disease process.

Whatever the findings are, they should only be interpreted in view of the clinical setting. Remember to treat the patient - not the X-ray! Occasionally there will be an unexpected finding, which may need to be considered with caution, especially if equivocal or if it does not fit the clinical scenario.

In the setting of an exam, you will score highly if you can fit the X-ray findings to the clinical features of the case.

No clinical information provided

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No clinical information provided

  • Without clinical information this patient may be considered to have a pneumonia in the left upper zone, and started on antibiotics.

Clinical information provided

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Clinical information provided

  • Recent increase in shortness of breath
  • No fever or productive cough
  • Left shoulder and arm pain
  • Heavy smoker
  • Weight loss

Findings

  • Left apical shadowing
  • Raised left hemidiaphragm
  • Increased extra-thoracic soft tissue density (asterisks) with displacement of the scapula on the left (arrowheads) - compare with right

Interpretation in view of clinical details

  • Cancer - Smoker with weight loss and left apical consolidation/mass and no clinical features of infection
  • Phrenic nerve palsy - Increased shortness of breath and raised left hemidiaphragm
  • Brachial plexopathy - Arm pain and axillary soft tissue swelling