Interpretation and Step-by-Step Approach to Reading a Chest X-ray (CXR)

Interpreting a chest X-ray (CXR) systematically ensures that no abnormalities are

Step 1: Confirm Patient Details and Image Quality

Before interpretation, check:

• Patient details (Name, Age, Date of X-ray, Clinical Indication).

• Projection type (Posteroanterior (PA), Anteroposterior (AP), Lateral).

• Penetration (Spine should be faintly visible behind the heart).

• Inspiration (At least 5-6 anterior ribs should be visible).

• Rotation (Check clavicular heads’ symmetry in relation to the spine).

• Magnification (In AP, heart appears artificially enlarged).

Step 2: Systematic Interpretation Using ABCDE Approach

A - Airways

• Trachea: Is it midline or deviated? (Deviations may indicate tension

• Carina and bronchi: Any narrowing or displacement?

• Endotracheal tube (if present): Correct positioning (2-5 cm above the

B - Bones and Soft Tissues

• Clavicles, ribs, vertebrae: Look for fractures, lytic lesions, or asymmetry.

• Soft tissues: Check for masses, subcutaneous air, or foreign bodies.

C - Cardiac Silhouette & Mediastinum

• Heart size: Cardiothoracic ratio (CTR) should be <50% in PA view.

• Borders:
 • Right: Right atrium.

• Left: Left ventricle.

• Aortic arch & mediastinum: Widened mediastinum could indicate aortic

D - Diaphragm & Pleura

• Diaphragm: Normally dome-shaped, with the right side slightly higher

• Blunting of costophrenic angles: May indicate pleural effusion.

• Pneumothorax: Look for absence of lung markings and pleural edge.

E - Everything Else (Lungs, Lines, and Devices)

• Lung Fields: Compare both lungs for opacities, consolidation, nodules, or

• Interstitial markings: Check for increased markings (suggestive of

• Foreign devices: Correct positioning of NG tubes, central lines,

Comprehensive Table: Chest X-ray & Physical Exam Findings for Common
Pulmonary Conditions
Condition Chest X-ray Findings Percussion Auscultation
Pneumonia Focal lung Dull Bronchial breath
consolidation, dense sounds, decreased
opacity in a lobe, air breath sounds over
bronchograms, no consolidation,
significant volume inspiratory crackles,
loss. egophony (E to A
change), whispered
pectoriloquy.
COPD Hyperinflated lungs, Hyperresonant Decreased breath
flattened sounds, prolonged
diaphragm, expiratory phase,
increased wheezing.
retrosternal
 airspace, reduced
peripheral vascular
markings.
Pulmonary Edema Bilateral diffuse Dull (if significant Bilateral inspiratory
opacities, Kerley B fluid accumulation) crackles (rales),
lines, batwing possibly wheezing
distribution, pleural in severe cases.
effusion.
Pneumothorax Absence of lung Hyperresonant Absent or
markings on the significantly
affected side, visible decreased breath
pleural line, possible sounds on the
tracheal deviation in affected side.
tension
pneumothorax.
Pleural Effusion Blunting of the Dull Decreased or absent
costophrenic angles, breath sounds,
meniscus sign, decreased vocal
homogenous resonance, possible
opacity at the lung pleural friction rub
base, possible lung if inflamed.
compression.
Pulmonary Fibrosis Reticular or Normal or slightly Fine inspiratory
honeycombing dull crackles (Velcro-
pattern, reduced like).
lung volumes,
prominent
interstitial
markings, basal and
peripheral lung
involvement.
Lung Cancer Solitary pulmonary Dull (if mass effect Localized wheezing
nodule or mass, is significant) if airway
irregular borders, obstruction,
possible mediastinal decreased breath
lymphadenopathy, sounds if effusion or
pleural effusion in atelectasis.
advanced cases.
Sarcoidosis Bilateral hilar Normal Normal or fine
lymphadenopathy, inspiratory crackles
reticulonodular in fibrotic cases.
pattern, upper lobe
fibrosis in advanced
cases.
Tuberculosis (TB) Upper lobe cavitary Dull in areas of Crackles, bronchial
lesions, nodular consolidation breath sounds,
opacities, miliary amphoric breathing
pattern in over cavities.
disseminated
 disease.
Atelectasis Opacification with Dull Decreased or absent
volume loss, breath sounds over
tracheal deviation the affected area.
toward the affected
side.
Pulmonary Embolism Westermark sign (focal Normal
oligemia), Hampton’s
hump (wedge-shaped Possible pleural friction
opacity), Palla’s sign rub, tachypnea, possibly
(enlarged right decreased breath sounds
descending pulmonary
if infarction occurs.
artery), may appear
normal.