Chest X-ray/Chest XRay (OSCE)

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  • name
  • date
  • modality


  • Right or Left


  • Medial ends of the clavicles should be equidistant from the spinous processes at the midline to rule out rotation


  • Penetration
    • thoracic disc spaces should be just visible through the heart
      • overexposure → too dark
      • underexposure → too white


  • good inspiration → 6th anterior, 10th posterior ribs at MCL
  • right hemidiaphragm at 6th anterior rib
  • poor inspiration:
    • poor aeration, vascular crowding, widened central shadow


  • Comment on any lines, lead placements, tubing, etc.


  • C-spine, T-spine → alignment, disc space spacing, lytic or blastic lesions
  • shoulder girdle, ribs, humerus, sternum → fractures, osteopenia, deformities
  • vertebra OA (lateral view)
    • subchondral (beneath the cartilage) sclerosis
    • subchondral cysts
    • narrowing of joint space
    • osteophytes

Extrathoracic soft tissueEdit

  • breast shadow, nipple
  • supra-clavicular, axillary areas → masses
  • subcutaneous emphysema


  • size, shape
  • mainstem and segmental bronchi, lymph nodes
  • great vessels
  • hila → relationship, size


  • position (centered, some rightward shift at level of carina)
    • shift - pneumothorax, mass
    • carina widened - LA enlargement, subcarinal node

Heart ShadowEdit

  • cardiothoracic ratio (only on full inspiration PA views)
    • should be < 50%
  • enlarged chambers
    • LA - double shadow on right border
    • RA - ↑ width of right hemidiaphragm
    • LV - ↑ heart width
    • RV - lateral view: retrosternal space ↓
  • calcifications
  • aortic knuckle - unfolded due to age

Chest WallEdit

  • follow pleura for signs of pneumothorax
    • loss of lung markings in the periphery
    • line of visceral pleura seen on expiration view
  • pleural thickening
    • ↑ width of white line along inside of ribcage, esp. near diaphragm
  • costophrenic angles → pleural effusion
    • small effusions (< 100 mL) may be only seen in the lateral view


  • compare hemidiaphragms
    • obscured → lower lobe pneumonia, pleural effusion
    • flattened → hyperinflation, tension pneumothorax
    • elevated → phrenic nerve paralysis, hepatomegaly
    • air under diaphragms → perforated GI tract

Lung FieldsEdit

  • compare lung fields in the ICS on L vs. R, up vs. downs

Air Space DiseaseEdit

  • cardinal features:
    • air bronchogram
    • fluffy, patchy poorly marginated appearance
    • lobar or segmental distribution
  • ddx:
    • pus (pneumonia)
    • fluid (pulmonary edema)
    • blood

Interstitial DiseaseEdit

  • pathology involves the interlobular connective tissue
  • cardinal features:
    • linear densities - Kerley B lines (< 2 cm long, 1 mm thick, reach lung edge)
    • reticular pattern (thin, well defined linear densities, honeycomb arrangement)
    • nodular pattern
  • ddx: pulmonary edema, collagen disease (fibrosis), sarcoidosis, viral pneumonia

Pulmonary EdemaEdit

  • edema initially collects in the interstitium
    • loss of definition of pulmonary vasculature
    • peribronchial cuffing
      • bronchi seen end-on appear as white rings
  • in CHF, the normally thin-walled bronchi become framed in interstitial fluid
    • best seen in vicinity of hila
  • Kerley B lines
  • reticulonodular pattern
  • thickening of interlobar fissures
  • with progression, fluid begins to collect in the alveoli, causing diffuse air space disease (bat wing or butterfly pattern), tend to spare the intermost lung fields
  • ddx: cardiogenic, renal failure


  • cardinal signs:
    • deviation of a fissure
    • crowding of vessels
    • hilar, mediastinum shift
  • common causes: obstructive, compressive
  • in absence of a known etiology, bronchogenic carcinoma must be ruled out


  • lymph node groups: paratracheal, hilar, aorto-pulmonary window, subcarinal
  • hilar, AP window → widen mediastinum, flatten AP window contour
    • lung cancer, lymphoma, sarcoidosis, and tuberculosis
  • subcarinal - ↑ angle of tracheal bifurcation to 90°


  • liver size
  • spleen size
  • stomach (gastric bubble)
  • colon (bowel gas)

- free air under diaphragm - pneumoperitoneum



  • upper lobe redistribution of vessels
  • Kerley B-lines (usually seen near diaphragm)
  • right effusion at base
  • perivascular cuffing
  • pulmonary edema (interstitial, then airspace consolidation)
  • venous engorgement
    • normally extend 2/3 of the distance to periphery
    • vessels seen to extend farther than normal

Unilateral Left Sided EffusionEdit

  • trauma, infection, SLE, PE, malignancy

Mediastinal MassEdit

  • anterior mediastinum
    • thyroid masses, thymomas, teratomas, lymphomas
  • middle mediastinum
    • lymphadenopathy, lymphoma, aortic aneurysm
  • posterior mediastinum
    • aneurysm of descending aorta, esophageal masses, hiatus hernia
  • lateral view
    • RVH
    • effusion → accentuation of lines of major and minor fissures

Other OSCE modulesEdit