What is the interpretation of this chest X-ray (CXR)?

Chest X-Ray Interpretation

I cannot provide a specific interpretation of your chest X-ray without seeing the actual image. However, I can guide you through the systematic approach that should be used to interpret any CXR.

Systematic Approach to CXR Interpretation

A chest X-ray should be evaluated systematically by examining specific anatomical structures in sequence to avoid missing pathology. 1

Key Structures to Evaluate:

• Airways and trachea: Assess for deviation, narrowing, or foreign bodies 1
• Cardiac silhouette: Evaluate size (cardiomegaly if cardiothoracic ratio >0.5), borders, and contours 2
• Pulmonary vasculature: Look for prominence of hilar vessels, peripheral pruning, or vascular redistribution 2
• Lung parenchyma: Examine for consolidation, ground-glass opacities, nodules, masses, or interstitial patterns 2
• Pleural spaces: Identify effusions, pneumothorax, or pleural thickening 2, 3
• Hemidiaphragms: Check for elevation, flattening, or loss of costophrenic angles 4
• Bones and soft tissues: Assess ribs, clavicles, spine, and chest wall for fractures or lesions 1

Important Limitations of Chest X-Ray

CXR has significant limitations in sensitivity and specificity for many pathologies, and normal findings do not rule out serious disease. 2, 5

• Pneumonia detection: CXR misses 9.4% to 56.5% of pneumonias that are subsequently detected on CT, and may be normal early in disease course 6, 2
• Pulmonary nodules: CXR sensitivity for detecting pulmonary metastases is only 28% compared to chest CT 2
• Stroke-associated pneumonia: Initial CXR demonstrates only 69% sensitivity compared to 91% for RT-PCR, with typical appearances present in only 36% of cases 2
• COVID-19 pneumonia: CXR may be normal early in disease and has lower sensitivity than chest CT 2

When CT is Indicated

If clinical suspicion remains high despite normal or equivocal CXR findings, chest CT without contrast should be obtained as it is far more sensitive for detecting parenchymal abnormalities, nodules, and infiltrates. 6, 5

• CT chest is the gold standard for evaluating multifocal opacities, suspected malignancy, or persistent symptoms with non-diagnostic CXR 6
• Ultra-low-dose CT protocols can now achieve radiation exposure comparable to CXR (0.11 mSv) while providing superior diagnostic yield, changing diagnosis in 41% of cases 5
• CT is particularly indicated when evaluating cachexia concerning for cancer versus pneumonia, as it provides optimal evaluation of pulmonary parenchymal abnormalities 6

Common Pitfalls to Avoid

• Do not rely solely on CXR to rule out pneumonia in immunocompromised patients or early disease - repeat imaging or proceed to CT if clinical suspicion is high 2, 6
• Avoid misinterpreting subpleural fat as pleural thickening - this can be differentiated by high-resolution CT 4
• Do not overlook subtle findings - CXR interpretation requires expertise, with senior radiologists achieving significantly higher accuracy than other clinicians (p = 0.002) 7
• Recognize that bilateral interstitial patterns may represent multiple etiologies - including infection, pulmonary edema, or interstitial lung disease requiring further workup 2, 1

All chest X-rays should be reviewed by a senior clinician and formally reported by a radiologist at the earliest opportunity to optimize patient care. 7