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Systematic Approach to Chest X-Ray Interpretation

I recommend following a structured, systematic approach to chest radiograph interpretation that evaluates technical quality first, then proceeds through anatomical regions in a consistent order to avoid missing clinically significant findings. 1

Initial Technical Assessment

Before interpreting any findings, verify the following technical parameters:

• Check patient identification, date of examination, and image quality including proper penetration, rotation, and inspiration 1
• Assess for rotation by evaluating the relationship between the medial clavicular heads and spinous processes—rotation can mimic or obscure true pathology such as pneumothorax, pleural effusions, or mediastinal masses 1
• Recognize that portable AP radiographs have significantly lower sensitivity (approximately 40% of patients with "normal" portable chest radiographs may have injuries detected on CT) for detecting pneumothorax, hemothorax, lung contusions, and rib fractures compared to standard PA and lateral views 1

Systematic Anatomical Review

Airways and Mediastinum

• Trace the trachea and main bronchi noting any deviation, narrowing, or mass effect 1
• Assess mediastinal width and contour for widening that might suggest aortic pathology, lymphadenopathy, or masses 1
• Evaluate the aortopulmonary window and hilar regions for abnormal masses, lymphadenopathy, or vascular enlargement 1
• In suspected pulmonary hypertension, measure the main pulmonary artery (>35 mm from midline to left lateral border) and right descending pulmonary artery (>15 mm in women, >16 mm in men)—these measurements have 93% sensitivity and 88% specificity 1

Lung Parenchyma

• Systematically examine all lung zones (apices, upper, middle, and lower zones bilaterally) for opacities, nodules, masses, or consolidation 1
• Recognize that chest radiography has only 69-75% sensitivity for pneumonia, with lower sensitivity early in the disease course 1
• Evaluate for signs of chronic lung disease including hyperinflation, bullae, or interstitial changes 1

Pleura and Diaphragm

• Trace the pleural surfaces looking for effusions, pneumothorax (which may be missed in up to 50% of cases on radiography compared to CT), or pleural thickening 1
• Assess diaphragmatic contours for flattening, elevation, depression, or discontinuity 1
• For suspected diaphragmatic or hiatal hernias, look for abnormal bowel gas pattern, air-fluid levels in the chest, or retrocardiac masses—but recognize that normal chest radiographs occur in 11-62% of diaphragmatic hernias 2, 3

Cardiac Silhouette

• Evaluate cardiac size and contour noting that accurate assessment requires proper patient positioning without rotation 1
• Assess for cardiomegaly and abnormal cardiac contours that may suggest chamber enlargement or pericardial effusion 1

Bony Structures and Soft Tissues

• Examine ribs, spine, shoulders, and clavicles for fractures, lytic or blastic lesions—recognizing that radiography misses approximately 50% of vertebral and rib fractures compared to CT 1
• Assess soft tissues for abnormal air (subcutaneous emphysema), calcifications, or masses 1
• Identify all surgical hardware, monitoring devices, tubes, and lines, confirming proper positioning 1

Integration and Clinical Correlation

• Correlate radiographic findings with clinical information (symptoms, physical examination findings, laboratory data) to narrow differential diagnoses 1
• Recognize that perceptual errors are the predominant source of missed findings on chest radiography and a leading cause of malpractice litigation 4
• Maintain a low threshold for advanced imaging when radiographic findings are abnormal, equivocal, or when clinical suspicion remains high despite normal radiography 1

Critical Decision Points for Advanced Imaging

Order chest CT with IV contrast when:

• Radiographic findings are abnormal or equivocal and require further characterization 1
• Clinical suspicion remains high for pneumonia, pulmonary embolism, aortic dissection, or traumatic injuries despite normal or equivocal radiography 1
• Evaluating for pulmonary metastases (CT has far superior sensitivity compared to chest radiography, which detects only 28% of pulmonary metastases) 5
• Suspected diaphragmatic hernia with inconclusive chest radiograph findings—CT is the gold standard with 14-82% sensitivity and 87% specificity 2, 3

For suspected hiatal hernia specifically:

• First-line imaging should be fluoroscopic studies (biphasic esophagram or upper GI series with 88% and 80% sensitivity respectively) rather than CT, as these provide both anatomic and functional information 2
• CT with IV contrast is reserved for complicated presentations or when strangulation/ischemia is suspected 2

Common Pitfalls to Avoid

• Never assume a normal chest radiograph excludes significant pathology—up to 40% of patients with normal portable radiographs have injuries on CT, and chest radiography misses 50% of pneumothoraces and 80% of hemothoraces 1
• Do not rely solely on focused review—perceptual errors from incomplete systematic review are the leading cause of missed findings 4
• Avoid interpreting rotated films without correction—rotation can create false impressions of mediastinal widening, pneumothorax, or effusions 1
• Do not order oblique views of the lumbar spine—these double radiation dose without providing additional diagnostic information 5