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The Complete Idiot’s Guide to Reading the X Ray PowerPoint PPT Presentation

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The Complete Idiot’s Guide to Reading the X Ray. By Sangwan. The PA view. Left chest appears on the right and Right chest on the left. The lateral view Receptor Film against left chest. Distinguishing Right from Left Lung in the Lateral View.

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The Complete Idiot’s Guide to Reading the X Ray

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The Complete Idiot’sGuide toReading the X Ray



The PA view

Left chest appears on the right and Right chest on the left.

The lateral viewReceptor Film against left chest.

Distinguishing Right from Left Lung in the Lateral View.

  • Right ribs are posterior and Larger than left ribs.

  • The left hemi-diaphragm is hidden anteriorly by the heart.

  • The Right hemi-diaphragm extends to the right ribs- more posteriorly.


The difference between the projector and the patient is 6 feet in the PA & 40 inches in the AP view.

The supine AP viewIn the AP supine film there is more equalization between the pulmonary vasculature of the upper and lower lobe & heart is enlarged.

The lateral decubitus

  • Pleural fluid volume.

  • Whether mobile / loculated.

  • Pneumothorax in a supine patient.


8-10 posterior ribs & 5-6 anterior ribs is adequate inspiration.


  • In PA enough to just see disk spaces in thoracic spine, left hemi- diaphragm behind heart and vessels only up to 2/3 of lung area.

  • In lateral view 2 sets of ribs should be seen, sternum seen, spine appears clearer as it goes down.

Under and Over Exposure

RotationAssess by determining if clavicular heads are equidistant from spinous process of the thoracic vertebrae.

The Mediastinum

Fissures and lobes

Fissures and Lobes

Pleural Effusion extending into fissures

Lobes & Silhouette sign

  • Loss of lung/soft tissue interface.

  • Abnormality adjacent/anatomic contact.

  • Opacity in Posterior pleural cavity or posterior mediastinum or Right Lower lobe will cause OVERLAP but not an SILHOUTTE sign.

Air Bronchogram

  • A tubular outline of an airway visible due to alveolar filling/ collapse.

  • 6 causes- lung consolidation, pulmonary edema, non-obstructive pulmonary atelectasis, severe interstitial disease, neoplasm, and normal expiration.

The solitary nodule

Find the cancer

Atelectasis -Collapse/ incomplete expansion.

  • Endobronchial– mucus plug/ tumor.

  • Extrinsic compression– mass/ effusion/ ascites.

  • Scarring-- post TB/ Radiation/ inflammation.

  • Linear/curved/wedge(apex-hilum) density with hilar/tracheal/media-stinal/diaphragm deviation with volume loss +/- compensatory hyper- inflation.

Left Upper & Lower lobe atelectasis

Right upper and lower lobe atelectasis

Right middle lobe atelectasis

Pulmonary edema

Batwing Bronchogram

Cephalization Cardiomegaly

Septal lines Effusion


Kerley B lines

Major differentiating factors between atelectasis and pneumonia

Atelectasis Pneumonia

Volume Loss normal or increased volume

Associated Ipsilateral Shift no shift/ contralateral shift

Linear, Wedge-Shaped air space process

Apex at Hilum not centered at hilum

  • Air bronchograms can occur in both.

Type of pneumonia

  • Lobar - entire lobe consolidated and air bronchograms common

  • Lobular - multifocal, patchy.

  • Interstitial - starts perihilar ,can become confluent and/or patchy as disease progresses, no air bronchograms

  • Aspiration pneumonia

  • Diffuse pulmonary infections - nosocomial (Pseudomonas, debilitated, mechanical vent, high mortality rate, patchy opacities, cavitation, immuno-compromised host(bacterial, fungal, PCP)

Right middle lobe pneumonia

Right upper lobe pneumonia

Round Pneumonia

Pleural Effusion


Supine pneumo & hydropneumo

Interstitial Pulmonary Fibrosis


Hampton’s Hump



Pericardial effusion


Diaphragmatic hernia

OPACIFIED HEMITHORAX 1)Atelectasis, 2) pleural effusion, 3) Pneumonia, 4) pneumonectomy.

Unilateral pulmonary edema

  • Re-expansion

  • Venous


  • Dependent


  • Bronchial


  • PE on the

    other side

Aortic Aneurysm

Lung Masses

Causes of lung nodules-by frequency


Bronchogenic ca




Doubling time

Cavitating nodule

Squamous cell most common




Mass with air bronchogram

Alveolar cell ca



Inflammatory pseudotumor

Types of bronchogenic carcinoma

Squamous cell ca (30-35%)

Adenocarcinoma (25-35%)

Small cell or oat cell (25%)

Large cell undifferentiated (10%)

Squamous cell - Central Location (2/3), Atelectasis, Post-obstructive pneumonia, May cavitate.

Adenocarcinoma - Usually peripheral, Found in scars, Solitary nodule (52%), Upper lobe distribution (69%)

Small cell- Mediastinal adenopathy, Hilar mass, Small or invisible lung nodule, High metastatic potential, Rapid growth. May be associated with Hypoglycemia, Cushing's syndrome, Inappropriate secretion of ADH, excessive gonadotropin secretion

Large cell undifferentiated (10%) -Large peripheral mass, Pleural involvement

Roentgenographic findings

Airway obstruction – Atelectasis, No air bronchogram, postobstructive pneumonia

Hilar enlargement - From either the carcinoma itself or nodes, common in oat cell, uncommon in adenoca

Mediastinal node enlargement -Particularly anaplastic ca

Cavitation - 2-16% -Especially in squamous cell, mostly in upper lobes, Cavity is usually thick-walled with nodular inner margin

Pleural involvement - 10%- Hemorrhagic effusion denotes direct tumor invasion , Effusion carries a poor prognosis even if no malignant cells are found


Radiation Pneumonitis


Abdominal X Ray


Normal Gas Pattern

Stomach -Always

Small Bowel -Two or three loops of non-distended bowel with Normal diameter = 2.5 cm .

Large Bowel-In rectum or sigmoid – almost always

Normal Fluid Levels

Stomach -Always (except supine film)

Small Bowel - Two or three levels possible

Large Bowel -None normally

Large Vs Small Bowels

  • Large Bowel -Peripheral ; Haustral markings don't extend from wall to wall

  • Small Bowel – Central, Valvulae extend across lumen, Maximum diameter of 2“

Small Bowel Obstruction

Large Bowel Obstruction

Localized ileus

Adynamic ileus


Sentinel Loops

Gallstone ileus

Free Intraperitoneal AirCrescent Sign Rigler’s Sign

Ischemic Colitis


  • Sorry , no image available

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