A chest radiograph in the exam setting may contain a vast variety of pathology. However, consider the history and correlate the likely diagnoses that may be demonstrated on film. Furthermore, check your review areas to ensure that the abnormality is not at the corner of the film.

Locating pathology

When you are presented with an adult chest radiograph in the exam setting and you see an abnormality, you need to work out where it is. Simple, or, at least, it should be by the time you are preparing for your exams.

So, where is the pathology?

• pulmonary parenchyma

• mediastinum

• pleura

• chest wall

• outside the chest

The 'normal' film

When confronted with an apparently normal chest x-ray in the radiology exam, it is useful to consider a list of ‘check areas’ and ‘check pathology’.

Check areas

Check areas (also known as review areas) are areas on the film where pathology can be easily overlooked. Quickly reviewing these areas is essential to avoid missing an important abnormality, especially if the x-ray looks otherwise normal at first glance. 

• lung apices: Pancoast tumor, pneumothorax

• hilum: lymphadenopathy, mass

• cardiophrenic and costophrenic recesses: nodules, masses

• retrocardiac region: consolidation, nodules

• below the diaphragm: free gas, lines and tubes (e.g. nasogastric tube)

• bones: fractures, bone lesions

• soft tissues: subcutaneous emphysema, mastectomy, surgical clips

• lines and tubes

Check pathology

Check pathology is a useful concept to keep in mind if, despite looking at all the common check areas, you still haven’t identified an abnormality. This involves thinking specifically about high yield exam pathology with subtle imaging findings. Many of the examples below are favorites in the radiology viva.

Lungs

• pneumothorax

• bronchiectasis

• cystic lung disease

• apical mass (Pancoast tumor)

• Kerley B lines

Heart and mediastinum

• right sided aortic arch

• hilar mass

• paraspinal mass

• pneumomediastinum

Bones

• distal clavicular erosions

• diffuse sclerotic metastases

• rib erosions

• inferior rib notching

• vertebral body destruction 

Soft tissues

• mastectomy

• supraclavicular soft tissue mass 

See also

• adult chest radiograph in the exam setting

  • adult chest radiograph set-pieces

  • adult chest radiograph common exam pathology

  • adult chest radiograph pathology checklist