This document provides guidance on interpreting chest x-rays by describing the key elements to evaluate in the lungs, heart, bones, and soft tissues. It outlines the systematic "ABCDE" approach of assessing the airway, breathing, circulation, disability, and everything else visible on the x-ray. Details are given on normal anatomy and common injuries or pathologies to identify, such as pneumothorax, hemothorax, rib fractures, and lung opacities. The document also reviews interpreting abdominal x-rays and genitourinary imaging studies like KUB, IVP, and identifying kidney stones, masses, and structural abnormalities.

1. Basics of X Ray image
• Identification of type of imaging:
– X Ray/ Roentgenogram
• Patient’s details/identification
• Projection of film
• Position of patient
• Exposure
• Site marking
• Systematic approach of description

2. Projection

3. Projection

4. Basics of X Ray image
• Five basic densities on X rays:
Gas Black
Fat Dark grey
Soft tissue/fluid Light grey
Bone/
Calcification
White
Metal Intense white

6. Description of X Rays
• A- AIRWAY
• B- BONES/ BOWEL
• C- CIRCULATION/ CALCIFICATION
• D- DISABILITY
• E- EVERYTHING ELSE!!

7. CHEST
Chest Injury

9. CHEST INJURY

13. Airway
• Trace down the trachea to the carina
– Is it straight and midline?
– Is there any narrowing?
• Trace down both main bronchi
– Is the carina wide (more than 100 degrees)?
– Is there bronchial narrowing or cut-off?
– Is there any inhaled foreign body?

14. Breathing
• Both lungs should be well expanded and
similar in volume
– Can you count 10 posterior ribs bilaterally?
– Is one lung larger than the other?
• Compare the apical, upper, middle and lower
zones in turn
– Are they symmetrical?
– Are there areas of increased density?

15. Breathing..
• Trace the lung vessels
– Do they branch out progressively and uniformly?
– Can you see the retrocardiac and
retrodiaphragmatic lung vessels?
– Are there extra lines in the periphery that aren't
vessels?
• Trace the lateral margins of the lung to the
costophrenic angles
– Are the costophrenic angles crisp?

16. Breathing..
• Trace the hemidiaphragms in to the vertebra
– Can you see the whole of the hemidiaphragm?
• Trace the cardiac borders
– Can you clearly see the left and right heart
border?
– Can you see the descending aorta?

17. Circulation
• Check the cardiac position
– Is 1/3 to the right and 2/3 to the left?
• Assess cardiac size
– Is the cardiothoracic ratio < 50%?
• Check the position and size of the aortic arch and
pulmonary trunk
• Check the width of the upper mediastinum
• Look at the hilar vessels
– Can you see them clearly on both sides?
– Are they at a similar height?
– Can you see a preserved hilar point bilaterally?

18. Disability
• Trace along each posterior (horizontal) rib on
one side of the chest
– Is there a fracture or abnormal area?
• Repeat with the other side of the chest
• Now trace lateral and anterior ribs on the first
side
• Repeat on the other side

19. Disability..
• Now, check the clavicles and shoulders
– Can you trace around the cortex of the bones?
• Finally the check the vertebral bodies
– Are they all rectangular and of a similar height?
– Can you see 2 pedicles per vertebral body?
– Are there disc spaces?

20. Everything else
• Is there free gas under the diaphragms?
• Is there subcutaneous emphysema?
• Is the gastric bubble in the correct place?
• Is there a hiatus hernia?
• Is there an absent breast shadow?
• Are there any surgical clips?
• Check again...
– Are the lung apices clear?
– Is there any retrocardiac or retrodiaphragmatic
pathology?

21. B/L HEMOTHORAX

22. LEFT SIDED HEMOTHORAX,UNDERLYING LUNG
COLLAPSE, I/L MEDIASTINAL SHIFT

23. RT HYDROPNEUMOTHORAX

24. LT UPPER LOBE LUNG CONTUSION , HEMOTHORAX, B/L MULTIPLE RIBS #

25. RT ENCYSTED EFFUSION IN FISSURE

26. B/L HEMOTHORAX WITH OCCULT
PNEUMOTHORAX
RIGHT 1,2,3 RIBS #

27. B/L RIBS #, LEFT SCAPULA AND CLAVICLE #

28. B/L LUNG CONTUSIONS,LT LUNG MULTIPLE
SMALL LACERATIONS

29. LUNG CONTUSION

30. RIGHT PNEUMOTHORAX, B/L ICD,
MULTIPLE RIBS # B/L, LEFT SCAPULA #
RESOLVED PNEUMOTHORAX

31. OCCULT PNEUMOTHORAX LEFT SIDE

32. MULTIPLE DOUBLE POINGT RIBS # LEFT SIDE, SUBCUTANEOUS EMPHYSEMA,
HEMO/PNEUMOTHORAX

33. TRAUMATIC DIAPHRAGMATIC HERNIA

34. ABDOMEN
Gas under diaphragm & Obstruction

39. DILATED SMALL BOWEL LOOPS

40. DILATED SMALL BOWEL LOOPS

41. DILATED SMALL BOWEL LOOPS

42. MULTIPLE FLUID LEVELS

43. MULTIPLE FLUID LEVELS

44. DILATED LARGE GUT LOOPS

45. DILATED LARGE GUT LOOPS

46. DILATED LARGE GUT LOOPS

47. MULTIPLE AIR FLUID LEVELS

48. MULTIPLE AIR FLUID LEVELS

50. DUODENAL ATRESIA

51. Bowel Obstruction
• SMALL BOWEL OBSTRUCTION
– Dilated loops are mostly central and numerous.
– Measure less than 3 cm in diameter
– Have a small radius of curvature
– Contain valvulae conniventes which pass right
across the bowel lumen, are thin and are close
together
– Fluid levels are seen in erect film, if more than 3-5
fluid levels are seen, it is suggestive of small bowel
obstruction.

52. Bowel Obstruction
• LARGE BOWEL OBSTRUCTION
– Large bowel loops are peripheral.
– Loops have wide radius of curvature.
– Are greater than 5 cm in diameter.
– Contain Haustrations which are thick, incomplete
and widely separated.

55. RIGLER’S/ DOUBLE WALL SIGN

58. CHILAIDITI’S SYNDROME

60. PNEUMOPERITONIUM
• Free gas in the peritoneal cavity
• Causes:
– Bowel perforation
– Post abdominal surgery (up to 3 weeks)
– Penetrating trauma (e.g. Stabbing)

61. • PERFORATION OF GUT
– Presence of free gas under the diaphragm on one
of both sides
– At times this may be confused with colon lying
between liver and diaphragm but presence of
haustral markings will make it clear that this is not
free gas but colon inter posed between diaphragm
and liver
– Free gas is usually seen under both domes of
diaphragm.

62. GENITOURINARY
X Ray KUB & IVP/U

65. LEFT STAGHORN CALCULUS AND RIGHT‐SIDED RENAL CALCULI

66. BILATERAL RENAL CALCULI

67. TWO RIGHT URETERIC CALCULI

68. URINARY BLADDER CALCULUS

69. URINARY BLADDER CALCULUS

70. STONE URINARY BLADDER

71. NEPHROCALCINOSIS

72. NEPHROCALCINOSIS

73. (IVP)
INTRAVENOUS PYELOGRAPHY/
UROGRAPHY

74. IVP
• PRINCIPLE
– iodinated contrast flows through the renal
vasculature and filtered into the collecting system
highlighting the anatomic structures on the X-ray
image
• Imaging includes the area from the suprarenal
region to below the pubic symphysis.

78. LT NON FUNCTIONING KIDNEY

83. RETROCAVAL URETER

84. TUBERCULOSIS OF KIDNEY WITH STRICTURE LEFT URETER IN UPPER THIRD

85. BILATERAL PUJ BLOCK

86. MASS LOWER POLE OF RIGHT KIDNEY
COMPRESSING CALYCES

87. TUBERCULOSIS OF RIGHT URETER WITH THIMBLE BLADDER

88. MALROTATED RIGHT KIDNEY PELVIS IS DIRECTED ANTERIORLY

89. Attendance plz !!
Any queries?

98. LEFT STAGHORN CALCULUS AND RIGHT‐SIDED RENAL CALCULI

99. TRIPLE URETER RIGHT SIDE

100. EMPHYSEMATOUS PYELONEPHRITIS

101. CALCIFIED URINARY BLADDER

102. Take home message
Be Systematic!!
• To ensure you cover all areas and do not miss anything
important
This is how you should present:
1. Give the type of radiograph
2. Give the patient’s name
3. Give the date the radiograph was taken
4. Briefly assess the radiograph quality- adequate
5. Run through the ABCDE of abdominal radiographs
6. Give a short summary at the end