How to present an X-ray

A short guide to help you improve your presentation of radiographs in an exam situation or on the ward


The purpose of this guide isn't to teach you what you’re going to see, but how you should say it!  Guides to help you get through looking at images systematically can be found elsewhere; our aim is to improve your presentation skills.

Opening line

Imagine you’re sat in an OSCE.  You are presented with a radiograph and invited to comment on it.  How might you start presenting?  Just as you wouldn’t jump straight to the heart sounds when presenting a cardiovascular exam, so you shouldn’t jump straight to the interesting bit of the image.

An opening line of:

“frontal chest radiograph of an adult patient”

...can virtually never be wrong.  This is often enough as an opening line, but you could expand if you can with the details you’re given - especially if you are given some of the patient’s history. For example:

“frontal chest radiograph of an adult male patient with shortness of breath”

Adequacy

For the first radiograph you see, it’s good to briefly demonstrate you know what an adequate radiograph looks like.  DO NOT SPENT LONG DOING THIS (10 seconds at most).  Some medical schools do not award any marks for talking about the adequacy of a radiograph so whatever you do, do not spend much time on this!  The interesting bit is describing the pathology on the radiograph itself.  On your second or subsequent radiograph during a station, if the image is clearly adequate, simply stick with your single opening line and proceed to the lungs.

There are broadly 3 categories of adequacy to assess:

  • Rotation: are the clavicles equidistant from the spinous processes?
  • Penetration: can you see the spine through the heart?
  • Expansion: The anterior aspect of the 6th rib (the sloping ones) should meet the diaphragm near the mid-clavicular line. You should be able to see the apices and costophrenic angles.

 

Example radiograph with left upper zone solitary mass lesion

Example radiograph

 

So you might introduce the above radiograph as follows:

“frontal chest radiograph of an adult female patient. It is not rotated, with good penetration and good expansion of the lungs, although the tips of the costophrenic angles are not included on this radiograph”

As a note of caution, some medical schools do not award any marks for talking about the adequacy of a radiograph so whatever you do, do not spend much time on this!  The interesting bit is describing the pathology on the radiograph itself.  On your second or subsequent radiograph during a station, if the image is clearly adequate, simply stick with your single opening line and proceed to the lungs.

Main abnormality

So you’ve made it to the lungs and something looks wrong.  This almost always means there is opacity (whiteness) where there shouldn’t be.  Describe this in terms of appearance and location.

Is the opacity:

  • Patchy - hard to draw round properly, heterogeneous (e.g. pulmonary oedema)

Radiograph of pulmonary oedema

  • Dense – very white so that you can barely see structures through it (e.g. pleural effusion)

Radiograph of a left sided pleural effusion

  • Rounded – discrete, round(ish) in shape (e.g. a mass lesion in the lung)

Radiograph of a left sided mass lesion

Then ask yourself, where is the lesion located?

The lung lobes overlap significantly on a frontal chest radiograph, so it is hard to place an abnormality in a specific lobe when viewed only from the front.  A solution to this is to split the lung into zones – upper zone is above the heart, mid-zone is level with the top half of the heart, and lower zone is below that.  It is also worth looking under the diaphragms and behind the heart for subtle, 'hidden' lesions.

Ok, so now think how you might describe the abnormality in the radiograph we showed you at the start.

“there is a solitary rounded opacity in the left upper zone”

Review areas

To complete your assessment of a radiograph, particularly if it’s your first of a session, it’s worth quickly summarising the rest of the radiograph to show you have assessed everything.  If the abnormality is in the lungs, you might also comment on:

  • The heart: is it enlarged?
  • The diaphragm: can you see any free gas?
  • The bones: are there any fractures?

So for our radiograph:

“the heart is not enlarged, there is no free air below the diaphragm, and there are no fractures identified”

Put everything above together and you’ll have had 30 seconds or so to think up a differential diagnosis to put the icing on your presentation:

“this could represent a primary lung malignancy, but might also be a metastasis”

Finally, finish by saying what you would do next:

“I would like to request a CT chest to further evaluate the lesion and look for evidence of malignancy”

So that's it!

Stick to these basic rules and you will go a long way in your exams and when presenting on the ward.  Good luck!

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