Educational scope: Published teaching radiographs with fictional histories; not a reporting or diagnostic service. Free, with no account or email needed.
Written by Dr. Ezekiel Aluda Osolika, emergency physician (MBChB, FEBEM). Clinical content reviewed by the author on 24 October 2026; review covered the case histories, answers, explanations, calculations, image interpretation, annotation guides and teaching diagrams. This is author review, not an independent second review. All patients and orders are fictional. Content version 2026-10-24-1. Spotted an error? Report a correction and name the case ID.
Quiz: consolidation, pneumothorax, effusion and failure
Each case shows the full radiograph; select it to open the full-resolution image with zoom. Commit to a description before you check, then compare with the worked answer and its annotation guide.
The interactive practice needs JavaScript. Every case, answer and explanation is also written out in the worked answers below.
A systematic approach to reading a CXR
- Check image identity in actual practice, then projection, orientation, rotation, inspiration and exposure. In these de-identified teaching examples, inspect the supplied markers and any stated source limitation.
- Use a consistent sweep through airway, lungs, pleural spaces, cardiac and mediastinal contours, diaphragms, bones and visible devices. Describe a finding before deciding on its cause.
- Compare both sides, inspect the edges and bases, and avoid stopping after the first abnormality. A radiograph is one part of assessment; a normal image does not exclude every serious cause of chest symptoms.
- The effusion case is guided because the source image already includes a circle. A normal reference image is deliberately reused in an emergency vignette about the limits of a normal film.
Worked answers
Every case in full, with the correct answers and the reasoning. Open one when you have committed to your own answer.
Beginner: cases 1–3
Case 1 Start with a systematic review Beginner
This reference PA radiograph accompanies a fictional, stable adult assessment. Check orientation and image quality before interpreting it.
Question 1: Which statement best describes the major finding?
Answer: No focal acute abnormality is apparent on this reference film
Question 2: What is the best conclusion from an apparently normal film?
Answer: It is one part of assessment and does not exclude every important diagnosis
Worked answer
- Check the visible right and left markers and review the entire image.
- Compare both lungs, pleural margins, diaphragms and cardiomediastinal contour. The source provides this as a normal PA example.
- A normal radiograph does not replace assessment of the presentation.
Limitation: This teaching image and the fictional vignette are not a claim about the original patient’s full clinical course.
Answer annotation guide
What the marks show: 1: Right costophrenic region. 2: Left costophrenic region.
What to trace on the image
- Trace the right and left costophrenic angles.
- Identify both hemidiaphragms and the cardiac contour.
- Explain Dx and Sin without changing or hiding the original markers.
Case 2 Focal air space opacity Beginner
A fictional adult presents with fever, cough and pleuritic discomfort. Interpret the provided radiograph.
Question 1: Which description best fits the principal abnormality?
Answer: Right sided air space opacity; the source localises it to the middle lobe
Question 2: Which conclusion is justified?
Answer: Pneumonia is plausible in this context, but the image does not identify the organism
Worked answer
- Start with the descriptive finding: focal right sided air space opacity.
- The source identifies right middle lobe pneumonia; relate the opacity to the right cardiac border and the clinical history.
- Consolidation is an imaging pattern. Clinical information determines the differential and urgency.
Limitation: Do not infer microbiology, severity or a treatment prescription from a single radiograph.
Answer annotation guide
What the marks show: 1: Right-sided focal air-space opacity. Source identifies the middle lobe; confirm final annotation with the clinician.
What to trace on the image
- Outline the focal right mid to lower zone opacity on the viewer’s left.
- Point to its relation to the right cardiac border.
- Keep a toggle to remove all teaching annotations.
Case 3 Read the pleural contour Beginner · Guided case
This is a guided case: the original teaching image already circles an abnormal region. A fictional patient reports progressive breathlessness.
Guided case. The black circle is part of the original published image. This case teaches you to read the pleural contour, not to find a hidden lesion.
Question 1: What is the best description of the circled region?
Answer: A substantial left pleural effusion
Question 2: What should guide the next clinical step?
Answer: The patient’s condition, examination and further assessment, including ultrasound when appropriate
Worked answer
- The left lower hemithorax is opacified and the left costophrenic angle is obscured.
- The upper fluid contour and distribution are compatible with pleural effusion, as documented by the source.
- The amount of radiographic opacity does not independently determine urgency or the cause of the fluid.
Limitation: Guided recognition only. Do not count this as a hidden lesion localisation test.
Answer annotation guide
What the marks show: 1: Upper contour of the left pleural fluid region. The black circle already exists in the source image.
What to trace on the image
- Label the left costophrenic region and the upper fluid contour.
- Retain the source’s existing circle and identify it as a source annotation.
The annotation layer is an adaptation of a CC BY-SA 3.0 image and is shared under the same licence.
Emergency: cases 4–6
Case 4 Diffuse opacities in an acutely breathless patient Emergency
A fictional adult has acute breathlessness and hypoxaemia. The source identifies this teaching film as pulmonary oedema.
Question 1: Which pattern best fits this image and source context?
Answer: Bilateral interstitial and air space opacities compatible with pulmonary oedema
Question 2: Which is the best immediate priority?
Answer: Assess and support breathing while arranging senior clinical evaluation
Worked answer
- Describe the bilateral abnormal opacities before naming a cause.
- The source context supports pulmonary oedema. Bilateral opacities can have other causes, including infection and inflammatory lung injury.
- Clinical examination, oxygenation, haemodynamics and complementary tests guide management.
Limitation: A portable frontal film alone should not be used to make precise cardiac size claims or to prove a single aetiology.
Answer annotation guide
What the marks show: 1 and 2: Examples of bilateral perihilar abnormal opacity. These highlight broad regions, not exact disease boundaries.
What to trace on the image
- Highlight examples of bilateral perihilar air space opacity.
- Use the full-resolution view to look at the lower lateral zones before discussing interstitial lines.
The annotation layer is an adaptation of a CC BY-SA 3.0 image and is shared under the same licence.
Case 5 Recognise a major pleural air collection Emergency
A fictional adult is acutely breathless. Use the source’s declared orientation for this teaching case; the original film has no reliable visible side marker.
Orientation limitation. No reliable radiopaque side marker is visible. Source labels the abnormality as left sided. The side is taken from the source’s description, not from a marker on the film.
Question 1: Which major abnormality is present?
Answer: A large pneumothorax, labelled left sided by the source
Question 2: The patient becomes hypotensive with severe respiratory distress. What is the key principle?
Answer: Escalate and treat suspected tension physiology clinically without waiting for another image
Worked answer
- A large lucent hemithorax and displaced or compressed lung are the major findings.
- The source identifies the affected side as left. The missing reliable marker limits independent orientation checking.
- Tension physiology is a clinical emergency, not a label established by image appearance alone.
Limitation: Do not teach procedural decompression technique from this image. Emergency action follows trained scope and local protocols.
Answer annotation guide
What the marks show: 1: Example peripheral region with no normal lung markings. Source identifies left pneumothorax. A reliable side marker is not visible.
What to trace on the image
- Outline the visible compressed lung margin and the peripheral region without normal markings.
- Add a text note stating that side attribution comes from the source, not from an inserted marker.
The annotation layer is an adaptation of a CC BY-SA 2.5 image and is shared under the same licence.
Case 6 The image that does not answer the whole question Emergency
Reuse the normal reference image deliberately. In this different fictional vignette, an adult has pleuritic pain, tachycardia and unexplained breathlessness.
This case deliberately reuses the normal reference image from case 1 with a different fictional history.
Question 1: Which interpretation is safest?
Answer: No focal acute abnormality is apparent, but the presentation still needs clinical assessment
Question 2: What is the learning point?
Answer: An imaging test can be normal despite an important disease outside its reliable rule out capability
Worked answer
- The same image can sit within very different clinical presentations.
- Do not diagnose pulmonary embolism from this picture, and do not exclude it because the picture is normal.
- Apply an appropriate clinical assessment pathway rather than treating the radiograph as a universal rule out test.
Limitation: This case uses a previously shown image; it tests limitations of interpretation, not recognition of a new film.
Answer annotation guide
What the marks show: 1: Right costophrenic region. 2: Left costophrenic region.
What to trace on the image
- Keep the film unmarked initially.
- On reveal, show the same normal landmarks used in the beginner case.
Reading a chest X-ray when the film is not perfect
Emergency films are often AP, supine, rotated or taken in poor inspiration. Name the limitation first, then read around it rather than over it.
- AP projection. The heart sits further from the detector and looks larger, so do not call cardiomegaly on an AP film alone.
- Rotation. Compare the medial ends of the clavicles with the spinous processes. A rotated film shifts the mediastinum and makes one lung look denser than the other.
- Poor inspiration. With fewer than about six anterior ribs above the diaphragm, the bases crowd together and can mimic consolidation or a wide mediastinum.
- Supine film. Fluid layers behind the lung as a diffuse haze rather than a meniscus, and air collects anteriorly and inferiorly, so effusions and pneumothoraces both look smaller than they are.
- Exposure. On an adequately exposed film you can just see the vertebral bodies through the heart. Under- and over-exposure both hide detail.
What a normal chest X-ray does not rule out
A normal film answers fewer questions than it seems to. On its own it does not exclude:
- Pulmonary embolism. The chest film is often normal in PE; it is mainly useful for finding another cause.
- Acute coronary syndrome or aortic dissection. A normal mediastinum does not exclude dissection when the history fits.
- Early pneumonia. Consolidation can lag behind the clinical picture by hours or longer.
- A small or anterior pneumothorax, especially on a supine film.
- Rib fractures and some inhaled foreign bodies, which may not be visible on a single frontal view.
Case 6 practises this conversation, and OSCE station 8 asks you to explain the uncertainty to a patient.
How do you spot a small pneumothorax?
- Look for the visceral pleural line: a thin, sharp white line with no lung markings beyond it. Check both apices, where air collects first on an upright film.
- Separate it from mimics. A skin fold usually runs beyond the chest wall and lung markings continue across it; the medial edge of the scapula can be traced to the bone.
- On a supine film, look low and anterior: a deep, lucent costophrenic angle (the deep sulcus sign), an unusually sharp heart border or hemidiaphragm, or one lower zone that is darker than the other.
- Use ultrasound when the film is uncertain. Absent lung sliding with no B-lines suggests pneumothorax, and a lung point confirms it. In trained hands, lung ultrasound detects pneumothorax better than a supine chest film. The lung ultrasound practice covers these patterns.
See the large collection in case 5 first, then look for the same line in a subtler film.
CXR practice for medical students
Start with Beginner mode (cases 1–3), then Emergency mode. Say your answer out loud in the order examiners and seniors expect: patient and projection, image quality, the findings described in plain words, then a conclusion and what you would do next. Describing an abnormality accurately counts for more than naming it quickly. The student learning route puts this quiz alongside ABCDE, ECG and ABG practice.
Image credits and licences
Five published teaching radiographs are used across six cases; case 6 deliberately reuses image 1. The image files are served unaltered. Thumbnails are resized copies, and the answer annotations are a separate drawing placed over the image. Annotations on CC BY-SA images are adaptations shared under the same licence. Each licence applies to its image and adaptation only, not to the rest of this site. The case histories are fictional and make no claim about the original patients.
| Image | Title | Creator | Source | Licence | Used in |
|---|---|---|---|---|---|
| Image 1 | Normal posteroanterior PA chest radiograph X ray | Mikael Häggström | Source page | CC0 1.0 | Case 1 and 6 |
| Image 2 | X ray of lobar pneumonia | Mikael Häggström | Source page | CC0 1.0 | Case 2 |
| Image 3 | Effusionhalf | James Heilman MD | Source page | CC BY-SA 3.0 | Case 3 |
| Image 4 | Pulmonary oedema | Frank Gaillard | Source page | CC BY-SA 3.0 | Case 4 |
| Image 5 | Pneumothorax CXR | Clinical Cases; source crop by Doc James | Source page | CC BY-SA 2.5 | Case 5 |
Questions about this practice
Are these real X-rays?
Yes. The included images are published teaching radiographs with the source and reuse licence shown. The accompanying case histories are fictional.
Why can I toggle the annotations?
Inspecting the unmarked image where available, then comparing the answer overlay, helps you review what supports the interpretation.
Can this diagnose my own X-ray?
No. This page uses fixed teaching cases and does not accept patient images for diagnosis.
Educational disclaimer
Educational use only. These are fixed teaching images with fictional histories. This page does not accept or interpret your own images. Educational fictional practice only. Not patient-specific advice or an assessment of clinical competence. Scores are informal feedback on one practice attempt; no pass mark, certificate or competence decision is made from them. Follow your supervision, scope of practice and local protocols.
Sources and further reading
Reference ranges, formulae and pathways vary between laboratories, services and countries. Use your own local guidance in practice.