How to present an X‑ray

Written by the X-Ray Atlas editorial team from the sources listed below · Medical review pending · Updated 24 October 2026 · Level: Beginner

Being able to say what you see is a separate skill from seeing it. In an OSCE, a ward round, a phone referral or a handover, the listener judges you on structure as much as content. A presentation that wanders, guesses early or misses the urgent finding loses trust quickly. This page gives you a reusable script, explains what each part is for, and works through examples for the chest, abdomen and skeleton. The core rule is simple: urgent first, describe before you diagnose, and finish with a plan.

1. The script

If anything on the film needs immediate action, such as a tension pneumothorax, free intraperitoneal gas or an NG tube in the airway, say it first, before the opening line: "This film shows a large right pneumothorax with mediastinal shift, which needs urgent action. To present it in full…" Nobody will mark you down for prioritising safety.

2. Opening: patient, film and quality

• Identity and date. In an exam, the name may be anonymised; say "of an adult patient" or "of a child", and confirm the date. In practice, checking identity and date prevents interpreting the wrong film.
• Projection and position. PA or AP, erect or supine, and the body part. For skeletal films, list the views: "AP and lateral views of the right ankle." See X-ray projections.
• Quality. For a chest film, use RIPE in one sentence: "The patient is not rotated, there is adequate inspiration and the film is adequately penetrated." Only expand on a problem if it affects interpretation: "the left costophrenic angle is not included" or "this is an AP film, so heart size cannot be reliably assessed".

3. Findings: describe before you diagnose

Lead with the most important abnormality, then describe it in a fixed order:

1. Where: side, zone or bone, and anatomical landmarks. Zones on a chest film are upper, middle and lower; they are not lobes. Use the silhouette sign to localise further.
2. What: increased opacity or lucency, its shape, margins and size.
3. Density: air, fat, soft tissue/fluid, calcium or metal (see how X-ray images are made).
4. Effect on surroundings: volume loss or gain, mediastinal or tracheal shift, lost borders, displacement.
5. Associated findings: air bronchograms, effusion, fractures, devices.

Then give the other findings, including lines and tubes, and the pertinent negatives: the things the listener needs to know are absent. For a breathless patient with consolidation, "there is no pneumothorax or effusion" matters. For a fall with a wrist fracture, "the carpal alignment is normal" matters. Do not list every normal structure; choose the negatives relevant to the question.

4. Summary and next step

A good summary is one sentence: the likely diagnosis, hedged appropriately, and a differential if there is genuine doubt. Use language that matches the certainty:

• "consistent with" or "in keeping with" when the appearance fits well and the clinical picture agrees
• "suggests" when it is likely but not certain
• "the differential includes" when two or three possibilities are realistic

Then the plan. This is where many candidates fall short. Typical next steps:

• compare with previous imaging
• assess the patient (observations, examination)
• escalate to a senior or specialty team
• a specific further test, chosen for the question: CT for suspected obstruction or aortic injury, ultrasound for an effusion before drainage, a follow-up chest film after pneumonia in a patient at risk of cancer, or further imaging for a suspected occult fracture
• check the formal report

5. Worked examples

Chest: right lower zone consolidation

"This is a PA erect chest radiograph of an adult, taken today. The film is adequately rotated, inspired and penetrated. The most obvious abnormality is an area of increased opacity in the right lower zone, with ill-defined margins and air bronchograms. The right hemidiaphragm outline is lost but the right heart border is preserved, placing it in the right lower lobe. There is no volume loss. The costophrenic angles are clear and there is no pneumothorax. In summary, the appearances are consistent with right lower lobe consolidation, most likely pneumonia in the right clinical context. I would like to compare with previous films, assess the patient and their severity, and consider a follow-up film at about six weeks if they remain symptomatic or are at higher risk of malignancy." See pneumonia and consolidation.

Chest: pneumothorax (urgent first)

"This film shows a large left pneumothorax with tracheal and mediastinal shift to the right, which raises concern for tension and needs immediate clinical review. To present it fully: this is an AP erect chest radiograph… there is a visible visceral pleural line with no lung markings beyond it… the left hemidiaphragm is depressed." See pneumothorax.

Abdomen: small bowel obstruction

"This is a supine AP abdominal radiograph of an adult, covering the diaphragm to the hernial orifices. There are multiple dilated central loops of bowel, the largest about 5 cm, with folds crossing the full width of the loops, consistent with small bowel. The colon contains little gas. I see no evidence of free gas. In summary, the appearances suggest small bowel obstruction. I would examine the hernial orifices, check for previous surgery, and discuss with the surgical team; CT would confirm the cause and level." See how to read an abdominal X-ray.

Skeleton: ankle fracture

"These are AP, mortise and lateral views of the left ankle of an adult. There is an oblique fracture of the distal fibula at the level of the joint line. The fragments are minimally displaced. The ankle mortise appears congruent, with an even joint space. No medial or posterior malleolar fracture is seen. In summary, an undisplaced distal fibular fracture at the level of the syndesmosis. I would check the neurovascular status and assess for medial tenderness, which affects stability." See how to describe a fracture and ankle fractures.

6. Writing it down

A written interpretation in the notes follows the same structure, more briefly. Include the date and time of the film, who interpreted it, the key findings and the plan. Write "my interpretation" and make clear it is not the formal report. Radiographers who provide preliminary clinical evaluation comments should follow Society of Radiographers guidance and their local scheme. Whatever your role, check the formal report when it arrives and act on any discrepancy.

7. Common pitfalls

• Diagnosing in the first sentence. "This is pneumonia" invites the question "how do you know?" Describe first.
• Burying the urgent finding. A misplaced tube mentioned at the end of a two-minute presentation is a safety failure.
• Stopping after the first abnormality. Always finish the system and the review areas (apices, behind the heart, below the diaphragm, bones). See how to read a chest X-ray.
• Using lobes when you mean zones. Say "right lower zone" unless you have evidence for a lobe.
• Over-certainty. Many signs are non-specific. "Consistent with" is honest, not weak.
• No plan. Always end with what you would do next.

Red flags: act now

What to focus on, by role

Role	Priorities
Medical student	Rehearse the script aloud until it is automatic. Practise ending every presentation with a plan.
Nurse	Use a short structure (situation, finding, request) when escalating a concern about a film, for example a suspected misplaced tube.
Junior doctor	Phone referrals: urgent finding first, numbers where they matter (bowel diameter, angulation), and a clear request.
Radiographer	Concise, precise preliminary comments within your local scheme of work.
Advanced / FRCR	Short, decisive reports with a clear conclusion and recommendation. Practise speed in rapid reporting mode.

Practise presenting films →

References

1. Life in the Fast Lane (LITFL). Chest X-ray interpretation. litfl.com
2. Radiology Masterclass. Chest X-ray anatomy. radiologymasterclass.co.uk
3. Radiology Masterclass. Fracture description. radiologymasterclass.co.uk
4. British Thoracic Society. Community acquired pneumonia in adults guideline. brit-thoracic.org.uk
5. Royal College of Radiologists. iRefer. irefer.org.uk

For education only. Not a substitute for a formal report, senior review or your local policy. Never use this page to make decisions about a real patient.