Chest x-ray review is a key competency for medical students, junior doctors and other allied health professionals. Using A, B, C, D, E is a helpful and systematic method for chest x-ray review:
A: airways
B: breathing (the lungs and pleural spaces)
C: circulation (cardiomediastinal contour)
D: disability (bones - especially fractures)
E: everything else, e.g. pneumoperitoneum
Summary
Airways
Start at the top in the midline and review the airways.
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trace down the trachea to the carina
is it straight and midline?
is there any narrowing?
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trace down both main bronchi
is the carina wide (more than 100 degrees)?
is there bronchial narrowing or cut-off?
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is there any inhaled foreign body?
Read more: chest x-ray assessment of the airways
Breathing
Look for lung and pleural pathology.
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both lungs should be well expanded and similar in volume
can you count 10 posterior ribs bilaterally?
is one lung larger than the other?
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compare the apical, upper, middle and lower zones in turn
are they symmetrical?
are there areas of increased density?
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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?
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trace the lateral margins of the lung to the costophrenic angles
are the costophrenic angles crisp?
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trace the hemidiaphragms in to the vertebra
can you see the whole of the hemidiaphragm?
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trace the cardiac borders
can you clearly see the left and right heart border?
can you see the descending aorta?
Read more: chest x-ray assessment of lungs and pleural spaces
Circulation
Look at the heart and vessels (systemic and pulmonary).
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check the cardiac position
is 1/3 to the right and 2/3 to the left?
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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
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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?
Read more: chest x-ray assessment of the cardiomediastinum
Disability
Check for any bony pathology (fracture or metastasis).
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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
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now, check the clavicles and shoulders
can you trace around the cortex of the bones?
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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?
Read more: chest x-ray assessment of the bony thorax
Everything else
Review the upper abdomen, soft tissues and take a look at some final check areas.
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?
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check again...
are the lung apices clear?
is there any retrocardiac or retrodiaphragmatic pathology?
Read more: chest x-ray assessment of everything else