Chest x-ray review: ABCDE
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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:
B: breathing (the lungs and pleural spaces)
C: circulation (cardiomediastinal contour)
D: disability (bones - especially fractures)
E: everything else, e.g. pneumoperitoneum
Start at the top in the midline and review the airways.
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?
Read more: chest x-ray assessment of the airways
Look for lung and pleural pathology.
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?
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?
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?
Look at the heart and vessels (systemic and pulmonary).
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?
Check for any bony pathology (fracture or metastasis).
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
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?
Read more: chest x-ray assessment of the bony thorax
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?
are the lung apices clear?
is there any retrocardiac or retrodiaphragmatic pathology?
Read more: chest x-ray assessment of everything else