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:
- A: airways
- 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?
- check again...
- are the lung apices clear?
- is there any retrocardiac or retrodiaphragmatic pathology?
Read more: chest x-ray assessment of everything else