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A methodical way of interpreting chest x-rays.

  1. Orientation
    1. Correct patient
    2. Verify left and right
    3. Type of View
      1. PA –most common
      2. AP –used when the patient cannot stand upright
      3. Lateral –for structures obscured on PA
      4. Decubitus –useful for detecting free fluid
      5. Lordotic –to visualize the lung apices
  2. A –Airway
    1. Identify the trachea –is it midline? Is it patent?
    2. Hilum–are the mainstem bronchi clear? Is there any occlusion? The left hilum should be higher than the right.
    3. Check for any lines, wires, endotracheal tube placement.
    4. Mediastinum –are there masses? Is it widened?
  3. B –Bones
    1. Check for presence (or absence), fractures, displacements, lytic lesions, bone density, alignment of the vertebrae.
  4. C –Cardiac
    1. Heart size –is it less than half the diameter of the thorax? (note: the heart may appear enlarged in the AP view)
    2. Heart borders –are they well defined? If borders are blurred think atelectasis or consolidation in corresponding lung lobe.
  5. D –Diaphragm
    1. The right hemidiaphragm should be 2-3cm higher than the left one.
    2. Shape –a flattened diaphragm suggests increased lung volumes.
    3. Check the costophrenic angles –is there any blunting suggestive of effusions?
    4. Air below the diaphragm indicates bowel perforation.
  6. E/F –Equal lung Fields
    1. Are the lungs equally lucent and air-filled? Is there a pneumothorax?
    2. Check for atelectasis, infiltrates, consolidation –what pattern are the infiltrates (interstitial, alveolar, diffuse, lobar)?
    3. Increased vascular markings are seen in pulmonary HTN.
    4. Check for any masses or nodules.
  7. G –Gastric air bubble
    1. Identify the gastric air bubble beneath the left hemidraphgram.
    2. Check for hiatal hernias.