systematic way of reading CXR?

[Informer]

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Hi, can you share with us your systematic way of reading CXR?

name, in to out, rib counting, etc and in what order?
any pneumonics?

thanks

 

[waterski232002]

There is no "right way" to read a CXR; however, there are ways that will help you to prevent missing something. The important thing is to make sure you cover all your bases and do NOT stop looking at the CXR when you find 1 abnormalitiy (particularly when it is what you are looking for) or you will miss something major.

That being said... here's my 2 cents on "How to read a CXR for the 3rd yr med student"....

In this order:
-the basics-
1) check name
2) check date
3) check R vs. L side & positioning

-hardware ABC's-
1) check airway hardware (Endotracheal tube/tracheal deviation)
2) check breathing hardware (chest tube placement)
3) check circulatory hardware (central lines, swans, EKG leads, pacer wires)

-the outside-
1) check bones (peripheral arm/jaw bones & shoulder joints)
2) check soft tissue (SQ emphysema)
3) check under diaphragm (stomach bubble & peritoneal air)

-the inside-
1) check bones (ribs & vertebrae, r/o pneumothorax)
2) check soft tissue/mediastinum (widening, cardiomegaly, heart displacement, hilar LAD)
3) check above diaphragm (costodiaphragmatic blunting for pleural effusions)

-the lung fields-
1) lung periphery (r/o pneumothorax)
2) lung parenchyma (emphysema, pulm. edema, opacifications, congestion, atlectasis etc)

IMO if you can do this then you will do very well 3rd & 4th year. If you are asked to read a CXR by an attending/resident, I would talk your way through this entire process out loud so they can hear you (relatively quickly) and they will be very impressed. It shows you are systematic, and pay attention to all detail, not just the 1 reason you shot the film.

Going in that order is also important b/c you move from less concerning areas (periphery) to more concerning areas (heart & lung fields). This way you're less likely to miss the small bullet lodged in the shoulder when there's a huge pneumothorax distracting you on the other side.

Also, NEVER just jump out and say "Mrs. X has a Left pneumothorax" without fully evaluating the film quickly... make sure you at least check the name to insure it is in fact Mrs. X's chest you are looking at. Sometimes they will throw up a wrong patients X-ray to see if you are paying attention to the name on it!!!!

Also... just like EKG's... ALWAYS look at the previous day's CXR, or the last CXR that was done to see if there are any major changes.

Hope this helps

 

[waterski232002]

How to read a CXR for idiots

If the last post was too complicated... look for these 5 things and you'll still do fine IMO...


- Endotracheal tube placement
- Pneumothorax
- Pleural effusion
- Cardiomegaly / Mediastinal widening
- Lung opacities / Pulm edema

These are the majority of ALL major abnormalitites on CXRs... probably about 90% of sick patient in the hospital will in fact have either a pleural effusions, pulm edema, pneumonia, or cardiomegally... so if you comment on these things, you'll have something intelligent to say even if you don't know squat about the patient's history...

checking for a pneumothorax is always important b/c you don't want to miss a life threatening problem... and ET tube placement should be reflex

 

[spikyhairedgirl]

I've always used the ABC method myself and it's served me well.

A: Airway/Airfields
B: Bones
C: Cardiac shadow, cardiac system
D: Diaphragm
E: Equipment, everything else.

It doesn't matter what you do first. Just find a pattern and stick with it and that will mean you never forget to check part of the exam.

 

[IndyXRT]

An excellent resource is Felson's Principles of Chest Roentgenology , if you have the time to read it. It is in a format similar to Dubin's EKG book, and worth reading at least once.

 

[14022]

A resident taught me how to read a film today actually and gave me a similar pnemomic to one already posted. He said the biggest mistake you can make is to look at the expected finding first. For example, if you have a pt with a history of myocardial infarction who presents with SOB and edema, do not look at the heart first. You may find pulmonary venous congestion, but you may miss an incidental solitary pulmonary nodule (an early sign of cancer). Develop a system that makes sense to you and stick with it for the rest of your life because you will be looking at chest xrays for the rest of your life. His pnemonic was ABCDEF.

A- airways- make sure the trachea is midline; look for stenosis; look for air bronchograms

B- bones- look for fractures in clavicles, ribs, shoulders, etc.; make sure the clavicles are symmetric (if not the pt may be rotated in relation to the film)

C- cardiac silhouette- look to see if it is well defined- assess for size (but remember an AP film makes the heart look bigger); assess width of mediastinum, assess for pulmonary venous congestion (sign of CHF)

D- diaphragm- assess for symmetry; look for well defined costophrenic angles; see if there is subdiaphragmatic air; loops of dilated bowel may be seen underneath

E- expansion- assess the inspiratory effort by counting the ribs (if you can count 9 ribs on each side, the patient had a good inspiratory effort; if less than 8 or so the xray is technically poor)

F- foreign objects- placement of central lines, endotracheal tubes, NG/OG tube, pacemaker, etc

 

[14022]

A- airways- make sure the trachea is midline; look for stenosis; look for air bronchograms

oh yeah...one more thing...A was for airfield as well, so look for pneumothorax, pulmonary nodules, infiltrates, atelectasis, etc

 

[Dr.Evil1]

I found this website:

http://www.uab.edu/emig/yellow_book/the_yellow_book.htm

It has "how to read a CXR" as well as several other useful pieces of information. Seems it was written by students for students too.

 

[carve em up]

Here is how I kind of learned it:

RIP--ABCDEFG

R--rotation--is the patient's body rotated in the study--look at the clavicles and spinous processes for this
I--inspiration--count the visible ribs, need at least 8
P--penetrance--should easily have vertebral bodies visible (on PACS this is adjustable)

These first three allow you to determine whether you have an adequate study or need to get a repeat. . . .then proceed. . . .

A--airway--deviation, etc
B--bones--fractures, etc
C--cardiac shadow
D--diaphragm--flattening, pneumoperitoneum (look at right, not to be confused with gastric bubble on left)
E--everything else
F--fields--as in lung fields
G--gadgets--like ET tubes, and the very tricky tube to the nasal cannula

Hope that kinda helps

 

[roja]

I use this one as well.


Works well.

 

[bulldog]

is there a book or a site that goes by the abcdefg method? i.e. it describes the "a", then the "b", then the "c", etc. interesting thing i noticed, but most of the xray books i've seen so far are written in the UK...none in the usa.

 

[FionaS]

Maybe we have to present x-rays more? Who knows!

My system is pretty similar to most people's version of ABC:

A - Adequacy (all the positioning, good inspiratory effort etc) and Airway

B - Bones

C - Cardiac Outline

D - Diaphragm

E - Effusions

F - (lung) Fields

G - Gadgets

Useful to have a good summarising spiel as well - This is a PA erect chest radiograph of Joe Bloggs, taken on 12th September of this year. It is an adequate radiograph (because...). Findings include... With the history, this would be consistent with...

Don't know if they're anal about it in the states, but avoid saying "This is an x-ray..." Nasty docs will look at you and go, "Is is really? You can see in that particular wavelength spectrum can you?" And so on.

Have fun with the CXRs!