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Chest X-ray: The step-by-step approach


When interpreting a chest x-ray it is important to have a systematic step-by-step approach. It is critical to be able to identify the basic anatomy on a chest x-ray.


One helpful way is to use a mnemonic. One popular mnemonic is DRS.ABCDE

D – Details  Date, patient name and date of birth

R – RIPE  …in other words, what is the quality of the film?

Rotation – Is the film centered ?  

Inspiration – Is it a good inspiration film? – 10 posterior ribs should be visible.

Picture – Is it a PA or AP film ? PA – the x-rays penetrate through the back of the patient on to the film (posterior to anterior) , AP (portable) -the x-rays penetrate through the front of the patient on to the film (anterior to posterior).

Exposure – is the hemidiaphragm visible through cardiac shadow.










– Soft tissue & Bones

Bones: Check for fractures, dislocations, symmetry, lytic lesions, bone density

Soft-tissues and great vessels: symmetry, swelling, subcutaneous air, masses, fat pads, normal and abnormal shadows, calcifications










A – Airway & mediastinum

Trachea, carina, bronchi, mediastinal masses or adenopathy, mediastinal width, aortic knob, hilum, great vessels.









B – Breathing

Lungs fields, pneumothorax, bullae, opacities, atelectasis, consolidation, fissures, infiltrates, pleura.











C – Circulation

Heart size, shape, borders, aortic stripe









D – Diaphragm

Diaphragm shape, contour, levels. Cardiophrenic and costophrenic angles. Gastric bubble.










E – Extras

Lines, tubes, catheters, etc.







In this image, there are two right chest tubes and 1 left chest tube (white arrows). The tip of the endotracheal tube (yellow arrow) is noted to be in line with the air in the trachea and above the carina. The ideal position is between the clavicular heads and the carina. The nasogastric tube is seen overlying the stomach (black arrow). The ECG wires and leads crossing the chest represent visual distractions that can lead to diagnostic errors. All wires and tubes that are outside the patient should be carefully repositioned to the side of the patient before taking the x-ray.






Another similar mnemonic is ABCDE. The A stands for airways, B for bones, C for cardiomediastinal silhouette, D for diaphragm, E for everything else.


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