Search pattern for Chest X-ray, How to read CXR systematically?
Search pattern for CXR
Systematic reading of Chest X-ray
Abbas A. A. Shawka
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• Always you are vieing the graph from the patients anterior
face. (Whaether it was an AP or PA views)
• Start reading every radiograph—chest or otherwise—by
scanning the areas of least interest first, working toward the
more important areas. You are less likely to miss secondary but
important findings this way. For the chest x-ray, start in the
upper abdomen, then look at the thoracic cage (soft tissues
and bones), then the mediastinal structures, and finally the
lung. Look at each lung individually, then compare left lung and
• Correct sequence:
• 2—Thorax (soft tissues and bones)
• Notice the normal gas bubble below the heart represent stomach fundus
• Lateral to it is the gas bubble of splenic fleure
• The liver and R. Hemidiaphragm are not destingusished
• Usually R. Hemidiaphragm is higher than the left one.
• Upper abdominal disease (subphrenic abscess, perforated
viscus, pancreatitis, and cholecystitis) may mimic lung
disease clinically. Similarly, basilar lung disease
(pneumonia, pleurisy) may mimic upper abdominal
disease. This is real!
• start at the right base (*), looking at the soft tissues (e.g.,
muscles, breast) of the chest wall, the ribs, and the
shoulder girdle in sequence.
• Finish by reversing the order down the left side.
• Note that the posterior ribs tend to be horizontal, while
the anterior ribs descend from lateral to medial.
• Identify the structures ?
• A. Right breast , B. 6th posteriro rib , C. Scapula, D. Clavicle
, E. 4th anterior rib , F. Stomach bubble, G. Liver.
• An organized search of the mediastinum is complicated
because there are multiple overlapping structures. Start
with a global look at the mediastinum for contour
abnormalities (i.e., focal or diffuse widening). Figures 3-5A
and 3-5B show three rapid searches of the mediastinum: A
= for the trachea and carina; B = for the aorta and heart; C
= for the hilum
• ✅ 3 searching patterns for
• 1. For trachea and carina
• 2. For heart and aorta
• 3. For hila
• Most chest x-rays are ordered to evaluate lung disease, so
the lungs are examined last. The lungs are so important
that we search them twice.
• Start in the right costophrenic angle (*) as outlined in
Figure 3-6A, examining the right and then left lung. The
second look involves a side-by-side comparison of the
lungs (Figure 3-6B). This also should give you a second look
at costophrenic angles and the hilum. Practice this search
pattern in Figure 3-7A. Are There Many Lung Lesions?
• Try to apply this searching pattern, do you notice any
• For the novice, subtle, and not so subtle, abnormalities are
easy to miss. In searching the lungs, three helpful
strategies to minimize oversights are (1) searching the
lungs individually, (2) searching the lungs side by side, and
(3) taking advantage of old graphs, if available.
• The lateral is a valuable but often ignored radiograph.
Don’t ignore it! The search pattern is identical (ATMLL). In
Figure 3-8A, start by searching below the diaphragm (A).
Continue at the lower spine (B), searching the soft tissues
and bones posteriorly, then anteriorly (C). Return to the
trachea and work your way down the mediastinum (D). In
Figure 3-8B, crisscross the superimposed lungs and
costophrenic angles (E)
apply the search pattern in this lateral chest x ray
What is the interstital lung diseases and the alvolar diseases?
• in interstitial lung diseases the supporting vonnective tissue of
alveoli will affected and thickens and this will appear as a
radiodense lines with normal alveoli (black) indicating a well
• Thickened lung marking
• in alveolar diseases, alveoli are filled with fluids or any thing,
that is they will be radiodense and appears as a patchy whites
• Invisible lung marking
• the pulmonary vessels are not visible in the peripheral third of
lungs normally because of the resolutiin of CT or X ray are
munimum, so in interstitial lung diseases these may appear at
the periphery. (kerely B lines)
• Try to gues wich film repesent an
interstitial disease and which one
represent an alveolar disease?
• Search this CXR systematically, what are the radiological findings?
• rotated film, displaced trachea, right lung is rsdiolucent
• diagnosis is right mastectomy
• search this CXR aystematically, what are the findings?
• Diagnosis is perforated viscus