Chest radiograph checklist for FRCR 2B Rapid Reporting

CHEST RADIOGRAPH CHECKLIST

1. Situs
2. Air: Pneumothorax, pneumomediastinum, pneumoperitoneum, surgical emphysema.
• Always look for any abnormal gas first. Beware of soft tissue shadows like skin folds mimicking pneumothorax.
3. Trachea, carina, bifurcation.
• After the first two steps follow the trachea from above down, to the carina and look into the proximal bronchi. Don't miss any metallic foreign bodies (coins, safety pins), or obvious bronchial occlusions.
4. Hilum : Can say enlarged hilum.
• After the bronchi, look both hila, look for enlargement, nodularity, calcifications.
• We will get marks even if we dont distinguish between mass or nodes, can say enlarged hilum - will be sufficient to fetch you the 1 mark.
5. Mediastinum : 
• Look for pneumomediastinum, mediastinal masses, silhouette sign. 
• Mediastinal lucencies / air fluid level could represent achalasia cardia and absent fundic gas favors hiatus hernia.
6. Heart - usually not much cases.
7. Lung parenchyma : Compare both sides (Upper zone - Upper zone, MZ-MZ so on). 
8. Pleura : Pleural plaques (calcified). 
9. Bones: 
• Follow the clavicles from medial to lateral. Distal clavicular erosions with shoulder joint arthritis can point to RA.
• Look for AC joint subluxation or dislocation.
• Shoulder dislocation can be seen occasionally in CXRs. 
• Watch out for Proximal humeral lytic areas in cases of mastectomy, which will get you the other 1/2 marks.
• When you are looking for rib pathologies, look in pairs, comparing both sides at the same time.
10. Soft tissue – Never miss mastectomy. Look for axillary surgical clips. Look for neck/axillary soft tissue lesions. Don't mistake hair braids in female patients for neck /lung apical lesions.
11. Review Areas : Lung Apices (small pneumothorax, nodule, even obvious Pancoast may be missed if you dont look), Retroardiac lung, retro-diaphragmatic lung, gas under diaphragm, upper abdomen (calcifications). 

References
1. frcrtutorials.com by Dr.Sameer Shamshuddin.
2. Dr. Gaurav Shankar's Tips for FRCR 2B (Wordpress).