A systematic approach to comprehensively reviewing the lung parenchyma, airways, pleura, mediastinum, cardiovascular structures, and upper abdomen on routine diagnostic chest CT.
RadPhrases Editorial Team5 min read
A systematic approach to comprehensively reviewing the lung parenchyma, airways, pleura, mediastinum, cardiovascular structures, and upper abdomen on routine diagnostic chest CT.
Scope This content provides a general reading sequence for routine diagnostic chest CT. CT pulmonary angiography, aortic CT angiography, high-resolution CT, lung cancer screening, and oncologic response assessment require separate protocols and reporting systems.
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Browse the other checklists, phrase sets, and systematic approaches in this topic.
Chest CT is not a single-organ examination. In addition to the lung parenchyma, the airways, pleura, mediastinum, lymph nodes, cardiovascular structures, chest wall, and imaged upper abdomen are all part of the report.
A systematic reading sequence helps prevent mediastinal or upper abdominal findings from being overlooked while attention is concentrated on the lungs. This draft provides a repeatable checklist for routine adult chest CT reporting.
1. Define the protocol and clinical question
☐ Read the indication. Infection, malignancy, nodule follow-up, interstitial disease, trauma, and postoperative assessment require different priorities.
☐ Identify contrast status and phase. Noncontrast, venous phase, or a dedicated angiographic phase determines the limits of vascular and mediastinal interpretation.
☐ Assess inspiration and motion. Poor inspiration may increase dependent opacities and create a false mosaic appearance.
☐ Confirm coverage. The entire thorax from the apices to the costophrenic angles, together with the required upper abdomen, should be included.
☐ Open the prior examination. For changes in nodules, masses, lymph nodes, and pleural fluid, note the date and similarity of technique.
2. Perform a rapid safety survey first
☐ Pneumothorax and large pleural collection. Is there mediastinal shift or cardiac compression suggesting tension physiology?
☐ Obvious aortic or vascular emergency. Within the limits of a routine protocol, do not miss visible signs such as a dissection flap, rupture, or active bleeding.
☐ Large-airway obstruction. Is there a foreign body, mucus plug, or tumor-related obstruction in a main bronchus?
☐ Extensive acute parenchymal process. Dense consolidation, edema, or severe aspiration may alter clinical priority.
3. Lung window: review the parenchyma systematically
☐ Use a fixed lobar and segmental sequence. Review both lungs from apices to bases on axial images and confirm findings on coronal and sagittal reconstructions.
☐ Nodule and mass. Describe location, size, morphology, margins, attenuation, and change from prior imaging.
☐ Consolidation and ground-glass opacity. Assess distribution, lobular or segmental pattern, air bronchograms, and associated volume loss.
☐ Atelectasis. Interpret possible passive, obstructive, or scar-related appearances together with bronchial patency and pleural disease.
☐ Interstitial findings. Note reticulation, septal thickening, traction bronchiectasis, honeycombing, and distribution; state when routine CT may not substitute for HRCT.
☐ Emphysema and clues to air trapping. Assess type, distribution, and associated bullae; if no expiratory series is available, remain cautious about air-trapping assessment.
☐ Pneumothorax. Check for small anterior or basal air collections on multiplanar images.
☐ Pleural nodule/plaque. Note calcification, extent, and suspected invasion.
☐ Diaphragm. Is there elevation, hernia, defect, or focal contour abnormality?
6. Mediastinum, hila, and lymph nodes
☐ Mediastinal compartments. Systematically assess for masses, fluid, air, and distortion of fat planes.
☐ Lymph nodes. State station, short-axis size, morphology, and change from prior imaging, interpreted in the clinical context.
☐ Hila. Review the vessels, lymph nodes, and bronchi together and try to explain any asymmetry.
☐ Esophagus. Is there marked wall thickening, dilatation, hiatal hernia, or alteration of the surrounding fat planes?
☐ Thymus and visible thyroid. Note an obvious mass or nodular enlargement according to age and clinical context.
7. Heart, pericardium, and great vessels
☐ Cardiac size and chambers. Assess obvious enlargement while respecting the measurement limitations of routine nongated CT.
☐ Pericardium. Is there fluid, thickening, or calcification?
☐ Aorta. Assess caliber, atherosclerosis, and visible acute abnormality; when measurements are needed, pay attention to the imaging plane.
☐ Pulmonary arteries. Check the main pulmonary artery caliber and visible filling defects; when appropriate, state that embolism cannot be excluded on a nondedicated examination.
☐ Coronary calcification. Report conspicuous calcification in keeping with image quality, remembering that this is not a substitute for cardiac CT.
8. Chest wall, bones, and upper abdomen
☐ Ribs, sternum, vertebrae, and shoulder girdle. Review bone windows for fracture, destruction, sclerotic foci, or compression deformity.
☐ Soft tissues. Is there an obvious mass or collection in the breasts, axillae, subcutaneous tissues, or muscle planes?
☐ Upper abdomen. Systematically assess the imaged portions of the liver, adrenal glands, spleen, pancreas, and kidneys.
☐ Surgical and radiotherapy changes. Compare with prior images to distinguish expected changes from complications or suspected recurrence.
9. Impression
Place the finding that answers the main clinical question first.
For nodules, masses, or other findings that may require surveillance, clearly state measurement, location, and comparison; base follow-up recommendations on the current guideline adopted by your institution and the patient's context.
State limitations of a nondedicated protocol explicitly only when they are clinically important.
Make secondary cardiovascular or upper abdominal findings that could alter management visible in the impression.
Communicate time-sensitive findings directly to the clinical team and document the communication.
Communication of critical findings
Emergency findings can occur on routine CT Tension pneumothorax, large-airway obstruction, massive hemothorax, suspected aortic rupture/dissection, substantial device malposition, or other urgent findings should trigger the local critical results communication process. If uncertainty results from a nondedicated protocol, clearly communicate that limitation to the clinical team.
10. Commonly overlooked areas
Tracheal and main bronchial lumina
Small anterior pneumothorax
Costophrenic angles and diaphragmatic regions
Paraesophageal region and hiatal hernia
Axillary and internal mammary lymph nodes
Vertebrae and ribs on bone windows
Adrenal glands and upper abdomen
Small interval growth of a nodule
11. Example report framework
INDICATION: [Clinical question] TECHNIQUE: [Noncontrast / IV contrast-enhanced] chest CT. [Phase, reconstructions, and limitations]. COMPARISON: Examination dated [date]. FINDINGS: - Lung parenchyma: [...] - Airways: [...] - Pleura: [...] - Mediastinum/hila/lymph nodes: [...] - Heart/pericardium/great vessels: [...] - Chest wall and bones: [...] - Imaged upper abdomen: [...] IMPRESSION: 1. [Primary clinical finding.] 2. [Interval change / important secondary finding.] 3. [Context-based recommendation for follow-up or further evaluation, when appropriate.]
References
ACR Practice Parameter for Communication of Diagnostic Imaging Findings, Revised 2025. Report components and principles for nonroutine/urgent communication. Source (opens in a new tab)
ACR-SABI-SPR-STR Practice Parameter for the Performance of Thoracic CT, Revised 2023. Framework for thoracic CT performance, documentation, and quality. Source (opens in a new tab)
ACR-SPR Practice Parameter for Performing and Interpreting Diagnostic CT, Revised 2022. General CT interpretation and documentation principles. Source (opens in a new tab)
Clinical use note
This content is educational and is not patient-specific medical advice. Every phrase, template, classification result, and recommendation must be verified and adapted by a physician using the complete examination, clinical context, current guidelines, and institutional protocol.
Turn the checklist into a report template
Use this sequence as an editable RadPhrases template and verify it against the images in every case.
