Search Patterns

Search Pattern - XR Chest

1. Do you have the right study open?

Are you looking at the right patient? Always confirm patient identity with two constant identifiers (name, MRN, DOB).
Never use room number for patient identity.
Are you looking at the most current exam? Confirm the date and time of exam that you're viewing.

Use the RIPE-F acronym.

Rotation - is the patient rotated left or right? You will need to account for this when assessing the trachea.
Inspiration - adequate inspiration is about least 8 lucencies between ribs. In pediatric patients, comment on lung volume - low, normal, or hyperinflated.
Projection - AP, PA, lateral radiographs are the most common.
Exposure - actually determining penetration - are the intervertebral discs distinct and separate from the vertebral bodies? If not, the study is underpenetrated. Are there blacked out areas of lung? If so, the study is overpenetrated.
Field of view - adequate field of view requires the image to include the lower neck and lung apices superiorly and the upper abdomen inferiorly, including the full extent of the diaphragm.

Use this ABCDE acronym🌟, not the other 🗑 variations out there.

Airway, airspaces, and vessels that travel through the air (pulmonary vasculature)

Airway includes the trachea and bronchi. ex.) - diffuse peribronchial thickening.
Airspaces are the alveoli. ex.) focal consolidation, pneumothorax.
Pulmonary vasculature is graded in order of severity. ex.) normal, pulmonary vascular congestion, interstitial pulmonary edema, or alveolar pulmonary edema.
Alveolar pulmonary edema is sudivided into mild, moderate, or severe. Compare versus the prior study to determine better or worse, which will inform your treatment strategy.

Fractures, lytic and sclerotic lesions.

Gestalt view - full image on the screen. Window and level to bring out the cortical vs. medullary bone and the trebeculations, to increase your sensitivity for fractures and bony lesions.
Zoomed view - zoom, pan, and pause to modulate your attention to details. Don't zoom in so much that you loose anatomical orientation. Be sure to window and level as needed to keep the bones visible.
Complete assessment - any bones in the study are your responsibility. Assess the vertebral bodies (are they full height, or has there been compression fractures?), posterior and anterior ribs, clavicles, scapula, and humerus.

Check for enlarged cardiomediastinal silhouette - on PA radiograph, heart size > 50% = enlarged cardiomediastinal silhouette. This could mean cardiomegaly or pericardial effusion - you may need ultrasound, CT, or MRI distinguish the two.
Don't be fooled by AP radiograph - normal hearts look enlarged on AP radiograph because the heart is farther from the x-ray detector in the AP radiograph, resulting in magnification.
Look at the hila for lymphadenopathy - only extreme cases will show up on radiograph, and CT is more sensitive if you're tyring to assess mediastinal lymph nodes.

Is there a pleural effusion? Evaluate the costophrenic angles for blunting. With moderate pleural effusions, you'll see a meniscus, the curved shape of the effusion.
Small pleural effusions might be invisible on frontal radiographs. A pleural effusion needs to be several hundred milliliters in size before it appears on a frontal radiograph (AP or PA). Use a point-of-care ultrasound probe for the greatest sensitivity to pleural effusions.
Is the diaphgram obscured? If the diaphragm blends in with additional opacity in the hemithorax, that can mean atelectasis, lung collapse, infiltrate, pleural effusion, or a combination of any of those.
Is there air above the diaphragm? This is worrisome for pneumothorax.
Is there air below the diaphragm? This is worrisome for pneumoperitoneum.
Is there hemidiaphragm elevation? This happens most commonly with atelectasis. If you suspect diaphragmatic paralysis following thoracic surgery from injury to the phrenic nerve, you can get a sniff test, where the radiologist evaluates diaphragm movement under fluoroscopy.

Tubes/lines/devices - mention pacemakers and AICDs. check if central venous catheters end at the cavoatrial junction (2 vertebral bodies below the carina) or the SVC or right atrium. Midline catheters can be positioned in the brachial vein or mid-brachiocephalic vein, but won't reach the cavoatrial juction by design.
Upper abdomen - check for distended bowl loops, which can be seen in small or large bowel obstruction. You might also see cholecystectomy clips or other signs of prior surgery.