Identifying Patient: Name, date
Assessment of Film Quality: (if technique poor, must influence final interpretation).
Always note position - Supine, Erect, AP, PA, Lateral.
The quality assessment can be remembered as RIP:
Rotation - Spinous processes should be equidistant between clavicular heads.
- Left Rotation: left head farther from spinous process.
- Right Rotation: right head farther from spinous process.
- Inspiration - Count the posterior ribs (> 8 indicates good inspiratory effort)
Penetration - Should visualize inter-vertebral disc spaces (lucencies) to the carina.
- Over-penetrated: If see spaces down to abdomen
- Under-penetrated: If can't see spaces down to the abdomen.
- Rotation - Spinous processes should be equidistant between clavicular heads.
The remainder of this algorithm is remembered with ABCDEFGHI:
A: Airway: Survey the trachea and mainstem bronchi for patency and deviation from midline (tracheal air column should be over spinous process).
B: Bones and Soft Tissue: Survey the chest wall, shoulders, clavicles, ribs, and sternum to identify any fractures or dislocations. Also, survey the soft tissue for abnormalities such as subcutaneous emphysema.
C: Cardiac and D: Diaphragm:
- Trace the contours of all heart borders and both diaphragms, look for any shadows obscuring these contours.
- Look at the left atrium, hila and note any observed prominence.
- Survey the diameter of the heart, and if greater than 1⁄2 the chest may represent cardiomegaly (inaccurate in portable film).
- Look at contour of diaphragm – flattening may suggest emphysema, tenting or pulling up may suggest lobar collapse/volume loss.
- Look at costophrenic angle if blunted or obscured may suggest pleural effusion.
E: Empty Survey for "empty" spaces - as in pneumothoraces - best way to do this is to trace the pleura completely, looking for visceral pleural line apart from the edge.
F: Fields Survey lung fields bilaterally for any and all shadows (shadows is anything that obscures the normal air-vascular pattern within the lungs!) Look especially for any asymmetry in this normal pattern – where is it normal, where is it not? Describe the shadows you see:
- Hazy or patchy opacity - Heterogeneous shadow that totally obscures the air-vascular pattern
- Consolidation - More confluent opacity that often has air bronchograms within it
- Reticular opacities - Increased linear markings in net-like pattern extending to the periphery of the lung
- Nodule - Round opacity with four trace-able borders, size < 3cm
- Mass - Size > 3cm
G: Gastric Bubble Observe for any lucency in the left upper abdominal quadrant.
H: Hardware Survey for central lines, OGT/NGT, PPM wire, endotracheal tube, chest tubes, surgical drains, prosthesis.