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Notes for radiology

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Radiology notes can be organized into:
  1. Imaging physics and safety
    X-ray production, attenuation, CT, MRI, ultrasound, nuclear medicine, contrast agents, radiation protection.
  2. Chest radiology
    Chest X-ray approach, pneumonia, tuberculosis, pleural disease, COPD, interstitial lung disease, lung masses.
  3. Neuroradiology
    CT and MRI brain, stroke, head injury, intracranial hemorrhage, tumors, spine imaging.
  4. Musculoskeletal radiology
    Fracture description, dislocations, bone tumors, arthritis, osteomyelitis, common trauma films.
  5. Abdominal and pelvic radiology
    Acute abdomen, bowel obstruction, perforation, hepatobiliary disease, renal and urinary imaging, pelvic imaging.
  6. Cardiovascular imaging
    Cardiac silhouette, pulmonary edema, aortic disease, CT angiography basics.
  7. Pediatric radiology
    Common congenital and emergency conditions, including intussusception and neonatal bowel obstruction.
  8. Breast and obstetric imaging
    Mammography, BI-RADS basics, antenatal ultrasound, ectopic pregnancy.
  9. Interventional radiology
    Image-guided biopsy, drainage, vascular procedures, embolization.
  10. Systematic image interpretation
    Reading approaches for X-ray, CT, MRI, and ultrasound, plus how to write a structured report.
A useful core principle is to identify the modality, use a fixed checklist, describe findings objectively, then give a short prioritized impression. For example, chest X-rays are often read with an ABCDE method: airway, breathing/lungs and pleura, cardiac silhouette, diaphragm, and everything else such as bones and devices.
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Make a chest X-ray interpretation checklist

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Chest X-ray Interpretation Checklist

1. Confirm patient and study details

  • Patient name, date of birth, and hospital number
  • Date and time of examination
  • Correct side marker: R / L
  • Projection: PA, AP portable, lateral, or decubitus
  • Position: erect, supine, semi-erect
  • Compare with prior imaging, if available
  • Clinical indication reviewed

2. Assess image quality: RIPE

  • R - Rotation: medial clavicular heads should be roughly equidistant from the thoracic spinous processes.
  • I - Inspiration: approximately 5-6 anterior ribs or 8-10 posterior ribs visible above the diaphragm.
  • P - Projection/Position: PA films best assess heart size. AP portable films can magnify the cardiac silhouette.
  • E - Exposure/Penetration: vertebral bodies should be faintly visible through the heart; underpenetration can mimic basal opacity, while overpenetration can hide lung markings.
  • Entire lungs included: apices and both costophrenic angles visible.

3. Systematic review: ABCDE

A - Airway and mediastinum

  • Trachea central or deviated?
  • Carina and main bronchi visible and patent?
  • Hilar size, position, and contour normal?
  • Mediastinum widened, shifted, or abnormal?
  • Check for mediastinal air.

B - Breathing: lungs and pleura

Review each lung from apex to base, comparing right with left.
  • Lung volumes: low, normal, or hyperinflated?
  • Focal opacity or diffuse increased opacity?
  • Consolidation, atelectasis, interstitial pattern, edema, cavitation, or mass?
  • Pulmonary vascularity: reduced, normal, or congested?
  • Pleural line or absent peripheral markings suggesting pneumothorax?
  • Pleural effusion: blunted costophrenic angle, meniscus, or subpulmonic fluid?
  • Pleural thickening or calcification?
  • Fissures displaced, thickened, or fluid-filled?

C - Cardiac and circulation

  • Cardiac position and contour
  • Cardiac size: calculate cardiothoracic ratio only on an erect PA film. A ratio below 50% is generally normal.
  • Pulmonary arteries enlarged or reduced?
  • Signs of pulmonary venous congestion or edema:
    • Upper-lobe venous diversion
    • Septal lines
    • Perihilar "bat-wing" opacity
    • Pleural effusions
  • Aortic contour: unfolding, aneurysmal appearance, or calcification?

D - Diaphragm

  • Right hemidiaphragm usually slightly higher than left
  • Both costophrenic angles sharp?
  • Diaphragm flattened, elevated, or obscured?
  • Free subdiaphragmatic air?
  • Retrocardiac lower lobes reviewed through the cardiac silhouette

E - Everything else

  • Bones: ribs, clavicles, scapulae, vertebrae, proximal humeri
  • Fracture, lytic/sclerotic lesion, deformity, or degenerative change?
  • Soft tissues: surgical emphysema, breast shadows, chest wall mass
  • Lines and tubes:
    • Endotracheal tube tip ideally 3-5 cm above carina
    • Nasogastric tube passes below diaphragm, tip in stomach
    • Central venous catheter tip near cavoatrial region
    • Chest drain side holes within thoracic cavity
    • Pacemaker/ICD leads in expected position

4. Formulate the report

Technique:
“Single portable AP chest radiograph.”
Findings:
“Cardiomediastinal silhouette is mildly enlarged. Patchy right lower-zone air-space opacity is present. No pleural effusion or pneumothorax. No acute osseous abnormality.”
Impression:
“Right lower-lobe air-space opacity, likely pneumonia in the appropriate clinical context. Mild cardiomegaly.”

Quick safety check before signing

  • Apices checked for pneumothorax
  • Costophrenic angles checked for effusions
  • Retrocardiac and lower-lobe regions checked
  • Hila and mediastinum checked
  • Lines, tubes, and devices checked
  • Compared with previous study
  • Urgent finding communicated, if present
The RIPE quality assessment and ABCDE structure help avoid missed abnormalities, particularly on portable AP films, where positioning and cardiac magnification can be misleading. A structured approach like this is consistent with commonly taught chest X-ray reading methods in the Radiology Assistant-style guidance and DRSABCDE framework.

Approach to chest x ray interpretation

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Approach to Chest X-ray Interpretation

Use the same sequence every time:
1. Details → 2. Image quality → 3. ABCDE review → 4. Compare → 5. Report
A fixed method reduces missed findings. Poor inspiration, rotation, projection, and exposure can all create misleading appearances or obscure disease.

1. Check the details

Before interpreting the image, confirm:
  • Patient identity, date, and time
  • Right/left marker
  • Projection: PA, AP, or lateral
  • Position: erect, supine, semi-erect
  • Whether it is portable
  • Clinical history and indication
  • Previous radiographs for comparison
Important: AP portable films magnify the heart, so apparent cardiomegaly should be interpreted cautiously.

2. Assess technical quality: RIPE

R - Rotation

  • The medial ends of the clavicles should be equidistant from the thoracic spinous processes.
  • Rotation can falsely suggest mediastinal shift or alter apparent heart size.

I - Inspiration

  • Adequate inspiration: about 6 anterior ribs or 8-10 posterior ribs visible above the diaphragm.
  • Poor inspiration causes crowded lung markings, raised diaphragms, and can mimic basal opacity or cardiomegaly.

P - Projection and position

  • PA erect is the standard view.
  • AP portable can magnify the heart and is often suboptimal.
  • Check that both apices and costophrenic angles are included.

E - Exposure or penetration

  • Vertebral bodies should be faintly visible through the cardiac shadow.
  • Underpenetration makes lungs look too white.
  • Overpenetration can obscure subtle lung markings or infiltrates.

3. Review systematically: ABCDE

A - Airway and mediastinum

  • Is the trachea central?
  • Is there tracheal narrowing or deviation?
  • Are the carina and main bronchi visible?
  • Check hilar size and contour.
  • Is the mediastinum widened, shifted, or containing air?
Tracheal deviation clues
  • Deviates toward volume loss: lobar collapse, fibrosis, pneumonectomy.
  • Deviates away from increased pressure/volume: large pleural effusion, tension pneumothorax, large mass.

B - Breathing: lungs and pleura

Inspect both lungs from apices to bases, comparing side to side.
Look for:
  • Lung volume: normal, reduced, or hyperinflated
  • Opacity: focal or diffuse, unilateral or bilateral
  • Consolidation and air bronchograms
  • Collapse/atelectasis and signs of volume loss
  • Interstitial markings or pulmonary edema
  • Nodules, masses, cavities
  • Pleural effusion
  • Pneumothorax, especially at the apices
  • Pleural thickening or calcification
When an opacity is found, describe:
  1. Location: right/left, upper/middle/lower zone
  2. Pattern: air-space, interstitial, nodular, linear
  3. Extent: focal, multifocal, diffuse
  4. Associated signs: volume loss, effusion, air bronchograms, hilar enlargement

C - Cardiac silhouette and circulation

  • Check heart position and contour.
  • Assess cardiac size. Cardiothoracic ratio should only be measured reliably on a PA erect film; it is generally below 50%.
  • Review pulmonary vessels for congestion or redistribution.
  • Look for signs of pulmonary edema:
    • Enlarged upper-lobe vessels
    • Kerley B lines
    • Bilateral perihilar air-space opacity
    • Pleural effusions
  • Inspect the aortic arch for unfolding, calcification, or enlargement.

D - Diaphragm

  • Right hemidiaphragm is usually slightly higher than the left.
  • Are both costophrenic angles sharp?
  • Is either hemidiaphragm elevated, flattened, or obscured?
  • Check for free air below the diaphragm.
  • Look behind the heart for left lower-lobe disease.
  • Check the gastric bubble and retrocardiac region.

E - Everything else

Bones and soft tissues

  • Ribs, clavicles, scapulae, shoulders, and visible spine
  • Fractures, destructive bone lesions, deformity
  • Chest wall mass or surgical emphysema
  • Breast shadows and skin folds that may mimic pathology

Lines, tubes, and devices

Check all visible devices:
  • Endotracheal tube
  • Nasogastric tube
  • Central venous catheter/PICC
  • Intercostal chest drain
  • Pacemaker/defibrillator leads
  • Prosthetic valves or sternotomy wires
For an endotracheal tube, the tip is commonly expected about 3-5 cm above the carina in a neutral neck position.

4. Compare with old images

Ask:
  • Is the finding new, improving, stable, or worsening?
  • Has the size of an effusion, infiltrate, or pneumothorax changed?
  • Are lines and tubes in a new or altered position?
Comparison is especially useful for pulmonary edema, infection, pleural fluid, postoperative change, and suspected malignancy.

5. Formulate a structured report

Technique
“Portable AP chest radiograph.”
Findings
“Cardiomediastinal silhouette is mildly enlarged. Patchy right lower-zone air-space opacity is present. No pleural effusion or pneumothorax.”
Impression
“Right lower-lobe consolidation, compatible with pneumonia in the appropriate clinical setting. Mild cardiomegaly.”
Keep the impression short, prioritized, and clinically useful. State urgent findings first, such as tension pneumothorax, misplaced tube, free subdiaphragmatic air, or a new large pleural effusion.

Quick final check

Before signing off, re-check:
  • Apices
  • Hila
  • Retrocardiac region
  • Costophrenic angles
  • Bones and soft tissues
  • Lines and devices
  • Prior comparison
A structured RIPE + ABCDE method is a commonly used framework for reproducible chest radiograph review, as outlined in the Radiology Assistant guide and the DRSABCDE method.
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