How to Read a Chest X-ray like a Radiologist! (My Search Pattern)

So you want to know how to read a chest x-ray, do you? I think I can teach you a thing or two. Let's go! All right guys, so today we are going to be discussing how to read a chest x-ray. Again, this is my search pattern. It is not necessarily the best search pattern. This is just what I've adopted over the last few years. So let's get started. The first thing I do always is get an overall look at the patient. I want to know if the patient is really sick. Are they an outpatient like this one is when they can stand up? As you notice, this is an upright radiograph. I guess they could be sitting down, but this patient looks well enough that they could be probably standing during this one. So the next thing I do is go straight to the lung aphyses. I'm trying to rule out a pneumothorax because that is one of the most important things you can see on an x-ray. So what I do is I zoom in real closely to the lung aphyses. I make sure there's no fine linear pleural line up here that would indicate a pneumothorax. There isn't on this patient. So then what I do is I go down to the lung bases because sometimes you can have a nice linear pleural line down here which would indicate a basilar component of a pneumothorax or even a loculated basilar pneumothorax down here. Sometimes if I'm having trouble deciding if there's a pneumothorax or not, I can switch to the inverted windows which can sometimes give you a nice contrast between the pleura and the adjacent ribs or whatnot. All right, so the next thing I do is go straight to the bones. And I know it's weird, but I've seen so many missed fractures on a chest x-ray, and I don't want to miss those. So I go straight to the bones to make sure I know that I looked at them. So what I do is I start up at the right shoulder. So I take a look at the right humerus, on into the glenohumeral joint, follow down the scapula, take a look at the distal right clavicle down to the sternoclavicular junction, followed on to the left clavicle down distally, take a look at the scapula and to the glenohumeral joint on the left and any portion of the visualized proximal left humerus. Then what I do is I start at the right first posterior rib, and I count each posterior rib on down. I do this quickly with my eyes, but for the sake of this video, you'll see me follow each posterior rib. Then what I do is I come over on the left, follow all the posterior ribs up, and sometimes you can see a nice posterior rib fracture on these radiographs. After I've cleared the posterior portion of the rib, I will take a look at the lateral aspect of the rib or the posterior lateral rib. For this, I usually like to zoom up a little bit. You'll be able to see a nice displaced rib fracture out here, which you often are able to pick up. Again, I follow this up on the right, and once I've cleared that, I go to my spine. Sometimes you can window really hard to take a look at your vertebral bodies and make sure you're not missing any compression fracture. Once I've cleared the bones, I start with my cardiometastinal silhouette. What I do is I follow the right side of the mediastinal silhouette down, making sure there's no mediastinal widening. Follow this on down through my right heart border to make sure it's not obscured or silhouetted out by some consolidated opacity like a pneumonia. Again, I come down lower on my left heart border. Really pay attention to this AP window here just below the aortic knob because you can have nice little enlarged lymph nodes or masses that like to live in this region. Same goes for the right hilar and left hilar region as well. You can find a nice mass in there that'll bow this out subtly. Then what I do is I follow my mediastinal border on up as well. Next, what I finally do, I look at the airways and the lungs. What I do is I follow down my trachea onto the right mainstem bronchus and left mainstem bronchus, making sure there's no filling defects or mass within the trachea or foreign body which would be aspirated. And then take a look at my lungs. I do an overall feel for what the lungs look like, like right and left. Then what I do is I compare each side in a zigzag sort of manner. And over here, and then what I do is the opposite zigzag on the way back, comparing right and left, right and left, right and left. Really paying attention to any opacity that will catch my eye. Once I do that, I window really hard below the diaphragm because as you notice, there's a lot of lung that's just below this diaphragm and you can see through the diaphragm to see it. Then what I do is I take a look to make sure I'm not missing any free air, especially on an upright radiograph. And then I look at my gastric bubble. So after I've cleared the frontal portion of the radiograph, I go to the lateral view if there is one. The lateral view is great for problem solving. If I see something on the frontal radiograph, I can always use the lateral view to kind of pinpoint where exactly it is. For instance, if I see something in this lung region and I look at lateral and it's down here, I would know it's in the left lower lobe. So how I approach the lateral view is I usually just take an overall outline of the lateral lung view. And I look at my costophrenic angles down here to make sure there's no layering fluid, which would mean there's a pleural fusion. I follow my right hemidiaphragm up, followed by my left hemidiaphragm. Take a look at the overall view of the cardiac silhouette. I should see a nice retrosternal clear space, which I do. I follow my lateral view of the trachea down and esophagus if you can see it. And I take a look at my highler region as well. Next, what I do is I window really hard to take a look at the osteostructures, making sure I'm not missing any obvious compression fracture or rib fracture. I usually zoom in a little bit because you can see how you would be able to catch a nice posterior rib fracture back here or even a compression fracture as well. While I'm over here, I usually take a look at my sternum. You can sometimes catch a nice displaced sternum fracture over here as well. Then I go underneath the diaphragm, making sure there's no obvious free air, which I may have missed on frontal radiodrop. And I take a look at the bowel. And that is pretty much it. So that, ladies and gentlemen, is how I read a chest x-ray. I hope you enjoyed it, and I hope you learned something. If you liked the video, as always, make sure you like and subscribe. And I will see you on the next video.