Ian Bickle 24th March 2007, Data Interpretation Day, Belfast Radiology of Finals Ian Bickle 24th March 2007, Data Interpretation Day, Belfast

Skills Stations for Medical Finals Skills stations will appear in medical finals. Skills outlined by the GMC (“Tomorrow's doctors - Clinical and practical skills”) as essential for graduates (FY 1 doctors) include: (a) Take and record a patient's history, including their family history. (b) Perform a full physical examination, and a mental-state examination. (c) Interpret the findings from the history, the physical examination, and the mental-state examination. (d) Interpret the results of commonly used investigations. (e) Make clinical decisions based on the evidence they have gathered. (f) Assess a patient's problems and form plans to investigate and manage these, involving patients in the planning process. (g) Work out drug dosage and record the outcome accurately. (h) Write safe prescriptions for different types of drugs.

Skills Stations for Medical Finals (3) Our top tips for OSCE stations are: Venous Cannulation Male Urinary Catheterization NG tube insertion Arterial Blood gas Perform an ECG Present & Interpret a Chest Radiograph

Learn to Love X-Rays The single most requested imaging investigation The Chest X-ray (CXR) The single most requested imaging investigation The most likely film to feature in an exam The perfect prompt for questioning other aspects of a patient's condition and management.

Normal CXR Anatomy Remember that a CXR is a 2-D representation of 3-D structures. Think of a CXR as a picture containing 5 'shades’, each shade representing different 'tissues': The big two are: (1) Bone is White (2) Gas is Black The others are: (3) Soft tissue is Grey (4) Fat is Darker Grey (5) Anything Man-Made is Bright White

Film specifics & Technical factors Before interpreting a CXR, always comment on film specifics and technical factors. Film Specifics Name of Patient Age & Date of Birth Location of Patient Date Taken Film Number (if applicable) Raymond Chin 22/07/1978 M 28 Ward F1 11/02/2007

Technical Factors Type of projection Special techniques used (eg. taken in expiration RIP Rotation Inspiration Penetration

Can say FRONTAL CXR to cover all bases Projection Can say FRONTAL CXR to cover all bases

Assessing the Film Don’t rush into interpretation and come out with statements like: “There it is - a big lump” or “Oh I see the heart is big”. But this will almost certainly lead to important details being missed. A structure is needed for thorough interpretation. It is good practice to mention a clear-cut abnormality at the outset. A reasonable way to say this would be: “The technical quality of the film is satisfactory. The most striking abnormality on initial assessment is .....”. The examiner will then expect the candidate to demonstrate an organized approach to looking at the rest of the film. Do not stop when one abnormality has been noted - there may be more to see.

Assess the Film in Detail: As long as all aspects are covered one cannot be faulted over the order in which they are reviewed. It is fair to assume however if one major abnormality is clearly seen from the beginning that this structure or system be commented on first. Review of Structures to Assess on CXR: Heart and Major Vessels Lungs & Pleura Mediastinum (including hila) Bones and soft tissues )

Review Areas Be careful not to miss the following review areas. They should be specifically checked as abnormalities in these areas may be easily overlooked. Review Areas: Costophrenic angles Apices Behind the Heart Below the diaphragms Breast Shadows (in females)

Review Areas 4 1 3 5 2

Heart & Major Vessels Assess: Size of heart Size of individual chambers of heart Size of pulmonary vessels Evidence of stents, clips, wires and valves Outline of aorta and IVC and SVC

Heart & Major Vessels

Lungs Assess: Size Intrapulmonary pathology Vascular lung markings

A closer view of the previous slide.

Intrapulmonary lesion

Interstitial Lung Disease

Pleura: Assess: Thickness Opposition against chest wall (i.e. is there a pneumothorax?)

Closer view of the previous slide Pleural Effusion << Closer view of the previous slide

Pneumothorax

Mediastinum (including hila) Assess: Width of mediastinum Contour of mediastinum Size of hila Level of hila The trickiest part to asses on CXR

Widening Mediastinum

Bones and Soft Tissues Assess: Generalized bone disease, fractures and bony deposits Surgical emphysema Breast presence/absence and symmetry

Mastectomy

Erect CXR – Number 1 for Pneumoperitoneum

Top 6 CXR OCSES Lobar pneumonia Cardiac Failure Pleural Effusion Bronchial Carcinoma Pneumothorax Sarcoidosis

Pneumonia

Cardiac Failure

Pleural Effusion

Bronchial Carcinoma

Pneumothorax

Sarcoidosis

Putting it into Practice X-Ray Presentation Practice – this afternoon. Everyone gets a Go! Online OSCES