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

2. 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.

3. 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

4. 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.

5. 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

6. 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/ M 28
Ward F1
11/02/2007

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

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

9. 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.

10. 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 )

11. 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)

12. Review Areas 4 1 3 5 2

13. 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

14. Heart & Major Vessels

15. Lungs
Assess:
Size
Intrapulmonary pathology
Vascular lung markings

16. A closer view of the previous slide.

17. Intrapulmonary lesion

18. Interstitial Lung Disease

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

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

21. Pneumothorax

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

23. Widening Mediastinum

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

25. Mastectomy

26. Erect CXR – Number 1 for Pneumoperitoneum

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

28. Pneumonia

29. Cardiac Failure

30. Pleural Effusion

31. Bronchial Carcinoma

32. Pneumothorax

33. Sarcoidosis

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