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General Medicine Quiz 1

admin — Sun, 13 Sep 2009 21:23:51 +0000

Question 1

This 65 year-old retired bus driver presented to hospital with shortness of breath and haemoptysis. He also complained of tender wrists bilaterally.

What do you think is the most likely cause for his painful wrists?

(a) Inflammatory arthritis

(b) Pathological wrist fractures

(d) Malignant infiltration of the brachial pleuxus

(e) Hypertrophic pulmonary osteoarthropathy (HPOA)

Answer+/-»

Question 2

Treeton Hospital’s medical SHO performed a pleural aspiration on the 50 year-old women whose chest x-ray is shown below.

PLEURAL ASPIRATION ANALYSIS

Total Protein = 2.35 G/L

Lactic Dehydrogenase (LDH) = 156 IU/L

pH = 7.36

Microbiology (Gram stain and culture) = Nil Growth

What is the most likely cause of the effusion from your interpretation?

(a) Bronchial carcinoma

(b) Hypothyroidism

(d) Rheumatoid disease

(e) Pulmonary embolus

Answer+/-»

Question 3

This 45 year-old women was admitted with abdominal pain and became short of breath. CT chest was performed.

What abnormality is seen on the CT scan?

(a) Bilateral pneumonia

(b) Bilateral pleural thickening

(d) Bilateral pleural effusions - THE CORRECT ANSWER

(e) Bilateral sub-phrenic abscesses

Answer+/-»

Question 4

Whilst acting as a medical volunteer for the St John’s Ambulance at a local fete a 21 year-old lady is brought to you with grossly swollen lips, face and wheeze following a bee sting. He is finding it difficult to breath and his BP is 83/45 from a manual reading,

What should be done next?

(a) Give 1:1000 IV adrenaline + IV hydrocortisone

(b) Observe and arrange transfer to casualty

(d) Give 1:1000 IM adrenaline + IV hydrocortisone

(e) Give 1:10,000 IV adrenaline + IV hydrocortisone

Answer+/-»

Question 5

A 26 year-old student takes a household substance in excess during a suicide attempt

ABG

pH = 7.27

pCO2 = 3.0

pO2 = 14.3

HCO3- = 16.2

BE = -7.4

U & E

Na+ = 143

K+ = 4.5

Cl- = 105

Urea = 12.4

Creatinine = 87

What is the patient’s anion gap?

(a) 26.3

(b) 21.3

(d) 47.7

(e) 2.13

Answer+/-»

Question 6

Mary is a 68 year old retired cleaner. She presents to her GP with pains in her ‘hand joints’. She is finding simple tasks like opening buttons increasingly difficult. Her pains tend to get worse as the day progresses. Her hands do get stiff particularly after use. She has never noticed her hands to be swollen but has noticed little ‘swellings on the ends of her fingers’. Clinically you do not detect any signs of synovitis.

What would be recommended first line pharmacological treatment for this patient?

(a) High dose NSAIDs

(b) Paracetamol

(d) Topical NSAIDs

(e) Sulfasalazine

Answer+/-»

Question 7

A 20 year old man with a history of type I diabetes is admitted with pyrexia, drowsiness, and fast deep breathing. You suspect diabetic ketoacidosis (DKA).

What is the initial treatment priority?

(a) IV drip of 5% dextrose solution

(b) IV drip of 0.9% Saline

(d) Insulin via infusion pump

(e) Potassium supplementation

Answer+/-»

Question 8

During a finals short case, you palpate a significantly enlarged liver and spleen.

What is the commonest cause of large hepatosplenomegaly in UK/Ireland?

(a) Zinc deficiency

(b) Haematological disease

(d) Infectious mononucleosis

(e) Malaria

Answer+/-»

Question 9

As on-call PRHO (foundation year 1) you are called to see a 52 year old post-op patient who is hypotensive (BP=80/60). You bleep your SHO who advises a fluid challenge.

Which of the following fluid regimes would be most appropriate?

(a) 1 litre 5% dextrose over 4 hours

(b) 500 ml Colloid (Gelofusion or Voluven) over 60 minutes

(d) 250ml Normal Saline over 2 minutes

(e) 1 unit of reheated fresh frozen plasma over 30 minutes

Answer+/-»

Question 10

You are called to see a patient in A+E, and are shown the following rhythm strip and ECG:

What does this show?

(a) Ventricular tachycardia (VT)

(b) Atrial Fibrillation (AF)

(d) Agonal rhythm

(e) Wolf-Parkinson-White (WPW)

Answer+/-»

(e) Hypertrophic pulmonary osteoarthropathy (HPOA) Chest X-ray Report:

This is a PA Chest X-ray of an adult male patient.

A large well circumscribed mass of soft tissue density is seen within the left lung. No central cavitation is seen.

No bony or pulmonary metastatic disease is noted.

HPOA is associated with malignancy and lung abscess. Associated malignancies include: bronchial carcinoma, metastatic disease and lymphoma.

(b) Hypothyroidism

Pleural effusions are divided into exudates and transudates. This is based on the total protein content of pleural fluid.

Exudate = greater than 30 g/l of protein

Transudate = less than 30 g/l of protein

Exudates tend to be unilateral and trasudates bilateral due to the nature of the causative factors.

The CXR shows bilateral pleural effusions – albeit larger on the left. The aspirate analysis also shows a transudate. The only option within the list which causes a transudate is hypothyroidism.

D. Bilateral pleural effusions

Acute pancreatitis is a common cause of abdominal pain and associated with the development of pleural effusions. Gallstones and alcohol are the most common causes of pancreatitis.

Pleural aspiration of an effusion can be undertaken and analyzed for amylase.

(d) Give 1:1000 IM adrenaline + IV hydrocortisone

Anaphylaxis requires immediate treatment. Those with known anaphylactic reactions (often to a specific substance such as peanuts) carry their own treatment in the form of a preloaded syringe of adrenaline. When the symptoms are mild and vital signs are within normal range the administration of IV hydrocortisone and chlorpheniramine is sufficient. Adrenaline being available should symptoms before more profound. If circulatory failure develops (SHOCK) adrenaline should be administered. This takes the form of 1:1000 adrenaline given via the intramuscular (IM) route. Note this is different to during cardiac arrest when it is 1:10,000 via an intravenous (IV) route. Hydrocortisone, even by intravenous route, takes several hours to have an effect. It is the inotropic action of adrenaline which gives an immediate response. It is also appropriate if anaphylactic shock occurs to give IV fluids to maintain the circulatory volume.

This deliberate overdose has caused a metabolic acidosis. One should always calculate the anion gap when a metabolic acidosis is observed. If the anion-gap is increased it is due to the presence of an exogenous acid or acid present in unmeasured small quantities during health. This is calculated by subtracting the main anions (negative charge) in the plasma, bicarbonate and chloride, from the main cations (positive charge), sodium and potassium. The anion gap is usually composed of negatively charged proteins, organic acids and phosphate.

Calculation of Anion Gap = (Na+ + K+) – (HCO3- + Cl-) (normal range 6-12 mmol/l)

Anion gap = ( 143 + 4.5 ) – ( 16.2 + 105 ) = 26.3

Causes of Anion Gap Metabolic Acidosis

Drug Poisoning

Lactic Acidosis (eg, shock, severe hypoxia, acute liver failure)

Renal Failure

Ketoacidosis (eg, diabetes, starvation)

(b) Paracetamol

This patient has nodal osteoarthritis (OA). This is a condition of synovial joints characterized by focal areas of damage to the articular cartilage and remodelling of underlying bone. OA affects up to 20% of the population who are greater than 60yrs of age. The main symptoms of OA include pain and immobility. In the photos graphs you can see classical Heberden’s nodes in her DIP joints. Similar nodes at the PIP joints are termed Bouchard’s nodes. The CMC joint in the hand is also commonly involved in nodal OA. Interestingly this lady has OA of the hip – hence the walking stick.

In most cases paracetamol is an effective and relatively safe treatment for patients with mild-moderate OA pain. NSAIDs have been proven to be effective in reducing OA pain but they do carry risks such as gastric ulceration; adverse renal effects and precipitating relapse of heart failure. Up to 1.5% of NSAID users per year develop serious upper GI complications such as a major bleed or perforation. More patients die of NSAID related upper GI bleeds, ulceration and perforations per year in the UK than RTA related deaths. There is conflicting evidence that topical NSAIDS have long term benefit, if any in OA. DMARDS have no place in the treatment of OA.

(b) IV drip of 0.9% Saline

Patients with DKA, tend to be significantly dehydrated due to osmotic diuresis, and reduced fluid intake. In adults this is usually at least 3.5 to 7 litres.

A treatment plan for DKA would typically be:

Check blood gas, capillary glucose, U+E, blood glucose, FBP.
Give IV Normal 0.9% Saline – at rate of 15 to 30 mL/kg per hour for first two hours, then at reduced rate. Be careful in children, as rapid rehydration can increase the risk of cerebral oedema.
Give typically 10 units actrapid insulin subcutaneously (although the subcutaneously route may absorb poorly if patient shut-down), followed by infusion at a rate of 2 to 6 units per hour.
Monitor potassium and capillary blood glucose – depending on U+E, typically starting KCl+ at 20 mmol per hour at in second hour.
Change to IV dextrose when capillary blood glucose falls, and continue with insulin infusion. The aim is to correct acidosis by flushing out the ketones, not just to correct the blood sugars.

(b) Haematological disease

Hepatosplenomegaly is enlargement of both the spleen and liver. Causes include:

(i) Haematological disease – Myeloproliferative disease, Leukaemia, Lymphoma, Pernicious anaemia, Sickle cell anaemia, Thalassaemia.

(ii) Acute Infection – Acute viral hepatitis, Infectious mononucleosis, Cytomegalovirus.

(iii) Chronic liver disease (including Chronic alcohol abuse, Chronic active hepatitis, NASH, Amyloidosis, Acromegaly, Systemic lupus erythematosus), with portal hypertension. In the early stages, cirrhosis can cause liver to enlarge, and indeed alcoholic hepatitis can produce tender hepatomegaly, but later as more scar tissue replaces normal tissue, the liver shrinks.

(d) 250ml Normal Saline over 2 minutes

Often colloid (eg. Gelofusion or Voluven) is recommended as it stays in blood vessels longer – but crystalloid (eg. Normal Saline) can be used.

The important thing is to give a small volume rapidly – this will not run through a drip counter (as drip-counter max rate is typical 999ml/hour) – whereas 250ml Normal Saline over 2 minutes = 7500ml/hour (although some suggest using a longer time of 10 minutes). A wide bore (16 or 14 gauge venflon) is needed. Measure the blood pressure before, during and 5 minues after this bolus.

If the pulse falls and BP rises this indicates the patient is hypovolaemic (absolute or relative) eg. from blood loss or sepsis, so more fluid should be given. It is also useful to note the duration of any BP rise.

(For more info see: Surgical Tutor – Fluid balance and: Student BMJ – Fluid challenge)

Causes of hypotension: (use mnemonic CPR):

C = Capacitance – eg. volume loss from dehydration, diarrohoea, internal/external bleeding, burns.

P = Pump failure – eg. MI, valve prolapse, tamponade, beta-blocker overdose.

R = Resistance – eg. increased in PE, decreased in sepsis/SIRS as vasodilation.

(e) Wolf-Parkinson-White (WPW)

The ECG has P-waves so is not Atrial Fibrillation (AF).

Is not First degree heart block as that would have long PR interval.

QRS’s are narrow so is not VF nor VT.

Is not an Agonal rhythm which would be extreme ventricular bradiacardia, with wide flattened QRS.

It is Wolf-Parkinson-White (WPW), as has shortened PR interval (less than 3 squares < 120ms) and delta waves (slurred upstroke to the QRS indicating pre-excitation), as shown in diagram below. This delta wave is the classical feature. The QRS may be broad, and there can be secondary secondary ST and T wave changes. WPW is due to an accessory pathway between atria and ventricles. Patients present with SVT which may be due to AV re-entry tachycardia, pre-excited AF, or pre-excited atrial flutter. In symptomatic patients, the ideal treatment is to use radio frequency catheter ablation to destroy the accessory pathway.

WPW showing shortened PR and delta wave.

A good illustration of normal, and Wolff-Parkinson-White Syndrome accessory path-way.

(For more info see ECG links on Links page on www.medicalfinals.co.uk.)

(ECG taken from: here.)

Skeletal & Vascular Films

admin — Thu, 10 Sep 2009 22:27:32 +0000

Important X-ray images to review, along with self-test questions and answers.

Rheumatoid Disease (figure 8):	What are the pulmonary and eye conditions associated with this condition? Remember the 4S’s (scleritis (and episcleritis), sicca syndrome, Sjogren’s & scleromalacia). Pulmonary fibrosis (fibrosing alveolitis), pulmonary nodules and pleural effusions are the more common (although not absolutely common in themselves). Bronchiolitis obilterans and the now very rare Caplan’s syndrome are also known associations.
Ankylosing Spondylitis (figure 9):	What other conditions is sacroileitis a feature of? Sacroileitis is a feature of all seronegative spondyarthritides; psoriasis, inflammatory bowel disease, Reiter’s syndrome.
Peripheral Vascular Disease (figures 19,20):	What are the management options for patients with PVD? Conservative (modify cardiovascular risk factors, exercise to develop collaterals) Angioplasty with/out stenting (the figures show before and after angioplasty) Bypass surgery
Severe Osteoarthritis (figure 23):	Features: Loss of joint space Subchondral bone cysts Subchondral sclerosis Osteophyte formation

BY: Ian C. Bickle.

CT Imagesradiology

admin — Thu, 10 Sep 2009 22:23:09 +0000

Important CT images to review, along with self-test questions and answers.

Pulmonary Embolus (figure 4):

Explain the CT findings.

This is a CT pulmonary angiogram, which uses contrast to visualize the veins during venous phase. Contrast within the veins is seen as areas of high attenuation. Thrombus within the vessel is seen as a ‘filling defect‘ (a low attenuation area as there is no contrast there). If seen in an axial plane through the vessel it has the appearance of a polo mint.

Colonic Polyp (figure 12):

Why is it important to remove bowel polyps?

Polyps have the potential to develop into colorectal carcinoma, especially in those suffering from FAP.

Bronchial Carcinoma (figure 14, 15):

What are the subtypes of bronchial carcinoma?

Squamous cell carcinoma,
adenocarcinoma,
large cell
small cell (oat cell)

The subtype dictates subsequent management.Those suspected of having a bronchial carcinoma require CT chest and abdomen (for staging) and if appropriate bronchoscopy with biopsy specimens or washings.

Abdominal Aortic Aneurysm (figure 17):

What size of aneurysm would be considered for repair?

Those aneurysms reaching 5.5cm are candidates for elective surgery. Most procedures are still by open repair, with trials ongoing of endovascular stenting – especially in those with poor co-morbid health.

Malignant Mesothelioma (figure 18):

What chest disease can occur following exposure to asbestos?

Malignant mesothelioma
Pleural plaques
Asbestosis
Bronchial carcinoma

BY: Ian C. Bickle.

Abdomen & Contrast Images

admin — Thu, 10 Sep 2009 22:22:24 +0000

Important X-ray images to review, along with self-test questions and answers.

Oesophageal Carcinoma (figure 1):	Explain the reason for the huge increase in oesophageal adenocarcinoma? Oseophageal adenocarcinoma is the most rapidly increasing malignancy in the western world. It is believed to be due to the high prevalence of gastro-oesophageal reflux disease (GORD) reflective of the western lifestyle. This in itself can cause Barett’s oesophagitis which is a precursor to adenocarcinoma in a proportion of individuals. The metaplastic epithelium of the lower oesophagus secondary to reflux can progress from dysplasia through to adenocarcinoma, hence a biannual OGD for screening purposes.
Ulcerative colitis (figure 2):	Explain the purpose and findings of this scan. This is a radio-labeled white cell (SEROTEC) scan. This is a nuclear imaging procedure whereby 100mls of venous blood are labeled with a radio-isotope (technetium 99m) and re-injected and then followed by gamma camera. The white cells are attracted to areas of inflammation. It helps to explore the extent and distribution of inflammation in inflammatory bowel disease. In this case there is increased uptake in the proximal ascending colon and rectum.
Colorectal Carcinoma (figures 3,10,11,13):	Describe the features of these images and how these tumours are classified? These three double contrast barium enemas illustrate fine examples of apple core strictures from annular colorectal carcinomas. The position of the tumour within the large bowel dictates the operative procedure and the histological diagnosis will influence whether adjunctive chemo/radiotherapy is used. Duke’s classification is widely used – the original described A,B, and C with the latter addition of D. A: confined to mucosa B: Extended through all muscle layers to serosa C: as for B and lymph node metastases D: distant metastases.
Gallstones (figure 6):	What percentage of gallstones are seen on AXR? Are gallstones significant in themselves?10-15% of gallstones are seen on plain AXR and their presence in themselves do not indicate they are causing an acute illness. Gallstones often remain in the gallbladder for years without any trouble.
Oesophageal Obstruction (figure 16):	This shows complete oesophageal obstruction
Small Bowel Obstruction (figures 21 & 22):	What are the characteristic features of small bowel obstruction on AXR? Dilated small bowel loops (greater than 3cm diameter) Central location of the small bowel Valvulae connivennte visible across bowel Multiple bowel loops (few in large bowel obstruction)

BY: Ian C. Bickle.

Foundation Programme Expected Competencies

admin — Fri, 06 Mar 2009 13:05:13 +0000

What follows is an excerpt from the guidance on clinical examination facing those foundation doctors applying from outside the UK Medical School Programme, it is dictated by the GMC and is likely to reflect subjects & procedures expected in UK medical Finals.

Focussed history-taking, including history-taking in difficult circumstances
History-taking is a core skill for F1 doctors. You will be expected to take a short history, focussing on the relevant problem, and you will be expected to establish the most likely diagnosis. Towards the end, you may be asked to tell the examiner your provisional diagnosis and explain your reasons. The examiner will be assessing how well you communicate with the patient as well as your problem-solving abilities. The difficult circumstances may include, for example, a patient with a hearing impairment, a patient who has speech or language problems, or a patient who has mental health problems.

Examination of patients with stable chronic disease
As an F1 doctor you must be confident and competent in examining the major body systems and recognising abnormalities. You will be expected to examine a real patient who has abnormal physical signs. You will be asked to examine the relevant system thoroughly, then to present your findings to the examiner. As well as your examination skills, your professional behaviour will also be assessed. We may ask you to examine the heart, chest, abdomen, skin, neck (including the ear, nose and throat), joints and all aspects of the nervous system.

Safe prescribing
As an F1 doctor, it is very important that you can prescribe safely and recognise where prescriptions issued by others could cause harm to the patient. We may ask you to take a medication history from a simulated patient. We may ask you to complete a prescription chart or review one completed by another doctor. Prescribing also includes fluid management. A copy of the British National Formulary (BNF) will be available for reference within the station if required.

Recognition and management of acute illness
As an F1 doctor, it is important to be able to recognise acute and serious illness and take urgent appropriate action. In these stations, you will either take a history from or examine a simulated patient who is simulating a medical, surgical or psychiatric emergency. If appropriate, the examiner will give you any abnormal findings. You will be expected to explain your management to the patient and/or examiner as appropriate. You will be assessed both on your problem-solving and communication skills.

Surgical and peri-operative care
As an F1 doctor, you will spend a significant proportion of time preparing patients for operations and caring for them afterwards. Patients may wish to ask questions about their operation, the anaesthetic, pain management and post-operative recovery. These stations will assess both your communication and management skills.

Discharge Planning
As an F1 doctor, you will have an important role in helping to ensure that patients can be safely discharged back into the community. Patients may have questions about their ongoing treatment or they may have social issues which need to be addressed. These stations will assess both your communication and management skills.

Teamwork
You will have to communicate with other members of the hospital team, in order to arrange further investigations or hand over care. This can include use of the telephone. These stations will assess your ability to communicate appropriately with other team members, but will also consider the accuracy of the information you give.

Challenging communication

As an F1 doctor, you may have to break bad news to a patient, handle complaints from patients or relatives or negotiate patient management decisions. These stations will assess your ability to communicate sensitively with the patients, but will also consider the accuracy of the information you give.

Ethical and Legal Issues
As an F1 doctor you will face ethical dilemmas and challenges on a regular basis. You must practise medicine in accordance with appropriate ethical frameworks and the British legal system. In these stations you will be required to communicate sensitively with a simulated patient in order to appropriately manage an ethical challenge. More information is vailable from the General Medical Council’s Good Medical Practice (www.gmc-uk.org).

Health promotion and patient education
As an F1 doctor, you will need to offer lifestyle advice and address risk factors for disease. Examples include smoking, excessive alcohol consumption, obesity etc. You must be familiar with how people in the UK may behave. You should not discriminate against patients because of their beliefs. More information is available from the General Medical Council’s Good Medical Practice (www.gmc-uk.org).

Practical procedures
You will be expected to perform practical procedures, usually on an anatomical model connected to a simulated patient. These stations will assess both your practical skills and your professional behaviour towards the patient. Practical procedures may include:
- performing venepuncture and interpreting the results of blood tests
- performing arterial puncture and interpreting the results
- giving intravenous, intramuscular and subcutaneous injections
- inserting a cannula into a peripheral vein
- setting up an intravenous infusion
- performing an electrocardiogram (ECG) and interpreting the results
- basic cardio-pulmonary resuscitation
- demonstrating the safe use of a defibrillator
- performing basic respiratory function tests
- administering a nebuliser
- administering oxygen therapy
- performing suturing
- performing urinary catheterisation
- performing a bimanual vaginal examination
- taking endocervical and high vaginal swabs
- performing a rectal examination
- examination of the breasts
- examination of the testes

Please note that some stations will assess more than one area.

The topics covered will be taken from the major body systems:
- Cardiovascular
- Respiratory
- Gastrointestinal
- Renal/urological
- Neurological
- Musculoskeletal
- Psychiatric
- Obstetrics/gynaecological
- Haematological
- Metabolic/endocrine
- Dermatological

Essential Reading For the Application Form

admin — Fri, 06 Mar 2009 12:52:29 +0000

The following documents will give you key information on what the scoring panel will mostly be looking for in their prospective foundation doctors. It will help you identify key points leading to a great answer.

Foundation Programme Key Documents & Personal Specificaltion

This brief document outlines the essential attributes required of an applicant to the foundation programme. Each year the questions on the application form have asked you to provide examples of where you have previously demonstrated these attributes. Some heavy clues to this year’s questions then!

Medical Students: Professional Behaviour and Fitness to Practise

This document, produced by the GMC, sets out the standards of professional behaviour expected of UK medical students. As a final year student you should be able to demonstrate competence in all of these areas. Again, there are some good clues in here as to the types of examples that will get you the most points on your application form – can you demonstrate from your experiences that you will be a professional Foundation Doctor?

Good Medical Practice (2006)

This is ESSENTIAL reading for all applicants. It sets out the principles and values upon which your profession is based. A strong applicant should be demonstrating these principles and values in all aspects of their work.

A fundamental guide to what is meant by ‘professionalism’ and ‘integrity’ as well as guidance on how a good doctor should interact in a team situation and communicate with patients.

Whatever you views on the use of application forms to recruit for foundation training you stand the best chance of success if you research the background.

Basic Radiology Overview

admin — Thu, 05 Mar 2009 14:01:48 +0000

A written overview of approaches to Abdominal & Chest X-rays, along with key tips. Presented by Ian Bickle

Chest X-ray:

Normal Anatomy
Types of Projection
Assessing the Film
Technical Qualities
Heart and Vessels
Lungs
Mediastinum
Bones
Soft Tissues
Presenting the Film (’30 second presentation’)

Abdominal X-ray:

Normal Anatomy
Assessing the Film
Technical Qualities
Gas containing structures
Solid Organs
Bones
Soft Tissues
Presenting the Film (’30 second presentation’)

KEY TIPS:

Always view with clinical information in mind.
Be systematic in approach.
Think of the anatomical structures on the image.
Compare with other x-rays if available.
Don’t stop looking if an abnormality is seen – there may be more!

Chest X-ray

Normal Anatomy

The chest x-ray (CXR) is the single most requested imaging investigation and is also the most likely film to feature in an exam. It is the perfect prompt for questioning other aspects of a patient’s condition and management.

To be able to comment confidently on the film’s findings, an appreciation of normality is required. Don’t forget a CXR is a two-dimensional representation of three-dimensional structures.

One may think of a CXR as a picture which contains 5 ‘shades’. These shades represent 5 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 (eg. a pace-maker), is BRIGHT WHITE

Film Specifics and Technical Factors

Before proceeding to interpret a CXR, always comment on film specifics and technical factors as shown in the tables below.

Film Specifics (details)
Name of Patient
Age & Date of Birth
Location of Patient
Date Taken
Film Number (if applicable)

Film Technical Factors
Type of projection (see box below)
Markings regarding any special techniques used (eg. taken in expiration)
Rotation
Inspiration
Penetration

Types of Projection

Postero-anterior (PA):	x-ray tube behind the patient and film against chest.
Antero-posterior (AP):	x-ray tube in front of patient and film against back.
Lateral:	x-rays ‘fired’ through the patient from the side.
Supine:	The patient is lying on his/her back.
Erect:	The patient is upright.
Semi Erect:	The patient is upright but poorly positioned (usually an ill patient).
Mobile:	The x-ray has been taken on a mobile unit (on the ward usually). The patient is likely to be ill.

These descriptions can be combined. For example an acutely unwell patient who has a CXR taken on a ward may have a MOBILE, SEMI-ERECT AP film.

You might think of this part of the interpretation like the safety announcement on an airplane one has heard many times: necessary to acknowledge, but boring and nothing will make any difference anyway. However, this could not be further from the truth. Changes in these parameters can give the impression of abnormalities in the structures seen and lead to a whole path of misguidance. Take some time to give it attention.

Assess the Film in Detail

Many students rush into interpretation and come out with statements like: ‘There it is – a big lump’ or ‘Oh I see the heart is big’. This approach 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.

The structures below need to be considered in the interpretation of the film. 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

Be particularly 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)

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

Lungs:

Assess:

Size
Intrapulmonary pathology
Vascular lung markings

Pleura:

Assess:

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

Mediastinum (including hila):

Assess:

Width of mediastinum
Contour of mediastinum
Size of hila
Level of hila

Bones and Soft Tissues:

Assess:

Generalized bone disease, fractures and bony deposits
Surgical emphysema
Breast presence/absence and symmetry

Abdominal x-ray

Normal Anatomy

The abdominal x-ray (AXR) has a much more limited value in diagnosis than a chest x-ray.

The radiation exposure of an AXR compared to a CXR is also considerably higher. One AXR is equivalent to 35 CXRs.

The AXR is of most use in the patient with an acute abdomen. As with a CXR, an appreciation of normal structures is vital.

Film Specifics and Technical Factors

The initial assessment of an AXR is the same as for a CXR.

Film Specifics:
Name of Patient
Age & Date of Birth
Location of Patient
Date Taken
Film Number (if applicable)

Film Technical factors:
Type of projection (Supine is standard)
Markings of any special techniques used

Assess the Film in Detail

A simple guide to interpretation is shown below. Working through these headings one covers, ‘dark bits’, ‘white bits’, ‘grey bits’ and ‘bright white bits’ in turn.

‘BLACK BITS’

Intra-luminal Gas:

Intra-luminal gas can be normal. Extra-luminal gas is abnormal. However, intra-luminal gas can be abnormal if it is in the wrong place or if too much is seen.

The maximum normal diameter of the large bowel is 55mm. Small bowel should be no more than 35mm in diameter. The natural presence of gas within the bowel allows assessment of caliber – although the amount varies between individuals. The caecum is not said to be dilated unless wider than 80mm.

Large and small bowel may be distinguished by looking at bowel wall markings, as shown in the box below.

The haustra of the large bowel extend only a third of the way across the bowel from each side, whereas the valvulae conniventes of the small bowel tranverse the complete distance.

It is usual to see small volumes of gas throughout the GI tract and the absence in one region may in itself represent pathology. For example, if gas is seen to the level of the splenic flexure and nothing is seen beyond this, a site of the obstruction at this site – a ‘cut off’ point is noted.

Extra-luminal Gas: When an bowel is obstructed, or any other gas containing structure perforates, its contained gas becomes extra-luminal. Extra-luminal gas is never normal, but may be seen following intra-abdominal surgery or endoscopic retrograde cholangio-pancreatography (ERCP).

Causes of Extra-luminal gas:
Post Abdominal Surgery/ERCP
Perforation of viscus (eg. bowel, stomach)
Gallstone ileus
Cholangitis (infection with gas forming organisms)
Abscess

An erect CXR (not AXR) is the best projection to diagnose a pneumoperitoneum (gas in the peritoneal cavity)

‘WHITE BITS’

Calcification

Calcified structures (‘WHITE BITS’) are often seen on AXR. The main question is – does its presence have any important implications. Calcification can be broadly divided into 3 types.

1. Calcium that is an abnormal structure
eg. gallstones and renal calculi

2. Calcium that is within a normal structure, but represents pathology
eg. nephrocalcinosis, splenic artery aneurysm

3. Calcium that is within a normal structure, but is harmless
eg. lymph node calcification

Bones are normal ‘white’ structures. On the AXR they comprise mainly those of the thoraco-lumbar spine and pelvis. Findings are largely incidental as direct bone pathology would be investigated with specific views.

‘GREY BITS’

Soft Tissues

Soft tissues represent most of the contents of the abdomen and feature heavily in the AXR. However, these tissues are poorly seen when compared to other imaging techniques such as ultrasound or CT.

The kidneys, spleen, liver and bladder (if filled) can be seen in addition to psoas muscle shadows and abdominal fat. Rarely would action be taken on the basis of this imaging alone.

‘BRIGHT WHITE BITS’

Foreign Bodies

Foreign Bodies represent an interesting final observation. Objects that may be seen include ingested and rectal foreign bodies, items in the path of the x-ray beam such as belt buckles, dress buttons and jewelry. Other objects may have been deliberately placed for example an aortic stent, an inferior vena cava filter or a suprapubic urinary catheter. Sterilization clips and an intra-uterine device are common findings in women.

Abdomen & Contrast films

admin — Thu, 05 Mar 2009 13:28:56 +0000

These are good X-ray images to review, along with self-test questions and answers. Further images will be added over time.

Oesophageal Carcinoma (figure 1):

Explain the reason for the huge increase in oesophageal adenocarcinoma?

Oseophageal adenocarcinoma is the most rapidly increasing malignancy in the western world. It is believed to be due to the high prevalence of gastro-oesophageal reflux disease (GORD) reflective of the western lifestyle. This in itself can cause Barett’s oesophagitis which is a precursor to adenocarcinoma in a proportion of individuals. The metaplastic epithelium of the lower oesophagus secondary to reflux can progress from dysplasia through to adenocarcinoma, hence a biannual OGD for screening purposes.

Ulcerative colitis (figure 2):

Explain the purpose and findings of this scan.

This is a radio-labeled white cell (SEROTEC) scan. This is a nuclear imaging procedure whereby 100mls of venous blood are labeled with a radio-isotope (technetium 99m) and re-injected and then followed by gamma camera. The white cells are attracted to areas of inflammation. It helps to explore the extent and distribution of inflammation in inflammatory bowel disease. In this case there is increased uptake in the proximal ascending colon and rectum.

Colorectal Carcinoma (figures 3,10,11,13):

Describe the features of these images and how these tumours are classified?

These three double contrast barium enemas illustrate fine examples of apple core strictures from annular colorectal carcinomas. The position of the tumour within the large bowel dictates the operative procedure and the histological diagnosis will influence whether adjunctive chemo/radiotherapy is used.

Duke’s classification is widely used – the original described A,B, and C with the latter addition of D.

A: confined to mucosa
B: Extended through all muscle layers to serosa
C: as for B and lymph node metastases
D: distant metastases.

Gallstones (figure 6):

What percentage of gallstones are seen on AXR? Are gallstones significant in themselves?

10-15% of gallstones are seen on plain AXR and their presence in themselves do not indicate they are causing an acute illness. Gallstones often remain in the gallbladder for years without any trouble.

Oesophageal Obstruction (figure 16):

This shows complete oesophageal obstruction

Small Bowel Obstruction (figures 21 & 22):

What are the characteristic features of small bowel obstruction on AXR?

Dilated small bowel loops (greater than 3cm diameter)
Central location of the small bowel
Valvulae connivennte visible across bowel
Multiple bowel loops (few in large bowel obstruction)

Skeletal & Vascular films

admin — Thu, 05 Mar 2009 13:26:42 +0000

These are good X-ray images to review, along with self-test questions and answers

Rheumatoid Disease (figure 8):

What are the pulmonary and eye conditions associated with this condition?

Remember the 4S’s (scleritis (and episcleritis), sicca syndrome, Sjogren’s & scleromalacia).
Pulmonary fibrosis (fibrosing alveolitis), pulmonary nodules and pleural effusions are the more common (although not absolutely common in themselves). Bronchiolitis obilterans and the now very rare Caplan’s syndrome are also known associations.

Ankylosing Spondylitis (figure 9):

What other conditions is sacroileitis a feature of?

Sacroileitis is a feature of all seronegative spondyarthritides; psoriasis, inflammatory bowel disease, Reiter’s syndrome.

Peripheral Vascular Disease (figures 19,20):

What are the management options for patients with PVD?

Conservative (modify cardiovascular risk factors, exercise to develop collaterals)
Angioplasty with/out stenting (the figures show before and after angioplasty)
Bypass surgery

Severe Osteoarthritis (figure 23):

Features:

Loss of joint space
Subchondral bone cysts
Subchondral sclerosis
Osteophyte formation

Radiology for Finals

admin — Thu, 05 Mar 2009 13:23:19 +0000

It is likely that many of you will get asked about images in long/short cases in finals.
You may be asked to quickly comment on any abnormality or to present a radiograph in full.
It is all about systematic approach in order to check that we are safe on the wards as JHO’s.
Don’t panic if the diagnosis is not obvious. Being able to spot abnormalities and comment that you need to ask for help from a radiologist is the important part.
If you know a little bit extra it is a good way to impress the examiners.
Remember physicians/surgeons are not radiologists, so are going to ask about the big classical signs.
Plain films are likely to figure most highly, although particularly significant other images may occur.
If the patient has a series of films get the right one and the right patient.
They’re unlikely to give anything that is not a big complaint/classic radiological sign. It may be NORMAL.
Imaging is likely to feature highly in most patient management. Therefore think of it when asked: “how would you manage/investigate this patient?

Below are Common films and Assessment/review of AXR and CXR’s. Film links in brackets are to the radiology images on this MedicalFinals website. I will also try to link the images to the appropriate Surgical cases and Medical cases contained within the PasTest Surgical and Medical Finals books.

Common Films:

Below are a Range of Films You May Come Across (‘*‘ means greatest chance of being asked to comment on or know):

Respiratory

*Bronchial CA (+ Pancoast’s) (CXR-fig6, CT-fig14,15)
Pulmonary metastases
*Pneumonia (several: lobar, bronchopneumonia and PCP) !! (CXR-fig3)
Bronchiectasis/Cystic fibrosis (CXR-fig4)
COPD (emphysema & chronic bronchitis spectrum)
*Pleural effusion (uni/bilateral). (CXR-fig7)
*Pneumothorax (standard and tension). Lung edge and black lateral to edge (no lung vessel markings). Mediastinal shift in tension seen as tracheal deviation. Seen best with expiratory erect CXR). (CXR-fig9)
Lobar collapse
Allergic Alveolitis (fibrosing lung)
Pneumoconiosis (asbestosis and coal miner’s)
Malignant mesothelioma and pleural plaques (CT-fig18)
*Sarcoidosis
Pulmonary embolus (Invasive pulmonary angiography remains the gold standard. Computed Tomography Pulmonary Angiography (CTPA) is now performed in most centres. Ventilation-perfusion radio-nucleotide imaging scan plays a limited role in contemporary practise.) (CT-fig4)
!!Silhouette Sign: loss of silhouette formed by lung adjacent to denser structures such as the heart.

Cardiovascular

*Heart Failure
Pulmonary hypertension
HOCM
ASD
Coarctation of aorta (notching of the ribs due to development of collateral circulation. Seen in older patients)
Pericardial effusion (globular appearance)
Ventricular aneurysm (CXR-fig8)
Valvular disease

Gastrointestinal

Hiatus hernia (retrocardiac air-fluid level. Paraoesophageal(rolling) hernia)
*Pneumoperitoneum (CXR-fig10) (can be small and subtle and takes on a crescenteric appearance. Remember Chaliditi’s sign)
*Small (XR-fig21,22), and large bowel obstruction (see distinguishing box below)

Feature	Small Bowel Obstruction	Large Bowel Obstruction
Bowel Diameter:	>3cm <5cm	>5cm
Position of Loops:	Central	Periphery
Number of Loops:	Many*	Few
Fluid Levels (on erect film):	Many, short	Few, Long
Bowel Markings:	Valvaulae (all the way across)	Haustra (partially across)
Large Bowel Gas:	No	Yes

Paralytic ileus & pseudo-obstruction (no cut off point)
Sigmoid & Caecal Volvulus (coffee bean and empty caecum signs respectively. Sigmoid gives bird of prey sign on barium)
Subphrenic abcess (usually under the right hemidiaphragm. Air/fluid level may be apparent)
Oesophageal candidiasis
Oesophageal web
Oesophageal varices
*Oesophageal carcinoma (raggy stricture, shouldering of stricture) (XR-fig1, XR-fig16)
Oesophageal benign (corrosive) stricture (smooth stricture)
Achalasia (CXR: widened mediastium, barium swallow: widened oesophagus)
Pharngeal Pouch
Gastric CA
*Crohn’s & ulcerative colitis (XR-fig2)
*Diverticular disease (outpouching of bowel that are lined with barium, v obvious. Think is there other pathology present)
*Colorectal cancer (the apple core lesion of an annular CA. Left side > right side of bowel) (XR-fig3,10,11,13)
Colonic polyps (don’t confuse with a residual faecolith in the bowel from poor preparation) (CT-fig12)

Hepatobiliary

*Gallstone disease (USS first line. Stone apparent and gives off an acoustic shadow. ERCP, PTC and MRC also used)
Hepatic metastases (seen well on USS and CT)
*Pancreatitis (acute & chronic), (sentinel loop. Speckled calcification due to deposition in intra-pancreatic ducts. Contrast enhanced Ct scan needed to see necrosis).

Urogenital Tract

Hydronephrosis
Renal calculi (80% seen on AXR. Contrast this with 10-20% gallstones (XR-fig6). Beware of phlebolith)
Bladder CA

Musculoskeletal

*Osteoarthritis (Hip, Knee). Unilateral & bilateral. Before & After surgery. (Big 4 signs on XR) (XR-fig23)
Osteoporosis (osteopenia, with vertebral crush #’s). (Crush # seen best on lateral spine. Increased thoracic kyphosis)
*Ankylosing Spondylitis (sacroiliac joint fusion 1st. Bamboo spine. Syndesmophyte formations and calcification of longitudinal ligaments, squaring of the vertebrae) (XR-fig9)
Paget’s disease (Often incidental finding on pelvis/AXR – that would impress! Classically tibia bowing and skull bossing too, Seen as increases bone deposition with coarsening of trabecular pattern that appears fuzzy).
*Bone metastases (lytic, sclerotic, expansile). (sclerotic – lighter than bone. Lytic – darker than bone (radiolucent).
Rheumatoid arthritis (hands chiefly) (XR-fig8)
Multiple Myeloma (pepperpot skull, pathological #’s)
*Femoral neck # (intracapsular v extracapsular. Gardner’s classification of 5 types of femoral neck #)
Dynamic hip screw, hemi-arthroplasty and total arthroplasty of hip

Breast

*Breast CA (big 3; micro-calcification, spiculation and distortion of normal breast contour)
Breast cyst
Fibroadenoma
*Breast shadows, mastectomy & prostheses (uni/bilateral)
Nipple markers

!! Imaging is only one part of the essential triple assessment of a women with a breast lump (USS/mammography, FNCA/biopsy, clinical examination).

Neurology

Brain neoplasm (macro and micro)
Cerebral abcess
Cerebral atrophy
Cerebral infarct
Multiple sclerosis (demyelinating)

Assessment/Review of Films:

Assessment of an AXR

Technical: Date, Age, Name and Sex of Patient
Type of AXR (supine, erect, decubitus)
Intraluminal Gas: Size (<3cm small bowel, <5cm large bowel)
Distribution of bowel loops (periphery – large bowel, central – small bowel)
Bowel Markings (large – haustra, small – valvulae connivente)
Ground glass/mottling – faecal shadowing.
Extraluminal Gas: under the diaphragm (see: CXR-fig10)
Biliary tree
Bowel wall
Calcification: any structures contain it?
Soft Tissues & Bones: Psoas shadows
Kidneys (T12-L2)
Spleen and Liver
Fractures
Paget’s
Metastatses (sclerotic or lytic)
Arthritis
Iatrogenic/Accidental & Incidental
Any man-made structures indicative of previous operations or other (stents, clips, IUCD, IVC filter).

Review Points

Technical Specifics of the Radiograph
Amount and distribution of gas
Extra-luminal gas (evidence of)
Evidence of calcification
Soft tissue outlines and Bony structures
Iatrogenic, accidental and incidental objects Radiology for Finals

Assessment of CXR

Patient Details: Name, Age, Sex
Film Details: Date Taken, Projection (PA, AP, L/R Lateral), single film or one of a series.
Technical Details: RIP, Rotation, Inspiration, Penetration.
Heart: Size, Border (start at aortic knuckle and work round to SVC) (see: eg. double heart border on CXR-fig1)
Trachea (pull just off box to see best)
Lungs: Hilia (size, level); Fields (including apices and behind the heart). Only vessels, (end on respiratory tree and horizontal fissure to see)
Diaphragm + costophrenic & costocardiac angles
Mediastinum (size and shape)
Bones (humerus, clavicle, scapula, ribs)

General points:

A central tenant of imaging is that two views 90 degrees to one another are taken in order to localise structures/lesions (orthogonal views). For example, the PA and lateral chest films with a lung mass.
One is able to distinguish a left and right lateral chest radiograph on observation. On the right lateral film the diaphragm can be seen to course from back to front without disruption. However, the left lateral film is disrupted by the intervening cardiac tissue, so not giving a continuous shadow.

Surgical Cases:

The information below is to correspond with the major cases identified in the PasTest – Passing Surgical Finals book.

Goitre

USS may show diffuse enlargement of the thyroid gland (see: CXR-fig2) and pressure on adjacent structures such as the trachea. Good at distinguishing solid from cystic structures.
Radio-isotope scan identifies ‘hot’ and ‘cold’ spots representing nodules that either secrete (hot) or do not (cold).
CT can help further delineate nodules and impingement, however the only way to definitely tell if the thyroid is malignant or not, is by an FNAC.

Parotid Gland Swelling

Seen very well on axial CT and MRI.

Cervical Rib

CXR (unlikely to get this)

Breast Carcinoma

Standard CXR: loss of breast shadow (mastectomy or rarely absent breast). Also identify prosthesis as round, well delineated soft tissue shadow. Nipples can appear as small round densities which must be distinguished from other lung mass (esp, bronchial CA). Repeat film with nipple markers if in doubt and compare.
Remember that a malignant pleural effusion is a relatively common complication so look for it if notice breast shadow absent.
All women 50-64 (soon to be 69) invited to attend 3 yearly mammography. Views taken (mediolateral and craniocaudal views). Mammography a special technique using x-rays. Under 40-45 year olds mammography of little value as glandular breast tissue: adipose ratio higher and difficult to detect masses. These women need an USS.
CA Features: Microcalcification
Spiculation (spider like)
Loss of regular border of breast

** calcification does not always mean cancer.

Fibroadenoma

Smooth, usually single round density that may calcify.

Hepatomegaly/Splenomegaly

AXR: diffuse soft tissue (grey) shadow extended below costal margin. USS: good images.

Large Kidney

AXR: normal kidney 3-3 and half vertebrae in length in T12-L2 region. May see much bigger soft tissue shadow. Can cause displacement of adjacent structures.
USS/CT: very clear images. Look for cystic change responsible for large kidneys.

Abdominal Masses/Ascites

Seen well on USS and CT, but unlikely to ask to look at these.
Ascites gives the appearance of a ‘grey haze’ on AXR as fluid in the peritoneal cavity.

Inguinal/Femoral Hernia

AXR: These can be seen (esp. if large) as bowel loops (maybe distended) within the LIF or RIF.

Femoral Aneursym

Arteriography is the gold standard for this and other arterial aneurysms but this does not mean it is what is used in practice. USS may demonstrate aneurysms well as can MR angiography.

Peripheral Vascular Disease

Arteriography before and after angioplasty (XR-fig19,20). Know the names of the main arteries of the leg.

Testicles

Everything to do with testicles is invariably seen on USS as they are superficial, covered in thin skin and soft tissue only. Varicocele seen as a ‘bunch of grapes’.

!! if asked what to do if detect left sided varicocele, “I would request a imaging of the kidneys for potential renal malignancy”. Renal mass can press on left testicular vein (asymmetrical anatomy).

AAA

AXR: May be seen incidentally as calcification indicates internal diameter of vessel.
USS first line: abdominal aorta should be 1.5-2.0 cm depending on the location. Greater than 3cm is abnormal. 3-4.5cm needs annual USS observation (surveillance), 4.5-5.5cm needs it 6 monthly. Greater than 5.5cm requires elective repair in most circumstances.
Complicated or incidentally found on CT (CT-fig17), where a thrombus may be seen within the aneurysm.

Hip OA

XR: loss of joint space, subchondral sclerosis, subchondral bone cysts (black appearance as air/fluid content) and osteophyte formation at the joint margins. (XR-fig23)

Knee XR:

As for hip above. Medial compartment loss of joint space >> genu valgus clinically.

RA

XR: (XR-fig8) loss of joint space. Periarticular erosions, periarticular osteoporosis. Soft tissue swelling. RA patients get systemic osteoporosis too.

** osteoporosis cannot be seen on XR. If there is bone loss it needs to be > 15% before detectable in which case it is osteopenia.

Medical Cases:

The information below is to correspond with the major cases identified in the PasTest – Passing Medical Finals book.

MI

CXR: usually very little. May indicate potential cause for MI.
ECHO and Cardiac Catheterisation may be undertaken.
- ECHO: structural integrity, valve function and ejection fraction.
- CC (Cardiac Catheterisation): vessel patency with view to CABG/PIC.

IE (Infective Endocarditis)

ECHO: Valve vegetation and destruction

Bronchial CA

CXR: (CXR-fig6, CT-fig14,15)
- coin lesion,
- area of consolidation (especially if fails to resolve),
- Lobe collapse (intrabronchial lesion),
- Pancoast’s apical mass +/- rib destruction.

** standard protocol to have CT of thorax and of liver and adrenals (for metastatic disease)

!!CXR shown in a patient that clinically has a Horner’s Syndrome – look at the apices for a Pancoast’s bronchial CA.

COPD:

Bronchovascular markings may be more evident. Overexpansion with flattened diaphragms.
CXR: depends to some extent on which end of the spectrum of chronic bronchitis-emphysema present. 50% will have no CXR findings. Hyperexpansion of lungs (more than 10 posterior or 6 anterior ribs, flattened diaphragm). Emphysema may be seen as bullae. If asked what further imaging one would like: high resolution CT scan identifies the bullae vividly.

Chronic Liver Disease

USS: shrunken liver +/- splenomegaly from portosystemic hypertension. Doppler’s allow assessment of flow direction in vein and artery. If following same direction = portosystemic hypertension.

IBD – UC

(XR-fig2)

AXR: Acute toxic megacolon: dilated large bowel loops, characteristically the transverse colon
BE: drain pipe/lead pipe colon (no haustral markings).

IBD – Crohn’s

Small Bowel Series: 4 big signs.
- String sign (of Kantor),
- Rose thorn ulceration (barium sitting in deep fissures),
- Bowel loop separation (inflammed bowel irritates nearby loops which move away),
- Cobblestone mucosa.

Multiple Myeloma

Pepperpot Skull, Multiple Pelvic deposits. Radioisotope bone scan reveals multiple increases uptake areas.

Stroke

CT: to distinguish haemorrhage (20%) from infarct (80%). Infarct may not be revealed for several days.
Carotid angiography, USS dopplers and MR angiography may all be used in trying to identify a carotid stenosis. If clinically a murmur, do ECHO for potential emboli source in heart.

CCF (5 big radiological signs. * perfect question)

Upper lobe venous diversion
Perihilar oedema (‘bat’s wings’)
Bilateral pleural effusions
Cardiomegaly
Kerley B lines (horizontal lines at the level of the cardiophrenic angles)

Pleural Effusion

(CXR-fig7)

Small vs. Large
Unilateral vs. Bilateral
Meniscus at the lateral aspect.
Large pleural effusions will give the impression of a complete white out of the lung (Differential diagnosis = pneumonectomy).
You may see the chest drain in situ.
If the line is straight there is fluid and air (ie, traumatic pneumothorax or iatrogenic on draining effusion).
A small effusion will need an USS to confirm it.

Fibrosing Alveolitis

Cannot specifically diagnosis FA. It is the same as other fibrosing lung disease; fine reticulonodular shadowing (dots and lines).

TB

CXR: TB favours the apices of the lungs, hence the review area of the apices on inspecting a CXR. TB lesions may cavitate – giving a central ‘black’ area with a fibrosed ‘white’ exterior. (CXR-fig5 shows unusual Miliary Shadowing)
Look at age and name of patient given its increased prevalence in the old and foreigner.

Spot diagnosis

Acromegaly: Large spade-like hands on XR. Cardiomegaly on CXR.
Marfans: Long, slender hands with spinderly fingers (arachnodactylyl).
Pepperpot Skull: Multiple Myeloma (pathological #’s too). (Note: ‘Pepperpot skull’ is a description given to multiple lucencies on the skull x-ray and can occur in other conditions such as hyperparathyroidism.)
Pituitary Tumour: Widened sella turcica on lateral skull.
Scleroderma: Calcinosis seen on hand XR at the pulps.
Ank. Spondylitis: Bamboo spine (due to squaring of the vertebrae), calcification of the longitudinal ligaments. Sacroileitis over the ileopectoneal lines (*first sign). (XR-fig9)
Paget’s Disease:
- Plain XR’s: pelvis, tibia and skull favoured locations.
- Disorder of bone resorption/deposition.
- ‘Fuzzy’ areas of XS bone.
- Radio-isotope scan: shows areas of high bone turnover which takes up the isotope.
Osteoporosis:
- DEXA (dual energy x-ray absorptiometry).
- Get T and Z Readings.
- T is overall bone density.
- Z compares it to age and sex matched controls.

MedicalFinals.co.uk

General Medicine Quiz 1

Skeletal & Vascular Films

CT Imagesradiology

Abdomen & Contrast Images

Foundation Programme Expected Competencies

Essential Reading For the Application Form

Basic Radiology Overview

Contents

Chest X-ray:

Abdominal X-ray:

KEY TIPS:

Chest X-ray

Normal Anatomy

Film Specifics and Technical Factors

Review of Structures to Assess on CXR:

Review Areas:

Lungs:

Pleura:

Mediastinum (including hila):

Bones and Soft Tissues:

Abdominal x-ray

Film Specifics and Technical Factors

Assess the Film in Detail

‘BLACK BITS’

‘WHITE BITS’

‘GREY BITS’

‘BRIGHT WHITE BITS’

Abdomen & Contrast films

Skeletal & Vascular films

Radiology for Finals

Common Films:

Respiratory

Cardiovascular

Gastrointestinal

Hepatobiliary

Urogenital Tract

Musculoskeletal

Breast

Neurology

Assessment/Review of Films:

Assessment of an AXR

Review Points

Assessment of CXR

General points:

Surgical Cases:

Goitre

Parotid Gland Swelling

Cervical Rib

Breast Carcinoma

Fibroadenoma

Hepatomegaly/Splenomegaly

Large Kidney

Abdominal Masses/Ascites

Inguinal/Femoral Hernia

Femoral Aneursym

Peripheral Vascular Disease

Testicles

AAA

Hip OA

Knee XR:

RA

Medical Cases:

MI

IE (Infective Endocarditis)

Bronchial CA

COPD:

Chronic Liver Disease

IBD – UC

IBD – Crohn’s

Multiple Myeloma

Stroke

CCF (5 big radiological signs. * perfect question)

Pleural Effusion

Fibrosing Alveolitis

TB

Spot diagnosis