In this teaching session for medical students preparing for their final ISCE exam, the focus will be on data interpretation for chest X-rays (CXR) and abdominal X-rays (AXR). Participants will learn how to analyze and interpret results from these imaging assessments, emphasizing the identification of key findings, understanding relevant anatomical structures, and correlating results with clinical scenarios. The session will cover common conditions associated with abnormal findings in both CXR and AXR, facilitating a comprehensive understanding of thoracic and abdominal pathophysiology. Through interactive discussions and case studies, students will enhance their diagnostic skills and clinical reasoning. The session will conclude with a summary of important concepts and a Q&A segment to address any questions from participants.
CXR & AXR interpretation
Summary
Improve your Radiology skills with this on-demand teaching session by Ronan Fitzgerald. The course focuses on imaging interpretation with a deep-dive into CXR and AXR film analysis. You'll learn how to assess the quality of a radiograph, identify normal features, and detect key abnormalities using a systematic approach. Packed with detailed overviews of patient details, film adequacy, and in-depth interpretation tactics, this session will enhance your diagnostic capabilities. The course structure also allows you to grapple with differentials and the completion of your summaries successfully.
Description
Learning objectives
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By the end of the teaching session, learners will be able to inspect and validate the quality of CXR and AXR imaging.
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Learners will be proficient in identifying the normal structures and aspects in a CXR, including the trachea, hilar region, lung fields, heart borders, aortic knob, diaphragm, and any medical apparatus.
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Participants will acquire knowledge on various key abnormalities that could be detected in a CXR and how to systematically approach their identification using the ABCDE method.
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At the end of the session, learners will have acquired a clear understanding of a normal AXR understanding various aspects such as bowel, other organs, and bones.
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Learners will acquire a practical and systematic approach, termed BOB, to identify key abnormalities in an AXR.
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Imaging interpretation part 1 By Ronan FitzgeraldItinerary -CXR interpretation -AXR interpretationObjectives By the end of this teaching session, we should be able to • Check the quality of a CXR and AXR film • Know what a normal CXR looks like • Use a systematic approach to pick up key abnormalities on a CXR (ABCDE) • Know what a normal AXR looks like • Use a systematic approach to interpret abdominal X-rays to pick up key abnormalitiesCXR interpretation - Patient details - Date of CXR - Type of CXR (AP/PA Erect/supine) - Adequacy: RIPE Mangoes - Interpret: ABCDE - Differential and how you would complete your summaryAdequacy of a CXR: RIPE Mangoes Rotation: equal distance between spinous processes and clavicles Inspiratory effort: if 6 anterior ribs ae visible then good inspiratory effort is achieved Penetration: Not too white or too dark- should be jusprocesses see the spinous Exposure: Can see all of the lung field both sides and the diaphragm as well (particularly the costophrenic angles). Markings: red mark-means radiographer has spotted an abnormality Normal CXR: Adequacy Rotation The film is slightly rotatedInspiratory effort therefore there is goodbs inspiratory effort Penetration I’m just able to see the spinous processesExposure I can’t see the Costo diaphragmatic recesses (i.e. the costophrenic angles) therefore the exposure isn’t adequate on this film.Interpretation A:Airway B:Breathing C:Circulation D:Diaphragm E: Everything elseNormal CXR - Tracheal deviation: Interpretation: volume loss drawing ABCDE- A for trachea towards or voltrachea away?ing Airway - Hilar region: hilar vasculature and major bronchi. Also contains LNs. Left hilum is usually slightly higher than the right. The hilar are usually the same indicates pathology.Normal CXR BHL ABCDE: B for breathing Lung fields: compare in thirds and always trace around the lung marking to ensure no air/fluid in pleural space. Note any consolidation/ whitening/ opacification or lesions in lung fieldsNormal CXRWidespread interstitial opacificationABCDE: C for Circulation remember AP films are crAP for this reason size)- in thoracic cavity (volume loss (lung collapse)/ volume gain (mass)) Heart borders Aortic knob Mediastinal width (widening=aortic dissection!!!) Aortic knuckle: reduced definition can indicate aneurysm Mediastinum Aortopulmonary window: If the space is lost then this can indicate mediastinal lymphadenopathyABCDE: D FOR DIAPHRAGM Flattening of diaphragm-hyperexpansion of lung (COPD background?) Any air under the diaphragm Costophrenic angles-blunting=pleural effusionHow can I tell the difference between this a pleural effusion and opacification (like a chest infection- consolidation)? A meniscus indicates the fluid level. DON’T ALWAYS ASSUME ONE PATHOLOGY: KEEP LOOKING FOR ANY OTHER SIGNS E.G. PNEUMOTHORAX UNDERLYING.Pneumoperitoneum vs gastric bubbleABCDE: E for everything else - Any medical apparatus in situ: chest drains, ECG leads, pacemakers e.t.c. - Bones: especially the ribs (any #s) - Soft tissue: subcutaneous emphysema or massesSubcutaneous emphysemaLoop recorder (records Permanent ICD: Implantable BIV-ICD: heart rhythms for up to 3 pacemaker: cardiac years): looks like a USB defibrillator thin Biventricular continuously same ICD stick thickness to line strand with denser line in the middle (the coil)AXR interpretation - Patient details - Type of AXR: standard AXR is an AP projection in supine position. Special projections include a PA prone, lateral decubitus, upright AP & lateral cross table - Adequacy: RiPE Mangoes - Interpretation: BOB - Differential and how you would complete your summaryNormal AXRAdequacy of film Rotation: assess symmetry of pelvis/ check spinous process is central of vertebrae Penetration: Not too white/not too dark Exposure: should be able to see up to the diaphragms and also see the pelvic joints where the femur inserts Markings: red dot=abnormalityRotationPenetrationExposure Can see femoral joint bilaterally but unable to visualise diaphragms well therefore inadequate AXR.Interpretation: BOB the minion (he looks jaundice and bloated) B: Bowels O: Other organs B: BonesInterpretation: BOB- B for bowels Small bowel: central position + valvulae coniventes; should be <3cm in diameter Large bowel: peripheral and haustra; should be <6cm in diameter (caecum and sigmoid <9cm) **The 3,6,9 rule Look for any gas in the bowel wall-ischaemia Look for any bowel on bowel appearance-Rigler’s signLarge bowel: white arrows Small bowel: black arrowsSIGMOID VOLVULUS-COFFEE CAECAL VOLVULUS-FETAL BEAN SIGN APPEARANCE SIGNInflammatory bowel disease Features of inflammatory bowel disease on abdominal X-ray include: •Thumbprinting: mucosal thickening of the haustra due to inflammation and edema causing them to appear like thumbprints projecting into the lumen. •Lead-pipe (featureless) colon: loss of normal haustral markings secondary to chronic colitis. •Toxic megacolon: colonic dilatation without obstruction associated with colitis. Lead pipe (featureless colon- i.e. loss of haustra TOXIC MEGACOLON IBD or infectious colitis with colonic dilatation + systemic toxicitiyInterpretation BOB- O for other organs Liver Spleen bowel obstruction. Don’t worry too much about this one ***** Kidneys Gallbladder Psoas shadow Pancreas ** most important one- calcification=chronic pancreatitisINTERPRETATION BOB- B FOR BONES Spine and pelvis -Paget disease -Mets (lytic/sclerotic) -Osteoarthritis (LOSS) -vertebral fracturesOSTEOARTHRITISYou should now be able to • Check the quality of a CXR film: RIPE Mangoes • Know what a normal CXR looks like: ABCDE • Use a systematic approach to pick up key abnormalities on a CXR: ABCDE • Check the quality of an AXR film: RiPE Mangoes • Know what a normal AXR looks like: BOB • Use a systematic approach to pick up key abnormalities on a AXR: BOBReferences (Vancouver) 1. Ward D, Potter L. Geeky Medics [Internet]. Abdominal X-ray Interpretation; 2025 Jan 3 [cited 2025 Jan 5]. Available from: https://geekymedics.com/abdominal-x-ray-interpretation/. 2. Radiopaedia.org, the peer-reviewed collaborative radiology resource 3. Mansbridge C. The OSCE Revision Guide for Medical Students. [place unknown]: OSCEstop LTD; 2018. 376 p. 4. Gambato M, Scotti N, Borsari G, Zambon Bertoja J, Gabrieli JD, De Cassai A, Cester G, Navalesi P, Quaia E, Causin F. Chest X-ray Interpretation: Detecting Devices and Device-Related Complications. Diagnostics [Internet]. 2023 Feb 6 [cited 2025 Jan 5];13(4):599. Available from: https://doi.org/10.3390/diagnostics13040599 5. Radiology Masterclass - [Internet]. Chest X-ray - Cardiac disease; [cited 2025 Jan 5]. Available from: https://www.radiologymasterclass.co.uk/gallery/chest/cardiac_disease/pleural_effusion