Data Interpretation: Additional Resources: Section1: Interpreting Abdominal Radiographs Systematic Approach

OSCE-Aid Revision Workshops: Data interpretation
Data Interpretation: additional resources

This resource covers interpretation of Abdominal Radiographs, Orthopaedic Radiographs
and Blood Test Resutls.
Please see the other listed documents on the data interpretation page to cover: Chest
Radiographs, Urine Dipstick Analysis, Spirometry, and Arterial Blood Gases.
Section1: Interpreting Abdominal Radiographs
Systematic approach:
1. Demographics and details: This is an abdominal radiograph taken of on at .
2. View- type and adequacy: It is a supine AP view and of adequate view as I can
visualize the hemidiaphragms to the hernial orifices
a. Supine AP view is standard. Decubitus view would be when lying on their
side.
b. Usually require 2 views to get adequate visualization from diaphragms to
hernial orifices. If this area isnt adequately visualized then can comment on
needing another view.
3. Penetration
4. Bowel gas pattern:
a. Stomach
b. Small bowel- valvulae coniventes (centrally positioned, span whole diameter
of the bowel)
c. Large bowel- haustra not going all the way across the diameter of the bowel,
usually have a mottled appearance as contain air, positioning is fixedascending, descending colon and rectum are usually clear to identify.
5. Soft tissues (trace around and comment on):
a. Lung bases
b. Liver and spleen
c. Psoas (iliacus and psoas muscles form the iliopsoas muscle attached to the
greater trochanter of the hip- they are the hip flexors.)
d. Kidneys- trace down ureters to bladder
6. Bones
a. Ribs
b. Vertebrae
c. Pelvis
d. Femurs
7. Additional calcifications and artefacts
a. Eg gallstones, mesenteric LN calcification, costochondral calcification,
phleboliths, fibroids
8. Summary:
a. In summary this is an a supine AP abdominal radiograph taken of on
with the main positive finding being . This could be consistent with a
diagnosis of
Examples of main findings
Abnormal bowel gas patterns:
- Pneumoperitoneum- air under the diaphragm or free gas can sometimes be seen
between the loops of bowel. **In an acute abdomen should always request an erect
chest X-ray.
- Riglers sign- the bowel appears double walled as there is air either side of the
bowel
2016 www.osce-aid.co.uk

-
Football sign: air risen to the front of the diaphragm creating a football appearance
Small bowel obstruction: >5cm distended small bowel. Centrally located, valvulae
coniventes (spanning the whole diameter of the small bowel). Commonest causes:
adhesions, Crohns, tumours, hernias.
Large bowel obstruction: >6cm colon, >9cm caecum. Peripherally located, haustra
(not spanning full diameter of bowel). Commonest causes: CRC, diverticular disease,
hernias, volvulus, pseudoobstruction (no mechanical cause but presents the same,
mostly in the elderly)
Volvulus- commonest types
o Sigmoid volvulus: sigmoid twists at its own mesentry in LIF. Coffee bean sign
pointing towards diaphragm.
o Caecum volvulus: 20% have a congenital malformation that means can twist
on its own mesentry.
Thumb-printing: mucosal thickening of haustral heads and increased space
between bowel= inflammatory bowel disease. (Colitis of any cause, most common of
which is IBD).
Lead pipe colon: loss of normal haustra in transverse colon= longstanding UC
Toxic megacolon: dilatation of bowel in absence of obstruction and presence of
acute bowel disease. Causes: IBD esp UC, colitis of other cause eg infection
***Please see radiologymasterclass.com for great examples of these radiographs***
Practice question: A 27 year old woman presents to A&E with vomiting and abdominal
pain. She previously had surgery for bowel obstruction. The below AXR is taken. Please
practice present the XR and give a differential for your findings.
Name: Mallory Weiss, DOB 1/1/1980, HN 5768958

Date of study: 12/1/2016, time 11:06am
Image from radiologymasterclass.com
Model answer
- This is a supine AP abdominal XR taken of MW DOB 1/1/1980 HN 5768958, on the
12/1/2016 at 11.06.
- It displays a view from the lower thoracic cavity to the ischial spines of the pelvis.
This is an inadequate view as I would like to visualize the hemidiaphragms to the
hernial orifices.
- Examining the bowel first I can see a central area of distended bowel with the
appearance of valvulae coniventes. This is likely to be small bowel. I cannot visualize
the stomach or the large bowel.
- Examining the area of the liver, spleen, kidneys, and psoas muscles there are no
abnormalities displayed.
- There appears to be no bony injuries of the visible ribs, vertebrae or pelvic crests.
- There are no abnormal calcifications, however in the right upper quadrant there
appears to be evidence of previous surgery. There are no additional artefacts.
- In summary this is a supine AP abdominal XR taken of .. on ... with the main positive
findings being that there appears to be small bowel distension caused by small bowel
obstruction. There is evidence of previous abdominal surgery which could indicate an
anastamosis. In this context and a history of previous bowel obstruciton, a likely
cause could be adhesions causing obstruction. Additional differentials would include
Crohns disease, hernias and tumours.
Abnormal soft tissues and bones:
- Organomegaly- spleen and liver
- Hydronephroiss
- Masses
- Fractures and OA
- Bone mets
- Pagets disease- expansion and coarsening of trabecular pattern
Abnormal calcifications:
- renal calcification
- nephrocalcinosis
- ureteric calcification
- bladder stones (urinary stasis)
- vascular calcification
- AAA- if wall calcified
- Chronic pancreatitis with calcification
- Adrenal gland calcification
- Gallstones and mesenteric LN calcification
Artefacts
- IVC filters
- Pigtail/JJ stents
- Foreign bodies
Section 2: Interpreting Orthopaedic Radiographs

Systematic approach:
1. Demographics this is a radiograph taken of on at
2. Film details:
a. AP/lateral and comment on whether additional view is needed
b. Penetration
c. Adequate view of what bone is being shown
3. What is shown anatomically in the radiograph
4. Describe the fracture seen:
a. Where: where fracture is- if in long bones split bone into 3rds for description,
use anatomical landmarks where possible
b. Type: there is a spiral/transverse/oblique fracture
c. Displaced/undisplaced/minimally displaced
d. Rotation/translocation/angulation/shortening/shift (ensuring you are
describing the distal portion in relation to the proximal portion)
e. Additional features you must comment on if present:
i. Comminuted/wedge shaped
ii. Avulsion fracture (portion of bone pulled away by ligament/tendon).
iii. Stress fracture (repeated low impact trauma to bone- will see
periosteal reaction in subtle calcification of bone but no clear fracture).
iv. Dislocation and subluxation
v. Diastasis (separation of 2 bones that are usually adjacent eg of pubic
symphysis- orthopaedic emergency)
5. Additional factors: soft tissue swelling, foreign bodies.
6. Summary:
a. This is a AP/lateral view of the L knee taken of on the at The main
positive findings are (describe fracture seen succinctly)
b. This is in keeping with (classification system if relevant for fracture shown)
c. The management of this fracture would include
i. DR ABCDE
ii. Full history paying particular attention to the mechanism of injury and
examining the injury.
iii. Treatment would include:
1. ANALGESIA!!!!
2. Conservative management: sling/POP/traction and follow up in
fracture clinic OR
3. Surgical management if open/ unstable/ complex/ polytrauma/
pathological/ nerve or BV involvement. Can be internal fixation
(IM nails and plates) or external fixation. Orthopaedic follow
up.
d. If relevant- say you would like to compare against old radiographs
Important discussion points that are easy to ask you about!
Principles of wound management (RIR)
- REDUCE
- IMMOBILISE
- REHABILITATION
Open wound management
1. DR ABCDE
2. History and examination
3. Tetanus booster
4. Clean and inspect the wound
5. Lavage, debride, remove necrotic tissue

6. Surgery
7. Antibiotics e.g. cefuroxime and metronidazole
Complications of fractures
Early complications
Wound infection
Fat embolism
Compartment syndrome
ARDS
Chest infection
DIC
Exacerbate general illness
Late complications
Deformity
OA
Aseptic necrosis
Reflex sympathetic dystrophy
Practice question 1:
Dorothy Branning, DOB 3/1/1930, HN 3647598

Date of study: 5/1/2016, time 14:30. L wrist.

1. Please present your findings.
2. What would your management be?
Model answer
- Displayed are radiographs taken of DB DOB HN at 14:30 on 5/1/2016. The
radiographs show an AP and a lateral view of the left wrist displaying a view from the
metacarpals, carpal bones and distal half of the forearm.
- There is adequate penetration and an adequate view of the wrist.
- There is a transverse fracture that can be seen at the distal radius above the level of
the radioulnar joint with dorsal angulation and displacement of the hand. There is
notably no ulnar fracture. I cannot see any other bony injuries.
- There is soft tissue swelling surrounding the wrist, most notably on the ventral side.
- There are no other findings.
- In summary this is a lateral and an AP radiograph taken of the left wrist of on
at Main positive findings are a transverse fracture of the distal radius above the
level of the radioulnar joint and no associated ulnar styloid fractures. This is therefore
a frykman type 1 fracture. There is dorsal displacement of the hand and surrounding
soft tissue swelling.
- This is consistent with a colles fracture.
- Management of this fracture would include
o A thorough DR ABCDE assessment
o Taking a full history paying particular attention to the mechanism of injury and
full examination looking for any other injuries
o The patient will require analgesia and then will likely be managed
conservatively although I would like orthopaedic input.
o Treatment of the fracture would include
Reduction, immobilization and rehabilitation
Following reduction, immobilization would likely be carried out with
POP cast and then follow up in fracture clinic.
Further investigation into bone density would be important in the OP
setting.
Practice question 2:
Name: Jeremy Hubbard, DOB 8/10/1960 HN 8907327

Study date: 5/1/2016, time 11:06am

1. Please present your findings.
2. How would you manage this patient?
Model answer
- These radiographs display an AP and lateral view of the R ankle of JH DOB HN.
They are taken on the at
- The radiographs show views of the distal third of the lower tibia and fibula to the
proximal metatarsal bones. This is an inadequate view as I would also like to
visualize the proximal tibia and fibula.
- There film is of adequate quality.
- There are a number of fractures visible, I will describe each in turn:
o There is a transverse fracture of the medial malleolus which appears
minimally displaced inferiorly.
o There appears to be a fracture of the distal tibia which on lateral view can be
determined to be a posterior malleolus fracture that is posteriorly displaced.
o There is also a spiral fracture of the fibula above the level of the tibio-fibular
syndesmosis.
o The talus is displaced posteriorly and laterally in addition to the lateral and
medial malleolus bone fragments.
o The joint space is widened anteriorly and at the tibio-fibular syndesmosis with
lateral talar shift which indicates that the joint in unstable.
- As mentioned I would like to visualize the proximal fibula to determine whether there
could be a Maisonneuve fracture.
- In summary, these are AP and lateral radiographs showing the R ankle of JH taken
on There are 3 visible fractures involving both medial and lateral malleoli, with talar
shift and unequal joint space resulting in an unstable joint. I would like an additional
proximal view including the proximal fibula. Management of this fracture would
include:
o DR ABCDE
o Full history and examination paying particular attention to the neurovascular
status of the foot.
o Analgesia
o Orthopaedic input as this is a complex fracture picture and is likely to require
surgery for definitive treatment. This could consist of internal or external
fixation.
Additional revision points and important classifaction systems to be aware of:

- Hip fractures (know how to describe them well!) with GARDEN CLASSIFICATION
o Type 1- incomplete or impacted bone injury with valgus angulation of the
distal component
o Type 2- complete fracture (across whole neck), undisplaced
o Type 3- complete fracture, minimally displaced
o Type 4- complete fracture, totally displaced
ALLMAN CLASSIFCATION: Clavicular fractures

o Type 1- middle 3rd
o Type 2- distal 3rd
o Type 3- proximal 3rd
FRYKMAN CLASSIFICATION: Wrist fractures
http://jbjs.org/content/80/4/582
WEBER CLASSIFICATION: Ankle fractures

o Weber A- fracture of lateral malleolus, below level of syndesmosis
o Weber B- fracture of lateral malleolus, usually below the syndesmosis but
extending more proximally then type A. Medial malleolus may be fractured.
o Weber C- fracture of lateral and medial malleolus. Fracture above level of
syndesmosis. Unstable.
Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 9642

Section 3: Interpreting Blood Results
Bloods results that are most likely to come up and you should know well include:
- Liver function tests
- Thyroid function tests
- Haematinics
- Electrolyte derangement
For each you should be able to interpret common pictures and list main differentials and
treatment options. Here we will cover electrolyte derangement as this is often most
confusing or not covered well in teaching.
Practice question:
Mrs Kleiner, a 72 year old lady, has attended GP feeling increasingly tired. She has a history
of congestive cardiac failure, hypertension and chronic kidney disease. She is on a number
of medications shown below. She has attended to discuss blood test results taken on her
last visit. Please review her results and discuss them with her, formulating a management
plan.
Medication list
Losartan
Ramipril
Furosemide
Spironolactone
Oxybutynin
Salbutamol
Budesonide
U&Es
K 5.4 (3.5-5 mmol/L)
Na 149 (135 -145mmol/L)
Ur 14 (2.5-7.8mmol/L)
Cr 130 (68-118mmol/L)

Model answer
These questions usually come in the setting of a communication station and may
incorporate multiple skills- consultation skills, explaining skills, checking
understanding and management formation skills. Always look carefully at the
medication list!!
-
Introduction and setting scene

o Introduce, explain and consent patient for discussion
o Check understanding of why test has been done and what is causing her
symptoms. Does she have any concerns?
o How has she been since last visit/bloods taken
o Explain took a routine blood test to determine the level of salts in the body
which can be altered by many things including medications, how kidneys
functioning etc. A few of these have come back slightly abnormal which could
be caused by lots of things. For that reason would like to ask a few questions
and see if we can find out why and then possibly make a few changes to
rectify the blood tests, is that ok?
History- check for signs of hyperkalaemia- keep it brief and concise
o Symptoms: chest pains/palpitations/problems with water works/ feeling sick/
abdominal pain or constipation/weakness.
o Cause: can see on spironolactone and ramipril- how long have you been on
these? Any new medications? Any known kidney problems? Any other
medical conditions (DM/addisons/kidney disease).
Explaining
o The tests that weve done show that the level of potassium in the blood is
slightly higher than normal. This could be because of a few factors, most
likely being that 2 of your medications, ramipril and spironolactone can
increase the level of K in the blood.
o The other factor is that with your kidney disease, sometimes you can get a
rise in K as its not being excreted from the body so effectively.
Form a management plan
o For that reason along with the fact that you dont have any symptoms and
youre well, I would like to do a few things today. Firstly I would like to get an
ECG. If everything is ok with that then I would want to stop the spironolactone
and then get you back in 5-7 days for a repeat blood test which will tell us if
weve done enough to treat it.
o Chunk and check as you go along
Safety net
o In the meantime if you feel. All symptoms then please come straight back
or attend A&E.
Check understanding and answer any questions
Close

POTASSIUM
Hypokalaemia
ECG changes
1. U waves
2. Tall tented P waves
3. Increased PR interval
Hyperkalaemia
ECG changes
1. Tall tented T waves
2. Sine wave appearance
3. Absent/small P waves
4. Broad QRS
5. VF
Presents
- Muscle cramps and weakness
- Lethargy
- Palpitations
Presents
- Arrhythmias
- Palpitations
- Chest pain
- Constipation
- Weakness
Causes:
1. DRUGS
a. Insulin
b. Salbutamol
c. Loops and thiazide diuretics
d. Laxatives
e. Steroids
2. Endocrine
a. Cushings
b. Conns
3. GI
a. Diarrhoea and vomiting
b. Villous adenoma- profuse
diarrhoea
4. Renal
a. Gitelmans syndrome
b. Barterrs syndrome
c. Liddles syndrome
Causes
1. DRUGS
a. Spironolactone
b. ACEi
c. Suxamethonium
d. Blood transfusion
e. Excessive K replacement
2. Endocrine
a. Addisons disease
b. DM with metabolic acidosis
3. Renal
a. Rhabdomyolysis
b. RTA4
4. Other
a. Burns
Management- dependent on severity

1. >2.5 PO replacement
2. <2.5 IV replacement e.g: 40 mmol
potassium in 1L 0.9% saline over 8
hours.
Management- dependent on severity

1. Stabalise myocardium: 10ml of 10%
calcium gluconate
2. Drive K into the cells: 10 units short
acting insulin in 50ml 50% dextrose,
5mg salbutamol (nebulized)
3. Sodium bicarbonate- according to
venous bicarbonate eg 500mg
4. Careful fluid resuscitation

SODIUM
Hyponatraemia
Presents
- Nausea and malaise
- Headache
- Irritability
- Confusion
- Weakness
- Reduced GCS and seizures
- Coma and death
Causes:
1. Hypervolemic (oedemtous)
a. Nephrotic syndrome
b. Cardiac failure
c. Liver cirrhosis
d. Renal failure
2. Euvolemic determine if urine
osmolality >100mmol/kg
a. >100= SIADH
b. <100= water overload, severe
hypothyroidism, glucocorticoid
insufficiency
3. Hypovolemic (dehydrated)
determine whether urinary Na
>20mmol/L
a. >20= addisons, renal failure,
diuretic excess, osmolar
diuresis (increased
glucose/urea)
b. <20= diarrhoea, vomiting,
fistulae, small bowel
obstruction, CF
Management
1. OVERALL!!! Involve seniors,
endocrine team and ITU early on.
2. Dependent on cause:
a. Hypovolemia: 0.9% saline
slowly. Check U&Es BD and
aim not to exceed increasing
Na by >10mmol in 24 hours
b. Hypervolemia eg CCF: fluid
restrict and give furosemide
c. Euvolemic eg SIADH: fluid
restrict and consider further
drugs.
3. RISK: central pontine myelinosis if
too quick!
Hypernatraemia
Presents
- Lethargy
- Thirst
- Weakness
- Irritability
- Confusion
- Seizures
- Coma and death
Causes
1. Diarrhoea, vomiting, burns
2. DI
3. Diabetic coma
4. Iatrogenic- excessive saline
Management
1. PO water
2. 5% dextrose IV slowly (if
hypovolemic can give 0.9% saline)
3. (Risks fluid shift in brain if
changed too quickly)

CALCIUM
Hypocalcaemia
ECG changes
1. Prolonged QT interval
Hypercalcaemia
Presents: SPASMODIC
- Spasms- Trousseaus sign
- Perioral parasthesia
- Anxious, irritable, irrational
- Seizures
- Muscle tone increased- smooth
muscle eg wheeze
- Orientation impairment
- Dermatitis
- Impetigo herpetiformis
- Chvosteks sign/ cataracts/ CM/
choreoathetosis
Presents: bones, stones, moans, groans

- Bone pain and fractures
- Renal stones
- Polydipsia
- Polyuria
- Depression and irritability
- Abdominal pain
- Contipation
- Spasms
Causes:
1. DRUGS
a. Furosemide
2. Hypoparathyroidism
3. Pseudohypoparathyroidism
4. Vitamin D deficiency
5. Acute pancreatitis
6. Acute rhabdomyolysis
Causes
1. DRUGS
a. Thiazides
b. Vitamin D
2. Malignancy
3. Primary hyperparathyroidism
Management
- Mild symptoms: PO calcium
- Kidney disease: alfacalcidol
- Severe symptoms: 10ml 10% calcium
gluconate
- Monitor patient with ECG
Management
1. Correct dehydration
2. Bisphosphonates e.g.: 60 mg
pamidronate infusion
3. Furosemide (although dehydration
may worsen hypercalcaemia!)
4. Monitor patient with ECG
5. Early involvement of endocrine
team
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OSCE-Aid Revision Workshops: Data interpretation