Prescribing errors cost healthcare systems millions annually, so early training in prescribing has become an urgent priority of medical education and now forms an essential part of teaching and assessment. It is written by junior doctors still close to the transition from theory to practice, overseen by a review panel of senior clinicians to ensure accuracy, and designed to help medical students practise and learn as much as possible about prescribing, in actual clinical scenarios, before they have to do it for real.
Each scenario is presented as you would see it in the hospital setting and covers: Initial step-by-step assessment of the patient: how to assess, assessment findings, and immediate management Initial investigations Initial management Reassessment Treatment Handing over the patient 'Prescribe' alerts throughout Written-up drug charts Blank drug charts for copying and practice.
Chest X-rays for Medical Students is a unique teaching and learning resource that offers students, junior doctors, trainee radiologists, nurses, physiotherapists and nurse practitioners a basic understanding of the principles of chest radiology. Since it was first published, Accident and Emergency Radiology: A Survival Guide has become the classic reference and an indispensable aid to all those who work in the Emergency Department.
The core and substantial value lies in the step-by-step analytical approaches which help you to answer this question: "These images look normal to me, but. Ensure accuracy in reading and interpretation of any given image. Common sources of error and diagnostic difficulty are highlighted. Prevent mistakes. Pitfalls and associated abnormalities are emphasized throughout.
Avoid misdiagnoses. Normal anatomy is outlined alongside schemes for detecting variants of the norm. Each chapter concludes with a summary of key points. Will provide a useful overview of the most important features in diagnosis and interpretation. Easily grasp difficult anatomical concepts. Radiographs accompanied by clear, explanatory line-drawings.
Spend less time searching with an improved layout and design with succinct, easy-to-follow text. A templated chapter approach helps you access key information quickly. Each chapter includes key points summary, basic radiographs, normal anatomy, guidance on analyzing the radiographs, common injuries, rare but important injuries, pitfalls, regularly overlooked injuries, examples, and references.
Grasp the nuances of key diagnostic details. Unfortunately it is often an overlooked subject in the medical school curriculum, which many medical students and junior doctors find difficult and daunting. It is designed to be a useful learning resource for medical students, junior and hospital doctors, nurse practitioners and radiology trainees. The chest, abdominal and musculoskeletal X-ray chapters contain step-by-step approaches to interpreting and presenting X-rays.
The content is in line with the Royal College of Radiologists' Undergraduate Radiology Curriculum , making it up to date and relevant to today's students and junior doctors.
The layout is designed to make the book as clinically relevant as possible; the X-rays are presented in the context of a clinical scenario. The reader is asked to "present their findings" before turning over the page to reveal a model X-ray report accompanied by a fully annotated version of the X-ray. This encourages the reader to look at the X-ray thoroughly, as if working on a ward, and come to their own conclusions before seeing the answers.
To further enhance the clinical relevance, each case has 5 clinical and radiology-related multiple-choice questions with detailed answers.
Smoking is a recognised risk factor margin. It is y r y r r Co p spontaneous pneumothoraces. Co p Patients Copyfor secondary, not primary considered a risk factor who have extensive emphysema and large bullae are spontaneous pneumothoraces. Which of the following clinical findings would be supportive of a large simple right sided Chest pneumothorax?
Hyperresonant percussion and reduced air entry on the right side of the chest. Z e of combinations of clinical findings associated Z e of with a o p y right o p y right o p y right C pneumothorax, a pleural effusion, lobar C collapse, and pneumonia. Briefly, the chestC examination should follow the pattern of inspection, palpation, percussion, and auscultation.
Look for symmetrical shape and chest expansion. Assess the position of the mediastinum trachea and apex beat and assess for chest expansion. Percuss and hiauscultate both lungs. Assessing routine shiobservations, such as oxygen shi ures Qure Qure an Qpressure, is also important. Dull percussion and reduced pyrig Coair pyrig Co percussion and reduced D Central trachea. Hyperresonant entry on the right side of the chest — Incorrect.
This air entry on the left side of the chest — Incorrect. These combination of findings is suggestive of a right sided findings would be in keeping with a simple left sided pleural effusion. With a pleural h effusion you would pneumothorax. Hyperresonant a n Q h h h stony dull o h t f Zes note, absent or reduced breathht of Zespercussion and reduced air entry onhthe percussion t f Zesside of oright i g pyr reduced vocal resonance, and no added r i g r i g Copy Copy — Incorrect.
This sounds, sounds Coon the side of the effusion. With large effusions there the chest. Hypotensive, tachycardic combination of clinical findings is worrying and should may be a shift of the mediastinum to the contralateral raise your suspicions of a tension pneumothorax. Dull percussion r e shand bronchial breathing simple u r e shi pneumothorax, there is mediastinal shift to Qures hi a n Q a n Q a n and cracklesf on sh right side of the chest — Incorrect.
Typically, there is Creduced hypotension, tachycardia,C reduced consciousness level. These findings are consistent withCaosimple Copy right pneumothorax.
You would expect to find reduced chest expansion, hyperresonant percussion, and absent breath sounds, with hino added sounds on hi i Q ures There should be no the side of the pneumothorax. Q ures Qu resh a n n shan Zesh esha of Ze mediastinal ight of shift. Patients n Q urefew have n Q ures ha sha ha h t o f Zes examination.
Chest X-ray is hatmore o f Zesensitive h t o f Zes test for identifying a pneumothorax, ig ig ig C opyr opyr particularly a small pneumothorax. C opyr C 2. Not all patients have classic findings on history and examination.
It is important to use your clinical findings to request appropriate investigations, such as blood tests and i i i Qu resha chest X-ray, to help narrow your differential resh Qu diagnosis. Which an Q an Q an Q f Zesof the following are appropriate f Zdifferential diagnoses for a patient f Zeswho h esh h h t o h t o h t o rig rig rig Copy presents with sudden breathlessness?
These py Coinclude respiratory conditions, cardiac diseases, and systemic problems. It is important to be able to formulate an appropriate differential diagnosis from the history and examination to guide suitable investigations and initial management. Establishing the time frame of the onset of breathlessness is very helpful in formulating your differential diagnosis. Sudden Q eshi refers to breathlessness that develops uronset Q hi uresover seconds and includes pulmonary Q ures hi ha n ha n a n t o f Zespneumothorax, anaphylaxis, and embolus, t o f Zesforeign bodies.
Dyspnoea associated inhaled t o Zeshpneumonia, f with rig h rig h rig h Copy heart failure, metabolic acidosis,Cand opyexacerbations C pydevelop more slowly, over of asthma or COPD tendoto minutes to hours. Other conditions, such as interstitial lung disease and anaemia, have a much more chronic onset. A Pulmonary embolus r—eCorrect. Other symptoms n ures over hours rather than seconds.
Other Qoccurring r n Qufeatures e a s h a s h a t of Zpleuritic chest pain and dizziness. Clinical Ze f Ze sputum, a raised y r i g hinclude y r i g ht of include a productive cough with y r i g ht ogreen Cop Cono examination of the chest often reveals p abnormal Cop temperature, and appropriate clinical findings.
There may be a swollen limb, suggesting an D Heart failure — Incorrect. Heart failure is a common underlying deep venous thrombosis. The patient may cause of breathlessness, but usually its onset is more have had recent surgery or have other risk factors s h i shi Patients may also complain of orthopnoea insidious. There n Q may ubereas a shmalignancy or a genetic prothromboticf Zesh a a underlying t of Ze t o previous history of cardiac disease.
A pneumothorax often results evidence of pleural effusions. Anaphylaxis is a systemic and life pain. There may be a history of an underlying lung threatening condition see question u i res1hfor examples of conditions u shi allergic reaction. It usually occurs shortly recontact ures hi a n which predispose Qto secondary pneumothoraces or a n Qafter a Q with the allergen previous sensitisation n esh esh esh r i g h t of Z The constellation of clinical findings trauma.
Symptoms Copy with a pneumothorax is discussed inCquestion opy 2. Copy facial swelling, wheezing, over minutes and include breathlessness, urticaria, and, potentially, shock. C Pneumonia — Incorrect. Pneumonia and other infections Urgent management using the ABCDE approach and are common causes of breathlessness; however, the administration of intramuscular adrenaline is required. But remember that some patients, such as those presenting with anaphylaxis, may need urgent treatment hi i resh and examination.
In these patients, hi n Q ures you will be able to complete anfull before Q uhistory n Q ures sha use the ABCDE approach to assessment sha and management. Which of the following is the most appropriate initial imaging investigation in a patient hi hi hi ures a simple pneumothorax? The chest X-ray is rthe i line imaging modality for suspected hfirst i hsimple pneumothoraces.
Imaging reshi n Q u es n Q ures Qu has a keysh Z e role a in confirming the diagnosis of a pneumothorax, Z e s ha assessing its size, and excluding Z e s hanother t of righdifferential diagnoses.
There are various t of righdifferent types of chest X-ray, which are t of righdiscussed below. The standard method han chest X-ray — Incorrect. Pneumothoraces D Supine a n can t for imagingo Zesh f pneumothoraces is an erect PA chest t o f Zesbe very subtle and difficult to identify t o on Zesh chest f supine h h h pyrigperformed during inspiration.
This provides CoX-ray Copy an rig rig Copy and there may not X-rays, as the air collects anteriorly, accurate and reliable assessment for a pneumothorax. Supine chest X-rays are thus not performed the lungs and cardiac contours compared to an AP or routinely.
Instead they are reserved for trauma patients expiratory X-ray. The key r e shi on a chest X-ray is finding u who cannoturebe i shsafely moved. Features suggestive ofQ a uresh i n Q n Q n ha ha a Zesha sharply f Zofesthe lung edge visceral pleura awayht of Zesoutlined dome of the hemidiaphragm, displacement pneumothorax on a supine chest X-ray include h t o h t o a fdeep lateral pyrigthe chest wall, with no lung markingsCvisible from Coperipheral opyr ig opyr ig costophrenic sulcus, and aChyperlucent upper quadrant to this.
The lateral chest pleural space overlying the upper abdomen. X-ray can provide helpful information if a pneumothorax is not visible on the PA X-ray. CT is the most sensitive and ures hi n Q n Q specific test a pneumothorax, its high radiationn Q dose routine practice.
CT is not the first line imaging modality for suspected However, there are not performed in the first instance. CT also provides the most reliable h a h t o f Zes h t o f Zesassessment of pneumothorax size.
Remember a s h a n Quhow easy or difficult it is to interpret s h a n Qu f Ze X-rays. For example, a brightly e f Zroom, lit with glare and a low resolution Ze fward p y r ight o p y r i ght o monitor, may makeCitodifficult or impossible to identify a small p y r i ght o Co Co pneumothorax.
Always try to optimise your chance of picking up pathology by using diagnostic quality workstations in a dark room if you are making diagnostic decisions. Pneumothoraces can be difficult to see on chest shi shi a n Qure a n QureX-rays. Inverting the image can an Qure esh make the lung edge more obvious. Always check the apices on an erect chest X-ray and around the lung bases on a u shi X-ray for evidence of a pneumothorax.
Which of the following is the most appropriate management option for a previously healthy patient with a small, asymptomatic primary pneumothorax? As isrethe hi n Q u es n Q u s n Q ures ha initially to approach the assessment patients, it is useful ha management of the patient using and ha the ABCDE h t o f Zes approach. Whilst asymptomatic not breathless and the pneumothorax has not increased in size. Patients should also be instructed s ton Q ha Z e Z e Z e r ht of in the outpatient clinic in weeks.
The patient should be h t o f Zes Incorrect. Needle aspiration, using a G Chest pneumothoraces. All patients with a pneumothorax needle, is as effective as chest drain insertion, but should avoid air travel until hi complete resolution.
These i shi should be performed in the safe triangle sh ures Diving shouldnbeQpermanently avoided in most u r e procedures Q Qure in s h a have had a pneumothorax. If the patient is intervention is required at that stage.
If, however, this not breathless and has a small primary spontaneous is not the case, the patient may require a chest drain pneumothorax, he or she can usually be managed hi repeat i eshneedle aspiration should not be performed. Supplementary oxygen not only improves hypoxaemia, but also increases shi the speed at which a shi hi pneumothorax Qure Qure nQ ures an resolves.
The size of the pneumothorax is one of the parameters used in deciding eshi Qurappropriate Qure treatment. Patients admitted with a pneumothorax should be reviewed by a respiratory physician within 24 hours. Patient details date a n Q on u r which the film was taken.
Technical adequacy pyrig Co pyrig 3. Technical Adequacy 4. Systematic X-ray. Copy 6. Systematic Review of the Film patient is supine but a lateralh i X-ray is taken eshi see figure 1 hi abdominal X-ray is n Q ures Such X-rays should Assessn the performed.
Which ur following are symptoms n Qur n Qthe abdomen. I would like to check B Nausea and vomiting the name and date of birth, as C Dysuria hi esthe shi hi well as the time and date n Qurof D Haematuria n Qure nQ ures h a esh a esha examination. Which type of renal stone is least likely to be included on the image; therefore, this is a technically inadequate ure hiX-ray.
D Struvite Given their position overlying the E Cysteine left renal outline and appearance, shi resh i resh i a n Qure 4. What is Qu diagnostic modality of choice anthe Qu an for they are most einshkeeping with small e s h e s h renal g h t of Z calculi. What is the most appropriate initial management oedema. There is ha a eshKUB? Otherwise, there is E Percutaneous nephrolithotomy no significant abnormality of the shi resh i resh i imaged skeleton.
They typically occur in middle age years and affect men more commonly than women. There are several risk factors for developing renal calculi. A Hypercalcaemia — Correct. Calcium is a component of Normally,i calcium within the lumen of the GI tract binds i hi of calcium esform resh and the resultant calcium oxalate is Q h most renal calculi,Qinurthe oxalate or touoxalate Q ures poorly s han There is increased risk of developing esha n n ha occurs in calcium t o f Z e phosphate.
Unabsorbed fats preferentially medications thiazides, vitamin D analogues, lithium. This results in oxalate binding hi with sodium hi in the GI tract. Sodium oxalate is absorbed B Renal tubular acidosise—sCorrect. There is an increased risk rescolon shi of developing a Qur renal stones in type 1 renal tubular an calcium n inuthe Q a Qure and results in high serum oxalatenlevels, sh is due to alkaline urine, hypercalciuria and f ZeThis acidosis.
E Copinfections Recurrent urinary tract — Correct. Struvite stones C Over hydration — Incorrect. Renal calculi are more common magnesium ammonium phosphate form in alkaline in hot climates due to dehydration. Dehydration results urine which contains ammonia. These conditions can in concentrated urine, which can become supersaturated occur in the presence of urease producing bacteria, such as with substances that eshi in stone formation.
Qurresult Proteus, Q ures i hKlebsiella and Enterobacter urease metabolisesresh Qustones i a n an urea into ammonia and carbon dioxide. Which of the following are symptoms associated with renal calculi?
A Pain — Incorrect. Renal colic is the classic symptom C Dysuria — Incorrect. Dysuria can occur with urinary tract associated with urinary u r e shi calculi. It is caused by a tract calculi. The 3 anatomical sites at which Copcalculi Cop with renal calculi.
It is often clinical finding in patients become obstructed are a the pelvi-ureteric junction, b microscopic and is related to inflammation and trauma where the ureter crosses over the iliac vessels, and c at caused by the calculus.
However, the absence of the vesico-ureteric junction. Additionally, any pathological haematuria on urinalysis does not exclude renal calculi.
As the previousaanswersn Qure The pain usually Zes starts acutely, spreads from the loin to s h h h t of and groin comes in waves. In contrast to peritonitis, h of Ze t patients h f Zes of symptoms. Copy and rigors if there is super- They can also cause fever added infection, acute kidney injury secondary to B Nausea and vomiting — Incorrect.
Nausea and vomiting ureteral obstruction, as well as being asymptomatic. It is mediated via an autonomic response to the pain. The ganglion which i receives pain signals from i i u r e shthe resh resh the kidneys alsonQ a supplies stomach.
In addition, if the aneurysm is adjacent to a ureter, there may be haematuria. Therefore, it is important to consider this serious differential i i hi Q resh udiagnosis resh65 years presenting with renal colic particularly in patients ageduover Q Q ures a n a n a n f Zesh for the first time. Overall, Different types of renalucalculi Q ureapproximately Q n n shan are radio-opaque o f Z esha i.
The esall o f Z eexception ispy right that form in HIV patients beingotreated calculi ht pyrig with the protease inhibitor indinavir; ght stones are ithese Abdominal Coclassically opyr X-Rays radiolucent even on CT. C C A Uric acid — Correct. Uric acid stones are the least radio- C Calcium phosphate — Incorrect. They are typically D Struvite — Incorrect. Struvite calculi form in the presence hi shi bacteria see Question 1 and accountureshi radiolucent on X-ray butQ ures visible on CT.
They o f Zare o with p y h gout rig or o p y right are being treated for myeloproliferative ight opyr densest type of renal radio-opaque, and are the second C disorders. Most staghorn calculi are composed of struvite. Xanthine stones are also typically radiolucent but E Cysteine — Incorrect. Cysteine stones are rare.
They are a rare cause of renal calculi. Calcium shi containing renal hi condition. They are the most radio-opaque for approximately o f Zescalcium f Zes g h t pyri calculi. What is the diagnostic modality of choice for identifying renal calculi?
All the options listed can help diagnose urinary hi tract calculi. Ultrasound can occasionally be difficult to differentiate urinary tract calculi from identify renal calculi. However, this modality is not as other causes of renal, abdominal or pelvic calcification sensitive as CT. Additionally, it is usually impossible such as nephrocalcinosis and calcified i phleboliths.
Ultrasound f Zisegood at o p y r i response g h treatment if the calculus is radio-opaque o p y right o p y identifying urinary tract obstruction h t rig which may be C and visible on the X-ray. Additionally, if a patient C is C caused by calculi. Furthermore, it can identify other known to have radio-opaque calculi, plain X-rays can be causes of loin pain and haematuria such as renal used if they re-present with acute pain to assess any tumours, as well as gynaecological pathology, such as change in position of the knownhcalculi.
Non contrast f esCT pyrig However, they have now been superseded Cocalculi. Copy rig is the imaging modality of o C pyrigIt is a low dose non- choice. It is readily available and ureters and bladder KUB once the contrast is within quick to perform.
As it is a non-contrast examination, the urinary collecting system. Additionally, urinary tract ht of t ourinary Zescalculi. Standard contrast t o f ZesCT can identify enhanced h rig rig ig opyitruses a higher dose of radiation Copy assessment of the other abdominalCand opypelvic organs, Cbut urinary tract calculi, helping to identify or exclude other differential than CT KUB and requires intravenous contrast. It does, although the accuracy for this is limited by the low however, provide a better assessment of the abdominal i shi organs.
Additionally, a delayed phase u i dose nature of the Q resh uexamination and the lack of urepelvic and Q Q resh scan, s h n acontrast. As discussed in Question 3, eshan ha n intravenous of Z e t of Z where the patient is imaged when the o Zescontrast f urogram is being righatsmall proportion of urinary tract calculi ighnot rare excreted into the urinaryytract rig h t CT , would help Abdominal o p y o p y Cop calculi as these would appear X-Rays C visible on CT; however, there may stillC be secondary identify non-radio-opaque signs of urinary tract calculi, such as perinephric and as filling defects in the urinary tracts.
The correct answer is D Conservative approach supportive treatment with shi shi X-ray KUBs [if the stone is ureshi n Qure and anti-emetics and follow analgesia n urewith Qup Q Z e s h a Z e s h a Z e s han ht of visible on X-ray] until the hstone t of has passed. Most ureteric are used as 1st line , anti-emetics and IV fluids if calculi are accessible.
However, results are best for dehydrated. If t o t o ofsuch t of righ igh opyr reserved visible on X-rays, the progress r i g h stones can be Copy Incorrect. If the stone fails to large stones. An external energy source causes shock pass after weeks, the pain becomes intolerable, waves which are targeted towards the stone. The aim is or if the patient develops an infected, obstructed to fragment stones toeallow hi them to pass through the collecting hi system, an alternative treatment option is i ureters.
It is usually reserved for large patients with an obstructed kidney and super-added or complex stones or patients in which ESWL and infection. It is usually performed under sedation ureteroscopy have failed. Orthopaedic This introduction shthe f Zeto f Zes f Zes o o o X-Rays Further g h t ridetails h t igfindings discussed below are coveredpmore and examples of the specific X-rays h t rig extensively in the Copy cases later in the chapter and theCbonus opyr Co y example X-ray chapter.
Projection Copy Copy 4.
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