FRCR 2B Rapid Reporting : CXR cases

The rapid reporting cases when we sometimes miss the finding include:

• Subtle pneumothorax (especially Apical and Supine PT).
• Apical pulmonary nodule / mass.
• Lytic lesion rib.
• Mastectomy.

Other less subtle ones include : Rib fracture, distal clavicular fracture, Left Upper Lobe collapse, Right middle lobe pneumonia, RLL/LLL collapse.

Patterns of pulmonary edema, SPN, Hilar lymphadenopathy, lobar consolidation are usually the obvious 'abnormal's in the exam, which should not pose any problems.

Ill-defined air-space opacification in right mid-zone, with poor definition of right cardiac margin (loss of silhouette), consistent with a right middle lobe pneumonia.  Unless careful, can pass this as normal. 

Case courtesy of Dr Jan Frank Gerstenmaier, Radiopaedia.org. From the case rID: 25805

The above case is a case of D10 ivory vertebra due to sclerotic metastasis from breast Ca.
However for the RR purpose, see the left mastectomy, with increased transradiancy of left hemithorax.
In addition there are few surgical clips seen in the lateral chest wall on left side.

The above image shows how to follow a checklist in each CXR case. The importance to follow a checklist for each region cannot be discounted in any case. This image also shows how subtle rib lytic lesions can be.

Click here for the Chest Radiograph RR Checklist

Good web resources for RR:

1. Radiology Masterclass

2. Radiopaedia ( Now have 6 packets of RR free).

3. Norwich Image Interpretation Course.

4. FRCR Academy (Paid Membership, ~30 RR packets).

5. Dr. Sameer Shamshuddin's Website : This site has numerous other resources and links for FRCR.
6. Dr. Gaurav Shankar's FRCR 2B Tips.

Chest radiograph checklist for FRCR 2B Rapid Reporting

CHEST RADIOGRAPH CHECKLIST

1. Situs
2. Air: Pneumothorax, pneumomediastinum, pneumoperitoneum, surgical emphysema.
• Always look for any abnormal gas first. Beware of soft tissue shadows like skin folds mimicking pneumothorax.
3. Trachea, carina, bifurcation.
• After the first two steps follow the trachea from above down, to the carina and look into the proximal bronchi. Don't miss any metallic foreign bodies (coins, safety pins), or obvious bronchial occlusions.
4. Hilum : Can say enlarged hilum.
• After the bronchi, look both hila, look for enlargement, nodularity, calcifications.
• We will get marks even if we dont distinguish between mass or nodes, can say enlarged hilum - will be sufficient to fetch you the 1 mark.
5. Mediastinum : 
• Look for pneumomediastinum, mediastinal masses, silhouette sign. 
• Mediastinal lucencies / air fluid level could represent achalasia cardia and absent fundic gas favors hiatus hernia.
6. Heart - usually not much cases.
7. Lung parenchyma : Compare both sides (Upper zone - Upper zone, MZ-MZ so on). 
8. Pleura : Pleural plaques (calcified). 
9. Bones: 
• Follow the clavicles from medial to lateral. Distal clavicular erosions with shoulder joint arthritis can point to RA.
• Look for AC joint subluxation or dislocation.
• Shoulder dislocation can be seen occasionally in CXRs. 
• Watch out for Proximal humeral lytic areas in cases of mastectomy, which will get you the other 1/2 marks.
• When you are looking for rib pathologies, look in pairs, comparing both sides at the same time.
10. Soft tissue – Never miss mastectomy. Look for axillary surgical clips. Look for neck/axillary soft tissue lesions. Don't mistake hair braids in female patients for neck /lung apical lesions.
11. Review Areas : Lung Apices (small pneumothorax, nodule, even obvious Pancoast may be missed if you dont look), Retroardiac lung, retro-diaphragmatic lung, gas under diaphragm, upper abdomen (calcifications). 

FRCR 2B Rapid Reporting : The Beginning

Rapid reporting at present consist of viewing 30 radiographs in 35 minutes, writing which is normal OR abnormal and if 'abnormal', what is the abnormality you saw. Usually there is only one clear abnormality in the 'abnormal' x-rays.

And it requires to follow a diagnostic checklist FOR EACH RADIOGRAPH, so as not to miss any subtle abnormality. Every body part radiograph has its own checklist.

Deviating from the checklist can bring disastrous consequences to your overall result. 

Exam consists of Rapid Reporting (8 marks), Viva ( 8 + 8 marks) and Long cases reporting (8 marks). Out of which we need to get 24 out of 32 to pass the exam. And should not get less than 6 marks in more than two components. If we get less than 6 in more than two components (for example 5.5 + 5.5 + 5 + 8) and even if we make it up to 24, it's a fail.

TOTAL MARKS IN RR	OVERALL MARKS IN RR
0 to 24	4
24 ½	4 ½
25 to 25 ½	5
26 to 26 ½	5 ½
27	6
27 ½  to 28	6 ½
28 ½ to 29	7
29 ½	7 ½
30	8

 As we can see beyond the pass mark (6), it becomes increasingly difficult or in other words each mistake costs you more, going down from the 30 correct. (For example you got 29 correct, you will get 7 marks out of 8, loosing one mark for a single mistake).

Two things to remember is that however bad you do the RR, you will get 4 marks, and if you make 20 marks for the Viva and Long Cases, you can still pass, which is rather very difficult (7 + 7 + 6, 6.5 + 6.5 +7) and you will have to be exceptional to get that !. 2nd thing (common myth) its not like if you fail in one component ( get less than 6 marks), you will fail in the exam, and exemplified in the aforesaid example. (Similarly in Long cases, for a question which you don't know the answer, if you write anything, even if irrelevant, you will get '3' marks, giving you a fighting chance for getting the passing '6' marks average. On the other hand you just left the answer blank, you will get '0' marks)

You can get free great RR materials and instructions from frcrtutorials.com. Or you can purchase 30 RR packets from FRCR Academy. Other option is you make your own, with the help of few friends, whose interest and goals align with you.

We might not get 27/30 from the start itself. But with 'practice - practice - practice' we can reach the goal. Making an Individual RR Checklist and Reporting Templates will help.

 Sample RR template, which I used.

In the next few posts we will look into individual RR-Checklists, likely siting examples for each finding, which is going to be an arduous task ! .

D.V.