OSCESup.com
Year 2 Stations
Data Interpretation
ECG, blood results, urine dipstick, and imaging for all 4 Year 2 communication stations. Use alongside the station file. Reveal answers when ready.
4 stations
ECG
Bloods
Urine dipstick
Imaging
Year 2
01
Year 2
Renal / Urology
Data Interpretation
Mr Dennis Hartley, 67 — Haematuria
History taking station · Renal / Urology
📋
Clinical context
Mr Dennis Hartley, 67. Retired painter and decorator. 3 days of painless visible haematuria throughout the stream. Ex-smoker (30 pack-years). On aspirin 75mg for known AF. Uncle had bladder cancer. Lost 4kg over 3 months. GP has ordered urgent investigations.
12-lead ECG — Mr D. Hartley · 67yrs
25mm/s · 10mm/mV · Automated report: Atrial fibrillation
Rate
92 bpm
Borderline
Rhythm
Irregularly irregular — no discernible P waves
Abnormal
P waves
Absent — replaced by chaotic fibrillatory baseline
Absent
PR interval
Not measurable
N/A
QRS duration
80ms — narrow complex
Normal
QTc
420ms
Normal
ST / T waves
No ST elevation or depression. No T wave inversion.
Normal
Axis
Normal axis (0° to +90°)
Normal
Interpretation questions — reveal when ready
Q1
What is the rhythm diagnosis?
Atrial fibrillation (AF). Irregularly irregular rhythm with absent P waves and a chaotic fibrillatory baseline — the classic triad. Narrow complex QRS confirms this is not ventricular in origin.
Q2
How does this ECG relate to Mr Hartley's history and medications?
He is on aspirin 75mg for known AF — this ECG confirms his diagnosis is active. AF is relevant to his haematuria: aspirin has antiplatelet effects that can worsen or prolong bleeding. It does not directly cause haematuria but can make it more apparent.
Q3
What is the significance of AF in the context of his overall risk picture?
AF is a major risk factor for cardioembolic stroke. His CHA₂DS₂-VASc score should be calculated. If ≥ 2 in males, anticoagulation (e.g. DOAC) should be considered — though this will be weighed against his risk of haematuria from a potential bladder malignancy.
Key clinical link
AF + aspirin + painless haematuria in a 67-year-old male ex-smoker with occupational chemical exposure = urgent 2-week-wait urology referral required. The antiplatelet use must be documented but does not explain away the haematuria — bladder cancer must be excluded first.
Exam tip — AF on ECG
Three findings = AF: (1) irregularly irregular rhythm, (2) absent P waves, (3) fibrillatory baseline. If QRS is broad, consider AF with bundle branch block or AF with aberrant conduction — but narrow complex AF = simple AF with ventricular rate response.
Urgent Bloods — Mr D. Hartley · GP request
Collected 09:15 · Lab ref: NB-20250709-4421
| Test | Result | Reference range | Flag |
|---|---|---|---|
| Full Blood Count | |||
| Haemoglobin (Hb) | 119 g/L | 130–170 g/L (M) | Low |
| MCV | 84 fL | 80–100 fL | Normal |
| White cell count | 7.2 × 10⁹/L | 4–11 × 10⁹/L | Normal |
| Platelets | 218 × 10⁹/L | 150–400 × 10⁹/L | Normal |
| Renal Function (U&E) | |||
| Sodium (Na⁺) | 138 mmol/L | 133–146 mmol/L | Normal |
| Potassium (K⁺) | 4.1 mmol/L | 3.5–5.3 mmol/L | Normal |
| Urea | 6.8 mmol/L | 2.5–7.8 mmol/L | Normal |
| Creatinine | 108 µmol/L | 59–104 µmol/L (M) | Borderline ↑ |
| eGFR | 58 mL/min/1.73m² | > 60 mL/min/1.73m² | Stage G3a CKD |
| Inflammatory Markers | |||
| CRP | 42 mg/L | < 5 mg/L | Raised |
| ESR | 64 mm/hr | < 20 mm/hr (M) | Raised |
| Tumour Markers | |||
| PSA (Prostate Specific Antigen) | 2.1 µg/L | < 4.0 µg/L (age 60–69) | Normal |
Interpretation questions — reveal when ready
Q1
What does the mild anaemia suggest in this context?
Hb 119 g/L with a normocytic picture (MCV normal) is consistent with anaemia of chronic disease or early blood loss. In the context of visible haematuria and 4kg weight loss, this raises further concern for an underlying malignancy causing chronic insidious blood loss.
Q2
What does eGFR 58 tell you, and is this relevant to his haematuria?
eGFR 58 = CKD stage G3a (mildly to moderately decreased). This is relevant for two reasons: (1) it may indicate underlying renal pathology contributing to haematuria (glomerulonephritis, renal tumour), and (2) it affects choice of medications and contrast use if CT urogram is ordered.
Q3
Raised CRP and ESR — what is your interpretation?
Elevated inflammatory markers with weight loss and haematuria form a concerning triad pointing towards malignancy rather than infection. The normal WCC argues against acute infection. This should prompt expedited investigation.
Q4
The PSA is normal — does this exclude prostate cancer?
No. PSA < 4 µg/L makes significant prostate cancer less likely but does not exclude it entirely. Haematuria is more commonly from bladder or upper urinary tract in this demographic. The PSA result is reassuring but the haematuria workup (cystoscopy + CT urogram) must still proceed.
Key clinical picture
Anaemia + raised CRP/ESR + haematuria + 4kg weight loss + 30 pack-year history + 40 years of chemical exposure = strong suspicion for bladder transitional cell carcinoma. Refer urgently via 2-week-wait pathway for cystoscopy and CT urogram.
Urine Dipstick — Mr D. Hartley
Mid-stream urine · GP surgery
Glucose
NEG
Ketones
NEG
Protein
+
Blood
+++
Nitrites
NEG
Leucocytes
NEG
pH
6.0
SG
1.018
Bilirubin
NEG
Urobilinogen
Normal
Blood +++Significant haematuria. Visible (frank) blood on dipstick correlating with patient's history. Requires urgent further investigation — do not attribute to aspirin alone.
Nitrites NEGNegative nitrites make a bacterial UTI (e.g. E. coli) unlikely. Note: some organisms do not produce nitrites (e.g. Enterococcus, Staphylococcus saprophyticus).
Leucocytes NEGNo leucocytes — further reduces likelihood of infective cause. Haematuria without pyuria or nitrites in a 67-year-old male = non-infective aetiology until proven otherwise.
Protein +Mild proteinuria — could reflect glomerular involvement (e.g. IgA nephropathy, glomerulonephritis) or early renal impairment in the context of CKD G3a. Worth monitoring.
Interpretation questions — reveal when ready
Q1
Blood +++ with negative nitrites and negative leucocytes — what does this pattern suggest?
This is non-infective haematuria — the absence of nitrites and leucocytes makes a UTI very unlikely. The differential for blood-only haematuria in a 67-year-old man includes bladder cancer, renal cell carcinoma, urothelial cancer, glomerulonephritis, and renal calculi. Malignancy must be excluded urgently.
Q2
Can aspirin account for the haematuria?
No — this is a common misconception. Antiplatelet agents and anticoagulants can unmask pre-existing pathology or worsen bleeding, but they do not cause de novo haematuria. Any patient on aspirin with visible haematuria still requires full investigation. Attributing haematuria to aspirin without investigation is a patient safety error.
Q3
What is the significance of the mild proteinuria alongside haematuria?
Haematuria + proteinuria together (especially with reduced eGFR) raises the possibility of glomerular disease (e.g. IgA nephropathy, thin basement membrane disease, vasculitis). This pattern warrants renal workup in addition to urological investigation. Urine protein:creatinine ratio and renal USS would be appropriate next steps.
NICE NG12 — 2-Week Wait Criteria
Unexplained visible haematuria in a patient aged ≥ 45 = urgent 2-week-wait referral regardless of other findings. Mr Hartley meets this criterion (age 67, visible haematuria). Additional risk factors (smoking, occupational exposure, weight loss) make this even more pressing.
KUB X-ray (Kidneys, Ureters, Bladder) — Mr D. Hartley
AP supine · Radiology dept
Illustrated report
No radio-opaque calculi identified along the course of either ureter or within the renal collecting systems
Both renal outlines visible and within normal limits on plain film
Bladder outline appears unremarkable on plain film
No bony lesions identified; mild degenerative changes in lumbar spine consistent with age
Important limitation: KUB only identifies radio-opaque stones (calcium oxalate/phosphate). Radiolucent stones (uric acid), tumours, and soft tissue masses are NOT visible on KUB.
Radiological report summary
RADIOLOGY REPORT
Patient: D Hartley · 67M
Study: Plain radiograph KUB · AP supine
Clinical indication: Visible haematuria — exclude calculi
FINDINGS:
No radio-opaque calcific densities identified within the renal tracts bilaterally. Renal outlines appear within normal limits on plain radiograph. Bladder not adequately visualised. Bony pelvis and lower lumbar spine show mild degenerative change.
IMPRESSION:
No radio-opaque renal tract calculi. This does not exclude soft tissue pathology. CT urogram is recommended as the investigation of choice for haematuria workup.
No radio-opaque calcific densities identified within the renal tracts bilaterally. Renal outlines appear within normal limits on plain radiograph. Bladder not adequately visualised. Bony pelvis and lower lumbar spine show mild degenerative change.
IMPRESSION:
No radio-opaque renal tract calculi. This does not exclude soft tissue pathology. CT urogram is recommended as the investigation of choice for haematuria workup.
Interpretation questions — reveal when ready
Q1
The KUB is normal — does this reassure you? What does it tell you and what does it miss?
A normal KUB is not reassuring in this context. KUB only detects radio-opaque calculi (calcium stones ≈ 90% of stones). It cannot detect: radiolucent stones (uric acid), bladder tumours, renal cell carcinoma, upper tract urothelial cancers, or soft tissue masses. A normal KUB does not change the management plan.
Q2
What imaging is actually required for this patient?
CT urogram (CT KUB with contrast, three phases: non-contrast, nephrographic, and excretory) is the gold standard investigation for haematuria. It detects renal and ureteric calculi, renal masses, urothelial tumours, and upper tract pathology. Cystoscopy (performed by urology) visualises the bladder directly and allows biopsy.
Important limitation — KUB in haematuria
KUB is increasingly considered an outdated first-line investigation for haematuria. NICE and the British Association of Urological Surgeons recommend CT urogram + flexible cystoscopy as the standard haematuria workup. KUB may be used in known stone disease follow-up but is insufficient to exclude malignancy.
Exam tip — imaging for haematuria
If asked "what investigation would you request?": CT urogram + urine cytology + cystoscopy (via urology 2WW referral). Do not say "KUB and renal ultrasound" for a 67-year-old with painless visible haematuria and red flags — this is insufficient and would delay cancer diagnosis.
02
Year 2
Neurology
Data Interpretation
Mrs Patricia Osei, 71 — Stroke
Breaking bad news station · Neurology
📋
Clinical context
Mrs Patricia Osei, 71. Admitted after husband found her confused with right-sided weakness. CT + MRI confirmed left-sided ischaemic stroke in MCA territory. Treated with thrombolysis. Mild residual right arm weakness, otherwise improving. PMHx: hypertension. No known AF prior to admission.
12-lead ECG — Mrs P. Osei · 71yrs · Acute admission
25mm/s · 10mm/mV · Taken on admission
Rate
~115 bpm (ventricular response)
Raised
Rhythm
Irregularly irregular — no P waves
AF
P waves
Absent — chaotic fibrillatory baseline
Absent
QRS duration
80ms — narrow complex
Normal
ST segments
No ST elevation or depression
Normal
Classification
AF with fast ventricular response — new diagnosis
New AF
Interpretation questions — reveal when ready
Q1
What is the diagnosis and what is its significance for Mrs Osei's stroke?
Atrial fibrillation with fast ventricular response (≈115 bpm). This is the most likely cause of her stroke — cardioembolic stroke secondary to AF. AF causes stasis of blood in the left atrial appendage, forming clots that can embolise to the cerebral circulation. AF accounts for approximately 20% of all ischaemic strokes.
Q2
What is her CHA₂DS₂-VASc score and what does it mean for management?
Mrs Osei scores: CHF 0 · Hypertension +1 · Age ≥75 +2 (she's 71, so Age 65–74 = +1) · Diabetes 0 · Stroke +2 · Vascular disease 0 · Age 65–74 already counted · Sex (female) +1 = Total: 5. This mandates long-term anticoagulation. A DOAC (e.g. apixaban, rivaroxaban) is first-line.
Q3
When should anticoagulation be started after a stroke?
The timing of anticoagulation after ischaemic stroke in AF is guided by stroke severity and haemorrhagic transformation risk. The "1-3-6-12 rule" is a common clinical guide: TIA = day 1, minor stroke = day 3, moderate = day 6, severe = day 12. In practice this is a consultant decision guided by imaging. Do not start anticoagulation immediately — there is a risk of haemorrhagic transformation of the ischaemic infarct.
AF as a cause of stroke
This ECG is clinically critical — it identifies the likely cause of her stroke (cardioembolic from AF) and drives the secondary prevention strategy (anticoagulation, rate control). Without this ECG finding, she might be given antiplatelet therapy alone, which would be insufficient for AF-related stroke.
Admission Bloods — Mrs P. Osei · Stroke unit
Collected on admission · Urgent screen
| Test | Result | Reference range | Flag |
|---|---|---|---|
| Metabolic / Glucose | |||
| Blood glucose (random) | 8.4 mmol/L | < 7.8 mmol/L (random) | Borderline ↑ |
| HbA1c | 41 mmol/mol | < 48 mmol/mol | Normal |
| Lipids | |||
| Total cholesterol | 6.8 mmol/L | < 5.0 mmol/L | High |
| LDL cholesterol | 4.2 mmol/L | < 3.0 mmol/L | High |
| HDL cholesterol | 1.4 mmol/L | > 1.0 mmol/L (F) | Normal |
| Triglycerides | 2.1 mmol/L | < 1.7 mmol/L | Mild ↑ |
| Coagulation | |||
| PT / INR | 1.0 | 0.9–1.2 | Normal |
| APTT | 28 seconds | 26–37 seconds | Normal |
| Renal & Electrolytes | |||
| Sodium | 136 mmol/L | 133–146 mmol/L | Normal |
| Potassium | 3.8 mmol/L | 3.5–5.3 mmol/L | Normal |
| eGFR | 72 mL/min/1.73m² | > 60 mL/min/1.73m² | Normal |
Interpretation questions — reveal when ready
Q1
Why is blood glucose checked on admission in all suspected strokes?
Hypoglycaemia and hyperglycaemia can both mimic stroke symptoms. Hypoglycaemia is a stroke mimic that must be excluded immediately with a bedside glucose. Additionally, hyperglycaemia worsens ischaemic injury after stroke — glucose above 11 mmol/L should be treated. Her glucose of 8.4 is mildly elevated but HbA1c is normal, suggesting acute stress hyperglycaemia rather than undiagnosed diabetes.
Q2
What do the lipid results tell you, and what is the management implication?
She has elevated total cholesterol (6.8) and LDL (4.2) — significant dyslipidaemia. This is a major modifiable stroke risk factor. She should be started on high-intensity statin therapy (atorvastatin 80mg OD) for secondary prevention after ischaemic stroke, regardless of baseline cholesterol level. This is NICE guideline recommendation.
Q3
The coagulation screen is normal — what does this tell you?
Normal PT/INR and APTT confirms she was not on anticoagulation prior to admission and has no baseline coagulopathy. This is relevant for: (1) confirming thrombolysis eligibility (she was not anticoagulated), and (2) establishing a baseline before starting a DOAC for secondary prevention.
Secondary prevention package for AF-related stroke
Based on these bloods + ECG, her secondary prevention should include: (1) DOAC (anticoagulation for AF — timing per stroke severity), (2) atorvastatin 80mg (dyslipidaemia + ischaemic stroke), (3) antihypertensive optimisation, (4) lifestyle advice — no smoking, alcohol guidance, diet. She does not need antiplatelet therapy if anticoagulated.
CT Head (Non-contrast) — Mrs P. Osei · 71yrs
Taken on admission to ED · Stroke protocol
Illustrated axial CT slice (approximate)
Subtle hypodensity in left MCA territory — early ischaemic change. Hypodense (dark) area in the distribution of the left middle cerebral artery, corresponding to right-sided weakness.
No haemorrhage identified — no hyperdense (bright) areas consistent with intracerebral haemorrhage. This is critical for thrombolysis eligibility.
No midline shift — no significant mass effect from early infarct
Early changes may be subtle on non-contrast CT within first 6 hours — MRI DWI is more sensitive for acute ischaemia
Radiological report summary
RADIOLOGY REPORT
Patient: P Osei · 71F
Study: CT head non-contrast · Stroke protocol
Clinical indication: Right-sided weakness + confusion — ?stroke
FINDINGS:
No intracranial haemorrhage. No hyperdense MCA sign. Subtle loss of grey-white matter differentiation in left MCA territory, in keeping with early ischaemic change. No midline shift. Ventricles normal. No space-occupying lesion.
IMPRESSION:
Findings consistent with left MCA territory acute ischaemic stroke. No haemorrhage. Patient eligible for thrombolysis if within time window and clinical criteria met.
No intracranial haemorrhage. No hyperdense MCA sign. Subtle loss of grey-white matter differentiation in left MCA territory, in keeping with early ischaemic change. No midline shift. Ventricles normal. No space-occupying lesion.
IMPRESSION:
Findings consistent with left MCA territory acute ischaemic stroke. No haemorrhage. Patient eligible for thrombolysis if within time window and clinical criteria met.
Interpretation questions — reveal when ready
Q1
Why is a CT head the first imaging done in suspected stroke?
CT head is fast, widely available, and most critically — it excludes haemorrhagic stroke, which looks identical clinically but is managed completely differently. Thrombolysis is contraindicated in haemorrhagic stroke (it would worsen the bleed). CT must be done before giving thrombolysis or anticoagulation.
Q2
Why might the CT appear normal or near-normal in the first few hours after ischaemic stroke?
Early ischaemic changes can be very subtle on non-contrast CT — cytotoxic oedema takes several hours to develop into clearly visible hypodensity. MRI with diffusion-weighted imaging (DWI) is far more sensitive and can detect ischaemia within minutes of onset. A normal CT does not exclude ischaemic stroke; MRI or clinical judgement must guide management.
Q3
Left MCA territory infarct — what deficits would you expect clinically, and why?
The left MCA supplies: motor cortex (arm > leg), somatosensory cortex, and (in most right-handed people) Broca's and Wernicke's language areas. Expected deficits: right-sided hemiparesis (arm predominant), right-sided hemisensory loss, and potentially aphasia (expressive/receptive). Mrs Osei has right arm weakness — consistent with left MCA territory infarction.
Exam tip — CT vs MRI in stroke
CT: fast, rules out haemorrhage, often done first. MRI DWI: most sensitive for acute ischaemia, can detect within minutes, also shows extent of infarct and penumbra. Both are used in stroke — CT first to exclude haemorrhage, then MRI for definitive characterisation and stroke cause workup.
03
Year 2
Cardio / Resp
Data Interpretation
Mrs Shirley Dawson, 64 — Breathlessness
History taking station · Cardio / Resp
📋
Clinical context
Mrs Shirley Dawson, 64. 3-month progressive breathlessness. Orthopnoea (3 pillows), bilateral ankle oedema, dry cough × 6 weeks. On ramipril + amlodipine for hypertension. Kept pigeons for 20 years (sold 6 months ago). Ex-smoker (15 pack-years). BMI 34. Two differentials: heart failure vs hypersensitivity pneumonitis (bird fancier's lung).
12-lead ECG — Mrs S. Dawson · 64yrs
25mm/s · 10mm/mV · Sinus tachycardia with LVH changes
Rate
105 bpm
Sinus tachycardia
Rhythm
Regular — sinus tachycardia
Regular
P waves
Present, regular, but broad and notched — "P mitrale" (bifid P wave > 120ms)
Abnormal
PR interval
170ms — upper limit normal
Borderline
QRS
Narrow — 90ms · Tall R waves in lateral leads
LVH pattern
Sokolow-Lyon
S(V1) + R(V5) = 42mm (> 35mm threshold)
LVH criterion met
ST / T waves
No acute ST changes. T wave flattening laterally.
Borderline
Interpretation questions — reveal when ready
Q1
What does "P mitrale" indicate, and what is its significance here?
P mitrale (broad, bifid P wave > 120ms in lead II) indicates left atrial enlargement. This occurs in conditions that increase left atrial pressure or volume — classically mitral stenosis, but also heart failure with raised left atrial pressure, hypertensive heart disease, or mitral regurgitation. Combined with her hypertension history, this strongly supports a cardiac aetiology.
Q2
What does the LVH pattern (Sokolow-Lyon criterion) suggest?
Left ventricular hypertrophy (LVH) — thickening of the left ventricular wall, typically secondary to longstanding hypertension (pressure overload). LVH is a known complication of hypertension and a risk factor for heart failure. Combined with her symptoms (orthopnoea, ankle oedema), this ECG provides strong supporting evidence for hypertensive heart disease leading to heart failure.
Q3
Does this ECG help differentiate heart failure from bird fancier's lung?
Yes, partially. This ECG supports heart failure — LVH and P mitrale are cardiac findings. Bird fancier's lung (hypersensitivity pneumonitis) would typically show a normal ECG (it is a primary pulmonary condition). However, the ECG alone does not confirm heart failure — BNP and echocardiogram are needed. The pigeon history still needs to be investigated with CT chest and HRCT.
Sokolow-Lyon criterion for LVH
S wave in V1 + R wave in V5 (or V6) > 35mm = LVH. Other criteria: Cornell (R in aVL > 11mm), or Romhilt-Estes scoring. Sensitivity is only ~20–30% but specificity is ~95% — a positive result is meaningful even if many LVH cases are ECG-negative.
Bloods — Mrs S. Dawson · GP urgent request
Fasting sample · Lab ref: NB-20250822-5510
| Test | Result | Reference range | Flag |
|---|---|---|---|
| Cardiac Biomarker | |||
| NT-proBNP | 1840 ng/L | < 125 ng/L (<75yrs) | Significantly raised |
| Thyroid Function | |||
| TSH | 2.1 mU/L | 0.4–4.0 mU/L | Normal |
| Free T4 | 14.8 pmol/L | 9–25 pmol/L | Normal |
| Renal & Electrolytes | |||
| Sodium | 131 mmol/L | 133–146 mmol/L | Low |
| Potassium | 4.4 mmol/L | 3.5–5.3 mmol/L | Normal |
| Urea | 10.2 mmol/L | 2.5–7.8 mmol/L | Raised |
| Creatinine | 110 µmol/L | 45–90 µmol/L (F) | Borderline ↑ |
| eGFR | 54 mL/min/1.73m² | > 60 mL/min/1.73m² | CKD G3a |
| Liver Function (Cardiac screen) | |||
| ALT | 58 U/L | 7–45 U/L | Mildly raised |
| Albumin | 32 g/L | 35–50 g/L | Low |
| Bilirubin | 14 µmol/L | < 21 µmol/L | Normal |
Interpretation questions — reveal when ready
Q1
NT-proBNP is 1840 ng/L. What does this mean, and why is this significant?
NT-proBNP is markedly elevated — the NICE threshold for ruling in heart failure is > 2000 ng/L (highly likely) and > 400 ng/L (possible). At 1840 ng/L this is in the "possible to likely" range. BNP/NT-proBNP is released by stretched ventricular myocytes in response to pressure or volume overload. This strongly supports heart failure as the cause of her breathlessness and mandates urgent echocardiography.
Q2
Why is thyroid function checked in breathlessness workup?
Hypothyroidism can cause breathlessness, fatigue, and ankle oedema — it can mimic or worsen heart failure. Hyperthyroidism can cause tachycardia, palpitations, AF, and high-output heart failure. Both are important and treatable causes. Her TFTs are normal, which reassures that thyroid disease is not contributing here.
Q3
What does the mild hyponatraemia (Na 131) suggest in the context of heart failure?
Hyponatraemia in heart failure occurs due to dilutional hyponatraemia — reduced cardiac output activates the renin-angiotensin-aldosterone system and ADH, leading to water retention in excess of sodium. It is a marker of severity in heart failure and associated with worse prognosis. It may also be partly due to her ramipril (ACE inhibitor).
Q4
Why are LFTs and albumin relevant in suspected heart failure?
Raised ALT and low albumin suggest congestive hepatopathy (cardiac hepatitis) — right-sided heart failure causes hepatic venous congestion, leading to mildly deranged liver enzymes and reduced albumin synthesis. Low albumin also worsens peripheral oedema by reducing plasma oncotic pressure. This pattern supports right heart involvement alongside the left-sided findings.
Next step from these bloods
NT-proBNP > 400 ng/L + clinical features of heart failure = urgent echocardiogram within 2 weeks (NICE NG106). Echo will determine ejection fraction (HFrEF vs HFpEF), valve pathology, and guide treatment. Do not withhold treatment pending echo if clinically decompensated.
Chest X-ray (PA erect) — Mrs S. Dawson · 64yrs
GP referral — acute breathlessness workup
Illustrated CXR (schematic)
Cardiomegaly — cardiothoracic ratio (CTR) > 0.5. Enlarged cardiac silhouette with prominent left heart border consistent with left ventricular enlargement.
Bilateral pleural effusions — blunting of both costophrenic angles, with meniscal opacification at the lung bases. Left > right.
Kerley B lines — short horizontal lines at the lung bases, representing thickened interlobular septa from pulmonary oedema. Consistent with elevated pulmonary venous pressure.
No focal consolidation, masses, or pneumothorax identified. Hila not enlarged.
Radiological report summary
RADIOLOGY REPORT
Patient: S Dawson · 64F
Study: Chest radiograph · PA erect
Clinical indication: Progressive breathlessness — ?cardiac ?respiratory
FINDINGS:
Cardiac silhouette enlarged — CTR estimated at 0.58. Bilateral pleural effusions, greater on the left. Kerley B lines identified at lung bases bilaterally. Upper lobe blood diversion. No focal consolidation. No pneumothorax.
IMPRESSION:
CXR appearances in keeping with heart failure with pulmonary oedema. Bilateral pleural effusions likely cardiac in aetiology. Recommend echocardiography and cardiology review.
Cardiac silhouette enlarged — CTR estimated at 0.58. Bilateral pleural effusions, greater on the left. Kerley B lines identified at lung bases bilaterally. Upper lobe blood diversion. No focal consolidation. No pneumothorax.
IMPRESSION:
CXR appearances in keeping with heart failure with pulmonary oedema. Bilateral pleural effusions likely cardiac in aetiology. Recommend echocardiography and cardiology review.
Interpretation questions — reveal when ready
Q1
How do you calculate the cardiothoracic ratio, and what is significant about CTR > 0.5?
CTR = widest cardiac diameter ÷ widest thoracic diameter (measured at the inner rib margin). CTR > 0.5 on a PA film = cardiomegaly. Causes include heart failure, cardiomyopathy, pericardial effusion, and valvular heart disease. Note: AP films (e.g. portable) appear magnified — CTR is only reliable on a PA erect film.
Q2
List all the CXR features of heart failure using the mnemonic ABCDE.
Alveolar oedema (bat-wing perihilar haziness) · B-lines / Kerley B lines (interlobular septal thickening) · Cardiomegaly (CTR > 0.5) · Diversion of upper lobe blood flow (upper lobe vessels larger than lower) · Effusions (pleural, bilateral in heart failure). This CXR shows C, D (implied), B, and E.
Q3
Does this CXR help or hinder the differential of bird fancier's lung?
This CXR strongly favours heart failure over bird fancier's lung. Bird fancier's lung (hypersensitivity pneumonitis) on CXR would show: bilateral ground-glass opacification, micronodules, or a reticular pattern — not cardiomegaly or effusions. However, HRCT chest is the gold-standard investigation for hypersensitivity pneumonitis and should still be requested given the pigeon history, as both diagnoses could theoretically coexist.
Exam tip — Heart failure on CXR vs chest infection
Heart failure: bilateral, perihilar (bat-wing), cardiomegaly, effusions, Kerley B lines, upper lobe diversion. Chest infection/pneumonia: usually unilateral or lobar consolidation, air bronchograms, no cardiomegaly. Always check the cardiac silhouette when interpreting any CXR — it's frequently missed under time pressure.
04
Year 2
MSK / Orthopaedics
Data Interpretation
Mr Raymond Cole, 74 — Knee Replacement
Shared decision making station · MSK / Orthopaedics
📋
Clinical context
Mr Raymond Cole, 74. Retired postman. Severe right knee osteoarthritis — failed physiotherapy and two steroid injections. BMI 28. No significant cardiac or respiratory comorbidities. Lives alone. Being considered for total knee replacement. Pre-operative assessment results available.
Pre-operative ECG — Mr R. Cole · 74yrs
25mm/s · 10mm/mV · Pre-op assessment
Rate
72 bpm
Normal
Rhythm
Regular sinus rhythm
Normal
P waves
Present before every QRS, morphology normal
Normal
PR interval
160ms
Normal
QRS duration
90ms — narrow complex
Normal
QTc
420ms
Normal
ST / T waves
No ST elevation or depression. Normal T waves throughout.
Normal
Axis
Normal (+45°)
Normal
Overall
Normal ECG — no evidence of ischaemia, arrhythmia, or conduction disease
Normal
Interpretation questions — reveal when ready
Q1
This ECG is completely normal. Why is a pre-operative ECG performed in a 74-year-old?
Pre-operative ECG in patients ≥ 65 (or younger with known cardiac disease) screens for: (1) AF or other arrhythmias that increase anaesthetic and perioperative risk, (2) Q waves suggesting previous MI, (3) LBBB or RBBB that changes anaesthetic management, (4) QTc prolongation relevant to drug choices, (5) baseline ECG for postoperative comparison if the patient develops chest pain.
Q2
What features on a pre-op ECG would delay or cancel elective orthopaedic surgery?
Findings requiring cardiology review before proceeding: new AF or SVT, significant ST changes (new ischaemia), new LBBB (may represent ACS), complete heart block, QTc > 500ms, or evidence of recent MI (Q waves with ST change). Elective surgery should generally be deferred for at least 30–90 days after MI.
Q3
His ECG is normal. What does this tell the anaesthetic team for his TKR?
A normal ECG in a 74-year-old with no known cardiac disease is reassuring for anaesthetic risk stratification. Combined with his normal pre-op bloods (see next tab), he has a low cardiac risk profile. He remains medically fit for elective surgery under general or spinal anaesthetic, without the need for cardiology input before proceeding.
Exam tip — Normal ECG interpretation
Describing a normal ECG confidently is as important as identifying abnormalities. Structure your answer: rate, rhythm, axis, P waves, PR interval, QRS duration and morphology, ST segments, T waves, QTc. "Normal sinus rhythm at X bpm, normal axis, normal intervals, no ST or T wave changes" is a complete normal ECG interpretation.
Pre-operative Bloods — Mr R. Cole · Orthopaedic pre-op
Routine pre-operative screen · 6 weeks pre-surgery
| Test | Result | Reference range | Flag |
|---|---|---|---|
| Full Blood Count | |||
| Haemoglobin (Hb) | 138 g/L | 130–170 g/L (M) | Normal |
| MCV | 88 fL | 80–100 fL | Normal |
| Platelets | 244 × 10⁹/L | 150–400 × 10⁹/L | Normal |
| Coagulation | |||
| PT / INR | 1.1 | 0.9–1.2 | Normal |
| APTT | 30 seconds | 26–37 seconds | Normal |
| Renal & Metabolic | |||
| Sodium | 140 mmol/L | 133–146 mmol/L | Normal |
| Potassium | 4.2 mmol/L | 3.5–5.3 mmol/L | Normal |
| Creatinine | 88 µmol/L | 59–104 µmol/L (M) | Normal |
| eGFR | 72 mL/min/1.73m² | > 60 mL/min/1.73m² | Normal |
| Glucose (fasting) | 5.2 mmol/L | 3.9–5.5 mmol/L | Normal |
| Inflammatory Markers | |||
| CRP | 18 mg/L | < 5 mg/L | Mildly raised |
| ESR | 32 mm/hr | < 20 mm/hr (M) | Mildly raised |
Interpretation questions — reveal when ready
Q1
Why is haemoglobin checked pre-operatively, and why does it matter for TKR?
TKR involves significant blood loss (average 500–1000mL intraoperatively and postoperatively). A pre-operative Hb of 138 g/L is normal — he is not anaemic and therefore at lower risk of requiring blood transfusion. If Hb were below 100 g/L, surgery would typically be delayed to optimise iron stores or treat anaemia with IV iron or transfusion. Pre-op anaemia significantly increases surgical morbidity.
Q2
CRP 18 and ESR 32 — mildly raised. Should this delay surgery?
Mild elevation of CRP and ESR is expected in a patient with severe osteoarthritis — inflammation of the joint is part of the disease process. These values are not significantly elevated and do not indicate septic arthritis or systemic infection that would contraindicate surgery. However, if there were any concern about septic arthritis (hot, red, swollen joint with very high CRP/WCC and fever), surgery would be contraindicated and joint aspiration would be required first.
Q3
Why is coagulation checked before orthopaedic surgery, and what would happen if INR were raised?
Coagulation is checked to identify bleeding risk. If a patient is on warfarin (INR > 1.5–2.0), it should be stopped and bridged if necessary before elective surgery. If on a DOAC (e.g. rivaroxaban), it is held for 24–48 hours pre-op. Undiagnosed coagulopathy (haemophilia, liver disease) can cause catastrophic intraoperative haemorrhage. Mr Cole's coagulation is normal — no modifications needed.
Pre-operative blood screen — why each test is done
FBC: anaemia (transfusion risk), infection (WCC). Coagulation: bleeding risk, anticoagulant status. U&E: renal function (affects drug choice, IV fluid management, contrast if needed). Glucose/HbA1c: diabetes affects wound healing and infection risk. Group & save: TKR requires crossmatch in case of transfusion. CRP/ESR: exclude active infection contraindication.
Right Knee X-ray (AP + Lateral) — Mr R. Cole · 74yrs
Weight-bearing views · Orthopaedic clinic referral
Illustrated AP knee schematic
Severe medial compartment joint space narrowing — bone-on-bone contact medially on weight-bearing views. Absent medial joint space.
Medial osteophytes — prominent bony spurs at medial femoral and tibial margins, consistent with severe osteoarthritis.
Subchondral sclerosis — increased density of bone beneath the articular cartilage on the medial side, indicating long-standing mechanical load.
Lateral compartment relatively preserved — joint space maintained laterally, consistent with unicompartmental (medial) OA pattern.
No fracture, dislocation, or lytic lesion identified. No calcification consistent with calcium pyrophosphate deposition.
Kellgren-Lawrence grading system
KL Grade scale — Osteoarthritis severity
Grade 0 — Normal joint
Grade 1 — Doubtful narrowing, possible osteophytes
Grade 2 — Definite osteophytes, possible joint space narrowing
Grade 3 — Moderate osteophytes, definite narrowing, some sclerosis
Grade 4 ← Mr Cole — Severe narrowing, large osteophytes, severe sclerosis, ± deformity. Bone-on-bone contact.
RADIOLOGY REPORT
Study: Right knee · AP and lateral · Weight-bearing
Indication: Severe right knee pain — ?OA for surgical review
FINDINGS:
Severe medial compartment joint space loss with bone-on-bone contact. Prominent medial osteophytes. Subchondral sclerosis medially. Relative preservation of the lateral compartment. No fracture.
IMPRESSION:
Kellgren-Lawrence Grade 4 osteoarthritis, right knee, medial compartment predominant. Appearances support surgical referral.
Severe medial compartment joint space loss with bone-on-bone contact. Prominent medial osteophytes. Subchondral sclerosis medially. Relative preservation of the lateral compartment. No fracture.
IMPRESSION:
Kellgren-Lawrence Grade 4 osteoarthritis, right knee, medial compartment predominant. Appearances support surgical referral.
Interpretation questions — reveal when ready
Q1
What are the four classic radiological features of osteoarthritis on X-ray?
Remember LOSS: Loss of joint space (narrowing), Osteophytes (bony spurs at joint margins), Subchondral sclerosis (increased bone density below the cartilage), Subchondral cysts (geodes — lucent areas below the joint surface). All four may be present in severe OA; Mr Cole demonstrates L, O, and S on this X-ray.
Q2
Why are weight-bearing views specifically requested for knee OA?
Weight-bearing views load the joint, which causes joint space to narrow more on the affected side under compression. Non-weight-bearing films can significantly underestimate joint space loss — a knee that appears to have residual joint space at rest may be bone-on-bone when loaded. This matters clinically for surgical decision-making and for monitoring progression.
Q3
His X-ray shows predominantly medial OA. Does this affect the surgical choice?
Yes. Unicompartmental (medial only) OA in a lower-demand patient could be managed with a unicompartmental knee replacement (UKR) rather than total knee replacement (TKR). UKR preserves more native tissue and has faster recovery, but is not suitable for patients with inflammatory arthritis, severe deformity, or tricompartmental disease. However, given his age (74), surgeon preference, and the extent of disease, TKR remains a reasonable choice and is the option being discussed in his consultation.
X-ray in the SDM consultation
Showing a patient their X-ray is a powerful tool in SDM — it helps them understand why conservative treatment has limited benefit when bone is contacting bone. "This dark line is the space where your cartilage should be — there's very little left" makes the imaging tangible and helps patients make an informed decision about surgery.