Chest X-Ray (CXR) — Proforma Paragraph

"I have been given a PA erect chest radiograph. I will assess it systematically using the RIPE mnemonic — Rotation, Inspiration, Projection, and Exposure.

Technical adequacy: The film is [adequately/inadequately] rotated — the medial ends of the clavicles are equidistant from the spinous processes. There are [adequate/inadequate] inspiratory effort — [number] posterior ribs are visible above the diaphragm. The exposure is [adequate] — the vertebral bodies are just visible through the cardiac shadow.

Airway: The trachea is central/deviated to the [left/right]. The carina angle is normal at less than 70 degrees.

Bones and soft tissues: The ribs, clavicles, and visible thoracic vertebrae show no fractures, lytic or sclerotic lesions. The soft tissues are unremarkable.

Cardiac: The cardiothoracic ratio is [within/exceeding] the normal limit of 50% on a PA film. The cardiac contours are well-defined. The aortic knuckle and hilar shadows are of normal size and position.

Diaphragm: The right hemidiaphragm is higher than the left, with clear costophrenic and cardiophrenic angles bilaterally. There is [no/evidence of] free gas under the diaphragm (pneumoperitoneum).

Lung fields: The lung fields are [clear/show abnormalities]. I note [consolidation / collapse / pleural effusion / pneumothorax / nodules / haziness] in the [zone and side]. A pleural effusion, when small, blunts the costophrenic angle (>200–500 mL) and, when massive, causes dense hemithoracic opacification with contralateral mediastinal shift. Absence of mediastinal shift with a large effusion raises the possibility of obstructive collapse or pleural malignancy.

In summary, this CXR shows [primary finding], which is consistent with [diagnosis/differential diagnoses]."

Abdominal X-Ray (AXR) — Proforma Paragraph

"I have been given a supine abdominal radiograph. I note the film includes the area from the diaphragm down to the hernial orifices with the obturator foramina visible, confirming adequate coverage.

Gas pattern: I will account for all visible gas and attribute it to normal anatomical structures. The stomach gas shadow is visible in the [epigastric/left hypochondrial] region. Small bowel loops, if visible, should be central, have valvulae conniventes, and measure less than 3 cm in diameter. Large bowel is peripheral, haustrated, and should measure less than 6 cm (or less than 9 cm for the caecum). I [do/do not] see evidence of small or large bowel obstruction — [dilated loops / multiple air-fluid levels on erect film].

Free gas (pneumoperitoneum): On a supine film, free intraperitoneal gas may be visible as Rigler's sign (gas outlining both sides of the bowel wall), gas over the liver, or the football sign. This almost always indicates perforation of a viscus.

Solid organs: The liver, spleen, and kidney outlines are [visible/obscured]. There is [no/evidence of] organomegaly.

Calcifications: I [do/do not] see any abnormal calcifications in the line of the ureters, renal areas, gallbladder fossa, aorta, or elsewhere.

Bones: The visible lumbar vertebrae, sacrum, and pelvic bones show no obvious fractures or destructive lesions.

In summary, this AXR shows [primary finding], which is consistent with [diagnosis/differential diagnoses]. I would correlate with clinical findings and, if indicated, request an erect CXR to look for subdiaphragmatic free gas, or proceed to CT abdomen for definitive assessment."

Key viva tips:

• Always state technical adequacy first — examiners want to know you won't misinterpret a rotated or underpenetrated film.
• For CXR: mention the mediastinum, trachea, hila, lung fields, diaphragm in that order.
• For AXR: the ABCDE approach works — Air, Bones, Calcification, Density of organs, External/soft tissues.
• On erect CXR, free gas under the diaphragm is the most sensitive plain film sign of viscus perforation — the patient should ideally stand for 10 minutes before the film. — Grainger & Allison's Diagnostic Radiology