Use this sequence in the practical: identify the film and view -> comment on adequacy/orientation -> state normal structures seen -> describe abnormalities systematically -> give impression.

“This is a plain chest radiograph, likely an AP view, including both lung fields, hila, mediastinum, cardiac silhouette, diaphragms and visualised bony thorax. No side marker is visible.

The trachea is central. The cardiac silhouette is not enlarged. Both hemidiaphragms and costophrenic angles are visualised, with no pleural effusion or pneumothorax. The ribs, clavicles and visualised shoulder girdles show no obvious acute bony abnormality.

There are bilateral, predominantly lower-zone and peripheral coarse reticular to reticulonodular interstitial opacities, more conspicuous at the lung bases. This produces a bibasal fibrotic/interstitial pattern. There is no focal lobar consolidation or cavitary lesion.

Impression: Bilateral bibasal interstitial infiltrates/fibrotic changes, consistent with interstitial lung disease. In a dermatology setting, this should raise the possibility of connective-tissue-disease-associated ILD, especially systemic sclerosis.”

One-line viva answer:
“Chest X-ray shows bilateral basal-predominant reticular interstitial opacities suggestive of ILD, as may occur in systemic sclerosis.”

Important caution: Do not call honeycombing confidently on this plain radiograph. HRCT is the investigation that defines the ILD pattern and extent. In systemic sclerosis, basal-predominant ground-glass/reticular change and fibrosis are typical imaging patterns. A recent systemic-sclerosis musculoskeletal review also notes the association of acro-osteolysis with ILD.

“These are AP and oblique radiographs of the right hand, as indicated by the R marker. The film includes the distal radius and ulna, carpal bones, metacarpals, phalanges and the interphalangeal joints.

Normally, the hand radiograph demonstrates the distal radius and ulna, eight carpal bones, five metacarpals, proximal, middle and distal phalanges, and preserved joint spaces at the wrist, metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints.

In this radiograph, there is resorption of the terminal tufts of several distal phalanges, producing tapering and shortening of the distal phalangeal ends. This is acro-osteolysis. There is associated flexion deformity/contracture of the digits. The joint spaces are relatively preserved, with no dominant erosive inflammatory arthropathy. There may be soft-tissue thinning around the fingertips. No obvious fracture is seen.”

Impression:
“Acro-osteolysis of the distal phalangeal tufts with digital flexion contractures, a characteristic skeletal manifestation of systemic sclerosis (scleroderma).”

One-line viva answer:
“Right-hand radiographs show terminal tuft resorption or acro-osteolysis with flexion contractures, consistent with systemic sclerosis.”

Extra point if asked:
Other radiographic features of systemic sclerosis include soft-tissue calcification, joint-space narrowing, erosions, subluxation and flexion contractures. Acro-osteolysis and calcinosis are the two particularly characteristic hand findings in systemic sclerosis, as described in this radiology review.

“These are AP and lateral radiographs of the right elbow, identified by the R marker. The films include the distal humerus, proximal radius and ulna, elbow joint, and surrounding soft tissues.

Normally, the distal humerus articulates with the radial head and proximal ulna. The humeroulnar and radiocapitellar joint spaces should be maintained, and the surrounding soft tissues should not contain radio-opaque deposits.

There are extensive, dense, lobulated, amorphous, sheet-like and nodular radio-opaque calcific deposits in the periarticular soft tissues around the elbow, particularly posteriorly and around the olecranon region. The deposits are extra-articular and lie within the soft tissues. The elbow joint alignment is maintained, with no convincing intra-articular calcification, acute fracture, or major underlying bony destruction.”

Impression:
“Extensive periarticular soft-tissue calcification around the right elbow, consistent with calcinosis cutis.”

One-line viva answer:
“X-ray right elbow shows extensive extra-articular lobulated soft-tissue calcification around the elbow, consistent with calcinosis cutis.”

Extra point if asked:
Calcinosis cutis represents deposition of insoluble calcium salts in skin and subcutaneous tissue. In dermatology it may occur in systemic sclerosis, dermatomyositis, lupus, metabolic disorders or after local tissue damage. Plain radiography is a useful first-line test to demonstrate its extent, as noted in this calcinosis imaging review.

Do not describe the red handwritten markings in the film. Describe only the radiographic findings.