FRCR Part 2B (Radiology) - preparatory resources for candidates

History: An 18-year-old male referred from Emergency Department with pleuritic chest pain

Findings:

• Small right apical pneumothorax

• Lung apex at level of posterior 2nd/3rd posterior intercostal space

• No pneumomediastinum

• No signs of tension

• Lungs appear normal

• No rib fracture

Diagnosis:

Small right apical pneumothorax

Management:

• Inform ED team of finding

• If patient stable, pneumothorax may resolve with conservative management

History: A 38-year-old female referred from GP with several months of tiredness and lethargy.

Findings:

• Lobulated, non-calcified soft tissue mass projected over left side of mediastinum, inseparable from left heart border

• Separate from left hilum (hilum overlay sign)

• Mediastinum otherwise normal

• Lungs and pleural spaces clear

• No evidence of splenomegaly

• Bones normal

Diagnosis:

• Anterior mediastinal mass. Could be lymphadenopathy, thymic neoplasm or mediastinal germ cell tumour (teratoma)

• Thymoma most likely, given history and lack of calcification or fat

Management:

• Inform GP + 2WW referral to chest clinic

• Requires CT thorax, abdomen and pelvis for further evaluation

• Myaesthenia gravis screen (blood tests to identify antibody subtype)

• Lung MDT discussion with view to image guided mediastinal biopsy

History: An 81-year-old male referred from GP with cough and weight loss

Findings:

• Left lower lobe collapse with no visible hilar mass

• Numerous calcified pleural plaques indicating previous asbestos exposure

• No mediastinal lymphadenopathy

• No pleural effusion

• No bone metastases

Diagnosis:

• Left lower lobe collapse – likely due to small central lung cancer obstructing left lower lobe bronchus in a patient with prior asbestos exposure

• Mucus plugging, inhaled foreign body or endobronchial carcinoid less likely in this case

Management:

• Lung MDT referral

• CT chest and abdomen with IV contrast agent

• Bronchoscopic biopsy likely to provide diagnosis unless CT reveals other target such as supraclavicular lymph node or liver/bone metastases

History: A 3-year-old female referred from Emergency Department with painful right elbow after fall from swing

Findings:

• Fracture dislocation of right proximal radius

• Displaced (avulsed) medial humeral epicondyle

• No other injury seen

Management:

• Inform ED staff and advise referral to fracture clinic

History: A 20-year-old female referred from Emergency Department with acute asthma exacerbation

Findings:

• Rounded area of consolidation in left upper zone

• Lungs otherwise clear

• No pneumothorax or pneumomediastinum

• No pleural effusion

Diagnosis:

• Likely round pneumonia left upper lobe

• Differential diagnosis pulmonary infarct but less likely

Management:

• Inform ED staff

• Suggest repeat CXR after antibiotic treatment to ensure resolution (although may not be necessary as patient is young)

History: A 25-year-old male referred from Emergency Department with painful left shoulder after rugby injury

Findings:

• Anterior dislocation of left humeral head

• Bony defect in posterior humeral head (Hill Sachs impaction fracture)

• Left glenoid appears intact

• Acromioclavicular joint intact

• No rib fracture or pneumothorax

Diagnosis:

• Likely round pneumonia left upper lobe

• Differential diagnosis pulmonary infarct but less likely

Management:

• Suggest orthopaedic referral

• May require CT or MRI shoulder after reduction for surgical planning

History: A 66-year-old male referred from GP with increasing shortness of breath on exertion

Findings:

• Reduced lung volumes

• Coarse reticulonodular opacification in both lungs, most severe at the bases

• Ill-defined oval mass projected above right hilum

• No mediastinal or hilar lymphadenopathy

• No pleural effusions

• No bony destruction

• No cardiac enlargement

Diagnosis:

• Likely right-sided lung cancer in patient with fibrotic interstitial lung disease (ILD)

Management:

• Compare with previous imaging

• 2WW referral to lung MDT if patient not already under care of respiratory team

• CT thorax and abdomen + IV contrast enhancement for assessment of ILD and staging of lung cancer

• CT guided lung biopsy high risk due to ILD

History: A 75-year-old male referred from Emergency Department with severe hip pain

Findings:

• Large, ill-defined lucency in right iliac bone extending to right sacroiliac joint medially and extending inferiorly to ischium with destruction of superior and posterior acetabulum

• Wide zone of transition

• No internal calcification

• No other bony lesion

Diagnosis:

• At this age, a bony metastasis is likely (from lung, kidney or thyroid primary). Prostatic primary less likely as not sclerotic.

• Differential diagnosis multiple myeloma

• Primary bone sarcoma much less likely

Management:

• Urgently inform ED staff and find out whether patient has known malignancy

• CT thorax, abdomen and pelvis + IV contrast enhancement for further evaluation of lesion and identification of primary cancer

• Patient should be immobilised to avoid risk of pathological fracture

History: A 54-year-old female referred from GP with persistent cough

Findings:

• Cystic bronchiectasis basal segments of left lower lobe

• Fluid levels seen in some dilated airways, but no focal consolidation seen

• Mild volume loss (depressed left hilum) likely due to recurrent mucus plugging

• Cardio mediastinal contour otherwise normal

• Right lung clear

• Pleural spaces clear

Diagnosis:

• Cystic bronchiectasis in left lower lobe

Management:

• Compare with previous imaging

• If no previous imaging, CT would assess extent of bronchiectasis and exclude any other pathology such as a small lung cancer

• Patient may benefit from referral to respiratory clinic for ongoing management of her bronchiectasis

History: A 61-year-old female referred from GP with chest pain

Findings:

• Left mastectomy and left axillary clips

• Pleurally-based mass right lateral chest wall with underlying destruction of lateral aspect of right 8th rib

• No other bone lesions

• Lungs and pleural spaces clear

• No mediastinal or hilar lymphadenopathy

Diagnosis:

• Likely right 8th rib metastasis from previous breast cancer

Management:

• Inform GP and make 2WW referral back to breast oncologists

• Restage with CT thorax, abdomen and pelvis + IV contrast agent

• If histology is needed, the rib lesion is amenable to ultrasound or CT-guided biopsy

History: A 31-year-old male referred from Emergency Department after alleged assault

Findings:

• Depressed fracture right zygomatic arch

• No other bony injury

• Right maxillary antrum clear

Diagnosis:

• Depressed fracture right zygomatic arch

Management:

• Inform ED and recommend maxillofacial surgical referral

• Many need surgical reduction (non-urgent unless associated with restriction of mouth opening due to trapping of mandibular condyle or temporalis muscle)

• Consider CT to aid in surgical planning

History: A 1-month-old male referred from Neonatal Unit with abdominal distension

Findings:

• NG tube tip within stomach

• Numerous dilated small bowel loops

• No pneumatosis or free intraperitoneal gas

• Portal venous gas

• Ground glass opacification at lung bases (worse on right)

Diagnosis:

• Necrotising enterocolitis (NEC)

• Respiratory distress syndrome (RDS)

Management:

• Inform NNU staff of findings

• CXR for further evaluation of lung changes

History: A 10-year-old female referred from Outpatient Clinic for follow-up imaging

Findings:

• Sclerosis, flattening and irregularity of right femoral capital epiphysis

• Widened right femoral neck (coxa magna)

• Left femur normal

Diagnosis:

• Right-sided Perthes disease (idiopathic avascular necrosis of femoral head)

Management:

• Compare with previous imaging

• Surgical referral (if not already under care of paediatric orthopaedic surgeons)

• Consider MRI of hips to ensure no early changes on left side (15% cases are bilateral)

Observations

• US abdomen – heterogenous soft tissue mass with calcifications in right suprarenal region, closely related to the liver

• CT thorax and abdomen with contrast - mass adjacent to the liver likely right adrenal in origin. Internal calcifications and cystic areas.

• Right adrenal not separately seen. Normal left adrenal

• Mass crosses midline with encasement and displacement of major vessels including abdominal aorta and its branches.

• Compressed slit-like intra-hepatic IVC.

• Left supraclavicular and bilateral retroperitoneal and iliac lymphadenopathy

• Bilateral iliac wing periosteal reaction and left sclerotic bone lesion

• No renal mass or hydronephrosis

• Small volume abdominal free fluid

• A few non-specific peripheral lung lesions

Interpretation

• Aggressive right adrenal/retroperitoneal malignancy

Principle diagnosis

• Neuroblastoma with nodal and bony metastases

Differential diagnosis

• Lymphoma less likely due to calcification

Management

• Urgent referral to paediatric oncology MDT

• Urinary catecholamines

• MIBG scan

• MRI spine

• Image‑guided biopsy

Observations

• Previous gastrojejunostomy

• Stomach, duodenum, afferent and efferent jejunal loops dilated with transition point at level of proximal jejunum in right mid abdomen.

• Well defined, gas containing intraluminal lesion at transition point

• Distal small bowel and large bowel collapsed

• Normal bowel wall enhancement

• No free gas or free fluid

• Mild fatty liver

• Post cholecystectomy clips

• Other solid organs unremarkable

• Urinary catheter in situ

• Small fat containing umbilical hernia

• Minor linear atelectasis lung bases, no features of aspiration

Interpretation

• See below

Principle diagnosis

• Mechanical small bowel obstruction due to a bezoar (such as a phytobezoar) in the efferent limb of jejunum beyond gastrojejunostomy

Differential diagnosis

• None

Management

• Urgent surgical referral. Advice placement of NG tube to reduce risk of aspiration.

• Possibly can be treated endoscopically rather than surgically

Observations

CT chest with contrast

• Thickened interlobular septa both lungs, worst in upper zones

• Bilateral ill-defined air space opacifications

• Bilateral pleural effusions (right > left) with no thickening

• Previous right mastectomy with enlarged axillary lymph node

• Normal left axilla

• No thoracic lymphadenopathy

• Multiple hypodense liver lesions

• Bulky left adrenal -indeterminate

• Sclerotic vertebral lesions

• Small hiatus hernia

Interpretation

• Right axillary node, liver and bony metastases

• Pulmonary features suggestive of lymphangitis carcinomatosis

• Air space opacification could be due to infection or drug related pneumonitis

Principle diagnosis

• Widespread metastatic breast carcinoma

Differential diagnosis

• Metastases from another primary

Management

• Compare with previous imaging to determine if findings are new

• Right axillary node accessible for US guided biopsy if needed

• Inform oncologist to raise possibility of infection and drug related pneumonitis if on chemotherapy

The short case reporting component will take place first, with a two-hour duration. There will be a 30-minute break before the long case reporting component will start. The long case reporting component has a 75-minute duration.

Details of timings will be provided to candidates with their individual timetables.

The risr/assess platform is used for the delivery of all CR2B components. We are happy that the image definition and manipulation features are sufficient for allowing a fair assessment of candidates’ abilities. Image quality checks are performed ahead of each sitting as part of the exam's routine quality assurance processes.

Consultant radiologists now have less exposure to plain radiographic reporting during training but will be expected to answer queries from junior radiologists or reporting radiographers for challenging cases throughout their career. Core competence in plain radiograph reporting therefore needs to undergo thorough assessment as part of the exam to ensure that residents are motivated to master this important component of departmental workload.

Resident radiologists are well aware that, for example, a ‘normal’ chest radiograph does not exclude an underlying lung cancer and that a normal appendicular radiograph does not exclude a fracture in the appropriate clinical setting, so may be reluctant to call a case normal in the absence of clinical information.

It is difficult to create a fair mark scheme for a normal case with appropriate weighting within the structure of the exam without unwittingly demonstrating to the candidate which cases are normal. Abnormal cases included in the exam all contain numerous normal anatomical structures and, as such, will also test a candidate’s ability to recognise normality.

Exclusion of normal cases allows the candidate to be assessed on a greater range of pathological conditions, thus making the assessment more robust.

Short, simple statements of your observations, diagnosis and recommendation are all that is needed. You do not need to write full sentences. Sample exam content is available.

Yes, facial bone and spinal radiographs may be included in the Short Case Reporting component and will be classified as MSK cases.

There may be congenital abnormalities. Likewise, there may be “normal variants” - however the short case is an exam of radiology pathology so in the assessment of the radiograph it is important to take into account these findings and determine their relevance by their imaging appearance and the supplied history, which should form part of the image report.

Like reporting any radiograph if there are relevant positive findings this should be part of the report/question answer.

Yes, please include this in your response, even if you are recommending no further management. Candidates should also reflect urgency if relevant to do so.

Yes, please include this in your response, even if you are recommending no further management. Candidates should also reflect urgency if relevant to do so.

If the angle is relevant to the report, then a relevant comment on the angle should be included in the question answer.

Yes, relevant pertinent negatives should be included in the report the same as they should be included in a normal radiology report.

Standardised exam content is used across each examining day. To maintain the integrity of the materials and to ensure that nobody has an unfair advantage, we must keep candidates isolated in the quarantine waiting area. Candidates must ensure that they arrive for quarantine by the time specified on their exam timetable. Candidates who arrive after this time will not be allowed entry to the exam.

Exam venues will have rooms set aside for candidates to wait before and after taking the Oral component. Whilst quarantine times may vary, all candidates should be prepared to spend most of the day at the venue. Quarantine times will be indicated on candidates’ individual timetables.

Your timetable will clearly state the time that you must be at the exam venue and details of your quarantine arrangement. You should bear this in mind when looking to make any travel arrangements.

Food, drink and study material is permitted for those in the quarantine room. No electronic devices permitted.

You will not be allowed to use electronic devices whilst being quarantined. Paper-based reading material (such as books, printed text or handwritten notes) is allowed. Candidates suspected of breaking quarantine rules will be investigated in line with the RCR’s Exam Misconduct Policy.

Candidates will be shown 12 cases across two oral sessions. All modalities in each case contribute to that one particular case and the candidate’s overall performance in that single case will be scored across the scoring domains. Individual modalities are not scored separately.

Yes, examiners will progress candidates through the cases. Examiners may move candidates onto the next case, this may be to ensure candidates have enough opportunity to view the next case or if there is no further discussion needed on that case.

No, once you have moved to the next case in the oral component it is not permitted to go back to a previous one.

If the examiners have no further questions, the session can finish early.

Yes.

Examiners have standard questions as the basis for each case but have flexibility to seek clarification of responses or ask for further detail.

Each of the examiners assessing a candidate in the oral component will provide a rating for candidate communication. This is using the same rating scale as for the other assessed domains. The communication rating is based on performance across the six cases in one oral session (rather than per case). As the communication score is assessed per oral session, it is multiplied by six to ensure it has the same weighting as the other four skill domains.

Examiners will have access to question-specific marking schemes for each case.

The oral component is marked by the pair of examiners conducting each session. Scores from all examiners (across both stations) are then totalled.

All Short Case and Long Case questions are independently double marked and scores from both examiners contribute to your total final score.

See the scoring system for more details.

All candidates will receive a pass/fail notification with a breakdown of their scores across the three components and standardised feedback. As candidates will be provided with all available details of their performance across each component, no further information will be provided.

As the oral component is delivered using the risr/assess platform, all marking is captured within the platform and no marking retained in paper-based marksheets.

Specific result release dates will be added on the website for each exam sitting. Ordinarily results will be available within four weeks after the exam week.

Yes. This can be awarded to an outstanding candidate on recommendation of the Examining Board, based on performance, at each sitting of the exam

An initial pass mark for the oral component has been determined (via the Ebel/Angoff standard setting methodology). A post exam review is conducted to ensure consistency and fairness to candidates. This may result in adjustment to the oral pass mark for a particular day of the orals. Information on the pass mark for this component is included in the information sent to candidates following their exam.

You will receive a breakdown of your scores across the three CR2B components. If you receive a zero score for a question or specific domain this means the examiners have allocated a zero score. It does not relate to a missing mark. A number of checks are conducted to ensure that all marking is complete and no marks are missing. You can find more information on the scoring scales used in the CR2B scoring system information.

A thorough post-exam review is conducted to ensure consistency of standards and fairness to candidates whilst upholding patient safety. This may result in the removal of individual questions from the score calculation. Decisions on question removal are taken by an expert panel and with consideration to the question performance and question content. If a decision is made to remove a question, there is a review to ensure that the remaining content still represents appropriate content coverage and exam metrics remain robust and fair. When a flawed question is removed from an exam, candidates are not penalised. This is because a question that doesn’t reliably distinguish between stronger and weaker performance introduces random error rather than meaningful assessment. Removing such a question helps ensure that everyone’s final score is a fairer and more accurate reflection of their true competence.