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Referral and warning signs
When to refer
Refer complex or uncertain films for Radiologist review. Discuss findings with clinical team.
Red flags
- CXR: Pneumothorax (tension), Large pleural effusion, Mediastinal widening, Signs suggesting aortic dissection, Lobar collapse, Large mass.
- AXR: Pneumoperitoneum (free air), Signs of bowel obstruction with suspected strangulation/ischaemia, Signs of volvulus, Toxic megacolon.
Signs and symptoms
- Not applicable - Guidance topic.
Risk factors
- Not applicable.
Diagnosis
Clinical assessment
Integrate imaging findings with clinical presentation.
Investigations
- Chest X-ray (PA/AP, Lateral).
- Abdominal X-ray (Supine, Erect/Left Lateral Decubitus).
Diagnostic criteria
Systematic approach to interpretation.
Management
Non-pharmacological management
- Systematic Approach (ABCDE for CXR, similar for AXR):
- - Patient Details & Quality: Check Name, Date, View (PA/AP/Lat), Rotation, Inspiration (CXR - 8-10 posterior ribs), Penetration/Exposure.
- - Airway (CXR): Trachea central?
- - Breathing (CXR - Lungs & Pleura): Lung fields clear? Consolidations (pneumonia)? Infiltrates (TB, oedema)? Masses? Pneumothorax (absent lung markings, pleural line)? Pleural effusion (blunting costophrenic angle, meniscus)?
- - Circulation (CXR - Heart & Mediastinum): Heart size (Cardiothoracic Ratio <0.5 on PA)? Heart shape? Mediastinal widening? Hilar prominence?
- - Disability (CXR - Bones): Ribs, clavicles, vertebrae for fractures, lesions.
- - Everything Else (CXR): Soft tissues, diaphragm position/shape, tubes/lines.
- - Abdomen (AXR):
- - Gas Pattern: Normal distribution in stomach/bowel? Dilated loops (small >3cm, large >6cm, caecum >9cm)? Air-fluid levels (erect/decubitus - significant if >2 levels >2.5cm wide)? Free air under diaphragm (pneumoperitoneum - perforation)? Air in bowel wall (pneumatosis)?
- - Soft Tissues: Organomegaly (liver, spleen)? Masses? Psoas outlines obscured?
- - Bones: Spine, pelvis, ribs for abnormalities.
- - Calcifications / Foreign Bodies: Stones (renal, gall), abnormal calcifications, ingested objects.
Pharmacological treatment
- Not applicable.
Monitoring
- Compare with previous films if available.
- Follow-up imaging as clinically indicated.
Complications
- Misinterpretation leading to incorrect diagnosis or management.
- Missed findings.
Prevention
- Systematic review process.
- Clinical correlation.
- Requesting appropriate views.
- Seeking senior/radiologist opinion when unsure.
Patient education
- Explain purpose of the X-ray in simple terms.
- Discuss findings and implications relevant to their condition.
Uganda-specific notes
X-ray is the most common imaging modality. Quality may be variable. Ultrasound increasingly available at HC4/Hospitals. Systematic interpretation and clinical correlation are vital. Access to radiologist reporting is limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 24, Section 24.2.1 (Table of indications/findings)