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 Radiology for
Medical Finals
A case-based guide

K30031_Book.indb 1 9/6/17 1:34 PM

K30031_Book.indb 2 9/6/17 1:34 PM
 Radiology for
Medical Finals
A case-based guide
Lt Col Edward Sellon
BSc (Hons), MBBS, MRCS, FRCR, PgD (SEM), Dip (ESSR), RAMC
Consultant Musculoskeletal Radiologist
Oxford University Hospitals
Oxford
and
Consultant Military Radiologist
Centre for Defence Radiology
Birmingham, UK

Professor David C Howlett

MBBS, PhD, FAcadMEd, FRCP (London), FRCP (Edinburgh), FRCR
Consultant Radiologist
Eastbourne Hospital
East Sussex Healthcare NHS Trust
Eastbourne
and
Honorary Clinical Professor
Brighton and Sussex Medical School
Brighton, UK

Preparation of the illustrations by:

Mr Nick Taylor
MIMI, RMIP, MRCR(Hon)
Honorary Teaching Fellow, Brighton and Sussex Medical School
and Medical Photographer
East Sussex Healthcare NHS Trust
Eastbourne, UK

K30031_Book.indb 3 9/6/17 1:34 PM

 CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2018 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-4987-8216-6 (Paperback)

This book contains information obtained from authentic and highly regarded sources. While all reasonable
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accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish
to make clear that any views or opinions expressed in this book by individual editors, authors or contributors
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K30031_Book.indb 4 9/6/17 1:34 PM

 For Louise and Lottie,
for their constant love, support and belief (ES)

To my dear wife Lara and all the children, Thomas, Ella, Robert and Miles,
also to my parents, Ken and Margaret, and remembering fondly
Joanna and Christopher (DCH)

K30031_Book.indb 5 9/6/17 1:34 PM

K30031_Book.indb 2 9/6/17 1:34 PM
 Contents

Foreword by Professor Malcolm Reed ix

Foreword by Dr Giles Maskell xi
Preface xiii
Contributors and acknowledgements xv
Abbreviations xvii

1 Overview of imaging modalities 1

THOMAS KURKA AND DAVID C HOWLETT

2 Hints and tips for finals Objective Structured Clinical Examination 7

THOMAS KURKA

3 The normal chest X-ray 15

THOMAS KURKA

4 The normal abdominal X-ray 35

SEAN MITCHELL

5 Thoracic cases 51
HANNAH ADAMS, SARAH HANCOX, CRISTINA RUSCANU, AND DAVID C HOWLETT

6 Cardiovascular cases 175

HANNAH ADAMS, SARAH HANCOX, CRISTINA RUSCANU, AND DAVID C HOWLETT

7 Abdomen and pelvis cases 205

FAYE CUTHBERT, AMANDA JEWISON, AND OLWEN WESTERLAND
8 Musculoskeletal cases 319
EDWARD SELLON AND ANDREW SNODDON

9 Neurology cases 407

VINCENT HELYAR AND EDWARD SELLON

10 Paediatric cases 461

UDAY MANDALIA AND LUCY SHIMWELL

Bibliography 555
List of cases 557
Index 559

K30031_Book.indb 7 9/6/17 1:34 PM

K30031_Book.indb 2 9/6/17 1:34 PM
 Foreword by
Professor Malcolm Reed

From the initial discovery of X-rays and their application to medical imaging by Wilhelm Röntgen,
imaging has been an increasingly vital part of medical practice. The modern doctor needs a strong
understanding of the different modalities and their application in the diagnosis and management
of a wide range of medical conditions. While in many situations images are reported by expert
radiologists, the ability to understand and interpret radiological images is essential and the vast
majority of medical schools will require students to demonstrate fundamental skills in this area.
More importantly, diagnostic and therapeutic imaging opens a window to the internal struc-
ture and function of the human body and links the fundamental sciences of anatomy, physiol-
ogy, and pathology to the patient as a whole presenting with symptoms and signs of disease.
The clues gleaned from a careful history and thorough examination lead us to select the most
appropriate investigations to expedite a diagnosis, allowing us to inform the patient about their
condition and commence appropriate treatment. It is the distinction between normal and abnor-
mal structure and function, which is at the core of radiological diagnosis, that provides an illus-
trative basis for learning and a truly patient-orientated understanding of medical disorders. As
such, the use of radiology in teaching and learning facilitates and enhances the understanding
of medicine and is of enormous benefit in preparing for examinations such as medical school
Finals. This textbook edited by Edward Sellon and David Howlett provides an invaluable learn-
ing resource not just for students preparing for medical school Finals but any doctor preparing
for subsequent professional assessments. In addition to the well-illustrated cases and a use-
ful introduction to OSCE-style exams, the real value in this text is in the clearly structured
cases based on high-quality radiological imaging, which span the whole spectrum of medicine.
The book takes a regional anatomy approach with additional chapters on the normal chest and
abdominal X-rays and paediatric cases.
The contributors and editors are to be commended for producing a high-quality, com-
prehensive compilation of cases with clear and concise questions, answers, and explanatory
notes. I would commend this text book to its target audience of final year medical students but
also to doctors in training in a wide range of clinical disciplines as well as those in established
practice.

Professor Malcolm Reed BMedSci, MBChB, FRCS

Dean, Brighton and Sussex Medical School
Brighton, UK

ix

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K30031_Book.indb 2 9/6/17 1:34 PM
 Foreword by
Dr Giles Maskell

Radiology is an unusual medical discipline in being able to trace its origin precisely to a specific
event – the discovery of X-rays by Wilhelm Röntgen in 1895. The practice of medicine was trans-
formed almost overnight by the use of X-rays in diagnosis. The development of further imaging
techniques such as ultrasound, computed tomography (CT) and magnetic resonance imaging
(MRI) followed in the second half of the twentieth century and has led to medical imaging occu-
pying a central place in the management of patients with a very wide range of conditions.
Whatever branch of medicine you pursue as a career, at some stage you will find that an under-
standing of medical images – X-rays and scans – will be essential to your work. You will need to
understand not only the principles of interpretation of tests such as the chest X-ray but also their
strengths and limitations and how to make the best use of these tests to benefit your patients.
Although imaging findings can occasionally be so characteristic that they could almost be
called “pathognomonic”, one of the most important lessons that you will learn is that the inter-
pretation of an imaging test depends critically on the clinical context. The classic diagnostic
sequence – history, examination, tests – is as valid today as it ever has been, despite the increas-
ing sophistication of the imaging tests. The doctor who makes a diagnosis based only on imaging
findings without due regard to the clinical context is more than likely to be tripped up.
Radiology is not a discipline that can be learned in isolation from clinical medicine. In this
book, David Howlett, Edward Sellon, and their colleagues, renowned educators in this field, have
therefore embedded the teaching of radiology in a series of clinical cases, which illustrate not only
the specific imaging findings in certain conditions but, importantly, the principles that underpin
the effective use of imaging tests in clinical practice.
Although there are encouraging signs with the establishment of undergraduate radiology
societies in many medical schools, the teaching of radiology to undergraduates has not always
kept up with the progress in medical imaging. I believe that this book will prove invaluable, not
only in preparing students for medical Finals, but also in giving them a better understanding of
the central role of imaging in modern clinical management, which will serve them well in the
early years of their careers as doctors. Maybe some will even be inspired to consider a future
career in this most exciting and rapidly developing discipline.

Dr Giles Maskell MA, FRCP, FRCR, FRCPE

President, Royal College of Radiologists (2013–2016)
Consultant Radiologist
Royal Cornwall Hospitals NHS Trust
Truro, UK

xi

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K30031_Book.indb 2 9/6/17 1:34 PM
 Preface

This book has been a long time in the making and is the product of many years of both teaching
and examining undergraduate medical students. Over this time there has been an exponential
increase in the use of all forms of imaging in both acute and elective patient care and this has been
reflected in undergraduate medical school curricula and also examinations. Radiology images
feature prominently in both Finals written papers and Objective Structured Clinical Examination
(OSCE), and whole OSCE stations may be based upon a chest X-ray for example. Various imag-
ing modalities tend to feature, in particular X-rays of the chest, abdomen, and common fractures,
but increasingly CT and MR images. The incorporation of radiology/imaging into Finals reflects
the increasing exposure of both medical students and junior doctors to all forms of radiology and
the requirement for trainees to be able to provide provisional interpretation of many forms of
imaging.
This book is not intended to be an all-encompassing textbook of radiology, and the bibliog-
raphy provides supplementary reading for those who wish to dig deeper. A case-based approach
has been adopted and radiology images in questions have been selected in two broad categories –
those that students could expect to encounter in Finals or, alternatively, to cover key learning
points/educational aspects of radiology. This structure should allow students and also foundation
doctors to approach both Finals and the foundation years with more confidence.
Inevitably within the book there is a strong emphasis on plain film interpretation, as these
investigations are the most common form of imaging that students and junior doctors will
encounter and they will also often be expected to provide a provisional interpretation. Extensive
additional examples are used in case answer sections to explain and reinforce learning points
throughout the book. There is widespread use also of common/important CT/MR images, again
because these modalities are increasingly frontline; for example, CT head interpretation in stroke
care. There is less emphasis on ultrasound and nuclear medicine, as these modalities occur less
frequently in Finals, although an understanding of their use is necessary. Ultrasound does feature
in some cases reflecting more widespread use of this modality on the wards and in the emergency
department.
We hope you will enjoy this book and that it will stimulate and enhance your knowledge and
understanding of radiology, and improve your confidence in image interpretation.

Edward Sellon
David C Howlett

xiii

K30031_Book.indb 13 9/6/17 1:34 PM

K30031_Book.indb 2 9/6/17 1:34 PM
 Contributors and
acknowledgements

Dr Hannah Adams BSc (Hons), MBChB Dr Uday Mandalia MBBS, BSc,

Radiology Registrar MRPCH, FRCR
Brighton and Sussex University Hospitals Consultant Radiologist
NHS Trust, Brighton, UK Hillingdon Hospital, Uxbridge, UK

Dr Faye Cuthbert MBBS, MRCP, FRCR Dr Sean Mitchell BMBS, BSc (Hons)
Consultant Urogenital Radiologist General Practitioner Specialty Trainee Year 2
Brighton and Sussex University Hospitals Brighton and Sussex University Hospitals
NHS Trust, Brighton, UK NHS Trust
Honorary Clinical Teaching Fellow
Dr Sarah Hancox MBBS, BSc (Hons)
Brighton and Sussex Medical School
Resident Medical Officer, Emergency
Brighton, UK
Department
Townsville Hospital, Townsville Dr Cristina Ruscanu MBBS
Queensland, Australia Foundation Year 2 Doctor
East Sussex Healthcare NHS Trust
Dr Vincent G Helyar MBBS, BSc, MSc,
Eastbourne, UK
FRCR, EBIR
Interventional Radiology Fellow Lt Col Edward Sellon BSc (Hons),
Guy’s and St Thomas’ NHS Foundation Trust MBBS, MRCS, FRCR, PgD (SEM),
London, UK Dip (ESSR), RAMC
Consultant Musculoskeletal Radiologist
Professor David C Howlett MBBS, PhD,
Oxford University Hospitals, Oxford
FAcadMEd, FRCP (London), FRCP
and
(Edinburgh), FRCR
Consultant Military Radiologist
Consultant Radiologist
Centre for Defence Radiology
Eastbourne Hospital, East Sussex Healthcare
Birmingham, UK
NHS Trust, Eastbourne
and Dr Lucy Shimwell MB BCh, BAO
Honorary Clinical Professor Resident Medical Officer
Brighton and Sussex Medical School Royal Perth Hospital, Perth
Brighton, UK Western Australia, Australia

Dr Amanda Jewison BMBS, FRCR Dr Andrew Snoddon MBChB, FRCR

Specialist Registrar in Radiology Specialist Registrar in Radiology
Brighton and Sussex University Hospitals Leeds General Infirmary, Leeds, UK
NHS Trust, Brighton, UK
Dr Olwen Westerland MBBS, BSc, FRCR
Dr Thomas Kurka BSc, BMBS Consultant Radiologist
Academic Foundation Doctor (Management & Guy’s and St Thomas’ NHS Foundation Trust
Leadership) London, UK
Brighton and Sussex University Hospitals
NHS Trust, Brighton, UK

xv

K30031_Book.indb 15 9/6/17 1:34 PM

 Contributors and acknowledgements

ACKNOWLEDGEMENTS
Two people in particular have been fundamental to the successful production of this book.
Nick Taylor, medical photographer, has worked tirelessly and with great skill preparing the
images, which are such a vital component of any book on imaging. Also Susi Arjomand who has,
with her customary patience and attention to detail, typed up the numerous editing iterations of
the manuscript. Thank you both.
The editors would also like to thank Jo Koster, commissioning editor at Taylor Francis, for her
support and guidance throughout the publishing process. Dr Gillian Watson and Dr Justin Harris
kindly provided some of the radiological images used in the text and Kirstie Leach also helped
with manuscript preparation.
Finally, we would like to gratefully acknowledge all the book’s contributors for their hard work
and enthusiasm, and for finding the time to prepare their cases amidst busy schedules.

xvi

K30031_Book.indb 16 9/6/17 1:34 PM

 Abbreviations

AA aortic arch CO2 carbon dioxide

AAA abdominal aortic aneurysm COPD chronic obstructive pulmonary
AAFB acid-and-alcohol fast bacilli disease
AAST American Association for the CPPD calcium pyrophosphate deposition
Surgery of Trauma disease
ABCDE airway, breathing, circulation, CRP C-reactive protein
diaphragm, everything else CSF cerebrospinal fluid
ABG arterial blood gas CT computed tomography
ACE angiotensin-converting enzyme CT IVU computed tomography intravenous
AIDS acquired immune deficiency urogram
syndrome CT KUB computed tomography kidneys
ALP alkaline phosphatase ureters and bladder
ALT alanine transaminase CTR cardiothoracic ratio
ALARA as low as reasonably achievable CTPA computed tomography pulmonary
ANA antinuclear antibodies angiogram
AP anteroposterior (view) CXR chest X-ray
ARB angiotensin receptor blocker 2D two-dimensional
AST aspartate transaminase 3D three-dimensional
AVN avascular necrosis DCIS ductal carcinoma in situ
AVPU alert, voice, pain, unresponsive DEXA dual energy X-ray absorptiometry
AXR abdominal X-ray DHS dynamic hip screw
BCG bacille Calmette-Guérin DJ duodenojejunal
BMI body mass index DIP distal interphalangeal
BNP brain natriuretic peptide DLCO diffusion capacity of the lung for
BP blood pressure carbon monoxide (test)
BPD bronchopulmonary dysplasia DMARD disease modifying antirheumatic
bpm beats per minute/breaths per drug
minute DRUJ distal radioulnar joint
CABG coronary artery bypass graft DSA digital subtraction angiography
CBD common bile duct DVT deep vein thrombosis
CC craniocaudal (view) DWI diffusion-weighted imaging
CDH congenital diaphragmatic hernia ECG electrocardiogram
CF cystic fibrosis ECMO extracorporeal membrane
CFTR cystic fibrosis transmembrane oxygenation
conductance regulator (gene) ED emergency department
CLD chronic lung disease of prematurity eGFR estimated glomerular filtration rate
CLL chronic lymphoid leukemia ENT ear, nose, and throat
CMC carpometacarpal ERCP endoscopic retrograde
CNS central nervous system cholangiopancreatography

xvii

K30031_Book.indb 17 9/6/17 1:34 PM

 Abbreviations

ESR erythrocyte sedimentation rate LBO large bowel obstruction

ESWL extracorporeal shock wave LCIS lobular carcinoma in situ
lithotripsy LDH lactate dehydrogenase
ET endotracheal LFTs liver function tests
ETT endotracheal tube LHB left heart border
EVAR endovascular aneurysm repair LMP last menstrual period
FAST focused assessment with LMWH low molecular weight heparin
sonography for trauma LUQ left upper quadrant
FBC full blood count LV left ventricle
FDG fluorodeoxyglucose LVA left ventricular aneurysm
FEV forced expiratory volume MAC Mycobacterium avium complex
FFDM full field digital mammography MAS meconium aspiration syndrome
FLAIR fluid-attenuated inversion MCA middle cerebral artery
recovery MCP metacarpophalangeal
FOOSH fall on an outstretched hand MCV mean cell volume
GCS Glasgow coma scale MDT multidisciplinary team
GFR glomerular filtration rate MI myocardial infarction
GGT gamma-glutamyl transferase MIBG metaiodobenzylguanidine
GH glenohumeral micromol/L micromoles per litre
GI gastrointestinal MIP maximum intensity projection
GORD gastro-oesophageal reflux MLO medial lateral oblique (view)
disease mmol/L millimoles per litre
GP general practitioner MR magnetic resonance
GTN glyceryl trinitrate MRCP magnetic resonance
Hb haemoglobin cholangiopancreatography
HCG human chorionic gonadotropin MRI magnetic resonance imaging
HER2 human epidermal growth mmHg millimetres of mercury
factor 2 MS multiple sclerosis
HIV human immunodeficiency virus MSU mid-stream urine
HLA human leukocyte antigen mSv millisieverts
HR heart rate MTP metatarsophalangeal
HRCT high-resolution computed NAI nonaccidental injury
tomography NEC necrotising enterocolitis
HU Hounsfield units NG nasogastric
ICD implantable cardiac defibrillator NHL non-Hodgkin lymphoma
ICE ideas, concerns, and expectations NICU neonatal intensive care unit
ICP intracranial pressure NPSA National Patient Safety Agency
ICU intensive care unit NSAID nonsteroidal anti-inflammatory
Ig immunoglobulin drug
INR international normalised ratio NYHA New York Heart Association
IP interphalangeal OA osteoarthritis
ITU intensive therapy unit OGD oesophago-gastro-duodenoscopy
IUCD intrauterine contraceptive device ORIF open reduction and internal
IV intravenous fixation
IVC inferior vena cava OSCE Objective Structured Clinical
kg kilogram Examination
LA left atrium PA posteroanterior (view)

xviii

K30031_Book.indb 18 9/6/17 1:34 PM

 Abbreviations

PAOD peripheral artery occlusive SCFE slipped capital femoral epiphysis

disease SH Salter–Harris
PCR polymerase chain reaction SIADH syndrome of inappropriate
PE pulmonary embolism antidiuretic hormone (secretion)
PEFR peak expiratory flow rate SOBOE short of breath on exertion
PET positron emission tomography SPO2 saturation pressure of oxygen
PIC peripherally inserted catheter STIR short tau inversion recovery
PIP proximal interphalangeal SUFE slipped upper femoral epiphysis
PKD polycystic kidney disease TB tuberculosis
PPHN persistent pulmonary TFCC triangular fibrocartilage
hypertension of the newborn complex
PPP projection, personal TFTs thyroid function tests
demographics, previous CXR THA total hip arthroplasty
comparison THR total hip replacement
PR per rectum TIA transient ischaemic attack
PTH parathyroid hormone TNF tumour necrosis factor
RA right atrium TNM tumour, nodes, metastases
RCC renal cell carcinoma UAC umbilical arterial catheter
RDS respiratory distress syndrome U&Es urea and electrolytes
RhA rheumatoid arthritis UGI upper gastrointestinal
RHB right heart border US ultrasound
RhF rheumatoid factor UVC umbilical venous catheter
RIF right iliac fossa VBG venous blood gas
RIP rotation/inspiration/penetration VCF vertebral compression fracture
RLQ right lower quadrant VUJ vesicoureteric junction
RR respiration rate V/Q ventilation/perfusion scan
RTA road traffic accident WBC white blood cell
rTPA recombinant tissue plasminogen WCC white cell count
activator WHO World Health Organisation
RUQ right upper quadrant XR X-ray
SBO small bowel obstruction ZN Ziehl–Neelsen

xix

K30031_Book.indb 19 9/6/17 1:34 PM

K30031_Book.indb 2 9/6/17 1:34 PM
 Overview of imaging
modalities
1 THOMAS KURKA AND DAVID C HOWLETT

Plain films: chest X-ray, abdominal Magnetic resonance imaging 4

X-ray, and orthopaedic bone/joint X-rays 1 Nuclear medicine 5
Ultrasound 2 Fluoroscopy techniques 6
Computed tomography 3

It is helpful for finals to have an understanding of the core imaging modalities you are likely
to encounter and to have an idea of the relative strengths/weaknesses and indications/­
contraindications for each.

PLAIN FILMS: CHEST X-RAY, ABDOMINAL X-RAY, AND

ORTHOPAEDIC BONE/JOINT X-RAYS
Conventional X-ray remains an important diagnostic tool in medicine and remains the most com-
monly used imaging modality. Plain films are commonly the chest X-ray (CXR), abdominal X-ray
(AXR), and orthopaedic bone/joint X-rays (XRs). An XR is relatively inexpensive, time effective,
and does not require any special preparation of the patient. There is a degree of ionising radiation
associated with X-ray exposure and this radiation dose varies with body part; a lumbar spine XR
entails a far higher radiation dose than a wrist XR for example owing to radiation of pelvic organs.
However, generally X-ray doses are far lower than those associated with computed tomography
(CT). Dose information is included in Chapters 3 and 4. As always ’justify‘ the exposure: does the
benefit to the patient outweigh the potential risk of irradiation?
When a radiograph is taken, the X-ray beam passes through the body part onto an X-ray sen-
sitive screen. Bones, owing to their high calcium content, absorb most of the X-rays whereas
soft tissues absorb a smaller amount, depending on composition and density. As a result, X-rays
from the bones do not reach the screen and appear white on the radiograph, with the soft tis-
sue appearing darker. X-rays pass through the air without being absorbed at all, which is then
detected by the screen and appears black on the radiograph.

ADVANTAGES
• Inexpensive.
• Usually quick to perform.

K30031_Book.indb 1 9/6/17 1:34 PM

 1 Overview of imaging modalities

• Painless, noninvasive.
• Good diagnostic tool for many pathologies.

DISADVANTAGES
• Soft tissue, lung, bone resolution much reduced compared with CT/magnetic resonance
imaging (MRI).
• Provides a two-dimensional (2D), single image only.
• Radiation exposure.

INDICATIONS – ARE BROAD

CXR
• Respiratory – infection, septic screen, pneumothorax, chest trauma, inhaled foreign body,
pleural effusion, suspected malignancy.
• Cardiac – clinical heart failure, clinical cardiomegaly, heart murmurs.

AXR
• Abdomen – bowel obstruction, perforated viscus (erect CXR more sensitive), ingested
foreign body, abdominal pain in the emergency setting.
• Pelvic – pelvic fracture, neck of femur fracture.

Soft tissue XR neck

• Inhaled foreign body.
• Retropharyngeal abscess.

Bone XR
• Limbs – trauma, fractures, skeletal survey, acutely swollen joint, osteomyelitis, septic
arthritis, bone pain, tumour/metastasis.
• Skulls – skeletal survey, myeloma, dental imaging.
• Spine – trauma, scoliosis.

ULTRASOUND
Ultrasound (US) uses sound waves of high frequencies, which are emitted towards the studied
tissues and are reflected/echoed back to the probe depending on the tissue density and composi-
tion. This signal is then translated into an US image. US is a ‘live’ imaging modality and requires
interpretation while the investigation is being carried out. US colour Doppler techniques are used
to assess moving blood and are used in vascular assessment, e.g. carotid stenosis.

ADVANTAGES
• No radiation, noninvasive (some US is performed using endocavity probes, e.g. transrectal,
transvaginal, transoesophageal).
• Real-time assessment and interpretation of results.
• Relatively inexpensive.

K30031_Book.indb 2 9/6/17 1:34 PM

 Computed tomography

• Useful for imaging of soft tissue and muscles, extremities, testes, breast, and eye, plus
abdomen, pelvis, chest, and vascular colour Doppler applications.

DISADVANTAGES
• Requires a skilled practitioner with US interpretation skills, operator dependent.
• No use for bone imaging as sound is attenuated/absorbed by bone.
• Images are degraded by gas and fat, and this restricts US use in the abdomen/pelvis in
some patients.

INDICATIONS
• Abdomen – trauma, malignancy, abdominal aortic aneurysm (AAA) surveillance,
gallstones, suspected hydronephrosis.
• Chest – assessment of pleural spaces.
• Musculoskeletal – assessment of muscles, ligaments, and tendons.
• Scrotal – assessment of testicles, epididymis, and scrotum.
• Obstetrics – growth scans, placental sighting, anomaly scans.
• Gynaecology – transabdominal and transvaginal imaging of ovaries, uterus, and Fallopian tubes.
• Baby hips.
• Breast, eye assessment.
• Vascular applications – suspected upper/lower limb deep vein thrombosis (DVT), carotid/
peripheral vascular assessment.

COMPUTED TOMOGRAPHY
CT uses X-rays, which are emitted from a rotating X-ray source around the patient with mul-
tiple detectors to produce a series of 2D axial images of the studied body part. This can then be
­computer-reconstructed to obtain axial, coronal, sagittal 2D, and three-dimensional (3D) images
of the studied body parts. There are other imaging modalities that make use of CT imaging such
as positron emission tomography (PET scan).

ADVANTAGES
• Provides 2D cross-sectional images of the body, which are rapidly acquired with the
potential to reformat in multiple planes; 3D reformatting is also possible.
• Provides a detailed image of the studied body part and the surrounding tissue.
• High sensitivity and specificity in particular for assessment of the lungs, mediastinum,
bones, abdomen/pelvis structures, the brain – especially acute blood.

DISADVANTAGES
• CT scanners are expensive.
• Moderate to high dose of radiation, depending on areas scanned.
• May require intravenous (IV) iodinated contrast use – risk of contrast reaction (allergy,
anaphylaxis) and nephrotoxicity in those at risk.

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 1 Overview of imaging modalities

INDICATIONS
• Head – trauma, brain imaging (ischaemic/haemorrhagic strokes, calcifications,
haemorrhage, malignancy).
• Chest – detailed imaging of the lungs to detect abnormalities not seen on CXR, used
in diagnosis and surveillance of malignancy, pulmonary embolism (CT pulmonary
angiogram: CTPA), emphysema, fibrosis. Cardiac – CT to image coronary arteries.
• Abdomen and pelvis – diagnosis, staging, and surveillance of malignancies, bowel
obstruction, AAA, pancreatitis, renal calculi (CT kidneys ureters and bladder [CT KUB] and
CT IV urogram [CT IVU]).
• CT angiography and venography – for example, suspected limb or mesenteric vascular
occlusion, sagittal sinus thrombosis.
• Orthopaedic – complex fractures.
• CT-guided biopsy, surgery, and radiosurgery.

MAGNETIC RESONANCE IMAGING

MRI does not use any X-rays, thus does not expose the patient to ionising radiation. It is superior
to CT in obtaining detailed images of the soft tissues and also the brain. MRI uses strong mag-
netic fields, radio waves, and field gradients to generate the image.
In structural MRI, the images are obtained by proton alignment by an external magnet and
a subsequent radiofrequency pulse disrupts the equilibrium, which gives an MRI signal. Details
of MRI protocols and sequences are not needed for finals – T1- and T2-weighted are common
sequences (in the brain cerebrospinal fluid [CSF] appears bright/white on T2), and IV contrast can
also be used (gadolinium).

ADVANTAGES
• No ionising radiation exposure.
• Provides 2D and 3D cross-sectional images of the body.
• Superior to other imaging modalities in obtaining high-resolution images of the brain and
musculoskeletal system.
• Ideal for soft tissue structures, cartilage, and ligament imaging.
• Vascular and cardiac applications.

DISADVANTAGES
• Expensive equipment – the most expensive imaging modality.
• Time consuming, requiring patient cooperation, ability to lie still, often for 30–60 minutes.
• Contraindicated in patients with ferrous metal implants – pacemakers, cochlear implants,
metallic foreign bodies in the eyes.
• MRI is undertaken in a relatively enclosed space – unsuitable for patients with
claustrophobia and young children (may need general anaesthesia).
• Relatively contraindicated in pregnancy, particularly first trimester.

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 Nuclear medicine

INDICATIONS
• Head and neck – neuroimaging – clear differentiation between the grey and white
matter, diagnosis of demyelinating disease, cerebrovascular disease, detailed imaging of
malignancies and infectious diseases, epilepsy imaging, functional MRI brain studies.
CT is more accurate in the detection of acute blood; new MRI techniques, e.g. diffusion
weighting, can detect cerebral ischaemia very early (minutes) when compared with CT.
• Spine imaging – nerve compression (cord and cauda equina), malignancies, disc disease.
• Hepatobiliary – liver, pancreas, and biliary lesions, MR cholangiopancreatography (MRCP)
for structural imaging of the biliary tree.
• Small bowel – Crohn’s disease diagnosis.
• Knee and other joints – used in cartilage and ligament imaging.
• Angiographic, vascular protocols, cardiac MRI.
• Prostate imaging, diagnosis, and staging of prostate cancer.
• Rectal, gynaecological cancer staging.

NUCLEAR MEDICINE
Nuclear medicine uses injected (or inhaled) radioactive isotopes to diagnose or treat many con-
ditions: endocrine, heart, and gastrointestinal (GI) diseases. It images the emission of isotope
radiation from within the body and can construct a 2D/3D image of the areas of the radioactive
substance uptake. It is used for functional imaging, rather than structural imaging, as contrast/
spatial resolution is poor. Some nuclear medicine is combined with CT/MRI to improve anatomi-
cal detail.

IMAGING MODALITIES
• Myocardial perfusion scan – assessment of the function of myocardium for diagnosis
of hypertrophic cardiomyopathy and coronary artery disease, in combination with
MRI +/– CT.
• Genitourinary scan – assessment of renal blood flow and function, evaluate renovascular
hypertension, and assess vesicoureteral reflux.
• Bone imaging – assessment of bone metastases, infection.
• PET – imaging of metastases, neuroimaging – imaging of brain activity in dementias,
combining injection of metabolically active substances, e.g. fluorodeoxyglucose (FDG) and
tomography/CT detection.

ADVANTAGES
• Provides functional information of organs and disease processes.
• Advancement of treatment options for cancer patients.
• Allows early or improved detection of metastases (PET).
• Provides detailed and accurate information in hard to reach areas.
• Radioisotopes are used to treat some cancers, e.g. radioiodine and papillary thyroid
cancer.

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 1 Overview of imaging modalities

DISADVANTAGES
• High cost.
• Exposure to radiation doses, which may be significant, e.g. PET.
• Not all techniques are widely available, e.g. PET.

FLUOROSCOPY TECHNIQUES
Fluoroscopy combines ionising radiation from X-ray exposure with administration (ingested/
injected) of contrast medium, which is then imaged passing through the structures/organs of
interest to assess their function and structure in real time. Examples include:

• Contrast swallow – assessment of the structure and function of the pharynx and
oesophagus (largely replaced by oesophago-gastro-duodenoscopy [OGD]).
• Barium follow through – assessment of the structure and function of the small bowel
(MRI small bowel replacing).
• Contrast enema – assessment of structure and function of the large bowel and rectum
(colonoscopy replacing), used particularly to evaluate the integrity of postoperative bowel
anastomoses.
• Tubogram (hysterosalpingography) – assessment of the shape of the uterine cavity and the
shape and patency of the Fallopian tubes.
• Arteriogram, venogram (CT/MRI replacing).

ADVANTAGES
• Allow a ‘live’ assessment.
• Relatively inexpensive, readily available.
• Relatively noninvasive.

DISADVANTAGES
• Exposure to ionising radiation, which may be significant, e.g. barium enema.
• Poor soft tissue resolution.
• Endoscopy techniques are more accurate in bowel mucosal assessment and allow tissue
biopsies.

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 Hints and tips for finals
Objective Structured Clinical

2 Examination
THOMAS KURKA

Logistics of preparation and the day itself 7 Examination stations 10

Your communication skills 8 Imaging, blood results, and other test
Communication stations 9 results in OSCE 12
History taking stations 10 Final words 13

The OSCE (Objective Structured Clinical Examination) is designed to test clinical and communi-
cation skills in a structured environment in real time. Many medical schools use the ‘integrated
station’ approach in their OSCE exams, which means that you may be asked to take a focused his-
tory, do a part of a clinical examination, and interpret a test result all in one station. This tests your
knowledge, skills, and your thinking process towards reaching a working diagnosis. Remember
that most people pass their OSCE and you are allowed to fail a small proportion of the stations –
your medical school will be able to advise on the specific rules of the exam.

LOGISTICS OF PREPARATION AND THE DAY ITSELF

• Practice ... practice ... practice! Then practice even more. It is important to have some regular
quality group study time before your OSCE. This exam is about your skills and practical
experience, and you cannot pass the OSCE if you only study from books.
• You should observe other students practicing OSCE-style scenarios, give each other
constructive feedback, and correct mistakes. It is important to be helpful and polite to your
colleagues and friends but it is very important to be constructive with your feedback and
verbalise what went wrong. Some people may not be aware of their mistakes and cannot
improve unless you tell them.
• Although it may seem intimidating, do ask doctors to assess you when on the wards. Most
are keen to teach and help you pass and it will give you more experience in presenting real
cases.
• The OSCE is a role play, not a real-life scenario. You need to learn to play the game. Speak
to previous students who passed finals OSCE at your medical school to understand the
structure of the stations and the day.
• Have a good night’s sleep before the OSCE day. Tiredness decreases concentration and
organisational skills and hinders your ability to communicate effectively. The OSCE is a
type of performance and you need to be fresh and alert to perform well.

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 2 Hints and tips for finals Objective Structured Clinical Examination

• Read the OSCE station instructions properly and follow the script – this ensures you stay
on the topic of the OSCE station and will earn you points. If the station says take a history
from the patient you will not score any points on educating or advising the patient. Stay
focused on the tasks specified in your station brief.
• Begin every station with a polite introduction of yourself. Knock on the door before
entering and say hello with a smile on your face (even a nervous smile counts). Introduce
yourself with a full name and your role, and do not forget to articulate. Most feedback
from the patients from OSCE stations was that they could not understand the students’
names and introduction because they spoke too fast as they were nervous. Be the one to be
remembered for appearing calm, with a smile on your face and a clear introduction.
• Ask your patient’s permission to take their history and/or examine them – there is a mark
for gaining a verbal consent.
• Follow up with letting the patient tell you their story – this will allow you to have a minute
to catch your breath and to connect with the patient.
• Finally, the staff who are examining you want you to pass and you need to give them the
opportunity to give you the points!

YOUR COMMUNICATION SKILLS

• Smile and adopt an approachable body language.
• Make sure that each station is a dialogue between you and the patient. Avoid leading and
closed-end questions, especially in the history of the presenting complaint.
• There is a balance between letting the patient explain their symptoms or problems, and
them rumbling on for too long, which could be a distraction taking you off the path of
the station – keep the conversation focused to the topic of the station but ensure you do
not cut the patient off too soon, which could appear impolite and potentially damage the
doctor–patient relationship. If you need to interrupt their story, apologise for doing so,
acknowledge what they were saying, and offer to return to it if there is time at the end.
• Avoid all medical jargon! It is natural for medical students in the final year to be very
familiar and fluent in medical jargon but most patients do not understand these terms and
OSCEs will test that you can communicate using simple terms.
• Be clear and succinct when giving advice to the patients and always ensure their
understanding – the best way is to ask the patient to repeat it back to you in their own words.
• Do not ever sound patronising or forceful with any advice you give to the patient!
Remember, patients have a right to autonomy, which means that you should only advise
and they can choose to accept or decline your advice (assuming full mental capacity).
• Many students like to repeat the history back to the patients at the end to summarise and
buy some time to think about what next. This may not be recommended in finals especially
if your OSCE station is only 8–10 minutes long. During a finals OSCE, you will have more
than the history to get through (blood results, imaging or further questions) so do not waste
time on repetition as you could run out of time by the end and lose some valuable points.
• OSCE stations are often divided into two sections, an 8-minute station has 4 minutes for
history, for example, and then 4 minutes for further questions/looking at results/differential/
further management. The examiner will usually prompt you at 4 minutes if needed.
• Listen to your patients and respond directly to what they are saying. The patient (or actor)
is playing by the script and they will not mislead or give you any wrong information.

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 Communication stations

It is important to acknowledge their worries and concerns directly, even if you need to
divert to continue gathering the essential information for your history. Sometimes patients
can talk for a long time and go off the topic, and it is your job to politely interrupt them,
acknowledge you will return to their point, and only then divert to what you want to talk
about. You need to appear to be in control but do it politely.
• The examiner will nudge you if you start slowing down or diverge from the main topic or
time is running short. Take the hint as they are trying to set you back on the right path, the
path of the marking sheet.
• Avoid talking too much. It can be tempting to try to talk a lot to show you know your
subject but remember this is a two-way discussion, not a monologue. This applies mainly to
communication stations when you are asked to explain a procedure, counsel the patient or
discuss a new treatment. It is tempting to quickly say everything you know about the subject
to impress your examiner but remember this is about giving information to the patient who
needs to understand it, be able to ask questions, and share their point of view with you.

COMMUNICATION STATIONS
• Communication stations are those where you are asked to discuss a certain treatment or
procedure with a patient, to break bad news or to deal with a complaint.
• Practice communication stations with your friends and colleagues.
• Many medical schools use communication stations in their finals OSCE. Commonly the
instructions prior to entering the communication stations will be very brief, allowing
consultation for the full time of the station. This can be both an advantage and a
disadvantage, as you need to be very organised to structure your discussion to fill the time
and cover the most important areas.
• It is crucial to have a general structure on how to approach any station. There are a number
of structures that ensure you are able to obtain and give all the necessary information about
any topic and allow for a two-way discussion. Prior to entering the examining room decide
which structure you are going to use. For example, when asked to explain a procedure,
discuss a new treatment or counsel a patient, always start by gaining permission to discuss
the topic with your patient: ‘I am here to talk to you about X, would it be OK?’ This is
usually followed by, ‘What do you know about X?’ By asking this question, you gain the
patient’s understanding, perceptions, and concerns about the topic. This often provides
the narrative you should use to elaborate on. Always ensure you pause regularly and check
the patient’s understanding and give time for questions. You have to address all of their
concerns and answer all their questions by the end of the station. It is good practice to start
winding down in the last minute of the station, recap all of the important points, and allow
for final questions.
• Remember you cannot know everything and it is important to admit it. It is appropriate
to say that you do not know but you would check with your senior and tell the patient later.
By doing this, you show that you understand your limitations and that you will be a safe
practitioner.
• It may happen that the station instructions ask you to discuss a topic you have absolutely no
knowledge about. Do not panic! In such situations, remember that following a script could
get you out of trouble. Allow the patient to tell you what they know about the topic, which
may trigger some of your knowledge. Be honest and acknowledge that this is a topic you do

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 2 Hints and tips for finals Objective Structured Clinical Examination

not know a great deal about but state that you will find out. Also, if you find yourself totally
lost and have no more to talk about, remember to consider the patient’s ideas, concerns, and
expectations (ICE). One tip would be to discuss the patient’s social support – do they have a
partner, family or friends who they could talk to or get help from? Would they benefit from
counselling, group sessions or further information from the Internet or leaflets? Do they have
a general practitioner (GP) with whom they would feel comfortable discussing this further?
This not only keeps the conversation going but it shows that you understand that difficult life
situations and decisions require support from those who are closest to the patient.
• Sometimes you may encounter a difficult conversation station such as an angry patient or
relative, or having to break bad news. Many students feel that they have to show knowledge
of the topic to score all the points but often the main point is to be empathetic, respond to
the patients’ concerns, allow them to express their feelings and emotions, and remember
that the use of silence in difficult conversations can be exactly what the patient needs.
• Practice breaking bad news with your friends and colleagues before your OSCE. It is often
uncomfortable to be silent through a stressful or a sad discussion but it is important to use
silence at the right moment. The more you practice, the easier it becomes.

HISTORY TAKING STATIONS

• Practice history taking stations with your friends and colleagues.
• You may be asked to take a full history, focused history or medical history. Whatever it is
called, you should ensure that you always take a full history including past medical, drug,
family, and social history.
• Before you start your station, be clear on how long you have to obtain the medical history.
Sometimes you may only have 4 minutes out of an 8-minute station but this should be
clearly stated in the station instructions. Pace yourself and do not forget to ask about drugs,
allergies, smoking, alcohol intake, and social situation before you run out of time. You will
lose valuable marks on relatively simple questions, which can be rehearsed and used in
every history taking station.
• As a rule of thumb, in every adult history taking station, always ask the ‘B questions’ of
cancer screening: ‘Have you noticed any unexpected weight loss, if so how much and over
how long? Have you had any fevers or night sweats?’ You will never fail to score on these
points if you make these questions a habit.
• If you run out of steam when asking about history of the presenting complaint, skip to
the other sections of the history taking – drugs, allergies, family, and social history – and
then return back to history of the presenting complaint. By doing this, you score all the
important points for other sections and give yourself some time to think about other
aspects of the presenting complaint.

EXAMINATION STATIONS
• Practice examination stations with your friends and colleagues.
• Always gain an informed consent from your patient.
• Never hurt your patient during a physical examination. It is important to ask about pain
before your examination. Always check with the patient if you are causing them discomfort
during the examination and warn the patient if you have cold hands before you touch them!

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 Examination stations

• Read your instructions clearly to understand which part of the body you are supposed to
examine. If it says to examine the cardiovascular system, than start at the bottom of the bed
with general inspection, moving onto the hands, face, neck, etc. If it says to examine the
precordium, then you are only being asked to concentrate on the chest. If in doubt, always
ask the examiner to clarify the instructions for you.
• Be systematic! You need to develop a sequence by which you can examine any body system.
The general rule is to OBSERVE, PERCUSS/PALPATE, AUSCULTATE/MOVE. You can
examine somebody’s shoulder by following the sequence of observe, palpate, and move
even if you cannot remember precisely how to do it.
• Students are never sure whether to narrate during the examination or not. Some medical
schools have specific rules about this and you should follow them. A rule of thumb is to
narrate only those parts of the examination that are not obvious to the examiner. For
example, when you are inspecting the hands during an abdominal examination, you should
comment on nicotine tar staining, clubbing, palmar erythema, etc. If you did not narrate
this part and the examiner had a separate point for each of these findings on their scoring
sheet, it would be difficult to award you all the points. On the other hand, if you were
auscultating the heart, the examiner can see the areas that you are auscultating and you
would not need to state this. However, you would need to state your findings with regard to
heart sounds.

• Avoid saying, ‘I am looking for...’ because this does not inform the examiner whether
you found it or not. You should always say, ‘There is no pitting oedema of the legs’ rather
than, ‘I am looking for leg oedema.’

• Practice summarising your examination findings in three succinct sentences. You do not
need to state everything. Unless you found any peripheral signs of a disease, it is perfectly
acceptable to say that there were no peripheral signs of disease. You have to mention all
your positive findings. For example: ‘I performed a full cardiovascular examination on
Mr X, a 35-year-old male who had no peripheral signs of cardiovascular disease. His blood
pressure was 135/70 mmHg with a regular pulse of 70 bpm, heart sounds one and two were
audible with no additional sounds, and his lung bases were clear. I would conclude this to
be a normal cardiovascular examination.’
• Practice using instruments. It is easy to spot a student who has never held a patellar
hammer or ophthalmoscope in their hand. When practicing for your OSCE, make sure you
have all the required equipment and you practice using it.
• Use alcohol gel when practicing examination stations with your colleagues. It is an easy
point on the mark scheme to gain and many students forget to use it because of stress.
Use it in your practice time to ensure it becomes second nature. You should gel your hands
before examining your patient and again after, just before leaving the room.
• If you find something abnormal during your OSCE examination and you cannot remember
what it is, what it is called or what sign of disease it represents, describe it to the examiner
in your own words and say that you recognise this as abnormal but you cannot remember
what it signifies. Also offer to seek advice from senior colleagues; this will demonstrate that
you are safe, and there are usually OSCE points for stating this.
• Do not forget to look around the bedside. Some patients may have a walking stick, inhaler,
glyceryl trinitrate (GTN) spray, glasses or hearing aids on the table. These are there to give
you a hint; take it!

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 2 Hints and tips for finals Objective Structured Clinical Examination

• Often, if there is something on the patent’s table in the OSCE station, it is there to be used.
If you were asked to examine the thyroid gland, make sure you use the glass of water on
their table to assess swallowing. If you were to examine someone’s hands, make sure you
use the 50p coin on the table to observe grip and dexterity.
• Always thank the patient afterwards. In many stations the examiner will ask for the
opinion of the actor with regard to how you treated them and your general demeanour.
Patient opinion does not usually attract marks but will add to the overall impression of the
examiner. Often patients are volunteering their services, especially if they are real patients,
and although you are only doing the station once they will be repeating it with nervous
students multiple times. A kind word and a smile will go a long way.

IMAGING, BLOOD RESULTS, AND OTHER TEST

RESULTS IN OSCE
• You will encounter imaging and test results in many stations of your finals OSCE.
• They are often incorporated into the station but can be the main focus of the station as well.
You may be asked to take a history from the patient, be asked what investigation you would
want to do, and then be presented with the results of these to interpret.
• If you are asked to take a medical history or examine the patient, you should have a good
grasp of the presenting problems or signs and therefore be able to interpret the test results.
You should be almost able to predict what the blood results or CXR would show even before
you see it.
• Be systematic when approaching test interpretation and take into account any medical
history or examination findings.
• Remember that test results can be normal! Do not be scared to say that a CXR is normal if
that is what you think.
• At the end of a medical history or examination you may be asked what investigations you
would like to do. Always start with the easiest/noninvasive investigations first and build
it up. First, you should mention bedside tests – general observations, bloods (FBC, U&Es,
CRP, LFTs, TFTs, ESR, amylase, group and save, cross-match, Ca 2+, Mg2+, PO34− , and
glucose). Often not all of those are required; be guided by your differential diagnosis.
Also consider blood cultures, urine dip/MSU, capillary blood glucose, ECG, arterial/
venous blood gas, wound swab, etc. Then move onto imaging tests, starting with the
least invasive appropriate test first (e.g. US, CXR, AXR). Then, if appropriate, add more
complex diagnostic tests at the end if indicated (CT, MRI, diagnostic laparoscopy, etc.).
• It is important to emphasise that listing these key and baseline tests is essential to pick
up easy marks in the exam. Do not assume the examiner knows which tests you would
request; you need to specifically go through the lists of investigations and mention them to
the examiner.
• Many OSCEs will have imaging incorporated into the stations. This will most likely be
displayed on a computer screen, anonymised, and with an obvious pathology. You may only
have a minute or two to comment on the imaging results during the station so have a clear
system of reporting CXR, AXR, CT, and MRI. Do not forget to state that you would check
that the image is from the correct patient and is the most recent. Then continue describing
the abnormality on the film and correlate it with the history and examination.

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 Final words

• Imaging in the exam is covered in detail throughout the book and may occur in the OSCE
or the written papers. Imaging pathology will be clearly apparent and the image is usually
nonadjustable on the computer screen. Having a clear method and approach to image
presentation is essential and will reassure the examiner that you have seen/presented
imaging many times in the past.

FINAL WORDS
• Practice ... practice ... practice: be systematic, practice more, and remember to be seen to
wash your hands as needed. Do not panic because by the time you undergo your OSCE
exams you should have a system to tackle any problem, practice again, smile, and be kind to
your patients.
• Do not rely on books only to prepare for OSCE. You must get involved in regular group
revision.
• Eat healthily, keep hydrated, exercise, and get some quality sleep during your revision
period.
• Allow yourself some downtime to relax. Watch some television, visit friends, play your
favourite sport, go for walks or anything else you used to do before you started this
revision. Do not allow it to completely take over your life but at the same time make it your
priority.
• Remember, there is light at the end of the tunnel and the skills you are learning now are
genuinely useful for the future.
• Most people pass!

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K30031_Book.indb 2 9/6/17 1:34 PM
 The normal chest X-ray

3 THOMAS KURKA

Indications for requesting a CXR 15 Example OSCE stations with CXR

Medical ionising radiation exposure 15 interpretation 26
CXR reporting technique 16

The CXR is the most common radiological investigation performed. Interpretation can be dif-
ficult and often falls initially to those with relatively limited experience. It is important to have a
systematic approach to interpretation to ensure that the correct diagnosis is made and nothing is
missed. This will help both in the examination situation and in real life.
This chapter provides a step-by-step approach to reviewing the CXR. It provides a compre-
hensive problem-solving technique, which encourages a set format involving an introduction, a
detailed assessment of the key abnormality, and a systematic review of the rest of the film. It is
this systematic review that students have most difficulty with and we provide two different tech-
niques for dealing with it. We then illustrate these techniques with example cases.

INDICATIONS FOR REQUESTING A CXR

Even though a CXR may not be the diagnostic investigation of choice for pulmonary embolism
(PE), lung cancer or heart failure, for example, it can provide some very useful information and as
such is frequently used as the first-line investigation when cardiorespiratory patients present to
the hospital. Additionally, the radiation dose of a CXR is low (0.015 mSv) – around 440 times less
than a chest CT scan– making it the least invasive investigation of choice. A summary of the main
indications for CXR is shown in Table 3.1.

MEDICAL IONISING RADIATION EXPOSURE

X-rays and gamma rays damage DNA. Some of this damage is predictable and dose dependent.
There are dose-related and predictable effects, such as radiation sickness and alopecia, which
occur at set doses of radiation. Other effects, such as the development of cancer, are not dose
dependent and a safe level of radiation cannot be predicted. The chance of these events occurring
increases with dose but does not have a known safe threshold.

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 3 The normal chest X-ray

Table 3.1 Common indications for requesting a CXR

Diagnoses Symptoms
Respiratory Malignancy (primary or secondary) Haemoptysis
Infection – pneumonia, TB Dyspnoea
Pulmonary embolism Chest pain
Pleural effusion Productive cough
Inhaled foreign body Severe abdominal pain
Chest trauma
Pneumothorax
Acute exacerbation of asthma
Acute exacerbation of COPD
Cardiac Heart failure
Heart murmurs
Surgical Pneumoperitoneum
Other NG tube position
Central venous catheter position

The lifetime risk of developing cancer is influenced by the dose and cumulative exposure
to radiation. According to the Royal College of Radiologists, exposures of less than 1 mSv
(equivalent to 70 CXR or 6 months of background radiation) confer a cancer development risk
of less than 1:20,000. This rises to about 1:4,000 for 5 mSv and 1:2,000 for 10 mSv exposures.
The risk ratio, however, is heavily influenced by age and sex, with infants and females at the
greatest risk. The risk of a medical exposure, however, should always be put into the context of
the population cancer risk (currently 1 in 3 in the UK) and be balanced against the investiga-
tion benefits.
Each of us is exposed daily to background radiation from the earth and space. The background
radiation in the UK is around 2.2 mSv per year with a regional variation of as much as 1.5–7.5 mSv
per year depending largely on rock type (notably granite in the Aberdeen area and the rocks of
Cornwall). In addition, we expose ourselves to further radiation during air flight. A return flight
from London, UK to New York, USA adds approximately 0.1 mSv radiation exposure, which is
equivalent to seven CXRs.
ALARA (as low as reasonably achievable) is an American safety principle and regulatory
requirement, which sets standards for a reasonable level of radiation exposure. The main princi-
ples are time (minimising the time of direct exposure), distance (double the distance, quarter the
dose), and shielding (using absorbent materials to reduce radiation exposure). Table 3.2 illustrates
the associated radiation dose of some common imaging tests with the equivalent dose in CXR or
background radiation.

CXR REPORTING TECHNIQUE

Much of this section refers to real-life CXR review and most is also applicable to the exam sce-
nario. Remember X-rays in the exam will appear on a computer screen or an examination ques-
tion sheet – they will be anonymised and pathology should be obvious. Image manipulation on
the screen is not usually allowed or needed.

16

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 CXR reporting technique

Table 3.2 Radiation doses for the main imaging modalities

Equivalent period
Equivalent of background
Modality DOSE (mSv) in CXRs radiation
CXR 0.015 1 2.5 days
AXR 0.4 30 2 months
XR pelvis 0.3 20 1.5 months
XR skull 0.07 5 12 days
XR hip 0.8 60 4 months
XR hand/foot <0.001 <1 <2 days
XR cervical spine 0.05 3 7.5 days
XR thoracic spine 0.4 30 2 months
XR lumbar spine 0.6 40 3 months
CT head 1.4 90 7.5 months
CT chest 6.6 440 3 years
CT abdomen 5.6 370 2.5 years
CT abdomen/pelvis 6.7 450 3 years
CT chest/abdomen/pelvis 10 670 4.5 years
CT KUB 5.5 370 2.5 years
CT colonography 10 670 4.5 years
Barium swallow 1.5 100 8 months
Barium meal 2.0 130 11 months
Barium enema 2.2 150 1 year
Bone (Tc-99m) scan 3.0 200 1.4 years
DEXA scan 0.0004 <1 <2 days
Mammogram 0.5 35 3 months
PET scan 18 1200 8.1 years

LEARNING POINTS: REPORTING TECHNIQUE

▪▪ Introduction:
– ‘PPP’ (projection, personal demographics, previous CXR comparison).
– Technical factors: ‘RIP’ (rotation/inspiration/penetration).
▪▪ Describe the obvious abnormality: what and where.
▪▪ Systematic review: ABCDE (Table 3.4) or anatomical approach.

First, you need to introduce the CXR by checking the projection of the image and men-
tioning any available personal demographic information (i.e. ‘This is a PA CXR of an adult
female.’). It is really important to check you are reviewing the correct CXR for the correct
patient, and from the correct date and time. In the exam you will not be able to do this as
the XR should be anonymised but mention to the examiner that you would wish to do this
as part of your usual practice. Then consider its technical quality (i.e. ‘There is no rotation,
and inspiration and penetration are adequate.’). This ensures that any visible abnormality is

17

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 3 The normal chest X-ray

likely to be related to pathology rather than an artefact of the film. Exam XRs should not have
any technical issues.
Second, describe any obvious abnormality in terms of what and where.
Third, a systematic review of the entire CXR is required to make sure that you have not missed
anything. Two different approaches to this (ABCDE or anatomical) are discussed below. Finally,
summarise your findings, give a diagnosis or differential diagnosis, and recommend further
management.
These three stages of reporting will now be discussed in greater detail.

INTRODUCTION
A number of factors should be considered for PPP.

PPP
Projection
• Pay attention to letters PA (posteroanterior) or AP (anteroposterior) on the CXR and also
the words erect or supine (Figure 3.1).
• A standard CXR is taken in a PA, erect position (i.e. the patient is standing up with
shoulders internally rotated, hands on hips, which moves the scapulae laterally so they are
less visible on the film). If it is not labelled, this is the default position.
• AP films are taken for patients that are difficult to mobilise and/or very unwell and may be
labelled portable where the patient is sat up in bed with the film cassette tucked behind them.
• AP films have more of the scapulae projected over the chest. They also have a more
prominent cardiac silhouette, which can be misinterpreted as cardiomegaly. Only assess
heart size on a PA projection (Figure 3.1).

PA AP

X-ray film X-ray film

Fig. 3.1 The size of the heart on the PA and AP CXR. Note on PA projection that the heart is closer to the
X-ray film and thus less magnified by the divergent beam than on the AP view.

18

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 CXR reporting technique

PA erect is a standard for CXR

Projection
AP – cannot comment on the heart size

Personal Name, age (date of birth), hospital number, gender

demographics Date and time when film taken

Previous CXR Allows for differentiation between

comparison acute and chronic changes

Fig. 3.2 PPP (projection / personal demographics / previous CXR comparison).

• Other projections are available (i.e. lateral, lordotic, apical, rotated, and oblique) but they
have been almost entirely replaced by the use of CT. You will not see these projections in
medical school exams.

Personal demographics (Figure 3.2)

• Always ensure you present the full name, date of birth (age), and hospital number of the
patient (more applicable to ward rounds, rather than the exam).
• The CXR will be anonymised in the exam but you should offer to check the personal
demographics at this stage. You may be able to tell if they are adult or paediatric by the
presence of growth plates, also male or female by the breast shadows.
• If there is a date and time on the image remember to mention it.

Previous CXR comparison

• Offer to compare the current CXR with any previous films available. This helps to
differentiate between acute and chronic changes.
• It is also important to check you are reviewing the correct CXR for the correct patient from
the correct date and time.

RIP
Rotation
• To assess for rotation, find the medial heads of the clavicles and compare their distances
away from the spinous process of the adjacent vertebral body (Figures 3.3 and 3.4).
• If the spinous process of the vertebral body is equidistant between both clavicle heads then
there is no rotation.
• If the gap is less on the right then the patient is rotated to the right, and vice versa.

Inspiration
• Patients are asked to breathe in and hold their breath when a CXR is taken so that the lungs
are optimally visualised.
• Poor inspiratory effort may be caused by pain, confusion or respiratory distress.

19

K30031_Book.indb 19 9/6/17 1:34 PM

 3 The normal chest X-ray

Fig. 3.3 Assessing the technical quality of CXR (M = medial clavicle).

Rotation Distance between the clavicular heads and

the spinous processes

9–11 posterior or 5–7 anterior ribs are visible

Inspiration
on a PA film

Vertebral bodies are just visible behind

Penetration
the heart

Fig. 3.4 Technical factors: RIP (rotation/inspiration/penetration).

20

K30031_Book.indb 20 9/6/17 1:34 PM

 CXR reporting technique

• Hyperexpanded lungs may be seen in COPD patients with obstructive airway disease.
The diaphragms will appear flattened.
• Inspiratory effort is described as adequate when 9–11 posterior or 5–7 anterior ribs are seen.

Penetration
• The vertebral bodies should just be visible behind the heart for adequate penetration.
• If the CXR is either over- or underpenetrated, then you will not be able to fully assess all
the structures and compare their densities accurately.
• An underpenetrated XR appears overly opaque/dense/white.
• An overpenetrated XR appears too lucent/dark/black.

DESCRIBE THE OBVIOUS ABNORMALITY: WHAT AND WHERE

Sit back and look over the whole CXR to spot any obvious abnormality. If you see something
abnormal, describe this in terms of what and where before proceeding with the systematic review.
Practice using the correct terminology to describe the common pathologies as outlined below.

WHAT
• Shape: describe the shape of the abnormality (round, diffuse, well/poorly demarcated).
• Size: describe size of lesion.
• Density: say if it is hypo- (dark) or hyperdense (bright) compared with the surrounding
soft tissues, also if it is homogeneous (same density throughout) or heterogeneous (various
densities). Cavitating lesions have a soft tissue rim with a hypodense core and may contain
an air/fluid level. Is there calcium or fat density associated?
• Associated factors: presence of lung oedema, fluid level or air bronchogram. For pleural
effusions, describe which side is affected, comment on the presence of a meniscus and how
high the fluid level extends.

WHERE
• Site: say which lung is affected.
• Site: describe whether it is in the upper, middle or lower zone of the lung. This is much
easier than trying to assess which lobe is involved, this may be difficult to evaluate on the
frontal XR.

Common descriptions include:

• Pneumonia: mostly unilateral, patchy, soft tissue consolidation. Look for air bronchograms.
• Pulmonary oedema: mostly bilateral, patchy, soft tissue consolidation with associated
cardiomegaly and pleural effusions (Table 3.3).
• Pleural effusion: mostly unilateral, homogeneous, soft tissue opacification. Blunting of
costo- and cardiophrenic angles with a meniscus at the air–fluid level.
• Pneumothora: loss of lung markings in the lateral aspect of the thorax with a visible pleural line.
• Tension pneumothorax: as above with mediastinal and/or tracheal shift away from the
pneumothorax and flattening of the ipsilateral hemidiaphragm.
• Lobar collapse: mediastinal and/or tracheal shift towards the collapse, raised ipsilateral
diaphragm, displaced hilum, and rib space narrowing.

21

K30031_Book.indb 21 9/6/17 1:34 PM

 3 The normal chest X-ray

Table 3.3 ABCDEF of pulmonary oedema

A Alveolar and interstitial shadowing
B Kerley B lines
C Cardiomegaly
D Upper lobe Diversion
E Effusion
F Fluid in the horizontal fissure

SYSTEMATIC REVIEW: ABCDE OR ANATOMICAL APPROACH

There are two different systematic approaches to reviewing the CXR. One follows the familiar
ABCDE approach to assessing the acutely unwell patient (Table 3.4 and Figure 3.5). The second
approach is used primarily by radiologists and follows the anatomical landmarks of the film.
These are just two examples of how to do it and in time you will establish your own approach.
Make sure before you start your systematic review that you have considered the nature of the film
and its technical qualities, as described above.

ABCDE APPROACH
Airway
• Trachea should be central. Deviation to the right may be related to ipsilateral lung
volume loss (lung or lobar collapse) or contralateral volume expansion (pneumothorax,
haemothorax, pleural effusion or large lung mass). It may also be deviated by a mediastinal
mass (thyroid goitre).
• Free gas in the soft tissues (surgical emphysema) secondary to penetrating trauma or severe
asthma.
• Neck masses, such as an enlarged thyroid goitre or calcified vascular calcification (subclavian
aneurysm), may be visible.

Breathing
• Lung apices should be compared. They should be symmetrical and have a similar density –
take care here as pathology in the apices can easily be missed!
• Upper, middle, and lower zones. Follow the lateral borders down to the bases and then up
towards the hila. Compare both sides (Figure 3.5).
• Pneumothorax. Close inspection of the lateral borders of each lung for a visible pleural line
and rim of absent lung markings. If you are shown a pneumothorax in the exam it will
usually be large and clearly demonstrated – small, subtle lesions will not be used.

Table 3.4 ABCDE of CXR

A Airway
B Breathing
C Circulation
D Diaphragm
E ‘Everything else’

22

K30031_Book.indb 22 9/6/17 1:34 PM

 CXR reporting technique

Fig. 3.5 Airway and breathing structures on CXR. Trachea (1), carina (2), right hilum (3), left hilum (4), right
costophrenic angle (5), left costophrenic angle (6), right cardiophrenic angle (7), left cardiophrenic angle (8).
Note bilateral, normal, symmetrical breast outlines (9).

• Pleural angles. The costophrenic and cardiophrenic angles are checked for blunting and
increased density, as seen with consolidation (pneumonia), pleural effusion or chronic
pleural thickening.
• Hilar position, shape, and density. The left should sit at the same level or slightly higher
than the right. The hila are made up of pulmonary arteries, veins, bronchi, and lymph
nodes. They should be equal in size, shape, and density. A displaced hilum may suggest
lung volume loss. A dense or enlarged hilum may be caused by lymphadenopathy
(due to infection, malignancy or sarcoidosis) or pulmonary hypertension (due to COPD
or heart disease).
• Nodules and masses may be dense and well defined (calcified) or soft tissue density and
poorly defined: the latter are more concerning for malignancy. They may be single or
multiple. Remember to check behind the heart for a subtle mass in the left lower lobe and
also to assess the basal segments of the lower lobes through the upper abdomen/diaphragm.
• Fissures. Check the normal appearance and position of the fissures, as these will be
distorted in lobar collapse.

23

K30031_Book.indb 23 9/6/17 1:34 PM

 3 The normal chest X-ray

Circulation
• Heart size (if it is a PA film). If you compare the width of the heart with that of the thorax,
the cardiothoracic ratio should be less than 50% in adults (Figure 3.6). Cardiomegaly may
be caused by heart failure.
• Mediastinal shift. If the heart no longer appears in the centre of the thorax the film may
be rotated, there may be volume loss pulling structures towards the pathology (lung or
lobar collapse) or volume increase pushing structures away from the pathology (tension
pneumothorax, haemothorax or large mass).
• Aortic arch (AA). This should be on the left. If small, there could be an atrial septal defect.
If enlarged, there may be hypertension, aortic stenosis or aortic dissection.
• Left heart border (LHB). The left atrium (LA) or left atrial appendage may be enlarged
in mitral valve disease (now rarely seen as rheumatic heart disease is less prevalent).

Fig. 3.6 Circulation structures on CXR. The left heart border (LHB) is made of the left atrium (LA)
superiorly and left ventricle (LV). The right heart border (RHB) is made up of the right atrium (dotted line)
only, as the right ventricle lies posteriorly. Aortic arch (AA), descending right pulmonary artery (PA). The
CTR (cardiothoracic ratio) is the greatest cardiac width ÷ the intrathoracic width at its widest point (inner rib
→ inner rib), <50% in adults.

24

K30031_Book.indb 24 9/6/17 1:34 PM

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The text on this page is estimated to be only 27.82%
accurate

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Michaol Croskoy and Rachel Lewis. March 17. 1S31. by Rev. William
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MuUin. March 9. 1S2G. by Donald MelntOsh. V. D. M. Robert Crossen
and Jane Crossen. JiUie G, ISL'O. by Robert Maxwell. J. P. Samuel
Crossau and Harriet Rioketts. .March 12. 1S33. by James McCoy.
Henry Crouch and Rachel Hoover. Dec. 29. 1S40, by John Gruber. J.
P. Joseph Crouch and Margaret Robinson. April IG. 1840. by Cyrus
McNeely. Robert Crouch and Ann dray, Sept. 23. 1823. by John Rea.
V. D. M. William Crouch and Elizabeth Fulton. April 1. 1830, by John
^k-Arthur, V. D. M. William Crow and Elenor Leslie. Dec. 25. 1823. by
John C. Huston. J. P. Thomas Crozier and Libby Ruhart. Oct. 5. 1830.
by John C. Huston. J. P. Abram Crum and Jane Mcllroy, March 23,
1820. by Rev. Elijah C. Stone. Peter Cvum and Phebe Ann Brown.
June 30. 1840. by Aaron Conaway. J. P. Ira Crumley and Jane
Dickerson. Jan. 30. 1840. by Rev. Parden Cook. Samuel Crumley and
Retsey Dickerson. Sept. 4. 1823. by Rev. James Roberts. Thomas
Crumley and Elizabeth Davis. Aug 31. 1830, by Rev. Jacob Lemmou.
Henry Crumrine and Ldyia Montz. April 2r>. 1839. by D. Rothacker.
Benjamin Culbertsou and Naucy Moore. Nov. 20, 1830, by William
Wallace. V. D. M. George Culbertsou and Sarah Crawford. Nov. 24.
1S3G, by John :Mc Arthur. V. D. M. Hugh Culbertsou and Mary
Lindsey. Feb. 12, 1835. by Rev. Jacob Coon. William T. Culleu and
Sarah Humpress. Nov. 0. 1817. by Daniel David. J. P. William T.
Cullen and Mary Holliday. Aug. 24. 1829. by Thomas P. Jenkins. Elias
Cullison and Polly Gridgeu. Dec. 29. 1S21, by Rev. Curtis Goddard.
Lemuel Culver and Mary Parmer. Sept. 10. 1839. by John Rea. V. D.
M. John Cummins and Susanna Lett. Nov. 25. 1818. by James
Roberts. Joseph Cnmmings and Jane Foster. Feb. 7. 1839. by Rev.
John Willinor. George Cunningham and Mary Ann Humphrey. Nov.
17. 1831. by Rev. Thomas Hanna. James Cunningham and Anna
Ekins. April IG. 1835. by John Rea, V. D. M. John Cunningham and
Nancy Sharp. Feb. 3. 1829. by William Taggart. V. D. M. Stephen
Cunningham and Margaret Ward. June 19. 1832. by John McArthur.
V. D. M. John Curry and Elizabeth Shirey. Jan. 20. 1840. by Joseph
W. Spencer. J. P. Johu W. Curtis and Sarah Palmer. March 28. 1827.
by Rev. Samuel Adams. Emanuel Custer and Matilda Veirs. Aug. 7.
1828. by John Rea. V. D. M. Emanuel H. Custer and Maria
Kirkpatrick. Feb. 23. 183G. by John McArthur. V. D. M. Jacob Custer
and Catherine Gutshall. Oct. 20. 1S3G. by David McGuire. J. P.
George Damm and Elizabeth McCardle. Sept 2G. 1839. by Rev.
Robert E. Carrot hers. George Dancer and Rachel Holland. Aug. 12.
1S23. by John Hnrless. J. P. John Dancer and Margaret Boyce. July
10. 1823. by Johu Hurless, J. P.
 EARLY MARRIAGES 253 Samuel Daniel anfl Nancy Maple,
Dec. 4, 1825. by Van Brown, J. P. Charles Darby and Eliza Ann Star,
.Jan. 1, 1833, by Rev. .Jacob Coon. Rufus Darby and Belinda B.
White, March 12, 183.5. by Rev. Jacob Coon. Joseph Darling and
Elizabeth Bedwell, Aug. 2r,, 1833. by Rev. Jacob Coon. John Darr
and Rachel VVater.s, June 16. 1831, by John Wa'^nor, J. P. James
Derrough and Polly Barr, Nov. 25, 1830. by George W. Bell, J. P.
William Darrow and Bettsy , Dec. 12, 1816. by Robert Erwin, J. P.
William Darrow and Namoi I^ukens, Oct. 2.5, 1827, by Michael
Conaway, J. P. Jesse Davidson and Nancy Dinning, April 10, 1821, by
Joseph Fry, J. P. Jesse Davidson and Eleanor Carey, March 31, 1836,
by Thomas P. Jenkins, J. P. Jonah Davidson and Sally Joice, Dec. 3,
1829, by Thomas P. Jenkins, J. P. Lewis Davidson anrl Trolly
J^ongshore, Nov, 28, 182G, by Joseph Fry, J. P. Lewis H. Davidson
and Lucinda I^atham, Jan. 7, 1830, by Moses Wright, J P. Thomas L.
Davidson and Rebecca Walker. Oct. 22, 1837, by .John Knox, J. P.
David Davis and Mary McCuinor, Dec. 24, 1819, by Desberry
Johnson, J. P. Evan Davis and Sarah Reed, Sept. 6, 1832, by John C.
Huston, J. P. Ezekiel Davis and Elizabeth Wiley, Nov. 7, 1833, by John
Rea, V. D. M. Ezekiel Davis and Catherine Norn's, Sept. 7, 1837, by
Rev. Thomas Foster. Francis A. Davis and Lucy Smith, Feb. 1, 1833,
by Joseph Fry, J. P. Guian Davis and Priscilla West, Sept. 5, 1839, by
James Kerr, V. D. M, James Davis and Nancy Baker, Jan. 18, 1838. by
George W. Bell, J. P. Jesse Davis and Mary Ann Wallcutt, Oct. 26,
1830. by George Waddell. John Davis and Elizabeth Knox, Sept. 11,
1819, by William Wyckoff, J. P. John Davis and Nancy Walker, Dec.
14, 1838, by L. G. Walker. Thomas Davis and Susan Spring, March
30, 1820, by John Russell, J. P. Thomas Davis and Eliza
McClenighan, March 6, 1828, by Joseph Johnson, J. P. John Davy
and Sarah Snider, Nov. 21, 1826, by John Wagner, J. P. Isaac
Dawson and Martha Daly, Dec. 22, 1836, by Samuel Moorhead, J. P.
William Dawson and Ann Porter, Nov. 6, 1832, by Lot Deming, J. P.
John Day and Margaret Wilkins, Nov. 10, 1829, by William Taggart,
V. D. M. Uriah Day and Luesia Keesey, June 3, 1831, by Peter Barger,
J. P. Uriah Day and Prudence Jones, Feb. 6, 1834, by Peter Barger, J.
P. John Deary and Polly MacCurdy, June 1.5, 1816, by John Rea, V.
D. M. Ephraim Deavenbaugh and Rebecca Redden, June 2, 1825, by
J. R. Kirkpatrick, J. P. Abraham Deens and Sarah Shouse, May 20,
1832, by John Chaffant, J. P. David Dehuff and Margaret Phillips.
Oct. 9, 1828, by Morris Allbaugh, J. P. John Dahuff and Hannah
Hasfilhom, Jan. 7, 1819, by William Anderson J. P. Samuel Delany
and Albina McXeely, June 21, 1826, by John Rea, V. D. M. Aaron Dell
and Isabella Conaway, Dec. 13, 1832, by John McArthur, V. D. M.
Peter Dell and Margaret Walsh, Nov 30. 1830, by John Gruber, J. P.
Thomas Dell and Jane A. Waller, June 23, 1836, by Rev. James C.
Taylor. Isaac Delong and Sarah Dickerson. Jan. 16, 1823, by Joseph
Johnson, J. P. Jesse Delong and Elizabeth Middleton. May 18, 1833,
by John W. Her. J. P. John Delong and Demaris Delong, Dec. 2,
1838, by Levi Peddycoart, J. P.. George Deming and Eliza Conrad,
Feb. 6, 1823, by Elias Cran, D. C. Treat Deming and Catherine Lyons,
Nov. 28. 1837, by Rev. Richard Brown. Jacob Dennis and Rebecca
Lyon, Jan. 11, 1827, by Robert Orr, J. P. John Dennis and Mary
Herrel, April 26, 1840, by John Brown, J. P. Jacob Devon and
Elizabeth Jones, M^ay 16, 1816, by David Custer, J. P.
 254 HISTORICAL COLLECTIONS OF HARRISON COUNTY
John Derry and Elizabeth Orr. March 1, 1832, by George W. Bell, J. P.
John Derry and Berthia Warton, Dec. 19, 1839, by Joseph Fry, J. P.
George Denser and Sarah Little, June 27, 1826, by Henry Ford. J. P.
Samuel Deusenberry and Susan Swallow. Jan. 17, 1840, by Rev.
Parden Cook. Moses Devore and Polly West, January 14, 1S36, by
William Arnold. J. P. John Dew and Winifred Kirby, March 6, 1840, by
William Arnold, J. P. John Dewalt and Rachel McLovedy, Dec. 18,
1823, by Robert Orr. J. P. William Dewalt and Hannah Strausbaugh,
June 28, 1830, by John Patterson, J. P. Solomon Dewel and Patience
Potts, June 1, 1815, by Martin Gu 1 nger, J. P. John Dewell and
Phebe Jolly, Jan. 30, 1828, by Van Brown. J. P. Samuel Dewell and
Mary Vanhorn, June 22, 1826, by Samuel Dunlap, J. P. Chauncey
Dewey and Nancy Prichard, Feb. 11. 1823, by John Rea, V. D. M.
George Dewit and Sarah Britt, Sept. 2. 1828, by Jesse Hooper, J. P.
John Dewit and Mary Ruble, Jan. 19, 1832, by Thomas P. Jenkins, J.
P. Lyle Dewitt and Nancy Simpson, March 29, 1831, by John Graham.
Robert Dick and Elizabeth Dick, April 23, 1829, by Rev. William
McMillan. Samuel Dick and Martha Clark, May 13, 1836, by Thomas
P. Jenkins J. P. William Dick and Sarah Biggart, Dec. 16, 1828, by
William Taggart, V. D. M. Asa Dickerson and Jane Dunlap. April 27,
1836, by John McArthur, V. D. M. Eli Dickerson and Sarah Crumley,
Sept. 12, 1822. by Rev. James Roberts. Hiram Dickerson and Mary
Crumley, Jan. 14, 1830, by Thomas M. Hudson. John Dickerson and
Eliza McFadden, Feb. 23, 1832, by William Taggart, V. D. M. Joshua
Dickerson and Nancy Glasener, Sept. 21, 1820, by Thomas
Dickerson, J. P. Joshua Dickerson and Belijah Lafferty, Jan. 28, 1830,
by William Wallace, V. D M. Joshua Dickerson and Elizabeth Crumley,
May 2, 1833, by Rev. William Tipton. Levi Dickerson and Margaret
Hanna, Dec. 20, 1823. by Salmon Cowles. V. D. M. Thomas
Dickerson and Mary Chew, May 6, 1819, by Rev. James B. Finley.
William Dickerson and Elizabeth Holmes, Jan. 7, 1818, by James
Roberts. William Dickerson and Jane Lafferty, March 8, 1838, by
William Wallace, V. D. M. William W. Dickerson and Susan Ann
McCoy, Oct. 17, 1839, by James H. White. Benjamin Dickey and
Nancy Watson, Oct. 29, 1840, by M. F. Burkhead, J. P. Joseph Dicks
and Anna Smith, Jan. 2, 18:^6, by James Smith, J. P. James Dillon
and Rachel McQueen, Jan. 6, 1825, by John Hurless, J. P. George
Dinger and Mary Heisler, March 11, 1821, by John Wagner, J. P.
Alexander Dinning and Margaret Couch, Sept. 18, 1834, by Rev.
Robert Cook. William Dinning and Margaret Hinton, June 8, 1826, by
Joseph Fry, J. P. Samuel Dixon and Delila Figley, Jan. 3, 1839. by
Samuel Skinner, J. P. Stacy Doan and Elizabeth Wells, Aug. 8, 1826,
by Silvanus Lamb, J. P . David Dobbins and Martha Smith, Oct. 23.
1828. by William Wallace, V. D. M. John Dobbins and Ann
McCullouch, April S, 1S19, by John Rea, V. D. M. Matthew Dobbins
and Eliza McKibbin. Feb. 3. 1820, by John Rea, V. D. M. James
Donaghey and Ruth Loudon, Jan. 9, 1835, by Mark Hogge, J. P. John
Donaghey and Sarah Picken, Dec. 11, 1823, by Michael Conaway, J.
P. Philip Donaghey and Eleanor Auld, April 12, 1821, by Abriam
Johnson, J. P. Benjamin Doney and Elizabeth Summers, Jan. 15,
1839, by Matthew Phillips, J. P.
 EARLY MARRIAGES 255 Samuel Doney and Mary Covert,
Jan. 15, 1828, by George Brown, J. P. Samuel Douglas and Isabella
Pritchard, March 23, 1827, by John McArthur. David Dougherty and
Mary Davidson, March 6. 1834, by John L. Grubb, J. P. James
Dougherty and Sarah Lucy, Sept. 22, 1831, by Elder George Lucy.
Michael A. Dowden and Ruth Greenland, Feb. 18, 1820, by Rev.
Elijah C. Stone. Merriam Downey and Jemima Vanhorn, April 3,
1826, by Rev. Salmon Cowles. Bazel Downing and Eliza Rees, Oct. 4,
1824, by Rev. Samuel Cowles. Richard Downes and Elizabeth
McKinney, April 5, 1821, by Joseph Johnson, J. P. David Drak and
Nancy Drummond, Dec. (i, 1838, by Samuel Skinner, J. P. George
Drake and Rachel Johnson, March 1, 1820, by Abraham Johnson.
Joseph Drake and Actions Greer, Sept. 23, 1827, by Samuel Dunlap,
J. P. Samuel Drake and Susan McCarthy, June 24, 1835, by William
Arnold J. P. Thomas Drake and Hannah Browning, Jan. 25, 1837, by
Samuel Skinner, J. P. James Drummoud and Fanny Phillips. Nov. 26,
1818, by William Taggart, James Drummond and Lydia Ann
Hutchison, Feb. 25, 1824, by William Tipton. Rev. James Drummond
and Catherine Taggart, July 29, 1840, by Rev. William Knox. John
Drummond and Sarah Leinerd, Jan. 6, 1818, by Charles Chapman J.
P. Samuel Drummond and Anna Bird, April 1, 1821, by Charles
Chapman, J. P. David Duff and Jane Carr, July 11, 1815, by John
Rea, V. D. M. William Dugan and Esther Gilmore, Jan. 23, 1834. by
Samuel Ramsey, J. P. Maxon Duly and Lydia Dawson, July 8, 1817,
by Daniel David, J. P. Joseph Dunbar and Eleanor Welch, Feb. 14,
1839, by William D. McCartney, V. D. M. Archibald Duncan and Mary
Williamson, April 21, 1831, by William Wallace, V. D. M. James
Duncan and Margaret Williamson, Nov. 25, 1834, by William Wallace,
V. D. M. Nicholas Dunfee and Rebecca Shaeffer, March 26, 1834, by
Lot Deming, J. P. Jesse Dungan and Margaret Grisell, May 1, 1823,
by Rev. James Roberts. Abel Dunham and Rachel Harding, Aug. 13,
1839, by Rev. G. D. Kinnear. Lewis Dunham and Sarah Ann Nelson,
Nov. 5, 1824, by Rev. John Crom. Adam Dunlap and Jane Patterson,
Oct. 2, 1817, by Thomas B. Clark, J. P. John Dunlap and Ann
Vanhorn, Nov. 2, 1815, by Martin Guilinger, J. P. John Dunlap and
Betsey Berger, Oct. 4, 1819, by William Haverfield, J. P. Joseph
Dunlap and Sarah Gilmore, May 18, 1819, by John Rea, V. D. M.
Joseph Dunlap and Mary Ann Roberts, Nov. 3, 1840, by Jacob Coon.
Mathew Dunlap and Ann Greer, July 1, 1813, by Alexander Lee, J. P.
Robert Dunlap and Polly Patterson. April 29, 1819, by Thomas B.
Clark, V. D. M. Samuel Dunlap and Hannah Greer, May 10, 1821, by
Robert McLaughlin, J. P. William Dunlap and Mariah Ramage, Sept.
12, 1839, by William Wallace, V. D. M. Thomas Dunn and Sarah
Dorsey. March S 1S36, by Rev. Cornelius D. Battelle. Jacob Dunmire
and Rebecca Snodiker, May 9, 1828, by John Wagner, J. P. John
Duvall and Rachel Jones. Nov. 22, 1834, by Joseph Fry, J. P. Nicholas
Durbin and Margaret Oliver, May 2i, 1829, by Thomas Parkinson.
Thomas Durban and Miram Groves, Oct. 9, 1837, by James McCoy.
Cyrenius Dusenberry and Isabella McConkey, Nov. 3, 1836, by R. H.
Sedwiclc. V. D. M.
 256 HISTORICAL COLLECTIONS OF HARRISON COUNTY
David Dvittnn and Hulda Strade, Aug. 8, -iSSQ. by Thomas Phillip. J.
P. William Kagle.-on and Jane Gourley, March 17, 1830, by John Rea,
V. D. M. William Eagleson and Matilda Biggart, April 7, 1831, by
William Taggart, V. D. M. John J. Eager and Ann Forbes, May 26,
1836, by Richard Brown. James Eakins and Elizabeth Foster, Jan. 24,
1830, by John Rea. V. D. M. Samuel Eakins and Mary Eagleson, May
27, 1840, by John Rea, V. D. M. William Eakins and Martha Osburn,
May 10, 1886, by John McArthur, V. D. M. Aaron Earley and Rebecca
Joy, Sept. 21, 1826, by James Clements, J. P. Aaron Earley and
Elizabeth Conner, July 26, 1831, by Rev. Benjamin Wood. Alexander
Earley and Nancy Davis, Dec. 18, 1822, by John Russel, J. P. Ira
Earley and Eliza Eicher, March 11, 1840, by Charles Thorn. John
Earley and Nancy Rankin, Dec. 10, 1835, by Rev. Cornelius D.
Battelle. Jonathan Earley and Matilda Ruby. Sept. 27, 1825, by Philip
Fulton, J. P. Richard Easley and Elizabeth Valentine, June 11. 1827.
by Rev. James Roberts. Isaac Easley and Mary Norris. April 8, 1830,
by Rev. Jacob Lemmon. James Easter and Sarah Maholm, Oct. 10,
1839, by Rev. William Taggart, V. D. M. Martin Easterday and Peggy
Shaber, Jan. 31, 1818, by John Rinehart. Joseph Eastland and Mary
Ann Norris, Dec. 24, 1835, by Joseph Masters. J. P. David P. Eaton
and Eliza Jane Marshall, Feb. 28, 1839, by Rev. Robert Cook. Johiel
E. Eaton and Sarah Coalman, March 26. 1840, by Rev. J. D. Kinnear.
Joseph E. Eaton and Peggy Anna Ankrim, Feb. 16, 1832, by William
Wallace, V. D. M. Jacob Ebert and Nancy Vandolah, April 6, 1812, by
Donald Mcintosh, V. D. M. Joshua Edie and Rachel Hall, Aug. 7, 1821,
by Rev. James Roberts. William Edgar and Betsey Kirkpatrick, Dec.
28, 1820, by Thomas B. Carter, J. P. Harvey Edwards and Edith
Voshel, Oct. 22, 1839, by David Bowers, J. P John Edwards and Eliza
Moore, June 25. 1833, by Cornelius Crabtree, J. P. Joseph Edwards
and Sarah Barkhurst, March 20. 1834, by Rev. Moses Scott. John
Eicher and Nancy Davis, Feb. 16, 1831, by William McMillin. Samuel
Eiraes and Eleanor Robinson. May 5, 1831, by John Wagner, J. P.
William Elgar and Nancy Watson, Nov. 2, 1830, by John Gruber. J. P.
John Elliott and Susan Kendal, March 24, 1830, by Alexander
Simpson, J. P. Martin Elliott and Mary Hawkins, Dec. 17, 1S40, by
Elias Gatchel. Berin Ellis and Mary Ann Moffet, March 17, 1831, by
Lentulus Kirk. J. P. Jonathan Ellis and Margaret Lister, Feb. 17, 1820,
by John Russel. J. P. Nathan Ellis and Margaret Brian, March 26,
1835, by Rev. Jacob Lemmon. Washington Ellison and Sarah Kent,
Jan, 29, 1834, by Samuel Ramsey, J. P. George Ely and Sarah Girt,
March 27, 1823, by Thomas Patton, J. P. Thomas Ely and Barbara
Ann Moore, Nov. 8, 1827. by Michael Conaway. J. P. William Emmons
and Catherine Bussler, Feb. 11, 1832, by John C. Huston, J. P. Simon
Emory and Rebecca Minick, June 3, 1840, by E. Greenwold. Thomas
Endsley and Matilda Kerr, March 4, 1824, by Thomas Hanna, V. D. M.
James Endsley "and Christian Baker, Oct. 29, 1829, by John
McArthur, V. D. M. Asa Engle and Mary Ripley. July 9, 1818, by
William Wyckoff. J. P. John English and Rebecca Miller, Dec. 3C,
1817, by Thomas Dickerson. John English and Elizabeth Baker, May
28, 1835, by William Arnold, J. P. Matthew English and Melila
Anderson, March 14, 1839, by Thomas Phillips, J. P.
 EARLY MARRIAGES 25^ Patrick English and Susanna
Dickerson. Feb. 3. 1818, by Thomas Dickerson, J. P. Thomas English
and Susanna Walraven, Oct. 28, 1820, by Thomas Dickerson, J. P.
Jacob Ensniinger and Elizabeth Huff. Nov. 17, 1825, by James Smith,
J. P. William Erskine and Rachel Barber, Feb. 20, 1838, by Rev.
James Drummond. Barney Ervin and Mary Fi:;her, Jan. 1-5, 1833, by
John Chalfan, J. P. Henry Ervin and Elizabeth Wheeler, Nov. 27, 1838,
by M. B. lAikins. J. P. John Ervin and Nancy Carson. Dec. 8, 1S33. by
Thomas M. Granfel, J. P. William Ervin and Anna Hardin, July 27,
1837, by Thomas M. Granfel, J. P. Erwin, see also Irwin. Andrew
Erwin and Esther Mcllroy, March 6, 1821, by Rev. William Knox.
James Erwin and Martha Dunham, Feb. 19, 1829, by Joseph
Johnson, J. P. Joshua Erwin and Nancy Hyret, May 23, 1825, by
Michael Conaway, J. P. William Ei'win and Sarah Dunham, Aug. 1,
1825, by Rev. John Crom. George Eschaltot and Nancy Hanna, Sept.
26, 1829, by Robert Pittis, J. P. Benoni Evans and Elizabeth Bradley,
Sept, 23, 1S19, by William Wyckoff, J. P. Ezekiel Evans and Mary
Simpson, Sept. 3, 1818, by Rev. William Knox. George W^. Evans
and Elizabeth Spiker. April 15, 1838, by Rev. Jacob Lammoa, James
Evans and Elizabeth Simpson, Feb. 13, 1821, by John Graham.
James Evans and Willimenah Rigel, May 10, 1832, by Silvanus Lamb,
J. P. Mordicai M. Evans and Lydia Dillon, Sept. 26, 1825, by Silvanus
Lamb. J. P. Robert Evans and Amanda McGrew, July 11, 1839, by
Samuel Lewis, J. P. Barnabas Everhart and Rachel Hofane, Aug. 3,
1813, by George Pfautz. J. P. David Everheart and Rachel Hicks, Nov.
13, 1819, by Rev. John Rinehart. John Everhardt and Cerrillah Shaw,
June 20, 1832, by Charles Fawcett, J. P. Peter Everhart and Polly Fry.
Feb. 27, 1816, by Martin Guilinger. Philip Everhart and Polly
Carpenter, March 23, 1830, by John Gruber, J. P. Thomas Everhart
and Mary Wheeler. Nov. 13, 1817, by Rev. M. Cole. John Fairchild
and I>enday Welch, April 20, 1824, by Thomas Parkinson, J. P.
William Faris and Elizabeth Riley, Feb. 13, 1831, by Thomas Phillips.
J. P. Alexander Fawcett and Elizabeth Brooks, Aug. 16, 1826, by
Josiah Foster. Charles Faucet and Marjery Brooks, Jan. 25, 1820, by
John Graham. Jonathan Faucett and Caroline McGibbons, March 21,
1839, by Matthew H. Phillips, J. P. George Faulknor and Mary Hidey,
Aug. 22, 1825, by Morris Albaugh, J. P. John Faulkner and Ellen
Miller, Sept. 18, 1817, by David Custer, J. P. .Jonas Fayley and Nancy
Johnson, March 28. 1814, by Henry Barricklow. William Feinery and
Mary Smith, Feb. 18, 1813, by Rev. Thomas B. Clark. Charles Feister
and Margaret Thompson, July 3, 1827, by Jesse Hooper, J. P. Robert
Feister and Mary Crabtree, Oct. 13, 1828, by C. E. W^eirich. Joseph
Fell and Sarah Peck, Aug. 26, 181b, by James Roberts. Thomas Fell
and Willy Ann Gray, Feb. 15. 1827, by Rev. William B. Evans. Henry
Feltenbarger and Susan Stonebrook, Dec. 28, 1838, by John Gruber,
J. P. Benjamin Ferguson and Cynthia Haskings, Nov. 17, 1833, by
Rev. Benjamin W^ood. Hugh Furgeson and Margaret Sharp. June
12, 1832, by John McArthur, V. D. M. Macomb Ferguson and Mary
Patton, June 19, 1840, by John Walker. Rczin Ferguson and Martha
Ann Andrews, Oct. 29, 1832, by John Chalfan. 17
 258 HISTORICAL COLLECTIONS OF HARRISON COUNTY
Vincent Ferguson and Mary Araspokcr, March 19, 1835, by John
McArthur, V. D. M. William Ferguson and Rebecca Walker, Aug. 18,
1831, by John Gruber, J. P. Benjamin Ferrell and Sarah Ann
McNamee, Nov. 5, 1840, by John Knox. J. P. James Ferrell and Peggy
Ann Cook, Aug. ]8, 1836, by William Arnold, J. P. John Ferrell and
Jane McGoogan, Sept. 30, 1824, by Thomas Hanna, V. D. M. David
Ferrier and Susan Hendricks, Nov. 23, 1820, by Robert Maxwell, J. P.
John Fife and Cassander Lyon, Dec. 23, 1828, by Robert Orr, J. P.
Jacob Figley and Maria Shannon, July 10, 1834, by William Wallace
V. D. M. William Figley and Margaret Chord, Aug. 11, 1823, by Rev.
Curtis Goddard. John Finney and Betsey Cannon, Dec. 10, 1816, by
William Taggart, V. D. M. David Finnicum and Elizabeth Lowmiller.
June 29, 1828, by John Gruber, J. P. William S. Finnicum and Maria
Richards, Sept. 28, 1822, by Robert McLaughlin. Daniel Firebaugh
and Caty Little. March 30, 1827, by Henry Ford, J. P. Jacob Firebaugh
and Catherine McCarroll, Dec. 30, 1835, by Thomas Foster. Barak
Fisher and Jane Pickering, Nov. 14, 1822, by George Brown, J. P.
Boanaparte N. Fisher and Lydia Canagey, Feb. 17, 1836, by Rev.
Alexander Biddle. Eli Fisher and Elizabeth Maxwell, Feb. 26, 1831, by
Rev. Thomas Hanna. Garret Fisher and Ann Hamilton, Oct. 31, 1816,
by James Roberts. George Fisher and Susanna Johnson, Dec. 24,
1818, by Thomas Dickerson. J. P. George Fisher and Elizabeth
Burkhead, Dec. 23, 1823, by Isaac Allen, J. P. George M. Fisher and
Anna L. Brown. Dec. 21, 1830, by John Gruber, J. P. George Fisher
and Mary Welch, Sept. 4, 1833, by John McArthur, V. D. M. George
Fisher and Sarah Lisle, Oct. 17, 1839, by Rev. William Taggart. James
Fisher and Ann Harrison, Oct. 13. 1815, by James Roberts. John
Fisher and Mary Fowler, Oct. 27, 1S25, by Rev. Elijah C. Stone. John
R. Fisher and Sarah Early, Oct. 21. 1830, by John Russel, J. P. John
Fisher and Eliza Edwards, Jan. 4. 1838. by David Bowers, J. P.
Samuel Fisher and Elenor Marshall. Nov. 4, 1824, by Michael
Conaway, J. P. Thomas Fisher and Elizabeth Picken, Oct. 5, 1815, by
Charles Chapman, J. P. Thomas Fisher and Elizabeth Holtzman, Nov.
5, 1829, by Morris Allbough, J. P. Michael Fivecoats and Nancy
Cheney. Aug. 31, 1815, by Charles Chapman, J. P. Nathan Fivecoats
and Eleanor Steel, Oct. 30, 1837, by Thomas Phillips, J. P. Absalom
Flemming and Sarah Wright, March 10, 1821, by John Russel, J. P.
Robert Fletcher and Martha Moorehead, Aug. 21, 1832, by John Rea,
V. D. M. Abraham Flory and Catherine Hagney. Sepjt. 3, 1821, by
John Hurless, J. P. Joseph Fogle and Sabra Cochran, March 27, 1836,
by Thomas P. Jenkins. J. P. Frederick Foltz and Anna S. Williams, Oct.
11, 1832, by Rev. Jacob Lemmon. James Force and Mary Williams,
June 1, 1821, by John Graham. James Ford and Susan Delany, June
16, 1833, by John L. Grubb, J. P. Lewis Ford and Rebecca Dodd,
April 15, 1819, by William Wyckoff, J. P. Richard Ford and Darkey
Pierce, April 4, 1821, by Phineas Inskeep, J. P. Stephen Ford and
Elizabeth Thompson. Feb. 4, 1838, by David G. McGuire, J. P.
Thomas Ford and Catherine Polen, Dec. 13, 1821, by Williamson
Carrothers, J. P. David D. Fordyce and Margaret Feister. June 28,
1831, by Rev. Jacob Lemmon. John Fordyce and Lydia Ann Parkes,
Nov. 28, 1826, by Joseph Fry, J. P. Henry L. Foreman and Jane
Cosgrove, April 25, 1833, by Thomas Lakin.
 EARLY MARRIAGES 259 Levi Foreman and Elizabeth
Amanda Jones, March 24, 1836, by Kev. Benjamin Wood. William
Foreman and Susanna Cummins, Sept. 5, 1839, by John Graham.
Joseph Forker and Mary Conwell, Oct. 16, 1834, by William Taggart,
V. D. M. Peter Forney and Fanny Gundy, March 20, 1823, by Rev.
John Crom. John B. Forsythe and Christena Burkhart, June 2, 1831,
by John Gruber, J. P Abraham Foster and Lucinda Coleman, Dec. 25,
1823, by William Holmes, J. P. Alansin Foster and Mary Ann Prouf,
Nov. 16, 1839, by Samuel Ramsey, J. P. David Foster and Jane
Johnston, Feb. 24, 1831, by John Rea, V. D. M. Eli Foster and Sarah
H. Edie, Jan. 3, 1828, by Rev. William B. Evans. George Foster and
Jane Davis, May 24, 1837, by David G. McGuire, J. P, John Foster
and Fanny Hendrickson, Feb 14, 1822, by Joseph Fry, J. P. Josiah
Foster and Rebecca Johnson, May 24, 1831, by Robert Pittis. J. P.
Moses Foster and Hannah Randels, March 14,' 1819, by Charles
Chapman, J. P. Samuel Foster and Sarah Young, May 9, 1815, by
Charles Chapman, J. P. Samuel Foster and Mary Moore, March IS,
1824, by Isaac Allen, J. P. Samuel Foster and Anne Johnson, Jan. 27,
1831, by Robert Pittis, J. P. Andrew Fowler and Betsy Martin, April
26. 1821, by William Carrothers, J. P. Francis Fowler and Mary Giles,
Nov. 4, 1830, by Rev. Elijah C. Stone. Garret Fowler and Hannah
Eagleson, April 3, 1819, by Rev. Elijah C. Stone Harrison Fowler and
Elizabeth Bridgeman, Oct. 7, 1839, by M. B. LuKens, J. P. James
Fowler and Mary Gifford, Feb. 11, 1830, by Rev. John Crom. Joel
Fowler and Esther Fisher April 20, 1836, by Rev. Elijah C. Stone.
John Fowler and Cassander Keepers, April 10, 1822, by Rev. Elijah C.
Stone, John Fowler and Amanda Burchfield, Dec. 24, 1835, by
Thomas Foster. Thomas Fox and Sarah Hartley, June 28, 1838, by
George Shaffer, J. P. James Francis and Amelia Selby, May 21, 1813,
by Rachel Hall. James Fransis and Nancy Boals, Aug. 11, 1835, by
William Taggart, V. D. M. James Frasure and Rebecca Erwin, June
20, 1833, by George W. Bell, J. P. Daniel Frester and Rachel Ann
Darling, July 10, 1831, by Rev. Jacob Lemmon. Ludwig Frietsh and
Catherine Manbeck, Feb. 21. 1832, by Rev. Adam Hetzler. Robert
Fryer and Susanna Oram, Aug. 30, 1836. by Rev. Thomas Hanna.
David Furby and Fanny Luke, Dec. 16, 1838, by Samuel Lewis, J. P.
James Furbay and Beulah Stephen, May 8, 1838. by George
Atkinson, J. P. Thomas Furbay and Margaret White, Sept. 15. 1825,
by Rev. James Roberts. Alexander Fulton and Sarah Ramsey, Nov. 2,
1826, by Joseph Rea. J. P. William Fulton and Polly Moore, Oct. 28,
1823, by Donald Mcintosh, V. D. M. William Fulton and Elizabeth
Pugh, May 3, 1832, by James Miller, J. P. James M. Galbreath and
Caty Delany, Nov. 10, 1819, by Elijah C. Stone. Robert Galbraith and
Lydia Yarnell, Nov. 27, 1820, by John Rea, V. D. M. Samuel Galbraith
and Rebecca Able, Oct. 24, 1839, by John Gruber, J. P. Henry
Galentine and Ellen Treacle, March 5, 1838. by Mark Hogge, J. P.
John Gallaher and Levina Young, May 10, 1832, by William Arnold, J.
P. Patrick Gallaher and Sarah Gibson, May 15, 1819, by Phineas
Inskeep. Patrick Gallaher and Martha Bevard, Aug. 25, 1837, by Rev.
William Knox. Thomas B. Gallaher and Jane Farmer, Feb. 15, 1838,
by Rev. Joseph Clokey. William C. Galaher and Eleanor Green, Dec.
5, 1839, by Rev. Parden Cook. John Gamble and Sarah Heck, Dec.
29, 1839. by B. W. Veirs, J. P. Joshua Gamble and Elizabeth Heck,
March 27, 1834, by William Arnold, J. P. John Gant and Elizabeth
Cellar, Oct. 9, 1828, by Salmon Cowles, V. D. M.
The text on this page is estimated to be only 24.10%
accurate

260 HISTORICAL COLLECTIONS OF HARRISON COUNTY

Joseph Gant and Sarah McCUsh. June 2. 1S36. by W. B. Luklus, J. P.
Androw Gardner and Elizabeth Riddlemoser, Nov. 20. 1S34. by
George Blown. J. P. Georire Gardner and Sarah Wright. May 9.
1S2(5. by Alexander Moore. J. P. Isaao Gardner and Nancy Rose.
May 12. ISIS, by Rev. Samuel Hamiltou. Lemi'el Gai'dner and Mary
Derault. Feb. 10. 1S31. by Robert Orr, J. P. John Garner and Sarah
Cusick. May t5. 1S30. by Jesse Hooper. J. P. Edward B. Garrett and
Catherine Suddith. March 23. ISoI. by Rev. Benjamin Wood. John
Garret and Margaret Haines. J.^n. 13. 1S20. by Phineas Inskeep. J.
P. Joseph W. Gari-etson and Jane N. Pooi\ Dec. 15. 1S3»>. by Rev.
Jacob Coon. John Garvin and Hannah Whan. March 11. 1S19. by
Thomas Diokerson. J. P. John Garvin and Ag^ness Rankin. Jan. 25.
1S3S. by Rev. Jacob Coon. Charles Gassuch and Matilda Roberts.
July IT. iS2S. by Rev. James Moore. Amor Gatchel and Almira Moore.
April 16, 1S35. by John McArthur, V. D. M. Amos Getchell and
Elizabeth Burger. June 23. 1S36. by John McArthur. V. D. M. Elias
Gatchel and Mary Sudduth. Nov. S. 1S25. by Donald Mcintosh. V. D
.M. Elijah Getchell and Harriett Drake. July 29. 1S27. by Philip Fulton.
J. P. Job w:. Gatchel and Fi-ancis Clemens. Aug. 7. 1S35, by William
Wallace. V. D. M. Henry Gayer and Betsey McAfee, Nov. 21, 1S33. by
B. W. Viers. J. P. Anderson Geary and Catherine Vanhom, Nov. 2,
1S20. by Rev. Thomas B. Clark. Matthew Geary and Driisilla Johnson,
May 1. 1S17. by John Crawford. J. P. James Gearwood and Mary
McCleary. Oct. 19. 1S24. by John Hurless. J. P. B ' ■ Geasy and
Juliann Ruble. Oct. 6, 1S39. by Joseph Fry. J. P. K. Geddes and
Tamer Yarnell. Oct, 17. 1S2S. by Ezekiol Paramer. E. C. C. John
Geddes and Julian Geddes. July 24, 1S31, by Edward Talbott. J. P.
George B. George and Mary Warfel, March 13, 1SS4, by William
Taggart. V. P. M. Edward Gibbins and Emily E. White. June 30. 1S36.
by Rev. C. D. Battell. Henry Gibbins and Ann "\i\ilson. Nov. 17. lS3o,
by Rev. Jacob Coon. David Gibny and Rebecca Henry. Dec. 23. 1S30.
by Thomas Phillips. J. P. James B. Gibson and Polly Ann Maxwell.
Jan. 29. 1S29, by Rev. Thomas Hanna. Robert Gibson and Elizabeth
S. Maxwtll. Nov. S, 1S2T. by Thomas Hanna. V. D. M. Robert
Gilbreath and Mary Beeman. June 5. 1S2S. by Michael Conaway. J. P.
Thomas C. Gilcrest and Eleanor Guttery. May 26. lS3o. by John
McArthur. V. D. M. James Giles and Lettice Gordon. Jan. 2S. 1S3S. by
Rev. Henry Wharton. John Giil and Caroline Richards. Dec. IS. :S32,
by Joseph Wolff. J. P. Charles Gillaspie and Margaret Himebaiigh.
Dee. 37, 1S32. by Dewalt Rothacker. James Gillespie and Susan
Catherine Painter, June 7, 1S32, by Rev. David C. Merryman. John
Gillespie and Tama Biggart. Jan. 16, 1S35. by Rev. Jacob Coon.
Moses Gillespie and Catherine Turner. April 16. 1S36. by David
Finnicum. J. P. Thompson Gillespie and Hetty Chapman. Dec. 17,
1S26. by Daniel Limerick. E. of M. E. C, Cyrus Gilmore and Hannah
Moore. Oct. 23. 1S34. by John McArthur. V. D. M. Francis Gilmore
and Elizabeth Shimer, Feb. 1, 1S33, by John ?IcArthur. V. D. M.
The text on this page is estimated to be only 25.98%
accurate

EARLY MARRIAGES 261 Francis Gilmore and Mary Ann

PattersjoiL Aug. 29, 1839, by M. F. Burkhea
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