RADIOLOGY

Work Smart
Time taken: 00:20

Theme:Investigation of weight loss

A Barium enema

B Barium meal

C Bronchoscopy

D Faecal occult blood

E Gastroscopy

F Lateral chest x ray

G Prostate specific antigen

H Plasma glucose

I Thyroid function tests

J Ultrasound abdomen

K ZN stain sputum for acid fast bacilli

For each presentation below choose the single most discriminating investigation from the
given list of options.

Each option may be used once, more than once, or not at all.

A 78-year-old woman complains of being restless and losing weight, despite having a good
appetite. Examination reveals atrial fibrillation.

Incorrect - The correct answer is Thyroid function tests

She has features of thyrotoxicosis, that is, being restless and fidgety, and development of
AF. Classic features include weight loss, tremor, palpitations and hyperactivity. Apathy,
weight loss and depression may be the main symptoms in the elderly.

The commonest cause of thyrotoxicosis is Graves' disease, followed by toxic nodular goitre
(often in older people with goitre).
A 38-year-old Indian presents with a troublesome productive cough, with weight loss and night
sweats. His chest x ray shows some shadowing in the left upper zone.

Incorrect - The correct answer is ZN stain sputum for acid fast bacilli
Tiredness, anorexia, weight loss, fever and cough are features of pulmonary tuberculosis. In
the UK, the incidence of TB in immigrants from the Asian subcontinent is 40 times higher
than the local Caucasian population.

Pulmonary TB is unlikely with a normal CXR. (It normally shows shadow/loss of

volume/fibrosis in the upper zones.)

Bronchoscopy with bronchial lavage may be needed if sputum is not available.

A 76-year-old woman complains of a six month history of dysphagia and weight loss. It has been
gradual in onset and mainly affects solids, which seem to stick retrosternally.

Incorrect - The correct answer is Gastroscopy

A gastroscopy is probably the best investigation, because it is possible to see lesions,
perform biopsies and also laser/stent/dilate the stricture as necessary.

A 30-year-old man presents with a four week history of weight loss, polyuria and polydipsia.

Incorrect - The correct answer is Plasma glucose

Diabetes mellitus, hypercalcaemia and hypokalaemia are causes of polyuria and polydipsia.

In DM, there is osmotic diuresis due to glycosuria, resulting in dehydration and thirst
(hypertonic extracellular fluid). Weight loss may be due to dehydration and accelerated
breakdown of fat and muscle due to insulin deficiency. Diabetic ketoacidosis may be the
presenting feature if early symptoms are missed.

A 67-year-old man complains of tiredness and weight loss. He has iron deficiency anaemia (Hb
7.2 g/dl). His recent gastroscopy reveals gastric erosions.

Correct
The gastric erosions found may not account for the weight loss, that is, it is a red herring. It
is important to exclude pathology of the large bowel, with either a colonoscopy or barium
enema.

Blood loss of >20 ml/day will result in iron deficiency anaemia (0.5-1.2 ml/day in normal
person).

If investigations do not provide diagnosis (exclude haematuria) in presence of persistent

bleeding, consider barium meal and follow through to study small bowel. Also consider
coeliac or superior mesenteric angiography.

Work Smart
Time taken: 00:33

Theme:Skull x ray appearances

A Acromegaly

B Cranio-facial dysostosis

C Fracture of base of skull

D Haemoglobinopathy

E Histocytosis X

F Hypoparathyroidism

G Metastatic disease

H Multiple myeloma

I Osteogenesis imperfecta

J Osteopetrosis

K Paget's disease

From the given list select the most likely diagnosis for each of the following abnormalities of
the skull:

The skull x ray of a 6-year-old Greek Cypriot child reveals widening of the bones with a hair-on-
end appearance.
 Incorrect - The correct answer is Haemoglobinopathy
The first case of a young child with thickened skull bones and the characterisitic hair-on-end
appearance indicating marrow hyperplasia suggests a diagnosis of haemoglobinopathy. In a
Cypriot child this is likely to be thalassaemia.

The skull x ray of a 55-year-old male who presents with headaches reveals prognathism and an
enlarged sella turcica.

Correct
The 55-year-old man has prognathism and an enlarged sella turcica (pituitary fossa)
suggesting acromegaly.

The skull x ray of a 32-year-old female who complains of headaches and occasional muscle
cramps reveals flecks of calcification around the base of the brain.

Incorrect - The correct answer is Hypoparathyroidism

This woman with brain calcification and tetany would suggest hypoparathyroidism. The
calcification tends to focus at the basal ganglia.

The skull x ray of a 72-year-old male who presents with headaches, weight loss and backache
reveals numerous small lytic lesions within the vault resembling a pepper-pot.

Incorrect - The correct answer is Multiple myeloma

The 72-year-old man has weight loss, backache and a pepper pot skull suggesting multiple
myeloma.

The skull x ray of a 65-year-old female who complains of headache and weight loss reveals a
punched out lesion of the temporo-parietal region of the skull.

Incorrect - The correct answer is Metastatic disease

The lytic lesion in this case together with the weight loss would be suggestive of metastatic
disease, in particular breast carcinoma.
 Work Smart
Time taken: 00:41

Theme:Backache

A Ankylosing spondylitis

B Congenital scoliosis

C Normal

D Osteoporosis

E Potts disease

F Psoas abscess

G Reactive arthritis

H Sciatica

I Scheuermann's disease

J Spina bifida occulta

K Vertebral metastases

From the given list, select the most likely cause for each of the following cases:

A 63-year-old retired male presents with back pain and stiffness. Examination reveals a general
limitation of all spine movements. Neck movements are particularly restricted and he finds
difficulty with neck extension.

Correct
This patient has restriction of all spinal movements suggesting ankylosing spondylitis.
Characteristically, a bamboo spine would be noted on x ray.
A 44-year-old male civil servant presents with lower back pain which tends to locate to the left
buttock and back of leg. Examination reveals an inability to flex the spine due to pain and straight
leg raising on the left is limited to 45 degrees.

Incorrect - The correct answer is Sciatica

This patient has sciatica with impaired straight leg raising and consistent symptoms. Dermatomal
sensory loss may be found and loss of reflexes (ankle may be noted).

A 26-year-old male presents with lower back and buttock pain. He also complains of painful feet.
Examination reveals restricted lateral flexion of the spine and tenderness on palpation of the
soles of the feet. One month ago he returned from a foreign holiday where he contracted a
diarrhoeal illness.

Incorrect - The correct answer is Reactive arthritis

This patient has Reiter's syndrome with plantar fasciitis and sacroiliitis acquired after a diarrhoeal
illness often due to Yersinia.

A 26-year-old male factory worker attends complaining of lower backache with shooting pains
and inability to perform any work. Examination reveals marked tenderness to palpation over his
entire back and an inability to bend. Straight leg raising is to 90 degrees bilaterally but he denies
any pin-prick or light touch sensation in both legs. Reflexes are preserved.

Incorrect - The correct answer is Normal

This patient has inconsistent signs and symptoms and as sometimes happens is feigning back pain to
avoid work.

A 24-year-old pregnant female presents in the second trimester of pregnancy with lower back
pain. Examination reveals a curvature of the spine on bending forward.

Incorrect - The correct answer is Congenital scoliosis

This patient has a congenital scoliosis and this may only present during the stresses and strains of
pregnancy.
 Work Smart
Time taken: 00:49

Theme:Radiological Investigations

A Chest radiograph

B Computed tomography of the brain

C Computed tomography of the pelvis

D Computed tomography of the thorax

E Computed tomography pulmonary angiogram

F Echocardiography

G Hysterosalpingogram

H Intravenous urography

I Magnetic resonance imaging of the brain

J Radionucleotide ventilation/perfusion scan

K Skull radiography

L Transcranial ultrasound

M Ultrasound of the abdomen

N Ultrasound of the pelvis

Each item below is an extract from the clinical information written on a referral card sent to
the radiology department.

For each subject, select from the list of options the imaging investigation most likely to be
informative.

"... 65-year-old male hypertensive; acute central chest pain; a widened superior mediastinum on
his chest radiograph ..."
 Incorrect - The correct answer is Computed tomography of the thorax
The presumed diagnosis here must be aortic dissection, and this will be revealed using a CT
of the thorax and aorta. In the past, aortic arch angiography was considered the optimal
diagnostic tool but this has been superseded by imaging with CT or MRI.

"... 24-year-old female non-smoker; pleuritic chest pain and haemoptysis; a normal chest
radiograph ..."

Incorrect - The correct answer is Computed tomography pulmonary angiogram

These clinical features suggest pulmonary embolism and CTPA is regarded as the best test
to diagnose this condition.

"... 24-year-old female; 12 weeks pregnant, with vaginal bleeding ..."

Incorrect - The correct answer is Ultrasound of the pelvis

Ultrasound of the pelvis does not deliver any ionising radiation to the fetus at a critical time in
its development, whilst investigating the cause of the vaginal bleeding, for example,
threatened miscarriage.

"... 22-year-old female, unable to conceive; history of pelvic inflammatory disease ..."

Incorrect - The correct answer is Hysterosalpingogram

The hysterosalpingogram will investigate the anatomy of the uterus and fallopian tubes.
Pelvic inflammatory disease is associated with infertility, due to scarring in the fallopian tubes
secondary to salpingitis.

"... 4-day-old male; convulsions and bulging fontanelles ..."

Incorrect - The correct answer is Transcranial ultrasound

Transcranial ultrasound is an useful tool in the assessment of brain injury in the newborn.

Work Smart
 Time taken: 00:54

A 26-year-old woman recently arrived in the United Kingdom from Somalia complains of
marked neck pain with pins and needles affecting the right arm associated with a weak grip.

Examination reveals her to be tender over the cervical spine with spasm of trapezius on the
right hand side. Radiographs of the cervical spine show narrowing of the C3/4 and C4/5 joint
space and partial collapse of C4.

Investigations show:

Hb 8.9 g/dL (11.5-16.5)

WCC 12.1 109/L (4-11)

Lymphocytes 9.7 109/L (1.5-4)

Platelets 597 109/L (150-400)

Serum ferritin 972 mg/dL (15-300)

ESR 134 mm/1st hour (0-20)

CRP 321 g/L (<10 mg/L)

Calcium 2.11 mmol/L (2.2-2.6)

Albumin 32 g/L (37-49)

Alkaline phosphatase 197 units/L (45-105)

Phosphate 0.8 mmol/L (0.8-1.4)

Which of the following is the most likely diagnosis?

(Please select 1 option)

Metastatic cancer of the cervix

Multiple myeloma

Ostemalacia 's disease

Osteoporotic collapse
 Pott's disease Correct

Pott's disease, that is tubercular infection of the spine with associated collapse of the
vertebral body, is the most likely diagnosis due to the marked acute phase response with a
lymphocytosis in an ethnic group at increased risk of tuberculosis.

The elevated alkaline phosphatase is due to the recent fracture rather than metabolic bone
disease and will remain elevated for several months following a fracture. The neurology is
due to radicular compromise.

Tubercular osteomyelitis often involves two vetebral bodies either side of an involved disc
and this and the associated soft tissue mass contributes to the neurological damage.

Osteomalacia would not explain the inflammatory response and is unlikely to cause vertebral
body collapse.

Cervical cancer does not commonly metastasise to bone (bronchus, breast, bone marrow,
kidney, thyroid and prostate classically metastasise to bone).

She is too young for myeloma and osteoporotic fractures. It is rare for osteoporotic fractures
to involve nerve roots.

Work Smart
Time taken: 01:00

Theme:Imaging Techniques

A Antegrade pyelography

B CT

C Doppler ultrasonography

D Excretion urography

E Micturating cystourethrography

F Plain ultrasonography

G Plain x ray

H MRI

I Renal arteriography
J Retrograde pyelography

Please select the most appropriate initial imaging technique for the scenarios below.

You may use each option once, more than once, or not at all.

A 22-year-old man attends for screening for adult polycystic kidney disease.

Incorrect - The correct answer is Plain ultrasonography

A 62-year-old man presents with weight loss and occasional night sweats. On examination he
has a ballotable mass in the left flank.

Incorrect - The correct answer is Plain ultrasonography

Plain ultrasonography can be used to measure the size of kidneys accurately. It is used in
screening of patients who have polycystic kidney disease in their families.

A ballotable mass and symptoms of fever and weight loss suggest renal carcinoma.
Ultrasound is used as a first line investigation.

A 55-year-old man with a long history of hypertension is found to have a bruit over the right loin.

Incorrect - The correct answer is Doppler ultrasonography

A bruit over the renal artery suggests renal artery stenosis as a cause of the hypertension.
Doppler may be used to show reduced blood flow in renal artery stenosis.

A 35-year-old woman presents with a two hour history of back pain radiating from the left side of
her loin to her groin.

Incorrect - The correct answer is Plain x ray

Severe back pain radiating from loin to groin, which occurs acutely suggests renal calculi.
Because of the high calcium content of most renal stones, x-ray may be used to show their
presence and would be the appropriate initial investigation.
A 55-year-old man is demonstrated to have right renal cell carcinoma. Prior to surgery, he
requires staging.

Incorrect - The correct answer is CT

CT is usually used for staging in renal cell carcinoma.

Work Smart
Time taken: 01:07

Theme:Investigation of hepatopancreaticobiliary disease

A Computed tomography

B Endoluminal ultrasound

C Endoscopic retrograde cholangiopancreatography

D HIDA scan

E Laparoscopy

F Liver function tests

G Magnetic resonance cholangiopancreatography

H Percutaneous transhepatic cholangiopancreatography

I Ultrasound

For the hepatobiliary conditions indicated in the following cases, which is the optimum next
line investigation?

A 50-year-old woman attends the OPD for ongoing investigation of colicky right upper quadrant
pain. She has had normal LFTs and ultrasound.

Incorrect - The correct answer is HIDA scan

This case scenario illustrates acalculous cholecystitis in which the gallbladder is non-
functional. A HIDA scan will allow assessment of the emptying of the gallbladder in response
to stimulation and an ejection fraction less than 30% is considered diagnostic for the
condition.
A 40-year-old woman is admitted from the clinic with a diagnosis of obstructive jaundice. An
ultrasound demonstrates gallstones and dilated extra- and intra-hepatic biliary tree but no
obvious cause for the obstruction. Examination is unremarkable.

Incorrect - The correct answer is Magnetic resonance cholangiopancreatography

In the case of obstructive jaundice and dilated ducts in which gallstones are seen in the
gallbladder, it is most likely that a stone has migrated and simply not been seen. If the
patient is well but remains jaundiced then an MRCP allows visualisation of the ducts without
the risk of complications. However, if the patient develops cholangitis then an ERCP and
decompression should be performed.

A 34-year-old woman is seen in the clinic with intermittent colicky right upper quadrant pain and
fatty food intolerance. She is otherwise asymptomatic and examination is unremarkable.

Incorrect - The correct answer is Ultrasound

The history is suggestive of gallstones and so the ideal primary investigation is a
percutaneous ultrasound. This will show the classic picture of hyperechoic calculi with post
acoustic shadowing.

A 56-year-old man is admitted with painless jaundice. He does not report any other symptoms
and there are no risk factors for jaundice. Examination is unremarkable.

Incorrect - The correct answer is Liver function tests

For patients who present with jaundice the first investigation is an LFT to try and differentiate
hepatic from post-hepatic causes. In typical obstructive jaundice the alkaline phosphatase
and bilirubin are elevated whilst in intrahepatic causes, it is usually the transaminases that
are markedly abnormal. Further investigations can then be targeted appropriately.

A 64-year-old man who has recently been diagnosed with colorectal cancer requires staging prior
to his colonic resection.

Correct
The standard staging modality for colorectal cancer is a CT scan as this allows examination
of both the liver and chest in one scan. Some centres advocate CT for chest and MRI for the
liver. For rectal cancer, MRI is used for local staging.
 Work Smart
Time taken: 01:14

A 17-year-old boy presents with a painful swollen wrist following a fall during a football
match.

He reports falling forwards and putting his arm out to break his fall. He is noted to have
tenderness in the region of the anatomical snuff box.

An x ray shows the following:

What is the diagnosis?

(Please select 1 option)

De Quervain's tenosynovitis
 Distal radius fracture

First metacarpal fracture

Scaphoid fracture This is the correct answer

Scapholunate fracture Incorrect answer selected

A scaphoid fracture injury normally occurs as a result of a fall on an outstretched hand, when
the wrist is extended and deviated radially. The result of this is dorsiflexion of the wrist and
compression of the radial side of the hand.

Symptoms commonly expressed by the patient are deep dull pain in the radial side of the
wrist which is often made worse by gripping. There may be some swelling and/or bruising
and occasionally fullness of the anatomical snuff box which suggests a wrist effusion.

A distal radius fracture is the other type of fracture associated with falls on an outstretched
arm, however in this case, it can be excluded mainly because of the x ray, but also due to
the symptom of tenderness in the anatomical snuff box which in 90% of cases is sensitive of
a scaphoid fracture.

Routine management includes plastering and bringing the patient back to fracture clinic in
two weeks for a scaphoid x ray.

Work Smart
Time taken: 01:21

Theme:Foregut Investigations

A Abdominal ultrasound

B Barium meal

C Barium swallow

D Chest x ray

E CT scan

F Endoscopic retrograde cholangiopancreatography (ERCP)

G Endoscopic ultrasonography

H Gastroscopy
I Laparoscopy

J Magnetic resonance scanning

From the given list select the most appropriate investigation for each of the following
situations:

A 65-year-old man is diagnosed with oesophageal adenocarcinoma. The surgeon wishes to

stage the local extent of the tumour and to assess whether there is local lymph node spread or
invasion of the thoracic aorta.

Incorrect - The correct answer is Endoscopic ultrasonography

Endoscopic ultrasonography. This patient has an oesophageal carcinoma. It could be staged
by doing a CT scan which will look for liver metastases but a more accurate way of
assessing whether or not it has spread to the local structures including thoracic aorta is by
use of an endoscopic ultrasound.

A 70-year-old man presents with painless obstructive jaundice. He has undergone assessment
by ultrasonography showing a mass in the head of the pancreas. The surgeon wishes to stage
the tumour.

Incorrect - The correct answer is CT scan

The history is suggestive of pancreatic carcinoma. An ultrasound has shown dilated common
bowel duct. The possible diagnosis is carcinoma of the head of the pancreas. A CT scan
would be the best way of staging this and would show the evidence of liver metastases and
whether or not the pancreatic carcinoma involves the superior mesenteric vessels.

A 55-year-old man presents with flatulent dyspepsia, fatty food intolerance and right upper
quadrant pain.

Incorrect - The correct answer is Abdominal ultrasound

The history is suggestive of gallstones and the most appropriate test to make this diagnosis
is an abdominal ultrasound.

An 80-year-old man presents with intermittent cervical dysphagia and has a soft swelling on the
left side of his neck. He coughs and splutters after eating and often aspirates liquids.
 Incorrect - The correct answer is Barium swallow
The history is suggestive of a pharyngeal pouch. It is not appropriate to do an endoscopy
because of a risk of perforation. A barium meal looks at the stomach and duodenum and not
the oesophagus. A barium swallow is therefore the most appropriate investigtion which will
assess the function and anatomy of the oesophagus.

A 59-year-old man has carcinoma of the stomach. He is suitable for surgical resection but the
surgeon wants to exclude peritoneal seedlings before undertaking a laparotomy.

Incorrect - The correct answer is Laparoscopy

This gentleman has carcinoma of the stomach. A CT scan has shown no evidence of liver
metastases and an endoscopy shows a localised lesion in the antrum of the stomach. A CT
scan suggests operability but a CT is not appropriate for diagnosing peritoneal metastases
as they may not be evident on a CT. A laparoscopy is therefore, the appropriate way forward.

Work Smart
Time taken: 01:25

A 45-year-old mechanic develops pain over his lower back that radiates to the umbilicus.
The pain is constant, but worse on straining.

Investigations show a normal full blood count (FBC), erythrocyte sedimentation rate (ESR),
urea and electrolytes (U&E) and liver function tests (LFT). Chest x ray is reported as normal.

You send him for an MRI of the lumbar spine. This demonstrates a homologous mass in the
intra-dural extra-medullary space.

What is this most likely to be?

(Please select 1 option)

Astrocytoma

Ewing's sarcoma

Metastatic lesion

Multiple myeloma
 Schwannoma Correct

A difficult question!

Metastatic lesions tends to be heterogeneous, involve bone and spread within the
intramedullary space; they are quite rare in the extra-medullary space.

Ewing's sarcoma occurs in children (as does neuroblastoma), usually in the thoracic spine;
85% occur in women. It is unusual to find Ewing's in patients less than five years old, or
older than 30.

Most cases of astrocytoma occur in the first decade of life, with the peak age at 5-9 years.
Most astrocytomas are indolent low-grade (that is, WHO grade I-II) tumours that
predominantly arise in midline locations, such as the cerebellum and diencephalic region,
including the visual pathway and hypothalamus. Spinal cord astrocytomas are rare.

Myeloma is unlikely given the normal biochemistry, and the mass would be adjacent to
marrow.

Schwannoma, according to some authors, is the most common intramedullary tumour of

adults. It causes pain by enlargement of nerve roots - pain which is worsened by the
Valsalva manoeuvre. Schwannomas arise from the nerve sheath and consist of Schwann
cells in a collagenous matrix and are associated with neurofibromatosis type 2.

Work Smart
Time taken: 01:31

This CT was performed on a 63-year-old male who presents with acute central chest pain, 9
out of 10 in severity.

He gave up smoking 10 years ago, has a past history of hypertension for which he takes
amlodipine and has no family history of heart disease.

On examination, he is sweaty and pale, has a blood pressure of 162/80 mmHg, a pulse of
108 per minute. Auscultation of the heart reveals a soft early diastolic murmur but nothing
else.

Investigations show normal FBC, U&Es and a cholesterol of 6 mmol/l.

ECG reveals 1 mm ST segment elevation of the leads II and III.

What is the most appropriate treatment for this patient?

(Please select 1 option)

Aspirin

Cardiac catheteristion +/- angioplasty

IV metoprolol This is the correct answer

Low molecular weight heparin and isoket

Thrombolysis Incorrect answer selected

This computerised tomography (CT) scan demonstrates an obvious flap in the thoracic aorta
indicating aortic dissection. The flap is in the middle of the descending aorta (the dark line)
which separates the true lumen anteriorly from the intimal flap posteriorly. The aortic
regurgitant murmur would alert the examiner to this and mediastinal widening may be seen
on x ray.

Occasionally, there is involvement of the right coronary artery in the dissection process
giving rise to the acute electrocardiographic changes.

However, if you said that you would give thrombolysis, then you would have killed this
patient!

The most appropriate management strategy1 is to provide adequate analgesia and urgently
reduce the blood pressure with intravenous antihypertensives: beta-blockers first line, and
then nitroprusside. Then the cardiothoracic surgeons should be contacted.
 Key Learning Points

Gastroenterology

Plasma not serum

Radiology

Plasma not serum

Renal disease investigation

Surgery

Renal disease investigation

Nephrology

Renal disease investigation

Urology

Renal disease investigation

Clinical Sciences

Renal disease investigation