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Autumn 2010

• NEC with perforation(Plain Abdomen x-rays)

o chest and abdomen radiography of neonate :chest (preterm with endotracheal tube in situ, with no other abnormality, abdomen with bad resolution but no intramural air : my D was NEC

• Gall stone ileus(CECT Abdomen & Pelvis)

o CT abd with contrast: stone in rectosigmoid, suspected Choledoco-colonic and duodenal fistula, hiatus hernia …D: Gall stone ileus with Choledoco-colonic and duodenal fistula

o Rigler triad

• HPOA with right hilar mass(Bone Scan, Wrist X-ray and Chest X-ray)

• Wegner's Granulomatosis(Chest X-ray and NECT PNS)

o Chest X-ray and NECT PNS: chest with multiple cavitary nodules, opacified paransal sinuses with hyperdensity within I give DD (fungal infection in chest and PNS and immunity state of PT should be checked and wegner granulomatosis as other possibility so search for cANCA)

• Rt Humerus epiphysis AVN post traumatic(MRI and X-rays)

o MRI and X-rays of the right shoulder: surpiginous lesion in humeral epiphysis with double line sign, radiography shows sclerosis inside epiph plus mild rib expansion , CVP in situ, H shaped dorsal vertebrae and paraspinal density (right hemithorax appear in the film of the shoulder as the patient was young ) D: sickle cell anemia with AVN of humeral epiph

• Female with CECT Abdomen and Pelvis, with inflammatory mass in left adnexa and multiple dermoids on right side, fibroid uterus.

• L renal massess, L hydronephrosis. Pulmonary noudles. Dx TCC and gave diff as RCC with mets.

• Diastematomyelia

• Aortic ulcer with psuedo aneurysm? or was it aortic rupture

• Triphasic scan including liver. Patient presented with malaena and haematamesis.

• Baby presented with distended abdomen. Mother has oligohydramnios. ? renal disorder?

• SAH? TOF of the MRA circle of Wills in neon green?

Spring 2010

• huge anterior mediastinal mass with calcification and faint enhancement, low density contents. no lymphnodes. no pulmonary nodules. no pleural eff. mild mass effect on aorta and rt pulmonary artery: teratoma. gave ddx and discussed why teratoma is my number1.

• periosteal reaction and soft tissue swelling in the fibula , CT: sinus tract: osteomyelitis, gave ddx of trauma and neoplasm. i suggested galium&bone scan and referral to ortho. could have suggested mri with gado too.

• esophageal 2cm stricture at C6-7. said esophageal mass , could be malignant or benign, adviced for endoscopy and if malignant Ct chest&A&pelvis for staging.

• scrotal ultrasound and ct chest , abd, and pelvis: ( i didn't know where was the clinical history and was running out of time, so i said : scrotal intratesticular mass, heterogenously hypodense, assumably in an adult by looking at the CT (fused epiphysis of the prox humerus and femurs) dx: seminoma with pulmonary mets and retroperitoneal lymphadenopathy, rt hydronephrosis. ddx. non seminoma, mixed cells, lymphoma but said the latest was less likely.

• trauma that i didn't know was truama bcz i didn't read the clinical history, o/w was supposed to be the easiest case in the exam: liver hypodense lesion (should have said laceration) , ascitis, pseudoaneurysm in the sma. refer to a vascular surgeon and interventional radiology.

• suprasellar mass low t1, high t2, heterogenously enhancing after gado: craniopharyngioma. and gave a quick ddx of pituitary adenoma and rathke's cyst saying it's less likely because of the enhancement, , as i was running out of time, i didn't notice the invasion of the cavernous sinus (the hint was in the clinical history as i was told later )

• Trauma CT Brain:

• Bifrontal EDH + mass effect, splayed ant horns, uncal and sub-falcine herniation

• Subdural extension

• Bn window: # frontal bone

• IVU: Control, 15min and 1hr. DTPA renogram with a postvoid image showing full bladder. %fn Rt-46 and Lt 54

Dx: Lt hydronephrosis + Lt VUJ calc

DDX: calc, clot or tumour

• MRI Spine: Thoraco-lumbar TB discitis with paraspinal abscess and extradural spinal extension

• 11yo Haematuria:

CT RK- heterogenous lx, almost in renal pelvis and not cortex. Retrocrural L/N. No renal v / IVC invasion. Pulm and Bony mets on windowing.

MR spine: bone marrow mets and spinal extension

• CXR: RLL – lymphangitis carcinomatosa

CT: lt eye-prosthesis (? Malg melanoma), enhancing mass in the floor of 4th ventrical

• CT abdo:

Acute on chronic pancreatitis( pancreatic calcifications), pseudopancreatic cyst with contrast gushing in the centre of cyst. Significant peripancreatic fat stranding and fluid tracking along gastro-splenic and gastro-colic ligaments

Lt Gastric aneurysm rupture as a complication of acute pancreatitis. (Clinical history: haematemesis, on and off pain abdomen for 6 months)

• Young patient with proptosis: Pre and post contrast T1 axial and coronal section, single image of each series: Enlarged enhancing cavernous sinus with enhancing soft tissue in the right orbital apex- i said caverenous sinus thrombosis

• CECT abdomen and MIBG scintigram: Right adrenal neroblastoma in a child with right acetabular metastasis, both were hot on MIBG.

• Axial CECT Abdomen in a patient with haematuria: bilateral RCC with renal vein and IVC invasion. There was large left adrenal mass-metastasis. i said bilateral RCC or VHL. Mammogram: Multicentric right breast carcinoma, one of them contained microcalcification.

• CECT abdomen: Multiple small hypodense lesions in liver and spleen with few enlarged peripherally enhancing lymph nodes, Focal destruction of L1 with left small paravertebral abscess. There was also loculated collection anteriorly showing peripheral enhancement and one of them contained air. Gave the possibility infection, likely tuberculosis / pyogenic AND I MENTIONED FIRST LYMPHOMA

• Haemoptysis and H/O fall. CECT chest

Right Hydropneumothorax with complete collapse of the lung. Multiple air space opacities in the left lung, possibly contusions. PATIENT WAS OLD AND FALL SO I GAVE DIAGNOSIS O OESOPHGEAL TEAR

• Young patient with proptosis: Pre and post contrast T1 axial and coronal section, single image of each series: Enlarged enhancing cavernous sinus with enhancing soft tissue in the right orbital apex- Tolosa hunt syndrome

• CECT abdomen and MIBG scintigram: Right adrenal neroblastoma in a child with right acetabular metastasis, both were hot on MIBG.

• Axial CECT Abdomen in a patient with haematuria: Right RCC with renal vein and IVC invasion. There was large left adrenal mass-metastasis. There was one small enhancing soft tissue density mass in the left kidney, which also probably RCC.

• Mammogram: Multicentric right breast carcinoma, one of them contained microcalcification.

• CECT abdomen: Multiple small hypodense lesions in liver and spleen with few enlarged peripherally enhancing lymph nodes, Focal destruction of L1 with left small paravertebral abscess. There was also loculated collection anteriorly showing peripheral enhancement and one of them contained air. Gave the possibility infection, likely tuberculosis / pyogenic.

• Haemoptysis and H/O fall. CECT chest

Right Hydropneumothorax with complete collapse of the lung. Multiple air space opacities in the left lung, possibly contusions. Although I gave diagnosis secondary to trauma with possible bronchopleural fistula, there was no rib fractures, no soft tissue swelling. Thus I gave alternative possibility of infective process.

Autumn 2009

• metastatic rcc ,metastasis to ischium and chest wall

• sigmoid colon malignancy on barium enema

• thyroid mass /lung nodules with interval increase in 7years suggested thyroid malignancy

• sacral anomaly,pelvis cystic lesion,duplicated renal system--currarino triad (includes bony sacral abnormalities, a presacral mass, and an anorectal malformation.)

• metaphyseal lytic lesion on chest xray, retroperitoneal lymph nodes in a 4yr old--lymphoma,leukaemia,metastatic neuroblastoma

• chronic osteomyelitis distal metaphysis of knees

• CT with Obstruction secondary to calculi with pyelonephritis.

• RIF collection with ilio-psoas abscess.

• Single plain film - babygram (neonate) with pneumoperitoneum and abdominal calcification.

• HRCT - Pulmonary fibrosis - didn't look typical for sarcoid but not absolutely sure.

• MRI sinuses and orbits - Wegener's.

Spring 2009

• Sickle cell disease – single abdominal radiograph

H shaped depression and gall stones

• B/L mammogram 4 films – Right breast mass and left breast calcified fibroadenoma

• Sinusitis, frontal osteomyelitis and left orbital cellulitis – 1 CT /2 MR

• Choledochal cyst – 2 MRCP films

• Infrarenal aortic aneurysm with perianeurysmal fat stranding – 2 CT

• Controversial – But I wrote as multiple polyposis in colon

Other candidate had written as IBD

Autumn 2008

• Right pulmonary artery hypoplasia/pulmonary hypoplasia/Bronchial atresia: chest x-ray- right opaque hemithorax with mediastinal shift to the same side. V/Q scan- showed perfusion defects more than the ventilation defects.

• Sickle cell disease: CXR, abdomen. Every possible finding on plain films was there. Cardiomegaly, H shaped vertebra, AVN humeral head, small calcified spleen, and cholecystectomy. AVN of one of the femoral head, hemireplacement arthroplasty of the other femur.

• Pancreatic pseudocyst: 2 CT- on presentation and follow up- improvement.

• CT Brain only plain scan: Subarachnoid hemorrhage.

• CT Chest and abdomen: Stanford TYPE-A aortic dissection with polycystic renal disease.

• Pelvic MRI: Dermoid

Autumn 2007

• 50y/F - Head CT - pre and post contrast

Pineal region mass with obstructive hydrocephalus

• Young female - IVU, Plain film and L spine lateral

Nephrocalcinosis/lithiasis, Osteoporosis and brown tumour left iliac bone

• Young female – MRI Abdomen and Sulphur colloid scan

Enhancing mass in right lobe with scar

No defect on sulphur colloid scan

FNH

• Child 10y/F – Leg radiograph and bone scan

Lower end fibula aggressive lesion – Ewing’s

Bone scan – uptake at left hip region – secondary

• Adult – CT Abdomen pre and post contrast

Large retroperitoneal mass with fat and calcific densities displacing right kidney- Teratodermoid

Incidental GB calculi

Suspicious GE junction thickening

• Old male – CT chest Plain and contrast

Atheromatous descending thoracic aortic aneurysm with leak and left pleural collection

• CXR - bilateral upper lobe bronchiectasis with finger-in-glove mucous plug. Dx - ABPA. Ddx - cystic fibrosis

• CXR + Bilateral hands XR - Acro-osteolysis + soft tissue Ca + chest wall calcification. Dx - Scleroderma.

• CT brain - frontal midline extra-axial hyperdense mass (which simulate a butterfly tumor). Dx - meningioma. (We have a similar film in our museum - Case 7xx)

• Ba enema 70s male - apple core lesion in sigmoid colon, another long segment of narrowing is seen along the descending colon which is separated from the tumor stricture. Mucosal thickening and ulcerations are seen. Incidental findings of cecal mucosal irregularity. No terminal ileal lesion is detected. I and stephen were not sure about the answers, but definitely there is a tumor in sigmoid colon, on top of that, may be Crohn's or ischemic colitis.

• AP Lt shoulder + Bone scan + CT shoulder - aggressive lytic lesion at left scapular with laminated periosteal reaction. Posterior cortical break is seen. Dx - Ewing sarcoma. Ddx - eosinophilic granuloma. I and Stephen think this is an Ewing, due to the aggressive appearance. Other candidates think that is an EG. Anyway you need to Bx the lesion, and you will still pass if you mention both.

• IVU + US + MR (T1W axial abdomen only) middle age patient with uremia - Most difficult question - Non-excretory left kidney in IVU. USG Doppler left interpolar renal artery showed dampened waveform with reverse diastolic flow, left kidney is swollen. MR showed lack of flow void in left renal artery and IVC. Dx - Left renal vein thrombosis with extension into IVC due to uremia.

• History: Acute headache

CT brain non-contrast: acute SAH without noticeable intra-cranial aneurysm.

(Most simple one). No angiogram.

• History: female with pelvic pain

MRI T1, T2 and fat sat.

Multi-loculated pelvic mass with fat components. Calcification is seen inside the mass. Uterine fibroid.

Dx: dermoid.

• CT abdomen 3/7/2003 and 13/7/2003

First CT findings: swollen pancreas, cystic lesion in lesser sac, increase bilateral peri-nephric soft tissue strandings, ascites, left pleural effusion. (acute pancreastitis with pseudo-cyst/ abscess.)

Second CT: the pseudocyst got smaller in size but multiple air pockets are noted inside. It can be due to infected pseudo-cyst or abscess formation.

• CT thorax with contrast. Type A aortic dissection with intimal flap.

Also see bilateral numerous renal cysts. Adult type polycystic kidneys disease.

• History: abdominal colicky pain and acute shortness of breath.

CXR: congested lungs, central line, both humeral heads AVNs, cardiomegaly.

AXR: gallstones, splenic calcification, H-shaped vertebrae and left hip prostheses.

Diagnosis: sickle cell anemia.

• Pediatric: CXR: right lung diffuse opacity mimicking RLL collapse, small right lung volume.

V/Q scan: right lung multiple perfusion defects.

Dx: Macleod’s syndrome

Ddx: sequestration, hypogenetic lung, vasculitis, sickle cell anemia and pneumonia.

Spring 2007

• 23F dysuria

Dx:  Desmoid tumour

IVU showing pelvic calcification and mass effect on distal ureter 

• 8F hip pain

Dx:  Aggressive bone primary

Pelvic x-ray showing lucent lesion at medial aspect of femoral head with destroyed cortex and periosteal reaction 

• IVDU

Dx:  Septic emboli

CT chest lung windows showing multiple cavitating lesions throughout

CT pelvis showing gas in the left femoral vein 

• 80F in AF

Dx:  Haemorrhage 2° to warfarin

CT abdo – rectus sheath haematoma

CT head – acute on chronic subdurals 

• 80F recent contrast study, malaise for 2/52

Dx:  Pre-sacral collection

Contrast enema – extravasation of contrast around rectum 

• 2y child

Dx:  Neuroblastoma

AXR – RUQ mass with soft tissue calcification

CT – Large adrenal mass with calcification crossing midline and encasing major vessels 

• Vascular calcification and multiple bone lucencies of different appearances in the forearm and leg - browns tumours in hyperparathyroidism.

• CXR of 4 year old - paucity of gas in RUQ, paraspinal mass, lucency in humerus - metastatic neuroblastoma.

• Ba enema - I think two areas of narrowing - descending and caecum,  and perforation on descending colon = abscess on CT - I think Crohns rather than UC (also sacro-ileitis)

• MRI brain post contrast - posterior fossa mass with serpiginous flow voids, further lesion in thoracic cord, and angio showing vascular tumour with large draining vein = haemangioma in someone with von Hippel Lindau (given history of father having nephrectomy)

• IVU - medial deviation of ureters- CT contrast showed retroperitoneal fibrosis

• CXR - mid zone consolidation and CT with ring enhancing lesion in high frontal lobe - ?TB with tuberculoma

• L spine plain film and L spine MRI Sag and axial.Child with pain

Paediatric sclerotic T11 with partial collapse

DD infection vs E Granuloma vs Osteid osteoma unlikely mets

• CXR and CT thorax Middle age female

Massive Left mediastinal mass.

Aggressive cystic solid huge mass. eroding chest wall, invading ribs Not from abdomen. Not from breast.

DD Aggressive tumour Liposarcoma vs rhabdomyosarcoma.

• SBFT and CT Male 35

Nodular filling defects multiple ++ on FT

CT thickened sb loops. No RP nodes, no other lymphadenopathy. Soft tissue nodules in right chest wall.

DD Melanoma with mets to SB, not enough nodes for lymphoma, other mucosal abnormality

• CXR x2 elderly male

Interstitial changes Rt paratracheal mass subtle on the first CXR. 2nd more obvious plus Rt apical mass.

DD background changes and right apical bronchogenic carcinoma.

• MRI Paediatric brain yr child increasingly irritable.

Mass in posterior fossa. ! Cetred on cerebellar vermis

Further extension into basal cistern. Enhances post contrast. Calcification.

DD Cerebellar medulloblastoma, neuroblastoma, ependymoma.

• CT Abdomen male adult with recurrent pain.

Pancreatic duct dilatation No intrahepatic dilatation mass in head of pancreas splenic artery involvement Stranding of fat. no calcification. no lymphadenopathy.No other pseudocysts.

DD Pancreatitis and pseudotumour eroding/invading vessel.

Pancreatic tumour with vascular involvement.

Autumn 2005

• XR and MRI LS SPINE Sagittal only (T1, T2. no contrast!) 2 films. Collapsed L2 vertebra with replaced bone marrow signal. No soft tissue mass. End plate, disc intact. Cauda equina compression. Another focus of both T1 & T2W hypointensity in L4. M/55 ? Metastasis, myelmoa, lymphoma. Urgent inform orthopedic surgeon.

• CXR x2.(3months apart, showing intersistial lung disease without lung volume reduction and interval increase in right paratracheal soft tissue mass) CT thorax x1. UIP CT thorax (lung window only): honeycombing, paratracheal lymph nodes and small hilar lymph nodes. Right apical lung nodule with no interval change over 3 months. Not a game of searching causes of UIP. Just UIP and Ca lung.

• CXR: PAVM. CT Thorax: more than one PAVM. CT brain: Brain abscess. (I think it’s the most reasonable question) Dx HHT. Remember to put Osler first in ORW syndrome as Osler is an Englishman.

• SXR (Paed)(AP, Lat): HX (Yes! It’s that simple!)

• CT Abdomen: Leaking AAA. Bilateral hydronephrosis,chronic on left side. ? RPF causing bilateral hydronephrosis.

• CT Abdomen and USG abdomen: Porcelain GB + porta hepatic mass+liver mass. (so many films, with some useless USG wasting your time..) ? Porcelain gall bladder with malignant change to gall bladder carcinoma. DDx is intra-hepatic cholangiocarcinoma but expect more ductal dilatation.

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