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VIVA

1) Trauma C-spine XR, adult

• Loss of spinal lines at C5/6, fracture through posterior elements of C5, no soft tissue swelling

• Took a bit of prompting – unusual appearance at dens (looked like 3 overlapping spinous processes posteriorly at C1/2) – but did say would definitely need CT

2) CT brain, 6m old, unwell

• High density in leptomeninges with some surrounding hypodensity and mild mass effect (effacement post horn lat ventricle and sulci)

• Said I would want to see pre-contrast, which showed some leptomeningeal enhancement

• Dx meningitis - communicate to clinicians (gave Ddx Sturge Weber when wasn’t sure if enhancement or calcification)

3) AXR, 70 year old with back pain

• Densely calcified left kidney = TB autonephrectomy

• Scoliosis with vertebral flattening/sclerosis, indistinct pedicles

• Gave ddx of TB discitis with subligamentous spread (thinking they were after something exotic) – then dx of sclerotic mets (breast)

4) Paeds CXR

• Retrocardiac triangular opacity (like LLL collapse), patchy shadowing elsewhere

• Suggested LLL collapse, ddx sequestration when prompted

• Asked if anything simpler -> infection

5) Paeds CXR - neonate

• Cardiomegaly with plethoric lungs, aorta not clearly enlarged

• They asked what else would want to know -> cyanosis?

• Asked for causes of cyanosis with plethora

6) Paeds CXR

• Rounded large mass right hemithorax, well-defined with a less well-defined area inferiorly, appeared intrapulmonary rather than pleural based

• Suggested round pneumonia (but thought unlikely), other infection (no bronchogram, fairly homogeneous though), pseudotumour?

• Said would see on lat -> shown lat film which showed rounded mass, still appeared intrapulmonary

• Unsure of actual diagnosis (subsequently thought to be Bronchogenic cyst)

7) Paeds CXR

• Widening of superior mediastinum (left paraspinal widening too, didn’t notice till later), couldn’t see aortic knuckle on R or L -> suggested could be double aortic arch

• Said it could be thyroid (since looked like it was continuous with root of neck) but backtracked under grilling since it contradicted loss of visualisation of aortic knuckles

• They said if not that, where would a mass lie – I said could be anywhere since aortic arch passes from ant to post, more likely mid mediastinal or most likely posterior mediastinal

• Asked for differential of post med masses in kids – said often neurogenic e.g. tumour, could be haematoma (with widened paraspinal line) if trauma, perhaps paraspinal abscess although endplates crisp. Also gave ddx of extramedullary haemopoesis if relevant Hx

8) XR humerus, 50 year old female

• Erosion of outer cortex of diaphysis with soft tissue mass, looked aggressive

• Asked for Ddx – mets, lymphoma, myeloma, osteosarcoma less likely

• Asked for most likely –> mets

9) Adult CXR

• Bilateral upper zone masses, R>L, several smaller masses with reticulonodular shadowing, loss of volume

• Said findings depend on history, e.g. if occupational history of dust exposure, could be e.g. CWP/silicosis with PMF – they seemed to want to lead me down that track so I said also could be Ca which is assoc with silicosis -> needs comparison with previous XR, CT.

• Asked what infection is associated with silicosis in upper zones (unsure – probably should have suggested TB). Did mention possibility of Caplans too (?extra brownie points)

10) Bone scan adult patient

• Increased uptake rib but in particular right (and left, to lesser extent) along outer aspects of ankle/distal leg – after saying this, they gave a coned ankle view

• Said appearances raised suspicion of HOA (possibly pulmonary), could be venous insufficiency if relevant history or pachydermoperiostosis

• Said would want radiographic correlation – shown ankle XR. Showed thin periosteal reaction involving metaphysis (not epiphysis i.e. not pachydermoperiostosis) – said not entirely typical of HOA as not matured periosteal reaction but said was sufficiently suspicious to merit a CXR

• CXR provided – showed LLZ mass with smaller nodules -> said needed CT/resp referral

11) AXR, adult trauma

• Gaseous bowel but showed air round upper pole of right kidney and adrenal with bubbly appearance below -> retroperitoneal air leak

• Asked source of air leak -> duodenum

• Asked best investigation – I said CT with water soluble contrast, they said a meal would probably be OK, though I pointed out if there was a history of trauma there may be other findings which is why I’d do CT

12) Lateral lumbar spine XR in teenager

• Multiple biconcave vertebrae, osteopaenic with crisp endplates

• Ddx – osteomalacia, mucopolysaccharidosis (but no beaking), Schuermanns (but no convincing kyphosis)

• Then shown leg XR – slender tib with IM nail and slender fib, dense metaphyseal bands

• Suggested healed rickets, lead poisoning, also neurofibromatosis

• Unsure of final answer but they said I’d said it at some point!

13) Adult CXR

• Endotracheal tube down RMB -> said would call anaesthetists ASAP

• Also surgical clips left chest wall ?type of surgery, 2 intercostal drains pointing superiorly on the left, probable hydropneumothorax behind heart but could be hiatus hernia (heart not seen clearly ?LLL consolidation/effusion), probable loculated effusions elsewhere including tracking up left chest wall and no definite lung edge

• Asked why 2 drains – suggested loculation, unsure of actual answer

• Pointed to left axilla and asked why hazily grey – suggested muscle loss ?due to surgery ?Polands – unsure of final answer, they didn’t disagree with me

14) Female pelvic XR, elderly

• Relatively smaller, more lucent right hemipelvis (hip/ilium/pubis) compared with left, not explained by rotation

• No acute findings

• Asked longevity ?2 years ?since childhood – said must have been since childhood or so since matured bones smaller

• Asked Dx – polio

15) CT abdomen elderly pt, IV and oral contrast

• Ill-defined hypodensities in liver, said would come back to later and usually would measure HU but more in keeping with mets than cyst

• Distal desc colon/sigmoid colon – concentric thickening, pericolic stranding, small local nodes

• Asked for differential – said could be Ca with liver mets (though on quizzing suggested length of affected bowel made it unlikely – but would need direct visualisation), ddx IBD, ischaemic (if segmental arteries affected, when they asked if that corresponded to vasc territory), infectious/pseudomembranous (so would enquire about Abx/WCC etc), then spotted a few diverticula elsewhere so suggested could be due to diverticulitis – no clear final answer but they didn’t seem to disagree

16) Adult trauma CXR

• Bilateral rib fractures, intercostals drains, no definite pneumothorax but lucency over liver ?PTx ?Pneumoperitoneum.

• Asked about mediastinum – said there was superior mediastinal widening

• Asked about distribution of rib fractures (led into it...) – said upper ribs damaged -> chance of neurovascular damage e.g. subclavian/axillary, causing mediastinal haematoma

• Said would need CT with angiography sequence – they agreed but said they did a catheter angio

• Showed arch angiogram – pseudoaneurysm at base of brachiocephalic trunk – said would need urgent IR/cardiothoracic surgery input (asked Mx options – coils, glue, onyx – they agreed but said it was stented)

• They said there was another finding on angio – had a look, dissection line (looked to be type A but they said prob type B – I clarified that I wasn’t certain whether it started at LSA or just proximal – so said type B would be more likely medical Mx (though obviously urgent for pseudoaneurysm!)

• I also mentioned I thought there was an anatomical variant of aortic arch (but probably not – may be just the view)

17) Barium enema, female patient, single view

• Narrowing at sigmoid – asked if opened on other views, apparently it didn’t

• Some diverticula but said didn’t appear enough to account for narrowing

• Said needed to rule out Ca by direct visualisation but unlikely and longish segment affected

• Said the patient looked youngish (bones all normal etc) therefore needed to consider things like endometrioma/endometriosis, ddx dermoid so was looking for calcifications etc (they weren’t too keen on this differential but it does appear in books e.g. Rapid Review of Radiology – I did say it was possible, if not as likely as the former diagnosis) -> said MR would be advised

• MR – High T1, low T2, no STIR suppression (plus adjacent low T1/high T2 area – N ovary) in keeping with endometrioma

18) Paeds XR knees in patient with knee pain

• Subtle lucency, well-defined but small and no sclerosis, in medial tibial metaphysis, gave ddx LCH, FD (but no definite ground glass), GCT, infection (asked for name – Brodies abscess)

• Examiner agreed – said lesion was missed first time around and put up a follow up radiograph

• Follow-up showed eccentric, expanded lesion in med tib metaphysis, more suggestive of ABC, could be SBC but perhaps too eccentric, less likely GCT

• Asked what ABC shows on MR -> fluid/fluid levels

19) IVU, single image, patient with previous left nephrectomy

• Said would see with control film -> none available but no calcifications

• Ureter deviated medially, impression of enlarged right kidney placed posteriorly

• No left renal shadow in keeping with nephrectomy

• Examiner pointed out a rounded lucency in the right kidney -> said could be a cyst (examiner wasn’t keen on this although have seen cyst which looked just like this) or RCC, particularly if prev left nephrectomy for ?RCC – needed further imaging, possibly US in first instance but would almost certainly need staging CT

20) Paeds cranial US

• Showed minor asymmetry in ventricles, right appeared more prominent

• I mentioned this and hyperechoity in region of left caudothalamic groove which could represent germinal matrix haemorrhage

• They asked me to point out caudothalamic groove on sagittal -> vaguely did!

• I said no ventricular dilatation/involvement, ?intraparenchymal involvement -> backtracked under scrutiny and said just localised i.e. grade 1

• Said I would ordinarily ask a paeds radiologist to look at images to clarify!

• Asked why the subependyma is hyperechoic? Unsure

So NO breast imaging, NO hand XR, NO barium meals/swallows

40% of viva was paeds!

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