Question 1 History. Likely Diagnosis Differential. Further Investigation or Management. Requires Paediatric Surgical referral for laparotomy

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1 Question 1 Male newborn spilling green tinged vomit day 1 of life Imaging Abdominal X-Rays performed on 03/05/2012 Upper and lower gastrointestinal contrast studies performed on 03/05/2012 Abdominal X-Rays Bowel obstruction Likely proximal (Very dilated proximal loops, no distal gas) No skeletal abnormality No contraindication to contrast study (no free air) Upper Gastrointestinal Contrast Study Normal duodenal rotation Lower Gastrintestinal Contrast Study Normal rectosigmoid ratio Microcolon Very small terminal ileum Very dilated proximal small bowel Ileal Atresia Jejunal (proximal small bowel obstruction) atresia Meconium ileus Requires Paediatric Surgical referral for laparotomy Page 1 of 8

2 Question 2 64 year old female Un-resolving right 6 th cranial nerve palsy Imaging CT Brain performed on 13/12/2005 MRI (F/u) Brain performed on 02/12/2013 Brain CT Solitary hyper-attenuating 1.5cm mass in the dorsal pons right of midline Minor effacement / distortion / compression of the 4 th ventricle no hydrocephalus No appreciable enhancement No definite calcification No obvious associated vascular pedicles/structure Brain MRI Some years later allowing for technical differences no change in size: non aggressive Mixed signal lesion (popcorn like) T1 and T2: high central and peripheral low signal Susceptibility/haemorrhagic signal: blooming characteristics but no frank haematoma No obvious associated vascular pedicles Increased size and T2 signal right inferior olivary nucleus Deviated globe with atrophic lateral rectus on the right, Small vessel ischaemic disease Primary diagnoses: Pontine Cavernous Haemangioma (Cavernoma) No associated DVA, or frank haematoma Associated diagnosis: Hypertrophic Olivary Degeneration Small vessel ischaemic disease Telangectasia, aneurysm, tumour (low grade, haemorragic) Continued follow-up at least annually unless clinically indicated vascular risk factors should be considered Page 2 of 8

3 Question 3 30 year old female presented with 3 weeks history of increasing low back pain after epidural anaesthetic for caesarean section. Imaging MRI lumbar spine (pre and post Gadolinium) performed on 10/11/2013 CT of pelvis performed on 11/11/2013 MRI Distended IVC and iliac veins Thrombus in IVC and iliac veins (T1 hypointense and T2 hyperintense, no Gadolinium enhancement) Oedema in the retroperitoneal and pelvic fat surrounding the IVC and iliac veins CT Thrombus in iliac veins which are distended Fat stranding surrounding the iliac veins Dilated and tortuous left ovarian veins Thrombosis of IVC and iliac veins Nil - CT/MRI/Doppler ultrasound to assess the upper extent of the IVC thrombosis - Septic screen to exclude infection in pelvis as a cause of IVC and iliac thrombosis Page 3 of 8

4 Question 4 53 year old male with previous history of gunshot injury has a preoperative Chest x-ray prior to hernia repair. Imaging Chest x-ray performed on 27/12/2012 CT chest performed on 28/12/2012 Chest x-ray 2 left posterior subpleural nodular opacities with the superior opacity projecting over the left hilum Elevated and irregular left diaphragm CT chest 2 soft tissue density nodules related to pleural surface of the left mid and lower zones. No calcification. Irregular and elevated left diaphragmatic contour. Absent spleen. 1cm soft tissue density in the left upper quadrant. Splenosis in left pleural cavity and left upper quadrant Previous left diaphragmatic injury Lymphoma but unlikely because of history of gun-shot injury and left diaphragmatic abnormality. Red cell nuclear medicine scan Page 4 of 8

5 Question 5 13 year old female presenting with a painful swollen knee following cross country run Imaging Xray Knee performed on 21/8/2012 MRI Knee performed on 31/8/2012 Xray Knee Large effusion Bony fragment on lateral view projected inferior to patella. Abnormal contour to lateral femoral condyle on lateral view. MRI Knee Effusion with fluid-fluid level Loose body on plain film seen just anterior to inferior aspect of ACL. Bone edema medial patella. Osteochondral injury lateral femoral condyle with defect in cartilage and underlying subchondral plate and edema Medial patella retinaculum torn at insertion to patella. Lateral patella dislocation/ relocation with osteochondral injury to lateral femoral condyle with free fragment Orthopaedic review Page 5 of 8

6 Question 6 33 year old female presents for a routine morphology scan. Low risk first trimester screening. Imaging Ultrasound morphology scan performed on 22/8/2013 Ultrasound Lemon shaped head with frontal bone depression Banana cerebellum c/w Chiari II malformation Ventricles not dilated, but choroid dangling Level of defect L2/3 to low sacrum Defect open No other abnormality Lumbosacral neural tube defect No differential Urgent Specialist/MDM referral Recurrence risk in subsequent pregnancies approx. 5%, Recommend high dose folate in subsequent pregnancies No association with chromosome abnormalities, would not recommend amniocentesis Page 6 of 8

7 Question 7 68 year old female presents for a screening mammogram. At screening reports that she has felt a small superficial lump in the right breast superiorly in the past few weeks. Imaging Bilateral Mammogram performed on 23/10/2013 Ultrasound right breast, both axillae and abdominal wall performed on 05/11/2013 Mammogram Well defined ovoid mass superior right breast Ultrasound Well defined solid mass superior right breast. Enlarged lymph nodes left axilla Two solid nodules abdominal wall Right breast cancer with metastases left axilla and abdominal wall Metastatic disease, particularly melanoma Biopsy right breast and left axilla Surgical referral Page 7 of 8

8 Question 8 46 year old male collapses with severe upper abdominal pain Imaging CT Abdomen and Pelvis performed on 28/12/2010 Enhancing mass in left lobe of liver (HCCa) Active extravasation of contrast due to bleeding Main portal vein invasion Cirrhotic liver disease Free blood in peritoneal cavity with high attenuation Collapsed IVC Hepatocellular carcinoma with portal vein invasion Bleed from the carcinoma Metastasis bleeding in liver Active resuscitation and review with interventional radiology- possibly not a candidate due to PV occlusion Page 8 of 8