A 76 year old male presented with sudden increase of dyspnoea on 15 November 2014, following a biopsy. A previous CXR was reviewed.

Question 1 A 76 year old male presented with sudden increase of dyspnoea on 15 November 2014, following a biopsy. A previous CXR was reviewed. Imaging A CXR was performed on 28 May 2014. A CT of the chest was performed on 15 November 2014. Modality 1 (CXR) Interstitial lung disease, predominantly in both lower lobes or Fibrosis Honeycombing Hiatus hernia (incidental) Shoulder degeneration (incidental) Modality 2 (CT) Subpleural and basal honeycombing Pneumomediastinum Surgical emphysema Right anterior pneumothorax (inferiorly) Usual interstitial pneumonitis (or alternatively interstitial pulmonary fibrosis) Complicated by pneumomediastinum and small pneumothorax Level 9, 51 Druitt Street, Sydney NSW 2000, Australia Ph: +61 2 9268 9777 Fax: +61 2 9268 9799 Web: www.ranzcr.edu.au Email: ranzcr@ranzcr.edu.au ABN 37 000 029 863

Question 2 A 32 year old female with G3 P0 presents with no screening and dates confirmed with early scan. A growth scan at 20 weeks is performed after concerns raised at morphology scan. Imaging An US was performed on 12 February 2014. Modality 1 (US) Globally small baby. Growing along the curve, i.e. at normal rate since previous scan. Abdominal calcifications. Absent end diastolic flow in umbilical artery Doppler. Normal uterine artery Doppler. Normal foetal MCA Doppler. Thickened placenta. Liquor volume looks normal. Early Intrauterine Growth Restriction. Foetal Infection. Aneuploidy. Obstetric referral. TORCH infection screen. Consider amniocentesis.

Question 3 A 32 year old male presents with headache. Imaging A MRI was performed on 13 June 2012. Modality 1 (MRI) Right subdural fluid collection. High T2, intermediate T1 consistent with blood products or protein. Tonsillar / brainstem herniation. Sagging splenium or flattened tentorium. Flattened anterior pons. Diffused thickening and enhancement of the pachymeninges. Intracranial hypotension. Look for causes of CSF leak. Consider spine MRI. Consider blood patch.

Question 4 Imaging A 62 year old female presents with a history of hot tender left breast. Possible mastitis. A bilateral mammogram was performed on 28 June 2012 A bilateral breast ultrasound was performed on 28 June 2012 Modality 1 (Mammography) Diffuse Increase in density both breasts. Enlarged abnormal lymph node right axilla. Modality 2 (US) 15 mm ill-defined mass right breast. 2mm nodule right breast Diffuse large ill-defined mass left breast. Bilateral abnormal axillary nodes, Abnormal supraclavicular nodes right. Primary diagnosis: Bilateral breast cancer with probable inflammatory cancer on left. Associated diagnosis: Bilateral nodal metastases. There is no viable differential, does not look like infection. Next clinical recommendation: Full US of both breasts and left axilla Biopsy is indicated bilaterally. Other clinical recommendation: MRI may be of value to determine extent. CT staging.

Question 5 Imaging An 11 month old male child presents with a 2 week history of non-weight bearing. The child is afebrile with slight tenderness and swelling over the proximal left tibia. An X-ray was performed on 19 April 2011 An MRI was performed on 20 April 2011 Purpose of this case The trainee needs to identify that this is: An aggressive bone pathology As such needs urgent workup. The diagnostic possibilities should ALL be aggressive and age appropriate (ewings sarcoma and osteosrcaoma are NOT age appropriate). Osteomyelitis if mentioned should be low in the differential. CONSIDER FAIL IF is a benign lesion including osteomyelitis OR Don t recommend specialist referral (because this is an aggressive lesion) Modality 1 (X-ray) lytic proximal tibial metaphyseal lesion wide zone of transition distally/poorly defined margin or similar aggressive periosteal reaction pathologic fracture Modality 2 (MRI) doesn t involve epiphysis features indicating this is a cellular(solid) NOT cystic lesion e.g. enhances Aggressive features mentioned: cortical destruction pathologic fracture Important Negatives NO subperiosteal collection (so less likely osteomyelitis) NO soft tissue mass NO skip lesion Langerhans Cell Histiocytosis (Eosinophilic granuloma is acceptable) Neuroblastoma metastasis Leukaemia/Lymphoma Urgent Specialist Paediatric Orthopaedic/Oncologic Assessment

Question 6 A 42 year old male presents with a 6 month history of shoulder weakness following recurrent shoulder dislocations referred by Orthopaedic surgeon. Imaging A MRI Arthrogram Shoulder was performed on 2 July 2010 Modality (MRI) Large paralabral cyst Cyst in spinoglenoid notch Large Labral tear Inferior glenohumeral ligament avulsion on ABER view Abnormal signal in infraspinatus muscle belly = denervation edema Mention of suprascapular nerve No rotator cuff tear Hill-Sachs lesion Extensive labral tearing with associated paralabral cyst and secondary compression of the infraspinatus branch of the suprascapular nerve and subsequent denervation atrophy.

Question 7 Imaging A 45 year old female presents with intermittent claudication and foot numbness. No vascular risk factors. A CTA of aorta, iliac and lower limb arteries was performed on 18 February 2013. Modality 1 (CT) Multilevel stenotic disease, infra inguinal. Wall thickening of affected vessels. Absence of calcified plaques. No disease in aorta or iliac vessels. Calf vessels all affected. Large vessel vasculitis (this may include Giant Cell, but not Takayasu s). Features are not those of atheromatous disease. Correlation with inflammatory markers. Biopsy if indicated.

Question 8 A 65 year old male presents with RLQ pain and raised WCC. Imaging A CT was performed on 28 June 2014. Modality 1 (CT) Right colon Mass with thickened mucosa. Surrounding inflammation. Ileocolic lymph nodes. Diverticulum. Liver Liver lesion with peripheral puddling. Segment VI Ascending colon adenocarcinoma. Hepatic cavernous haemangioma. Diverticulitis / Colitis. MRI of liver.