cases radiology

Nottingham OSCE Simulator Pack

(Radiology)

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WARNING:DO NOT look inside this pack unless you are the radiology station examiner in the OSCE exam

simulationOrganisers: The next page indexes the stations. Diagnoses are given on each answer sheet…

Compiled by:Richard HastingsPaul LyonPilot version (1.0, March 2009)

mailto:[email protected]

IndexThis OSCE simulation pack contains the following stations:

CXR1MSK1CXR2MSK2CXR3MSK3CXR4MSK4AXR1AXR2

Note: We expect that the examiner will present two images during each 6 minute station. If a candidate fails to pick up a diagnosis and therefore is unable the answer management questions it is acceptable to flip to the abdominal images (AXR1&2) for another attempt, however the overall score should be reduced by 2 marks

Station: Radiology Case: CXR 1 (Q)

Scenario

You are a junior doctor who has been asked to review a chest x-ray by the orthopaedic registrar who has been called away to emergency theatre. It is of a 61 year old man on the orthopaedic ward who had a total knee replacement 6 days previously. He has been making a good recovery up until today. The nurse informs you he does not look very well at the moment and has been complaining of increasing chest discomfort since breakfast.

Station: Radiology Cases: CXR 1 (Ans.)

CXR 1 (Pulmonary embolus): 61 year old man on the orthopaedic ward who looks unwell with increasing chest discomfort

Questions

1. Describe the appearance of the radiograph (2 marks)

2. What is the most likely diagnosis? (1 mark)

3. The patient is started on high-flow oxygen and has had bloods taken and has had an ECG taken. What are the next steps in the medical management of this patient? (2 marks)

4. Once the patient is stable, what further investigation would confirm the diagnosis? (1 mark)

5. In this patient, what are his major risk factors for developing this condition? (1 mark)

6. How might this complication have been avoided? (1 mark)

Answers

1. Wedge-shaped shadow in the right upper zone and an enlarged right peri-hilar region (2 marks)2. Likely infarction of the lung which has resulted in haemorrhage or necrosis = PE (1 mark)3. The patient already has been treated using the ABC approach, next steps include: (max 2 marks of 3)

IV morphine (1 mark)Treatment dose subcutaneous low-molecular weight heparin (1 mark)Can also accept IV antibiotics for infarcted lung (1 mark)

4. Chest CTPA is gold standard, V/Q scan is an alternative (1 mark)5. Immobility due to orthopaedic surgery (1 mark)6. TED stockings or prophylactic LMWH (1 mark)

Mark out of 8 (max 8) (<4 = fail, 5 = bare pass, 6 = fair pass, 7 = good pass, 8+ distinction)

Station: Radiology Case: MSK1 (Q)

Scenario

24 year old window fitter presents to A&E after having falling into broken glass when under the influence. There is a deep laceration to the dorsum of his R hand.

Station: Radiology Cases: MSK 1 (Ans.)

MSK XR 1 (Scaphoid fracture): 24 year old man who has fallen onto his right hand

Questions

1. What are the two indications for imaging the hand in this presentation? (2 marks)

2. What is the commonest bony injury in a FOOSH in someone of this age group? (1 mark)

4. What is the abnormality is shown? (2 mark)

5. What would be the management and appropriate follow-up of this patient? (3 marks)

Answers

1.To eliminate foreign body (glass) and bone fracture (2 marks)2.Scaphoid fracture (commonest in young men aged 15-29) (1 mark)3.Identifies fracture (1) of the scaphoid (1) - beware of the distracting injury! (2 marks)4.Scaphoid cast for 10-12 wks (1) then open reduction (1) and internal fixation (1) (3 marks)

If the candidate does not recognise the scaphoid fracture 2 marks can be allocated for:Futura splint (1) and reimage in 14 days (1) if clinical suspicion of scaphoid fracture (2 marks)


Station: Radiology Case: CXR 2

Scenario

42 year old man who presents to A&E with a decreased GCS and an open fracture of the right tibia following a RTC. He is not able to give you his medical history. The patient has been stabilised and is on IV fluids. In addition to the radiograph of his right tibia you order a portable CXR to eliminate haemo-/pneumo-thorax before sending him for head CT.

Station: Radiology Cases: CXR 2 Q&A

CXR 2 (Heart transplant): 42 year old man who has been involved in a RTC with reduced GCS and unknown medical history

Questions

1. Describe the salient features of this radiograph including important negatives (5 marks)

2. Putting these features together, what is the likely PMH & PSH of this patient? (2 marks)

3. What medication is this pt. likely to be on which may complicate his recovery and why? (1 mark)

Answers

1. Important features of this radiograph include: (max=5 marks)This is a PA radiograph with ECG wires indicating acute setting (1 mark)No pneumo-/haemo-thorax or rib fractures are visible (1 mark)No air visible under the diapragm so unlikely traumatic bowel rupture (1 mark)There is a midline sternotomy wire indicating previous surgery (1 mark)There is an abnormal homogenous shadow on the left side of the mediastinum (1 mark)There is a pacemaker connected to this shadow so it must be a heart (1 mark)Impossible to comment on the size of the left heart as PA film, may be big (1 mark)

2. The medical and surgical history is most likely to be as follows:Development heart failure (possibly infective process or cardiomyopathy) (1 mark)End-stage heart failure has lead to requirement of a heart transplant (1 mark)

3. Likely to be on immunosuppressants so risks infection of his open fracture (1 mark)


Station: Radiology Case: MSK XR 2

Scenario

86 year old lady presents to A&E after slipping on ice, she is in a lot of pain and not mobilising.

Station: Radiology Cases: MSK XR 2 Q&A

MSK XR 2 (Fractured neck of femur): 86 year old lady who slipped on ice and has been unable to mobilise since

Questions

Describe the abnormality on the radiograph? (2 mark)

What is the initial (Emergency Department) management of this presentation? (5 marks)

What is the next step in the management of this presentation? (1 mark)

Answers

1. Intra-trochanteric or Garden IV fracture (1) of the neck of the left femur (1) (2 marks)

2. ABC approach:High flow O2 via non-rebreathe mask (1 mark)Wide-bore cannula and put up fluids (1 mark)Take bloods FBC, U&E, clotting screen, group and save (surgical candidate) (1 mark)Exposure – check for other associated injuries (1 mark)Analgesia IV morphine (1 mark)

3. Refer / fast-tract to orthopaedics for surgeryDisplaced (Garden IV) so likely a hemiarthroplasty (Austin-Moore) (1 mark)However also allow 1 mark for internal fixation with a dynamic hip screw


Station: Radiology Case: CXR 3

Scenario

68 year old man with known ischaemic heart disease presents to the Emergency department looking pale and sweaty. He is clutching his chest clearly in pain and visibly short of breath.


CXR 3 (Acute pulmonary oedema): 68 year old who presents to A&E with chest pain and breathing difficulties

Questions

1. Describe the appearance of the radiograph (1 mark)

2. What is the most-likely diagnosis? (1 mark)

3. What is the likely cause of the condition in this patient? (1 mark)

4. Give another possible cause of this condition? (1 mark)

5. Given the patient is already on high flow oxygen and has had bloods taken and an ECG,what are the next steps in the medical management of this patient? (4 marks)

Answers

1. Shows a diffuse ‘cotton wool’ shadowing & dilation of the upper lobe vessels (1 mark)

2. This is a presentation of severe acute pulmonary oedema (1 mark)

3. In this presention, given the Hx of IHD it is most likely to be acute MI / LVF (1 mark)

4. Other causes of pulmonary oedema to consider include (1 mark for any): (1 mark)Cardiovascular – arrhythmias, mitral stenosisARDSFluid overloadNeurogenic (head injury)

5. The patient already has been treated using the ABC approach, next steps include:IV morphine (1 mark)IV nitrates or GTN infusion (1 mark)IV furoseomide (1 mark)Treatment of underlying condition e.g. ACS Rx for MI, or meds for arrhythmia (1 mark)



Scenario

76 year old lady presents to A&E after a fall at a nursing home complaining of pain in the left wrist. She did not injury her head as she managed to break the fall with her hands.

Station: Radiology Cases: MSK XR 3 (Q&A)

MSK XR 3 (Colles’fracture): 76 year old who feel in the nursing home with outstretched hands

Questions

1. What is the main abnormality shown on the radiographs and what is the diagnosis? (2 marks)

2. Give the 4 cardinal features of this type of injury which can be seen radiologically? (2 marks)

3. What is the initial Emergency Department management of this patient? (2 marks)

4. What is the next step in the management of this patient? (1 mark)

5. Give one complication of a the management of this presentation. (1 mark)

Answers

1. Extension fracture of the distal radius (1) = Colles’ fracture (1) (2 marks)

2. Abnormalities shown on the radiograph are: (2 marks, half each)Dorsal Angulation & Dorsal DisplacementRadial Angulation & Radial Displacement

3. Initially requires manipulation (reduction) under local anaesthetic (1) and backslab (1) (2 marks)

4. After 24-48 hours when the swelling has gone down a full plaster cast is required (1 mark)

5. Complications include non-union or rupture of extensor pollicis longus (1 mark)


Station: Radiology Case: CXR 4 (Q)

Scenario

71 year old woman who is rehabilitating on the stroke ward following a partial anterior circulatory ischaemic CVA.


CXR 4 (Pneumonia): 71 year old recovering from a recent stroke on the stroke ward

Questions

1. Describe the salient features of this radiograph (4 marks)

2. Putting these features together with the history, what is the likely diagnosis? (2 marks)

3. What is the medical treatment for this patient? (2 marks)

Answers

1. Important features of this radiograph include: (max 4 marks)ECG tabs and lack of bra removal indicate this was taken in an acute setting (1 mark)The right hemidiaphragm is no longer visible (1 mark)The mediastinum is pulled to the right (see trachea and left heart border) (1 mark)The right heart border is silhouetted by a homogenous opacity (1 mark)The left lung field looks largely clear indicating the pathology is unilateral (1 mark)

2. Likely right-sided aspiration pneumonia (1) with associated right-sided collapse (1) (2 marks)

3. IV fluids (1) and IV antibiotics (1) (consult hospital protocol) may be life-saving (2 marks)



Scenario

32 year old woman presents to A&E after a a RTC. She says that she used her arms against the dashboard to protect herself. She has a swollen and tender right left elbow but no other obvious injuries.

Station: Radiology Cases: MSK XR 4 Q&A

MSK XR 4 (Elbow dislocation): 32 year old woman with swollen, tender left elbow after RTC

Questions

1. What else might you require to help you make the diagnosis? (1 mark)

2. Describe the major abnormality in this radiograph. (2 marks)

3. What is the Emergency Department management of this patient? (3 marks)

4. What two immediate complications might present in this patient? (2 marks)

Answers

1. A lateral projection of the same joint (1 mark)

2. The important features of this x-ray are:The elbow is contained in a supportive vacuum splint (paramedics) (1 mark)There is a complete closed lateral dislocation of the elbow (1 mark)(Unable to comment if posterior (most common) or anterior without a lateral)No fractures or obvious fat pads shown on this view so likely simple dislocation (1 mark)

3. Emergency management:Analgesia & sedation (1 mark)Reduction (1 mark)Post-reduction splinting at 90 degrees of flexion (10 days instability period) (1 mark)

4. There is significant neurovascular risk in such a severe dislocation (1 mark)(In particular median and ulnar nerves are at risk as is the brachial artery)Also accept fractures and compartment syndrome as an immediate complications


Station: Radiology Case: AXR 1

Scenario

45 year old man complaining of abdominal pain

Station: Radiology Cases: AXR 1 Q&A

Questions

AXR 1 (Pneumoperitoneum): 45 year old man complaining of abdominal pain

Questions

1. What is the most obvious abnormality? (2 marks)

2. What other type of X-ray imaging is mandatory in this case and why is it mandatory (1 mark)

3. Give 3 causes of bowel obstruction (3 marks)

4. Do you suspect a perforation has occurred in this example – justify your answer? (1 mark)

5. What could you do for this patient (as an F1) ? (3 marks)

Answers

1. There is colonic distension. Proximal bowel loops contain faecal material.There is a large bowel loop in the central abdomen with air visible on both side of the bowel wall.This appearance is consistent with a pneumoperitoneum. (2 marks)

2. Erect CXR – air under the diaphragm would indicate perforation. (1 mark)

3. Adhesions, strangulated hernia, neoplasm, inflammatory bowel disease, diverticular disease. (3 marks)

4. Yes. Wriggler’s sign is present (see answer 1) – i.e. this is caused by air in the abdomen (1 mark)

5. ABC, take bloods (FBC, U+E, G+S, LFT, Glucose), erect CXR, NG tube, IV fluids, call senior. (3 marks)

Mark out of 10 (max 10) (<5 = fail, 6 = bare pass, 7 fair pass, 8 good pass, 9+ distinction)

Station: Radiology Case: AXR 2

Scenario

39 year old man complaining of abdominal pain after he eats

Station: Radiology Cases: AXR 2 Q&A

AXR 2 (Gallstone): 39 year old man complaining of abdominal pain after he eats

Questions

1. What is the most obvious abnormality? (1 marks)

2. What percentage of gallstones are visible on plain X-ray? (1 mark)

3. What is the preferred modality for imaging biliary pathology? (1 marks)

4. Give 3 symptoms of gallstone obstructive cholestasis? (3 mark)

5. What is Charcot’s triad and what does it signify ? (2 marks)

Answers

1. There is a radio-opaque mass in the region of the gallbladder, i.e. a gallstone is present (1 marks)

2. Approximately 20% (1 mark)

3. Ultrasound (1 mark)

4. One mark for each of the following: (max 3 marks out of 5)Jaundice (1 mark)Pale stools (1 mark)Dark urine (1 mark)Pruritus (1 mark)Colicky pain in RUQ (1 mark)

5. RUQ pain & jaundice (1), fever signifies ascending cholangitis (1) (2 marks)

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