Radiology

Question 1

Smooth narrowing of lower oesophagus seen on barium swallow?
Most common complication
Mx?

Answer 1

achalasia
Nocturnal aspiration -> cough / pneumonia

Ballon dilation is mainstay

Question 2

Mx of primary pneumothorax if >2cm

Answer 2

aspiration of up to
2.5 litres with a 16–18G cannula is recommended.

If aspiration fails, a chest drain
should be inserted.

Question 3

Advice following primary pneumothorax ?

Answer 3

Possibility recur
stop smoking
Don’t fly for 1 week after full recovery

Question 4

What to do with likely TB Dx ?

Ix before treatment?

Answer 4

Refer to resp
Notify public health
patient education - transmission / compliance

Full blood count, liver and renal function, colour vision and acuity before mx

Question 5

bilateral hilar lymphadenopathy (BHL) with symmetrical
lobulated hilar enlargement. On CXR

In Pt with cough / swellings in neck / parotids

Dx?
Seen on biopsy

Answer 5

Sarcoidosis

Non caseating granuloma

Question 6

Name 3 conditions that could cause a non caseating granuloma

Answer 6

sarcoid, tuberculosis, lymphoma and fungal infections

Question 7

4 sarcoid Ix

Answer 7

CXR
CT
MRI brian 
ECG 
LuFT
LFT / *ALP
Serum ACE (often secreted by granulomas) 
Serum Ca

Question 8

Skin changes sarcoid

Answer 8

Erythema nodosum

Question 9

Sarcoid Mx ? If fail ?

Answer 9

Oral steroids / conservative

[Defs steroids if:

a. Hypercalcaemia
b. Neurological involvement
c. Cardiac involvement
d. Ocular involvement (if topical steroids have failed).]

Immunosupressant Eg azathioprine,
methotrexate, cyclophosphamide,

Question 10

Hyponatraemia in a euvolaemic patient with a suspected malignancy
What you thinking

Answer 10

Paraneoplastic syndrome -> SIADH

Question 11

Sx of hypoNa

Answer 11

Often Asx

malaise, nausea, generalized weakness, confusion and anorexia

Question 12

Most common Ca’s mets to brain

Answer 12

lung, breast, melanoma, renal and colon

Question 13

Older man with sclerosis of right hip shown on XR

2 key DDx

Answer 13

prostate Ca

Pagets (hip is most common location)

Question 14

3 phases of pagets ? What do you see in middle phase

Answer 14

osteolytic
mixed - cotton wool apperarnce on XR
osteoblastic

Question 15

3 classic XR features of pagets

Answer 15

bony enlargement, coarse trabeculae and a thickened

cortex

Question 16

Common mets to bone?

Answer 16

breast, prostate, lung

and kidney, but also thyroid, colon and melanoma

Question 17

Mx of ACUTE heart failure

Answer 17

Sit patient upright
• High flow oxygen by mask
• Intravenous access (bloods)
• Furosemide 40–80 mg i.v. slowly
• Diamorphine 2.5–5 mg i.v. (slowly, morphine is a venodilator and off loads the
heart, watch for respiratory depression).

Question 18

Name 3 XR signs of chronic heart failure

Answer 18

Cardiomegaly (>50%)

Upper zone vessel enlargement – a sign of pulmonary venous hypertension

Septal (Kerley B) lines – a sign of interstitial oedema – see next picture

Airspace shadowing – due to alveolar oedema – acutely in a peri-hilar (bat’s wing) distribution

Blunt costophrenic angles – due to pleural effusions

Question 19

Anaemia, raised inflammatory markers and white cell count, thrombocytosis, electrolyte
abnormalities, fever, tachycardia and hypotension, with a metabolic alkalosis

DDx

Answer 19

Toxic colitis - see thumbprinting on xray
Secondary to - inflammatory bowel disease (most likely),
infective, drug-induced or ischaemic colitis

Question 20

name 4 parts of Toxic colitis Mx

Answer 20

Urgent referral
to the gastroenterologists is required and review by the colorectal surgeons

stool specimens for culture + Clostridium difficile toxin

blood cultures.

IV fluids + electrolyte abnormalities,

blood transfusion if necessary,

Catheters - Fluid balance

NBM
NG tube - assist deflation of the bowel.

IV steroids 5 days - can add ciclospoin

IV ABx if indicated

Repeat AXR to monitor .

Sigmoidoscopy or proctoscopy may be required in this case if the cause of colitis is uncertain, as the rectal mucosa can be visualized and biopsies taken.

Question 21

Name 3 things that might predispose someone to toxic colitis

Answer 21

Drugs that slow gastric motility, such as opioids, anticholinergics (e.g. buscopan),
and antidiarrhoeals (e.g. loperamide), non-steroidal anti-inflammatory drugs
(NSAIDs), chemotherapy and barium enemas.

• Infection: Salmonella, Shigella, Entamoeba histolytica,
Campylobacter, Escherischia coli and Clostridium difficile (pseudomembranous colitis),
- ESP in IBD.
[Cytomegalovirus (CMV) causes colitis in patients with
immunodeficiency.]

• Hypokalaemia/hypomagnesaemia

• Patients who abruptly discontinue treatment with 5-aminosalicylic acid (5-ASA) or
corticosteroids may also induce toxic colitis

Question 22

3 signs AXR toxic colitis

Answer 22

Wall thickening due to mucosal oedema
• Loss of haustra
• Mucosal islands (oedematous mucosa surrounded by deep ulceration)
• Thumbprinting due to submucosal oedematous infiltration
• Dilated large bowel loops, more commonly of ascending and transverse colon
• Multiple loops of dilated small bowel, worrying sign of imminent perforation.

Question 23

3 Indications for surgery in toxic coltis

Answer 23

free air, 
localized or diffuse peritonitis, 
distension of the colon >10 cm, 
major haemorrhage
uncontrolled sepsis

Question 24

OsteoA XR

Answer 24

LOSS
Loss of joint space 
Osteophytes 
Subcondral cysts 
Sclerosis

Question 25

what is caplan syndrome?

Answer 25

RhA + lung nodules in the upper lobes and periphery of the lung which may cavitate

[There may be associated pulmonary fibrosis and a pleural effusion (usually unilateral)]

Question 26

Felty syndrome is?

Answer 26

RhA associated with splenomegaly, neutropenia and lymphadenopathy

Question 27

Why is atherosclerosis accelerated in RhA?

Answer 27

increased production of cytokines

Question 28

3 extra articular RhA

Answer 28

Lung nosules
splenomegaly, neutropenia and lymphadenopathyeye disease (e.g. keratoconjunctivitis
sicca), pericardial effusion, vasculitis, peripheral sensory neuropathy, carpal
tunnel syndrome, elbow nodules and periungal erythema

Question 29

Key SEs of DMARDS

Answer 29

myelosupression, hepatotoxicity, pneumonitis and proteinuria

Question 30

Tumor found in apical lung (superior sulcus) called?

What structures can it affect and Sx of these?

Answer 30

Pancoast tumour

Horner syndrome- compression of sympathetic plexus – this comprises ptosis, miosis and anhydrosis on the
affected side.
[There are other causes of Horner syndrome where the sympathetic plexus is involved in the neck or at the skull base (e.g. trauma, tumour)]

Pain/loss of function due to brachial plexus infiltration (look for small muscle
hand wasting).

Pain due to chest wall/rib invasion.

Hoarse voice due to infiltration of the recurrent laryngeal nerve.