RD MCQ 2013 September WA: Formatted

Question 1

1. Woman with gastric band with abdominal pain. UGI shows phi angle 90, emptying time 90 mins
   a. Normal
   b. Slippage
   c. Over inflation
   d. Erosion into stomach

Answer 1

b. Slippage

WJI: normal <60

Question 2

2. 99m - what does ‘m’ mean
   a. Metastable
   b. Man made
   c. Molybdenum
   d. Mass

Answer 2

a. Metastable

Question 3

4. Which of the following lymphomas shows low PET uptake
   a) Mycosis fungoides
   b) B cell modular sclerosis
   c) T cell burkitt peripheral T cell and indolent B cell (such as marginal zone, SLL, primary FL)
   d) Burkitts
   e) Nodular sclerosis

Answer 3

c) T cell burkitt peripheral T cell and indolent B cell (such as marginal zone, SLL, primary FL)

*LW:
Types of lymphoma that can be false negative on PET.
MZLs, peripheral T-cell lymphomas, small lymphocytic lymphomas, and primary FLs.

Stat Dx also includes MALT, MCL, CLL.

Question 4

5. Tc99m Regarding imaging with Tc 99m, which is FALSE?
   a. The half-life of Tc 99m is 8 hours, making it suitable for imaging
   b. The decay product, Tc 99, doesn’t cause additional radiation to the patient.
   c. Tc 99m emits only gamma radiation.
   d. The range of energies emitted is 50 kev to 5000 kev

Answer 4

*LW:
Needs review:

a. The half-life of Tc 99m is 8 hours, making it suitable for imaging: FALSE - 6 hrs, but this makes it ideal for imaging.
b. The decay product, Tc 99, doesn’t cause additional radiation to the patient. Also false although minimal.
c. Tc 99m emits only gamma radiation: false. Also internal conversion (high energy electrons). Gamma is 88%.
d. The range of energies emitted is 50 kev to 5000 kev: 99 % are at 140 keV

SCS:
5000keV seems a bit high, and thus false too?

Question 5

6. Boy with bone pain, cardiomegaly, wide ribs, decreased vertebral height
   a. Sickle
   b. Thalassaemia
   c. Aplastic anaemia
   d. Glycogen storage

Answer 5

a. Sickle

Repeat question - debate re sickle cell versus thalassaemia.
*RY - would probably favour thalassaemia because of the expansion. Statdx describes the marrow replacement of sickle cell as very subtle, usually not detectable on plain radiograph. Rib expansion is well documented for thalassaemia, compression fractures also known to occur.

Question 6

7. Eosinophilic granuloma in a child – which is least supportive?
   a) Associated with mass
   b) Involvement of posterior elements
   c) Wedge shaped compression
   d) Involvement of other bones

Answer 6

*LW: Preferred answer is B:

A. Small Paraspinal soft tissue has common.
B. Involvement of posterior elements is rare / excitedly unusual / uncommon finding. Thus favoured answer being least supportive.
C. Vertebral plana is a common feature, while wedge compression or uneven lateral compression is enchanted in early stages.
(radiographics 1992)

Radiographic states: EG can initially cause wedge like or uneven lateral compression of vertebral bodies, before developing complete vertebra plana.
Often multifocal
Commonly small para spinal soft tissue mass.
Involvement of posterior elements uncommon / destruction of posterior elements is atypical - hence most unlikely.

b) Involvement of posterior elements

Also no wedging

Question 7

8. Patient with known prostate cancer presents with back pain and leg weakness (note that no history of radiation was given). By the time patient presents to the scanner, he is catheterized and power in the legs is 2/5. Which of the following is most likely?
   a) Cord infarct
   b) Transversemyelitis
   c) Leptomeningeal metastases
   d) Radiation myelitis

Answer 7

• LW:
  a) Cord infarct: possible, but no vascular risk factors provided, so less likely. Presents abruptly with acute onset. May be answer if question stem provides an abrupt time frame.

b) Transversemyelitis: favoured Dx given acute onset and sphincter and motor involvement. Usually presents over days to weeks. Can also be associated with known malignancy.
c) Leptomeningeal metastases: unlikely.
d) Radiation myelitis: delayed onset radiation myelitis, possible, given malignancy Hx, but less likely given no mention of treatment.

Previous answers:
a) Cord infarct because of time course

8. Patient with known prostate cancer presents with back pain and leg weakness (note that no history of radiation was given). By the time patient presents to the scanner, he is catheterized and power in the legs is 2/5. Which of the following is most likely?

a) Cord infarct because of time course
b) Transversemyelitis could be.
c) Leptomeningeal metastases
d) Radiation myelitis too fast

Question 8

9. Tarlov cyst
   a) Most commonly S1,4
   b) Causes bone erosion
   c) Confused for mets on CT
   d) More than one indicates genetic disease

Answer 8

b) Causes bone erosion

*LW: causes boney remodelling not erosion per say.
Most common S2 S3
Hopefully not confused for Mets
Can be multiple in absence of genetic disease.

Question 9

10. Portovenous CT of renal trauma with laceration into pelvis, no contrast blush, surrounding collection. What is next best step?
    a) CT angiogram
    b) Catheter angiogram
    c) Excretory CT
    d) Repeat scan tomorrow
    e) Drain the collection

Answer 9

c) Excretory CT

Question 10

11. Liver biopsy patient hypotensive
    a) Atropine 0.6mg
    b) Lignocaine
    c) Various doses of adrenaline but none according to RANZCR guidelines.

Answer 10

a) Atropine 0.6mg Assuming that they are bradycardic. Never actually seen this being done, usually trendelenburg, O2, time.

Question 11

12. Lung biopsy of cavitary lesion, as you remove inner stylet, patient coughs and develops seizures
    a) Air embolism
    b) Pericardial tamponade

Answer 11

a) Air embolism

This article explains the proposed mechanism
https://www.ncbi.nlm.nih.gov/pubmed/25435664

Question 12

13. Following contrast CT, you notice lucent (this was the word used) area in the right atrium. Which of the following is not a recognised treatment?
    a) Trendenlenburg
    b) 100%oxygen
    c) Left lateral decubitus
    d) Restore cardiopulmonary circulation

Answer 12

All are I would have thought.

*ESG agree, all options recommended as per StatDx.
100% inspired oxygen: To decrease partial pressure of nitrogen in the air bubbles
Left lateral decubitus position or Trendelenburg position: To trap air in right heart and prevent embolization to lungs
Restore cardiopulmonary circulation - no justification, but a good idea anyway

Question 13

18. Elderly man falls down a ladder. CXR shows several left sided rib fractures and a pneumothorax. Which of the following is an indication for urgent treatment of the pneumothorax?
    a) Diaphragmatic depression
    b) Sharp pleural line
    c) Air fluid level
    d) Ipsilat mediastinal shift
    e) No peripheral lung markings

Answer 13

*LW:
Majority of options describe a PTx, no indication as listed under the BTS are listed here.
If there was contra lateral shift - this would require active intervention.
Patient symptomatic regardless of size - requires active treatment.
Diaphragmatic depression, is likely most suggestive of developing tension out of optins listed - hence preferred option.

a) Diaphragmatic depression: sign of PTx - favoured option
b) Sharp pleural line : sign of a PTx
c) Air fluid level : sign of a haemoPTx
d) Ipsilat mediastinal shift: not tension, not usually associated with PTx.
e) No peripheral lung markings: sign of Ptx.

**LJS - agree. Suspect diaphragmatic depression is supposed to indicate increasing pressure in that pleural space and suggest a degree of tension

a) Diaphragmatic depression

Question 14

21. Patient with bladder dome tumour. Which is best method for TNM staging?
    a) PET CT
    b) MRI pelvis
    c) CT pelvis
    d) Cystoscopy
    e) TRUS

Answer 14

• LW: B - MRI pelvis.
  a) PET CT: FALSE - urinary excretion of radio tracer into bladder.
  b) MRI pelvis: true, T stage deemed most important and treatment altering, for which MRI best at. Can also detect nodal disease in similar / slightly better confidence than CT.
  c) CT pelvis: MR felt superior
  d) Cystoscopy: can’t appreciate serosal or peritoneal spread.
  e) TRUS
  https: //pubs.rsna.org/doi/full/10.1148/rg.322115125

**LJS - the above paper says MRI is “moderately accurate in the diagnosis and local staging of bladder cancer, with cystoscopy and pathologic staging remaining the standards of reference”. Assuming answer d) cystoscopy includes biopsy - ?this remains best local staging method
https://www.ajronline.org/doi/full/10.2214/AJR.16.17114 This more recent (2017) paper says same thing - progress has been made with MRI but there are limitations to its use in local staging
Statdx: cystoscopy and bx for T stage. If there is muscle invasive disease - get imaging as well. MRI is the best imaging modality

Standard CT for N and M staging (though since this isn’t an option I assume the are asking about T staging)
RP says PET is no good for local disease but “has a role to play in the assessment of nodal or distant metastases”

Previous answer:
a) PET CT

Question 15

22. Woman with recurrent mid-trimester miscarriage. HSG shows y shaped uterine cavity with single cervix.
    a) Bicornuate
    b) Didelphys
    c) Arcuate
    d) (No septate option)

Answer 15

a) Bicornuate

Didelphys - complete duplication of uterine horns as well as duplicstion of cervix
Septate can look similar to didelphys on HSG, next step USS to characterise fundal contour.

Question 16

23. Which of the following is an indication for chorionic sampling as an isolated 20 wk abnormality?
    A) Clinodactyly
    b) Echogenic cardiac focus

Answer 16

Neither are concerning in isolation.

A) Clinodactyly soft sign
b) Echogenic cardiac focus soft sign

Question 17

25. 28 yo young woman, her mother died of breast ca in her 30’s, her sister has breast ca in her 20’s. Genetic analysis shows she has BRCA2. Based on multicentre trials, what screening advice would you give?

a) No hard evidence that any strategy improves mortality, discuss her risks of increased cancer and ongoing screening needs (No specific screening method was mentioned)
b) Various combinations of mammo, uss, physical at various ages
c) No option of MRI was given

Answer 17

*LW:
Hopefully poor recall:

Literature review states annual MRI starting age 25, with annual Mammorgraphy +/- tomo starting from 30.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6315500/

Further reading:
https://pubs.rsna.org/doi/full/10.1148/radiol.2019181814

a) No hard evidence that any strategy improves mortality, discuss her risks of increased cancer and ongoing screening needs (No specific screening method was mentioned)

Question 18

26, 27. This was actually 2 different questions. I don’t remember which options were in which question. Regarding angiography

a) Profunda best seen in external rotation
b) Adductor canal is in lower thigh
c) With TKR, popliteal best visualised in lateral
d) Peroneal ends above ankle
e) 5 fr sheath sufficient for most diagnostic studies
f) Ant tibial and ?peroneal seen separately in lower leg on AP projection
g) SFA origin best seen on AP projection - ipsilateral anterior oblique.

Answer 18

b) Adductor canal is in lower thigh
c) With TKR, popliteal best visualised in lateral
d) Peroneal ends above ankle; true dividing into calceneal branches at the inferior tibio-fibular syndesmosis.
e) 5 fr sheath sufficient for most diagnostic studies
f) Ant tibial and ?peroneal seen separately in lower leg on AP projection

Question 19

28. Shoulder uss position to visualise subscapularis
    a) Elbow flexed, shoulder external rotation
    b) Supination, shoulder neutral
    c) Arm across chest
    d) Internal rotation

Answer 19

a) Elbow flexed, shoulder external rotation

Question 20

29. Regarding bone lesions, which is incorrect?
    a) Calcified rim is marker of benign lesion
    b) Wide zone of transition is marker of malignant
    c) Bone expansion is marker of aggressive lesion

Answer 20

c) Bone expansion is marker of aggressive lesion

Question 21

30. Postpartum woman with confusion. CT shows swollen bilateral basal ganglia and thalami
    a) Venous sinus thrombosis
    b) Reversible cerebral vasoconstriction syndrome
    c) Posterior reversible encephalopathy syndrome

Answer 21

a) Venous sinus thrombosis

Question 22

1. Which is false regarding demyelinating diseases?
   a) ADEM is seen following bacterial infections
   b) DAI causes demyelination
   c) Dawson’s fingers are peri medullary
   d) MS is perivenular
   e) DAI causes demyelination

Answer 22

*LW:
Options A and B are likely most correct answers of being false……
unsure which is more false

a) ADEM is seen following bacterial infections: technically true, but viral is the most common cause (https://www.sciencedirect.com/science/article/pii/S0733861908000364)
b) DAI causes demyelination: contentious: Actual complete tearing of the axons is only seen in severe cases. It is also known that some neurones may undergo degeneration in the weeks or months after trauma, it is called secondary axonotmesis. Axonal depolarisation and swelling is most common histological feature. In agreement with LJS, there is likely an element of demyleinisation associated with these tearing injuries……
c) Dawson’s fingers are peri medullary: TRUE, referring to peri medullary veins.
d) MS is perivenular: TRUE

**LJS - I think demyelination does occur secondary to DAI:
“Two to three weeks later however there is decrease in the number of retraction balls with predominance of microglial cells followed by astrocytosis and demyelinization.” Then even later there is Wallerian degeneration. From this paper: 10.15406/frcij.2015.01.00026.

Is this or ADEM with bacterial infection more false??

Question 23

32. Which of the following is NOT a characteristic CT feature of acute herpes simplex encephalitis
    a) Sparing of the basal ganglia
    b) Unilateral changes seen on MRI
    c) Evidence of hemorrhage on MRI
    d) Involvement of the limbic system
    e) Mass effect

Answer 23

b) Unilateral changes seen on MRI

Question 24

3. Study looking at uss in liver haemangioma with MRI as gold standard. 
a is true positive,
 b false positive, 
c true negative, 
d false negative. 

Calculate the specificity.

a) a/(a+b)
b) Various other combinations of a b c and dc)

Answer 24

c) Correct answer is: true negative / (true negative + false positive) The odd that patient without disease is identified as without disease

SCS:
Specificity = true neg/ total non-diseased
(SPIN- A Specific test when Positive rules IN a disease. Not many false positives if highly specific)
Sens: true positive/ total diseased (SNOUT- A SeNsitive test, when Negative rules OUT disease. Not many false negatives if highly sensitive)

Question 25

34. 10 year old with cough, bibasal atelectasis, no lobar consolidation. What is most likely organism?
    a) Mycoplasma
    b) Staph
    c) Strep
    d) PCP

Answer 25

a) Mycoplasma

Question 26

35. Child with recurrent pneumonia represents and is treated with antibiotics. One week later, there is RLL opacity but the child is otherwise well
    a) BPS
    b) Resolving pneumonia
    c) Pneumatocoele
    d) Abscess
    e) (No round pneumonia option)

Answer 26

a) BPS ( i think this means sequestration)
* WJI - agree with answer, I think this is probably what they are getting at with “recurrent pneumonia” and “RLL” but sequestration is probably not the most common cause of recurrent pneumonia in childhood (immunocompromise, bronchiectasis etc.) and CXR changes of consolidation probably don’t normalise within 1 week so I think b. is probably a better real life answer.

Question 27

36. Which is TRUE?
    a) I-123 MIBG is used to diagnose adrenocortical carcinoma
    b) Tc 99m CEA is used to diagnose thyroid cancer
    c) Onco-Scint is used to diagnose ovarian cancer
    d) I-131 Pentetreotide is used to diagnose medullary thyroid cancer

Answer 27

c) Onco-Scint (Indium-111) is used to diagnose ovarian cancer (and 95% of colon cancer)

*ESG agree:
d) I-131 Pentetreotide (=octreotide) is used to diagnose medullary thyroid cancer metastases
**SCS additional Note this distractor has fused I-131 MIGB (iodine) and In-111 Pentetreotide (Indium).
(Above ESG/SCS evidence As per StatDx)

Question 28

38. Not associated with ACL rupture
    a) Lat meniscus tear
    b) Medial meniscocapsular separation
    c) MCL tear
    d) Bone bruise posterolateral tibial plateau

Answer 28

*LW:
All occur with ACL rupture, hopefully non recalled option E was the correct option.

A - Lateral meniscal injury is more commonly associated with acute ACL injury, while medial meniscal injury more commonly associated with Chronic ACl injury and resulting instability. (multiple references)

b) Medial meniscocapsular separation TRUE (uncommon, but true)
c) MCL tear TRUE
d) Bone bruise posterolateral tibial plateau - TRUE

Previous efforts:

• *LJS (al Al agrees) - lateral meniscus least correct
• AJL on further review agree that all are associated and have no idea what the answer should be.

Question 29

39. Young man presents with sudden onset of pain. MRI shows soft tissue lesion with high t1, high t2, with and without fat sat.
    a) Myosotis ossificans
    b) Haematoma
    c) Lipoma
    d) Liposarcoma

Answer 29

b) Haematoma

Question 30

40. Equivalent number of CXRs for CT Chest with contrast, for young adult using 16 slice scanner.
    a) 50
    b) 100
    c) 300
    d) 1000
    e) 5000

Answer 30

c) 300

Question 31

41. CT chest, abdo, pelvis
    a) 50
    b) 100
    c) 300
    d) 1000
    e) 5000

Answer 31

1000

(WJI - prior Q was no. of CXRs to equal radiation dose of CT chest, if you are in random mode you might not have seen this)

Question 32

42. Child in MVA needs urgent angiographic intervention. His mother died in the same accident.His father died many years ago. Who is the most appropriate person to give consent?
    a) mother’s defacto (yes, this was all that was written, but in previous years, defacto partner was written)
    b) Hospital Medical Director
    c) grandmother
    d) 16 year old sister
    e) public advocate office

Answer 32

c) grandmother

Question 33

43, 44. This question was repeated twice! Patient with chronic renal failure has stricture of the arterial anastomosis of mature forearm fistula. Which of the following would give longest patency?

a) Balloon angioplasty
b) Covered stent
c) Bare metal
d) Non covered
e) Laser angioplasty

Answer 33

a) Balloon angioplasty

Question 34

47. You suspect discitis on plain X-ray. Which of the following would favour TB over pyogenic?
    a) Noncontiguous vertebral involvement rules out TB
    b) Discs can be affected late in TB
    c) TB only seen if there is an associated lung lesion
    d) Cold abscess is high T1, low T2
    e) Subligamentous spread

Answer 34

b) Discs can be affected late in TB
e) Subligamentous spread

Tuberculous infection tends to spread beneath anterior longitudinal ligament and spare disc space

Question 35

48. Patient with vague breast mass, history of trauma 3 weeks ago, architectural distortion onmammo, normal uss. Biopsy shows radial scar. What would you recommend at MDT?
    a) Hook wire and open biopsy
    b) Mastectomy
    c) Follow up mammogram
    d) WLE + sentinel lymph node Bx

Answer 35

a) Hook wire and open biopsy

Question 36

50. Woman with hemiparesis. ICA Doppler shows systolic dampening, reversal in early diastole
    a. Normal
    b. ICA stenosis distally
    c. ICA occlusion
    d. CCA stenosis
    e. CCA occlusion

Answer 36

**LJS - ICA occlusion - at the site of occlusion get “thud flow” - damped systolic flow and early diastolic reversal. https://pubs.rsna.org/doi/pdf/10.1148/rg.256045013

*

• ESG agree with above, but new consensus terminology uses “dampened” to mean “combined finding of abnormal delayed upstroke and broad peak, often with decreased velocity”, i.e. tardus parvus
  https: //journals.sagepub.com/doi/full/10.1177/1544316720943099

Question 37

50. Regarding DAI
    a) non haemorrhagic
    b) mainly in frontal and temporal grey white matter jcn
    c) DWI not useful
    d) SWI not useful
    e) accurately staged with CT

Answer 37

*LW:

A) non haemorrhage: true 80% are non haemorrgic lesions.

b) mainly in frontal and temporal grey white matter jcn: true - grade 1

Wji: so depending on wording i would chose b. Whilst many lesions are non haemorrhagic it is incorrect to say the condition is non haemorrhagic

Question 38

51. Regarding myelination

a) Myelinated white matter appears dark on T1.
b) Myelination can be present in the posterior limb of internal capsule at birth
c) Myelination is complete in optic pathway at 4 months
d) Myelination starts in the splenium and progresses anteriorly in the corpus callosum.

e) Between 24 -30 months myelinated white matter is isointense to grey matter on T2.

Answer 38

b) Myelination can be present in the posterior limb of internal capsule at birth yes the posterior part d) Myelination starts in the splenium and progresses anteriorly in the corpus callosum.
52. Regarding myelination
a) Myelinated white matter appears dark on T1.
b) Myelination can be present in the posterior limb of internal capsule at birth yes the posterior part
c) Myelination is complete in optic pathway at 4 months occipital white matter T2 dark >1 year.
d) Myelination starts in the splenium and progresses anteriorly in the corpus callosum.
e) Between 24 -30 months myelinated white matter is isointense to grey matter on T2.

Question 39

52. On scan for dementia, 10mm lesion in atrium of ventricle. Marginal enhancement.
    a) Choroid plexus cyst
    b) Ependymoma
    c) Meningioma
    d) Ependymal cyst
    e) Metastases

Answer 39

a) Choroid plexus cyst

Question 40

54. Not associated.
    a) NEC and diabetes.
    b) Fap and desmoids.
    c) Msk and caroli.

Answer 40

a) NEC and diabetes. Not convincingly

**LJS - variable reports in papers. Caution - is the most correct answer in other MCQs

Question 41

54. Regarding hepatic gas

a) Gas in liver can be seen after tumour chemoembolisation
b) PV gas is central
c) Biliary gas is recognised feature of bowel ischaemia
d) PV gas seen in haemorrhagic pancreatitis
e)

Answer 41

a. Gas in liver can be seen after tumour chemoembolisation

Question 42

55. Weightlifter on steroids. Plain ct liver shows low density lesion with streaky hyperdensities.
    Heterogenous arterial and pv enhancement.

a) Adenoma
b) hcc
c) fnh
d) haemangioma

Answer 42

Adenoma

Question 43

56. 3 incidental liver nodules on CT. All hot on red cell scan.
    a) Fnh
    b) Adenoma
    c) Haemangioma
    d) Mets
    e) HCC

Answer 43

c) Haemangioma

SCS: from StatDx:
referring to Tc-99m labelled RBC scan w SPECT. High accuracy reported.
Early phase: focal photopoenic defect/less uptake.
Delayed scans: over 30-50mins persistent filling
Vascular tumours (Adenoma, FNH, HCC): ALL exhibit early uptake, variable persistent uptake (depending on specific lesion)

Question 44

57. Not congenital
    a) Fistula bet portal vein and IVC
    b) Portal vein aneurysm
    c) Duplicated portal vein
    d) Intrahepatic portosystemic shunts
    e) SMA/SMV reversal in malrotation

Answer 44

a) Fistula between portal vein and IVC

SCS: referring to TIPS procedure

Question 45

58. Most common D2 extrinsic compression on barium study.
    a) Annular pancreas
    b) Pancreatic divisum
    c) Ectopic pancreas
    d) Pancreas head agenesis

Answer 45

a. Annular pancreas

Question 46

59. G1P0 woman attends for 11+3 week nuchal scan. Bowel is seen between abdominal wall andumbilical cord
    a) Normal gut herniation
    b) Exomphalos
    c) Pseudoexomphalos
    d) Gastroschisis
    e) Cord AVM

Answer 46

a) Normal gut herniation

**LJS - getting pretty late for physiological herniation. Some say can’t diagnose until 12 weeks. Others say 11.4 weeks, which is pretty much 11+3. Stat dx says can dx at nuchal translucency scan. I’d be suspicious and looking carefully at descriptors in the question to differentiate at this gestation

**SCS: note specifically Omphalocoele is NOT listed as a distractor makes me favour Normal herniation. Otherwise agree w Oracle
Radiopaedia says “up until 12-13 weeks in-utero”

Question 47

60. Highest risk of post partum haemorrhage
    a) Bilobed placenta
    b) succemturiate
    c) marginate
    d) velamentous
    e) circumvallate

Answer 47

b) succinturiate lobe

***LJS - agree. Placental previa and accreta spectrum have highest risk PPH (along with things that cause atonic uterus like twins, polyhydramnios etc). And anything that increases risk of placental tissue remaining in uterus e.g. succenturiate lobe. Not really sure what marginate means - circummarginate or marginate cord insertion.

Question 48

61. Low lying placenta with cervix measuring 6 cm long.
    a) Over distended bladder
    b) Placenta praevia

Answer 48

a. Over distended bladder

**LJS - bladder distention overestimates cervical length on TA scanning

Question 49

62. Fleishner guidelines for 7mm nodule in non smoker
    a) No need to follow
    b) follow CT at 12 months, if stable no further monitoring
    c) follow CT at 6-12 months and 18-24 months, if stable no further monitoring
    d) Follow CT at 9-12, 18 and 24 months if stable no further monitoring
    e) Follow CT at 3-6, 9-12, 18-24 months, biopsy and PET

Answer 49

c. follow CT at 6-12 months and 18-24 months, if stable no further monitoring

Wji: if Solid or GGO. If part solid 3-6/12

Question 50

63. Regarding UBC
    a) Metaphyseal
    b) Femur more common than humerus
    c) Fluid-fluid levels in 50%

Answer 50

a) Metaphyseal

Radiopaedia: Usually there no fluid-fluid levels unless there has been a complication with haemorrhage.

Question 51

64. Regarding cortical lesions
    a) Benign lesions can cause periosteum thickening
    b) Benign lesions can erode periosteum
    c) Can’t remember rest of options

Answer 51

a) Benign lesions can cause periosteum thickening

Question 52

64. Adolescent with skateboard injury, deformity forearm, pain in elbow. Regarding radiographs
    a) Perform after IV analgesia
    b) Include elbow
    c) Views in pronation and supination
    d) Opposite side for comparison
    e) Scaphoid views

Answer 52

b. Include elbow

Question 53

65. 50 year old, CT demonstrates long segment distal ileal target sign appearance with milddilatation of proximal small bowel. Likely cause
    a) long segment intussusception
    b) short segment intussusception
    c) carcinoma
    d) Meckel’s diverticulum
    e) lymphoma

Answer 53

a) long segment intussusception

c) carcinoma malignancy 30 percent of small bowel (66% of large bowel).
Most common malignant lead point in small bowel is mets and lymphoma. Meckels and diverticulum make up half of the benign cases (35% each overall). Lipomas most common benign in colon

Question 54

66. PASH (pseudo angiomatous stromal hyperplasia)

a) Most common presenting as palpable mass
b) 5-10% upgrade on open biopsy
c) 5-10% progress to cancer in 10 years
d) Often an incidental finding and needs no treatment
e) Is malignant and needs to be removed

Answer 54

*RY - favour ‘d) often an incidental finding and needs no treatment’. Although it can present as a palpable mass, it is more commonly encountered as an incidental microscopic finding on biopsy. There is no malignant potential. (statdx).

Prior answer:
a) Most common presenting as palpable mass

Question 55

67. Headache for 26 hrs. Normal CT. CSF analysis shows copious RBC but no xanthochromia or bilirubin on spectroscopic analysis. Most likely
    a) Traumatic tap
    b) SAH due to berry aneurysm
    c) SAH due to perimesencephalic bleed
    d) Venous sinus theombosis
    e) Reversible cerebral vasoconstriction syndrome

Answer 55

a) Traumatic tap

Question 56

68. Regarding seminoma
    a) Homogenous on USS
    b) Most common childhood tumour
    c) Invades tunica vaginalis
    d) Not radiosensitive

Answer 56

a) Homogenous on USS

Question 57

69. Which of the following is true? (Please see answers in mrisafety.com)
    a) A patient with a ferromagnetic piercing which can’t remove it can safely have an MRI at1.5T if the piercing can be secured
    b) A patient with a copper IUD is excluded from 1.5T MRI
    c) A patient with an insulin pump can have a 1.5T MRI while the external pump is stillattached
    d) A patient with a cochlear implant is not excluded from having a 1.5T MRI
    e) A patient with combat shrapnel in their body cannot have a 1.5T MRI, even if theshrapnel is not near a vital organ

Answer 57

a. A patient with a ferromagnetic piercing which can’t remove it can safely have an MRI at 1.5T if the piercing can be secured
* AJL - A patient with a cochlear implant is not excluded from having a 1.5T MRI. I think this is also true. (it is conditional but they are not excluded completely).

Question 58

70. Which of the following is not associated with alcohol?
    a) HOCM
    b) Parotitis
    c) Communicating hydrocephalus
    d) SDH
    e) AVN

Answer 58

a. HOCM

SCS: alcohol causes Dilated CM.

Question 59

71. Regarding phaeochromocytoma. Which is false? (I think there was more than one questionon phaeo)

a) MRI good for diagnosis
b) Does not show signal loss on out of phase scan
c) MIBG is good for diagnosis
d) Some radiopharmaceutical good for benign phaeos
e) Some radiopharmaceutical good for malignant phaeos
f) PET CT is good for differentiating between benign and malignant phaeos

Answer 59

• LW:
  a) MRI good for diagnosis: TRUE

b) Does not show signal loss on out of phase scan: FALSE - May demonstrate signal loss on opposed-phase chemical shift imaging due to presence of intracellular fat
Can be confused with adrenal adenoma

c) MIBG is good for diagnosis: Reasonably true - MIBG has almost 100% specificity but limited sensitivity ~ 80% for PHs
d) Some radiopharmaceutical good for benign phaeos: unsure what this is asking…. *AJL - LJS has previously said MIBG for benign (has a B in it)
e) Some radiopharmaceutical good for malignant phaeos: unsure what this is asking… *AJL - LJS has previously said pentetreotide for malignant (has an N which is almost an M in it)
f) PET CT is good for differentiating between benign and malignant phaeos: Reasonably true….FDG uptake is found in greater percentage of malignant than benign PHs

Previous Answer:
c) MIBG is good for diagnosis

Question 60

72. Lateral dislocation patella not associated with
    a) PLC injury
    b) Patella alta
    c) Bone bruise medial patella facet
    d) Bone bruise lateral femoral condyle
    e) Haemarthrosis

Answer 60

a. PLC injury

? PCL

Question 61

73. Which of the following is true?
    a) CRL is more accurate marker than 2nd trimester dating
    b) CRL should include chorionic thickening

Answer 61

a. CRL is more accurate marker than 2nd trimester dating

Question 62

74. Which of the following is false?
    a) Obstruction at the level of the urethra has high mortality
    b) PUJ obstruction bilateral in 70%
    c) Bilateral renal agenesis associated with oligohydramnios

Answer 62

b. PUJ obstruction bilateral in 70% 30%

Question 63

Single umbilical artery is associated with anomalies – cardiac anomalies.

Answer 63

Single umbilical artery is associated with anomalies – cardiac anomalies.

Question 64

76. Fracture of tip of lateral malleolus below ankle joint
    a) Weber A
    b) Weber B
    c) Weber C
    d) Maisonneuve
    e) Dupuytren

Answer 64

a. Weber A

Pott or Dupuytren fracture (obsolete): Fracture of distal fibula above syndesmosis

Question 65

77. Woman with well defined breast lesion. Further work up shows fat and parenchymal stroma.
    a) Lipoma
    b) Hamartoma
    c) Phylloides

Answer 65

b) Hamartoma

Question 66

8. Which of the following is false?
   a) TAPVR is non cyanotic
   b) Ebstein anomaly is a cause of cardiomegaly
   c) VSD shunt is highest in first week

Answer 66

a) TAPVR is non cyanotic
* ESG also c) VSD typically do OK in the first week of life, and then as pulmonary pressures gradually reduce the left to right shunting increases.

Question 67

79. Middle aged man with known cardiac disease develops portal hypertension.
    a) ASD
    b) VSD
    c) Mitral stenosis
    d) Aorticstenosis

Answer 67

I think it is ASD -> cause right heart failure

• LW agrees ASD most likely.
• *LJS - unsure. Most common cause RVF is LVF, and ASD is simple fix, seems unlikely somebody would have “known cardiac disease” and it not be treated for so long that they develop portal HTN. ?AS correct
• AJL thinks this is a stupid question as it requires mind reading. It could be any of these things though you’d think AS or MS would be the slowest to be fixed. Hopefully there were some other clinical details provided.
• ***LW: further go, although I shouldnt be doing this a few days before, UTD lists restrictive and constrictive as common causes, while MS and Trsicupid regurg….So maybe MS (if only they told us the auscultation findings….)

81. Middle aged man with known cardiac disease develops portal hypertension.
    a. ASD
    b. VSD
    c. Mitral stenosis
    d. Aortic stenosis ? Most common cause of right heart failure is left heart failure, aortic stenosis more common than mitral stenosis.

Question 68

80. 18 month old child with undisplaced spiral fracture of tibia. Which is the likely mechanism?
    a) NAI
    b) Fall from 10 stairs
    c) Fall from high chair
    d) Fall whilst walking
    e) Direct impact

Answer 68

d. Fall whilst walking

Question 69

85. Drowsy child with fever and neck stiffness and aversion to light, what should be the next appropriate investigation
    a) LP
    b) NCCT
    c) CECT
    d) MRI

Answer 69

The child is drowsy - need CT first. Could be an intracranial abscess
CONCLUSIONS:In adults with suspected meningitis, clinical features can be used to identify those who are unlikely to have abnormal findings on CT of the head.

**LJS - high risk features for having raised ICP dictate CT prior to LP: decreased LOC, focal neurological signs, papilloedema etc.

Question 70

84. Regarding bloody nipple discharge
    a) Papilloma is most common
    b) Malignant cause most common
    c) In pregnancy, suggestive of malignancy
    d) Seen with dilated ducts (?duct ectasia)
    e) Normal ultrasound and mammogram excludes papilloma

Answer 70

a. Papilloma is most common

UpToDate:
Papillomas most common
25% due to malignancy (most often DCIS)

Question 71

85. What defines coronary artery dominance? Origin of
    a) Posterior descending artery
    b) Obtuse marginal
    c) Ramus intermedius
    d) Conus

Answer 71

a) Posterior descending artery

Question 72

86 Young man presents with binge drinking preceding night and bloodstained vomitus in the morning, now pain on swallowing. Barium examination shows extravasation of barium at the GOJ. What is the most likely diagnosis? (note change from previous years, where barium examination was normal)

a) Mallory Weiss tear
b) Boerhaave syndrome
c) reflux esophagitis
d) esophageal varices
e) Barrett’s esophagus

Answer 72

b) Boerhaave syndrome

Question 73

87. 3 month old child with posterior neck mass present since birth. Doppler shows low flow, compressible.
    a) Infantile haemangioma
    b) Congenital lymphagioma
    c) Lymphangioma
    d) Venous malformation
    e) AVM

Answer 73

d) Venous malformation

Question 74

88. Which perfusion parameter is most useful to assess for cerebral autoregulation in cerebral ischaemia?
    a) MTT
    b) CBV
    c) CBF

Answer 74

b) CBV

**LJS - penumbra has normal or slightly increased CBV due to auto-regulatory vasodilatation

Question 75

89. Left sided SVC drain into:
    a) Right atrium
    b) Right ventricle
    c) Coronary sinus
    d) IVC

Answer 75

c) Coronary sinus

Question 76

90. Melorrheostosis - which is false
    a) Sclerotomal distribution
    b) Malignant transformation
    c) Joint contractures
    d) Soft tissue calcification

Answer 76

90. Melorrheostosis
    a) Sclerotomal distribution: TRUE
    b) Malignant transformation: FALSE
    c) Joint contractures: TRUE
    d) Soft tissue calcification: TRUE

Question 77

91. Not associated with portal vein thrombosis
    a) Abdominal sepsis
    b) Islet cell transplant
    c) HCC
    d) Haemorrhagic pancreatitis

Answer 77

93. Not associated with portal vein thrombosis

a. Abdominal sepsis yes
b. Islet cell transplant yes
c. HCC yes
d. Haemorrhagic pancreatitis yes

so i’m not sure

Question 78

92. Anaphylactic reaction is clinically defined. Which of the following combination is most appropriate?
    a) Swelling of mucosal tissues and hypotension
    b) Skin rash and hypertension
    c) Various other choices with either normotension or hypertension

Answer 78

a. Swelling of mucosal tissues and hypotension

Question 79

93. Churg Strauss
    A) Also known as eosinophilic granulomatosis with polyangiitis or allergic granulomatosis

B) Caused by fungal infection

C) Not associated with eosinophilia

Answer 79

a. Also known as eosinophilic granulomatosis with polyangiitis or allergic granulomatosis

Question 80

94. Peripheral venogram (didn’t specify upper or lower limb), how many frames a second?
    a) 0.5
    b) 1
    c) 2
    d) 3
    e) 4

Answer 80

c) 2

Question 81

95. Gestational trophoblatic disease
    a) Partial mole is diploid
    b) Complete mole is triploid
    c) Partial mole has 5-10% risk of choriocarcinoma
    d) Abortion accounts for 25%
    e) Gestational and non-gestational choriocarcinoma have same prognosis

Answer 81

d. Abortion accounts for 25%
gestational choriocarcinoma may look identical to hydatidiform mole
arises following known molar pregnancy (50%), miscarriage (30%), normal pregnancy (20%)

Question 82

96. Regarding V/Q scan in a young patient with cough, temperature, and right pleuritic chestpain, what is the expected finding? (that was all the information given)

a) Wedge shaped segment of non-ventilation, with preserved perfusion
b) Central accumulation of tracer, with non uptake in periphery
c) Multiple large matched perfusion defects
d) Multiple small unmatched perfusion defects
e) I’m not sure I remember the wording correctly.

Answer 82

**LJS:
Pneumonia - most common finding is matched defect of V/Q (shunting of blood away from poorly ventilated lung
When perfusion partly preserved - get reversed mismatch
Commonly get stripe sign - preserved perfusion at pleural border (makes PE very unlikely)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065883/

*LW - agree with LJS, and likely incomplete recall on wording of correct answer.

Previous answer:
a) Wedge shaped segment of non-ventilation, with preserved perfusion - I think sounds like an infection

Question 83

97. Type 3 peri-anal fistula
    a) Translevator extension
    b) Intersphincteric
    c) Trans-sphincteric
    d) Intersphincteric with abscess

Answer 83

c) Trans-sphincteric

grade 1: simple linear intersphincteric
grade 2: intersphincteric with abscess or secondary tract
grade 3: transsphincteric
grade 4: transsphincteric with abscess or secondary tract within the ischiorectal fossa
grade 5: supralevator and translevator extension