RD MCQ april 2013 VIC: Formatted

Question 1

With regards to I-131 vs I-123, which of the following statements is MOST TRUE
a. I-131 is cheaper than I-123
b. I 131 has a higher dose
c. I 131 can afford higher doses
d. SPECT I-131 has better spatial resolution
e. I-131 has a shorter imaging time, at 4-8 hours post injection

Answer 1

b. I 131 has a higher dose

Iodine-123
- pure gamma emitter
- excellent characteristics for imaging with modern scintillation cameras.
- lower dose

I131
- higher dose
- for treatment of thyroid cancer and MNG

*ESG I-131 also cheaper than I-123 as it comes from a nuclear reactor rather than a cyclotron. Whether this conventional wisdom applies to nuclear free NZ is undefined and unknowable.

Question 2

2. V/Q scanning, which is MOST TRUE

a. PIOPED high probability defined as one or more unmatched perfusion defects

b. complete absence of perfusion to one lung is more commonly secondary to extrinsic compression from lung carcinoma than massive pulmonary embolus

c. Technegas is give at 5 times the dose of macro-aggregated albumin

d. Technegas given after macro-aggregated albumin

e. 90% of perfusion defects resolve on repeating imaging in 12 months

Answer 2

complete absence of perfusion to one lung is more commonly secondary to extrinsic compression from lung carcinoma than massive pulmonary embolus

*LW agrees, based on the high end research of a single 1987 Radiographic paper where there 8 cases of lung cancer vs 3 cases of PE accounting for complete absence of perfusion.
*Prometheus - agree with LW, see p485 of my book where I state that a unilateral perfusion defect without a ventilation defect is due to central obstructing mass more commonly than fibrosing mediastinitis and central PE.

**LJS - agree. Also, ventilation scan done before perfusion.
Common dose 37MBq technegas vs 150MBq MAA

Perfusion scintigraphy
- microembolization with 99mTc-labeled macroaggregates of human albumin (MAA).
ventilation studies
- inert gas 81mKr or - DTPA or- (Technegas; Cyclomedica Ltd.) are currently recommended (11).
81mKr is of limited use because of its high cost and short half-life.

Ventilation (Xe-133) before perfusion (Tc-99m MAA) because Tc-99m has a longer half life and higher energy - doing perfusion first would interfere with a subsequent ventilation scan. Because physics. And Prometheus.

Question 3

3. V/Q scanning, which is MOST TRUE
   a. the PIOPED reporting criteria includes a “normal scan” category
   b. A rim of pleural perfusion overlying a central perfusion defect is a high probability finding
   c. a “low probability” V/Q scan completely excludes pulmonary embolism
   d. is absolutely contraindicated in pregnancy
   e. something about ventilation or perfusion performed first.

Answer 3

a. the PIOPED reporting criteria includes a “normal scan” category

**LJS:
Revised PIOPED 2:
PE present (high probability)
Non-diagnostic (low/int prob)
PE absent (normal or very low probability)

Ventilation performed first

Question 4

4. DTPA scan is for
   a. renal scarring
   b. renal obstruction
   c. renal artery stenosis
   d. renal function
   e. renal cell carcinoma metastases

Answer 4

d. renal function

4. DTPA scan is for

a. renal scarring DMSA (can also assess differential function)
b. renal obstruction MAG3,
c. renal artery stenosis MAG3 with captopril
d. renal function - “true GFR” (not eGFR)
e. renal cell carcinoma metastases

*RY - Removed incorrect indications for DMSA (is used to look at cortex, not as a dynamic renogram). DTPA can also be used instead of MAG3 for renal obstruction (with frusemide) or renal artery stenosis (with ACEi), but is generally worse because it almost exclusively filtered (i.e. significantly worse when there is poor renal function). DTPA mainly used for calculating GFR. (Crack the core, radprimer)

Question 5

5. MAG 3 with captopril for
   a. renal scarring
   b. renal obstruction
   c. renal artery stenosis
   d. renal function
   e. renal cell carcinoma metastases

Answer 5

c. renal artery stenosis

Question 6

. Regarding multislice CT scanning and dose, most correct
a. Automated dose modulation technique may minimise dose
b. Dose is proportional to kVP
c. the mAs should not be altered regardless of body size
d. the efficiency of radiation is increased with less slices
e. isotropic voxels in multislice CT increases the dose

Answer 6

a. Automated dose modulation technique may minimise dose

6. Regarding multislice CT scanning and dose, most correct
   a. Automated dose modulation technique may minimise dose
   b. Dose is proportional to kVP proportional to kVp squared (roughly)
   c. the mAs should not be altered regardless of body size ramp that shit up in fatties.
   d. the efficiency of radiation is increased with less slices possibly?? - *ESG - no, reduced, something to do with a bit of unavoidable wasted radiation at both ends of the beam, so (assuming a constant slice width): the more slices, the greater the collimated beam width, the less proportion wasted, the greater the efficiency of the dose
   e. isotropic voxels in multislice CT increases the dose

Question 7

7. Regarding fat suppression techniques, which is TRUE
   a. Inversion recovery techniques are very suspectible to static magnetic field inhomogeneity
   b. Inversion recovery is lipid specific
   c. Inversion recovery is better on lower magnet strength MR
   d. a typical adenoma show lower signal on out of phase imaging than fat suppressed image
   e. fat suppression cannot be applied to T2 weighted imaging

Answer 7

d. a typical adenoma show lower signal on out of phase imaging than fat suppressed image

7. Regarding fat suppression techniques, which is TRUE

a. Inversion recovery techniques are very suspectible to static magnetic field inhomogeneity - F, relatively insensitive to magnetic field inhomogeneity (radiopaedia)
**SCS: hence STIR is used if metalware is in situ…

b. Inversion recovery is lipid specific - F if this means it can only be used for fat suppression, and can’t be used for fluid (FLAIR) - also F if it’s saying that only lipids will be nulled because anything that happens to have the same T1 will also be nulled (can’t do IR post-gad due to T1 shortening and inadvertently nulled tissue)

c. Inversion recovery is better on lower magnet strength MR (SCS -false asked a tech)

d. a typical adenoma show lower signal on out of phase imaging than fat suppressed image

e. fat suppression cannot be applied to T2 weighted imaging (FLAIR, STIR)

Question 8

8. Most frequently accepted theory of NSF mechanism

a. free gadolinium reaches soft tissues and activates fibroblasts
b. free chelate reaches soft tissues and activates fibroblasts
c. chelated gadolinum reaches soft tissues and activates fibroblasts
d. antibody bound chelated gadolinium reaches soft tissues and activates fibroblasts
e. antibody bound free gadolinium reaches soft tissue and activates fibroblasts

Answer 8

a. free gadolinium reaches soft tissues and activates fibroblasts

Question 9

9. Which is the correct association
   a. I 131 Sodium iodide is used for the diagnosis of papillary thyroid cancer
   b. I 131 penteotide is used for diagnosis of medullary thyroid cance
   c. MIBG for adrenal cortical adenocarcinoma
   d. something-Onco-scan for ovarian cancer
   e. 99mTc-antiCEA is used for diagnosis of breast cancer

Answer 9

d. something-Onco-scan for ovarian cancer Onco-scint for ovarian and colon cancer

Question 10

Which of the following is TRUE regarding safety issues with 1.5 T MRI
a. Pt with ferromagnetic body piercing not able to be removed is disqualified from entering the magnet
b. A patient with a copper IUCD is disqualified from entering the magnet
c. External insulin pump which is connected to the patient can get into the magnet
d. A patient cochlear implant is disqualified from getting into magnet
e. Person with metallic sharpnel foreign bodies from combat is disqualified from getting into magnet even if they are not near vital organs

Answer 10

**LJS - see www.mrisafety.com
-piercing can be stuck down or cooled with ice pack to avoid heating. Not contraindication
-Cochlear implant - these days can remove outer part and wrap head. Some are now MRI compatible. But this would recently have been most true

d. A patient cochlear implant is disqualified from getting into magnet probably this one although there are some devices that have received FDA approval now.

a. ferromagnetic body piercing not being able to removed - not sure
b. IUCD is safe
c. MRI can damage insulin pump
d. cochlear implant may need to be removed
e. metallic shrapnel is ok if not the region of interest imaged

Question 11

Patient requires CT contrast injection: least likely to predict renal impairment
a. Myeloma
b. Gout
c. Thyrotoxicosis
d. CHF
e. Previous renal disease

Answer 11

Thyrotoxicosis relative contraindication because of iodine dose (can exacerbate thyrotoxicosis) not because of renal impact

Question 12

12. Diabetic man presents with first seizure, is requested for an MRI. The patient has bad renal function with an estimated GFR of 28. What is the MOST APPROPRIATE approach to MRI contrast.
    a. Haemodialysis immediately after the study and again within 24 hours
    b. Use a linear gadolinium
    c. Use a non-ionic gadolinium
    d. Use a macrocyclic gadolinium
    e. Do not give contrast

Answer 12

. Do not give contrast screening examination, don’t give contrast straight up. If absolutely required, use macrocyclic and dialyse afterwards (risk still <1%). Also at increased risk with liver disease.

**LJS - see RANZCR guideline.
At GFR 15-30 ml/min are low risk for NSF (0.1% per dose of higher risk agent). High risk agent (linear Gad agents) contraindicated.
Haemodialysis only recommended for high risk patients (GFR <15 ml/min)
Need to balance risk of NSF vs risk of misdiagnosis.
Answer = low risk agent (macrocyclic or gadobenate) in this setting

https://www.ranzcr.com/college/document-library/gadolinium-containing-mri-contrast-agents-guidelines

Question 13

13. 54yo man with diabetes with ischaemic foot. Very low GFR. Vascular surgeon requests an angiogram. Best contrast agent:
    a. non ionic iodine based contrast
    b. carbon dioxide
    c. nitrogen
    d. oxygen
    e. lipidol

Answer 13

b. carbon dioxide Co2 is a technique used in 60s and 70s

Question 14

Regarding rheumatic heart disease, which of the following is TRUE:

a. aortic valve is most commonly affected
b. mitral stenosis is due to thickened shortened chordae
c. myocarditis is typically fatal
d. chronic rheumatic valve disease is due to group A streptococcus endocarditis in childhood
e. infective endocarditis is relatively common complication

Answer 14

*LW:
If wording is accurate: Option E would be preferred option, although unsure of “common”
Ensure correct wording of option D - if states strep endocarditis = FALSE, if Strep Pharyngitis = this would be most correct option.

**LJS - infective endocarditis is a complication, due to abn valves of chronic RHD. Not sure what constitutes “relatively common” but I think this is most correct of options given

Regarding rheumatic heart disease, which of the following is TRUE:

a. aortic valve is most commonly affected: False Mitral

b. mitral stenosis is due to thickened shortened chordae: False - commissural fusion of valve leaflets is a characteristic feature.

c. myocarditis is typically fatal: false

d. chronic rheumatic valve disease is due to group A streptococcus endocarditis in childhood: group A beta haemolytic streptococcus pharyngitis that evokes a immune reaction against valves, myocardium and pericardium.

e. infective endocarditis is relatively common complication: False.

Question 15

15. 60 year old non-smoking male. SOB, restrictive lung function tests. HRCT has posterobasal predominant interlobular septal thickening with subplueral cysts, mild bronchial dilatation and mild ground glass opacity
    a. Respiratory bronchiolitis - interstitial lung disease
    b. Desquamative interstitial lung disease
    c. Cryptogenic organising pneumonia
    d. Non-specific interstitial pneumonitis
    e. Usual interstitial pneumonitis

Answer 15

. Usual interstitial pneumonitis

Question 16

16. Which of the following regarding pulmonary amyloidosis is FALSE: .
    a. multiple nodules
    b. bronchial obstruction
    c. bronchopleural fistula
    d. pulmonary ossification

Answer 16

c. bronchopleural fistula

Question 17

17. 50 year old man with 4/12 of haemoptysis. CXR shows perihilar infiltrates, with three nodules, one of which is cavitating. Most likely diagnosis:
    a. Sarcoidosis
    b. Wegeners
    c. Septic emboli

Answer 17

b. Wegeners

Question 18

. 55yo man with intermittent claudication, 3cm long <50% stenosis SFA - first line treatment
a. embolectomy
b. angioplasty
c. bypass surgery
d. exercise program
e. stent graft

Answer 18

d. exercise program

Assuming this will stimulate collaterlisation?

Question 19

19. 80 year old male with enlarging abdominal aortic aneurysm despite treatment with stenting. A CT angiogram demonstrates filling of the aneurysm from a lumbar artery, what is the likely cause:
    a. type I endoleak
    b. type II endoleak
    c. type III endoleak

Answer 19

b. type II endoleak

Question 20

20. Which of the following regarding acute aortic syndrome in relation to penetrating ulcer is FALSE?
    a. penetrating aortic ulcer extends to at least the media (macroscopic penetration)
    b. acute aortic syndrome from intramural haematoma
    c. most commonly occurs in the abdominal aorta
    d. acute aortic syndrome from aortic rupture
    e. acute aortic syndrome from dissection

Answer 20

c. most commonly occurs in the abdominal aorta - mid and distal thoracic.

Question 21

21. Young guy with hypertension. Elevated left apex. Irregular rib margins. Indentation of the left lateral border of the aorta. Retrosternal soft tissue mass. Most likely
    a. Aortic coarctation
    b. TAPVR
    c. Aortic insufficiency

Answer 21

a. Aortic coarctation

Question 22

22. Regarding dissection, which is TRUE
    a. requires visualisation of the dissection flap on MRA for diagnosis
    b. dissection is a cause of spinal dural AV fistula
    c. high attenuation within the lumen is a CT sign of dissection
    d. vertebral artery dissection more common than carotid artery dissection
    e. dissection is not a cause of subarachnoid haemorrhage

Answer 22

c. high attenuation within the lumen is a CT sign of dissection if within false lumen on non-contrast. (talking about IMH)

22. Regarding dissection, which is TRUE

a. requires visualisation of the dissection flap on MRA for diagnosis No. Not visualised in intramural haematoma.

b. dissection is a cause of spinal dural AV fistula
**LJS - cause usually unknown. Can’t find any paper suggesting dissection as cause

c. high attenuation within the lumen is a CT sign of dissection -if within false lumen on non-contrast.

d. vertebral artery dissection more common than carotid artery dissection- carotid more common.

e. dissection is not a cause of subarachnoid haemorrhage -yes it is.

Question 23

23. Patient being prepared for a left AV fistula for dialysis. Has never had a dialysis catheter before. Best place to site a tunnelled catheter in the interim:
    a. right IJV
    b. right subclavian vein
    c. left IJV
    d. left subclavian vein
    e. femoral vein

Answer 23

a. right IJV

Question 24

24. Correct statement regarding three vessel runoff :

a. Doppler ultrasound is more sensitive for demonstrating three vessel run off than DSA
b. CT angiogram is more sensitive for demonstrating three vessel run off than DSA
c. MRA is more sensitive for demonstrating three vessel run off than DSA
d. in phase (or similary) MR is more sensitive for demonstrating three vessel run off than DSA
e. catheter angiography is more sensitive than non-invasive methods for demonstrating three vessel run off

Answer 24

e. catheter angiography is more sensitive than non-invasive methods for demonstrating three vessel run off

Question 25

25. Regarding CTPA for pulmonary embolus, what does NOT form a criteria of the Well’s score
    a. Tachycardia > 100 bpm
    b. PE most likely diagnosis
    c. haemoptysis
    d. previous history of DVT/PE
    e. OCP use

Answer 25

e. OCP use

clinical signs and symptoms of DVT = 3
an alternative diagnosis is less likely than PE= 3
heart rate more than 100 = 1.5
immobilisation for 3 or more consecutive days or surgery in the previous 4 weeks = 1.5
previous objectively diagnosed PE or DVT = 1.5
haemoptysis = 1
malignancy (on treatment, treatment in last 6 months or palliative) = 1

Question 26

26. Which of the following is not a sign of progressive congestive cardiac failure?
    a. vascular cephalisation
    b. perihilar bat-wing opacity
    c. pulmonary calcification
    d. increasing definition of pulmonary vessels
    e. interstitial opacities

Answer 26

d. increasing definition of pulmonary vessels

Question 27

27. Young man, testicular ultrasound shows 2cm intratesticular hypoechoic lesion with internal debris and increased peripheral vascularity associated with acute pain. Best management:
    a. core biopsy in theatre
    b. antibiotics and clinical review in 72hrs
    c. surgical referral in one week
    d. US in 3 months
    e. orchidectomy

Answer 27

antibiotics and clinical review in 72hrs

Question 28

28. 50yo man, 4cm mass in small bowel with stranding radiating into the mesentery. Mild proximal small bowel dilatation. Most likely
    a. carcinoid
    b. GIST
    c. lymphoma

Answer 28

a. carcinoid

Question 29

29. 55 year old from Nigeria. Continuous linear calcification along the bladder with sessile mass. Most likely
    a. adenocaricnoma
    b. transitional cell carcinoma
    c. squamous cell carcinoma
    d. schistosomiasis

Answer 29

c. squamous cell carcinoma probably from schistosomiasis

Question 30

30. Rectal mass detected on DRE. MR rectum shows eccentric mass with intact muscularis layer. CT abdomen/pelvis shows no lymphadenopathy or metastases. What is the stage after imaging?
    a. stage 1
    b. stage 2a
    c. stage 2b
    d. stage 3
    e. stage 4

Answer 30

a. stage 1

Stage groupings
stage I: T1-2, N0 M0

stage
IIa: T3, N0, M0
IIb: T4a, N0, M0
IIc: T4b, N0, M0

stage
IIIa: T1-2, N1, M0
IIIb: T3-4, N1, M0
IIIc: T3-4b, N2, M0
stage IV: any T, any N, M1

Question 31

31. 40 year old male with RIF pain and fever. CT shows inflammatory stranding surround a 1cm lesion at the caecal tip, which has a CT density of 345 HU. Most likely diagnosis:
    a. appendicitis
    b. diverticulitis
    c. epiploic appendagitis
    d. crohn’s disease
    e. pseudomembranous colitis

Answer 31

**LJS - “lesion” is probably an appendicolith, which could have this density. Answer = appendicitis.

*LW: agree with above.

DDx: If HU was -45, this implies fat, and is normally a rounded lesion of approx 1cm = Epiploic appendicitis.

Previous answer:
a. appendicitis

Question 32

. Regarding prostate cancer, which is TRUE
a. doesn’t arise from the peripheral zone
b. typically more often hypoechoic than hyperechoic compared to surrounding parenchyma
c. PSA correlates directly to tumour load
d. PSA does not relate to prostate size
e. PSA is elevated in <50% of patients with prostate cancer

Answer 32

. typically more often hypoechoic than hyperechoic compared to surrounding parenchyma

Question 33

33. Adult male, blunt trauma, which is FALSE regarding bowel injury
    a. interloop fluid is a strong predictor
    b. pneumoperitoneum is seen in almost all cases on CT
    c. bowel loops may show increased enhancement
    d. duodenum and jejunum are commonly affected
    e. focal bowel wall thickening is sometimes seen

Answer 33

pneumoperitoneum is seen in almost all cases on CT

Question 34

34. 30 year old woman with abdominal pain. Barium follow through shows proximal jejunum dilated to 4cm diameter and featurelesss before a 5 cm stricture with fistula to the terminal ileum. What is the most likely diagnosis?

a. Crohns disease
b. carcinoid
c. lymphoma
d. scleroderma
e. SLE

Answer 34

a. Crohns disease

Question 35

35. 40 year old male presents with fever of unknown origin. CT abdomen shows a 20 cm retroperitoneal mass encases the adrenal and left kidney, which are otherwise normal. The density ranges from -60 HU to 60 HU. What is most likely:
    a. ruptured xanthogranulomatous pyelonephritis
    b. adrenal myelolipoma
    c. myxoid liposarcoma
    d. renal angiomyolipoma
    e. retroperitoneal haematoma

Answer 35

c. myxoid liposarcoma

liposarc types:
well differentiate
myxoid
round
pleomorphic
mixed

Question 36

36. Haemochromatosis, which is false
    a. Autosomal dominant
    b. Fe deposition in liver and reticuloendothelial system

Answer 36

*LW: likely incomplete recall:

Primary Haemochomatosis:
- Autosomal recessive, so hence Auto Dominant is False.
- However tends to affect liver and NON-reticuloendothelial system, hence this is also technically false.

Secondary Haemochomatosis:
- Secondary to haemosiderosis
- Tends to affect liver and reticuloendothelial system, i.e. spleen and bone marrow.

(WJI: secondary haemochromatosis is still haemochromatosis so only a. is false)

Question 37

37. What is not an indication for TIPS a.
    b. large varices
    c. fulminant liver failure
    d. hepatorenal syndrome
    e hepatopulmonary syndrome

Answer 37

c. fulminant liver failure
(LW agrees)

*LW:
StatDx states the following:

Indications
- Variceal hemorrhage
- Portal hypertensive gastropathy
- Refractory ascites or hepatic hydrothorax
- Budd-Chiari syndrome
- Other possible indications (no proven benefit in controlled trials)
—> Hepatorenal or hepatopulmonary syndrome
—> Sinusoidal obstruction syndrome

No definitive absolute contraindications
Relative contraindications
- Heart failure
- Elevated right or left heart pressures
- Pulmonary hypertension
- Rapidly progressive liver failure
- Hepatic encephalopathy (HE)
- Portal vein thrombosis
- Sepsis or ongoing infection
- Risk of TIPS stent colonization
- Hepatic tumors
- Coagulopathy
-Biliary obstruction
- Polycystic liver disease
- Elevated model for end-stage liver disease (MELD) score
- - > MELD score of > 24 associated with 30-day mortality of 60%

Question 38

38. Which of the following associations regarding congenital heart disease is FALSE?
    a. VSD and pulmonary plethora
    b. D-transposition of the great vessels and egg-on-side cardiac contour
    c. Ebsteins anomaly and left heart enlargement
    d. Trisomy 21 and atrioventricular septal defect
    e. Tetralogy of Fallot and right sided aortic arch

Answer 38

c. Ebsteins anomaly and left heart enlargement
*LW: Ebstein –> right heart enlargement. Atrialisation of the right ventricle.

*RY - note: ‘egg on string’ is called ‘egg on side’ by some people

Question 39

39. Child seen by paediatrician. Pit seen high over nasal bridge. T1 and T2 high signal 1 cm lesion on dorsum of nose with tract seen toward foramen caecum. Most likely
    a. encephalocoele
    b. nasal glioma
    c. lacrimal dacrocystocoele
    d. dermal sinus tract

Answer 39

d. dermal sinus tract

Question 40

40. Least likely finding on CXR for viral pneumonia in a child
    a. peribronchial thickening
    b. atelectasis
    c. hilar lymphadenopathy
    d. focal consolidation
    e. hyperexpansion

Answer 40

d. focal consolidation

least likely yes, but can sometimes occur

Question 41

41. 6 year old boy with short stature and developmental delay has MR which shows hydocephalus with cerebellar tonsillar herniation into the foramen magnum and dysgenesis of the corpus callosum. What is the LEAST LIKELY associated finding?
    a. fenestration of the falx
    b. concavity of the posterior temporal bones
    c. normal 4th ventricle
    d. enlargement of the massa intermedia
    e. tectal beaking

Answer 41

c. normal 4th ventricle

**LJS - elongated displaced 4th V = obstructive hydrocephalus

Question 42

42. Intern approaches you about hip screening for a new born infant whose 2 year old brother had hip dysplasia. What do you recommend?
    a. hip ultrasound in 2 weeks after birth
    b. hip ultrasound at <6 weeks
    c. hip ultrasound at <12 weeks
    d. no risk of hip dysplasia, screening not required
    e. radiograph at 6 months

Answer 42

hip ultrasound at <12 weeks ejb thinks this one, should be after 6 weeks (we aim to do ours at 6 weeks).

Screening hip US not recommended < 4 weeks of age due to presence of physiologic laxity. However, US should be performed if clinical exam suggests dislocation or significant instability

Radiographs necessary after 4-5 months. Proximal femoral epiphysis ossifies, blocks ultrasound beam, limits evaluation

*ESG
Starship hospital guidelines recommend the following for a baby with risk factors (FHx in a close relative) but no “soft” signs (clicky hips/asymmetrical crease) on exam:
GP re-check hips at the regular baby checks AND arranges as AP pelvis X-ray at 4-6 months of age
But RCH Melbourne recommends:
Screening ultrasound if risk factors present after the age of six weeks if no evidence of clinical instability.
For the purposes of exams, Melbourne > Auckland so I agree with <12/52 being the best answer

Question 43

43. Regarding non-accidental injury in children, which is TRUE?
    a. long bone fractures are spiral
    b. anterior rib fractures are more common than posterior fractures
    c. nuclear medicine is only useful to date fractures already seen on x-ray
    d. metaphyseal corner/bucket handle fractures are caused by twisting

Answer 43

a or d
d- should be shaking though

SCS: Unsure, i favour A, ? Imperfect recall
A. Radiopaedia says: Humeral spiral fractures is moderately suspicious pattern. Also i would assume if child wasnt walking this would also suspicious.
B. Posterior ribs more common than anterior
C. Nah bro.
D. Never SHAKE a baby- repetitive microfractures at metaphysis. limbs moving back and forth with a resultant whiplash or shear force. The microfractures occur in immature mineralised bone AGE >2 y/o.

Question 44

44. 25 year old female presents for second trimester ultrasound. Most likely findings (seriously no other information provided)
    a. congenital pulmonary airway malformation
    b. congenital diaphragmatic hernia
    c. extraloblar sequestration
    d. cardiac rhabdomyoma
    e. neuroblastoma

Answer 44

b. congenital diaphragmatic hernia - slightly more common than CPAM

Question 45

45. 4mm nuchal translucency on a good quality first trimester ultrasound, which of the following is TRUE?
    a. suggestive a risk trisomy 21 of 75-80%
    b. suggestive of chromosomal abnormality (Turners/Trisomy 21) or cardiac anomalies
    c. within normal limits
    d. does not suggest a cystic hygroma

Answer 45

b. suggestive of chromosomal abnormality (Turners/Trisomy 21) or cardiac anomalies increased risk of these or d. does not suggest a cystic hygroma probably best answer. Too small.

45. 4mm nuchal translucency on a good quality first trimester ultrasound, which of the following is TRUE?

a. suggestive a risk trisomy 21 of 75-80%

b. suggestive of chromosomal abnormality (Turners/Trisomy 21) or cardiac anomalies increased risk of these

c. within normal limits mildly elevated (above 2.8 Needs to be adjusted for CRL)

d. does not suggest a cystic hygroma probably best answer. Too small.

Question 46

46. 16 year old girl with presents with menometrorrhagia (heavy prolonged bleeding). Blood tests shows she has hyperoestrogenism. A 4 cm ovarian mass is seen. What is the MOST LIKELY diagnosis?
    a. granulosa tumour
    b. leydig cell tumour
    c. serous cystadenoma
    d. mucinous cystadenoma
    e. sertoli-leydig cell tumour

Answer 46

a. granulosa tumour

Question 47

47. 1st trimester screening. What does NOT affect risk assessment of chromosomal abnormalities?
    a. nuchal translucency
    b. maternal age
    c. ossification of the nasal bone
    d. small middle phalanx of the little finger
    e. twin pregnancy

Answer 47

. small middle phalanx of the little finger

Question 48

48. Fetal ascites, LEAST likely cause:
    a. rhesus incompatibility
    b. parvovirus
    c. multicystic dysplastic kidney
    d. urinary tract obstruction
    e. twin-twin transfusion syndrome

Answer 48

multicystic dysplastic kidney

Question 49

49. Which is the LEAST likely cause of hydrops:
    a. large gastroschisis
    b. congenital diaphragmatic hernia
    c. rhesus incompatibility
    d. TORCH infection

Answer 49

a. large gastroschisis

Question 50

50. Regarding gastroschisis which is TRUE
    a. can be diagnosed on ultrasound at 10 weeks
    b. bowel is covered by a membranous sac
    c. contains liver in 30-50% of cases
    d. the abdominal wall defect is small (2-4 cm)
    e. is associated with congenital heart disease most of the time

Answer 50

d. the abdominal wall defect is small (2-4 cm) and right sided

Question 51

51. Third trimester ultrasound is requested with for LMP giving 33 weeks gestation. US gestational age on 7 week scan gives current GA of 35 weeks. 2nd trimester morphology scan gave current gestation age of 34 weeks. On current ultrasound measures corresponding to a gestational age of 32 weeks. What is the diagnosis?

a. use 7 week ultrasound date - small fetus for dates
b. use LMP dates - normal size
c. use LMP dates - small for dates
d. use 2nd trimester ultrasound - normal growth
e. use 2nd trimester ultrasound - small for dates

Answer 51

a. use 7 week ultrasound date - small fetus for dates

Question 52

52. 3rd trimester US, woman has painful PV bleeding. Hypoechoic retroplacental region seen, most likely
    a. placental abruption
    b. placenta praevia
    c. placental lake .

Answer 52

a. placental abruption

Question 53

53. A woman presents at 32 weeks with a cephalic presentation. There is what you think is cranial calcification. What is true?
    a. perform a TV ultrasound to be sure
    b. TORCH infections do not cross the placenta in the 3rd trimester and are therefore excluded
    c. this is seen in DiGeorge syndrome

Answer 53

a. perform a TV ultrasound to be sure not a hundy on this

**LJS - DiGeorge have hypocalcaemia (b/c no parathyroids). Multiple intracranial calcification (of the BG) are ass/w hypocalcaemia/hypoparathyroidism. ?but presumably not in utero

*LW:
toxo, for example, is most commonly transmitted in 3rd trimester - hence option incorrect.
I would back TV US for further assessment, based upon these options.
Di George Hypo Ca++ develops in the newborn period in up to 60 percent of DGS patients and may present with jitteriness, tetany, or seizures, with low serum calcium, elevated serum phosphorus, and very low parathyroid hormone levels. So ante natal may not be a cause…. extrapolating here.
**Should check with RB or P.D…..

Question 54

54. Which of the following regarding male breast cancer is TRUE?
    a. most commonly presents between 40-60 years of age
    b. presents as a painful retroareolar mass
    c. is seen as a dense mass with typically malignant calcification on mammogram
    d. is more commonly invasive ductal carcinoma than invasive lobular carcinoma

Answer 54

d. is more commonly invasive ductal carcinoma than invasive lobular carcinoma

STATdx - 87% are invasive ductal carcinoma; invasive lobular cancer rare (male breast lacks lobules)

–>Male breast Ca
-60-70 yo
-favours subareolar region, rounded, oval or lobulated mass on mamo. Calc not as common as female breast ca
-RF incluide: obesity, klinefelter, cryptorchidism, prostate ca, BRCA2, chest trauma, testicular injury, ionzing rad
-overall prognosis tends to be worse than for female breast cancer

Question 55

55. Not associated with breast cancer
    a. BRCA 2
    b. Ataxia telangiectasia
    c. Li Fraumeni
    d. Cowden syndrome
    e. VHL

Answer 55

e. VHL

Li Fraumeni = cancer syndrome

Ataxia telangiectasia - Associated abnormalities
Malignancy develops in 1/3 of cases
Lymphomas, lymphoid leukemias in children
Breast and gastric carcinomas in adults

Cowden syndrome, also known as multiple hamartoma syndrome, is characterised by multiple hamartomas throughout the body and increased risk of several cancers

Question 56

56. 60 year old woman for screening mammography. Average build (BMI 24), best combination
    a. Molybdenum anode and Molybdenum filter at 28kv
    b. Molybdenum anode and Molybdenum filter at 42kv
    c. Molybdenum anode and Rhodium filter at 28kv
    d. Molybdenum anode and Rhodium filter at 42kv
    e. Tungsten anode and Rhodium filter

Answer 56

a. Molybdenum anode and Molybdenum filter at 28kv

56. 60 year old woman for screening mammography. Average build (BMI 24), best combination

a. Molybdenum anode and Molybdenum filter at 28kv

b. Molybdenum anode and Molybdenum filter at 42kv less dose but poorer contrast

c. Molybdenum anode and Rhodium filter at 28kv more dose (better if fatter)

d. Molybdenum anode and Rhodium filter at 42kv

e. Tungsten anode and Rhodium filter

Question 57

. Patient suspects ruptured implant, US performed, which is true

a. US most sensitive test for implant rupture

b. calcification seen along the implant on mammo in 25% of cases

c. smooth contours of the implant on mammo virtually exclude rupture

d. mild bulge in the implant contour is suggestive of implant rupture

e. Multiple anechoic areas are seen through the breast parenchyma with ruptured implant

Answer 57

b. calcification seen along the implant on mammo in 25% of cases - must be this one

57. Patient suspects ruptured implant, US performed, which is true

a. US most sensitive test for implant rupture MRI

b. calcification seen along the implant on mammo in 25% of cases - must be this one

c. smooth contours of the implant on mammo virtually exclude rupture not intracapsular

d. mild bulge in the implant contour is suggestive of implant rupture Nope

e. Multiple anechoic areas are seen through the breast parenchyma with ruptured implant silicone – generally hyperechoic but can be hypoechoic

Question 58

58. Woman presents with lesion on mammography. Further work up shows the lesion contains fat. Next step
    a. reassure that it is benign
    b. Biopsy to exclude malignancy
    c. F/u with early mammo at 3 and 6 months

Answer 58

a. reassure that it is benign

**LJS - well circumscribed fatty masses are benign

Question 59

59. Woman with well circumscribed mass on mammography. On ultrasound is anechoic with no posterior shadowing. What is the best next step?
    a. reassure and routine follow up
    b. US guided core biopsy
    c. follow up with early mammography
    d. surgical referral for excision

Answer 59

a. reassure and routine follow up - PROBABLY THIS

if well circumscribed, anechoic, posterior enhancement, edge shadows – cyst, no follow-up. If any suspicious features - biopsy

Question 60

60. Which of the following is TRUE regarding invasive lobular carcinoma?

a. They are commonly seen only on one view on mammogram
b. US has poor sensitivity (<50%) for detection of invasive lobular carcinoma
c. Usually seen as a circumscribed mass on mammography
d. Mammography is highly sensitive (>70%) in detecting invasive lobular carcinoma
e. Is almost always palpable

Answer 60

a. They are commonly seen only on one view on mammogram

StatDX: Mammography: Spiculated mass; developing asymmetry
Can be seen in only one view (more often CC)

wji - statdx: us 88% sensitive, MMG 70% sensitive

other shit:
-Invasive lobular carcinoma is more often multicentric and bilateral (10-15%)
- mamo sens up to 81%
-spiculated mass lesion (most common)
-most common sonographic appearance is that of a heterogeneous, hypoechoic mass with angular or ill-defined margins and posterior acoustic shadowing. An ill-defined heterogenous infiltrating area of low echogenicity with disproportionate posterior shadowing is one of the sonographic characteristics of invasive lobular carcinoma.
-Due to its propensity for multicentricity, breast MRI is usually recommended in many countries when histology of a lesion reveals invasive lobular carcinoma.

Question 61

61. Young female with family history mother breast cancer at 35 and sister breast cancer at 28. brca negative. you advise

Answer 61

High risk, alternating yearly MRI and mammography (eg one every 6 months)

Question 62

62. Young female, returns from extending hiking trip in the Andes with headache. CT shows low density lesion with rim enhancement and associated nodule. Most likely
    a. Cysticercosis
    b. Hydatid
    c. Cryptococcus

Answer 62

a. Cysticercosis

Question 63

63. Regarding DWI which is TRUE?
    a. infarct is high signal on ADC
    b. vasogenic oedema shows reduced water movement
    c. intracellular methaemoglobin is dark on DWI
    d. DWI is normal at the periphery of a pyogenic cerebral abscess

Answer 63

**LJS - according to RP, IC MetHb is low on DWI and ADC
All phases except chronic have reduced ADC (lower than normal WM). DWI images variable with age.
https://radiopaedia.org/articles/haemorrhage-on-mri?lang=gb

d. DWI is normal at the periphery of a pyogenic cerebral abscess if this means around the abscess (written as surrounding abscess in the other recall from 2013)
*LW favor this option FALSE, as if surrounding abscess, there will shit load of peri lesional oedema, and thus likely DWI shine through component, hence DWI not normal. ADC correlation recommended.

Regarding DWI which is TRUE?

a. infarct is high signal on ADC

b. vasogenic oedema shows reduced water movement

c. intracellular methaemoglobin is dark on DWI - all compartmentalised Hb (ie still in cell) tends to have restricted diffusion

.d. DWI is normal at the periphery of a pyogenic cerebral abscess if this means around the abscess (written as surrounding abscess in the other recall from 2013).

Question 64

64. FLAIR ?stem?
    a. epidermoid and arachnoid cyst are best distinguished by FLAIR
    b. cholesterol granuloma T1 and T2 bright

Answer 64

b. cholesterol granuloma T1 and T2 bright (and doesnt Diffusion restrict)

SCS: note Epidermoids dont FLAIR suppress cf Arachnoid cyst should largely suppress except for pulsation. BUT BEST discriminator is DWI.

Question 65

65. 20 yo man, MVA 9 month ago with head injury but normal CT brain at the time. Ongoing cognitive impairment and memory issues. If looking for DAI, best sequence?
    a. T2 spoiled gradient
    b. DWI
    c. T2 * GRE
    d. FLAIR

Answer 65

c. T2 * GRE or SWI

Question 66

66. Herpes encephalitis on CT, what is FALSE
    a. sparing of basal ganglia
    b. involvement of insular cortex
    c. involvement of inferior frontal lobes
    d. avid enhancement may be seen in early disease
    e. mass effect

Answer 66

d. avid enhancement may be seen in early disease

**LJS - also affects cingulate gyrus, insular cortex and inferior frontal lobe
Enhancement is gyriform and late

Question 67

67. 30 year old woman, 3 months post partum, headache and hypopituitarism. What is most likely?
    a. lymphocytic hypophysitis
    b. rathke’s cleft cyst

Answer 67

a. lymphocytic hypophysitis

Question 68

68. Regarding lymphocytic hypophysitis, which is FALSE
    a. pituitary enlargment
    b. enlargement of the sella
    c. involvement of the anterior and posterior pituitary
    d. enlargement of the stalk
    e. thickening of the anterior pituitary and adjacent dura

Answer 68

b. enlargement of the sella - not chronic enough to do this

*LW:
Based on prior question of sella enlargement, hypophysitis has been listed as a cause especially chronic situation….
Involvement of the posterior pituitary is rare.
Dural enhacement can be seen, so I think this can be extrapolated to thickening…
So unsure over all

**LJS - RP lists all except b). as findings, yet also said to mimic macroadenoma (which expands the sella)
RP also lists “macroadenomas are expected to enlarge the sella turcica” under differentiating features between macroadenoma and lymphocytic hypophysitis. ?this might still be best answer and could be explained by differences in chronicity
Statdx also differentiates on this basis

Question 69

69. 20 year old man with painless neck mass, ultrasound shows cystic mass at level of angle of the mandible, anterior to sternocleidomastoid, with small part of the lesion directed between the internal and external carotid vessels, most likely (repeat)
    a. branchial cleft 1
    b. branchial cleft 2
    c. thyroglossal duct cyst
    d. ranula
    e. submandibular gland tumour

Answer 69

b. branchial cleft 2

Question 70

70. What does not show leptomeningeal enhancement
    a. idiopathic intracranial hypertension
    b. lymphoma
    c. metastases
    d. bacterial meningitis
    e. viral meningitis

Answer 70

*LW:
Intracranial hypotension causes pachymeningeal enhancement, rather than leptomeningeal enhancement (RP).
So either intracranial hypertension or hypotension would technically be wrong….

a. idiopathic intracranial hypertension

Question 71

71. 60 year male with a history of stuffy nose and facial numbness. On further questioning he admits to weight loss over the last 6 months. Imaging shows a nasopharyngeal mass. What is the most likely cause of face symptoms
    a. perineural spread along trigeminal nerve
    b. perineural spread along facial nerve
    c. eustachian tube obstruction with otitis media and referred facial symptoms
    d. extensive parapharyngeal lymph node involvement

Answer 71

a. perineural spread along trigeminal nerve

Question 72

72. AJCC classification of cervical lymph nodes includes which group in level 1?

a. submental
b. transcervical
c. posterior cervical
d. superior mediastinal

Answer 72

a. submental

Question 73

73. Synchronous (or almost synchronous) bilateral optic neuritis and spinal cord demyelination is compatible with?
    a. Beriberi
    b. Devic disease

Answer 73

b. Devic disease

Question 74

74. Regarding inverted papilloma, which of the follow is FALSE?
    a. 5% have associated squamous cell carcinoma
    b. when large and fill the maxillary sinus and ipsilateral nasal cavity
    c. replacement of bone with soft tissue indicated malignancy
    d. appearances of lateral growth with extension beneath the mucosa
    e. is one of the Schneiderian papillomas

Answer 74

c. replacement of bone with soft tissue indicated malignancy probably the most incorrect. Can’t distinguish reliably on imaging.

74. Regarding inverted papilloma, which of the follow is FALSE?

a. 5% have associated squamous cell carcinoma 10%

b. when large and fill the maxillary sinus and ipsilateral nasal cavity

c. replacement of bone with soft tissue indicated malignancy probably the most incorrect. Can’t distinguish reliably on imaging.

d. appearances of lateral growth with extension beneath the mucosa

e. is one of the Schneiderian papillomas yes

Question 75

75. Which is least likely to be seen in neurofibromatosis 2?
    a. pseudarthrosis
    b. dural ectasia
    c. schwannoma
    d. meningioma
    e. scoliosis

Answer 75

a. pseudarthrosis cant find anything on this on the line.

Question 76

76. Which is TRUE of imaging of the knee in knee pain?
    a. disproportionate patellofemoral involvement is suggestive of CPPD
    b. Low signal on all MR sequences is pathognomonic for PVNS
    c. Unilateral involvement is suggestive of rheumatoid arthritis
    d. Osgood-Schlatter is commoner in women than men (another well constructed sentence)

Answer 76

a. disproportionate patellofemoral involvement is suggestive of CPPD

Question 77

77. 55yo old woman with bilateral knee pain. X-rays show medial joint space narrowing with ostoeophyte formation. Most likely diagnosis?
    a. Rheumatoid arthritis
    b. Osteoarthritis
    c. Septic arthritis
    d. Reactive arthritis

Answer 77

b. Osteoarthritis

Question 78

78. 20 year old female with chest pain. CT shows chest wall lesion with rib destruction and pleural effusion. Most likely?
    a. Askin tumour
    b. neuroblastoma metastases
    c. elastofibroma
    d. fibrous dysplasia

Answer 78

a. Askin tumour

Question 79

79. MRI knee, which is FALSE?
    a. Normal ACL is perpendicular to Blumenstaadts line
    b. Tears of the posterior horn of the medial meniscus are more common than the anterior horn
    c. The lateral facet of the patella is typically larger than the medial facet
    d. Normal PCL is subject to “magic angle” effect
    e. MCL and ACL disruption are associated

Answer 79

a. Normal ACL is perpendicular to Blumenstaadts line >15 deg suggestive of tear

Question 80

80. A 45 year old house painter presents with limited range of motion. The GP diagnoses frozen shoulder and sends the patient for ultrasound. Your consultant elects to perform a Directly Observed Procedure (DOPS) of your ultrasound scanning technique. You are the first person to scan the patient. How would you position the arm to examine supraspinatus on ultrasound (repeat)
    a. neutral position elbow flexed
    b. hand touching opposite shoulder
    c. internal rotation with arm behind back
    d. external rotation elbow flexed
    e. elbow extended arm abducted

Answer 80

. internal rotation with arm behind back or elbow at 90 degrees and shoulder extended – “hand in pocket” position. Good for those with shitty shoulder ROM.

SCS. Radiopaedia.
A= biceps tendon
B= infra
C = supra, “ wallet from back pocket or sratching between shoulder blades”
D= Subscap

Question 81

81. Regarding foot deformity which is FALSE?
    a. talipes refers to congenital foot deformity
    b. pes refers to acquired hindfoot deformity
    c equinus refers to plantar flexion of calcaneum
    d. valgus is medial angulation of the forefoot
    e. talipes equinovarus refers to club foot

Answer 81

*AJL - 2 false answers
b. pes mean foot NOT hindfoot
d. valgus is medial angulation of the forefoot

Wji: prob a wording thing but you plantarflex at the ankle not the calcaneus

Question 82

82. Regarding MR of the ankle, which is TRUE
    a. fluid within the tendon sheath indicates tendonitis
    b. any intermediate signal within the tendon on PD may represent normal fascicles
    c. the achilles tendon is normally convex anteriorly on axial imaging
    d. the tendon is atrophic in chronic tendinopathy
    e. rupture of achilles tendon typically occurs at calcaneal insertion

Answer 82

b. any intermediate signal within the tendon on PD may represent normal fascicles

82. Regarding MR of the ankle, which is TRUE

a. fluid within the tendon sheath indicates tendonitis - Tenosynovitis.
*WJI - trick question achilles has no tendon sheath

b. any intermediate signal within the tendon on PD may represent normal fascicles

c. the achilles tendon is normally convex anteriorly on axial imaging this is a sign of tendinotpathy

d. the tendon is atrophic in chronic tendinopathy usually enlarged

e. rupture of achilles tendon typically occurs at calcaneal insertion mid substance

Question 83

83. A long winded stem about a patient presenting with ankle pain. Which of the following is included in the Ottowa ankle rules as a indication for x-ray

a. immediately non weight bearing post event and unable to weight bear 4 steps in the emergency department
b. brusing over either malleoli
c. unable to dorsiflex more than 45 degrees P;
d. anterior joint line swelling
e. ankle joint crepitus

Answer 83

a. immediately non weight bearing post event and unable to weight bear 4 steps in the emergency department plus tenderness in the malleolar zones – tips and posterior aspects of the malleoli.

Question 84

84. Regarding spinal fractures, which is FALSE
    a. 5% of spinal injuries have fractures at non-contiguous levels
    b. cervical anterior teardrop fractures are associated with ventral cord injury
    c. Chance fractures are almost universally associated with neurological deficit
    d. limbus vertebrae are most common in the lumbar spine at the anterosuperior endplate

Answer 84

c. Chance fractures are almost universally associated with neurological deficit

Question 85

85. 21 year old male in a MVA has fractures involving the zygomaticotemporal, zygomaticofrontal and zygomaticomaxillary regions as well as the lateral maxillary sinus wall. What is the best description of this injury?
    a. tripod fracture
    b. nasoethmoidal fracture
    c. le fort 1
    d. le fort 2
    e. le fort 3

Answer 85

a. tripod fracture best description actually zygomaticomaxillary complex (ZMC) fracture but whatevs.

Question 86

86. Regarding cortical desmoid, which is TRUE
    a. arises from the posterior medial femoral epicondyle (not condyle, typo vs significant?)
    b. causes pain
    c. does not have a periosteal reaction
    d. has no uptake on bone scan

Answer 86

a. arises from the posterior medial femoral epicondyle (not condyle, typo vs significant?) I flip flop between this and d every time I see this question

*LW:
RP states on bone scan there is an abnormal increase in activity.
Can have periostitis.
Usually asymptomatic, although can occasionally be painful.
The adductor tubercle is a bony protuberance on the medial condyle of the femur and is located superior to the medial epicondyle.

Question 87

87. Which of the following is the earliest indication of aseptic loosening in a cemented hip prosthesis?
    a. development of a lucent channel surrounding the cement, most marked in zone
    b. pedestal development
    c. thickening of the cortex adjacent to the tip of the prosthesis
    d. formation of a sclerotic line parallelling the cortex
    e. fragmentation of the cement

Answer 87

a. development of a lucent channel surrounding the cement, most marked in zone probably this one depending on what zone it was. Normal to have lucency zone 1 of acetabular component, zones 1 and 7 femoral component.