Station 1

ELEMENT FEATURE

History 9 y.o. female with headache, vomiting and visual disturbance. Presents with
seizures. Recent migrant from Asia

Imaging CT Scan Brain ± Contrast, 2 sheets

MR Brain (selected images), 1 sheet

Findings CT Brain (noncontrast)

Punctate calcifications right putamen and left occipital lobe
Vasogenic oedema around occipital lesion
CT Brain (contrast)
Focal enhancement around occipital calcific focus
No enhancement around putamen calcific focus
MRI Brain (various series)
T1: Hypointense foci corresponding to calcific foci. Mild hypointense left
occipital oedema
T2: Round hyperintense ring around occipital calcification. Hyperintense
occipital vasogenic oedema
FLAIR: Calcific lesion left occipital lobe has hypointense ring enclosing
hyperintense focus with surrounding hyperintense vasogenic oedema
(“bulls-eye” appearance). Similar appearance in right putamen lesion.
T1+Gd: Thin enhancing rim at both lesions, no central enhancement.

Likely Neurocysticercosis
Diagnosis

Differential Metastases; however, “bull’s-eye” appearance with calcification characteristic or

even pathognomonic

Approach NA

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 Station 2

ELEMENT FEATURE

History 68 year old man with nasal stuffiness for 3 months. Recent epistaxis

Imaging CT Scans with contrast enhancement

2 sheets

Findings Bulky mass posterior nasopharynx

May extend to left carotid space
Bone destruction lower clivus
Enlarged retropharyngeal node
No other cervical lymphadenopathy

Diagnosis Nasopharyngeal carcinoma

Stage T4

Differential Non-Hodgkin Lymphoma

Approach Bone windows to confirm bone involvement

MRI to evaluate skull base, perineural & intracranial spread
CT chest for lung mets

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 Station 3

ELEMENT FEATURE

History 47 y.o. male passenger in motor vehicle accident. Generalised abdominal pain.
Prominent abdominal wall seatbelt mark.

Imaging CT Scan abdomen and pelvis, 3 sheets

Findings Free intraperitoneal gas

Upper small bowel wall thickening
Concentric, diffuse
From duodenojejunal flexure to proximal jejunum in left flank
Intraperitoneal free fluid around thickened bowel
Trace of free fluid in paracolic gutters

Diagnosis Intramural haematoma of duodenojejunal flexure and upper jejunum

Small bowel perforation

Differential Nil

Approach Immediate notification of ED and/or general surgical team

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 Station 4

ELEMENT FEATURE

History 57 y.o. male. Right upper quadrant pain for 4 days. Has vomiting, diarrhoea, positive
Murphy sign. Afebrile. White cell count 21,000.

Imaging CT scan abdomen and pelvis with IV and oral contrast

3 sheets

Findings Normal gallbladder

Small hepatorenal pouch collection with gas bubbles
Approx. 3.5 x 3.5 x 4 cm
Elevated caecal base
Retrocaecal appendix
Thickened wall
Widened diameter max 1.4 cm
Periappendiceal stranding
Thickened right perirenal fascia

Diagnosis Retrocaecal appendicitis

Perforation with periappendiceal abscess in hepatorenal pouch

Differential Nil

Approach Inform surgical team immediately

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 Station 5A

ELEMENT FEATURE

History 68 y.o. male. Pain left groin and hip for 2 years, especially on weight-bearing

Imaging X-ray pelvis and left hip (2 sheets)

Findings Severe osteoarthritis left hip

Joint space narrowing
Subchondral cysts
Osteophytes
Subchondral sclerosis
Shallow acetabular roof
Femoral head flattening ? old hip dysplasia
Paget disease right hemipelvis
Right hip articular chondrocalcinosis (calcium pyrophosphate deposition
disease)

Diagnosis Left hip severe osteoarthritis (?old CPPD)

Right hip CPPD
Right pelvic Paget disease

Differential Nil

Approach NA

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 Station 5B

ELEMENT FEATURE

History 58 y.o. male. Upper lumbar back pain for 3 weeks

Imaging X-Ray upper lumbar spine AP/Lat (2 sheets)

Findings Abnormal L1 vertebral body

Erosion anteroinferior cortex
Slight narrowing L1-2 disc space
Slight retrolisthesis L1-2
Minor scoliosis convex right, probably due to muscle spasm

Diagnosis Vertebral osteomyelitis L1

(or L1-2 intervertebral septic discitis)

Differential Nil

Approach Recommend CT for further evaluation

Consider needle biopsy of disc under CT guidance

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 Station 6

ELEMENT FEATURE

History 58 y.o. female. Prior history of pancreatic carcinoma successfully resected 3 years
earlier. Presents with left hemiparesis and right visual field loss.

Imaging CT Brain with contrast (2 sheets)

MR Brain ± Gadolinium (3 sheets)

Findings CT Brain with contrast

Focal hypodensity left occipital pole
Associated gyral curvilinear enhancement
Possible similar area right high posterior parietal lobe
MRI Brain (FLAIR)
Bilateral cortical hyperintensity occipital poles
Focal hyperintensities - splenium corpus callosum, parietal and frontal
cortex biliaterally near vertex, periventricular regions both hemispheres
MRI Brain (T1 ± Contrast)
Mild cortical hyperintensity precontrast left occipital pole
Prominent gyral / sulcal enhancement over both occipital poles and right
posterior parietal cortex
Focal nodular enhancement in both parietal and left frontal cortical regions
No enhancement of callosal lesion, periventricular hyperintensities

Diagnosis Lemptomeningeal metastatic pancreatic cancer

Focal nodular cortical metastases
Chronic deep white matter ischemic changes

Differential Nil

Approach NA

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 Station 7

ELEMENT FEATURE

History 48 y.o. female migrant. Prior history of pulmonary tuberculosis. Frequent

exacerbation of dyspnoea.

Imaging HRCT Chest (2 sheets)

Findings Extensive cylindrical bronchiectasis

Both lower lobes
Cystic bronchiectasis right upper lobe
Subpleural bronchiectasis
Subpleural septal thickening RUL, RLL, Lingula, perhaps LLL
Complete collapse right middle lobe
Lingular partial atelectasis
Bronchial wall thickening
“Tree in bud” appearances in right lower lobe

Diagnosis Chronic bronchiectasis

Distribution atypical for TB, pyogenic infection
Consistent with Atypical Mycobacterium infection

Differential Idiopathic or post-viral bronchiectasis

Approach Obtain sputum cultures, esp. for atypical mycobacteria

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 Station 8

ELEMENT FEATURE

History 34 y.o. male surgeon. Pain and locking left knee for 1 year.

Imaging X-ray left knee (AP, lateral) – 2 sheets

MRI left knee – 3 sheets

Findings X-ray left knee

Narrowing lateral compartment on AP
Ossification of posterior horn of a meniscus on lateral
MRI left knee (STIR)
Focal subchondral hyperintensity posterior medial femoral condyle
Tear medial meniscal root posteriorly
MRI left knee (sag PD, T2)
Fat signal in posterior horn medial meniscus
Thinning of articular cartilage posterior medial femoral condyle
Anterior cruciate ligament tear (complete)
• Anterior shift of tibia

Likely Diagnosis Chronic ACL tear

Chronic joint instability
Medial meniscal ossicle
Overlying cartilage and subchondral injury

Differential NIL

Approach NA

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