Station 1A

ELEMENT FEATURE

History 31 y.o. male, assaulted while intoxicated. Presents with painful

swelling left face

Imaging Facial radiographs (1 sheet)

Findings  Left orbital emphysema

 Fluid level left maxillary antrum
 Soft tissue thickening left orbital floor
Likely Diagnosis Left orbital floor fracture into maxillary antrum

Differential None

Further Imaging & CT scan facial bones and orbits

Approach Examine for entrapment of inferior rectus and infraorbital anesthesia

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 Station 1B

ELEMENT FEATURE

History 18 y.o. male, well. Pre-admission Army Medical Examination. OPG

for reporting

Imaging Orthopantomogram (1 sheet)

Findings  Displacement and malformation of left upper canine (tooth 25)

 Lobulated mass in left maxilla
 Irregular small poorly defined densities of enamel and dentin
internally
 Thin sclerotic margin
 Well-defined marginal lucency
 No well-formed toothlets or denticles
Likely Diagnosis Complex odontoma

Differential Compound odontoma (these have well-organised denticles/toothlets)

Further Imaging &

Approach

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 Station 2

ELEMENT FEATURE

History 13 y.o. boy with painless swelling in floor of mouth

Imaging Axial and coronal CT, non-contrast (1 sheet)

Findings  Oval fluid density left floor of mouth

 In sublingual space
 No submandibular duct stone
 No intralesional fat
 No solid component

Likely Diagnosis Simple ranula

Differential  Sialocoele (duct not visible posteriorly)

 Lymphangioma/cystic hygroma (wrong space)
 Teratoma (usually midline)
 Lipoma (wrong density)

Approach Measure density to confirm HU values

Can aspirate and test for amylase (diagnostic)

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 Station 3

ELEMENT FEATURE

History 48 y.o. male with migraines. Transient right lower limb weakness.
Complains of memory loss. Wife reports mood swings and change of
affect. Family history of early stroke.

Imaging MRI scans of the brain (3 sheets)

T2W, FLAIR and DWI

Findings T2W and FLAIR

 Extensive bilateral subcortical hyperintensities
 Periventricular
 Subcortical
 External capsules (suggestive)
 Temporal poles (characteristic)
 Mild atrophy
 No haemorrhage or mass effect
DWI
 Focal hyperintensity left posterior internal capsule
Likely Diagnosis CADASIL (Cerebral Autosomal Dominant Arteriopathy With
Subcortical Infarcts and Leukoencephalopathy) with left corticospinal
tract infarct

Differential Binswanger disease (no family history, older onset)

Multi-infarct dementia (no well-established infarcts, no prior history)

Further Tests Skin biopsy

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 Station 4

ELEMENT FEATURE

History 67 y.o. female. Sudden onset right arm pain 5 days after bilateral
knee replacements. Also complains of shortness of breath

Imaging CT angiogram chest and right subclavian region (2 sheets)

Findings  Filling defect right subclavian artery

 Filling defect right main pulmonary artery
 Filling defects left upper lobe, lingular and lower lobe pulmonary
arteries

Likely Diagnosis Deep vein thrombosis

Pulmonary emboli
Paradoxical embolus right arm
Patent foramen ovale

Differential Nil

Approach  Urgent vascular surgical or VIR consult re. thrombolysis or

embolectomy
 Echocardiograophy with US microbubble contrast to detect
PFO

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 Station 5

ELEMENT FEATURE

History 79 y.o. female. Acute abdominal pain and distension for 1 day. PR
bleeding.

Imaging CXR (1 sheet)

AXR (erect and supine, 2 sheets)
CT Abdomen (axial and coronal, 2 sheets)

Findings CXR
 Right mastectomy noted
AXR
 Large bowel dilatation
 Left descending colon “cutoff” with left iliac fossa soft tissue
density
CT Abdomen
 Left descending/sigmoid colon obstruction
 Left iliac fossa mass with intraluminal fat and vessels (pseudo-
kidney sign)
 Mass extends into rectum
Likely Diagnosis Descending/sigmoid colo-colic intussusception
Most likely breast cancer serosal metastasis

Differential Nil

Approach Gastrografin enema could confirm

Surgical reduction

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 Station 6

ELEMENT FEATURE

History 5 y.o. female with several weeks of epigastric pain

Imaging CXR (AP & Lat, 1 sheet)

CT Lower Chest/Upper Abdomen (1 sheet)
MR Lower Chest/Upper Abdomen (1 sheet)

Findings CXR
 Retrocardiac mass
 Right paraspinal soft tissue mass
 Abnormal left lower ribs
 Widening of intercostal spaces
CT Scan
 Large paraspinal, retrocural and retroperitoneal mass in
continuity
 Speckled calcification within mass
 Abnormal left ribs, chest wall invasion
MRI
 Mass extends into spinal canal
Likely Diagnosis Neuroblastoma

Differential Ewing sarcoma

Approach Urinary catecholamines

MIBG scan

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 Station 7

ELEMENT FEATURE

History 27 y.o. female. 29 weeks pregnant. Presents with PV bleeding and

pain for 4 days.

Imaging Pregnancy ultrasound (2 sheets)

Findings  Single fetus, 26 weeks by BPD, HC, femur length

 Charts show global growth retardation (IUGR)
 Reversed diastolic flow in umbilical artery Doppler
 MCA Doppler: normal
 Ductus venosus Doppler: abnormal with deep A wave, elevated
S/D ratio
 Retroplacental hematoma
Likely Diagnosis Placental abruption
IUGR

Differential Nil

Approach Urgent obstetric treatment; immediate risk to pregnancy

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 Station 8

ELEMENT FEATURE

History 81 y.o. female. Complains of altered gait and bilateral leg sensory
changes for 3 weeks. Lhermitte’s sign on clinical examination.

Imaging CT craniocervical junction (1 sheet)

MR brain and cervical spine (3 sheets)

Findings CT Scan
 Partly calcified soft tissue mass surrounding dens
 Widening of atlantoaxial space
MRI Scan
 Soft tissue mass around dens – low signal on T2, minimal
enhancement after Gd
 Erosion of odontoid process
 Compression of brainstem and upper cord
 Early myelomalacia at C1/2
 Marked narrowing of foramen magnum
 Patchy enhancement of dens after Gd

Likely Diagnosis Destructive atlantoaxial arthopathy with soft tissue mass

Gout (calcification, nonenhancing tophus)

Differential Rheumatoid arthritis (usually no calcification)

Pseudogout (calcification, rarely at this site)
Osteomyelitis (usually no calcification, mass > destruction in this
case, usually reverse)

Approach Blood tests for serum urate, rheumatoid factor etc.

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