Table Of Content100 CASES
in Radiology
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100 CASES
in Radiology
Robert Thomas
Specialist Registrar, Guy’s and St Thomas’ Hospital, London, UK
James Connelly
Specialist Registrar, Guy’s and St Thomas’ Hospital, London, UK
Christopher Burke
Specialist Registrar, Guy’s and St Thomas’ Hospital, London, UK
100 Cases Series Editor:
Professor P John Rees MD FRCP
Dean of Medical Undergraduate Education, King’s College London School of
Medicine at Guy’s, King’s and St Thomas’ Hospitals, London, UK
First published in Great Britain in 2012 by
Hodder Arnold, an imprint of Hodder Education, Hodder and Stoughton Ltd,
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© 2012 Robert Thomas, James Connelly and Christopher Burke
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CONTENTS
Acknowledgements viii
Case 1 Deteriorating shortness of breath in a smoker 1
Case 2 The breathless asthmatic 3
Case 3 An icy fall 5
Case 4 Difficulty swallowing 8
Case 5 A mechanical fall in an elderly patient 13
Case 6 Right upper abdominal pain 15
Case 7 Heartburn, epigastric pain and a cough 17
Case 8 Lines, catheters and tubes on a radiograph 19
Case 9 Weakness and slurring while out for a drink 23
Case 10 Back pain relieved only by aspirin 27
Case 11 A persistent cough in an ex-smoker 31
Case 12 A schoolmaster with progressive breathlessness 35
Case 13 Numb right arm 39
Case 14 Jaundice following cholecystectomy 41
Case 15 Infant with clicking hips 45
Case 16 Painful wrist after falling 47
Case 17 Constipation in woman with ovarian tumour 49
Case 18 Thirty-year-old man with headache 51
Case 19 Persistent cough 55
Case 20 Chest pain and dyspnoea 59
Case 21 Young man with neck swelling 63
Case 22 Collapse and possible seizure 67
Case 23 Premature neonate with abdominal distension 71
Case 24 Young child with painful arm 75
Case 25 Acute epigastric pain 79
Case 26 Man with atypical chest pain 83
Case 27 Young woman with shortness of breath and chest pain 85
Case 28 Chest discomfort and dyspnoea 87
Case 29 Skateboarder with a painful foot 91
Case 30 Left-sided loin pain 93
Case 31 Unable to bear weight after a cycling accident 97
Case 32 Strange bone appearance after falling 99
Case 33 Lower back pain 103
Case 34 Vomiting baby boy 105
Case 35 Painless haematuria 107
Case 36 Sudden onset weakness in an 80-year-old woman 109
Case 37 Young man with ankle pain 111
Case 38 Painful shoulder 113
Case 39 Chest pain after falling 117
Case 40 Swelling of the big toe 119
Case 41 A young man with progressive dyspnoea on exertion 121
v
100 Cases in Radiology
Case 42 Pain on deep inspiration 123
Case 43 An elbow injury 127
Case 44 Pain in the hand following a punching injury 129
Case 45 A fall on the hand and pain in the wrist 131
Case 46 Shortness of breath and pleuritic chest pain 133
Case 47 A new arrival with cough and a fever 135
Case 48 A seatbelt injury 137
Case 49 A device in the pelvis 139
Case 50 A cardiac abnormality 141
Case 51 A mirror image 143
Case 52 A distended and painful abdomen 145
Case 53 Bloody sputum and weight loss 147
Case 54 A soft fluctuant lump 149
Case 55 Abdominal distension and shifting dullness 151
Case 56 A painful hand 153
Case 57 A retired construction worker with a cough 155
Case 58 Distended abdomen and unable to pass gas 157
Case 59 Torrential haematemesis 159
Case 60 An incidental finding on chest radiograph 161
Case 61 A worried nurse in intensive care 163
Case 62 Young man with abdominal pain 165
Case 63 Skin plaques and achy hands 167
Case 64 Teaching sport can be a headache at times 171
Case 65 A chesty infant 173
Case 66 Difficulty in swallowing 175
Case 67 Pregnant woman with vomiting 177
Case 68 Infant with a head injury 181
Case 69 Abdominal distension in a woman with ovarian cancer 187
Case 70 A woman with a breast lump 190
Case 71 A rising creatinine 193
Case 72 Neck pain after falling 197
Case 73 A young man with back pain 200
Case 74 A child with an injury 205
Case 75 A renal tract abnormality 209
Case 76 Shooting leg pain following lifting 213
Case 77 A chronic productive cough 215
Case 78 General fatigue and weakness 219
Case 79 A cervical spine injury following a horse riding accident 221
Case 80 Abdominal pain and diarrhoea in a 28-year-old woman 225
Case 81 Pain in the left wrist following a fall 229
Case 82 A known case of inflammatory bowel disease 233
Case 83 A tourist from New Zealand 237
Case 84 Spontaneous nose bleeds in a young person 241
Case 85 Abdominal weight gain and distension despite dieting 245
Case 86 Left mid zone crackles 249
Case 87 Traumatic injury to a farmer’s foot 253
Case 88 An accountant with abdominal pain 257
Case 89 Pain in a woman with breast cancer 261
Case 90 Headache and visual field defects 265
Case 91 A claudicant with worsening leg pain 269
Case 92 Normal variant on a chest radiograph 273
vi
Contents
Case 93 Flank pain and haematuria 275
Case 94 Patient with an intractable headache 279
Case 95 An unwell patient with a rash 283
Case 96 Chest wall swelling and a pleural effusion 287
Case 97 Chest wall deformity in a pacemaker patient 291
Case 98 Sudden onset back pain in a 72-year-old woman 295
Case 99 Constipation and colicky abdominal pain 299
Case 100 An ankle injury 303
Index 306
vii
ACKNOWLEDGEMENTS
The authors would like to thank the following people for their help in the preparation of
the text and illustrations: Dr Elisa Perry (consultant radiologist at Guys’ and St Thomas’
Hospital), Dr Russel Houghton (consultant radiologist at Guys’ and St Thomas’ Hospital),
Dr Haran Jogeesvaran (consultant radiologist at Guys’ and St Thomas’ Hospital),
Dr Andrew McGrath (consultant interventional radiologist at Guys’ and St Thomas’
Hospital), Dr H.K. Mohan (consultant nuclear medicine physician at Guys’ and St Thomas’
Hospital) and Dr David Howlett (consultant radiologist at Eastbourne Hospital). Many of
the images were produced during the authors’ time as registrars at Guy’s and St Thomas’
Hospital. Without the support of the hospital in allowing the use of anonymized images
this book would not have been possible.
CASE 1: DETERIORATING SHORTNESS OF BREATH IN A SMOKER
History
You are asked to review a 72-year-old man on the post-take ward round. He was admit-
ted last night with increasing shortness of breath. His breathing has been getting worse
for many years now, and he notices that it is especially bad in the winter. His general
practitioner (GP) has diagnosed asthma and has been managing him at home. He recalls
having several courses of antibiotics over the last few years.
His recent problems started 3 days ago with a cough productive of green sputum. He has
felt generally unwell and his breathing has deteriorated significantly. He cannot climb
the stairs at home now and slept on the sofa last night. His GP saw him this morning and
referred him to hospital as an infective exacerbation of asthma. He continues to smoke
despite advice, and has a 50 pack-year history. There is no other relevant past medical
history. He takes a salbutamol inhaler when needed but today this was of little help.
Examination
Some blood tests were performed and a chest radiograph was requested (Figure 1.1). His
white cell count is 16.3 × 109/L, neutrophil count 89 per cent and haemoglobin 14.2 g/dL.
Figure 1.1 Chest radiograph.
Questions
• What does this radiograph show?
• What is the likely diagnosis and how can this be confirmed?
1
