100 CASES in Radiology This page intentionally left blank 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, a division of Hachette UK 338 Euston Road, London NW1 3BH http://www.hodderarnold.com © 2012 Robert Thomas, James Connelly and Christopher Burke All rights reserved. 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Please visit our website: www.hodderarnold.com 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.