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100 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, 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. Apart from any use permitted under UK copyright law, this publication may only be reproduced, stored or transmitted, in any form, or by any means with prior permission in writing of the publishers or in the case of reprographic production in accordance with the terms of licences issued by the Copyright Licensing Agency. In the United Kingdom such licences are issued by the Copyright Licensing Agency: Saffron House, 6–10 Kirby Street, London EC1N 8TS.
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A catalogue record for this book is available from the British Library
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A catalog record for this book is available from the Library of Congress
ISBN-13 978-1-4441-2331-9
1 2 3 4 5 6 7 8 9 10 |
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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 admitted 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