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Simulator Pack
(Radiology)
nottinghamosce@googlemail.com
WARNING:
DO NOT look inside this pack unless you are the radiology station examiner in the OSCE exam
simulation
Organisers: The next page indexes the stations. Diagnoses are given on each answer sheet…
Compiled by:
Richard Hastings
Paul Lyon
Pilot version (1.0, March 2009)
Index
This OSCE simulation pack contains the following stations:
CXR1
MSK1
CXR2
MSK2
CXR3
MSK3
CXR4
MSK4
AXR1
AXR2
Note: We expect that the examiner will present two images during each 6 minute
station. If a candidate fails to pick up a diagnosis and therefore is unable the
answer management questions it is acceptable to flip to the abdominal images
(AXR1&2) for another attempt, however the overall score should be reduced by 2
marks
Station: Radiology Case: CXR 1 (Q)
Scenario
You are a junior doctor who has been asked to review a chest x-ray by the orthopaedic registrar who has been
called away to emergency theatre. It is of a 61 year old man on the orthopaedic ward who had a total knee
replacement 6 days previously. He has been making a good recovery up until today. The nurse informs you he does
not look very well at the moment and has been complaining of increasing chest discomfort since breakfast.
Station: Radiology Cases: CXR 1 (Ans.)
CXR 1 (Pulmonary embolus): 61 year old man on the orthopaedic ward who looks unwell with increasing chest
discomfort
Questions
3. The patient is started on high-flow oxygen and has had bloods taken and has had an ECG taken.
What are the next steps in the medical management of this patient? (2 marks)
4. Once the patient is stable, what further investigation would confirm the diagnosis? (1 mark)
5. In this patient, what are his major risk factors for developing this condition? (1 mark)
Answers
1. Wedge-shaped shadow in the right upper zone and an enlarged right peri-hilar region (2 marks)
2. Likely infarction of the lung which has resulted in haemorrhage or necrosis = PE (1 mark)
3. The patient already has been treated using the ABC approach, next steps include: (max 2 marks of 3)
IV morphine (1 mark)
Treatment dose subcutaneous low-molecular weight heparin (1 mark)
Can also accept IV antibiotics for infarcted lung (1 mark)
4. Chest CTPA is gold standard, V/Q scan is an alternative (1 mark)
5. Immobility due to orthopaedic surgery (1 mark)
6. TED stockings or prophylactic LMWH (1 mark)
Mark out of 8 (max 8) (<4 = fail, 5 = bare pass, 6 = fair pass, 7 = good pass, 8+ distinction)
Station: Radiology Case: MSK1 (Q)
Scenario
24 year old window fitter presents to A&E after having falling into broken glass when under the influence. There is
a deep laceration to the dorsum of his R hand.
Station: Radiology Cases: MSK 1 (Ans.)
MSK XR 1 (Scaphoid fracture): 24 year old man who has fallen onto his right hand
Questions
1. What are the two indications for imaging the hand in this presentation? (2 marks)
2. What is the commonest bony injury in a FOOSH in someone of this age group? (1 mark)
5. What would be the management and appropriate follow-up of this patient? (3 marks)
Answers
Mark out of 8 (max 8) (<4 = fail, 5 = bare pass, 6 = fair pass, 7 = good pass, 8+ distinction)
Station: Radiology Case: CXR 2
Scenario
42 year old man who presents to A&E with a decreased GCS and an open fracture of the right tibia following a
RTC. He is not able to give you his medical history. The patient has been stabilised and is on IV fluids. In addition
to the radiograph of his right tibia you order a portable CXR to eliminate haemo-/pneumo-thorax before sending
him for head CT.
Station: Radiology Cases: CXR 2 Q&A
CXR 2 (Heart transplant): 42 year old man who has been involved in a RTC with reduced GCS and unknown medical
history
Questions
1. Describe the salient features of this radiograph including important negatives (5 marks)
2. Putting these features together, what is the likely PMH & PSH of this patient? (2 marks)
3. What medication is this pt. likely to be on which may complicate his recovery and why? (1 mark)
Answers
Mark out of 8 (max 8) (<4 = fail, 5 = bare pass, 6 = fair pass, 7 = good pass, 8+ distinction)
Station: Radiology Case: MSK XR 2
Scenario
86 year old lady presents to A&E after slipping on ice, she is in a lot of pain and not mobilising.
Station: Radiology Cases: MSK XR 2 Q&A
MSK XR 2 (Fractured neck of femur): 86 year old lady who slipped on ice and has been unable to mobilise since
Questions
Answers
1. Intra-trochanteric or Garden IV fracture (1) of the neck of the left femur (1) (2 marks)
2. ABC approach:
High flow O2 via non-rebreathe mask (1 mark)
Wide-bore cannula and put up fluids (1 mark)
Take bloods FBC, U&E, clotting screen, group and save (surgical candidate) (1 mark)
Exposure – check for other associated injuries (1 mark)
Analgesia IV morphine (1 mark)
Mark out of 8 (max 8) (<4 = fail, 5 = bare pass, 6 = fair pass, 7 = good pass, 8+ distinction)
Station: Radiology Case: CXR 3
Scenario
68 year old man with known ischaemic heart disease presents to the Emergency department looking pale and
sweaty. He is clutching his chest clearly in pain and visibly short of breath.
Station: Radiology Cases: CXR 3 Q&A
CXR 3 (Acute pulmonary oedema): 68 year old who presents to A&E with chest pain and breathing difficulties
Questions
5. Given the patient is already on high flow oxygen and has had bloods taken and an ECG,
what are the next steps in the medical management of this patient? (4 marks)
Answers
1. Shows a diffuse ‘cotton wool’ shadowing & dilation of the upper lobe vessels (1 mark)
3. In this presention, given the Hx of IHD it is most likely to be acute MI / LVF (1 mark)
4. Other causes of pulmonary oedema to consider include (1 mark for any): (1 mark)
Cardiovascular – arrhythmias, mitral stenosis
ARDS
Fluid overload
Neurogenic (head injury)
5. The patient already has been treated using the ABC approach, next steps include:
IV morphine (1 mark)
IV nitrates or GTN infusion (1 mark)
IV furoseomide (1 mark)
Treatment of underlying condition e.g. ACS Rx for MI, or meds for arrhythmia (1 mark)
Mark out of 8 (max 8) (<4 = fail, 5 = bare pass, 6 = fair pass, 7 = good pass, 8+ distinction)
Station: Radiology Case: MSK XR 3
Scenario
76 year old lady presents to A&E after a fall at a nursing home complaining of pain in the left wrist. She did not
injury her head as she managed to break the fall with her hands.
Station: Radiology Cases: MSK XR 3 (Q&A)
MSK XR 3 (Colles’fracture): 76 year old who feel in the nursing home with outstretched hands
Questions
1. What is the main abnormality shown on the radiographs and what is the diagnosis? (2 marks)
2. Give the 4 cardinal features of this type of injury which can be seen radiologically? (2 marks)
Answers
1. Extension fracture of the distal radius (1) = Colles’ fracture (1) (2 marks)
3. Initially requires manipulation (reduction) under local anaesthetic (1) and backslab (1) (2 marks)
4. After 24-48 hours when the swelling has gone down a full plaster cast is required (1 mark)
Mark out of 8 (max 8) (<4 = fail, 5 = bare pass, 6 = fair pass, 7 = good pass, 8+ distinction)
Station: Radiology Case: CXR 4 (Q)
Scenario
71 year old woman who is rehabilitating on the stroke ward following a partial anterior circulatory ischaemic CVA.
Station: Radiology Cases: CXR 4 Q&A
CXR 4 (Pneumonia): 71 year old recovering from a recent stroke on the stroke ward
Questions
2. Putting these features together with the history, what is the likely diagnosis? (2 marks)
Answers
2. Likely right-sided aspiration pneumonia (1) with associated right-sided collapse (1) (2 marks)
3. IV fluids (1) and IV antibiotics (1) (consult hospital protocol) may be life-saving (2 marks)
Mark out of 8 (max 8) (<4 = fail, 5 = bare pass, 6 = fair pass, 7 = good pass, 8+ distinction)
Station: Radiology Case: MSK XR 4
Scenario
32 year old woman presents to A&E after a a RTC. She says that she used her arms against the dashboard to protect
herself. She has a swollen and tender right left elbow but no other obvious injuries.
Station: Radiology Cases: MSK XR 4 Q&A
MSK XR 4 (Elbow dislocation): 32 year old woman with swollen, tender left elbow after RTC
Questions
1. What else might you require to help you make the diagnosis? (1 mark)
Answers
3. Emergency management:
Analgesia & sedation (1 mark)
Reduction (1 mark)
Post-reduction splinting at 90 degrees of flexion (10 days instability period) (1 mark)
Mark out of 8 (max 8) (<4 = fail, 5 = bare pass, 6 = fair pass, 7 = good pass, 8+ distinction)
Station: Radiology Case: AXR 1
Scenario
Questions
2. What other type of X-ray imaging is mandatory in this case and why is it mandatory (1 mark)
4. Do you suspect a perforation has occurred in this example – justify your answer? (1 mark)
Answers
2. Erect CXR – air under the diaphragm would indicate perforation. (1 mark)
3. Adhesions, strangulated hernia, neoplasm, inflammatory bowel disease, diverticular disease. (3 marks)
4. Yes. Wriggler’s sign is present (see answer 1) – i.e. this is caused by air in the abdomen (1 mark)
5. ABC, take bloods (FBC, U+E, G+S, LFT, Glucose), erect CXR, NG tube, IV fluids, call senior. (3 marks)
Mark out of 10 (max 10) (<5 = fail, 6 = bare pass, 7 fair pass, 8 good pass, 9+ distinction)
Questions
Station: Radiology Case: AXR 2
Scenario
AXR 2 (Gallstone): 39 year old man complaining of abdominal pain after he eats
Questions
Answers
1. There is a radio-opaque mass in the region of the gallbladder, i.e. a gallstone is present (1 marks)
3. Ultrasound (1 mark)
5. RUQ pain & jaundice (1), fever signifies ascending cholangitis (1) (2 marks)