OSCE

1
• Identify the exam
• How will you conduct the
study?
 POSTOPERATIVE (T-TUBE) CHOLANGIOGRAPHY
Indications and filled with contrast medium (e.g. a butterfly needle). After
1. To exclude biliary tract calculi, where (a) operative cholangiography all air bubbles have been expelled, the needle is inserted into
was not performed, or (b) the results of operative cholangiography the tubing between the patient and the clamp. The injection is
are not satisfactory or are suspect made under fluoroscopic control, the total volume depending
2. Assessment of biliary leaks following biliary surgery on duct filling. In the case of recent biliary anastomosis (i.e. liver
Contraindications transplant), only a small volume of contrast (approximately 10 mL),
• None. gently injected, is required.
Contrast Medium Images
• HOCM or LOCM 150 mg I mL–1; 20–30 mL. Intermittent fluoroscopic ‘grab’ images during filling are frequently
• Equipment useful. PA and oblique exposures when there is satisfactory
• Fluoroscopy unit with spot image device. opacification of the biliary system.
Patient Preparation Aftercare
• Antibiotics may be considered if previous cholangitis or if • None.
immunosuppressed (e.g. liver transplant). Complications
Preliminary Image Due to the contrast medium
• Coned supine PA of the right side of the abdomen. • The biliary ducts do absorb contrast medium, and cholangio-
Technique venous reflux can occur with high injection pressures. Adverse
1. The examination is performed on or about the 10th postoperative reactions are therefore possible, but the incidence is small.
day, prior to removal of the T-tube. Due to the technique
2. The patient lies supine on the x-ray table. The drainage tube is • Injection of contrast medium under high pressure into an
clamped off near to the patient and cleaned thoroughly with obstructed
antiseptic. • biliary tract can produce septicaemia.
3. A 23G needle, extension tubing, and 20 mL syringe are assembled
 2
• Identify the instruments
C
• Explain steps of Seldinger
B
technique

D E
 Seldinger technique

a. Surgical blade
b. Trocha and stilette
c. Pigtail catheter
d. Introducer sheath
e. Guide wire
A. Nephrostomy tube
• Relieve obstruction
• Drainage of pyonephritis
• Prior to percutaneous nephrolithiasis
• Urinary diversion (to allow closure in ureteric or bladder
fistulae)
B. Coaxial biopsy gun
• Fine needle aspiration
• Core biopsy
• Seldinger set
• Guide wire
• Dilator
• Amplatz catheter
Identify the following instruments
• Straight catheter
• Pigtail catheter
• Cobra-head catheter
• Simmons catheter
State one indication for any two of the
instruments
• Diagnostic – Renal artery stenosis
• Intervention – injecting embolic agent
List 5 complications of the procedure in
which they are used
• Arrythmias
• Injury to vessels
• Hypersensitivity reactions
• Access site; Haematoma, pseudo
aneurysm, A-V fistula
• Infection
 5
• Identify the exam
CT Colonoscopy/Virtual
colonoscopy
• How will you prepare the
patient?
 CT colonoscopy
• Appropriate counselling or education to allay patients anxiety.
METHODS
• Essentially 2 ways:
1. CTC with faecal tagging (1 or 2 tagging agents)
• Faecal tagging after a standard bowel preparation
• Faecal tagging alone with no formal bowel preparation
• Tagging agent given orally
2. CTC without faecal tagging
2 days prior to scan low residue diet;
• Low fibre diet that decreases stool volume,
• avoidance of all fruits & vegetables .
A day prior to exam;
• 8am; clear liquid diet as breakfast.
• 11am;ducolax (bisacodyl) 10mg (2tabs) first dose.
• 8pm; 1st tagging agent-250ml 2% Baso4, tags faecal (stool) matter.
• Repeat dulcolax 10mg.
• 11pm; 2nd tagging agent-30mls gastrograffin, tags fluid. Good oral hydration maintained until midnight.
On exam day patient comes in the morning, by 8-10am exam is carried out.
 6
• Skill Demonstration station

• Perform Popliteal vein Doppler USS exam in a patient

being evaluated for DVT
 7
• A patient was sent to the Radiology Department with a
working diagnosis of ureteric calculus

• List the CT protocols

 CT protocols
• No specific patient preparation required, but patient should
remain well hydrated
• Unenhanced CT - KUB
• Scanogram from the hemidiaphragms to the symphysis pubis
• Scanning range from top of the kidneys to the symphysis
pubis
• Collimation 1.2mm/slice thickness
• Slice thickness-1.0mm
• 3mm multiplanar reconstruction
• Scans are acquired in arrested respiration
 8
• Identify the instrument
Biopsy gun

• How will you counsel a

25 year old lady sent to
the Radiology Dept for
breast lump biopsy
 9
• Identify the instrument
Hysterosalphingography
catheter
• How will you perform HSG
exam?
What procedure are these equipments
used for?
• Hysterosalphingography
Name the instruments and state their
uses
• Cusco speculum – for assessing the
cervix
• Vulsellum – for grabbing & stabilizing
the cervix
• Margolin’s cannula – for cervical
cannulation
• Sponge forcep – For cleaning the
patient
• Kidney dish/Gallipot – for keeping
antiseptics/gauze
State 1 complication of the procedure
• Pain
 10
• Identify the instruments

• How will you protect

yourself from ionizing
radiation in a fluoroscopy
unit?
• Thyroid shield
• Thermoluminescence dosimeter
• Lead goggle
• Geiger Muller counter

Protection during fluoroscopy

• Thyroid shield or a pull-down lead glass
• Reduce screening time
• Palpating patients should be on the side opposite the tube
• Drapes attached to the lower edge of the image intensifier
• Increased distance if possible – inverse square law
 5
D
A
B C
• Identify
labels A-E. 1
mk each

E
 9
• What technique is this? 1mk
• What is the route of contrast
administration?1mk
• List 1 indication for technique
1mk
• List 1 contraindication to it 1mk
• Name 1 common complication
of technique 1mk
 10
• What technique is this? 1mk
• What plane is this? 1mk
• List 1 indication for it 1mk
• List 2 other useful
supplementary windows
2mks
 8
• Identity a-c ½ mk each
• In what position was the
image taken ½mk
• List 4 important things on
C the trolley for this
procedure ½ mk each
• Name the procedure 1mk
B

A
 3
• A 60 year old diabetic returned from Europe with
cough and difficulty in breathing. The working
diagnosis is that of COVID 19.

• List the CT protocol

COVID-19 CT CHEST protocol
• A single-phase, non-contrast chest CT however, direct post-contrast arterial
phase CT can be performed in suspected pulmonary embolism
• low-dose CT acquisition at less than or equal to 100 kV and low tube current
• When possible, chest CT must be performed with an inspiratory breath-
hold, extending from the lung apex to the lung base.
• Protocols with faster gantry rotation time (0.5 s or less) and higher pitch
values (greater than 1:1)
• While thin sections (less than or equal to 1.5 mm) are optimal for assessing
pulmonary opacities, for patients with trouble holding the breath and higher
probability of motion artifacts, thicker sections may be optimal on older
scanners where thin sections require longer scan times.
• When available, iterative reconstruction techniques should be used so that
lower radiation doses can be applied without compromising diagnostic
quality.
 4
• A 50 year old HTN/DM patient presented with left sided
hemiplagia of sudden onset. CT scan done 3 hours after
onset was normal.

• Discuss the MRI protocol

 MRI stroke protocol
• Scan range from base of skull to the vertex
• Localizer
• Slice thickness – 0.5-1mm
• T1 (axial, coronal sagittal) – for detailed anatomy
• T1 + C - useful for detection of pathologies
• T2(axial, coronal, sagittal) – used mostly to demonstrate demyelination.
• Flair sequences (sagittal/coronal) – provides very good contrast resolution in the detection
of demyelinating plaques, infarcts and also periventricular pathology contrast with dark CSF
• SWI/Gre T2 – sensitivity to susceptibility effect makes them very sensitive to the presence
of blood products.
• DWI/ADC (axial) – examines free movement of water molecule at cellular level. In acute
infarct cytotoxic oedema prevents free movement of water(hyperintense on DWI,
hypointense on ADC)
• MRA (TOF, Phased contrast, Contrast enhanced – axial, coronal, sagittal MIP) – for
assessment of intergrity of blood vessels, flow rate and perfusion
• Functional MRI
 Carotid artery USS
• The patient lies supine, with their neck a little extended by placing a pillow under their
shoulders.
• Some patients may not be able to lie supine; if this is the case they can usually be examined
adequately in a sitting position.
• The examiner can sit beside the patient’s thorax and scan the neck from this position, or sit at
the patient’s head and scan the neck from this location
• A high-frequency transducer (7–14 MHz) is used and the examination starts with a transverse
scan of the carotid artery from as low in the neck as possible, to as high in the neck as possible
behind the angle of the mandible.
• Colour Doppler is then activated and the vessels are examined in the longitudinal plane, again
from the lower neck upwards.
• PSV measurement are obtained using spectral Doppler from the upper common carotid artery
2–3 cm below the bifurcation; the internal carotid artery from 1 to 2 cm above the bulb, or as
high as possible; and from the lower external carotid artery.
• For routine measurements the sample volume is set at about one-third of the total diameter
and placed in the centre of the vessel in order to avoid the natural turbulence at the edge of
the lumen and ‘wall thump’ from inclusion of the vessel wall in the sample volume.
 Carotid artery USS
• The Doppler angle is kept as low as possible, ideally in the range 45–60; it is
good practice to try to keep to a specific angle, such as 55 or 60.
• The machine settings should be set to give a clear, uncluttered image of the
vessel wall and the position of the transducer adjusted to show the
characteristic double-line appearance of the vessel wall.
• The image should be magnified as much as possible to make the measurement
easier to perform. The intima-medial thickness (IMT) is best demonstrated in
the upper common carotid artery on the posterior wall 1–2 cm below the
bifurcation where the vessel is usually at right angles to the ultrasound beam.
• The internal carotid artery is more difficult to assess as the vessel slopes
obliquely away from the transducer face in many cases. A minimum of three
measurements over a 1 cm segment of the upper CCA are taken.
IMT measurement Vertebral artery and vein
 The ECA and ICA
THE EXTERNAL CAROTID ARTERY
• Branches present
• Anterior position
Waveform characteristics:
• High resistance pattern with relatively little diastolic flow
• Appears more pulsatile on colour Doppler
• Dichrotic notch is more prominent
• Positive ‘temporal tap’ (tapping the superficial temporal artery by a finger as it passes
over the zygoma will produce rapid, clear fluctuations in the waveform in the ECA,
whereas there is generally little or no effect in the ipsilateral CCA or ICA)
THE INTERNAL CAROTID ARTERY
• The other branch of the bifurcation
• Bulb at origin
• Posterior position and course angled posteriorly
• Less pulsatile waveform on colour Doppler with relatively high diastolic flow
 Vertebral arteries
• The vertebral arteries are most easily located by placing the transducer
longitudinally over the common carotid artery and angling it medially so that
the vertebral bodies are identified
• The transducer is then rotated laterally so that the transverse processes of
the vertebrae and the spaces between them are visualised, the vertebral
artery and vein may then be seen in these gaps.
• If the vertebral artery cannot be identified in the vertebral canal, it may be
looked for in the lower neck as it passes backwards from the subclavian
artery towards C6; or in the upper neck behind the mastoid process as it
passes around the atlas (C1) and into the foramen magnum.
• Colour Doppler makes assessment of flow direction in the vertebral arteries
straightforward. They should have the same colour as the common carotid
artery in front of them.
What modality is this?
• Retrograde pyelourethrography
List 2 indications
• Demonstration of the site and nature of
an obstructive lesion
• Demonstration of the pelvicalyceal
system and potential urothelial
abnormalities after previous
indeterminate imaging
List 1 complication
• Damage or perforation of the ureters or
renal pelvis
1. There are multiple linear vertically oriented metallic
dense opacitities projected anterolateral to the body of
the demonstrated lumbar vertebra
The tips of the metallic dense opacities are seen to
converge superiorly and are divergent inferiorly.
2. Deep venous thrombosis
3. IVC filter insitu
1. Conventional Sialography
Technique
• Patient positioning
• Instruments
Technique proper
• Visualizing the orifice of the parotid duct adjacent to the 2nd upper molar
• Sialogogue (citiric acid) is given if ductal orifice is not visualized
• The orifice is dilated with silver wire probe and cannular or polythene catheter
• 2mls of contrast is injected and injection terminated whenever the patient complains of pain
2. Films: preliminary
• Immediate – during injection
• Post secretory
• Injection repeated after 5mins
3. Complications
• Pain
• Infection
• Injury to the duct
What modality is this?
• Conventional sialography (parotid gland
List 3 indications
• Sialiectasis
• Sialithiasis
• Sialiadenitis
• to guide endoluminal interventional
procedures
What are the other types of this
modality?
• MR sialography
• CT sialography
• Sialoscintigraphy
• Greeting the patient
• Explaining the procedure to the patient
• Patient positioning – supine with the neck extended
• Application of coupling agent
• Scanning of both thyroid lobes in longitudinal and transverse planes
and measuring the volume AP x L x W
• Isthmus imaged in transverse scan as it crosses anterior to the trachea
• Demonstrating retrosternal extension by angling the probe downward
and scanning during swallowing may enable the lowest extent of the
thyroid
• Demonstrating the surrounding vascular channels
• Doppler application
• Aftercare, cleaning the patient
 Mention 1 use of the following A - E
• Hydrocortisone
• Metrochlopromide
• Diazepam
• Adrenaline
• Atropine
Name the following equipment
• Curvilinear
• Linear
• Endocavitary
• Intrarectal/biplanar

List at least 1 applicaton for each

• Deep structures - Abdominal uss
• Superficial structures – Thyroid
• Endovaginal – tubo-ovarian pathology
What imaging modality is this?
• MRI fibre tractography

What is it used for?

• Fibre tractography (FT) is a 3D
reconstruction technique to
assess neural tracts using data collected
by diffusion tensor imaging.
• Identify the item
• State its uses
• State a possible complication that
could arise from its use
 1.1 - Identify the above examination
Percutaneous Transhepatic Cholangiography (PTC) (1.5marks)
1.2 - Mention 2 indications for the above examination (3marks)
a. Cholestatic jaundice, to confirm or exclude extrahepatic bile duct
obstruction. b. Prior to therapeutic intervention, e.g. biliary drainage procedure.
1.3 - Name the object marked with arrow. (1.5marks)
Chiba Needle
1.4 - List 4 complications of this examination (4marks)
– Due to the contrast medium: - Allergic/idiosyncratic reactions.
– Due to the technique: Local : - 1. Puncture of extrahepatic structures, 2. Intrathoracic injection, 3.
Cholangitis, 4. Bile leakage - may lead to biliary peritonitis (incidence 0.5%). More likely if the ducts are
under pressure and if there are multiple puncture attempts. Less likely if a drainage catheter is left in situ
prior to surgery. 5. Subphrenic abscess 6. Haemorrhage, 7. Shock - owing to injection into the region of
the coeliac plexus. Generalized : - Bacteraemia, septicaemia and endotoxic shock. The likelihood of
sepsis is greatest in the presence of choledocholithiasis because of the higher incidence of pre-existing
infected bile
 BARIUM MEAL EXAMINATION
FIGURE A FIGURE B

X
Y
• 2.1 – In Figure A: What is the difference in terms of position of the lesions shown with
arrows and those with arrow-heads? (4marks)
– Arrows: radiolucent filling defects surrounded by ring of barium on non-dependent stomach wall.
– Arrow heads: radiolucent filling defects with internal linear streaks and outer ring of barium on
dependent stomach wall.
• 2.2 – In Figure B: What is the patient’s position on this view? (2marks)
– Supine oblique

• 2.3 – Name the structures marked X and Y on Figure B. (4marks)

– X = 2nd part of the duodenum (C-loop); Y = 3rd part of the duodenum.
 A B
C

A
D
• 3.1 – Identify the above examination.
(2marks)
– Transcranial Doppler Imaging (TCDI)
• 3.2 – Name the structures labelled A, B and C.
(6marks)
– A = Doppler sampling gate; B = Colour Doppler box; C = Brainstem (cerebral peduncles).
• 3.3 - Looking at object A and trace D, state the exact position of object A. (2marks)
– Bifurcation of terminal internal carotid artery (MCA/ACA Junction)
 A

C
• 4.1 – Identify the above examination (2marks)
– First trimester uterine ultrasound scan
• 4.2 – Name the structure marked in between the cursors (2marks)
– Embryo
• 4.3 – Name the structures marked A, B and C (6marks)
– A = Decidua basalis; B = Secondary Yolk sac; C = Decidua capsularis
 A

B
• 5.1 – Identify the above examination. (2marks)
• Percutaneous pulmonary digital subtraction angiography (DSA)
• 5.2 – Mention 2 indications for this study. (4marks)
• Demonstration of Pulmonary embolism
• Demonstration of pulmonary vascular anomaly, eg. AVM
• 5.3 – Identify the structures labelled A and B. (4marks)
• A = Pig tail catheter; B = Right main pulmonary artery.
 tudy

• 6.1 - List 3 equipment needed to perform the above study. (3marks)

• Skull radiography unit; Lacrimal dilator; Lacrimal cannula
• 6.2 – Mention 4 complications that may arise from the conduct of the
above procedure. (4marks)
• Pain, Infection, Ductular orifice damage, Ductular rupture.
• 6.3 – State 3 important radiographic films/views needed to complete the
above examination. (3marks)
• Post secretory/sialogogue film, Lateral view, Lateral oblique view,
• 7.1 – Identify the above examination. (2marks)
• Cavernosography
• 7.2 – State 2 indications for the performance of the above study.
(4marks)
• Erectile dysfunction secondary to suspected penile venous leakage
• Erectile dysfunction secondary to suspected penile arterial inflow insufficiency
• 7.3 - Mention one other non-invasive complementary imaging test needed to
complete the above study. (1mark)
– Penile duplex Doppler ultrasound scan.
• 7.4 – State one useful abnormal diagnostic finding in relation to this study on the
imaging test mentioned in 7.3 above. (Any one, 3marks)
– Pointer to arterial insufficiency = Failure of the arterial peak systolic peak to reach
35cm/sec, non-sharp (blunted) PS peak.
– Pointer to penile venous leakage = Persistent forward venous flow above the base line
with high end diastolic velocity.
 A

B B

• 8.1 – Name the above study and mention 3 indications and 2 contraindications for the conduct of the
above study. (1mark each = Total of 6marks)
• STUDY = Inferior venacavography for IVC filter placement (Digital unsubtracted and subtracted
modes)
• INDICATIONS = To demonstrate the site of a venous obstruction, displacement or infiltration; To
demonstrate congenital abnormality of the venous system; Inferior venacavography for IVC
filter insertion.
• CONTRAINDICATIONS = Lack of venous access; Complete IVC thrombosis; Severe and
uncorrectable coagulopathy.
• 8.2 – Identify the structures marked A and B. (2marks)
• A = Inferior venacavogram (Digital unsubtracted and subtracted modes)
• B = IVC filter in-situ (Digital unsubtracted and subtracted modes)
• 8.3 – Give 2 reasons why A must always be obtained in this study. (2marks)
» To assess the size, patency and anatomy of the IVC before filter placement.
 B

D
A
C

• 9.1 – Identify the above examination.

(1mark)
• Digital subtraction selective renal arteriography
• 9.2 – Mention 2 indications for the conduct of this study.
(2marks)
• Renal trauma; Pretransplant assessment; Renal tumour assessment; Assessmt of distal renal art disease eg FMD.
• 9.3 – Name the structures labelled A, B, C, D.
(4marks)
• A = Renal selective catheter (SIM – 1)
• B = Main renal artery
• C = Interlobar artery
• D = Interlobular artery
 C
D
B

E A

• 10.1 – Name the structures labelled A, B, C, D, E (5marks)

• A = Left subclavian artery, B = Left vertebral artery, C = Left carotid siphon, D = Right vertebral artery, D = Right
internal mammary artery.
• 10.2 – Mention 10 complications that may be encountered during the conduct of this
procedure. (5marks)
• Due to contrast medium: Anaphylactoid reaction
• Due to procedure:
– LOCAL(Puncture site) = Haematoma/Haemorrhage, Infection, Pseudoaneurysm, Arteriovenous fistula, Arterial dissection;
– DISTANT = Distant embolus, Artheroembolus, Air embolus, Cotton fibre embolus, Catheter knotting, Catheter impaction,
Guide wire breakage, Bacteraemia.
 Film Sizes
Standard “inches”: Metric:
• 8” x 10” • 18cm x 24cm
• 10” x 12” • 24cm x 30cm
• 11” x 14” • 30cm x 35cm
• 14” x 17” • 35cm x 43cm