Consultant Diagnostic Radiology oral assessment prep

Knowledge: The ultrasound findings are diagnostic of an ileocolic intussusception, with the target or doughnut sign in transverse section and the pseudokidney sign longitudinally, and I would document the size, location and the presence of a lead point.

Management: Before the procedure I would ensure the child is properly resuscitated with intravenous access and fluids, that the surgical team is aware and available in the hospital, and that a nurse and a paediatric-competent assistant are present with size-appropriate resuscitation equipment.

Ethics and communication: I would obtain consent from the parents through a professional medical interpreter, not through a family member or a bilingual porter, and I would cover the realistic success rate, the perforation risk of roughly one per cent or less, the recurrence risk, the use of radiation, and the alternative of primary surgery.

Reference: ACR-SPR Practice Parameter for the Performance of Fluoroscopic and Ultrasound-Guided Reduction of Intussusception in Children, 2021; ESPR and Image Gently paediatric fluoroscopy dose guidance

Knowledge: This is a severe acute anaphylactoid reaction to iodinated contrast, defined by involvement of more than one organ system with cardiovascular and respiratory compromise, and it must be treated as anaphylaxis regardless of the fact that it is not classically IgE-mediated. The features that make it severe rather than moderate are the hypotension with tachycardia and the bronchospasm, and her asthma is a recognised risk factor for a more severe respiratory reaction.

Management: I would stop the injection, leave the cannula in place, call for the resuscitation trolley and the arrest team, and give adrenaline 0.5 mg of the 1 in 1000 preparation, which is 0.5 mL, intramuscularly into the anterolateral thigh, repeating every 5 minutes if there is no response. Simultaneously I would give high-flow oxygen, lie her flat with the legs elevated, and run a rapid intravenous crystalloid bolus of 500 to 1000 mL, since distributive shock here is largely volume responsive.

Ethics and communication: I would speak to the patient myself once she is stable, explain in plain language exactly what happened, that it was a reaction to the contrast agent and not something she did wrong, and answer her questions without minimising the seriousness of the event.

Reference: ACR Manual on Contrast Media, 2025 edition; ESUR Contrast Media Safety Committee Guidelines version 10.0, 2018; Resuscitation Council anaphylaxis guidelines, 2021

Knowledge: Pseudoprogression is a genuine phenomenon on checkpoint inhibitors, in which immune cell infiltration causes lesions to enlarge or new lesions to appear before subsequent response, but it is uncommon, occurring in the order of five to ten per cent in melanoma, and it cannot be diagnosed from a single time point.

Management: I would report the study as it is: new and enlarging FDG-avid disease consistent with progression, meeting criteria for unconfirmed progressive disease under iRECIST, with a clear statement that pseudoprogression cannot be excluded on a single time point and that confirmation would require repeat imaging in four to eight weeks if the patient is clinically stable enough to wait.

Ethics and communication: I would decline, courteously but firmly, to describe the findings as pseudoprogression, because writing a report to manage a family's emotions rather than to describe the evidence is a falsification of the medical record and would ultimately harm the patient by delaying honest planning.

Reference: Seymour et al, iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics, Lancet Oncology, 2017; Boellaard et al, EANM FDG PET/CT tumour imaging guidelines version 2.0, 2015

Knowledge: The immediate clinical issue is a patient with an untreated aneurysmal subarachnoid haemorrhage at home, in the window where rebleeding risk is highest in the first 24 hours and carries a very high mortality, so patient recall is the emergency, not the governance.

Management: My first action is to recall the patient: I would telephone the emergency consultant immediately, ensure the patient is contacted directly by phone and told to return by ambulance, and if she cannot be reached I would escalate through the hospital's patient recall process using next of kin and general practitioner contacts. On her return she needs urgent neurosurgical referral, CT angiography for an aneurysm, blood pressure control and nimodipine, with lumbar puncture for xanthochromia only if the CT were genuinely negative beyond the six-hour window.

Ethics and communication: Duty of candour applies to the hospital and to me: the patient and her family must be told openly that the overnight report missed the haemorrhage, that this delayed her diagnosis, and what is being done, and this conversation should not wait until the governance process concludes.

Reference: RCR Standards for the Provision of Teleradiology within the United Kingdom, 2016; ACR-ESR white paper on teleradiology and the ESR position on cross-border reporting; RCR Standards for Radiology Events and Learning, 2021