First FRCR Anatomy Practice Cases Constantinos Tingerides MBBS BSc MRCS Radiology Registrar, Leeds Radiology Academy, UK Ashley Uttley MBBS BSc Radiology Registrar, Leeds Radiology Academy, UK David Minks MBBS BSc Radiology Registrar, Leeds Radiology Academy, UK Claire Exley MBBS FRCR Consultant Radiologist Mid Yorkshire Hospitals NHS Trust, UK London • St Louis • Panama City • New Delhi © 2013 JP Medical Ltd. Published by JP Medical Ltd 83 Victoria Street, London, SW1H 0HW, UK Tel: +44 (0)20 3170 8910 Fax: +44 (0)20 3008 6180 Email: [email protected] Web: www.jpmedpub.com The rights of Constantinos Tingerides, Ashley Uttley, David Minks and Claire Exley to be identified as authors of this work have been asserted by them in accordance with the Copyright, Designs and patents Act 1988. All rights reserved. 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However readers are advised to check the most current information available on procedures included or from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from or related to use the material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. ISBN: 978-1-907816-37-6 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress JP Medical Ltd is a subsidiary of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India Publisher: Richard Furn Commissioning Editor: Hannah Applin Senior Editorial Assistant: Katrina Rimmer Design: Designers Collective Ltd Typeset, printed and bound in India. Preface In 2010, the Royal College of Radiologists introduced the radiological anatomy module into the First FRCR exam. The module is designed to test a candidate’s knowledge of radiological anatomy, as demonstrated in various different modalities and planes. This book is specifically designed as a tool to help candidates revising for it. The book is a compilation of over 200 images, which provide an excellent demonstration of human anatomy, using a wide range of different radiological investigations. Each case is followed by descriptive text discussing the salient points that can be taken from the case, as well as hints and tips to improve exam success. Where appropriate, artworks are included to help explain the anatomy that is being demonstrated. The images are presented in a similar format to those in the exam, allowing readers to become familiar with the exam structure. Each chapter focuses on a single anatomical area matched to the syllabus, allowing readers to consolidate knowledge as they progress through the book. Once the main chapters have been worked through, there are two practice papers at the end for self-assessment. Each of these papers comprises 20 cases to be answered within 75 minutes, with further explanatory answers and references to the main chapters. These practice papers allow readers to test knowledge and practise timings before the real exam. This book is an excellent revision tool to help trainees develop confidence and improve technique for the First FRCR Anatomy module. It provides a wide variety of images and a thorough grounding for candidates preparing to sit the exam. Constantinos Tingerides Ashley Uttley David Minks Claire Exley May 2012 v Contents Preface v Exam revision hints and tips ix Chapter 1 Head and neck 1 Brain 2 Face and neck 21 Skull 55 Answers 64 Chapter 2 Chest 109 Cardiac and vascular 110 Bronchopulmonary 128 Chest wall and diaphragm 135 Breast 142 Answers 143 Chapter 3 Abdomen and pelvis 165 Bowel 166 Upper abdominal viscera 180 Abdominal wall 187 Spaces and planes 193 Genitourinary 198 Gynaecology 206 Vascular supply and lymph node groups 213 Answers 224 Chapter 4 Musculoskeletal system 265 Lower limb 266 Spine 284 Upper limb 297 Answers 311 Chapter 5 Practice Paper 1 341 Cases 342 Answers 362 vii Contents Chapter 6 Practice Paper 2 369 Cases 370 Answers 390 Index 397 viii Exam revision hints and tips The exam The First FRCR anatomy module comprises 20 cases, with five questions presented in each case. The exam lasts for 75 minutes. The cases are viewed on an individual computer work station, with a mouse to navigate between the cases and a question booklet to record answers. Details of the viewing software and sample cases can be found on the Royal College’s website (http://www.rcr. ac.uk). What can you do to prepare? One of the most important methods to prepare for the anatomy module is to gain a breadth of experience of normal images. An understanding of normal anatomy as seen in different modalities and in different planes is essential. Testing yourself during normal day-to-day practice is a good way to develop knowledge and understanding. There are various ‘classic’ images that can be found in anatomy atlases and are important when studying for the exam. It is worthwhile learning the details of these anatomical sections, since they demonstrate the relationship between structures and are likely to appear in the exam. An understanding of anatomical relationships is the first step in learning radiological anatomy. However, knowledge of the imaging acquisition process will help to build on this and will greatly enhance the understanding of how anatomy is demonstrated radiologically. It is important not only to understand the relationship between anatomical structures and their surroundings, but also how they appear on different modalities and how they enhance. This background knowledge can be invaluable in the exam. For example, recognising whether an image has been acquired in the arterial or venous phase, or whether an image is T1 or T2 weighted can be very helpful when defining anatomy. When comparing the appearance of structures on different modalities, it is also worthwhile learning how the density, signal and echogenicity compare between neighbouring structures, for example that the liver typically appears slightly more dense than the spleen, or that it is usually more echogenic than the neighbouring renal cortex. To prepare for the exam, it can also be helpful to attend a revision course specifically designed for this exam. Courses can consolidate learning and offer a simulated exam environment to practise timings and technique. It is important to practise mock exams before the real one, since they provide an idea of how long is needed to complete the exam and will help you to manage time appropriately. If you perform well in a simulated exam environment, it will improve your confidence when sitting the real exam. In the exam Make sure you read the questions accurately and identify the labels properly. Do not assume that the labels A to E will be placed in the same order on each case. Sometimes they will go clockwise around the image and on other occasions they go anticlockwise – it is not worth losing marks by putting the right answer in the wrong place in your answer booklet. There may be extra information on the image, for example side markers – pay attention to these, since they can provide extra detail. ix Exam revision hints and tips Put as much detail into the answer as you can, while maintaining accuracy. It is important to add ‘left’ and ‘right’ to answers when appropriate, since this can contribute significantly to the mark. When labelling a structure, ask yourself whether there could be any more detail in the answer. For example, if labelling the aorta, add more detail by describing which part of the aorta is indicated, i.e. ascending, descending thoracic or abdominal. Good luck. We hope that you find this book a useful tool in your preparation for the anatomy exam! x Chapter 1 Head and neck Brain Cases 1.1–1.19 2 Face and neck Cases 1.20–1.53 21 Skull Cases 1.54–1.62 55 Answers 64