RD7.3 | Imaging in Internal Medicine — Assignment

CLINICAL SCENARIO

A 67-year-old man with a long history of hypertension and type 2 diabetes is admitted to the Internal Medicine unit with two days of increasing breathlessness, orthopnoea and bilateral ankle swelling. On the second day of admission he suddenly develops slurred speech and weakness of the right arm and leg. While being assessed, he also reports pleuritic right-sided chest pain. He is known to have a history of heavy alcohol use, and his admission bloods show mildly deranged liver function. This case asks you to integrate imaging across four internal-medicine problems — acute stroke, suspected pulmonary embolism, heart failure and chronic liver disease — into a coherent management plan.

The patient develops sudden right-sided weakness and slurred speech. State the single most urgent imaging investigation and its primary purpose. Explain why non-contrast CT brain precedes any decision about thrombolysis, and list the early CT signs of ischaemic stroke (including the hyperdense MCA sign, loss of grey–white differentiation and the insular ribbon sign) you would actively look for. Explain when and why diffusion-weighted MRI might be added.

Describe how each of two possible CT outcomes — (a) intracranial haemorrhage, and (b) no haemorrhage with a hyperdense MCA — would directly change the immediate management pathway (thrombolysis and/or thrombectomy versus supportive/neurosurgical care). Make the image-to-decision link explicit.

Outline the structured pathway BEFORE imaging (pre-test probability using Wells/Geneva, age-adjusted D-dimer in 'unlikely' patients). Then state the first-line definitive imaging study (CTPA) and what intraluminal finding confirms PE. Explain why a normal chest radiograph cannot exclude PE, and identify which CTPA feature (RV/LV ratio >1) signals a higher-risk PE. Note one situation in this patient that might push you toward a V/Q scan instead.

Describe the role of the chest radiograph as a 'pressure gauge' in heart failure and list the staged signs (cardiomegaly with CTR >0.5 on PA film, upper-lobe diversion, Kerley B lines, bat-wing alveolar oedema, effusions). State why echocardiography is the next study and how the ejection fraction (HFrEF <40%) classifies the failure and directs therapy.

State the first-line modality for diffuse liver disease and the ultrasound signs you would expect for (a) fatty liver and (b) cirrhosis with portal hypertension. Explain when multiphasic CT/MRI is escalated to and the characteristic enhancement pattern of HCC (arterial hyperenhancement with washout). Outline the surveillance recommendation in cirrhosis (6-monthly USG ± AFP).

Bring the case together: justify the ORDER in which you would perform these investigations given competing acute problems. Explicitly address how the patient's renal function would influence the use of iodinated contrast (caution if eGFR <30) and how you would balance radiation exposure against diagnostic yield. Summarise how the integrated imaging picture changes overall management.