Pimp Notes vol. 2

How you feel when you dominate every pimp question thrown at you

Over the last four years, I’ve started a small collection of questions that I repeatedly gotten pimped on by various attendings from many different services. We at QuickHits decided to empower the med student by starting a weekly post with a number of high yield questions along with some you-know-it-or-you-don’t type questions that you can impress some attendings with.

We hope this allows our readers to continue to build a thorough knowledge base. Give a shot at this week’s volume of pimp notes.

I’m on my radiology rotation right now, so this post is heavy on radiology pimping. I picked most things that are very relevant to the ED. Thanks to Radiopaedia for most of the images!

See how many you get right. Leave some comments!:

  • Diagnosis of this pelvic ultrasound finding (click for larger view):

  • What  are the five basic radiographic densities from least to most dense?
  • How can you assess for proptosis from a head CT?
  • Diagnosis? (click for larger view):
  • What is Rigler’s sign?
  • What is the x-ray measurements used to assess if bowel is dilated?
  • Diagnosis? What is the significance of this finding? click for larger size image


Diagnosis of pelvic ultrasound finding =

  • Transvaginal image of ectopic pregnancy demonstrates “ring of fire” appearance with prominent blood flow around the ring of the ectopic pregnancy.
  • Note that this “ring of fire” can be seen with both an ectopic pregnancy, as in this case, and in a hemorrhagic cyst
  • Source: Reviews and Commentary – Review for Residents: Deborah Levine
    Ectopic PregnancyRadiology November 2007 245:2 385-397;doi:10.1148/radiol.2452061031

Click for Emergency ultrasound OB/GYN imaging examples

Radiographic densities

  • Air < Blood < Soft tissue < Bone < Muscle
  • more thorough: Air < CSF < blood < hematoma < soft tissue < muscle < bone < metal

Proptosis from head CT

  • ” Extent of proptosis can be assessed by the technique described by Hilal and Trokel. Using a mid-orbital axial scan, a straight line is drawn between the anterior margins of the zygomatic processes. Normally it intersects the globe at or behind the equator. The distance between the anterior cornea and the inter-zygomatic line is normally 21mm or less. Asymmetry greater than 2mm or value above 21mm indicates proptosis.
  • Source = Sabharwal KK, Chouhan AL, Jain S. CT evaluation of proptosis. Indian J Radiol Imaging 2006;16:683-8

Diagnosis of lumbar spine x-ray: Spondylolysis

  • Defect in pars interarticularis
  • lateral views are most sensitive for detection of pars fractures, and the oblique views are most specific.
  • “scottie dog” appearance on oblique radiographs : a break in the pars interarticularis can have the appearance of a collar around the dog’s neck.

Radiopaedia page aobut spondylolysis


Rigler’s sign = also known as double wall sign. Will see both edge of bowel on abd x-ray due to air being present both inside lumen of bowel and in the peritoneal cavity.

Source: Radiopaedia. Click image for more info

X-raymeasurements used to assess if bowel is dilated = 3-6-9 rule

The maximum diameter of the bowel is shown below

Maximum Normal Diameter
small bowel 3 cm
large bowel 5-6 cm
caecum 9 cm

Diagnosis of knee radiograph = Lipohaemarthrosis

  • Significance = often associated w/ fractures. Should always suspect occult fracture if no evident fracture noted but presence of lipohemarthrosis is seen
  • EBM:

“Ancillary signs such as bone bruise and lipohemarthrosis can strengthen and sometimes indicate the diagnosis in CT of occult hip fractures.”


Bone bruise, lipohemarthrosis, and joint effusion in CT of non-displaced hip fractureActa Radiol March 2012 53:197—202; published ahead of print 16 January 2012,doi:10.1258/ar.2011.110466

Click here for all previous “Pimp weekly” posts

Miss anything? Forgot to include something important? Leave a comment and help us improve our knowledge base for medical students!

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