Chicago 2000 Random Answers
1.
A: a "low density hepatic mass with enhancement" is
1. hepatoma,
2. hypervascular mets,
3. cavernous hemangioma,
4. FNH with central fibrous scar,
5. hepatic adenoma.
Cavernous hemangioma is the most common benign liver tumor, second most common liver tumor after mets. They enhance, as we all know.
B: Abcesses shouldn’t have central enhancement
C: Caroli dz = communicating cavernous ectasia of intrahepatic ducts, rare probably autosomal recessive dz. Multiple cystic structures. Probably shouldn’t have central enhancement either
D: cystic dz of liver: not sure what this is, although it is listed in the differential for "cystic liver lesion" . Whatever it is, cysts don’t have central enhancement.
E: acute cholangitis: secondary to obstruction, leading to dilated intrahepatic bile ducts. Again, probably shouldn’t have central enhancement. (D571).
2.
A: nope. FNH = rare benign congenital hamartomatous malformation or repair process in focal injury. Iso/hypo/hyperechoic (33%), can have hyperechoic central scar (18%).
B: nope. "Most small HCC are hypoechoic. Larger HCC are heterogeneous. Fibrolamellar HCC are hyperechoic."
C: yep. Lymphoma is one of the "echopenic liver mets" along with pancreas, cervical, lung and nasopharyngeal.
D: nope. Hemangioma in liver can be "uniformly hyperechoic 60-70% … inhomogeneous hypoechogenic (up to 40%)" (D589).
E: nope. Colon CA mets are one of the "echogenic liver mets" along with hepatoma and treated breast CA (D597).
3.
A: I think so. Insulinoma is the most common functioning islet cell tumor, associated with MEN I. Hypervascular by angio in 66% or 70%. It’s the only one where in discussion of the primary tumor are its mets referred to as "hypervascular."
B: nope. Pancreatic ductal adenoCA are the vast majority 80-95% of nonendocrine panc neoplasms. "hypovascular / neovascularity (50%)" which I assume to mean that its hypovascular.
C: maybe: Couldn’t find too much about mets from breast, but it is in the list of "hypervascular mets." But not in the mnemonic for hypervascular mets: CHIMP (carcinoid/colon, hypernephroma, islet cell, melanoma, pheo)
D: maybe: Again, not too much on colon mets in terms of vascularity.
4.
A: maybe. Amebic abcesses in the liver are the result of spread via the portal system from the colon. They can be aspirated but treatment is "conservative … with choroquine/flagyl" and only:
1. to r/o pyogenic abcess,
2. after 3-5 d Tx failure,
3. to prevent imminent rupture or
4. to prevent rupture of a L lobe abcess into the pericardium. "There is no evidence that aspiration … accelerates healing"
B: yep. Echinococcus granulosus is the "more common" causative organism for hydatid disease with E. multilocularis/alveolaris being the less common, more invasive form. It’s a little confusing as Taenia echinococcus and E. cysticus may be synonyms for E. granulosus.
C: probably not. Multilocular collections generally are more amenable to surgery.
D: nope. Hepatic abcesses are "pyogenic 88%, amebic 10%, fungal 2%."
5.
A: yep. Carcinoid sydrome is in part due to excess serotonin levels. The classic triad of Sx is cutaneous flushing, diarrhea and "right sided endocardial fibroelastosis (35%) resulting in TR, PS & RHF." Affecting the right heart requires avoiding metabolism to 5-HIAA in the liver. The left heart is spared with liver mets by serotonin metabolism in the lung by MAO inhibitor. "30-50% of patients with carcinoid syndrome have liver mets."
B: maybe. Bronichal carcinoid can result in left sided valvular heart disease, but "lung" carcinoid only causes carcinoid syndrome in 3.5%. This question hinges on whether (incidence of liver mets) * (likelihood of liver mets causing valvular disease) > (incidence of bronchial carcinoid) * (likelihood of bronchial carcinoid causing valvular disease) which seems to be true from the nonnumerical data.
F: nope. No reference to valvular disease. (D444).
G: maybe. Intracardiac myxomas can cause obstruction mimicking valvular stenosis. Is that "true" cardiac valve disease? (D531).
Which of the following vascular anomalies is symptomatic (1999):
R arch with aberrant l subclavian
L arch with aberrant r subclavian
c) Pulmonary sling (origin of left PA from right PA)
A: nope. RAA c ALSA is "usually asymptomatic (loose ring around trachea + eso) … may be Sx in infancy/early childhood provoked by bronchitis + tracheal edema … may be Sx in adulthood provoked by torsion of Ao" (D483).
B: nope. LAA c ARSA is "asymptomatic / dysphagia lusoria (rare)" (D485).
C: yep. Pulmonary slings are "usually symptomatic" causing "stridor, wheezing, recurrent pna, dysphagia, FTT" (D486).
140. Which does not cause unilateral rib notching (1999, 98):
a. Blalock Tussig shunt
b. AVM in arm
c. Brachial art stenosis
d. Aortic coarct between inominate and left common carotid
e. Aortic coarct with aberrant rt subclavian
A: nope. BT shunt is an "end to side anastamosis of subclav a to pulm a, performed ipsilateral to the inominate a/opposite to the Ao arch" and is in the DDx for rib notching. (D491, 14).
B: nope. An arm (or "chest wall") AVM can cause intercostal vein enlargement (D14)
C: maybe. Brachial arm stenosis should cause arterial collaterals to form, possibly in the ribs. This is corroborated by the Cornell 1999 answers but BID 1998 disagrees and states that this is the answer. (personal conjecture).
D: maybe. CoA between the inominate and LCC is a preductal coarctation typically repaired 3-5 yo, so rib notching would not have a chance to occur (rare before 6 yo). The Cornell 1999 answers state that there is no rib notching with "Type A – occluded after LSA, Type B – occluded between LCA and LSA, Type C – occluded between brachiocephalic artery and LCA." BID 1998 and Mayo 1998 disagree, though. (D519-20).
E: nope. CoA with LAA and ARSA can result in unilateral rib notching on the left. (D520).
142. Which is true re the ductus arteriosus (1998):
a) left recurrent laryngeal nerve passes around it
b) prostaglandins close it
c) Indomethacin keeps it open
A: probably. Per Dr Netter, the left recurrent laryngeal n loops around the aortic arch next to the ligamentum arteriosum. Is that what they mean by "around it?" (N201, 219)
B: nope. Prostaglandins are "potent duct dilators" (D532).
C: nope. Indomethacin "opposes prostaglandins" (D532).
143. Pt with supradiaphragmatic TAPVR and snowman heart. The density at the left sup mediastinum is due to (1998):
a) svc
b) left vertical vein
c) aortic arch
azygous vein
A: probably not. The (normal right-sided) SVC would probably form the right superior mediastinal density.
B: probably. Ralph states that the supracardiac shadow in the figure of 8 or snowman heart is from a dilated right SVC, vertical and inominate veins. (W125). Wolfgang further clarifies, stating that the configuration is secondary to a "dilated SVC + L vertical vein" (D506). William and Clyde contend that "this configuration is only present when the abnormal common pulmonary vein enters the persistent left superior vena cava or vertical vein." I believe that "vertical vein" and "persistent left SVC" are meant to be synonyms, particularly from the usage on the bottom of BH1057. (BH1057-8).
C: nope.
D: nope.
144. Best technique to evaluate cardiac blood flow dynamics (1998):
a) TOF
b) gradient echo
c) phase contrast
d) T2
A: probably not. TOF, while good for the relatively linear flow of the carotids, would be less useful for the complex flow of the heart. (personal conjecture, lecture by A. Marumoto 7/11/01 sic.)
B: probably not. GRE can identify turbulent flow on a white blood background as "turbulent blood loses its coherence when it passes thru reguritant or stenotic valves." (BH 581-2)
C: probably. Phase contrast can "calculate flow velocities and flow volumes in addition to the reguritant volumes." (BH582).
D: nope. T2 can give anatomic and tissue characterization information about the myocardium, but flowing blood would give a signal void. (BH581).
145. Pt is 3 days s/p MI, strongest indicator of poor prognosis is (1998)
a) pleural effusion
b) rapid atrial dilatation
c) pulmonary edema
d) pulmonary vascular distribution
A: probably not. Perhaps an indicator of severe pulmonary edema and LV failure.(D530).
B: maybe. Myocardial rupture usually occurs 3-5d post MI and can cause "enlargement of the heart." Rupture of the intraventricular septum occurs 4-21 d post MI and can cause "right-sided cardiac enlargement." But atrial dilatation is relatively nonspecific. (D530).
C: probably. A prognostic sign for LV failure. BID 1998 and Mayo 1998, give this as the correct response without comment. (D530).
D: probably not. Everyone’s got PVC, right? J
147. Concerning Tc99m sestamibi (1998):
a) passive diffusion into myocardium
b) better uptake into myocardium than thallium
c) bladder is critical organ
d) rapid redistribution
148. Which falsely overestimates LVEF on MUGA (1997):
a) oversubtracting background
b) undersetimating background
149. Ebstein's anomaly is associated with:
a)VSD
b) ASD
c) gooseneck deformity
A: nope. No VSD in Ebstein’s (D523-4).
B: yep. "Downward displacement of septal + posterior leaflets of TV " can create an "ASD with a R to L shunt." (D523-4).
C: nope. Gooseneck deformity is seen in endocardial cushion defect "secondary to downward attachment of the anterior MV leaflet close to the IV septum by accessory chordae tendineae." (D524).
Right cardiac apex, left stomach and left aortic arch:
a) Kartagener's
b) polysplenia
situs inversus viscerus
Ebstein's malformation
A: nope. Kartagener’s gives "complete thoracic and abdominal situs inversus" 50% which would have a right cardiac apex, right stomach and right aortic arch.. Triad also includes sinusitis and bronchiectasis (all from dysmotile cilia). (W 750, D414).
B: probably. Polysplenia is bilateral left sidedness and can result in a "cardiac apex on R / in midline", "stomach on right 40% / left side" and "aorta + azygous vein on left / right side of spine." (D534, W130)
C: nope. Situs inversus viscerus (abdominal) would give a left cardiac apex, right stomach and left arch. (W129).
D: nope. Ebstein’s malformation is intracardiac and hemodynamic only. (D523-4).
Most sensitive sign for left atrial enlargement:
a)double density
b) elevation of the left mainstem bronchus
c) prominent pulm vein
A: nope. "A similar appearance may also be found in: pts with nl sized LA, confluence of pulm v" (W133).
B: probably. "LAE is best confirmed by measuring the distance from the midinferior border of the L MSB to the right lateral border of the left atrial density." (BH567).
C: nope. Not mentioned. (W133, BH567).
Which is NOT a/w left atrial enlargement?
a) mitral stenosis
b) atrial fib
c) myxoma
d) vsd
A: nope. MS can cause LAE. (D529).
B: probably not. Can’t find it in HPIM, but I do remember a relationship from internship (HPIM 1264-5).
C: nope. A LA myxoma can cause LAE. (D531).
D: nope. A VSD can cause LAE (D545).
How to increase size of azygous vein:
a)supine valsalva
b) prone valsalva
c) supine Mueller
d) prone Mueller
A, B: nope. A valsalva maneuver is forced expiration, increasing intrathoracic pressure, decreasing venous return, decreasing the azygous vein size. (HPIM2374)
C: yep. Mueller maneuver is forced inspiration, lowering intrathoracic pressure, increasing venous return, increasing the azygous vein size (in the thorax). Supine positioning would discourage azygous drainage into the SVC, maximizing its size. (N226).
D: nope. Prone positioning would encourage azygous drainage into the SVC. (N226).
154. What is true re cardiac imaging with F18-FDG?
Lower dose is needed for PET than for coincidence imaging
PET requires a thicker NaI crystal
PET requires an on-site cyclotron
Recipient structure left in place after an orthotopic heart transplant
post wall of left atrium
pulmonic valve
sinus of Valsalva above coronaries
A: yep. "The surgeon removes the diseased heart but leaves the posterior wall of the RA in place and the superior and IVC intact. The posterior wall of the LA is also left in situ with pulmonary veins intact." (HPIM1299).
B: nope.
C: nope. Dr. H makes no mention of the coronaries, so I assume that the aorta is anastamosed somewhere beyond the sinuses of Valsalva (at the cusps of the AV where the LCA and RCA originate) and before the inominate. (N211, HPIM1299).
What is true re type A aortic dissection
older men are usually hypertensive
requires urgent surgery
A: probably not. While its true that "almost one-half [of a white suburban population] have pressures greater than 140/90" and hypertension is a predisposing factor, B’s a much better answer. (HPIM1380, 1396).
B: yep. "For ascending Ao dissection (type A), emergent or urgent surgical correction … is the preferred treatment." Recall Stanford type A: involves the ascending Ao +/- descending Ao, type B: descending Ao only. (HPIM1396-7).
Which is NOT a/w pulmonary hypertension
schistosomiasis
pulmonary AVM
A: yep. "Pulmonary hypertension appears to be due to obliteration of pulmonary arterioles by granulomatous inflammation induced by shunted and embolized schistosome eggs." (HPIM1219). Note, schistosomiasis can cause pulmonary AVM’s. (D429).
B: nope. a pulmonary AVM is a R to L shunt, not typically associated with pulm HTN. (D429).
What is true re perfusion imaging in a patient with chest pain
Tl-201 within 6 h of acute pain can demonstrate areas of acute MI
Normal resting MIBI virtually excludes ischemia as cause of pain
Increased lung uptake with MIBI is a sign of poor prognosis
Non-Q wave MI can be detected within 6 h of onset of chest pain
Angio is better than MR in the evaluation of what aspect of aortic dissection
entry point
visualization of coronary artery involvement
thrombosis of false lumen
pericardial effusion
A: yep. Angio is "superior to any other technique in demonstrating: entry + reentry points" (D510).
B: yep. (Continuing the above section) "…demonstrating: branch vessel involvement and coronary arteries" (D510).
C: nope. Angio gives a false negative with "complete thrombosis of false channel." (D510).
D: nope. MR would be able to detect pericardial effusions as it is superior in demonstrating nonluminal structures. (personal conjecture)
Best factor to differentiate cardiomyopathy from large pericardial effusion
water-bottle shape of the heart
dampened cardiac sounds
A: probably not.The shape of the heart isn’t a very specific or sensitive sign. (HPIM1335).
B: yes. "Heart sounds tend to become faint" (HPIM1335).
Importance of false aneurysms in patients that had MI's
tend to rupture
a/w arrhythmias
a/w thromboembolic phenomena
A: probably. By "false aneurysm" I assume they are referring to what Dr. H calls a "pseudoaneurysm" which is a "myocardial rupture … contained by a local area of pericardium, along with organizing thrombus and hematoma. … Spontaneous rupture of a pseudoaneurysm often occurs." (HPIM1364)
B: probably not. True aneurysms, aka "local expansile paradoxical wall motion" are associated with arrhythmias, but Dr. H makes no mention of them in reference to pseudoaneurysms. (HPIM1364)
C: probably not. While Dr. H does mention the "organizing thrombus and hematoma" he doesn’t say anything about embolic phenomenon. Of course this doesn’t mean that it doesn’t happen, but I think rupture is the primary complication. (HPIM1364).
What does NOT interfere with the cardiothoracic ratio
portable technique
A: nope. "The cardiothoracic ratio should not exceed 0.5 on a … PA radiograph or 0.6 on a portable or AP exam" (BH566).
Conus developmental abnormalities can cause:
Tetralogy of Fallot
AV septal defect
Mitral valve prolapse
A: yep. By "conus" I think they’re referring to the conus arteriosus aka the infundibulum aka "the smooth cephalic portion of the right ventricle that leads to the pulmonary trunk." Tet is the "underdevelopment of pulm infundibulum secondary to unequal partitioning of the conotruncus." The tetrad is: pulmonary outflow tract obstruction, VSD, RVH & overriding Ao. (BH560, D539).
B: probably not. The septum is inferior to the conus. (BH560).
C: probably not. The MV arises inferior to the conus. (BH560).
Endocardial cushion defect can give rise to:
atrial septal defect
ventricular septal defect
mitral valve abnormality
A, B, C: nope. Not sure if this question was misrecalled, but ECD can give rise to all three: ASD, VSD and abnl in both AV valves. (D524).
With respect to MUGA the following can be calculated:
right ventricular ejection fraction
must be to the left ventricular ejection fraction
under subtraction of background fraction can lead to overestimation of the left ventricular ejection fraction
Post myocardial infarction false aneurysms are asscociated most strongly with:
arrhythmias
peripheral emboli
poor diastolic filling
tend to rupture
D: yep. This is a near repeat of #161.
Regarding the aorta dissection tends to occur between
media and the intima
media and the adventitia
intima and the adventitia
muscularis propria and the media
A, B, D: nope. The blood is "in" the media. (D509, HPIM1395).
C: yep. "Spontaneous longitudinal separation of Ao intima + adventitia by circulating blood having gained access to the media of the Ao wall splitting it in two." From a "transverse tear in weakened intima 95-97%" or "intramural hematoma 3-5%." (D509).
A 3yo boy presents with a fever, cervical adenopathy and a rash on the palms and soles and trunk. Chest film shows an interstitial pattern in the lungs. Most likely diagnosis:
RS virus
tetralogy of Fallot
Kawasaki’s disease
Rheumatic fever
A: probably. RSV can present with an interstitial pattern, and the age group is good as viral pna are the most common pna in children < 5 yo. This question hinges on whether an uncommon manifestation of a common disease is more likely than a common presentation of an uncommon disease, which I think is true. (D446).
B: nope. TOF typically presents with cyanosis at 3-4 mo (previously concealed by PDA), DOE, clubbing of fingers and toes, squatting when fatigued (to incr pulm bl flow), LOC’s. Radiographically, there is decreased caliber and number of pulm vessels, asymm pulm vascularity, reticular pattern with a horizontal course (from pleuropulmonary collaterals). (D540).
C: maybe. Kawasaki’s or mucocutaneous LN syndrome is an idiopathic acute febrile multisystem vasculitis involving large, med and small arteries with a predilection for the coronaries. Its incidence is 1.1:100,000. It presents <5 yo with fever, mucosal reddening, cervical LAN, maculopapular extensor surface rash, erythema with desquamation of the palms and soles. No radiographic lung manifestations are mentioned. (D528, W140)
D: nope. Rheumatic fever peaks between 5-15 yo and is a distinct event following oropharyngeal group A strep infection. The criteria for diagnosis were updated with the 1992 Jones criteria: major: carditis, migratory polyarthritis, Sydenham’s chorea, subq nodules and erythema marginatum (trunk), minor: fever, arthralgia, incr ESR, prolonged PR interval. No pulmonary radiographic findings were discussed. (HPIM1310).
Which of the following tumors are most likely associated with valvular heart disease:
melanoma
carcinoid
colon carcinoma
breast Ca
B: yep. A near repeat of #131.
Which is not associated with unilateral rib notching?
Blalock-Taussing shunt
Peripheral AVM
Brachial artery stenosis
Coarctation with aberrant right subclavian artery
Coarctation between the innominate and left carotid.
C: probably. A near repeat of #140.
Best MR sequence to evaluate flow in a vessel:
T2
GRE
T1
Phase contrast
?
D: yep. A near repeat of #144.
On cardiac echo, which is associated with anterior movement of the anterior leaflet of the mitral valve?
Papillary muscle rupture
Mitral stenosis
Mitral regurgitation
Atrial myxoma
IHSS
A: probably not. "From infarction of posteromedial pap musc in inferior MI (common) or anterolateral pap musc in anterolateral MI (uncommon)." No mention of MV leaflet motion. (D530).
B: maybe. In MS, there is "diastolic anterior tracking of pML … secondary to diastolic anterior pull by larger + more mobile aML" seeming to imply that the aML moves anteriorly. (D529).
C: probably not. In MR, there is "bulging of the interatrial septum to the right during systole," but no mention of the MV leaflets.
D: probably not. With atrial myxoma, Wolfie describes "echoes posterior to aML soon after onset of diastole" and obscuration of the pML, but no such motion. (D531).
E: probably. With idiopathic hypertrophic subaortic stenosis, the basal septum of the LV is disproportionally thickened, there is "systolic anterior motion of [the] MV." (D519). This is also corroborated by the answers from the 1997 set (for what that’s worth) which states that only the anterior leaflet moves anteriorly.
On cardiac echo, which is associated with anterior movement of the anterior leaflet of the mitral valve?
Papillary muscle rupture
Mitral stenosis
Mitral regurgitation
Atrial myxoma
IHSS
E: probably. Is there an echo in here?
A 60yo man is 4yrs s/p RCA CABG (non-dominant RCA). His immediate post-op studies showed normal wall motion without infarct or ischemia. He now presents with a reversible posterior wall defect of thallium imaging. Most likely diagnosis:
Graft occlusion
New LAD ischemia
Infarct
Perioperative infarct
Ischemia in RCA distal to graft
A, E: probably not. The "inferior portion of the LV" which I think corresponds to the posterior wall is supplied by the LCA in a non-dominant RCA situation. (D502).
B: probably. In a non-dominant RCA situation, the posterior wall would be supplied by the left circulation and would give a reversible defect in the setting of ischemia. (D502, 917).
C, D: probably not. Infarcts give non-reversible defects on thallium imaging. (D917).
Which nerve courses under the aortic root in the aortopulmonary window?
Left vagus nerve
Left phrenic nerve
Right phrenic nerve
Left recurrent laryngeal nerve
Right recurrent laryngeal nerve
A: nope. The L vagus n runs down but not under the aorta at the APW. (N201).
B: nope. The L phrenic n runs along the pericardium at the APW. (N200).
C: nope. The R phrenic n runs along the pericardium on the other side. (N200).
D: yep. The L recurrent laryngeal n runs around the Ao at the APW. It doesn’t really run "under the Ao root" but I suppose it’s the best answer. Mayo 1998 gives this as the answer to a similar question. (N201).
E: nope. The R recurrent laryngeal n runs around the subclavian a on the right. (N214).
A 40yo female is scheduled for tricuspid and pulmonic valve replacement. What is the most likely diagnosis?
Pulmonary carcinoid
Gastrointestinal carcinoid with liver metastasis
Rheumatic heart disease
?
A: nope. See #131, pulmonary carcinoids would exert their effect on left sided heart structures.
B: yep. See #131, serotonin from carcinoid liver mets avoid deactivation by liver and lung enzymes to exert their effect on the right heart valves.
C: nope. Rheumatic carditis most frequently affects the MV followed by the AV. (HPIM1310).
Pulmonary hypertension is seen with all of the following except:
Eisenmenger syndrome
Pulmonary AVM
Mitral valve stenosis
Hypoxia
A: nope. Eisenmenger syndrome is the development of high pulm vasc resistance after chronic L to R shunting, leading to a balanced and ultimately R to L shunt. (D524).
B: yep. A pulmonary AVM is a low resistance extracardiac R to L shunt. (D429).
C: nope. MS leads to pulmonary HTN. (D529).
D: nope. Hypoxia can result from primary (and other types of ) pulmonary hypertension. (D534).
Which statement is true regarding coronary artery calcifications:
Is more sensitive for atherosclerotic disease thanTl-201 stress or EKG testing
Found in high grade stenosis
Is in equal frequencies in all coronary arteries
Is a contraindication for angioplasty
A: probably not. Wolfie says that CAC "predictive values in population <50 yo as good as exercise stress test." (D493).
B: yep. CAC "indicate >50% stenosis with 72-76% sens, 78% spec" and "in Sx pts 94% sec for obstructive dz (>75% stenosis)." (D493).
C: nope. CAC is seen at autopsy in the LAD 93%, LCx 77%, Lmain (70%), RCA (69%). (D493).
D: probably not. No mention of it, and if I had CAC, I’d want an angioplasty… (D493).
A 40yo man was in an MVA and hit the steering wheel with his chest. He has multiple contusions and presents with chest pain and a holosystolic murmur. What is the most likely injury?
Aortic laceration
Papillary muscle rupture
Traumatic VSD
Aortic valve rupture
A: probably not. Ao laceration or "transection" gives a "systolic murmur in then 2nd L parasternal interspace." (D513). Laceration can also result in AI which gives a "systolic ejection murmur + high-pitched diastolic murmur, [and] Austin Flint murmur = soft mid-diastolic or presystolic bruit." (D511).
B: nope. Papillary muscle rupture gives "sudden onset of massive MR" (D530).
C: yep. Holosystolic murmurs "accompany M/TR, VSD and, under certain circumstances, Ao-pulm shunts." (HPIM1236)
D: nope. AV rupture would result in an AI scenario. (D511).
Most common finding in aortic stenosis:
a)prominent aortic knob
b) LVH
c) angina
cerebral emboli
A: probably. AS can result in "poststenotic dilatation of ascending Ao (in 90% of acquired, in 70% of congentital)." (D512).
B: probably not. AS is associated with "normal-sized / enlarged LV (small LV chamber with thick walls)." (D512).
C: probably not. AS is related to "angina, syncope and HF." (D512).
D: nope. No relation is discussed. (D512).
BREAST
A woman has a 1cm, well circumscribed ST nodule on magnification spot compression views of her mammogram. No calcifications are seen. What is the chance of malignancy?
1-2%
5-10%
20-30%
40-50%
A: yep. Wolfgang presents a chart with "mammographically benign mass" having a 2% predictive value for malignancy. (D461). Ralph states that "circumscribed masses with well-defined borders: uncommon sign of malignancy; only 2% of solitary masses with smooth margins are malignant." (W659).
Two views of a pre-fire positioning of a needle biopsy of the breast. The needle position is:
Too shallow
Too deep
Too far right
Too far left
On target
I have no idea. I am not sure how to interpret these pictures. I will find out and get back to you.
Where is the lesion located?
Axilla
Upper outer
Upper inner
Lower inner
Lower outer
D: yep. Per Ralph’s picture, axilla is always up (W656).
Which process most commonly has ductal calcifications?
Adenosis
Pappillary carcinoma
Intraductal CA
Secretory disease
A: nope. Adenosis is a fibrocystic change and defined as "hyperplasia + hypertrophy of glandular elements." No mention of calcs. (D469).
B: nope. Papillary CA is associated with microcalcs 60%. (D460)
C: nope. Intraductal CA is a synonym for DCIS and is associated with "exuberant calc (heterogeneous and irregular)." (D458, W671)
D: yep. Secretory dz is divided into: retained lactiferous secretions, prolonged inspissation of secretions + intraductal debris, galactocele or plasma cell mastitis. Prolonged inspissation is associated with "calcs with linear orientation toward subareolar area." (D453). Plasma cell mastitis aka mammary duct ectasia can appear as "intraductal fairly uniform linear, often ‘needle-shaped’ calcs of wide caliver, occasionally branching." (D471).
a 4mm cluster of microcalcifications in the breast should be classified as:
Benign
Probably benign
Suspicious for malignancy
Malignant
A, B: nope. Benign calcs are round, dystrophic, large rodlike, skin, vascular, coarse, rim, milk of calcium, or suture. (W661).
C: probably. "Cluster of microcalcs is usually defined as >5 calcs per cm^3 of tissue" and is a malignant calc. Small particle size, spatial density, clustering and pleomorphism are malignant characterisitics. "Always biopsy suspicious calcs." (W660).
D: probably not. This category implies that it is cancer with 99% certainty. (W663).
Breast lesion on screening mammogram is seen only on the CC view, what is the next appropriate step?
Ultrasound
ML
Reverse CC
Rolled view
A: nope. Ultrasound should be used to evaluate a palpable lump in young women (<28 yo) or to differentiate a cyst from a solid mass. (W663).
B: probably. Willy and Clyde say "projections other than the standard CC and MLO views may help to visualize a lesion that is seen only in one standard view or that is obscured by surrounding parenchyma," but decline from further discussion. Cornell 1999, Mayo 1998 and the 1997 set all agree on this answer. (BH532).
C: probably not. A reverse CC is not discussed in any of my references, and wouldn’t seem to be much different than a CC.
D: nope. Rolled views are good for evaluating the depth of a lesion and would probably be performed after an ML in any case. (W656)
What is the most commonly missed breast carcinoma?
Tubular
Lobular invasive
Colloid
Medullary
Comedocarcinoma
A: nope. Tubular CA is a "well-differentiated form of ductal CA." (D460).
B: yep. Lobular invasive is the 2nd most common type of breast CA and is the "most frequently missed breast cancer (difficult to detect mammographically + clinically)." (D459).
C: nope. Colloid or mucinous CA has a favorable prognosis. The pure form is "aggregates of tumor cells surrounded by abundant pools of extracellular mucin" and the mixed form "contains areas of infiltrating ductal CA not surrounded by mucin." (D460).
D: nope. Medullary CA is the fastest growing breast CA and has a good prognosis. (D460).
E: nope. Comedo CA is high nuclear grade DCIS with extensive necrosis. 90% have calcs. (D458).
A core biopsy of a breast lesion shows a radial scar. What is the next step?
Excisional biopsy
?
?
?
A: yep. Wolfie says that "surgical excision required for definitive diagnosis." BID 1999 and Mayo 1998 agree. (D473).
A core biopsy of a breast lesion shows a sclerosing adenosis. What is the next step?
Excisional biopsy
?
?
?
A: probably. Wolfie says that it’s "focally dense breast appearing as a nodule / speculated lesion" and Ralph lists it in the DDx for lesions and that "all speculated masses are suspicious for neoplasm and should be biopsied." (D469, W680).
Mammographic patterns after reduction mammoplasty include all of the following except:
Skin thickening
Transposition of breast tissue from a low to a high position
High nipple
Retraction of the lower breast
Fat necrosis
A: probably not. Ralph lists "skin changes" as 95% present 0-6 mo postsurgery (type of surgery not specified). (W679).
B: probably not. Wolfie states "asymmetric tissue oriented in nonanatomic distribution" can be seen post reduction mammoplasy. (D472).
C: maybe. Neither Ralph nor Wolfie discuss changes in nipple position. (D472, W679).
D: probably not. Both Ralph and Wolfie discuss a "swirling appearance of the parenchyma in the inferior breast" which may include retraction. (D472, W679).
E: nope. Fat necrosis is listed by Wolfie. (D472).
Needle biopsy of a breast mass is done. 2 core samples contain calcifications. The pathologist says no malignancy of calcifications are seen. What is the next course of action?
Rebiopsy
Excisional biopsy
Repeat mammogram now
Mammogram in 1 yr
X-ray paraffin
Note: I think the question should state "no malignancy OR calcifications are seen" as there is an identical question in the 1999 set.
No discussion in my references. I will get back to you guys about it.
a 40yo woman has a nonpalpable, 5mm, well circumscribed mass in her right breast on her first screening mammogram. She is asymptomatic and ultrasound of this area is unable to demonstrate this mass or any other abnormality. Which birads classification does she fall into?
benign
1 prob benign
2 suspicious for malignanacy
3 very suspicious for malignancy
4 incomplete
A: probably not. Benign "includes typical nodes, calcified fibroadenomas, lucent lesions (implants), and scattered benign calcs; return to annual screening." (W663)
B: yep. Ralph states that a "well-circumscribed mass … <8 mm [should have] follow-up in 6 mo (US is less accurate in these small lesions." This corresponds to ACR #3 "Probably benign, follow-up suggested … g mo f/u." (W681, 663)
C, D, E: nope. Not sure why the numbers aren’t matching up with Ralph’s list. (W663).
The most common well-circumscribed carcinoma of the breast is:
Infiltrating ductal carcinoma
Mucinous carcinoma
Papillary carcinoma
Medullary carcinoma
Tubular ca
A: probably. In his differential, Wolfie states that "invasive [aka infiltrating] ductal CA NOS [is] (rare)," implying that it is an uncommon presentation, but it accounts for 65% of all invasive breast CA. Again the question hinges on a uncommon manifestation of a common disease (infiltratind ductal CA) versus a common manifestation of an uncommon disease, but by the way this question is worded, I think this is the answer. Cornell 1999 and Mayo 1998 agrees. (W681, D450).
B: probably not. Wolfie describes the classic presentation of mucinous CA as "well-circumscribed usually lobulated mass of round / ovoid shape." It accounts for 1.5-2% of invasive breast CA. (D460).
C: probably not papillary CA can present as a solitary well-circumscribed round / ovoid nodule" and accounts for 1-2-4% of invasive breast CA. (D460).
D: maybe. Medullary CA classically presents as a "well-defined round / oval noncalcified uniformly dense mass (hemorrhage) with lobulated margin." It accounts for 2% of invasive breast CA. Wolfie listed it first in his DDx. (D460, 450)
E: probably not. Wolfie describes it as a "high opacity nodule with speculated margins." It accounts for 6-8% of all invasive breast CA.
What region is most excluded from vew of an MLO film?
Axillary tail
Upper inner quadrant
Lower inner quadrant
Upper outer quadrant
Lower outer quadrant
B: probably. Ralph states that the CC view can "detect posteromedial tumors that may be missed on the MLO view." (W656). The BID1998 set gives this as the answer without explanation, Mayo 1998 agrees.
Motion and sharpness can be reduced by all of the following except:
better breast compression
increasing KVP
increased density on automatic exposure control
faster screen film combination
A: nope. Wolfie says "motion [can be] reduced by compression." (D457).
B: maybe. Wolfie says that sharpness is affected by "radiation quality … (kilovoltage)." Cornell 1999 states that low kVp is used to "maximize the relative contribution of the photoelectric effect, thereby increasing subject contrast and minimizing scatter." Increasing kVp would presumably worsen scatter. (D457).
C: maybe. Not really sure what this is, none of my references discuss it.
D: probably not. Screen-film combo affects "radiographic blurring" a component of sharpeness and faster is better. (D457).
Inflammatory carcinoma, which of the following is true:
thrombosis
internal mammary vein
blockage of the lymphatic
angioinvasion
multifocal and multicentric
A, B, D: probably not. The tumor invades lymphatics, not blood vessels. Unless they mean lymphangioinvasion. (D461, W671).
C: yep. Inflammatory breast CA is a synonym for "tumor emboli within dermal lymphatics." (D461).
E: probably not. Neither Wolfie nor Ralph discuss multicentricity or multifocality. (D461, W671).
Reasons to aspirate a cyst in a breast include all of the following, except:
symptomatic
size
questionable whether it represents the mammographic abnormality
lobulated contour
A: probably not. Neither Wolfie or Ralph discuss it, but I recall this discussion numerous times in the breast room. (personal).
B: maybe. Again, neither Wolfie or Ralph discuss it, but I don’t recall this as being a major factor, within reasonable limits, I suppose. (personal).
C: maybe. No specific discussion in the references, but ultrasound itself should be able to "correlate with palpation / mammogram as to size, shape, location, surrounding tissue density." (D465).
D: nope. A lobulated contour makes a cyst "complex" which should undergo "complete aspiration (assures benign cause)." (D465-6).
Woman undergoes conservative lumphectomy for ductal carcinoma in situ 2 years previously. She now presents for follow-up mammogram which demonstrates 7 rim calcifications around the lumphectomy site. This most likely represents:
Fat necrosis
ductal carcinoma in situ
invasive ductal carcinoma
lobular carcinoma in situ
A: probably. Rim calcs are a benign pattern. Fat necrosis "calcifies in 4-7% … occasionally curvilinear / eggshell calcification in wall." (D467).
B: probably not. The typical calcifications of DCIS are "microcalcifications" or "dystrophic / amorphous." (D458).
C: probably not. Invasive ductal CA has "malignant calcifications" which are earlier defined as "granular" or "casting .. fragmented cast of calcs within ducts." (D458, 452)
D: LCIS is typically mammographically occult, but may atypically present as "calcs + mass (in 10%)." (D459).
Most likely carcinoma to arise in a breast cyst include:
Tubular carcinoma
lobular carcinoma
papillary
medullary
DCIS
C: yep. "Tumor within a cyst is very rare, but if seen usually represents a papilloma (papillary CA would be the most common intracystic malignancy." (W674).
247. Outcome studies for mammography primarily intend to evaluate (1998):
a) mortality reduction
early detection
A: probably. Not clearly stated, but Ralph presents several studies and their results primarily concern mortality reduction. BID 1998 and Mayo 1998 give this as the answer.
B: probably not. This is a difficult thing to study, confounded by many factors. How would one know prospectively if detection is early? (personal).
248. Most common occult breast lesion (1998):
a) invasive ductal
b) invasive lobular
c) medullary
d) tubular
e) papillary
B: yep. Invasive lobular carcinoma is the "most frequently missed breast CA (difficult to detect mammographically + clinically) with 19-43% false negative rate (occult in dense breast)." (D459).
249. Most reliable indicator of intramammary lymph node on US (1998)
a) well-defined
b) notch
c) lobulated contour
d) acoustic shadowing
A: maybe. A "marked hyperechogenic well-circumscribed nodule" and a "smooth well-circumscribed ellipsoid shape" are both benign characteristics. (D451)
B: probably. Ralph states that "benign LN may have a characteristic central echogenic center due to fat in the LN hilum." (W663).
C: probably not. Three or less lobulations has a sensitivity of 99.2 and a specificity of 19.4 according to Wolfie, but "microlobulation" is a malignant sign. Which do they mean? (D451).
D: nope. Acoustic shadowing is a malignant characteristic. (D451).
250. Which is not an advantage of core biopsy vs fine needle aspiration (1998):
a) can be performed under US
b) special expertise by the pathologist is not required
c) can differentiate between DCIS and infiltrating ductal CA
d) better false negative
A: probably. Willy and Clyde say "US may also be used to guide placement of needles for either FNAB or core biopsy" and BID 1998 and the 1997 set state this is the answer. (BH554).
B, D: unknown.
C: probably not. The 1997 set states that this is true.
251. Core biopsy of a spiculated mass reveals fibroadenoma (1999, 97). Next step:
a) Excisional biopsy
b) F/u mammo in 1 yr
c) US
d) Repeat core
Willy and Clyde say "all patients … with benign results should have mammograms at 6, 12 and 24 months after the procedure to ensure stability of the lesion sampled." The Mayo 1997 test had 6 mo f/u as one of the options which was identified as the correct answer.
252. Core breast biopsy reveals atypical ductal hyperplasia. Next step (1999, 97):
a) 6 mos f/u mammo
b) 1 yr f/u mammo
c) excisional biopsy
d) repear core
e) US
C: probably. There was no direct discussion in my references, but Cornell 1999 states that ADH is a direct precursor for breast CA … ADH requires removal of the lesion. Wolfie merely states that its "a low-grade intraductal proliferation with partial / incompletely developed features of noncomedo DCIS." BID 1998 agrees without comment. (D469).
253. Likelihood of CA in a well circumscribed, non-Ca++, breast mass (1999, 98):
a) 1-2%
b) 5-10%
c) 15-20%
. d) 1-.3%
A: yep. Wolfgang presents a chart with "mammographically benign mass" having a 2% predictive value for malignancy. (D461). Ralph states that "circumscribed masses with well-defined borders: uncommon sign of malignancy; only 2% of solitary masses with smooth margins are malignant." (W659). Multiple old tests give the probability at 2% for "well-circumscribed" lesions (palpable or not) Cornell 1999, Mayo 1998.
GI
Which drug is more likely to be a/w a large benign antral ulcer?
Morphine
Prednisone
Aspirin
Potassium chloride
A: nope. No reference to MSO4 as associated with GU’s. (D687, HPIM1605-6).
B: maybe. Wolfie and Ralph list steroids as a cause of benign GU’s, but Dr. H doesn’t mention it. (D687, W162, HPIM1605-6).
C: yep. Dr. H says "almost all benign GU’s are found immediately distal to the junction of the antral mucosa and the acid-secreting mucosa of the body of the stomach. … NSAIDs are responsible for 15-25% of GU’s. NSAID-associated GU’s are frequently more superficial and are less often identified radiographiclaly." (HPIM1605-6).
D: nope. No reference to it. (D687, HPIM1605-6).
Regarding hepatic fluid collections:
Amebic abcesses are amenable to surgical or percutaneous drainage.
Echinococcus granulosus is the causative organism of cystic hydatid disease.
Multilocular collections can be treated percutaneously.
Hepatic abscesses are cryptogenic in 80% of the time.
B: yep. A repeat of #77.
A 50yo man has a 15mm polyp in the sigmoid colon. What is the chance of developing a malignancy?
1-2%
10%
35%
60%
80%
A, C, D, E: probably not.
B: probably. Ralph states that for "high risk groups" <1 cm: 1%, 1-2 cm: 25%, >2 cm: 40%. Dr. H contends <1.5 cm: <2%, 1.5-2.5 cm: 2-10%, >2.5 cm: 10%. I’ll go with Dr. H. (W182, HPIM572)
What medication can be given to suppress the gastric mucosal secretion of pertechnitate for a Meckel’s scan?
Pentagastrin
Phenobarbital
Cimetidine
?
?
A: nope. "Premedication with pentagastrin to stimulate gastric secretion of pertechnetate." (D928).
B: nope. No mention of it. (D928).
C: yep. "Premedication with cimetidine to reduce release of pertechnetate from mucosa." (D928, W835).
What is a contraindication for a TIPS?
Right heart failure
Portal vein thrombosis
INR >1.5
Budd Chiairi
Ascites
A, C, D: These are likely relative contraindications, but I have no references that discuss them. (D609, W608, HPIM).
B: yep. Portal patency must be confirmed pre-TIPS. (W607).
E: nope. Refractory ascites is an indication for TIPS. (W607).
What is an acceptable indication for TIPS?
New onset ascites before a trial of medication
Bleeding esophageal varices with failed sclerotherapy
Hepatic encephalopathy
?
??
A: nope. The ascites must be refractory. (W607).
B: yep. "Portal HTN with variceal bleeding that has failed endoscopic treatment" is an established indication. (W607).
C: nope. Encephalopathy is a complication post TIPS (HPIM1712).
Which organism does not commonly involve the small bowel in patients with AIDS?
Cryptosporidium
MAI
Candida albicans
CMV
A: nope. Cryptosporidiosis is "one of the most common causes of enteric dz in AIDS pts" affecting the "jejunum > other sb > stomach > colon." (D655).
B: nope. MAI is the "most common opportunistic infection of bacterial origin in AIDS pts" most commonly seen in the jejunum. (D656).
C: yep. Candidiasis is found in the oral cavity and esophagus. (D655).
D: nope. CMV is the "most common cause of life-threatening opportunistic viral infection in AIDS pts" and affects the "colon > sb (ti) > eso > stom." (D655).
A 30yo female presents with diarrhea, a serum protein of 4.5ng/100dl, a small bowel follow through demonstrates dilated bowel, hypersecretion, variable thickened folds with an intussuception appearance.
Sprue
Scleroderma
Whipple’s disease
?
?
A: yep. According to Wolfie, sprue is a "classic dz of malabsorption" and is either celiac dz from gliadin polypeptides in some grains, or tropical sprue from on infectious agent. Although Ralph contends that celiac dz and "nontropical sprue" are distinct entities. "Dilation is HALLMARK in untreated celiac dz." There is hypoproteinemia, hypersecretion, variable thickened folds and "transient nonobstructive intussuception 20%." Don’t forget the specific sign of "jejunization of ileal loops." (D715, W171).
B: nope. GI scleroderma, or progressive systemic sclerosis, is the "third most common manifestation … after skin changes + Raynaud phenomenon." There is malabsorption, sb dilatation and the "hidebound / accordion pattern 60% = sharply defined folds of normal thickness with decreased intervalvular distance (tightly packed folds) within dilated segment (due to predominant involvement of circular muscle)." (D710).
C: nope. Whipple dz, or intestinal lipodystrophy, is "thought to be caused by an infection with an as yet unidentified gram-positive bacterium" and can result in malabsorption, moderate fold thickening, and "no / minimal dilatation of sb." (D719-20).
The following statements regarding Glucophage (metformin) are false except:
Combines with iodine and causes nephrotoxicity
Can’t give iodinated contrast if taken within 48hrs of the study
Causes lactic acidosis in patients with impaired renal function
?
?
A: nope. No reference to it.
B: maybe. Ralph contends that it should be "withheld 3 days prior to and after C+ admin," but his book is older than Wolfie’s. (W868).
C: yep. "Metformin … should be d/c x 48h after C+ administration (accumulation … may result in lactic acidosis which is fatal in 50%!)" (D940).
A 50yo man presents with bloody stools after acute onset of abdominal pain. Films shows thickened folds of the transverse colon. Diagnosis?
Ischemic colitis
Pseudomembranous colitis
Ulcerative colitis
Granulomatous colitis
A: maybe. Ischemic colitis can present with abd pn, rectal bleeding, but the transverse colon is less commonly involved due to vascular supply. (D696).
B: probably. Pseudomembranous colitis from C. difficile cytotoxin can present with abd cramps/tenderness, fecal blood and can affect the right and transverse colon (5-27%). "Thumbprinting most prominent in transverse colon." (D712).
C: maybe. UC can present with abd cramps, bloody D, and has continuous circumferential involvement beginning in the rectum; it wouldn’t be limited to the transverse colon. (D718).
D: probably not. Granulomatous colitis is Crohns of the colon typically affects younger pts (15-30 yo) and can present with abd pn, occult blood and affects the "right side with the rectum + sigmoid requently spared."
A man undergoes a SBFT and has an excavating, freely mobile mass in the region of the TI.
Carcinoid
Crohns dz
Lymphoma
Adenocarcinoma
TB
A: probably not. Carcinoid can present in the appendix 30-45% and sb 25-35% (ileum 91%) as a "small smooth submucosal mass."
B: probably not. Crohns typically presents with regional enteritis but can present with inflammatory polypoid masses. (D670).
C: yep. GI lymphoma is 1/5 of sb malignancies making it the "most common malignant sb tumor." It can be infiltrating, present as "single / multiple polypoid mucosal / submucosal masses", endoexoenteric mass or as LAN. The "nodules may ulcerate." (D700).
D: probably not. Adeno CA of the sb is typically in the "duodenum (50%) … jejunum > ileum." And can present as an ulcerated mass 27%. (D654).
E: probably not. TB of typically affects the ileocecal area with "abundance of lymphoid tissue" and "fissures and ulcers." (D716).
Which one is true regarding leiomyosarcoma of the stomach?
Large necrotic mass
Better prognosis than gastric cancer
Broad based exophytic mucosal mass
Metastasizes by lymphatics
A: yep. Average size is 12 cm and can have "central zones of low density (necrosis with liquefaction)." (D698).
B: unknown. I found no data on prognosis. (D698, HPIM571).
C: probably not. Is typically an "intramural mass … may be pedunculated. (D698).
D: nope. "Characteristically do not met to LNs." (HPIM571).
What are area gastricae?
Clumps of gastric glands
Response to hypertrophic gastritis
Parietal cells
Precursor to malignancy
?
A: yep. It’s a normal pattern seen in the body and antrum. (BH725).
B: nope. Its normal. (BH725).
C: probably not. Parietal cells secrete HCl are located in the fundus and body, not the antrum whereas the area gastricae is seen in the body and antrum. (BH725).
D: nope. Its normal. (BH725).
Which has the highest risk of malignancy?
Juvenile polyposis
Barrett esophagus
Ulcerative colitis
Gardner syndrome
?
A: maybe. Wolfie says "colorectal CA by 35 yo in 15%." (D697) Dr. H makes no mention of this entity.
B: nope. "Adeno CA (0-10-46%)." (D661). "Adeno CA occurs in 2-5% of these cases." (HPIM1592).
C: nope. colonic adeno CA 3-5%. (D719). "The overall incidence of cancer [in patients with IBD] is estimated to be 0.5 to 1 percent per year after 10 years." (HPIM1641).
D: yep. Gardner syndrome has AD transmission, "characterized by the triad of 1. colonic polyposis, 2. osteomas, 3. soft-tissue tumors … malignant transformation in 100%." (D685).
Which site is least likely to be involved with hematogenous metastasis?
Rectum
Terminal ilium
Mid-transverse colon
Lateral ascending colon
Cecum
No idea, no references discuss mets to the colon.
A patient with a Mallory-Weiss tear and UGI bleeding is sent for angiogram. What is the most likely vessel bleeding?
Hepatic artery
Adrenal artery
Inferior phrenic artery
Left gastric artery
Inferior esophageal artery
A: probably not. Wolfie says that the bleeding site is at the gastric cardia. The hepatic a is typically a right sided structure. (D701).
B: nope. Too inferior, retroperitoneal. Not listed in Netter…
C: probably not. Courses from the aorta anteriorly along the diaphragm. (N181).
D: probably. In a good location at the cardia. (N225).
E: probably not. There is no "inferior esophageal artery" according to Frank HT, but there are esophageal branches from the aorta, bronchial, inferior phrenic, inferior thyroid and left gastric. (Napx3).
Clinical history of a 20yo black man with hepatomegaly, diarrhea and peripheral edema. Dense bones are seen on plain film. What is the most likely diagnosis?
Lymphoma
Mastocytosis
Carcinoid
Gardner syndrome
A: probably not. Lymphoma in bone presents as a "mottled permeative pattern of separate coalescent areas."
B: yep. Mastocytosis is a "systemic dz with mast cell proliferation in skin + RES … associated with eos and lymphocytes." It can present with hepatomegaly, D, "urticaria pigmentosa" and "scattered well-defined sclerotic foci with focal / diffuse involvement." (D93, 702).
C: probably not. Carcinoid can present with D, liver mets, "desquamative skin lesions" and osteoblastic bone mets. (D663-4).
D: probably not. Gardner syndrome is discussed in #293. It can present with skin pigmentation, and osteomatosis of membranous bone.
Which of the following are not typically seen with sprue?
Hypersecretion
Folds greater than 4mm
Villous atrophy on biopsy
Asymptomatic intussusceptions seen during exam
Moulage pattern on barium study
A: nope. Hypersecretion in sprue can cause A-F lvls, segmentation, flocculation or fragmentation of Ba. (D715).
B: maybe. Sprue can present with "normal / thickened / effaced mucosal folds (depending on degree of hypoproteinemia)." (D715).
C: nope. Celiac disease is associated with "atrophy of small intestinal villi." (D714).
D: nope. "Transient nonobstructive intissiception 20% without anatomic lead point." (D715).
E: nope. "Moulage sign 50% = smooth contour with effaced featureless folds resembling tubular wax mold." (D715).
Regarding gastric emptying studies by nuclear medicine:
Fluids show a linear emptying curve
There is exponential emptying with solids
Demonstration of 50% emptying at 30min for fluids is a normal study
Lipids increase the rate of emptying
A: nope. "Liquids empty faster and show a monophasic exponential clearance." (W836).
B: nope. "Solids empty after an initial delay, but emptying is nearly linear." (W836).
C: yep. "Normal result: 50% of activity in stomach at time zero; should empty by 60 +/- 30 minutes." (D927).
D: unknown. No references to lipids (D927, W836).
Most specific finding in portal hypertension:
enlarged portal vein
enlarged hepatic vein
portosystemic collaterals
ascties
splenomegaly
A: probably not. This is not discussed as a sign of portal HTN. (D607, W629-30, HPIM1710-1).
B: nope. Portal HTN may rarely result from extrahepatic postsinusoidal obstruction, but this is not a specific sign. (HPIM1710).
C: probably. This is the cause of the major clinical manifestations of portal HTN variceal hemorrhage, "splenomegaly … ascites … hepatic encephalopathy." I cannot locate a discussion of the relative specificity of these findings, but I can’t think of another reason for portosystemic collaterals to develop, making it a very specific sign. (HPIM1711, personal).
D, E: nope. The myriad reasons for the development of ascites/splenomegaly makes them relatively nonspecific. (HPIM210, 348).
Which of the following is true re giardia:
most commonly jejunal
most commonly gastroduodenal
can result in chronic malabsorption
negative stool exam rules it out
chronic GI bleeding
This question is probably worded incorrectly, as all but 1 answer seem to be true.
A, B: maybe. Wolfie says that is "most pronounced in the duodenum + jejunum." (D689).
C: true. It can result in "reduced fat absorption (simulating celiac dz)." (D689). "Symptoms may … persist for years [and] can be severe, resulting in malabsorption." (HPIM1202-3).
D: true. Its diagnosed by "detection … in formed feces or … diarrheal stools." (D689). "Because cyst excretion is variable and may be undetectable at times, repeated examination of stool … may be required to detect the parasite." (HPIM1203).
E: probably false. No mention of GIB. (D689, HPIM1202-3).
307. 70yo woman with asymptomatic RUQ mass which is hypovascular with punctate calcification. No change over 5 yrs. Most likely dx (1998):
a) macrocystic adenoma
b) microcystic adenoma
c) islet cell tumor
d) pseudocyst
e) mucinous adenoCA
A: probably. Macrocystic adenoma (mucinous) can be asymptomatic. They are hypovascular and can contain amorphous discontinous peripheral mural calcifications (10-15%)." Stability over 5 years is a little atypical as they exhibit "invariable transformation into cystadenocarcinoma." (D595).
B: nope. Microcystic adenoma (serous) present with pain, wt loss and jaundice. They are hypervascular and can have "amorphous central calcs in dystrophic area of stellate central scar." (D588-9).
C: nope. Islet cell tumors are neuroectodermal derivatives when large can have calcifications, but are typically hypervascular. Because of their secretory properties they are often symptomatic. (D600-2).
D: nope. Pseudocyst from pancreatitis can contain calcification and may be "hypervascular + increased parenchymal stain (12-45%)." They are typically symptomatic from the accompanying pancreatitis. (D604-5).
E: maybe. Macrocystic adenomas demonstrate "invariable transformation into cystadenocarcinoma" and are treated with "complete surgical excision." A malignancy would be unlikely to be stable for 5 years. (D595).
308. The right and left hepatic lobes are divided by the (1997):
a) RHV
b) LHV
c) MHV
d) falciform ligament
C: yep. "Middle hepatic vein divides the liver into R and L lobe. Also separated by main PV scissura (Cantlie line) passing through IVC + long axis of GB." (D561).
310. 60 yo man presents with acute abd pain and heme positive stool. KUB shows thickened folds in the transverse colon. Most likely dx:
a)ischemic colitis
b) colon CA
c) c. diff
d) IBD
Diverticulitis
A: maybe. See #289.
B: probably not. Colon CA can present with rectal bleeding and scirrhous CA is a "rare variant of diffusely infiltrating adeno CA." Abd pn is not typically a prominent feature. (D667).
C: probably. See #289.
D: maybe. See #289.
E: maybe. Diverticulitis can present with abd pn and "marked thickening + distortion of mucosal folds" but rectal bleeding is less common. (D673).
311.Contraindications to intussusception reduction in kids:
symptoms for 48 hrs
peritonitis
heme positive stool
A, C: probably not. No mention of either in my (admittedly sparse) resources. (D695, W764).
B: yep. Ralph lists it among the contraindications to reduction along with perforation. (W764).
312.What is true re Crohn disease
asymmetrical mural involvement
continuous involvement of colon and SB
most often involves SB and colon
frequently involves duodenum
A: probably not. It is most typically "transmural." (D669).
B: nope. Whereas UC demonstrates continuous involvement, skip lesions are more typical of Crohns. (D670).
C: yep. Wolfie lists involvement as follows: eso: rare, stom: 1-2%, duod 4-10%, sb 80%, colon 22-55%, appx 20%, rectum 14-50%. (D669-70).
D: nope. Unless one considers 4-10% as frequent. (D669-70).
313.Contraindications for rectal or vaginal drainage of abscesses
Crohn disease
A: Willy and Clyde list the following incomplete list of contraindications for biopsy (which they later state has the same general principles as perc drainage): "uncorrectable bleeding d/o … lack of safe pathway … uncontrolled pt." (D678). The tendency for fistula formation in Crohns makes this a plausible answer.