sunday 40 images for august 9 exam

@ MedicineShown below is the excretory urography image .

http://img.medscapestatic.com/pi/meds/ckb/42/18742.jpg

The most likely case history of this patient is

a) A 65 year old man presenting with painless hematuriab) A 32 year old female with SLE presenting with gross hematuriac) A 53 year old patient with ankylosing spondylitis who regularily takes

analgesicsd) A 70 year old with anemia , bone pains, High ESR

Ans CExcretory urography in a 53-year-old man with analgesic-induced nephropathy. A film obtained at 15 minutes after administration of contrast shows a wavy renal outline with tracks of contrast extending from fornix, ring shadows caused by the sloughing of papillae, and an egg-in-a-cup appearance characteristic of renal papillary necrosis. Note the bamboo spine, characteristic of ankylosing spondylitis.

analgesic-induced nephropathy. - Radiologically, ring sign. Also A/W sterile pyuria, distal RTA and nephrocalcinosis, mild proteinuria, inability to concentrate urine, anemia out of proportion to azotemia

@ Medicine A 75 year old woman presenting with azotemia had a bone marrow biopsy shown in Fig . The following features can occur in association with her diagnosis except:

http://healthfavo.com/wp-content/uploads/2014/09/Multiple-myeloma.jpgA. Eosinophilic intraluminal cast.B. Interstitial multinucleated giant cellsC. Distal RTAD. Post contrast ARFAns. C

Proximal RTA and Fanconi's syndrome occur in myeloma kidney

@ Medicine A 38 old female presents with eosinophiluria . Her renal biopsy is shown in Fig .The following are features of this condition except:

https://classconnection.s3.amazonaws.com/611/flashcards/3561611/png/eosinophils__aain-142C55B7DFE5C8B93F1.png

A. FeverB. Massive proteinuriaC. RashD. EosinophiliaAns. Beosinophils are the red dots; whole pic is acute allergic interstitial

nephritisallergic interstitial nephritis - Also present are eosinophiluria hematuria and pyuria.

@ 58. A 36 year old female had H/O joint pains ans her radiograph is shown in Fig .The most common glomerular involvement seen in this condition is:

http://nihdirectorsblog.files.wordpress.com/2013/01/05-05-0100.jpgA. MPGNB. Membranous nephropathyC. Amyloid nephropathyD. Minimal Change DiseaseAns. CX-ray image of the hands of a patient with rheumatoid arthritis. Note that the joints at

the base of the fingers are eroded — and some, like the index finger on both hands, are actually dislocated

@ A 32 year old femal presenting with dry mouth . Her labial biopsy and physical findings are shown in Fig .The most common renal manifestation of this condition is:

http://cdn2-b.examiner.com/sites/default/files/styles/image_content_width/hash/c1/07/c107839bec667bd77d04701bae7ebc43.jpg?itok=MRuS-yqR

http://www.nature.com/nrrheum/journal/v2/n5/images/ncprheum0165-f1.jpg

A. Membranous nephropathyB. MPGNC. Tubulointerstitial diseaseD. NoneAns. C

Sjogren's syndrome - a histologic slide prepared from a labial minor salivary gland biopsy that revealed lymphocytic infiltrates in two single foci

@ Medicine The physical examination and Liver biosy of a 34 year old male from Manipur presenting with hepatosplenomegaly are presented in fig .Which of the following manifestations of this condition is not reversed by phlebotomy?

http://www.intelligentdental.com/wp-content/uploads/2012/06/Pigmentation-of-the-skin.jpg

http://fe867b.medialib.glogster.com/media/75/75157893ee937e9c3265a7603a674cc7b03a45ee6c0af472c6517a3302eec4d8/iron-overload-jpg.jpg

A. DMB. Hepatic fibrosis

C. Cardiac failureD. ArthropathyAns. D

Hemochromatosis - Hypogonadism is also irreversible.

@ Pediatrics Shown in Fig is a female newborn child .An antenatal diagnosis of this condition can be made by demonstrating increased levels of which of the following in amniotic fluid:

https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcTkdwD-McifkJTQ-A-okR8Nr1HpxEWdRyI4ZSLUITJqtHsoJqAc

A. DHEA sulfateB. 17-hydroxyprogesteroneC. 11-deoxycortisolD. NoneAns. B

CAH in female

@ Orthopedics Dual-energy x-ray absorptiometry scan , radiograph and bone biopsy of a 72-year-

old woman is presented in Fig

http://img.medscapestatic.com/pi/meds/ckb/47/39347.jpg

http://img.medscapestatic.com/pi/meds/ckb/46/39346.jpg

http://www.clinicalimagingscience.org/articles/2014/4/2/images/JClinImagingSci_2014_4_2_1_129262_u5.jpg

Which of the following is true about the diagnosis?A. Ca++B. PO4C. Alkaline phosphataseD. AllAns. CDual-energy x-ray absorptiometry scan of a 72-year-old woman with Paget disease

of the lower leg and typical bowingRadiograph showing typical bowing.Hematoxylin and eosin stained biopsy tissue (×100) shows immature bone

either with osteoid and osteoblastic rimming, reversal lines, and enough fibrovascular stroma (arrow)

@ Radiology

http://www.nature.com/nrendo/journal/v3/n6/images/ncpendmet0513-f1.jpg

The imaging finding shown in Fig is because of which of the following content:A. Carbohydrate B. Phospholipid C. Glycoprotein D. HormoneAns. BPituitary bright spot on MRI

@ Surgery

http://diseasespictures.com/wp-content/uploads/2013/02/Graves-Disease-3.jpg

The following are risk factors for the condition shown in Fig except:A. Iodine deficiency B. SmokingC. StressD. Postpartum periodAns. A

Grave's disease - Iodine excess is a risk factor.

@Surgery

A 72-year-old male initially presented with left thyroid enlargement. The patient was clinically and biochemically euthyroid and without family history of thyroid disease, malignancy or personal history of radiation exposure. Fine needle aspiration is shown in Fig

http://images.radiopaedia.org/images/2124207/61695e7f081e707a858a179dd1e313_big_gallery.jpg

https://c1.staticflickr.com/9/8301/7782080648_618b75eecc_b.jpgThe following are true about papillary carcinoma thyroid except:A. Pathologically characterized by psammoma bodies.B. Orphan Anne nucleiC. Lymphatic spreadD. Poor prognosisAns. DUltrasound revealed a 1.5 cm right thyroid noduleFine needle aspiration was suspicious for papillary thyroid carcinoma with

hypercellular sheets and papillary arrangements of cells with occasional nuclear grooves

@ Pathology

The above shown histology of thyroid is a poor prognostic factor for:A. Papillary carcinoma thyroidB. Follicular carcinoma thyroidC. Anaplastic carcinoma thyroidD. Medullary carcinoma thyroidAns. BHurthle cell histologyThe thyroid follicular cells undergo metaplastic changes as a

result of continuing inflammatory cell damage resulting in so-called “Hurthle” cell or more appropriately “Oxyphil” cell change. These cells are larger with abundant finely granular eosinophilic cytoplasm and enlarged nuclei that may show some atypia (arrow). The oxyphil thyroid follicular cells either do not produce any thyroid hormones or produce it in negligible amounts. Note the presence of abundant lymphoplasmacytic infiltrate around follicles (curved arrow).

@ 166. BiochemistryA 67 year-old man with a history of hypertension and end stage renal disease on hemodialysis presented with the findings shown in Fig . . The lesions were painful but not pruritic . An enzyme-linked immunosorbent assay was positive for hepatitis C virus antibody, and serological tests were negative for other viral causes of hepatitis. The following are true about this condition except?

http://www.dartmouth.edu/~thabif/weeklyclinic111901/pictures/19porphyriact.jpg

http://imaging.ubmmedica.com/consultantlive/images/articles/2007/01092007/0709Con1PCTardaB.jpg

A. Cutaneous photosensitivityB. Neurological manifestations include autonomic neuropathy.C. Patients are at risk to develop hepatocellular carcinomaD. Treatment includes phlebotomyAns. B

Porphyria cutanea tarda - No neurological manifestations observed.

A 67 year-old man with a history of hypertension and end stage renal disease on hemodialysis presented with a blistering skin rash on his hands and face. Two weeks prior, the patient noticed blisters on his right and left hands; a blister on his lower lip developed and burst. The lesions were painful but not pruritic. On exam the patient’s blood pressure was elevated, but he was afebrile and vital signs were otherwise normal. His non- dermatologic exam was normal. The skin exam revealed a swollen, hypopigmented lower lip, and multiple flesh- toned plaques and ulcers on palmar and dorsal hands. No vesicles were

intact, and there were no lesions on his trunk, lower extremities, or genitals. An HIV ELISA was negative, but the hepatitis C (HCV) viral load >100,000/mL. Fractionated plasma porphyrins were elevated with uroporphyrin 262.4 mcg/L (<0.2mcg/L), heptaporphyrin 214.4 mcg/L (<0.2mcg/L), hexaporphyrin 7.8 mcg/L (<0.3mcg/L), pentaporphyrin 81.5 mcg/L (<0.4mcg/L) and coproporphyrin 12.8 mcg/L (<0.8mcg/L). Skin biopsy of the right hand was consistent with porphyria cutanea tarda (PCT). Based on the presence of elevated plasma porphyrins and characteristic skin biopsy, the patient was diagnosed with PCT.

@ Medicine

Most likey history of the patient with ECG shown in Fig is

a) A 38 year old female with h/o palpitations , diffuse enlargement of thyroid

b) A 42 year old patient suffering from sepsis with hypothermia

c) A 49 year old female with Mitral stenosis taking digoxind) 54 year old man with schizophrenia, bipolar affective

disorde who developed ventricular fibrillation

Ans D

The classic ECG pattern of Brugada is pseudo-RBBB with ST segment elevation in leads V1 through V3 . Clinical manifestations are nine times more common in men than women and more common in Southeast Asian populations. The pathophysiology is related to a defective myocardial sodium channel gene (SCN5A) in most patients, with variably penetrant autosomal dominant inheritance.

However, the syndrome is clearly heterogenous since the characteristic ECG findings can be seen with early right ventricular dysplasia, cocaine abuse, and certain psychotropic drugs. AICD implantation is the definitive treatment for Brugada syndrome, though one study suggests that administration of high-dose quinidine prevents arrhythmia while being both less expensive and less invasive. A proper diagnosis of Brugada syndrome will further allow the internist to screen the patient 8s family through regular ECG testing and to counsel avoidance of common medications that can precipitate a ventricular fibrillation pattern, including tricyclic anti-depressants and sodium channel blockers.

@ Pathology Peripheral smear shown in Fig is seen in:

http://www.mclno.org/webresources/kbase/cellatlas/cell%20images/Acanthocyte.jpg

A. UremiaB. Prosthetic valveC. CirrhosisD. Folate deficiencyAns. C

Acanthocytes@ pHARMACOLOGY

Liver histopathology is shown in Fig .The following drugs must be avoided in this patient except:

https://upload.wikimedia.org/wikipedia/commons/9/94/Cirrhosis_high_mag.jpg

A. IndapamideB. ParacetamolC. DiazepamD. AspirinAns. BCirrhosis

Paracetamol can be given in a dose of less than 2g/ d.

@ Pharmacology A 44 year old female presenting with pruritis with serologic positivity of anti-mitochondrial antibodies. Her Liver biopsy is shown in Fig .All of the following is used to treat this condition except ?

http://www.ojrd.com/content/figures/1750-1172-3-1-1-l.jpgA. UrsodiolB. Cholestyramine

C. Zinc supplementationD. Pegylated interferonAns. DPrimary biliary cirrhosis, demonstrating chronic non-suppurative

destructive cholangitis (stage 1 of Scheuer's classification).

@ Medicine A 47 year old patient with antiphospholipid syndrome presented with abdominal pain . The physical findings and angiogram are shown in Fig .Which of the following is not a clinical feature of this condition ?

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NewPicture.bmp?width=399&height=600

http://images.radiopaedia.org/images/1363866/95b1e965fe3b6897b06902cef949fc.jpg

A. Tender hepatomegalyB. Intractable ascitesC. Increased JVPD. Right upper quadrant painAns. CSpider web appearance - Budd - Chiari syndrome

@Surgery A 75 year old patient with refractory peptic ulcer . His CT abdomen image is shown in Fig . The most sensitive test for diagnose of this condition is:

http://lh3.ggpht.com/-cZnHu4jiduo/UtHg-serCCI/AAAAAAAAOZE/35r4sHz2nmw/image_thumb1.png?imgmax=800

A. BAO/MAO >0.6B. Increased fasting gastrinC. Calcium infusion studyD. Secretin stimulation testAns. D

Radiology images of gastrinoma in a 75-year-old man. Transverse precontrast CT identifies enlargement of the pancreatic head (arrow).@ Pathology

http://jcp.bmj.com/content/62/6/481/F6.large.jpgThe following are causes of the condition shown in Liver biopsy in Fig except:A. Alcoholic liver diseaseB. Reye's syndromeC. Syndrome XD. LipodystrophyAns. B

macrovesicular hepatic steatosisMicrovesicular fat.

@SurgeryA 57-year-old alcoholic man is being treated for acute hemorrhagic pancreatitis. He was in the intensive care unit for 1 week, where he required chest tubes for pleural effusions and was on a respirator for several days. Eventually, he improved sufficiently to be transferred to the floor. Three days after leaving the unit, and about 2 weeks after the onset of the disease, he spikes a fever and develops leukocytosis The following are risk factors for his condition except:

http://www.joplink.net/prev/200605/07_fig01.jpg

A. Post-op pancreatitisB. Early laparotomyC. Injudicious use of antibioticsD. Late oral feeding.Ans. D

Early oral feeding risk factor.pancreatic abscessContrast-enhanced computed tomography (CECT) of the abdomen

showing two hypodense collections with a thick enhancing wall (pancreatic abscess).

@ Medicine Which of the following is not a feature of the condition shown in a a 32-year old

woman from Kolkata presenting with hempptysis and lung biopsy was done ?

http://www.aafp.org/afp/2005/0315/afp20050315p1062-uf1.jpg

http://images.rheumatology.org/image_dir/album75674/md_05-12-0115.jpgA. Granulomatous vasculitis of upper respiratory tractB. Granulomatous vasculitis of lower respiratory tractC. Granulomatous glomerulonephritisD. All are trueAns. CChest radiography showing a large infiltrate with a central cavitation in the

right upper pulmonary field.Right upper lobe lung nodule biopsy from a 32-year old Asian woman showed

a necrotizing granuloma of loosely arranged mononuclear and polymorphonuclear leukocytes with giant cells (left, low power), consistent with diagnosis of Wegener’s granulomatosis. High power close-up of Langhans giant cell (right), characterized by peripheral localization of nuclei. (haematoxylin-eosin, low and high power of same lesion)Granulomas are only rarely seen on renal biopsy.

@ MedicineA 32 year old patient sexually active male with single partner without promiscuity presented with blurring of vision and findings as shown in Fig . His diagnosis is characterized of all except

https://www.rareconnect.org/uploads/assets/behcet-s-photos/single-oral-aphthous-ulcer.JPG

https://upload.wikimedia.org/wikipedia/commons/a/a0/Hypopyon.jpgA. Oral ulcerationB. Genital ulcerationC. Pathergy test positivity D. pANCA positivityAns. DBehcet's syndrome A person with hypopyon which can be seen in anterior

uveitis in a patient with Behcet's disease

@ Medicine The physical and radiologic features of 34 year old female from Mumbai

presenting with pulmonary hypertension are shown in Fig .The following are increased in patients with this diagnosis except:

http://www.immunologyclinic.com/jpg/300_96dpi/HH8_300.jpg

http://images.radiopaedia.org/images/130254/88c9ef8dc8ecd819c92dedcb755332_big_gallery.JPG

A. EDRFB. ICAM-1C. von Willebrand factor D. EndothelinAns. A.

systemic sclerosis EDRF not increased appropriately, suggesting impaired synthesis.

@ Pediatrics

A 12 year old child with past h/o measles that subsided presents with myoclonic seizures .His neuroimaging findings are shown in Fig . Which is not true regarding his diagnosis?

http://www.infobik.com/wp-content/uploads/2011/11/SSPE.jpgA. Chronic form of measles encephalitisB. associated with defective measles versusC. Antibody response to measlesD. Common in children who develop measles before the age of 2Ans. C

High levels of antibody to measles versus in blood andCSF.