Friday, October 4, 2013

Medicine Image MCQs: Retinal spots

Q. What do you see on this fundoscopic exam?

a. Retinal detachment
b. Hard exudates
c. Papilledema
d. AV nicking
e. Cotton spots
f. Macular edema
Answer E
1. You better know this. There is not much you need to know for ophthalmology, but this is one you need to know
2. These are cotton wool spots. Look at it and remember for the rest of your life

Q. You are most likely going to see cotton wool spots in a patient with-
a. Cataracts
b. Diabetes
c. Hyperthyroidism
d. Glaucoma
e. Horner syndrome
Answer B
1. Diabetes mellitus and systemic hypertension are by far the most common cause of cotton-wool spots. In patients who have a cotton-wool spot and no known history of diabetes, an elevated blood sugar level is identified in 20 percent of patients and an elevated blood pressure (diastolic blood pressure of 90 mmHg or greater) in 50 percent of patients.
2. Patients with diabetes mellitus might also harbor other typical retinal findings such as macular edema, retinal exudate, flame or dot/blot hemorrhages, microaneurysms, venous beading or microvascular abnormalities or proliferations. Conversely, patients with systemic hypertension would be expected to demonstrate generalized arteriolar narrowing, arteriolar/venous nicking and, in extreme cases, optic-disk swelling.

3. In addition to systemic hypertension and diabetes mellitus, cotton-wool spots may be found in numerous other diseases. These diseases can be generally divided by cause into ischemic, embolic, infectious, toxic, radiation-induced, neoplastic, tractional, traumatic, immune-mediated and idiopathic causes. 

Surgery Image MCQs: Barium enema

A 55 year old male with painless GI bleeding undergoes a barium contrast study. The image is shown below. What do you see in the left lower quadrant, highlighted in red?

a. AV malformation
b. Meckel diveerticulum
c. Polyps
d. Diverticuli
e. Intussusception

Answer D
1. Painless GI bleeding in adults is either cancer or diverticulosis
2. The bleeding can be massive and frightening from diverticulosis
3. What you see on the image are pockets of diverticuli which have retained the barium
4. Remember polyps are inside the lumen; diverticuli are on the external surface of the serosa
5. If bleeding is massive and ongoing, surgery is the only definitive treatment. You can’t embolize the blood supply to the colon, otherwise you will develop ischemic bowel and create another major problem- including a lawsuit for being a moron.

Anatomy Image MCQs: IM injection

Q.Which quadrant will you usually administer an IM injection?
a. A
b. B
c. C
d. D

Answer B 

Q. For an IM injection into the gluteus medius, your landmarks are:
a. Lateral aspect of thigh
b. Midline between trochanter and posterior iliac crest
c. Midline between anterior and posterior iliac crest
d. the softest part of the buttocks
e. Midline between anus and Trochanter

Answer B
1. One of the problems with IM injections in the buttocks is injury to the sciatic nerve-trust me I review at least one case a week from nurses who have injected in the wrong site
2. Find the trochanter. It is the knobbly top portion of the long bone in the upper leg (femur) which is the size of a golf ball
3. Find the posterior iliac crest. Many people have ‘dimples’ over this bone
4. Draw an imaginary line between the two bones. After locating the centre of the imaginary line, find a point one inch toward the head.

Thursday, October 3, 2013

Medicine Image MCQs: The eyes!

A 22 year old female is seen in the clinic for a rash on her hands which she developed while hiking in the woods.  During the exam, you notice something unusual on her face. She has no head and neck symptoms. She has no other prior medical history. She is on no medications and has no allergies. She denies any trauma. The image is shown below. Your diagnosis is:

a. Horner syndrome
b. Hyphema
c. Cataracts
d. Blepharitis
e. Anisocoria
f. Osteogenesis imperfecta

Answer E
1. Anisocoria, or unequal pupil sizes, is a common condition. The varied causes have implications ranging from life threatening to completely benign, and a clinically guided history and examination is the first step in establishing a diagnosis.
2. The history of anisocoria is dependent on the specific pathophysiology.
The pupil size difference itself seldom produces specific symptoms (eg, unilateral photosensitivity with mydriasis). Associated features (with an underlying condition) may produce symptoms that lead to evaluation (eg, diplopia, photophobia, pain, ptosis, blur).
3. Anisocoria may also be discovered incidentally by an observer.
Onset of anisocoria: Old patient photographs often help to date anisocoria that is unaccompanied by other symptoms.
4. Key aspects of the physical examination (eg, pupil size in light, pupil size in the dark, pupil reactivity to light and dark) help to localize the problem. Additional historical features such as pain, diplopia, or ptosis help generate a differential diagnosis.

Surgery Image MCQs: Colonoscopy

Q. A colonoscopy is done in a 24 year old with traces of blood in stools. The patient has a strong history of colon cancers. The colonoscopy image is shown below. If this patient also had a medulloblastoma at the same time, which syndrome does he have?

a. Gardner
b. Turcot
c. MEN
d. Cronkhite Canada
e. Peutz Jeghers
Answer B
1. First when you can see many polyps in  young patient and with a family history of colon cancer, you must suspect familial polyposis coli- You must entertain this diagnosis unless you want a malpractice case-no excuse.
2. Gardner syndrome is characterized by colonic polyposis typical of FAP, along with osteomas (bony growth most commonly on the skull and the mandible), dental abnormalities, and soft tissue tumors. Turcot syndrome is characterized by colonic polyposis typical of FAP, along with central nervous system tumors (medulloblastoma). AAPC is characterized by fewer colonic polyps (average number of polyps, 30-35) as compared to classic FAP. The polyps also tend to develop at a later age (average age, 36 y), and they tend to involve the proximal colonic area.
3. Colonoscopy is considered the diagnostic test of choice as it can provide not only a quantification of polyps throughout the colon but also a histologic diagnosis. Barium enema and virtual colonoscopy can suggest the diagnosis of FAP.
4. Once the diagnosis of FAP is made, close colonoscopic surveillance with polypectomy is required. Prophylactic colectomy is indicated if more than a hundred polyps are present, if there are severely dysplastic polyps, or if multiple polyps larger than 1 cm are present. When a partial colectomy is performed, colonoscopic surveillance of the remaining colon is necessary as the individual still carries significant risk of developing colon cancer.

Surgery Image MCQs: Barium enema

The 33 year old female presented with bloody stools for 2 years and abdominal pain. She had back pain and visual problems which had just started a few weeks ago. In which of the following disorders are you most likely to see a barium study as shown in the below image?

a. Crohn disease
b. Ulcerative colitis
c. Irritable bowel syndrome
d. Whipple disease
e. Celiac disease

Answer B
1. Lead pipe sign - describes the rigid and featureless appearance of the colon in chronic ulcerative colitis.
2. The sign is due to a complete loss of haustral markings and usually a degree of uniform luminal narrowing due to chronic bowel wall thickening. It is classically described on barium enema studies however it is also often seen with CT, MRI and plain radiography. 
 3. The diagnosis of ulcerative colitis is best made with endoscopy. Endoscopically, ulcerative colitis is characterized by abnormal erythematous mucosa, with or without ulceration, extending from the rectum to part or all of the colon. The inflammation is uniform, without intervening areas of normal mucosa, while skip lesions tend to characterize Crohn disease. Contact bleeding may also be observed, with mucus identified in the lumen of the bowel. Biopsy of the mucosa is recommended to identify the extent of the disease with respect to the thickness of the bowel wall

Wednesday, October 2, 2013

Medicine Image MCQs: Retina

Q. You are performing fundoscopy in a 57 year old male. Before we go into specifics, what do you see at letters a, b, and c?

a. Hollenhorst bodies
b. Cotton woolspots
c. AV nicking
d. Hard exudates
e. Proliferative retinopathy

Answer: see below. This is very basic stuff that you MUST know. Very common exam question.

Q. In which medical disorder are you likely to see the above fundoscopic changes?
a. Cerebral edema
b. Brain tumor
c. Diabetes
d. Hypertension
e. Glaucoma

Answer D
1. Signs of damage to the retina caused by hypertension include Arteriolar changes, such as generalized arteriolar narrowing, focal arteriolar narrowing, arteriovenous nicking, changes in the arteriolar wall (arteriosclerosis) and abnormalities at points where arterioles and venules cross. 
2. Manifestations of these changes include Copper wire arterioles where the central light reflex occupies most of the width of the arteriole and Silver wire arterioles where the central light reflex occupies all of the width of the arteriole, and "arterio-venular (AV) nicking" or "AV nipping", due to venous constriction and banking.