ABFM 2018 50-100 Flashcards
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34 y/o F with 3 month history of nonproductive cough.
Exam-negative.
Rx: intra-nasal corticosteroid.
68-year-old female presents with a history of episodic severe lower abdominal pain relieved by defecation.
Dx:IBS
Rx: Polyethylene glycol.
Distal biceps tendon rupture.
Dx: MRI of elbow.
72-year-old male with DM II takes Glucophage 1000 mg twice a day; BMI 32; hemoglobin A1c 9.5 .
Rx: Start basal insulin at 10 u/ day.
47-year-old male with bilateral L/Ext. edema with fatigue. Lipid levels were high; thyroid function normal with a positive periorbital edema
Dx: Nephrotic Syndrome; + urine proteinuria.
66-year-old female with bone metastasis having breakthrough pain. Given 10 mg of oxycodone 15 minutes ago.
Last dose peak effect one hour after given.
62-year-old female with history of COPD FEV1 165% PaO2 57; Dx: Pulmonary hypertension.
Rx: supplemental oxygen.
Antihypertensive drug that may reduce severity of sleep apnea.
Spironolactone (Aldactone).
US preventative services task force absolute risk reduction for developing diabetes mellitus.
1/7
25-year-old female with irregular menses, her to resume and moderate acne prefers not to be pregnant.
Rx: Levonorgestrel/ethinyl estradiol
68-year-old male with chronic right knee pain from osteoarthritis. Tylenol and NSAIDs - limited help.
Rx: A low impact aerobic exercise program.
52-year-old female with a history of gastric bypass, DJD of both knees and shoulder and chronic LBP.
Rx: Taper oxycodone by 5%-10% every 1-4 weeks.
13-year-old male with pain and throwing arm with no history of acute injury.+Tenderness over proximal and lateral humerus.
Dx: Plain x-ray to distinguish rotator cuff pathologies from disruption o proximal growth plate of the humerus.
30-year-old female with an episode of recurrent painful vesicular lesions on the labia with tingling sensation a few days before the lesions appeared.
Rx: Valacyclovir (Valtrex).
62-year-old Asian female with pain and redness in her left eye since last night. Now has headache, light sensitive sensitivity and mild nausea. Visual acuity 20/100 on left,
Rx: Emergent evaluation by ophthalmologist.
Dx: Acute angle-closure glaucoma.
24-year-old female with a history of bulimia nervosa . Which drugs has an increased risks of seizures in these patients?
Bupropion (Wellbutrin).
3-year-old male with in turning toes and clumsy gait. Dx: Internal tibial torsion.
Rx: Observation;Surgery after age 8, if no resolution.
24-year-old female with recent onset of coughing when running. Normal spirometry..
Rx: An inhaled short-acting beta 2 agonist 15 minutes before running.
Malignancy associated w Hereditary Hemochromatosis
Hepatocellular Carcinoma.
62-y/o F admitted to hospital for intractable nausea and vomitinng with volume depletion and hypotension. Living in New Mexico; cleaning out chicken coop with rodents. Blood cultures positive for gram-negative rods.
Dx: Yersinia pestis. (Western U.S.)
21-year-old female with secondary re hypertension. What test is most specific for fibromuscular dysplasia?
Magnetic resonance angiography of the renal arteries.
Greatest risks for developing knee osteoarthritis as an older adult.
Obesity.
88-year-oldd female at assisted living facilities with chronic urinary incontinence. Afebrile with urine culture greater than 100,000 Escherichia coli.
Rx: No antibiotics. (Asymptomatic bacteriuria).
61-year-old white M w DM II- wll-controlled BP 156/94;
Rx: Add an Ace Inhibitor.
66-year-old w previous h utilized motivationalx of HTN, and carotid endarterectomy presents with acute upper abdominal pain past 3 hours. (Suspect Mesenteric Ischemia)
Dx: CT angiography.
38-year-old female with migraine headaches wishes to start contraception.
Rx: Estrogen-containing products including patch and vaginal ring are contraindicated in patients with migraines.
45-year-old M truck driver with HTN and DM and obesity.. His BP is 166/94 and hemoglobin A1c is 9.7
Rx: Utilized motivational interviewing to explore patient’s level of desire to change.
47-year-old male attempts to climb Mt. Rainier. First day he ascends to 11,000 feet. Next morning he has a headache nausea dizziness and fatigue. As he climbs a becomes ataxic and confused
Rx: Administration of oxygen and immediate descent.
68 y/o M with basal cell CA; which procedure has highest rate of cure?
Rx: Mohs surgery.
55-year-old female pre-op evaluation for cataract surgery. Previous history of diabetes mellitus I. cardiovascular and pulmonary examinations are unremarkable.
No further preoperative evaluation necessary.
New anticoagulants-Eliquis. Pradaxa, Savaysa & Xarelto before starting get:
Renal Function.
42-year-old male alcoholic with his last drink 7 days ago asked for medication.
Rx: Acamprosate (ETOH).
46 y/o M 40 pp year hx of smoking presents with 2 month history of dyspepsia and difficulty swallowing reports 20 lb weight loss & takes Prilosec.
Dx: Upper endoscopy (Esophageal CA ?)
16-year-old white male with sports preop:Ht.-6’2”,wt.-152 lbs. w long arms,high arched palate, kyphosis,myopia,& pectus excavatum.
Dx: Marfan’s Syndrome (Aortic Insufficiency).
46 y/o M with 30 year hx of smoking w multiple episodes of quarter size bloody emesisis over the past few days; chest x-ray negative.
Dx: CT of chest with contrast.
68 y/o F with SOB with activity over the past few weeks, also reports lower extremity edema patient has hx of by tricuspid aortic valve and aortic stenosis. Ejection fraction estimated at 50%.
Rx: Referral for aortic valve replacement.
45 y/o F with IBS as a six-month hx of crampy, diffuse abdominal painn associated with defecation. According to the for Rome IV criteria and associated Sx would be-?
A change in stool frequency.
the U.S. Preventatiive Services Task Force recommend diabetes mellitus no sooner than:
24 weeks gestation.
20-year-old football player presents with pain in the fifth proximal metatarsal. + tenderness to palpation. Plain films show no signs of fracture.
Dx: MRI of foot. (Stress fracture ?).
84 y/o F with severe dementia secondary to Alzheimer’s disease is a resident of long-term care facility. She has shown increase aggression staff and other residents. Unsuccessful management of Sx’s; suggests starting low-dose Risperdal.
Potential side-effect: Inc. risk of mortality.
Diabetes treatment most likely to cause weight gain?
Glimepiride (Amaryl).
34-year-old healthy female presents with 1 hour history of palpitations. (EKG shows atrial fib).
Dx: Get TSH ( Subclinical Hyperthyroidism).
14-year-old male with 2 month history of left breast lump. PE: Slightly tender area of concentric firm mobile tissue under left areola No skin changes, nipple disch or at the adenopathy.
Rx: F/U in 6-12 months (Gynecomastia).
52y/o M presents with long-standing facial rash that is itchy, flaking and scaling around his mustache and nasolabial folds.
Dx: Seborrheic dermatitis;Rx: Topical fungal agents.
58-year-old male routine health visit has 20-pack-year smoking history but has stopped 1 year ago. U.S. Preventative Services Task Force recommends:
Hepatitis C Screening.
a 30-year-old female postpartum 3 months mild depressions in the past 7 weeks. Little joy in daily activities and not interacting with baby. U rule out postpartum psychosis and bipolar disorder
Rx: Appropriate treatment is referral to psychotherapy.
Preferred treatment for rheumatoid arthritis.
Rx: Methotrexate (Trexall).
68 y/o F with controlled HTN and OA of knee with BMI of 36. Scheduled for elective total knee replacement.
Rx: Start statin immediately to decrease risks of cardiovascular disease & peri-operative mortality
40 y/o M presents with clean catch U/A -5 red blood cells/hpf on microscopy.
Dx: Cystoscopy.
68-year-old female presents with a 3 month history of low back pain and fatigue. She also has unintentionally lost 15 pounds. Positive PE for vertebral point tenderness over t lumbar vertebrae. Lab: Normocytic anemia elevated total protein and mild decrease in renal function.
Dx: Serum protein electrophoresis (multiple myeloma).
48-year-old female with type 2 diabetes mellitus first line for initiating treatment.
Metformin (Glucophage).
22-year-old female prevent for evaluation of nasal and sinus congestion, frequent sneezing and itchy red eyes.
RX: Intranasal Budesonide (Rhinocort).
Elderly male presents with venous ulcer,
Rx: Compression therapy.
Most reliable measure to protect children from lead toxicity in the US
Eliminating the sources of lead in the community.
64 y/o female with HTN, DM, HLD and CKD with headaches.
Dx: MRI should not include use of gadolinium contrast,
29-year-old gravida 2 para 1 scchedule for induction of labor, Which one should be avoided to minimize the risks of postpartum hemorrhage in this patient
Routine episiotomy.
64-year-old male with midsternal chestt pain in ER with oxygen and IV line in place. Shortly after a viral he loses consciousness and be called once apnei and pulseless; CPR is initiated V. tach at 160.
Rx: Defibrillation.
Patients with COPD shown to reduce exacerbations with—-
Rx: Tiotropium (Spiriva).
52-year-old male with a BMI of 33.2 with mild elevations in ALT and AST.
Dx: Get serum ferritin (R/O Hereditary Hemachromatosis).
62-year-old white male with a 3 month history of diabetes mellitus with hemoglobin A1c of 7.8. Which test indicates whether he can safely take metformin (Glucoophage).
Estimated glomerular filtration rate’
43-year-old male with 6 week history off right ankle pain. No history of fall pain localized inn the right Achilles tendon area proximal to the insertion.
Initial treatment: Eccentric gastrocnemius-strengthening program.
45-year-old male presents with a Hx of 2 months nonpproductive cough, SOB, fatigue and 5 pound weight loss. Examination PPD negative lungs clear, chest x-ray shows bilateral hilar adenopathy and angiotensin converting enzyme level is elevated. Biopsy of lymph node showed noncaseating granuloma.
Rx: Prednisone.
40-year-old white female with history of anxiety, insomnia, fatigue, persistent depressed mood and low libido.
Dx: Dysthymia.
Vaccine recommended for all women with each pregnancy.
Tdap.
26-year-old male presents with rash on his anterior neck in the area of his beard past year with curly facial hair and tender red papules on the superior anterior neck.
Rx: Shave with electric clippers.
54-year-old male with past history of hypertension treated with lisinopril and hydrochlorothiazide has not taken medicine for over a year. BP is 200/115 on 2 separate readings 5 minutes apart. PE–Nl.
Rx: Restart prior HTN treatment follow-up in 1 week.
Follow-u p in 17-year-old female presents with a month history of menorrhea irregular menses with a BMI of 16.1
Dx: RED-S ( female athletic triad). Rule out osteoporosis-get DEXA scan.
45-year-old male with bump on left denies trauma. PE movable, slightly tender.
Dx: Olecranon Bursitis; no further evaluation.
25-year-old gravida 1 para 0, 24 weeks gestation with right lower DVT.
Rx: Lovenox (subcutaneous enoxaparin).
46-year-old female with history of polycystic ovary syndrome and migraine headaches presents with bilateral hyperpigmented patches along her mandible.
Dx: Malasma ( probably caused by oral contraceptives).
73-y with memory changes with Hx of HTN, depression and hypothyroidism.
Which medicines should be stopped because of possible hypoglycemia?
Glyburide.
75-year-old white male with a history of CHF. Which medicine would improve symptoms and decrease mortality risks?
Rx: Spironolactone (Aldactone).
67-year-old female with colon cancer and acute SOB X 2 days, diagnosed with PE.
Rx: Continue enoxaparin upon discharge.
32-year-old Iraqi female refugee should be screened–
Dx: posttraumatic stress disorder.
35-year-old m smokes half pack cigarettes a day and 3-4 beers per week. SGOT of 84. Lab findings suggest?
Dx: Alcoholic liver disease.
48-year-old female presents with dyspnea with exertion. Non-smoker chest x-ray–hyperexpansion of chest, FEV1/FVC ratio 0.67.
Dx: COPD; @1-Antitrypsin deficiency.
52-year-old pianist with carpal tunnel syndrome.
Dx: decreased sensation over the palmar aspect of the thumb, index, and middle finger.
67-year-old female with HTN and A. fib taking Coumadin for the past 10 years. Scheduled for elective bladder sling surgery. surgery.
Rx: Discontinue Coumadin 5 days prior to surgery and restart it 12-24 hours post-op.
48-year-old female smoker with solid discharge or, sometimes regurgitating food sticking below the suprasternal notch.
Dx: Endoscopy ( esophageal dysphagia).
7-year-old female with fivve-day history of abdominal pain and low-grade fever of 100.1 with non-pleuritic or painful rash; positive for micro-hematuria.
Dx: Henoch-Schonlein purpura.
Rx: sSupportive care only.
18-month old F with barking cough ,fever, hoarseness with X 2 days.
Dx: Croup.
Rx: Single dose of oral dexamethasone.
Hypoxemia during an acute illness is often short-lived.
Oxygen supplementation should be re-evaluated and most often discontinued.
26-year-old female with polycystic ovary disease (PCOS) would like to become pregnant.
Rx: Letrozole (Femara) —best treatment for live birth and ovulation rates.
58-year-old male with history of tobacco and alcohol abuse with sudden onset of well circumcised , old for,, rough papules on trunk and proximal extremities.(with “stuck-on” appearance).
Dx: R/O Adenocarcinoma of the stomach– Get upper and lower endoscopy.
6-yar-old male presents with fever and you suspect RMSF.
Rx: Doxycycline.
38 y/o F w DM, obesity & chronic abd. pain (Hx pancreatitis). HbA1c-9.0;Gluc.-200-300
Did poorly on Glucophage;Doesn’t want insulin.
Rx: Start Jardiance (empagliflozin).
AAof Peds: Suspicion of head lice.
Rx: Child to stay in class with no Rx, unless clear Dx with live lice seen.
False lowering of HbA1c w DM
Hemolytic Anemia.
52-year-old male w hx HTN,COPD, DM II, & bipolar disorder w new onset of tremors.
Most likely caused by Lithium Rx.
57-year-old patient is hospitalized for community-acquired pneumonia and treated with fluoroquinolone. Compared to 5 day course of antibiotics with longer course.
Rx: No difference in clinical outcome.
45-year-old female with intermittent asthma only taking albuterol inhaler. She is using inhaler daily and waking up at night once or twice a week with a cough.
Rx: add Advair ( Fluticasone/salmetterol).
In addition to group B-Streptococcus, the most common cause of neonatal sepsis.
E coli.
The US preventative services task force force recommends screening for major depression disorder in adolescence 12-18 years of age.
Screen if systems are in place for diagnosis, treatment and follow-up.
64-year-old male with tinnitus in both ears for the past 3 years. Troublesome at bedtime. Only medication iss Zyloprrim for gout. Cause of tinnitus most likely—
Dx: Sensorineural hearing loss.
49-year-old male with lesions on his penis over the past 6 months. Denies pain, itching or dysuria. Exam reveals multiple reddish-blue papules on the scrotum and shaft of penis.
Dx: Angiokeratoma’s (Fabry disease).
36-year-old female with 10 year history of daily headaches. Headaches are bilateral lateral and not aggravated by activity. Worse at night. Neurological exam-normal.
Rx: Amitriptyline ( chronic tension-type headache).
38-year-old female with five-year history of diabetes mellitus developed “pins and needles” sensation in her feet.
Rx: Pregabalin (first line therap painful diabetic peripheral neuropathy).
32-year-old female presents for evaluation of hair loss. PE: smooth circular area of hair loss on scalp.
Rx: Intralesional corticosteroids. (Alopecia Areata).
64-year-old female in ER for polynephritis.. Her temp 102, pulse rate 110, respiratory rate 24, blood pressure 136/72 and oxygen sat 94% on room air. Venous lactate level is 4.0
Dx: Sepsis
Rx: Normal Saline at 3000 ml. over 3 hrs.
54-year-old female in for wellness exam. She had screening mammography 10 years ago with dense breasts otherwise normal. Need for MRI of the breasts—
Chest radiation for Hodgkin’s disease.
To reduce dosing issues a nurse should supply parents with—-
An oral syringe.
26-year-old female presents with a skin rash and chronic diarrhea. Transaminase antibody is positive
Dx: Dermatitis herpetiformis
26-year-old male with a history of major 4-5 years;Rx: contraindicated—
Fluoxetine (Prozac)
35-year-old With a history of recurrent wheezing and coughing over the past few weeks brown sputum plugs.
Dx: Allergic bronchopulmonary aspergillosis
89-year-old female with a history of glaucoma and hypertension;EKG–Lt. Ventricular ballooning,
Dx: Takotsubo cardiomyopathy.
Leading cause of cancer death in men in the US.
Lung cancer.
Patient treated with buprenophine . Which is best adjuvant treatment?
Clonidine (Catapres).
5-month-oold female with temp 103.1 over the past 2 days . she does not appear ill on physical examination.
Dx: Urinalysis and culture with outpatient follow-up.
Medical directors edict for appropriate antibiotic use.
By writing a delayed antibiotic prescription when appropriate.
Presence of RBC casts on microscopic spun urine sediment.
Dx: Acute Glomerulonephritis.
15-year-old male injuring right index finger playing volleyball with flexion deformity at DIP joint.
Further evaluatiion before splinting: Inability to passively fully extend the joint. (Mallet Finger).
42-year-old male presents with fever, cough, and chest pain. is positive.
Rx: ibuprofen.
55-year-old male smoker with a history of diabetes mellitus, hypertension and hyperlipidemia. MI 2 years ago with stent
Rx: Stop taking Clopidogrel.
60-year-old male should take both Prevnar 13 and Pneumovax 23 with a diagnosis of:
Chronic renal failure.
36-year-old male with a 2 day history of painless right-sided facial droop.
Dx: Bell’s palsy.
Rx: Valacyclovir & a tapering dose of prednisone.
35-year-old female presents with fatigue her menstrual cycle has been irregular & heavy X 2 months.
Dx: B-hCG.
Patient presents with truncal obesity, hypertension, type 2 DM, osteopenia, and skin fragility.
Dx: Cushing Syndrome (Urinary free cortisol).
42-year with SOB over the past 6 months. 20-year-old cigarette smoker who quit 6 years ago. Serum bicarbonate level 35 mEq per liter.
DX: Obesity hyperventilation syndrome.
58-year-old female with drug eluding-stent the past 10 days for acute CAD.
Rx: Clopidogrel and aspirin for one year, then aspirin alone.
45-year-old female with throbbing right heel pain the past few weeks. Denies history of trauma. Tenderness along the plantar fascia.
Dx: Plantar fasciitis.
36-year-old female singer with 10 day history of hoarseness. Nonsmoker; normal PE.
Dx: Short duration laryngitis.
Rx: No talking, whispering, or throat clearing for 48 hours.
74-year-old female with long-standing history of CAD hospitalized for pneumonia. EKG: second-degree Mobitz I.
Rx: cardiac rhythm monitoring with no additional treatment.
Rx: For anaphylaxis—
Epinephrine.
A 50-year-oold male with hypertension should begin low-dose aspirin for what 10 year risk level for CVD?
10%.
Baby-friendly hospital initiative must include–
Providing no other food or fluids to breastfeeding infants without a medical indication.
50-year-old gravida 2 para 23 years postmenopausal presents with fatigue, headache, galactorrhea, and loss of libido. Evaluation reveals elevated serum prolactin and pituitary adenoma of 5-6 mm.
Dx: Pituitary microadenoma.
Rx: bromocriptine (Parlodel).
Referral for bariatric surgical evaluation is indicated for patients with a BMI of :
36 kg/m2 and DM II.
75-year-old patient requires medica reconciliation on admission and discharge to detect—
Medication discrepancies.
29-year–old male smoker with a 10 day history of cough. Low-grade fever X 2 days-resolved.. PE: mild rhinorrhea;lungs-clear.
Dx: Acute bronchitis-viral (90%).
Rx: Supportive care only.
According to the American heart association patients that need prophylaxis—
A 35-year-old female with a history of infectious endocarditis that was related to intravenous drug use.
69-year-old male presents with acute right hip pain. Denies history of trauma. PE: limited ROM; C-reactive protein mildly elevated.
Dx; Arthrocentesis; (Septic Arthritis).
Rx for obsessive-compulsive disorder.
Cognitive-behavioral therapy.
63-year-old female taking omeprazole 20 months.
Dx: Rx associated with hip fracture.
4-year-old male for well-child visit new skin lesions first appearing on back and now behind right knee. PE: Flesh-colored, dome shaped papules.
Dx: Molluscum contagiosum.
Rx: Observation only.
34 y/o M with 3 day history of runny nose, postnasal drainage, sinus congestion, and left- sided facial pain.
Dx: Acute Rhinosinusitis
Rx: Mometasone ( Nasonex).
What age to switch to universal screening strategy for colon cancer ?
Age 75.
18-month-old male for well child visit has suggestion finding of muscular dystrophy.
Dx: . Head lag when sitting up.
Commonly associated with oligohydraminios–
Posterior urethral valves.
47-year-old female carpenter secondary to trauma. Best coverage for MRSA or Strep pyogenes
Rx: Trimethoprim/sulfamethoxazole & Cephalexin..
65-year-old male with hemoglobin 10.2 mean corpuscular volume 80 ferritin level/millimeter, reticulocyte index 0.3%.
Dx: Iron deficiency anemia
Cross-side baby needs ophthalmology referral by what age?
6 months.
47-year-old male with three-day history of fever, chills, low back pain, and urinary urgency. Temp 100.6 pulse 88 respiration 14 per minute.
Dx; Culture of midstream 40 urine (acute bacterial prostatitis).
57-year-old female admitted for lower lobe pneumonia. No history of diabetes mellitus but has a blood glucose level of 172.. At what level should insulin B initiated.
180/dL
Best prevention for Traveler’s diarrhea?
Wash hands frequently.
52-year-old smoker presents with respiratory symptoms X 24 hours with rapid onset of fever chills nausea myalgias and sore throat. PE :temp 101.8, O2 sat 94% on room air, heart rate 102, respiration 24.
Dx: Influenza
Rx: Tamiflu (Oseltmivir).
33-year-old female gravida 2 para 2 presents with one-year history of a menorrhea, hot flashes, and vaginal dryness, Lab: elevated LH and FSH levels.
Dx: Primary ovarian insufficiency.
2-year-old female presents for health maintenance visit What preventional health screenings does she need.?
Screening for hepatitis C virus.
69-year-old male presents for follow-up of hypertension treated with spironolactone (Aldactone) and amlodipine. Hx of kidney stone. Lab: CA+ level 12.
Dx: Primary Hyperparathyroidism ( hypercalcemia is the most common cause).
a 7 year old male admitted for RSV bronchiolitis with attempt of 100.2, pulse 160, respirations 70, oxygen saturation 92% room air. PE: Lungs reveal diffuse wheezing and crackles with nasal flaring and retractions.
Rx: Nasogastric fluids (supportive care).
30-year-ol with intermittent right upper quadrant pain after meals. Temp is 102.6 and he appears toxic PE examination of abdomen reveals a positive Murphy’s s. Lab: WBCs 3000, ALT 132, AST 123, alkaline phosphatase, 200 bilirubin 2.6
Dx: Acute cholangitis.
3-year-old female with a three-day history of pain, numbness and weakness in her right arm and shoulder. Positive history
Dx: Dislocation of shoulder.
Rx: Shoulder reduction.
For women capable or planning pregnancy the US preventative service recommends—-
Rx: Folic acid 0.4–0.8 mg daily.
11 year old female brought in by her mother for scoliosis. What indicates referral to specialist?
A Cobb angle of 20°
a 43-year-old execuive with insomnia takes doxepin (Silenor).
Rx: Eszopiclone (Lunesta).
6-year-old male with persistent cough with no history of URI. Denies history of asthma.
Dx: GERD
Rx: PP Inhibitor trial.
25-year-old Guatemala female in for routine OB care. She does not speak English.
Recommend use of telephone interpreting service.
65-year-old female with T score of -2.0 with osteopenia. Treatment for 10 year risk of major fracture is indicated at what percent?
20%
21-year-olld gravida 1 para 0 diagnosed with hyper thyroidism in first trimester.
Rx: Propylthhiouracil..
55-year-old male presents with severe pain, swelling and erythema in his left first MT joint
Rx: Colchichine (Colcrys).
30-year-old male treated for with topical medications for papulopustular rosacea.
Rx: doxycycline.
25-year-old female with bulge in the vaginal opening..
Initial treatment—-
Rx: Ring pessary
2 week old infant brought in for well child check.. Primarily breast-fed.
he should be given 4000 international units of supplemental vitamin D daily.
70-year-old male presents preoperatively for THR replacement. What lab tests should he have?
Renal function studies.
12-year-old female presents with three-week history of left groin pain. PE: Limited internal rotation of hip.
Dx: Slipped capital femoral epiphysis
