Gamesmanship Flashcards
Mammo:
The calcifications don’t change configuration on CC and MLO views. This is the so called “tattoo sign “ for DERMAL calcifications. Next step: tangential view to prove it.
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Mammo:
Remember that secretory calcifications occur after menopause. Don’t call them secretory in a premenopausal patient (no matter how much they look like them).
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Mammo:
If they show you a ML view for calcifications. Think hard about milk of calcium - is it tea cupping?
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Mammo:
If a test writer wants you to say DCIS, they can prompt it 3 ways:
1) suspicious calcifications (fine linear branching or fine pleomorphic),
2) non mass like enhancement on MRI,
3) multiple intraductal masses on galactography.
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Mammo:
Skin thickening and trabecular thickening should get progressively better with time. It should start out worst, then better, then better. If it gets worse—this recurrent disease.
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Mammo:
Gynecomastia looks like a cancer on ultrasound. This is why a male breast cancer workup (palpable finding) always begins with a mammogram.
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Nukes:
Distinguishing
Tc-99 DTPA vs Xe-133.
DTPA can be done in multiple projections. DTPA tends to clump in the central airways.
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IR:
Sneaky things related to TIPS.
1) CO2 run during hepatic vein wedge—blowing liver dome off bc injection pressure too strong. Anytime see CO2 run over liver, think of this.
2) TIPS placed into hepatic artery (not portal vein). Pay attention to anatomy!
3) Could say portal systemic gradient was normal (3-6). Remember—TIPS treats portal hypertension. Don’t do TIPS on someone without portal HTN!
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IR:
Self Expandable: anywhere you might get external compression.
Balloon Expandable: if you need more precise placement
May Thurner Syndrome—Self
SFA—Self
Focal Atherosclerosis Stenosis in distal aorta—balloon
Renal Ostium Stenosis—balloon
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Vascular:
Thoracic Angiogram: If you see an angiogram through the great vessels and aorta, think about TOS, Takayasu, and Giant Cell. The locations are classic, and helpful.
Takayasu—young (probably Asian female),
Giant Cell-old person.
AGE TRUMPS LOCATION!
If they show you TOS, they’ll show arms up and down—dead give away.
If trauma, don’t forget to check great vessels (not just aorta)
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Vascular:
Aortic Dissection on Angiogram:
Can show as opacification of abdominal aortic branch vessels during aortography (cath in aortic true lumen) w/branch vessels (celiac axis, sup. mesenteric a., and renal arteries) arising out of nowhere. They appear to be floating, w/little or no antegrade opacification of aortic true lumen.
“Floating Viscera Sign”
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Vascular:
Collateral Filling:
If you inject SMA and the celiac branches fill—infers a tight stenosis at celiac origin.
If you inject celiac and the SMA branches fill—infers tight stenosis at the SMA origin.
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Vascular:
Hand Angiograms:
Pathology: it’s going to be either Buergers or Hypothenar Hammer Syndrome (HHS).
Ask yourself: is ulnar artery involved?
If yes, go with HHS.
If the ulnar nerve (typo?) looks ok, but the fingers are out, go w/Buergers.
Careful: fingers can be out w/HHS too (distal emboli).
Pseudo-aneurysm off ulnar artery: slam dunk HHS.
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Vascular:
Renal Artery Angiogram:
Ostial narrowing—think atherosclerosis; treat with balloon + stent
Beading mid vessel—think FMD; treat with balloon only
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Vascular:
Kidney Angiogram
First question should always be
“Is there an RCC or AML?”
Second question should be
“Is there PAN/Speed kidney/A bunch of little aneurysms?”
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Vascular:
Kawasaki:
Two classic ways to show this:
1) CT with a coronary artery aneurysm (obvious one),
2) calcified coronary artery aneurysm shown on CXR (old oral boards favorite)
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Cardiac:
Signs of left atrial enlargement:
1) Double density—superimposed over contour of the right heart
2) Splaying of the carina—Angle over 90*
3) Posterior placement of the heart—seen on lateral CXR
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Upper or Lower Lobe Predominant?
Most inhaled stuff (not asbestosis!)—coal workers, silicosis. Includes progressive massive fibrosis.
Upper
Upper or Lower Lobe Predominant?
CF
Upper
Upper or Lower Lobe Predominant?
RB-ILD
Upper
Upper or Lower Lobe Predominant?
Centrilobular Emphysema
Upper
Upper or Lower Lobe Predominant?
Ankylosing Spondylitis
Upper
Upper or Lower Lobe Predominant?
Asbestosis
Lower
Upper or Lower Lobe Predominant?
Primary Ciliary Dyskinesia
Lower
Upper or Lower Lobe Predominant?
Most Interstitial lung diseases (UIP, NSIP, DIP)
Lower
Upper or Lower Lobe Predominant?
Panlobular Emphysema (Alpha 1)
Lower
Upper or Lower Lobe Predominant?
Rheumatoid Lung
Lower
Upper or Lower Lobe Predominant?
Scleroderma
Lower
Obtuse margin with lung. Is it mediastinal or pulmonary origin?
Mediastinal
Acute margin with lung. Is it mediastinal or pulmonary origin?
Pulmonary
Ground glass nodule on PET:
HOT GGO = _______
Infection
Ground glass nodule on PET:
COLD GGO = _______
Cancer (BAC)
Collapse—
Always be on the lookout for collapse. Anytime see anything that could be, at least entertain idea.
-post intubation
-placement of central line
-ICU patient w/no other details (mucous plugging)
-outpatient w/no other history (cancer)
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Pulmonary edema—
After chest tube placement: re-expansion edema
After crack or heroin: drug induced edema
After head injury: neurogenic edema
After lung transplant: reperfusion edema related to ischemia/reperfusion (peak day 4)
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Collagen vascular tricks:
RA in shoulders on frontal CXR
Lower lobe UIP pattern
Collagen vascular tricks:
Ankylosing Spondylitis on lateral CXR
Upper lobe fibrobullous disease
Collagen vascular tricks:
Dilated esophagus on CT
Scleroderma with NSIP lungs
“Frozen hemithorax”—lack of contralateral mediastinal shift in association with massive pleural effusion . Diagnosis?
Mesothelioma.
It’s due to encasement of the lung (and fissures) by cancer
Infections in AIDS by CD4:
> 200
Bacterial infections,
TB
Infections in AIDS by CD4:
<200
PCP,
Atypical Mycobacterial
Infections in AIDS by CD4:
<100
CMV,
Disseminated Fungal,
Mycobacterial
AIDS:
Lung cysts = (diagnosis?)
LIP
LIP is AIDS defining in a pediatric patient
AIDS:
Lung cysts + ground glass + pneumothorax = (diagnosis?)
PCP
AIDS:
hypervascular nodes = (diagnosis?)
Castleman’s or Kaposi
AIDS:
Most common airspace opacity
Strep pneumonia
AIDS:
CT with ground glass = (diagnosis?)
PCP
AIDS:
Flame-shaped perihilar opacity = (diagnosis?)
Kaposi sarcoma
AIDS:
Persistent opacities= (diagnosis?)
Lymphoma
If they show you a varicocele, regardless of side (right being more suspicious than left), if it’s a next step question, look for the ____
Abdominal cancer
If “hyperemesis” is in question stem (repro), think ______
Things that give you elevated B-hCG—like moles and multiple pregnancy (twins)
If it’s a GYN case and has “history of abdominal surgery”, keep in mind _______
Peritoneal inclusion cysts (from adhesions)
Met to vagina in anterior wall upper 1/3 is “always” (90%) from _______
Upper genital tract
Met to vagina in posterior wall lower 1/3 is “always” (90%) from _______
GI tract
Fluid in endometrial canal in post menopausal woman should make you think ______
Cervix is obstructed (cancer, or more commonly stenosis)
Repro: combo of ovarian mass and thickened endometrium should make you think _____
Granulosa Cell Tumor
IUGR: Symmetrical
-baby or placenta issue?
Baby problem (placenta is fine)
IUGR: Symmetrical
-head spared or not?
head NOT spared
IUGR: Symmetrical
-when first apparent?
Early, including first trimester
IUGR: Symmetrical
-causes?
TORCHS,
Fetal EtOH,
Chromosomal abnormalities
IUGR: Asymmetrical
-baby or placenta issue?
Placenta problem
IUGR: Asymmetrical
-head spared or not?
Head spared
IUGR: Asymmetrical
-when first apparent?
Normal until third trimester
IUGR: Asymmetrical
-causes?
Maternal hypertension,
Severe malnutrition,
Ehler-Danlos
prostate CA v BPH:
______ is usually in the peripheral zone. When it is in central zone, T2 is “smudgy” or charcoal.
Prostate CA
prostate CA v BPH:
_______ is usually in central zone. Have a sharp border. Can “draw a line around them with a pencil”
BPH nodules
Gartner duct cyst v Bartholin cyst
______ is above pubic symphysis.
_______ is below.
GARTNER DUCT CYST is above pubic symphysis.
BARTHOLIN is below it.
Bicornuate v septate uterus
Distinguish the two by:
Apex of the fundal contour
Bicornuate v septate uterus
Apex of fundus >5mm above tubal Ostia
Septate
Bicornuate v septate uterus
Apex of fundus <5mm above tubal Ostia
Bicornuate
Bicornuate v septate uterus
Which has established increased 1st trimester loss?
Septate
Bicornuates have a lot less problems. Maybe no increased risk, depending who you ask
IVPs (GU section):
Haven’t been used since 1970s, but few tricks. If have medial deviation of the ureters, think______
Retroperitoneal fibrosis
IVPs (GU section):
Haven’t been used since 1970s, but few tricks. If have lateral deviation of the ureters, think______
Psoas hypertrophy, or lymph nodes
RCC v oncocytoma:
___ is typically colder than surrounding renal parenchyma on PET
RCC
RCC v oncocytoma:
___ is typically hotter than surrounding renal parenchyma on PET
Oncocytoma
Oncocytoma: if they wanted to ask it, can be shown 3 ways:
- CT solid mass with central scar
- ultrasound “spokewheel” vascular pattern
- PET CT it will be hotter than surrounding renal cortex
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Renal cysts syndromes:
Cysts in liver, kidneys are BIG
Diagnosis?
ADPKD
Renal cysts syndromes:
Cysts in pancreas
Diagnosis?
VHL
Renal cysts syndromes:
kidneys are small
Diagnosis?
Acquired (uremic)
Renal cancer syndromes:
Subtype: Clear Cell
Syndrome/Association?
Von Hippel-Lindau
Renal cancer syndromes:
Subtype: papillary
Syndrome/Association?
Hereditary papillary renal carcinoma
Renal cancer syndromes:
Subtype: chromophobe
Syndrome/Association?
Birt Hogg Dube
Renal cancer syndromes:
Subtype: Medullary
Syndrome/Association?
Sickle cell trait
If you’re shown a unilateral renal agenesis case, remember association with _______ in men, and _______ in women
Men: absent vas deferens, and ipsilateral seminal vesicle Cyst
Women: mullarian anomalies (unicornuate uterus)
Showing persistent nephrograms —either by plain film or CT is the classic trick for ATN—usually contrast induced nephropathy.
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CJD restricts diffusion (MRI).
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Dilated esophagus on CT, ground glass in the lung bases (and maybe sub-pleural sparing). Diagnosis?
Scleroderma with NSIP
Benign Liver Masses
Hemangioma:
-ultrasound appearance?
Hyperechoic
Benign Liver Masses
Hemangioma:
-CT appearance?
Peripheral nodular discontinuous enhancement
Benign Liver Masses
Hemangioma:
-MR appearance?
T2 Bright
Benign Liver Masses
Rare in cirrhotics.
Which one?
Hemangioma
Benign Liver Masses
FNH:
-ultrasound appearance?
Spoke wheel
Benign Liver Masses
FNH:
-CT appearance?
Homogeneous arterial enhancement
Benign Liver Masses
FNH:
-MR appearance?
“Stealth Lesion —Iso on T1 and T2”
Benign Liver Masses
Central scar, Bright on delayed eovist (Gd-EOB-DTPA).
Which is it?
FNH
Benign Liver Masses
Hepatic adenoma :
-ultrasound appearance?
Variable
Benign Liver Masses
Hepatic adenoma :
-CT appearance?
Variable
Benign Liver Masses
Hepatic adenoma :
-MR appearance?
Fat containing on In/Out phase
Benign Liver Masses
OCP use, Glycogen storage Disease, can explode and bleed.
Which is it?
Hepatic adenoma
Benign Liver Masses
Hepatic angiomyolipoma :
-ultrasound appearance?
Hyperechoic
Benign Liver Masses
Hepatic angiomyolipoma :
-CT appearance?
Gross fat
Benign Liver Masses
Hepatic angiomyolipoma :
-MR appearance?
T1/T2 Bright
Benign Liver Masses
50% don’t have fat (unlike renal AML); tuberous sclerosis.
Which is it?
Hepatic angiomyolipoma
GI location:
H. pylori gastritis
Antrum (usually)
GI location:
Zollinger-Ellison
Jejunal ulcer is buzzword.
Duodenal bulb is actually the most common location for ZE ulcers
GI location:
Crohns
Antrum when in stomach (but uncommon in stomach)
GI location:
Menetrier’s
Fundus (classically spares antrum)
GI location:
Lymphoma
“Crosses the pylorus “
Classically describes as doing so, although in reality adenocarcinoma does it more
GI location:
Giardia
Duodenum
GI location:
Strongyloides
Duodenum
GI location:
TB
Terminal ileum
GI location:
Yersinia
Terminal ileum
Herpes esophagitis v CMV and AIDS:
Multiple small ulcers
Herpes esophagitis
Herpes esophagitis v CMV and AIDS:
Solitary large ulcer
CMV and AIDS
Esophageal cancer:
Black guy who smokes and drinks—mid esophagus.
Diagnosis?
Squamous cell
Esophageal cancer:
White guy with reflux (history of PPIs)—Lower esophagus.
Diagnosis?
Adenocarcinoma
Uphill v downhill varices:
Caused by portal hypertension
Uphill Varices
Uphill v downhill varices:
Confined to bottom half of esophagus
Uphill Varices
Uphill v downhill varices:
Caused by SVC obstruction (Catheter or tumor related)
Downhill Varices
Uphill v downhill varices:
Confined to top half of esophagus
Downhill Varices
Traction v Pulsion Diverticulum:
Triangular
Traction
Traction v Pulsion Diverticulum:
Will empty
Traction
Traction v Pulsion Diverticulum:
Round
Pulsion
Traction v Pulsion Diverticulum:
Will NOT empty (contain no muscle in their walls)
Pulsion
Esophageal hernias, Sliding v Rolling:
GE junction ABOVE diaphragm
Sliding
Esophageal hernias, Sliding v Rolling:
GE junction BELOW diaphragm
Rolling
Carney’s Triad, parts
- Extra-Adrenal Pheochromocytoma
- GIST
- Pulmonary Chondroma (hamartoma)
Carney’s Complex, parts (vaguely)
-Cardiac Myxoma
(C is for Complex. Not Carney’s Triad!)
- skin stuff
- endocrine stuff
Benign v malignant ulcers (on barium):
Width>depth
Malignant
Benign v malignant ulcers (on barium):
Depth > width
Benign
Benign v malignant ulcers (on barium):
Located within lumen
Malignant
Benign v malignant ulcers (on barium):
Project behind expected lumen
Benign