path recall April 2016 - formatted Flashcards
- Young woman with fever and neck mass isoechoic to muscle on ultrasound and anterior to the carotid sheath - Repeat question.
a) Lymphoma
b) Metastatic papillary thyroid
c)
d)
e)
a) Lymphoma
- man / woman mildly elevated ESR fusiform AAA and perianeurysmal soft tissue swelling (These were two separate questions, one middle aged man and the other 40 year old woman)
a) Saccular mycotic
b) Inflammatory
c) Pseudoaneurysm
d) Takayasu
e) PAN
b) Inflammatory – if male
d) Takayasu – if female
- Man involved in high speed accident undergoes CT which demonstrates 2mm, well defined outpouching from thoracic aorta anteroinferior wall immediately distal to left SC origin
a) Ductus diverticulum
b) Traumatic aortic injury
c) Dissection
d) Transection
b) Traumatic aortic injury could be ductus diverticulum?? um
Traumatic pseudoaneurysm:- inferior aortic isthmus- acute angle- no calc. Surrounding stranding
Ductus- anteromedial isthmus- obtuse angle- calcium : very helpful clue
Location of aortic injury
Location aortic isthmus: 90%ascending aorta: 5%diaphragmatic hiatus: 5%
Aortic isthmus (90% of initial survivors); commonly along inferomedial aspect at level of left pulmonary artery Aortic root (5-14% of initial survivors), Most die at scene of accident Diaphragmatic hiatus (1-12%), May be associated with diaphragmatic injury
- Previous EVAR, sac increasing in size with evidence of contrast endoleak through porous graft materal
a) Type 1
b) Type 2
c) Type 3
d) Type 4
e) Type 5
d) Type 4
- Liver tumour between primary (primary is confluence of right and left hepatic duct, secondary is confluence of second order ducts) and secondary confluence - what type is it (Klatskin tumour question) – Bismuth Corlette classification.
Type 1 Type 2 Type 3a Type 3b Type 4 Cholangio
*LW:
type I
limited to the common hepatic duct, below the level of the confluence of the right and left hepatic ducts
type II
involves the confluence of the right and left hepatic ducts
type IIIa
type II and extends to the bifurcation of the right hepatic duct
type IIIb
type II and extends to the bifurcation of the left hepatic duct
type IV
extending to the bifurcations of both right and left hepatic ducts
or
multifocal involvement
type V
stricture at the junction of common bile duct and cystic duct
Type 3a If right
Type 3b If left
Type 4 Cholangio If both
- Granulosa cell tumour question. Was either a 15 yo or a 30 yo woman with hyperestrogenism symptoms.
a) Granulosa cell tumour
b)
c)
d)
e)
a) Granulosa cell tumour
- IVM additional information;
- granulosa cell tumours can be seen in any age, but more commonly post menopausal (2/3)
- Usually oetrogen secreting, but occasioanlly produce androen
- Infertility in a 25 yr old obese female with ultrasound demonstrating bilateral ovarian lesions with homogeneous low grade internal echogencity. Most likely
a) Endometrioma
b) PCOS
c) Teratoma
d) Mucinous cyst adenoma
e) Serous cyst adenoma
a) Endometrioma
- Infertility for 18 months - most likely cause
a) polycystic ovaries b) c) d) e)
polycystic ovaries
- Criteria for PCOS - false?
a) Follicle size <10mm
b) Androgen exess
c) Anovulation
d) Follicles >12
e)
d) Follicles >12 used to be true, now >20
**LJS - Criteria for polycystic ovarian morphology:
>20 follicles per ovary and/or enlarged ovary >10ml
Other supportive findings (but not required for diagnosis):
Echogenic stroma - very vascular
Follicles at periphery of ovary - string of pearls
Follicles of similar size (2-9mm)
Need 2 from 3 of (and exclusion of other cause e.g. CAH):
Polycystic ovarian morphology on USS
Ovulatory dysfunction - oligo or anovulation
Clinical and biochemical signs of hyperandrogenism
Wji: as lotte says 2-9m follicles is a feature but not a diagnostic criteria. So when this question was written a. was false. D. is now also false.
- 3 year old boy with outward bowing of the knees and mild beaking of the medial metaphysis
a) physiologic
b) Blount disease
c) AVN
d) NF1
e)
b) Blount disease
Classic findings:
Tibial shaft in varus position.
Wedge shaped epiphysis- under developed, sloping medially with adjacent irregular physis
Medial metaphyseal beaking/spur.
NF1 gets tibial pseudoarthrosis
- Women with menorrhagia and dysmenorrhoea, ultrasound demonstrates heterogenous myometrium and smooth serosa.
a) Endometriosis
b) Uterine fibroids – Would have irregular serosa (most are subserosal)
c) Endometriosis – Adenomyosis??
d)
e)
Adenomyosis??
- Smoker 40 yr old woman with multiple cystic masses in and around the parotid on ultrasound on US
a) Warthins tumour
b) Pleomorphic adenoma
c) Metastasis
d) Sarcoidosis
e) Benign lympoepithelial lesions
Benign lympoepithelial lesions – Esp if history of HIV
a) Warthins tumour Older and male.
b) Pleomorphic adenoma - not usually multiple, but are hypoechoic and may b=have posterior aoustic enhancment
c) Metastasis - possible, mets to intraparotid nodes and cervical LN to explain surrounding masses
d) Sarcoidosis – Solid enlargement
e) Benign lympoepithelial lesions – Esp if history of HIV
- ESG- favour mets if unilateral and includes truly extra-parotid lesions - BLELs and Sjogren shouldn’t be extra-parotid.
- WJI - disagree. BLEL characteristically has associated cervical adenopathy and adenoid hypertrophy secondary to HIV
- 3 weeks old with torticollis, US shows sternomastoid (whatever that is?) MASS which is moderately vascular on US
a) Rhabdomyosarcoma
b) FIbromatosis colli
c) Capillary haemoangioma
b) FIbromatosis colli Presents with enalrgement of muscle (there can be a mass, no pain).
a) Rhabdomyosarcoma If mass and il-defined margins
b) FIbromatosis colli Presents with enalrgement of muscle (no mass, no pain).
c) Capillary haemoangioma Possible?
- Painful 2nd MTP and 2nd inter tarsal. Compressive sc hypo echoic fat layer 2 3 4 MT heads
a) interstitial bursitis
b) inter metatarsal bursitis
interstitial bursitis (adventitial bursitis)
- Tarlov cyst - what is correct
a) Most often affects the 1st and 4th sacral levels
b) often has bone erosion remodelling anyway
c) If multiple then it’s likely syndromic
b) often has bone erosion remodelling anyway
a) Most often affects the 1st and 4th sacral levels 2,3
b) often has bone erosion remodelling anyway
c) If multiple then it’s likely syndromic
- Bx of ilium - how do you do it. Depends on what you are doing it for
a) most direct route
b) ant approach
c) post approach
d) FNA
e) core
) core ?? um
- Breast - 40yo woman asymptomatic. Well defined hypo echoic lesion taller than wide, most likely.
a) IDC
b) ILC
c) mucinous
a) IDC – Most common
17. Breast - 40yo woman asymptomatic. Well defined hypo echoic lesion taller than wide, most likely
a) IDC – Most common
b) ILC Not well defined
c) mucinous Well defined but micro lobulated, often mixed solid cystic. Pure type can be anechoic (usually acoustic enhancement) - older patient (75 yo +)
- PASH
a) incidental no treatment
b) palpable mass
c) d)e)
a) incidental no treatment - True, usually microscopic incidental. No malignant potential (statdx).
b) palpable mass - True, sometimes.
Differential diagnosis for breast cancer- due to fibroblast proliferation- circumscribed/partially circumscribed mass, or architectural distortion- may look like fibroadenoma
Wide spectrum ranging from incidental finding to palpable mass
Most commonly incidental microscopic finding
Seen in 23% of breast biopsies and 19% of (healthy) mastectomies
- Fleischner guideline 3mm smoker
a) 12 month, then no followup
b) c)d)e)
a) 12 month, then no followupf/u because of high risk
Fleischner Society Recommendations and this table do NOT apply to:
Patients who have a known cancer.
Immunosuppressed patients.
Lung cancer screening, which has separate criteria.
Intra-fissural, perifissural, and subpleural pulmonary nodules. Perifissural lung nodules are usually benign, unless suspicious nodule morphology is present (reference).
Spiculated margins.
Displacement of the pulmonary fissure.
Cancer history.In these cases, follow-up should be considered.
Diameter of lung nodule is the average of the short and long axes, rounded to the whole millimeter.
Lung Cancer Risk Factors:
Tobacco use.
Family history of lung cancer.
Upper pulmonary lobe location of nodule.
Presence of emphysema.
Pulmonary fibrosis.
Older Age.
Female gender.
- ovarian cyst complex 3.5 cm young woman
a) 6 week followup different cycle If complex means multiseptated
b) 4 week followup same cycle
c) no followup if simple, or haemorrhagic
d) gynae blah
a) 6 week followup different cycle If complex means multiseptated
- Left ventricle atrial mass 80 yo screen for dementia. Cystic with minimal peripheral enhancement. What is most likely.
a) met
b) CP Ca
c) CP cyst
d) e)
c) CP cyst
a) met Not sure
b) CP Ca No. Essentially only in children
c) CP cyst
d) e)
Choroid plexus cyst, as in choroid plexus xanthogranuloma
- Posterior fossa mass excision hx, falx density, jaw cystic lesion skin lesion
a) Basal cell naevus
b) c) d)
a) Basal cell naevus
aka Gorlin or Gorlin-Goltz
Multiple keratocystic odontogenic tumors, basal cell carcinoma, medulloblastoma, intracranial dural calcifications, bifid ribs (Statdx).
Robbins includes ovarian fibroma, cleft lip/palate, vertebral segmentation, bifid, fused, missing or splayed ribs.
- 40 yo headache vomiting. Cyst +nodule but cyst not enhancing
a) HGBL
b) met
c) Astrocytoma
d) e)
a) HGBL
a) HGBL
b) met possible, (most common posterior fossa mass in adults)
c) Astrocytoma Younger
d) e)
Presume question means cyst not enhancing, but nodule is.
Cyst wall does not enhance in HGBL, but does 50% of the time in astrocytoma.
- Hx rheumatic fever. Now unwell with meningism. Heart murmur.
a) multiple ring enhancing lesion
b) leptomeningeal enhancement
a) multiple ring enhancing lesion - septic emboli
- Diffuse axonal injury which is most correct?
a. All are haemorrhagic
b. Affects cortex
c. Genu of corpus callosum usually affected
d. Dark on T2
e. Affects dorsal midbrain dorsolateral midbrain and upper pons
e. Affects dorsal midbrain dorsolateral midbrain and upper pons
26. Diffuse axonal injury which is most correct?
a. All are haemorrhagic 80% non-haemorrhagic (stat dx)
b. Affects cortex grey-white matter junction
c. Genu of corpus callosum usually affected 2/3rds splenium
d. Dark on T2 - if haemorrhage
e. Affects dorsal midbrain dorsolateral midbrain and upper pons
- Progressive SOB. Symmetric peribronchovasc nodules, small-mod effusions, nodes, multiple small nodules.
a) Sarcoidosis
b) HP effusions
c) lymphangitis carcinomatosis
d) UIP effusions
e) NSIP (was it one of the options?? not sure)
c) lymphangitis carcinomatosis
27. Progressive SOB. Symmetric peribronchovasc nodules, small-mod effusions, nodes, multiple small nodules.
a) Sarcoidosis - no effusion
b) HP effusions - no effusion - (CCF - can have effusion in cellular type Statdx).
c) lymphangitis carcinomatosis
d) UIP effusions - no effusion
e) NSIP (was it one of the options?? not sure) - no effusion
- Male progressive restrictive lung disease. Nonsmoker bibasal septal thickening sub pleural cysts bronchiectasis
a) UIP
b) NSIP
c) RB ILD
d) DIP
e)
a) UIP
- Parathyroid gland
a) best seen on T2
b) Doesn’t enhance well on MRI
c) Ectopic seen above superior aspect thyroid
d) e)
a) best seen on T2
- Periprosthetic hip replacement a year ago, sclerosis and lucency for 6 months?
a) Loosening without infection
b) Infection and loosing
c) infection without loosening
b) Infection and loosing Could be either or both.better to use In-111 WBC scan
- Myeloma detection
a) Better with X-ray screen than bone scan
b) c)d)e)
a) Better with X-ray screen than bone scan
Bone scans can be normal
- Papillary thyroid ca on bx. Next best thing
a) MRI with contrast
b) CT with contrast
c) I131
d) Tc99m scan
e)
b) CT with contrast
- Most correct regarding knee injury what is correct
a) mostly lipohaemarthrosis detectable with a fracture
b) segond can happen with osteoporosis
c) subtle sclerosis medial femoral condyle may represent fracture
d) e)
c) subtle sclerosis medial femoral condyle may represent fracture
lipohaemarthrosis - a/w intra-articular fracture
- 15 year old generalised bone pain. Enlarged ribs, vertebral height loss cardiomegaly.
a) Sickle cell
b) MPS
c) thalassaemia major
d) Glycogen storage
e) Fibrous dysplasia
again debate around sickle cell or thalassaemia majorthalassaemia has more expansion
*RY - would probably favour thalassaemia because of the expansion. Statdx describes the marrow replacement of sickle cell as very subtle, usually not detectable on plain radiograph. Rib expansion is well documented for thalassaemia, compression fractures also known to occur.
**SCS: Sickle cell and Thalassaemia get cardiomegaly from high cardiac output (LVH etc).
**wji -dahnert only talks about widened ribs in thalassaemia and h shaped vertebrae in sickle cell. This is unhelpful.
- 15 year old generalised bone pain. Enlarged ribs, vertebral height loss cardiomegaly.
a) Sickle cell Probably most correct. Potentially but more infarcts, less expansion
b) MPS
c) thalassaemia major
d) Glycogen storage – Adenomas of the liver
e) Fibrous dysplasia – not generalised
- OCP use. Liver echo normal. No biliary tree dilatation. Jaundice
a) steatohepatitis - ? To have jaundice
b) cholestasis
c) fatty liver
d) e)
b) cholestasis ummm
**LJS ?? fatty liver or steatohepatitis should have echogenic liver at least, if not enlarged.
- CT liver vascular lesion. MRI with hepatobiliary agent (forgot its name) - hyperintense scar on delayed. Hyper early iso progressively on delayed
a) HCC
b) FNH
c) Adenoma
d) e)
b) FNH
- *LJS - FNH scar is only supposed to enhance on typical Gad agents (not hepatobiliary agents). Everything else fits with FNH though
- ESG disagree, hepatobiliary contrast agent will do everything that extracellular agents do (including enhancement of FNH central scar on 5 min delays), and in addition allow evaluation of hepatobiliary phase with FNH being iso- to hyper-intense (except for the central scar, which has now become hypointense).
- Breast cancer risk. Woman is 30. Mum at 60 and cousin at 60s. How would you advise screening?
a) 2 yearly screen starting at 45
b) Immediate MRI starting annually
c) Investigate then annual mammogram for life
d) annual ultrasound till 35 then annual mamm
a) 2 yearly screen starting at 45
- Breast implant - not sensitive on MRI
a) Rupture
b) free silicone
c) capsular contraction
d) Multifocal cancer
e) IDC
not sure
*RY - Probably capsular contraction (hardening, with rounding/deformation in later stages). Note the general disadvantage of breast MRI = low specificity for benign versus malignant abnormality. In terms of implants, MRI usually not needed for saline rupture because should be clinically apparent.
- Breast implant - if it ruptures we can tell which type it is on ultrasound…
a) intracapsular rupture
b) extracapsular rupture
c) d)e)
b) extracapsular rupture – snowstorm easier
- Which is better US vs MRI
a) intracapsular
b) extra capsular
c) capsule contour contraction
c) capsule contour contraction??
- Lesion femoral diaphysis cortex night pain
a) Osteoid osteoma
b) Ossifying fibroma
a) Osteoid osteoma
- Osteoblastoma
a) confined to vertebral body
b) smaller than 1.5cm at dx
c) Resolves
d) found in vertebra 1/3
e)
d) found in vertebra 1/3 (40% stat dx), mostly cervical
- Wrong option
a) Chance fracture almost always has neurologic involvement -
b) Tear drop fracture - ventral cord injury
c) DISH can fracture disc
d) remote vertebral injury in 2 different places 5%
e)
a) Chance fracture almost always has neurologic involvement -
- Wrong option
a) Chance fracture almost always has neurologic involvement -
b) Tear drop fracture - ventral cord injury true
c) DISH can fracture disc true
d) remote vertebral injury in 2 different places 5%
e)
- About to do an intervention. on clopidogrel (antiplatelet) clexane (LMWH) and metformin
a) stop clopidogrel for 10 days and clexane 12 hours 5 days adequate for clopidogrel
b) Stop clopidogrel for 12 hours clean 10 days
c) Stop clopidogrel and Metformin
d) Stop Clean and Metformin
e)
a) stop clopidogrel for 10 days and clexane 12 hours 5 days adequate for clopidogrel
- About to do an intervention. on clopidogrel (antiplatelet) clexane (LMWH) and metformin only consider stopping metformin if renal inpairment
a) stop clopidogrel for 10 days and clexane 12 hours 5 days adequate for clopidogrel
b) Stop clopidogrel for 12 hours clean 10 days
c) Stop clopidogrel and Metformin
d) Stop Clean and Metformine)
- Lung bx - SOB. Post biopsy haemoptysis with focal area of haemorrhage in the right lower lobe posterior segment. Whats the best position.
a) Right side down
b) Left side down
c) supine
d) prone
e) sit up
a) Right side down Biopsy side down (although its posterior so could argue for supine)
- Indication for tube on PTX in 80yr old with traumatic pneumothorax
a) air fluid level
b) clear pleural line seen
c) lung collapsed to hila
d) ipsilateral mediastinal shift - contralateral implies tension
e)
c) lung collapsed to hila
Indicating >50%
- 30 yo woman. 4cm jejunum with loss of pattern followed by 5cm stricture, and fistula to the terminal ileum fistula.
a) Crohn
b) Coeliac
c) Scleroderma
d) SLE
e) Was it UC????
a) Crohn
- 30 yr old with slowly growing neck mass, deep to parotid extending to the parapharyngeal space
a) 1st branchial cleft
b) 2nd branchial cleft cyst
c) 3rd branchial cleft cyst
d) Infected node
e)
- *LJS edit - caution calling branchial cleft cyst in adult - think cystic nodal met, esp p16 +ve SCC, even in young adult non-smokers. If branchial cleft cyst, location deep to parotid would make me think 1st branchial cleft. 3rd and 4th are infrahyoid neck, 2nd is typically below angle of mandible. From options listed, I would choose 1st branchial cleft cyst**
- LW –> Work type II, 1st BCC can occur within parotid or PPS space, so legit.
Previous answer:
b) 2nd branchial cleft cyst can extend between carotid arteries and abut pharyngeal wall.
*LW
Brachial cleft common feature summary:
1st branchial cleaft cyst:
–> Cystic mass near pinna & EAC (Work type I) or extends from EAC to angle of mandible (Work type II)
Location
- Type I: Periauricular cyst or sinus tract: Anterior, inferior, or posterior to pinna & concha
- Type II: Periparotid cyst or sinus tract: More intimately associated with parotid gland, medial or lateral to CNVII
Superficial, parotid space, or parapharyngeal space (PPS).
2nd branchial cleft cyst:
–> Cystic neck mass posterolateral to submandibular gland, lateral to carotid space, anterior to SCM
Most are at or immediately caudal to angle of mandible
Location
- Type I: Deep to platysma muscle, anterior to SCM
- Type II: Anterior to SCM, posterior to submandibular gland, lateral to carotid sheath (Most common)
- Type III: Protrudes between ICA & ECA, may extend to lateral pharyngeal wall or superiorly to skull base
- Type IV: Adjacent to lateral pharyngeal wall, probably remnant of 2nd pharyngeal pouch
2nd branchial apparatus fistula extends from anterior to SCM, through carotid artery bifurcation, & terminates in tonsillar fossa
3rd branchial cleft cyst:
–> Unilocular, thin-walled cyst in upper posterior cervical space or lower anterior neck
Location
- Anywhere along course of 3rd branchial cleft or pouch
- Upper neck: Posterior cervical space
- Lower neck: Anterior border sternocleidomastoid muscle
- Rarely in submandibular space, lateral to cephalad hypopharynx
Classically, 3rd branchial fistula would exit base of pyriform sinus, course superior to superior laryngeal and hypoglossal nerves and inferior to glossopharyngeal nerve
4th Branchial cleft cyst:
–> Sinus tract extending from apex of pyriform sinus to lower anterior neck after barium swallow
Abscess in or adjacent to anterior left thyroid lobe
Location
- May occur anywhere from left pyriform sinus apex to thyroid lobe
- Commonly against or within superior aspect of left thyroid lobe or attached to thyroid cartilage
- Upper end may communicate with or be adherent to pyriform sinus
- Incidental pick up 2cm renal mass. On MRI T1 high T2 and post contrast enhancement
a) Clear cell
b) Papillary
c) Haemorrhagicadenomyolipoma
d) Proteinaceous cyst
e) Simple cyst
a) Clear cell probably
50. Incidental pick up 2cm renal mass. On MRI T1 high T2 and post contrast enhancement
a) Clear cell
b) Papillary shouldn’t be high T1
c) Haemorrhagic – if haemorrhagic adenomyolipoma
d) Proteinaceous cyst wouldn’t enhance
e) Simple cyst
- Jejunal intussusception. Most likely
a) Pancreatic divisum
b) dorsal agenesis
c) ectopic pancreas
d) annular
e) some other pancreas variant
c) ectopic pancreas
- Most common in small bowel in ileum causing intussusception
a) Small bowel carcinoid
b) Lymphoma
c) Adenocarcinoma
d) e)
- *LJS edit - from radiographics paper: SB intussusception most commonly has benign lead point (less often neoplasm). Of neoplastic causes, mets are most common. Maybe the unrecalled answers were benign lesion or mets? Of those listed, I would choose adenocarcinoma, as it is most common. (I have assumed stem was about adults)**
- WJI -disagree with Lotte. Agree with prior answer: lymphoma. Adenocarcinoma most common small bowel tumour overall (30-50%, carcinoid 25-30%, lymphoma 15-20%) BUT adenocarcinoma favours duodenum then jejunum over ileum. Carcinoid and lymphoma favour ileum. “Small bowel lymphoma” listed on RP in malignant causes of intussusception with colon adenocarcinoma and mets.
b) Lymphoma
- Most common in small bowel in ileum causing intussusception
a) Small bowel carcinoid second most common malignancy of small bowel
b) Lymphoma
c) Adenocarcinoma most common malignancy of SB
https://pubs.rsna.org/doi/full/10.1148/rg.263055100
- 15 year old kid who med oncology referral US shows caecal wall thickening. Apps not seen
a) Typhilitis
b) Appendicitis
c) Colitis
d) Diverticultis
e)
a) Typhilitis
- Paraumbilical discharge, with mass in continuation with the bladder dome
a) Adenocarcinoma
b) SCC
c) TCC
d) e)
a) Adenocarcinoma
most common malignancy in urachal remnants
- Appendix inflammation on ultrasound. most correct
a) can be up to 6mm
b) surrounding fat less echogenic
c) fluid collection
d) vascular
e) caecal thickening
c) fluid collection
- Placenta within 1cm to os on 20 week anatomy scan, 4cm cx. Most likely
a) marginal
b) bladder overly filled
c) contraction
d) abruption
e) low lying placenta
*LW: Preferred option is bladder over filled.
I think over filled bladder is most likely, as why else would they state cervical length of 4cm, which is slightly increased from normal (3cm), as over filled bladder can increase cervical length, and a over distended bladdr can mimic a low lying placenta, as it stretches the lower uterine segment.
*RY - normal length at 20weeks is 4cm according to google, so low lying seems most correct. Boom. Mike drop. Get outta my house Logan.
- *SCS: depends on if TV/TA. Re TA; MOH Obstetric USS guidelines say “TA assessment with a full bladder falsely elongates the cervical length”. In order to see anything TA, you need the bladder full - sonographic window.
- also Obstetric guidelines; “Routine cervical length scanning at the time of the mid trimester ANATOMY scan is not currently recommended” they generally dont do TV scans at anatomy.
- If TV scan -> LLP.
- Im going with Disney prince… overfilled bladder on gameday.
Previous answer
e) low lying placenta
- PV bleed and pain. 3rd trimester. Retroplacental hypo echoic structure with septa
a) abruption
b) praevia
c) d)
a) abruption
