USMLE Step 2

Question 1

CARDIOLOGY Ergonovine Test 1. What is this? 2. When is ergonovine testing the answer? 3. What is the treatment?

Answer 1

CARDIOLOGY 1. Ergonovine testing involves the injection of ergonovine to provoke coronary vasospasm. This is the diagnostic maneuver to detect Prinzmetal’s angina, which is coronary vasospasm. 2. Answer ergonovine testing is the most accurate test when they give you a younger patient ( <45) complaining of atypical anginal-type chest pain who has clean coronaries on cardiac catheterization. The pain will not bear a fixed relationship to exercise. 3. Prinzmetals variant angina is treated with calcium channel blockers and nitrates.

Question 2

CARDIOLOGY Stress Echocardiogram 1. What is this? 2. How is it done? 3. What constitutes a positive test? 4. When do you answer it?

Answer 2

CARDIOLOGY 1. Stress echocardiogram is used to confirm the suspicion of coronary artery disease and estimate its severity. 2.It uses both 2D echocardiogram and Doppler echocardiogram to detect ischemia. Myocardial injury gives a decrease in systolic contraction of the ischemic area, called a “regional wall motion abnormality.” The patient is asked to exercise using a treadmill or bicycle. If she cannot exercise, Dobutamine can be used to increase myocardial demand. 3. A positive test consists of new regional wall motion abnormalities, a decline in ejection fraction, and an increase in end-systolic volume with stress on stress echo. 4. Answer stress echo when the case is equivocal for ischemic heart disease and the EKG is so abnormal that you cannot read it for ischemia.

Question 3

CARDIOLOGY Stress (Exercise Tolerance} Testing 1. What is it? 2. How is it done? 3. When is stress testing the answer? 4. What is the most accurate test?

Answer 3

CARDIOLOGY 1. Stress testing is the attempt to detect myocardial ischemia .in patients without the need for coronary angiography. It is used when the diagnosis of ischemia is not clear in a person who has chest pain. 2. The patient exercises to >80% of maximum heart rate based on a maximum rate of 220-age. The EKG is observed for signs of ischemia, such as ST segment depression. Hypotension, lightheadedness, and chest pain are taken as positive tests as well 3. Answer stress test: -when the pain is atypical and the story is equivocal; -post myocardial infarction to determine the need for angiography; -with patients on medications to determine if the amounts of medications are sufficient to prevent ischemia. 4. Abnormal stress tests are confirmed with coronary angiography.

Question 4

CARDIOLOGY Persantine Thallium 1. What is this? 2. How is it done? 3. When do you answer it? 4. When is it the wrong answer? 5. What is the alternative choice? 6. What is the most accurate diagnostic test?

Answer 4

CARDIOLOGY 1. Persantine thallium is a form of exercise tolerance or “stress” testing. It is a noninvasive method of determining myocardial perfusion that uses a medication to substitute for physical exercise. 2. Persantine (also called dipyridamole) is a phosphodiesterase inhibitor that dilates coronary arteries and increases oxygen flow to the myocardium. Thallium is a radioisotope that should be picked up by normal myocytes. Persantine gives increased thallium uptake m the normal areas of the heart and less in the diseased parts of the heart. 3. Answer persantine thallium when patients cannot exercise sufficiently to do a standard exercise tolerance test. The patient has a history chest pain but you are not certain if it is ischemic in nature. It can also be used for preoperative screening. 4. Persantine cannot be used for patients with asthma, COPD, or emphysema because it provokes bronchospasm. Stress testing in general should not be done with an acute infarction or unstable angina. 5. Use a dobutamine echocardiographic stress test when you cannot use persantine. 6. The single most accurate test of myocardial perfusion is the coronary artery angiogram.

Question 5

CARDIOLOGY Thallium Stress Testing 1. What is this? 2. When is thallium stress testing the answer? 3. What is the most accurate test?

Answer 5

CARDIOLOGY 1.Thallium scanning is the most accurate method of assessing myo­cardial perfusion without an angiography. 2.Thallium-labeled red cells are injected into the patient’s blood­ stream. A thallium scan provides a view of the blood flow into the heart muscle. Stress thallium is an alternative to stress echo. The indications for stress thallium are: -when resting EKG changes make exercise EKG difficult to interpret, such as the presence of an LBBB, baseline S-T changes, left ventricular hypertrophy, pacemaker. or the effect of digoxin on the EKG; -to localize the region of ischemia -to assess revascularization following bypass or angioplasty. 3. The most accurate test of myocardial perfusion is a coronary angiogram.

Question 6

CARDIOLOGY Dobutamine Stress 1. What is this? 2.How is it done? 3. When do you answer it? 4. What is the most accurate diagnostic test?

Answer 6

CARDIOLOGY 1 • Dobutamine stress testing is a form of exercise tolerance or “stress” testing that does not use physical exercise. It is a noninvasive method of determining myocardial perfusion. 2. Dobutamine is a direct~acting agonist at beta-1-adrenergic receptors, causing inotropic stress. Dobutamine is injected and the echo is observed for a decrease in wall motion. Ischemic myocardium does not move as well as normal myocardium. 3. Dobutamine is used in patients who cannot exercise. Look for a person who has a history of chest pain but in whom the story is equivocal and the EKG is nondiagnostic. The indications are the same as those for persantine stress testing. It is also used for patients with reactive airways diseases who cannot undergo a persantine thallium test. 4.The coronary angiogram is the most accurate test of myocardial perfusion.

Question 7

CARDIOLOGY Sestamibi Testing 1. What is this? 2. How is it done? 3. When do you answer it?

Answer 7

CARDIOLOGY 1. A sestamibi test is a type of nuclear stress test, also named Tc99m. 2. Tc99m-labeled compounds require intact perfusion, and a viable myocardial cell. Essentially, a myocardial perfusion agent is indicated for detectin coronary artery disease. Diseased or infarcted myocardium picks up less of the nuclear isotype. Ischemic myocardium re-perfuses at rest. The defect is “reversible.” Infarcted myocardium does not change with rest. 3. The bottom line answer for Sestamibi is that its a nuclear stress test that you use with obese patients and female patients with large breasts.

Question 8

CARDIOLOGY MUGA Scans (Multiple Gated Acquisition Scan} 1. For which condition is this the most accurate test? 2. How is it performed? 3. When do you answer MUGA scan?

Answer 8

CARDIOLOGY 1. MUGA is the single most accurate method of assessing ejection fraction. MUGA also assesses left ventricular wall motion and cardiac muscle damage. 2. MUGA is performed by injecting red blood cells, radiolabeled with technetium 99, into the patient’s bloodstream and recording the emissions with a gamma camera 3. MUGA is very userful in assessing and following cardiac function in patients during the delivery of potentially cardiotoxic chemotherapy such as adriamycin. The accuracy and reproducibility of the study make it suitable to detect subtle, early changes in cardiac function that might easily be missed by other techniques such as the echocardiogram.

Question 9

CARDIOLOGY Coronary Angiography or Cardiac Catheterization 1. What is it? 2. When is it the answer? 3. What does it show?

Answer 9

CARDIOLOGY 1. An angiography is the placement of a catheter from the femoral or brachialartery into the coronary artery with the injection of iodinated contrast material. 2. Angiography is the answer when: - the cardiac stress test is abnormal, - prior to coronary surgery or angioplasty, - in an acute coronary syndrome such as unstable angina. 3. Angiography provides an exact measure of the degree of stenosis of the coronary artery and the number of vessels involved. The degree of stenosis must be >70% to be considered significant.

Question 10

CARDIOLOGY CK·MB 1 • What is it? 2. When is this the right answer?

Answer 10

CARDIOLOGY 1. CK-MB is elevated in the serum as a marker for myocardial injury. CK-MB is useful in detecting infarction and therefore the right answer in assessing any patient with chest pain especially with cardiac risk factors. CK-MB normally increases within 4 to 6 hours from the start of the chest pain. It peaks at about 12-24 hours. CK-MB has a relatively short half-life when compared to the other specific myocardial marker troponin. CK-MB is particularly useful in detecting re-infarction. 2. Answer CK-MB when there is a patient with chest pain that is possibly ischemic in nature. The EKG does not have to have ST segment elevation in order for the CK-MB to be abnormal. Answer CK-MB when chest pain recurs after an infarction within the last few days.

Question 11

CARDIOLOGY
BNP (Brain Natriuretic Peptide)
1 • What is this?
2. When is BNP the answer?
3. What is the most accurate test?

Answer 11

CARDIOLOGY
1. Brain natriuretic peptide (BNP) is a hormone released from the
heart and brain in response to stretch of the atria and ventricles.
BNP has diuretic, natriuretic, and hypotensive effects and inhibits
the renin-angiotensin system in response to fluid over load states.
BNP goes up with congestive heart failure and other causes of
hypervolemia.

2. BNP is the answer when the patient is short of breath and the hisc
   tory and physical are not sufficiently specific to make an accurate
   diagnosis. BNP is sensitive but not specific for CHF. Is it CHF,
   pneumonia, COPD, or an embolus? Use BNP to help exclude
   CHF.
3. An elevated BNP is confirmed with an echocardiogram.

Question 12

CARDIOLOGY
Troponin Levels
1 • What are they?
2. When are they the answer?
3. What is the most accurate test?

Answer 12

1. Troponin is an enzyme that is released only from injured myocardium.
   Troponin is extremely specific for the myocardium and is
   rarely derived from other sites in the body.
2. Troponin levels are the answer in most acute coronary syndromes
   as the most accurate means of assessing myocardial ischemia or
   infarction. Answer troponins in all patients in the emergency
   department with acute, severe pain. This is true even if the EKG
   is normaL
3. Myocardial ischemia as found by elevated levels of troponins is
   confirmed with EKG, echocardiography, angiography.

Question 13

CARDIOLOGY
Tilt-Table Testing
1. What is tilt-table testing?
2. How is it performed?
3. When is it the answer?

Answer 13

CARDIOLOGY
1. Tilt-table testing is used to evaluate unexplained syncope. It is
the measurement of blood pressure and pulse at various angles
while the patient is tilted up and down while lying on a table.
2. Blood pressure and pulse are measured before and after moving
the patient into different positions. The development of syncope,
dizziness, or abnormal drops in blood pressure constitute
an abnormal test. Isoproterenol and nitroglycerin can be used as
provocative testing.
3. Answer tilt-table when there is unexplained syncope, particularly
when there are signs of orthostasis such as an inappropriate
bradycardia when standing up.

Question 14

CARDIOLOGY
Transesophageal Ec:hoc:ardiography (TEE)
1. What is this?
2. How is it done?
3. When do you answer it?
4. What is the most accurate diagnostic test?

Answer 14

CARDIOLOGY
1. Transesophageal echocardiography (TEE) is an extremely sensitive
method of assessing cardiac structure. TEE is particularly
sensitive at assessing posterior structures of the heart such as
diseases of the aorta; for example, dissection or aneurysm, atrial
thrombi, patent foramen ovale, or vegetations on valves for the
diagnosis of endocarditis. TEE is used when limited transthoracic
echocardiogram is inadequate.
2. TEE is performed by placing a sonographic transducer through
the mouth into the esophagus.
3. TEE is used to assess valvular heart disease as well as before the
cardioversion of atrial fibrillation exclude thrombi in left
atrium.
4. The most accurate diagnostic test is a cardiac catheterization of
the left heart.

Question 15

CARDIOLOGY
Transthoracic or 2D Ec:hocardiogram (ITE)
1. What is this?
2. How is it done?
3. When do you answer it?
4. What is the most accurate diagnostic test?

Answer 15

CARDIOLOGY
1. Transthoracic echo (TIE) is used to detect chamber size and
function, valve abnormalities, intracardiac masses, pericardia!
effusions, and aortic disease.
2. Images of the heart are obtained from a sonographic transducer
placed over the anterior wall of the chest.
3. TTE is done to assess every patient with an auscultory abnormality
for the severity of valve dysfunction. TTE has become the
second most frequently done test to evaluate the heart after EKG.
TTE is done to assess every patient with congestive failure (CHF)
to obtain the ejection fraction. Therapy for CHF differs markedly
based on whether there is systolic or diastolic dysfunction.
4. Both the transesophageal echo and the coronary angiogram are
more sensitive than the TTE.

Question 16

CARDIOLOGY
Cardiac Eled’rophysiological (EP) Studies
1 • What is an EP study?
2. When is an EP study the answer?

Answer 16

CARDIOLOGY
1. An EP study is the introduction of a catheter with an electrical
sensing and stimulating electrode into the heart. This allows both
the detection of abnormal cardiac rhythm disturbances as well as
the stimulation of the heart to determine the site of origin of an
abnormal rhythm.
2. EP studies are used for:
-definitive diagnosis of abnormal cardiac rhythms, particularly the etiology
unexplained syncope;
-mapping of the cardiac conduction system;
-ablation of aberrant conduction tract abnormalities such as SVT or WolffParkinson-
White syndrome;
-placement of automatic implanted cardioverter I defibrillators;
-searching for the site origin of sustained ventricular tachycardia.

Question 17

CARDIOLOGY
Holter Monitoring or 24-Hour Continuous
Ambulatory Cardiac Monitoring
1. What is this?
2. How does it work?
3. What is the most accurate test?
4. When do you answer Holter monitor?

Answer 17

CARDIOLOGY
1. Holter monitoring is a way of recording an EKG for 24 hours of
continuous readings from a single lead.
2. The patient wears leads on his chest and carries the recording
device around his neck like a portable tape or CD player while
he is at home. The strip can then be analyzed at high speed by the
physician to detect brief rhythm disturbances that may not have
been detected on the original EKG.
3. Abnormalities on the Holter can be further analyzed by electrophysiological
studies in a laboratory and by echocardiogram.
4. Answer Holter monitor when the patient has palpitations or syncope
and the EKG does not detect an abnormality.

Question 18

1. What is this?
2. What is the characteristic on the EKG that gives the
   diagnosis?
3. What is the case that will go along with this EKG?

Answer 18

1. The EKG shows Torsade de pointes.
2. The most distinctive feature of Torsade on EKG is the “undulating”
   amplitude that gives the impression of the EKG “twisting”
   around a point. Iorsade is a form of wide-complex tachycardia.
   The QRS width or duration is > 120 msecs. Essentially, Torsade is
   ventricular tachycardia with an undulating amplitude.
3. Just like ventricular tachycardia, Torsade may present with anything
   from simple palpitations to syncope to sudden death. You
   cannot tell without the EKG. Look for hypomagnesemia in the
   question. Torsade can also be caused by the toxicity of medications
   such as tricyclic antidepressants, amiodarone, dofetilide,
   ibutilide, macrolides, and, rarely, quinolone antibiotics.

Question 19

CARDIOLOGY

1. What is the diagnosis?
2. What case will go along with this EKG?
3. How do you treat it?

Answer 19

CARDIOLOGY
1. This EKG shows supraventricular tachycardia (SVT). SVT is a
regular tachycardia with narrow QRS complexes, and no apparent
P-waves, fibrillatory waves, or flutter waves. A normal QRS
duration is <120 milliseconds.
2. Look for a patient who presents with rapid palpitations and
lightheadedness. Triggers include the intake of caffeine or other
sympathetic system-stimulating drugs, psychological ·distress,
and hyperthyroidism.
3. Treatment includes carotid massage, followed by intravenous
adenosine. If adenosine does not work, calcium channel blockers
(e.g., verapamil or diltiazem), digoxin, or beta blockers can be
used.

Question 20

CARDIOLOGY
1. What is the diagnosis?
:2. What case will go along with this EKG?
3. How do you treat it?

Answer 20

CARDIOLOGY
1. This EKG shows a wide-complex tachycardia that is indicative of
ventricular tachycardia.
2. Look for a patient presenting with syncope, lightheadedness,
symptoms of congestive heart failure, or sudden death. The
range is very broad and there may only be palpitations.
3. Treatment for ventricular tachycardia depends on patient
stability:
-Unstable patients: electrical cardioversion
-Stable patients: amiodarone, lidocaine, procainamide

Question 21

CARDIOLOGY
1. What is this?
2. What is the characteristic on the EKG that gives the
diagnosis?
3. What is the case that will go along with this EKG?

Answer 21

CARDIOlOGY
1. The EKG shows ventricular fibrillation (Vfib).
2. The EKG has no organized activity at alL There may be either
low or high amplitude to the EKG tracing. If you see either an
organized P-wave, QRS, or regular rhythm, then it is not Vfib.
On the other hand, there is electrical activity. It is not flat like it is
in asystole.
3. Patients with Vfib have no pulse and no respirations. They have
no blood pressure and have suffered” cardiac arrest.” You cannot
distinguish between Vfib, asystole, pulseless electrical activi~
and certain forms of pulseless ventricular tachycardia without
an EKG.

Question 22

CARDIOLOGY
1 • What is this?
2. What is the characteristic on the EKG that gives the
diagnosis?
3. What is the case that will go along with this EKG?

Answer 22

CARDIOlOGY
1. The EKG shows asystole.
2. There is no significant activity of any kind. Asystole will not,
however, give you a perfectly flat line. There will still be a modest
bit of undulation of the baseline. When the term “flatline” is
used, howeve1; they are still referring to asystole.
3. Answer asystole for a patient who suddenly loses his pulse and
blood pressure, but other causes of pulselessness have been
excluded. It is not possible to distinguish between asystole, ventricular
fibrillation, pulseless electrical activity from tamponade,
or tension pneumothorax without an EKG.

Question 23

CARDIOLOGY

1. What is the diagnosis in this EKG?
2. What is distinct about this rhythm on the EKG?
3. What is the most common cause of this EKG finding?

Answer 23

CARDIOLOGY
1. The EKG shows multifocal atrial tachycardia (MAT).
2. MAT is characterized by irregularly irregular rhythm as demonstrated
by variability in the P-P intervals and the R-R intervals.
There are multiple P-R intervals and at least three different
P-wave morphologies. The atrial rate is over 100 per minute.
When the rate is lower it is no longer a “tachycardia” and is called
“wandering atrial pacemaker.”
3. MAT is caused by right heart strain and the effect of chronic pulmonary
disease on the right side of the heart such as in COPD.

Question 24

CARDIOLOGY
1. What disease would cause this EKG?
2. What characteristics of the EKG tell you the
diagnosis?
3. What case in the question will go along with this
EKG?
4. What is the pathology behind the EKG changes and
this disease?

Answer 24

CARDIOLOGY
1. This EKG shows the delta wave of Wolff-Parkinson-White
(WPW), which is a ventricular pre-excitation syndrome.
The EKG shows a short PR interval and slurring on the upstroke
of the QRS (delta wave).
3. The patient can have supraventricular tachycardia (SVT)
alternating with ventricular tachycardia. There will be both preexcitation
on the EKG and paroxysmal tachycardia. The SVT may
be described as “worsened after a calcium blocker or digoxin.”
4.An accessory pathway for cardiac conduction from fhe atria to
the ventricles that bypasses the AV node and causes earlier activation
(pre-excitation) of the ventricles.

Question 25

ONCOLOGY
Colposcopy
1. What is this?
2. What must be visualized for a sufficient study?
3. When is colposcopy the answer?

Answer 25

ONCOLOGY
1. A colposcopy is the direct visualization of the cervix by placing a
magnifying scope with a lamp into the vagina.
The transition zone must be visualized to ensure an adequate
colposcopy. This is the border between squamous and columnar
epithelium.
3. Answer colposcopy when the case describes a patient with an
abnormal Pap smear. The following findings on Pap smear necessitate
colposcopy:
-Atypical squamous cells–cannot exclude high grade lesion (ASC-H)
- Low-grade squamous intraepithelial lesion (LSIL)
-High-grade squamous intraepithelial lesion (HSIL)
-Atypical squamous cells of undetermined significance (ASCUS) if HPV
DNA testing is positive

Question 26

ONCOLOGY
Alpha fetoprotein (AfP)
1. What diseases is it associated with?
2. When do you answer AFP?

Answer 26

1. Alpha fetoprotein (AFP) is associated with the development of:
   -hepatocellular carcinoma
   - a ovarian cancer
   -non-seminomatous germ cell tumors
   Answer AFP when you see a patient with alcoholic cirrhosis or
   chronic hepatitis B or C. AFP together with radiologic imaging is
   used to screen for hepatocellular carcinoma.

Question 27

ONCOLOGY
Cardnoembryonic Antigen (CEA}
1 • What is it?
2. For which disease does it have prognostic value?
3. When do you answer CEA?
4. When do you answer CEA as a screening test?

Answer 27

ONCOLOGY
1 • CEA is a protein that is elevated in the serum in a variety of cancers,
including colorectal cancer (CRC).
2. Serum levels of CEA have prognostic value in patients with
newly diagnosed CRC. Those with higher levels have a worse
prognosis than those with lower levels.
3. Answer CEA level to monitor colon cancer patients after surgical
resection. This determines the presence of persistent, recurrent,
or metastatic disease.
4. CEA levels are never the right answer as a screening test for colon
cancer.

Question 28

ONCOLOGY
Estrogen and Progesterone Receptors
1 • What are these tests?
2. What is the therapy?

Answer 28

ONCOLOGY
1. Estrogen and progesterone receptors should be done on ·an
patients with breast cancer in order to determine who should
receive hormone receptor therapy.
2. Therapy with either tamoxifen or raloxifene should be added for
any patient with positive receptors. This is either for estrogen or
progesterone positivity alone or in combination. The response to
tamoxifen is better if both receptors are positive.

Question 29

ONCOLOGY
Mammogram
1. When do you answer mammogram?
2. When there is an abnormality what is the next best
step?
3. When does screening lower mortality the most?

Answer 29

ONCOLOGY
1. Screening mammogram should begin at age 40 and should be
performed every 1-2 years. Screening after age 50 is yearly.
2. When the mammogram shows abnormalities, a core biopsy
including sentinel node biopsy is the next best test. Carcinomas
of the breast are associated with clustered polymorphic microcalcifications.
Mammography is also used when a breast mass is
found on exam to locate additional lesions in the same breast or
bilateral disease.
3. Screening lowers mortality most after age 50, and the decrease is
greater than that with colonoscopy or Pap smear.

Question 30

ONCOLOGY
Papanicolaou (Pap) Smear
1. What is it?
2. When is Pap smear the answer?
3. If results are positive, what: is the next best test?

Answer 30

ONCOLOGY
1. The Pap smear is a test that examines the cells of the cervix: It
is a screening method to find cancerous or precancerous cervical
lesions. Pap smear does decrease mortality in screened
populations.
2. Pap smear should be started at age 21 or within 3 years the
onset of sexual activity, whichever is earlier. The test should be
done every 2-3 years and can be stopped at age 65.
3. Abnormalities on Pap smear are evaluated with colposcopy in
order to biopsy the cervix.

Question 31

ONCOlOGY
PET Scanning
1. What is this?
2. What makes it abnormal?
3. When is it the answer?

Answer 31

ONCOLOGY
1. PET means “positron emission tomography.” This measures the metabolic
activity of a lesion seen on a CT or MRI scan. it is based on
the ability of most cancers and some infections to have the increased
uptake of 18-fluorodeoxyglucose. It is a noninvasive test of the actual
function of a mass lesion, not just its size and location.
Most cancers and some infections have an increased uptake of the
tagged glucose.
3. A PET scan can tell if a lesion, such as a lung mass, that might otherwise
look malignant, really is malignant. For instance, if you are shown
a case of a localized lung cancer diagnosed with biopsy; you can use
the PET scan to see if there are metastases. If there is a mass in the
contralateral chest that is malignant, it makes the patient ineligible for
surgery with curative intent. If the PET scan shows a low uptake of the
tagged glucose, then the lesion is likely benign and you should proceed
with the surgery to remove the primary tumor site.

Question 32

ONCOLOGY
PSA (Prostate-Specific Antigen)
1. What is this?
2. When should it be done?
3. What is the most accurate test?
4. What test is done next if the PSA is positive?

Answer 32

ONCOLOGY
1 • PSA increases can occur in prostatitis, BPH, prostate cancet and
prostate biopsies. Levels are undetectable after total resection of
the prostate.
2. PSA testing is extremely controversial. There is no evidence that
PSA testing lowers mortality when used as a screening
test. If the question says the patient is requesting the test, then
you should do it.
3. Biopsy of the prostate is the most accurate diagnostic test.
4. If the PSA is elevated, a digital rectal exam is performed to palpate
a lesion. If a lesion is found, it should be biopsied. If no
lesion is found, a trans-rectal ultrasound should be performed
to find a lesion to biopsy. If no lesion can be found, then “blind
biopsies” should occur.

Question 33

ONCOLOGY
Sentinel Node Evaluation
1 • What is this?
2. How is this done?
3. When is this the answer?

Answer 33

ONCOLOGY
1. The sentinel node biopsy is used in the evaluation of breast
cancer.
2. A sentinel node biopsy is when dye is introduced into the operative
field. The first node it goes to is the “sentinel” node. If it has
cancer, you dissect the axilla. If it is negative, you do not need to
do an axillary lymph node dissection.
3. Look for a patient with an abnormal mammogram in whom the
biopsy shows cancer. Then answer sentinel node biopsy. Sentinel
node biopsy is the best test to do after the initial diagnosis of
breast cancer has been made with either a needle or excisional
biopsy. Sentinel node biopsy can eliminate the need for axillary
lymph node dissection.

Question 34

HEMATOlOGY
factor V leiden Mutation
1. What is this?
2. When do you answer factor V Leiden mutation?
3. What other tests should be sent with it?

Answer 34

HEMATOLOGY
1. Factor V Leiden mutation predisposes to thrombosis by resistance
to the antil:hrombotic effects of activated protein C Protein C
normally slows the dotting cascade by inhibiting Factor V. The
mutation allows Factor V to ignore the natural anticoagulant
action of protein C Factor V Leiden is the most common cause of
inherited thrombophilia.
2. Answer Factor V Leiden mutation as the most accurate test for
a young person with an unprovoked DVT or PE. Thrombotic
events after plane flights should evoke an investigation for
thrombophilia.
3. The other tests of hypercoagulable states are:
-ProteinS
-Protein C (when you see skin necrosis in the case)
-Lupus anticoagulant (when you see an elevated PTT or spontaneous
abortions in the case)
-Antithrombin III mutation (when you see resistance to heparin in the
case)

Question 35

HEMATOLOGY
Haptoglobin levels
1 • What is it?
2. When do you answer haptoglobin level?

Answer 35

EMATOLOGY
1. Haptoglobin is used to determine hemolysis. It is a protein that
binds to free hemoglobin. So when we have hemolysis, RBCs will
release free hemoglobin that will bind to haptoglobin. This will
result in decreased haptoglobin levels. In hemolysis we also find
an elevated level of LDH, reticulocytes, and indirect bilirubin.
2. The typical scenario will be the sudden onset of anemia without
gastrointestinal bleeding. The presence of jaundice is also highly
suggestive. Acute anemia minus GI bleeding equals hemolysis.

Question 36

HEMATOLOGY
Hemoglobin Electrophoresis
1. For which clinical condition(s) is this test used?
2. What signs/symptoms would prompt you to order
such a test?

Answer 36

HEMATOLOGY
1. Hemoglobin electrophoresis is the most sensitive test to diagnose
hemoglobinopathies such as sickle cell disease (SCD) or thalassemia.
It is the most accurate way to diagnose the presence of the
heterozygous forms of these diseases or the “trait”
2. With respect to SCD, clinical presentations include ulcerations
of the skin of the legs, recurrent infections with Pneumococcus or
Haemophilus, retinopathy, aseptic necrosis of the femoral head,
osteomyelitis, growth retardation, and splenomegaly. Typically,
the patient will be African-American with a possible family history
of the disease. Sickle cell trait will be in a patient who is
asymptomatic with a family member with sickle cell disease or
who has unexplained hematuria.
With respect to the thalassemia, clinical presentations range from
normal to severely symptomatic with growth failure, hepatosplenomegaly,
jaundice, and bony deformities.

Question 37

HEMATOLOGY
leukocyte Alkaline Phosphatase (LAP) Score
1. What is LAP?
2. When is LAP the answer?

Answer 37

HEMATOLOGY
1. Leukocyte alkaline phosphatase (LAP) is an enzyme in white
blood cells. If the cells are elevated in number and the function
is normal, the LAP score will go up in proportion to the elevated
cell count
2. LAP is a test for chronic myelogenous leukemia (CML). Answer
LAP when the white cell count is extremely high and the differential
shows mostly neutrophils. The case is likely also to have
a big spleen, giving left upper quadrant pain and early satiety.
LAP scores should be low in CML, and are used to differentiate
CML from a leukemoid reaction.

Question 38

HEMATOLOGY
Lymph Node Biopsy
1 When is a needle biopsy the answer?
2. When is an exdsional biopsy the answer?

Answer 38

HEMATOLOGY
1. Needle biopsy of a lymph node is used to detect infections such
as tuberculosis, fungi, and staphylococcus. Infections are suggested
by nodes that are warm, tender, and sometimes red
2. Excisional lymph node biopsy is the single most accurate test
to diagnose lymphoma. A needle biopsy of a lymph node is the
most common wrong answer in the diagnosis of lymphoma.
There is insufficient tissue in a needle biopsy of a node to diagnosis
lymphoma. In addition, the individual lymphocytes will
appear normal on a needle biopsy. The diagnosis of lymphoma
requires the visualization of the architecture of the entire node.
Nodes with lymphoma are nontender, not red, and not warm as
they would be with an infection.

Question 39

HEMATOLOGY
Mixing Studies
1. What is it?
2. When is this the best test?
3. If the test normalizes after the mixing, what does this
mean?
4. What is the next best test if the study normalizes?
5. If the test does not normalize after the mixing, what
does this mean?

Answer 39

HEMATOLOGY
1 • Mixing studies are done to distinguish between a clotting factor
deficiency and an inhibitor of the clotting factor as the cause of
an abnormal partial thromboplastin time (aPTT). You mix normal
pooled plasma with the patient’s plasma.
2. This is the best initial test when you have an abnormal aPTT.
3. If the test normalizes after the mixing, then the elevated aPTT is
caused by a clotting factor deficiency.
4. The next best test if the mixing study normalizes is individual
clotting factor assays of the patient’s plasma to determine which
factor is deficient.
5. If the test does not normalize means that an inhibitor is present,
i.e., Factor VIII inhibitor or the lupus anticoagulant.

Question 40

HEMATOLOGY
Methylmalonic Acid Level
1 • What is this?
2. When do you answer methylmalonic add level?

Answer 40

HEMATOLOGY
1. Methylmalonic add (MMA) builds up when vitamin B12 is
deficient. MMA has greater sensitivity than vitamin B12 levels.
Homocysteine is elevated in both B12 and folic add deficiency.
2. Answer MMA when the patient has macrocytic anemia and
hypersegmented neutrophils but a normal B12level. When there
is a story like B12 deficiency and the B12 level is normal, answer:
MMA leveL

Question 41

HEMATOLOGY
Osmotic fragility Test
1 • What is it?
2. How does it work?
3. When is the answer osmotic fragility?

Answer 41

HEMATOLOGY
1 • Osmotic fragility is the classic test for hereditary spherocytosis.
It measures the amount of hemoglobin released from red blood
cells (RBCs) placed in hypotonic solution. RBCs with a reduced
surface area-to-volume ratio will lyse at concentrations that do
not affect normal cells. This is because they do not have enough
cell membrane. They “stretch” and then “pop” when put in a
hypotonic solution.
3. Answer osmotic fragility when you are presented with a case
of hemolytic anemia and splenomegaly with spherocytes on the
peripheral smear. The other features that push the diagnosis and
this test are: family history of recurrent episodes of anemia, and
bilirubin gallstones.

Question 42

HEMATOLOGY
Philadelphia Chromosome
1. What is this?
2. When is it the most accurate diagnostic test?

Answer 42

1. A Philadelphia chromosome represents a genetic translocation
   between chromosomes 9 and 22. It is associated with chronic
   myelogenous leukemia. It is also known as BCR/ Abl and can be
   detected by PCR.
2. The answer is Philadelphia chromosome when you are presented
   a case of probable CML The white cell count will be very high,
   mostly neutrophils, and the LAP (or leukocyte alkaline phosphatase)
   score will be low. The Philadelphia chromosome also has
   prognostic value. If you give imitanib (gleevec) and the Philadelphia
   chromosome goes away, the prognosis is good.

Question 43

HEMATOLOGY
D-Dimer/Fibrin Split Products
1 • What are they?
2. How are they measured?
3. What do they detect?
4. What do the results tell you?
S. When should you order them?

Answer 43

HEMATOLOGY

1. D-dimer is the by-product of the degradation of fibrin by plasmin.
   Fibrin split products (FSPs) are produced by the activation
   of fibrinogen by thrombin. They are abnormal only if they are
   present in increased amounts.
2. D-dimer can be measured by either latex agglutination (more
   rapid) or ELISA (more accurate). The ELISA is far more
   sensitive.
3. Elevated levels indicate pathology involving clot formation and
   lysis from activation of the coagulation cascade. They provide no
   information about platelet function.
4. Elevated D-dimer/FSP levels are evidence of DIC. A negative
   result of the ELISA rules out DVT and PE but a positive result
   does not confirm the diagnosis.
5. Order these tests to confirm suspected DIC and to rule out PE in
   patients with a low pre-test probability.

Question 44

HEMATOlOGY

1. What is this?
2. What diseases are associated with it?
3. What is the most accurate test?
4. What is the therapy?

Answer 44

HEMATOLOGY
1. This is a hypersegmented neutrophil. Normal neutrophils contain
an average of 3.5 lobes per cell. When the average is above
4 lobes, or there are 5% above 5 lobes, or a single 6-lobed cell,
hypersegmentation is present. This is the defining feature of
megaloblastic anemia.
2. Hypersegmented neutrophils or megaloblastic anemia is present
with vitamin B12 and folate deficiency.
3. The most accurate test is B12 and folate levels. B12 deficiency is
also confirmed with an elevated methylmalonic acid level. The
etiology of B12 deficiency is confirmed with anti-intrinsic factor
and antiparietal cell antibodies, which are the diagnostic test for
pernicious anemia.

Question 45

HEMATOLOGY

1. What does this blood smear show?
2. When do you answer this?
3. What is the most accurate diagnostic test?

Answer 45

HEMATOLOGY
1. The blood smear shows cells with cytoplasmic projections consistent
With hairy cell leukemia.
2. Look for a middle-aged man presenting with the gradual onset
of fatigue. Splenomegaly is present and may be massive. The
Liver is enlarged in 50% of cases. Pancytopenia is the hallmark of
hairy cell leukemia.
3. The most accurate test is tartrate-resistant add phosphatase
(TRAP). This is done on a bone marrow biopsy.

Question 46

HEMATOLOGY
Peripheral Smear
1. What does the peripheral smear show?
2. When is this the answer?
3. What are the other cells characteristic of this disorder?
4. What is the definitive test for this disorder?

Answer 46

HEMATOLOGY
1 • This peripheral smear of red blood cells shows Heinz bodies. Heinz
bodies are precipitated, oxidized hemoglobin. They are found in glucose-6-phosphate dehydrogenase (G6PD) deficiency. G6PD is an
X-linked recessive disorder affecting 10-15% of African-American
males.
2. Look for a man who was healthy until exposed to oxidant stress and
suddenly develops intravascular hemolysis resulting in weakness,
tachycardia, jaundice, and dark urine. The most common type of oxidant
stress is from infection, not drugs. Drugs associated with this
stress include sulfa drugs, primiquine, dapsone, quinidine, and nitrofurantoin.
Fava beans also cause hemolysis.
3. Heinz bodies are removed, resulting in cells called bite cells.
4. The definitive test for this disorder is a G6PD leveL You must wait
2 months to do the level, because the G6PD level will be artificially
elevated immediately following a hemolytic event. All the most deficient
cells are destroyed.

Question 47

HEMATOLOGY

1. What is this?
2. What disease causes it?
3. When is it the answer?

Answer 47

HEMATOLOGY

1 • This is an Auer rod. An Auer rod is an eosinophilic needle-shaped
inclusion in the cytoplasm.
2. Auer rods are pathognomonic for acute myelogenous leukemia
(AML).
3. Answer Auer rods when you are shown a patient with pancytopenia
and blasts on the peripheral smear or greater than 20%
blasts on bone marrow exam. Histochemical stains demonstrating
myeloid enzymes such as peroxidase may further aid in
choosing AML as the answer.

Question 48

HEMATOLOGY
1. What are these?
2. What is the enzyme deficiency responsible for this
condition?
3. What are the precipitating factors?

Answer 48

HEMATOLOGY
1. These are bite cells. They are formed when Heinz bodies (denatured
hemoglobin) are removed from the cells by the spleen.
Macrophages in the spleen remove the denatured hemoglobin.
2. Bite cells are seen with G6PD deficiency, which is an X-linked
disorder. It is the most common enzymatic disorder of the red
blood cells in humans.
3. Patients with G6PD deficiency are prone to developing hemolytic
anemia in response to sulfonamide drugs such as dapsone
and sulfasalazine. Other precipitating factors are infections, diabetic
ketoacidosis, and Favism. Favism is the ingestion of fava
beans resulting in hemolysis. This happens in the Mediterranean
variant of G6PD deficiency.

Question 49

HEMATOLOGY

1. What is this?
2. What diseases are associated wil:h it?
3. What other abnormal lab tests are associated with it?

Answer 49

1. These are fragmented red blood cells. The individual pieces are
   also known as schistocytes and helmet cells. Collectively, this is
   also know as intravascular hemolysis or microangiopathic hemolytic
   anemia.
2. Fragmented cells are seen in thrombotic thrombocytopenic purpura
   (TTP), hemoytic uremic syndrome (HUS), major blood
   group incompatability, disseminated intravascular coagulation
   (DIC), paroxysmal nocturnal hemoglobinuria, artificial heart
   valves, and snake bites.
3. All forms of hemolysis are associated with an elevated LDH,
   indirect bilirubin, elevated reticulocyte count, and decreased levels
   of haptoglobin.

Question 50

HEMATOLOGY

1. What is this?
2. What causes this?
3. Which hematological disorder is associated with this?

Answer 50

HEMATOLOGY
1. This is a ringed sideroblast. Prussian blue stain is necessary in
order to visualize it. The ringed sideroblast is caused by iron
accumulation within mitochondria in the red cell. This is the
main finding in sideroblastic anemia.
2. Look for a case of microcytic anemia with an elevated serum iron
level in an alcoholic. Acquired sideroblastic anemias can occur as
a result of the ingestion of drugs such as alcohol, isoniazid, and
chloramphenicoL or toxins such as lead or zinc.
3. Ringed sideroblasts are also a feature of myelodysplastic
syndrome.

Question 51

HEMATOLOGY

1. What are these?
2. What diseases are associated with these?

Answer 51

HEMATOLOGY
1. These are Rouleaux formations. They occur when red blood cells
form stacks.
2. Rouleaux may form due to the presence of abnormal globulins
or fibrinogen, This formation of the red blood cells is found in
multiple myeloma and macroglobulinemia. Other dues that suggest
multiple myeloma might be anemia, hypercalcemia, renal
failure, and abnormal SPEP or UPEP.

Question 52

HEMATOlOGY

1. What are these?
2. What is the most accurate diagnostic test?
3. What is the genetic defect?
4. When do you answer this test?

Answer 52

HEMATOLOGY
1. The peripheral smear shows spherocytes.
2. The most accurate test for hereditary spherocytosis is the osmotic
fragility test. MCHC is not the most accurate test.
3. The defect is on the ankyrin gene, which leads to spectrin deficiency,
which results in membrane instability.
Look for a patient with recurrent hemolysis, a big spleen, and a
family history of anemia. The CBC reveals anemia and an elevated
mean cell hemoglobin concentration (MCHC).

Question 53

HEMATOLOGY
1 • What is this?
2. What diseases are associated with it?
J. What is the most accurate test?

Answer 53

HEMATOLOGY

1. Sickled cells.
2. Only sickle cell disease that is homozygous (SS) will produce
   sickled cells. Heterozygous disease (AS) will be hematologically
   normal.
3. The most accurate test for sickle cell disease is a hemoglobin
   electrophoresis.

Question 54

HEMATOLOGY

1. What are these?
2. What is the most accurate diagnostic test?
3. Do these cells have a shorter survival?

Answer 54

HEMATOLOGY
1 • These are target cells. These cells are associated with liver disease
and certain hemoglobinopathies such as sickle cell disease,
thalassemia, and, most notably, hemoglobin C disease. Iron deficiency
can also have target cells.
2. The most accurate test is a hemoglobin electrophoresis.
3. Despite their abnormal appearance on peripheral smear, target
cells do not have a shorter survival compared to normal cells.

Question 55

HEMATOLOGY
1. What does the peripheral smear show?
2. When these cells are in the stem, what is the answer
to the diagnostic question?

Answer 55

HEMATOLOGY

1. The smears show teardrop cells.
2. When teardrop cells are either shown or described in the question,
   you should answer infiltrative bone marrow disease such
   as myelofibrosis. Look for a case of pancytopenia and massive
   splenomegaly in which hairy cell leukemia has been excluded.
   The bone marrow biopsy will show reticulin fibers.

Question 56

HEMATOLOGY
Sucrose Lysis Test
1. What: is this?
2. When do you answer sucrose lysis test?
3. What is the most: accurate test?

Answer 56

HEMATOLOGY
1. The sucrose lysis test is a screening test for paroxysmal nocturnal
hemoglobinuria (PNH). A sample of the patient’s blood is
treated with sucrose and observed for evidence of hemolysis
from complement activation. The hemolysis of PNH is caused by
increased sensitivity of the patient’s red cells to lysis by complement.
Sucrose activates complement and evokes hemolysis.
2. Answer sucrose lysis test if a patient presents with dark urine
in the morning, with or without evidence of venous thrombosis
and pancytopenia. The Coombs’ test will be negative.
3. The most accurate test for PNH is flow cytometry for the absence
of CD55 and CD59, also known as decay-accelerating factor
(DAF).

Question 57

HEMATOLOGY
Serum Protein Electrophoresis (SPEP)
1 • What is this?
2. When is this the answer?
3. What is the most common reason for an abnormality?
4. What is the most accurate test?

Answer 57

HEMATOLOGY
1. The SPEP is the separation and fractionation of the patient’s
serum proteins in order to assess the individual components,
i.e., how much of the patient’s protein is albumin, how much is
immunoglobulin.
2.Answer SPEP to evaluate a high total serum protein. SPEP is the
best initial test to diagnose myeloma, particularly if an X ray of
the bone looking for lytic lesions has already been done, or if
X ray is not one of the answer choices.
3. The most common reason to have an abnormality on the SPEP
is a monoclonal gammopathy of unknown or undetermined
significance.
4. The most accurate test for an IgG abnormality detected as an
SPEP spike is a bone marrow. A total of > 10% plasma cells is
indicative of myeloma. Waldenstrom’s macroglobulinemia will
also give an abnormal SPEP with an IgM spike.

Question 58

HEMATOLOGY
Schilling’s Test
1. For which clinical condition(s) is this test used?
2. How is this test performed?
3. When do you answer Schilling’s test?

Answer 58

HEMATOLOGY
1 • Schilling’s test is used to find the etiology of a B12 deficiency. The most
common cause of Bl2 deficiency is pernicious anemia where there is
decreased intrinsic factor (IF) due to autoantibodies against IF.
2. In the first stage, radiolabeled cyanocobalamine is given orally, followed
by an intramuscular injection of cyanocobalamine 1 hour later.
Urine is collected for determination of the percent excretion of the oral
dose. In pernicious anemia, or malabsorption, excretion in the urine is
low. The test is repeated with added oral intrinsic factor (IF). Adding
IF should normalize cyanocobalamine absorption and urinary excretion
in patients with pernicious anemia, but not in those with intestinal
malabsorption.
3. Schilling’s test is rarely the right answer. Look for a case of vitamin
B12 deficiency when the intrinsic factor and parietal cell antibodies are
negative and the etiology of the diagnosis is not dear or the antibodies
are not in the choices. Schilling’s test is to diagnose B12 deficiency
when the diagnosis is not pernicious anemia.

Question 59

HEMATOLOGY
Russell’s Viper Venom Clotting Time (RVVT)
1. What is this?
2. When is this indicated?
3. What is a common clinical scenario?

Answer 59

HEMATOLOGY
1 • RVVT is a phospholipid-dependent coagulation test
2. It is used in detection of antiphospholipid antibodies or lupus
anticoagulant. Think of this in a patient who has a prolonged
PTT that does not correct with a mixing study. The dilute Russell
viper venom test may be indicated to confirm that the inhibitor
is a lupus anticoagulant.
3. Clinical scenario may be of a woman, with or without features
of SLE, with repeated abortions or giving birth to an infant with
heart block or presenting with venous or arterial thrombosis.

Question 60

HEMATOlOGY
Ristocetin Cofactor Assay
1. What is this?
2. When is this the answer?

Answer 60

HEMATOLOGY
1 • The Ristocetin cofactor assay is a test of the function of von Willebrand’s
factor (VWF). Along with a VWF level, it is the most
accurate test for von Willebrand’s disease. Ristocetin acts as an
artificial endothelial lining. If VWF is present and is functioning
normally then platelets should adhere to the Ristocetin.
2. Answer Ristocetin assay when you see a patient with platelet
type of bleeding and a normal platelet count and normal VWF
level. Platelet type of bleeding is superficial. Examples are epistaxis,
petechiae, purpura, and gum or gingival bleeding.

Question 61

HEMATOLOGY
Anti-Intrinsic fador Antibodies
Antiparietal Cell Antibodies
1. What are they?
2. When do you answer these antibody tests?

Answer 61

HEMATOLOGY
1. Anti-intrinsic factor (anti-IF) antibodies and antiparietal cell antibodies
are highly confirmatory for the diagnosis of pernicious
anemia. They are nearly 100% specific for the disease. Pernicious
anemia is an autoimmune disease in which you become “allergic”
to your own IF and gastric parietal cells. You can’t absorb
B12 without IF. You can’t make IF without parietal cells.
2. Answer anti-IF and antiparietal cell antibodies when you see a
case of B12 deficiency and you want to determine the etiology.
The case will describe a patient in whom the B12level will be low
or the methylmalonic acid level high. These antibodies are not to
diagnose B12 deficiency, they are to determine the etiology.

Question 62

HEMATOLOGY
Bleeding Time
1. What is it?
2. How is it done?
3. When is bleeding time the answer?
4. What is the most accurate test?

Answer 62

1. A test of the ability of the platelet to adhere to the endothelial
   lining of the capillary. Do not use it when the platelet count is
   abnormally low. Everyone with a low platelet count will have an
   abnormal bleeding time.
2. A blood pressure cuff is inflated to 40 mm Hg to engorge the
   blood vessels, then small cuts are made. The test is the amount of
   time it takes for the bleeding to stop.
3. Answer bleeding time when the patient has abnormal bleeding
   that seems to be from a platelet disorder but the platelet count
   is normal. Examples are Von Willebrand’s disease or uremiainduced
   platelet dysfunction.
4. The most accurate tests are a Von Willebrand’ s factor level, ristocetin
   cofactor assay, or in vitro platelet aggregation studies.

Question 63

HEMATOLOGY
Burr Cells
1. What are they?
2. What conditions are they associated with?
3. How do you differentiate them from spur cells?

Answer 63

1. Burr cells are red cells with many blunt, regular spicules. Burr
   cells are also called echinocytes.
2. Burr cells are present in end-stage renal disease and liver
   disease.
3. Spur cells, or acanthocytes, have only a few, irregular spicules.
   They are seen in severe liver disease and in some forms of hereditary
   spherocytosis and myelodysplasia.

Question 64

HEMATOLOGY
Decay-Accelerating factory (DAF} or
CD55/CD59 Assay
1. What is this?
2. When is this the most accurate diagnostic test?
3. When do you answer OAF?

Answer 64

HEMATOLOGY
1. CDSS/59 is a test for paroxysmal nocturnal hemoglobinuria
(PNH), also known as decay-accelerating factor. DAF is a membrane
component of the complement system.
2. Assay for DAF is the most accurate test for diagnosing PNH.
3. Answer DAF when you see a patient with intermittent dark
urine, particularly in the morning, pancytopenia, and large vessel
thrombosis.

Question 65

HEMATOLOGY
Cold Agglutinins
1 • What: is this?
2. What diseases is it associated with?
3. When do you answer cold agglutinins?

Answer 65

HEMATOLOGY
1. Cold agglutinins are IgM autoantibodies directed against RBC
antigens. Titers are measured when cold agglutinin disease,
which is a type of autoimmune hemolytic anemia, is suspected.
2. High titers have been found to be associated with malignancies
such as lymphoma, CLL, and Waldenstrom’ s macroglobulinemia,
as well as mycoplasma infections and infectious mononucleosis.
Answer cold agglutinins when you see a patient with hemolytic
anemia as well as skin discoloration when exposed to cold temperatures.
Do not confuse this with cryoglobulins, which give
purpuric skin lesions and glomerulonephritis.

Question 66

HEMATOlOGY
Coombs’ Agglutinin Test
1. What is this?
2. What clinical significance does this test have?
3. What is the most common cause?

Answer 66

HEMATOLOGY
1. Coombs’ test measures the presence of antibodies against red
cells.
Coombs’ test is used for the diagnosis of autoimmune hemolysis.
A positive Coombs’ test shows the agglutination of the
patient’s red cells.
3. A total of 30-50% of Coombs’ positive hemolytic anemia is idiopathic.
The most common identified etiologies are penicillin,
quinidine, alphamethyldopa, sulfa drugs, and aspirin.

Question 67

NEPHROLOGY

1. What are these?
2. What is the most accurate test?
3. When is this the answer?

Answer 67

NEPHROLOGY
1 • The crystals pictured are “enveloped-shaped” oxalate crystals.
They precipitate in the renal tubules when a toxic dose of ethylene
glycol, a component of antifreeze, is ingested.
2. The most specific test for ethylene glycol intoxication is to det:ermine
the blood level. Urine can be examined under a fluorescent
Wood’s light, however urinary fluorescence lasts only a few
hours. after ingestion. Because the oxalic acid precipitates with
calcium, the blood level of calcium is often low.
3. Answer ethylene glycol overdose and oxalate crystals when you
see an elevated anion gap and metabolic acidosis. The question
most often describes a depressed patient with a possible
attempted suicide. Hypocalcemia can lead toQT prolongation
and cardiac arrhythmias. Oxalate crystals deposit renal
tubules and cause acute tubular necrosis.

Question 68

NEPHROLOGY
Water Deprivation Test
1. What is this test for?
2.How is it done?
3. When is water deprivation test the answer?

Answer 68

NEPHROLOGY
1 • Water deprivation test allows us to distinguish between the causes
of diabetes insipidus (DI) and to objectively assess patients with
hypernatremia and high urine output.
2. You restrict water intake for 12-24 hours with observation for the
volume of urine, urine osmolality, and change in body weight to
evaluate whether the kidneys are conserving or excreting water
properly. If the urine volume stays elevated after the serum
osmolality goes up, then it is DI. H there is a decrease in volume
in response to giving vasopressin or ADH, then it is central DL If
there is no response, it is a nephrogenic DI.
3. When you see a case of hypernatremia and high urine output,
answer water deprivation test as the best initial test.

Question 69

NEPHROLOGY
Anti-Basement Membrane Antibodies
(Anti-BM Antibodies)
1. What is this?
2. When is this the answer?
3. What is the most accurate diagnostic test?

Answer 69

1. Anti-BM antibodies are indicative of Goodpasture’s syndrome.
2. Answer anti-BM antibodies when you are shown a patient with
   hematuria and hypertension, accompanied by cough, shortness
   of breath, and hemoptysis. Renal insufficiency and red cells or
   red cell casts in urine are characteristic.
3. The most accurate test for Goodpasture’s syndrome is a lung or
   kidney biopsy.

Question 70

NEPHROLOGY
Total Complement level (CH 50)
1 • When do you answer CH 50?

Answer 70

NEPHROLOGY
1. Complement deficiency leads to recurrent bacterial infections
CH 50, or the total complement assay, is performed on a young
patient with recurrent unexplained infections such as
pneumonia, meningitis, sinusitis, etc., with encapsulated organisms such
as Neisseriae, S. pneumoniae, and H. influenzae. The patient will
have normal CH50 assay indicates inherited or acquired complement deficiency.

Question 71

NEPHROLOGY
Urine Microalbumin
1 • What is this?
2. When do you answer urine microalbumin?
3. What is the treatment?
4. What is a positive test?
S. What is the most accurate test?

Answer 71

1. Microscopic urine albumin is a sensitive screening test for diabetic
   nephropathy.
2. Look for a case with diabetes for >5 years who has normal renal
   function and a negative urinalysis for protein. H the dipstick
   is already positive for albumin, there is no reason to look for
   microalbuminuria. Screening for microalbumin is done yearly in
   diabetic patients.
3. If the test is positive, you use ACE inhibitors or ARBs to prevent
   progression of the disease.
4. A negative test for microalbumin is <30 mg/ day. Levels between
   30 and 300 mg/ day are called microalbuminuria. Levels above
   300 mg would register as positive on the normal urinalysis.
   The renal biopsy is the only test of the effect of diabetes on the
   kidney that is more sensitive than microalbuminuria.

Question 72

EMERGENCY MEDICINE/SURGERY
Cystography (Voiding Cystography, Voiding
Cystourethrography)
1 • What is this?
2. When do you answer cystography?

Answer 72

1. Cystography is the radiographic visualization of bladder filling
   and emptying through the urethra. This not to be confused
   with cystometrics, which is a pressure measurement of the bladder
   useful in the evaluation of incontinence. Cystography is an
   evaluation of the anatomy of the urogenital system.
2. Answer cystography in evaluating the following conditions:
   -Trauma to the bladder
   -Neoplasia in and surrounding the bladder
   -Urinary tract infections (UTis) in children
   -All children younger than 5 years old with UTI
   -Children of any age with febrile UTI
   -Boys of any age with UTI

Question 73

EMERGENCY MEDICINE/SURGERY
Intravenous Pyelogram
1. For which clinical condition would you answer this
test?
2. What is the most accurate test?

Answer 73

1. Intravenous pyelogram (IVP) is an old test of virtually no clinical
   utility and is almost always a wrong answer. In an IVP, intravenous
   contrast is injected and multiple X rays are taken to look
   for radiographic visualization of the renal infrastructure (calices,
   pelvis, and ureter). This makes the test slow. It was used in
   the evaluation of a patient with renal colic when no stones were
   found on radiograph.
2. The IVP has been replaced by the renal ultrasound as the best
   initial test and the CT scan as the most accurate test. If an ultrasound
   or CT scan is in the answer, then the IVP is never correct.
   The IVP uses contrast, which has a risk of both renal failure and
   allergic reaction. The CT scan is much faster, is more sensitive,
   and does not use contrast when looking for stones.

Question 74

Renal Ultrasound
1. For which clinical conditions is this test commonly
used?
2. When do you answer renal ultrasound?

Answer 74

1. Renal ultrasound is the best initial test for:
   -Kidney stones
   -Congenital renal malformations
   -Pediatric tumors
   -Recurrent urinary tract infections
   -Chronic renal failure
   -Renal artery stenosis
   -Polycystic kidney disease
2. Answer renal ultrasound when you see a patient with unexplained
   hematuria {)f flank pain and tenderness.
   Answer renal ultrasound when you see a patient with dysuric
   symptoms such as frequency and burning, the urinalysis has
   white blood cells, and there is flank pain.

Question 75

EMERGENCY MEDICINE/SURGERY
Right Upper Quadrant Ultrasound
1. For which clinical scenarios is this test the right
answer?
2. What is the most accurate test?
3. What if the patient experiences pronounced
tenderness when performing the RUQ US?

Answer 75

1. Right upper quadrant ultrasound is the answer when the patient
   presents with right upper quadrant pain, with or without fever.
   The ultrasound will evaluate hepatobiliary structures for the following
   diseases:
   a) Liver pathology:
   b) Masses (tumor, abscess, cysts)
   c) Portal hypertension
   d) Gallbladder and tree
   e) Cholelithiasis
   f) Cholecystitis
   g) Choledocholithiasis
   h) Cholangitis
2. The most accurate test for biliary pathology is the ERCP or MRCP.
   The most accurate test for liver pathology is the liver biopsy.
3. If there is tenderness when the transducer presses against the
   abdomen, this is a positive Murphy’s sign. This is highly suggestive
   of acute cholecystitis.

Question 76

EMERGENCY MEDICINE/SURGERY
Skull X Rays
1. What abnormalities do they detect?
2. What do they miss?
3. When the patient has been hit in the head, when are
skull X rays the right answer?

Answer 76

1 • Skull X rays can detect fractures of the skulL They can also detect
lytic and blastic lesions such as from bony metastases or Paget’s
disease.
Skull X rays are incapable of detecting intracranial bleeding.
They provide no information on brain or cerebral structure.
3. For a patient who has experienced head trauma, skull X rays are
always the wrong answer. When there is a head trauma case,
skull X rays may be in the answer, but do bit choose them.

Question 77

1 • Skull X rays can detect fractures of the skulL They can also detect
lytic and blastic lesions such as from bony metastases or Paget’s
disease.
Skull X rays are incapable of detecting intracranial bleeding.
They provide no information on brain or cerebral structure.
3. For a patient who has experienced head trauma, skull X rays are
always the wrong answer. When there is a head trauma case,
skull X rays may be in the answer, but do choose them.

Answer 77

1 Pelvic ultrasound is indicated in the following scenarios:
-Pelvic or lower abdominal pain with amenorrhea or vaginal bleeding.
- Suspected pregnancy
-Suspected ectopic pregnancy
Transvaginal ultrasound is superior to transpelvic ultrasound
in:
-Placenta previa (painless vaginal bleeding in the third trimester)
- Fetal monitoring in the first trimester
-Obese women in examining pelvic anatomy

Question 78

EMERGENCY MEDICINE/SURGERY

1. What does this X ray show?
2. When is this type of X ray the answer?

Answer 78

1. This is an upright X ray of the chest. The usual chest film is done
   with the patient sitting up so it can show air accumulated under
   the diaphragm.
2. An upright chest X ray is the answer when you suspect the perforation
   of an abdominal organ. This can be in association with
   ulcer disease, penetrating trauma to the abdomen, or rupture
   secondary to diverticulitis, appendicitis, other infections, or iatrogenically
   from endoscopy.

Question 79

EMERGENCY MEDICINE/SURGERY
Skeletal Survey
1. What is this?
2. When do you answer skeletal survey?

Answer 79

1. Skeletal survey is a radiographic study of the entire skeleton.
2. Skeletal survey is used with the suspicion of child abuse, multiple
   myeloma, and metastatic bone tumors.
   Example
   a) 8-year-old falls from chair
   b) Multiple bruises on arms and legs
   c) Suspect child abuse and get skeletal survey

Question 80

EMERGENCY MEDICINE/SURGERY
Diagnostic Peritoneal lavage (DPl)
1. When do you answer DPL?
2. For which patients should you not answer DPL?
3. What is the abnormality you find on DPL that makes
it positive?
4. What does DPL miss?

Answer 80

1 • Look for the dnmk or unconscious patient who cannot have his abdomen
examined reliably with multiple trauma and unexplained shock
A catheter is inserted into the abdomen and saline is infused, aspirated,
and examined.
The following scenarios are not appropriate for evaluation with DPL:
a) Patient with signs of acute abdomen. Any indication of perforated viscus
or intraabdominal bleed is an indication for immediate surgical
exploration.
b) Patient with gunshot wound to the abdomen. Is indication for immediate
surgical exploration.
c) Hemodyamically stable patient with history of abdominal trauma but no
definite signs of viscus perforation on physical exam. Abdominal CT is
indicated here.
3. To be considered positive a DPL should show RBC count >100,000/
mm3, WBC >500/mm3, bile, or feces.
4. DPL is inadequate to diagnose retroperitoneal injuries.

Question 81

EMERGENCY MEDICINE/SURGERY
Pelvic loporoscopy
1. What is this?
2. When do you answer pelvic laparoscopy?

Answer 81

1. Pelvic laparoscopyis used for direct visualization of pelvic strucutures
   and is the most accurate test in the following conditions:
   a) Ectopic pregnancy
   b) Pelvic inflammatory disease
   c) Endometriosis
   d) Pelvic cyst
   e) Chronic pelvic pain
2. Answer pelvic laparoscopy when you see a womanwho presents
   with pelvic pain, vaginal bleeding, and a positive BhCG. This is
   particularly true if the level of BhCG is low for the estimated gestational
   age.
   Answer pelvic laparoscopy when you are shown a case of lower
   abdominal pain in a woman treated for pelvic inflammatory
   disease with an incomplete response in whom pregnancy is
   excluded.

Question 82

EMERGENCY MEDICINE/SURGERY
Diagnostic Abdominall.aparoscopy (DAI.)
1. What is this?
2. When do you answer DAL?

Answer 82

1. Diagnostic abdominallaparoscopy (DAL) is used for direct visualization
   of abdominal structures in !:he following conditions:
   a) Ascites of unclear etiology
   b) Liver disease with an inconclusive biopsy
   c) Staging of abdominal cancer
2. In a trauma patient:
   This modality may be used in stable patients as a less invasive
   alternative to laparotomy. DAL is especially useful in investigating
   injuries to !:he diaphragm.
   Look for a case of a victim of a motor vehicle accident in who
   the abdominal CT scan is nondiagnostic and organ damage is
   suspected.

Question 83

EMERGENCY MEDICINE/SURGERY
Prenatal Screening
1. What tests does prenatal screening include?
2. Which tests are specifically appropriate for high-risk
pregnancies or mothers over 35?

Answer 83

1. Basic prenatal screening is appropriate in all pregnancies. These
   tests include:
   a) Cervical cytology
   b) CBC
   c) Urinalysis
   d) Blood group, RH factor, and antibody
   e) Serology for syphilis
   f) Rubella antibody
   g) Glucose screening
   h) Fetal ultrasound
   i) Cervical Culture for
   j) Neisseria
   k) Group B streptococci
   l) Chlamydia trachomatis
2. In a woman over 35, answer chromosomal screening for fetal
   abnormalities.

Question 84

ENDOCRINOLOGY
C-Peptide
1 • What is this test?
2. What do low values represent in a patient with
hypoglycemia?
3. What do high values represent?
4. When do I answer C-peptide level?

Answer 84

1. Serum measurement of C-peptide is the best test to distinguish
   endogenous from exogenous hyperinsulin in patients with
   hypoglycemia.
   Low values of C-peptide in patients with hypoglycemia represent
   factitious insulin injection. The patient is abusing insulin.
2. High C-peptide values represent endogenous insulin production,
   such as that induced by sulfonylureas or from an insulinoma.
   Look for a patient with unexplained hypoglycemia, high insulin
   level, and multiple hospital visits. Answer C-peptide as the next
   best step to determine the etiology.

Question 85

ENDOCRINOLOGY
Oral Glucose Tolerance Testing
1 • What is this?
2. What constitutes a positive test?
3. When is this the most accurate diagnostic test?

Answer 85

1. An oral glucose tolerance test is the measurement of serum glucose
   levels at baseline and 2 hours after the ingestion of an oral
   load of 75 grams of glucose.
2. A positive test means that the glucose level 2 hours after the
   ingestion of the oral glucose load is >200 mg%. This is one of the
   methods of diagnosing diabetes. The ordinary method is to find
   two fasting glucose levels to be > 126 mg/ dL
3. The strongest indication for an oral glucose tolerance test is
   screening for diabetes during pregnancy Because of the short
   duration of pregnancy, the potential for marked worsening over
   a short period of time, and the harmful effects of diabetes on the
   fetus, this is the single most urgent time to make a prompt diagnosis
   of diabetes. Oral glucose tolerance testing is like putting
   your pancreas on a treadmill to evoke subtle amounts of disease
   not detected by the ordinary test

Question 86

ENDOCRINOLOGY
Beta-Human Chorionic Gonadotropin (B-hCG J
1 • What is this?
2. When is B-hCG the answer?

Answer 86

ENDOCRINOLOGY
1. B-hCG is a pregnancy test.
2. Urine and/ or serum measurement of B-hCG is the best initial test
for any woman reproductive age complaining of a missed
period (amenorrhea), delayed vaginal bleeding, or
abdominal Any unexplained abdominal pain in a woman
is an ectopic pregnancy until you have the B-hCG.

Question 87

ENDOCRINOLOGY
IGf-J (Insulin-like Growth factor- J J
1. For which disease(s) is this the single best test for
diagnosis?
2. What is the substance?
3. What is the best test to confirm the diagnosis?
4. What is the most common wrong answer for the best
confirmatory test?

Answer 87

1. Serum measurement of IGF-1 is the best initial test for
   acromegaly.
   IGF-1 is a somatomedin secreted from the liver. Growth hormone
   when combined with thyroid hormone stimulates linear skeletal
   growth in children through IGF-1. It stimulates protein synthesis
   in muscle (anabolic effect) in children and the release of fatty
   adds from adipose tissue (catabolic effect) in adults. Growth
   hormone secretion is pulsatile, has a short half-life, and reaches
   maximal life in the middle of the night. A single test of the GH
   level is not accurate. IGF-1levels are more stable and reliable.
2. The best confirmatory test for acromegaly is the oral glucose
   tolerance test. Glucose normally suppresses GH. In acromegaly
   glucose does not suppress GH.
3. The most common wrong answer is GH (growth hormone)
   levels.

Question 88

a) TSH
b) Thyroxine (T4}
c) Thyroglobulin
1. For which dinica1 scenario(s) are these tests used?
2. What are these substances?
3. When do you answer TSH and thyroxine (T4)?
4. When do you answer thyroglobulin?

Answer 88

1 • Serum levels of thyroid-stimulating hormone (TSH) and
thyroxine (T4) are measured to assess thyroid function (both
hypofunction and hyperfunction). Thyroglobulin is used to
monitor recurrence in patients who have been treated for papillary
or follicular cancer of the thyroid.
2. TSH is produced by the pituitary to stimulate the thyroid. T4 is
one of the principal metabolism-inducing hormones produced
by the thyroid gland, and thyroglobulin is an iodine-containing
glycoprotein synthesized by the thyroid gland from which
thyroxine (T4) is derived. Thyroglobulin is the storage form of
thyroid hormone. Thyroid-binding globulin is the transport
protein.
3. TSH and T4 are always the best initial test for thyroid diseases.
4. Thyroglobulin is to follow the response to the treatment of thyroid
cancer.

Question 89

ENDOCRINOLOGY
24-Hour Urine Cortisol level
1. For which diagnosis(es) is this the most sensitive test?
2. What is this substance?
3. When do you answer urinary free cortisol?

Answer 89

1. When collected for 24 hours, urinary cortisol excretion is the
   most sensitive indicator of endogenous hypercortisolism and is
   the most sensitive test for Cushing’s syndrome.
2. Cortisol is a glucocorticoid hormone produced in the adrenal
   cortex.
3. Look for a question with a case \Vith truncal obesity, “buffalo
   hump,” striae, and easy bruising. Answer either 24-hour urine
   cortisol or overnight dexamethasone suppression test as the best
   initial test.

Question 90

ENDOCRINOLOGY
ACTH (Cosyntropin) Stimulation Test
1. What is this?
2. When do you answer an ACTH stimulation test?

Answer 90

1. The ACTH stimulation (cosyntropin) test evaluates adrenal
   function and is the best test for adrenal insufficiency. Baseline
   cortisol levels are taken, then ACTH is administered and follow-
   up cortisol levels monitored. If cortisol is low, think primary
   adrenal insufficiency. If cortisol levels rise, the adrenal gland is
   functioning.
2. Look for a fatigued patient with skin hyperpigmentation, hyperkalemia,
   slight metabolic acidosis, and a taste for pickle juice
   (high salt content). Also look for an ICU patient with uneJ,.’Plained
   hypotension.

Question 91

ENDOCRINOLOGY
-Antimicrosomal Antibodies
-Antithyroid Peroxidase (anti·TPO)
Antibodies
-Antithyroglobulin Antibodies
1 • What are they?
2. When are they the answer?
3. Do you expect high or low values?

Answer 91

1 • These antibodies are associated with Hashimoto’s thyroiditis
and Graves’ disease. If hypothyroid, if they are positive, you will
move straight to treatment with synthroid because the etiology
of the hypothyroidism has been confirmed.
2. They are the answer once you have proven hypo- or hyperthyroidism.
They are not to diagnose the thyroid function state. They
are to confirm the autoimmune etiology of thyroid state.
3. You expect the levels to be high with autoimmune thyroiditis.
This is whether the person is hypo- or hyperfunctioning. Nutritional
problems and synthroid abuse will give low levels of the
antibodies.

Question 92

ENDOCRINOLOGY
24-Hour Urine for Metanephrine,
Vanillylmandelic Acid (VMA), and
Catec:holamines
1. For which condition is this the best initial test?
2. If positive, what is the next best imaging test?
3. If an imaging done is negative, what would you do
next?
4. This disease is associated with which syndrome?
5. When do you answer VMA, metanephrines, or
catecholamines?

Answer 92

1 • Twenty-four-hour urine collection for metanephrine, vanillylmandelic
acid (VMA), and catecholamines is the best initial test
for pheochromocytoma.
2. If the question says the VMA or catecholamines are elevated,
then answer CT or MRI of the adrenal glands as the next best test
to find the pheochromocytoma.
3. If CT /MRJ find nothing, a metaiodobenzylguanidine (MIBG)
scintigraphy would be the next best option. This is a norepinephrine
analogue that concentrates in the adrenals and
pheochromocytomas.
4. Pheochromocytoma is associated with MEN II MEN III
5. Look for a case of episodic hypertension, particularly with flushing
and diarrhea.

Question 93

ENDOCRINOLOGY
Venous Blood Gas (VBG)
1. When do you answer VBG?

Answer 93

1. Use the venous blood gas (VBG) for the follow-up of diabetic
   ketoacidosis (DKA). A VBG could replace the arterial sample for
   assessing the degree of acidosis and hypocarbia when all you
   need is pH and not the p02 while avoiding an additional painful
   procedure.

Question 94

ENDOCRINOLOGY
RA.IU (Radioiodine Uptake)
1. For which disease(s) is this test the right answer?
2. When do you expect uptake to be high?
3. When do you expect uptake to be low?
4. When do you answer RAIU (1121) scan?

Answer 94

1. The measurement of orally ingested radioactive iodine (I121 ) that
   accumulates in the thyroid gland is used to differentiate Graves’ I
   toxic multinodular goiter from Thyroiditis/Factitious.
2. RAIU is increased in Graves’ disease and with hot nodules (toxic
   multinodular goiter, toxic solitary nodule).
3. RAIU is decreased when thyroiditis induces a thyrotoxic state or
   when a person is abusing thyroid hormone (thyroditis factitia).
4. Answer RAID scan when the question shows a case of hyperthyroidism.
   The question will include a high T4level, for instance,
   and will ask you the next best step to determine the etiology.

Question 95

ENDOCRINOlOGY
Pro-Insulin
1. What is this test for?
2. What do high levels of pro-insulin represent?
3. When do I answer pro-insulin levels?

Answer 95

1. Pro-insulin assay is used to distinguish autoimmune causes of
   hypoglycemia from insulinoma.
2. High Levels of pro-insulin represent insulinomas.
3. Answer a pro-insulin level when you see a case of recurrent fasting,
   hypoglycemia, symptoms of weakness, and high C-peptide
   levels.

Question 96

ENDOCRINOlOGY
Progesterone Challenge
1. For which clinical scenario(s) is this the best test?
2. If bleeding occurs after the challenge, it indicates
what?
3. What is the next best test if the bleeding occurs?
4. If there is no bleeding what is the next best test?

Answer 96

1 Oral dosing of progesterone of 10 mg daily for 5 days is used in
amenorrheicwomen after pregnancy is excluded to determine
if the cause of amenorrhea is due to outflow tract obstruction or
secondary to the hypothalamus and pituitary. Look for a woman
who has no periods and a negative hCG.
If bleeding occurs following the challenge, it indicates that there
is adequate estrogen and that the outflow tract exists.
3. The next best test is to check FSH, LH, prolactin, and TSH to rule
out a hypothalamic or pituitary etiology
4. If there is no bleeding, the next best test is to evaluate for an
outflow tract obstruction with ultrasound, and with MRI if ultrasound
is not definitive.

Question 97

ENDOCRINOLOGY
Metaiodobenzylguanidine (MIBG) Scan
1 • What disease is this test for?
2. How is the test done?
3. When do you answer MIBG scan?

Answer 97

1 • Metaiodobenzylguanidine (MIBG) scanning is used to detect
occult pheochromocytoma if the blood and urine testing (VMA,
catecholamines, metanephrines) are positive and the scans are
nondiagnostic.
2. MIBG is injected into the body MIBG is an agent similar to norepinephrine
and should be taken up by adrenergic tissue. The
MIBG scan allows visualization of potential adrenal masses.
3. Answer MIBG scan when you see a patient with palpitations,
intermittent tachycardia, and biochemical evidence of pheochromocytoma
(e.g., catecholamines, metanephrines) when the CT
and MRI can’t visualize the lesion. You can’t remove a pheochromocytoma
and cure it if you can’t find where it is.

Question 98

ENDOCRINOLOGY
5-HIAA
1. What is this?
2. When do you answer 5-HIAA level?
3. What is the most accurate diagnostic test?

Answer 98

ENDOCRINOLOGY
1 • A 24-hour urine level of 5-HIAA is the best initial diagnostic test
for carcinoid syndrome. 5-HIAAis the end-product of serotonin
metabolism.
‘2. Look for a patient with episodic diarrhea and/ or hypotension
associated with unexplained flushing and wheezing.
3. The most accurate test for carcinoid syndrome is a biopsy.
Although CT and MRI scanning can localize the disease, they are
not as accurate as the tissue diagnosis you obtain from a biopsy.

Question 99

ENDOCRINOLOGY
17-Hydro.xyprogesterone Level
1. What is this?
2. When do you answer it?

Answer 99

1.17-hydroxyprogesterone level is the best initial test to diagnose
21-hydroxylase deficiency or congenital adrenal hyperplasia.
Answer 17-hydroxyprogesterone in a patient presenting with
one of the following syndromes:
a) Female infant with ambiguous genitalia (simple virilizing)
b) Infant with hyponatremia, hyperkalemia, and hypotension (salt-wasting
syndrome)
c) Young woman with hirsutism, acne, and irregular menses
d) Child with precocious puberty

Question 100

ENDOCRINOLOGY
fine-Needle Aspiration of the Thyroid
1 • What is this?
2. When is this the most accurate test?
3. When is this the wrong answer?

Answer 100

1. A sample of thyroid cells collected by a needle inserted into the
   thyroid is the initial test for all solitary nodules unless the patient
   is thyrotoxic.
2. Look for a case with a palpable nodule and normal thyroid function
   tests and the question asks for the next step in diagnosis.
3. This is the wrong answer in patients with a solitary nodule who
   are thyrotoxic. In such patients a SCINTISCAN (P21 scan) should
   be done first to see if the nodule is hyperfunctioning (hot) or
   hypofunctioning (cold). Hyperfunctioning modules are almost
   never malignant.