The correct answer is C

Infiltrating Lobular Carcinoma (invasive breast carcinoma)

Presentation

• May or may not have mass
• No desmoplastic response so hard to see and feel – clinically and mammogram occult
  

Pathology:

• Gross: solid mass but maybe completely undetectable
• Histo: linear, single cells or targetoid pattern of malignant cells, low nuclear grade, minimum mitotic activity
• NO desmoplastic response
  

Infiltrating Lobular Carcinoma is the second most common form of invasive breast cancer. Because it does not create a reactive desmoplastic response in the tissue, it may be clinically and mammographically occult. It also tends to be larger than clinically estimated preoperatively.

1. It has an increased propensity to be multicenteric (involve more than one part of the breast) and to be bilateral (affect both breasts). It also has the propensity to metastasize to unusual sites, such as the gynecologic and GI tract.
   
2. It has the same prognosis (comparable survival) as infiltrating ductal carcinoma, when matched, stage for stage!
   
3. It is usually ER+/PR+ , CerbB-2/HER2 –
   
4. It usually has single cells invading the stroma, thus it is hard to see on low power. You can do a positive cytokertain stain to confirm the epithelial nature of the lobular carcinoma.

The Correct Answer is D

The morphofunctional unit of the breast is composed of two units

- Terminal duct lobular unit (TDLU)

- consists lobule and smaller terminal ductules

- together empty into the segmental duct, then the lactiferous sinus, then the collecting duct

- Large collecting ducts

- Most of the breast stroma consists a loose connective tissue, adipose tissue, elastic fibers that support the larger ducts (interlobular stroma)

- However each lobule is surrounded by the intralobular stroma (hormonal responsive stroma)

- Blood supply of the breast is predominantly from the internal mammary artery and lateral thoracic artery

- Lymphatic drainage is a valveless unidirectional flow from superficial to deep

- Majority of lymphatic drainage is to axillary nodes, 97%

- 3% going to internal mammary chain

The Correct Answer is B

Periductal Mastitis is a condition where non-dilated subareolar breasts ducts become infected. It most commonly affects young women, with a mean age of 32 years.

The condition may present with periareolar inflammation, and the breast may be tender. There may be a history of nipple discharge and on examination the nipple may be retracted and there may be an associated inflammatory mass or abscess.


A total of 133 women with periductal mastitis and 98 women with intraductal papillomas were studied. Pathologists were asked to grade the degree of periductal inflammation and duct dilatation and to determine the presence or absence of squamous metaplasia without previous knowledge of the clinical condition of the women. The inflammation and dilatation were graded as mild, moderate or severe (acute). Cigarette smoking was defined as absent, light (one to 10 cigarettes per day). Approximately 50 percent of the women with periductal mastitis presented with acute inflammatory breast disease. Women with periductal mastitis were more likely to be premenopausal than were women with intraductal papillomas. No differences in parity or the use of hormones were apparent. Cigarette smoking was significantly more common in women with mastitis than in women with papillomas, and the number of cigarettes smoked per day was greater in women with periductal mastitis.

The correct answer is B

Breast development

• It is a progressive process initiated during embryonic life.
• Puberty marks the beginning of glandular maturation,full breast differentiation is only attained with pregnancy and lactation.
• At birth the breast is formed by 10-12 ductal elements located beneath the nipple-areola complex
• In boys,breast development does not progress much past the initial 10-12 ductal elements.
• In girls, however, puberty begins at 10-12 yrs of age and development is under the control of the Hypothalmic-pituitary axis
• Estrogen acts locally on mammary gland to increase branching of the ducts and is accompanied by an increase in the stroma
• This is thought to be mediated by an estrogen receptor (ER)
• Again full differentiation of mammary glands and of branching and secretory activity may never be attained without pregnancy
• During pregnancy and lactation the maximum branching capability of the breast is expressed.
• The breast of nulliparous women contains more undifferentiated structures
• The cells in ductal structures of nulliparous women are in a more proliferative phase vs. parous breast that are predominantly in Go-resting phase
• The content of ER in the lobular structures is directly proportional to the rate of cellular proliferation. The more differentiation of the lobule the less ER
• This provides an explanation for the greater susceptibility of these structures to be transformed by chemical carcinogens
• It is the observation that these more immature breast lobules is site of origin of ductal carcinomas.
• It is hypothesized that the differences of differentiation of the ductal structures lead to neoplastic changes

The correct Answer is C

Right to left shunt occurs in:

1. Transposition of great vessels
2. pulmonary stenosis
3. tricuspid atresia
4. tetralogy of Fallot

The correct answer is B


“Coarctation of the aorta” means a localised malformation characterised by deformity of the aortic media, causing narrowing of the lumen of the aorta;

• BP in arms > legs, absent femoral but palpable pedal pulses, thrills or bruits over the intercostals arteries
• Rib notching is present on inferior edge of rib
• Arteriography can be used to diagnose
• Usually distal to the origin of the left subclavian artery.
  
• Most children and young adults with isolated coarctation are asymptomatic.
  
• Headache, epistaxis, cold extremities, and claudication with exercise may occur.
  

The correct answer is C

VSD – most common CHD (25%), membranous type most common, large LA/RV, LV remains normal;
ASD – ostium secundum type most common, large RA/RV/PA;
PDA – premature infants, maternal rubella, large LA/LV/aorta;
ECD – ostium primum ASD, Down’s, gooseneck deformity on angio from LV outlet obstruction; PAPVR – right SVC most common, IVC (scimitar syndrome)

Tetralogy of Fallot – most common cyanotic CHD of childhood, pulmonic stenosis/RVH/VSD/overriding aorta, boot-shaped heart, right aortic arch in 25%, small or concave PA;

The Correct Answer is E

Tetralogy of fallot is characterized by four major defects. These four conditions include pulmonary stenosis, ventricular septal defect, overriding aorta, and hypertrophy of the right ventricle occur due to abnormal development of the fetal heart during the first 8 weeks of pregnancy. These problems include the following:

• Ventricular septal defect (VSD) - an opening in the ventricular septum, or dividing wall between the two lower chambers of the heart known as the right and left ventricles.
• Pulmonary (or right ventricular outflow tract) obstruction - a muscular obstruction in the right ventricle, just below the pulmonary valve, that decreases the normal flow of blood. The pulmonary valve may also be small.
• Overriding aorta - the aorta is shifted towards the right side of the heart so that it sits over the ventricular septal defect.

"Tetralogy" refers to four heart problems. The fourth problem is that the right ventricle becomes enlarged as it tries to pump blood past the obstruction into the pulmonary artery.

The Correct Answer is C

Trisomy 21 or Down syndrome

• 47, XY, +21 or 47, XX, +21 is seen in approximately 1/800 live births making it the most common. Was first described in 1866 by John Langdon Down.
  
• In 1959 it was discovered that it was caused by the presence of an extra chromosome 21.
• There are some significant medical problems associated with this condition.
  
• These include obstruction of the duodenum or atresia of the esophagus, duodenum, or anus.
  
• Respiratory infections are quite common and the risk of developing leukemia is 15 to 20 times higher in Down syndrome patients.
  
• In addition approximately 40% are born with structural heart defects including, atrioventricular canal, a defect which allows the blood to flow from the left to the right side and then the pulmonary vasculature producing pulmonary hypertension. Ventricular septal defects are also common in individuals with Down syndrome.
  
• Approximately 95% of Down syndrome cases are caused by non-disjunction the remainder is caused by chromosome translocation. In 90 to 95% of the cases the non-disjunction was found to be maternally derived. Mosaicism is seen in 1-3 % of all trisomy 21 cases. These individuals have some normal cells and some trisomy 21 cells. This often results in milder clinical symptoms. This is likely caused by a trisomy conception followed by specific loss of the extra chromosome from some cells.
  
• The part of chromosome 21 that is responsible for this phenotype has been narrowed down 21q22.
  
• There are a number of genes in this region of the chromosome that may be directly involved in this phenotype including DYRK kinase as well as the APP gene.
  
• The APP gene has been found to be mutated in some patients Alzheimers like dementia.

The correct answer is C

Pernicious Anemia

Common disorder: prevalence circa 0.1%: peak 60 yrs: M:F 1:2.

There is an autoimmune attack on the gastric parietal cell manifest histologically as atrophic gastritis. Patients are unable to secrete acid or intrinsic factor. There is a significant association with vitiligo and thyroid disease. There may be a family history of Pernicious Anemia and thyroid disease. Intrinsic Factor autoantibodies are present in the serum of 50-75% of cases, and are highly specific.

The correct Answer is A

• Fatty streak
• Earliest visible lesion – develop early in life
• Grossly –
• areas of yellow discoloration on inner arterial surface
• Usually <>
• Do NOT protrude into lumen
• Do NOT disturb blood flow
• Microscopically –
• Subendothelial accumulation of foam cells filled w/ intracellular lipid (majority derived from macrophages)
Asymptomatic and may regress over time (depends on location)
• Often precursors to fibrous plaques

Although heart disease is not common before age 40, fatty streaks in arterial walls have been found in some 5-year-old children. Over time, these streaks can become ‘plaques’ with the potential to block arteries.

The Correct Answer is C

CHOLESTEROL: Cholesterol is a fat-like substance found in all foods of animal origin (meat, poultry, fish, and dairy products) but not in food from plants. It is also produced by the liver. Cholesterol is a normal component of the blood and is needed for nerves, cell walls, and hormones. However, too much cholesterol can build up in arteries leading to heart disease, stroke, hypertension, and atherosclerosis. Cholesterol is transported in the blood in several forms - two important forms are high-density lipoprotein (HDL) and low-density lipoprotein (LDL). Levels are dependent upon age, diet, heredity and exercise.

LIPOPROTEIN: A combination of a lipid (fat) and a protein. Because fat and water don’t mix, cholesterol must be carried in the blood by protein capsules.

LDL CHOLESTEROL (Low Density Lipoprotein): This is the form of cholesterol often termed “the bad cholesterol.” It tends to build up on blood vessel walls, increasing the risk of heart disease.

HDL CHOLESTEROL (High Density Lipoprotein): HDL cholesterol, often termed “the good cholesterol,” appears to remove cholesterol from the body. Large amounts of HDL cholesterol are associated with a decreased risk of heart disease.

TOTAL CHOLESTEROL/ HDL RATIO: This value is used to predict heart disease risk.

TRIGLYCERIDE: The form of fat in the body's fat deposits. It forms when we eat more than we burn off. Triglycerides are a source of stored energy and can be imported through the blood. The role of high blood triglycerides in heart disease is unclear. However, for some people high triglycerides are a risk factor similar to high cholesterol. In this test, it is used to calculate LDL levels, as LDL values are difficult to measure directly.

The correct answer is C

There are four main blood fats that must be controlled in order to protect your heart and blood vessels.

The Correct Answer is B

BRONCHIECTASIS

Definition:
1. Bronchiectasis is a condition of the respiratory tract characterized by abnormal permanent dilatation of bronchi and bronchioles. It is associated with a severe, chronic infection of the airways.

2. Pathology:

a. Chronic, necrotizing infection of a segment or multiple segments of the lung.

2. Infection damages and weakens walls of bronchi so that these structures become markedly dilated and filled with mucous and pus.

3. Pathogenesis:

a. The major factors which contribute to the development of bronchiectasis are obstruction of bronchi (tumor, foreign body), infection, and congenital defects as in cystic fibrosis.

b. An obstruction causes atelectasis, accumulation of secretions, bacterial overgrowth and infection.

3. The chronic infection damages the integrity of the bronchial wall causing dilation.

4. Pathophysiology: Persistent cough producing foul-smelling, purulent sputum; fever; dyspnea.

The correct Answer is D

Endocardial Cushion Defects (ECD) result from the failure of the endocardial cushions to develop properly. Aplasia or hypoplasia of the EC is the cause. Children with ECD present with Congestive heart failure if defect is severe.

• Complete AV canal: involves a foramen primum ASD, a posterior VSD, and abnormal tricuspid and bicuspid valves (often with only a single, incompetent AV valve). A LVàRA shunt can occur if the AV portion of the septum is absent.
• Partial AV canal: foramen primum ASD, with cleft in mitral valve --> mitral incompetence.

There are several ways endocardial cushion defects can be treated. Typically a Dacron patch is used to close the holes in the atrial and ventricular walls and the AV valve is repositioned and/or repaired.

There can also be problems long-term with the heart's rate and rhythm (called cardiac arrhythmia) since the nerve fibers that cause the heart muscle to contract run through the wall of the heart that divides the chambers. Over time scarring can cause arrhythmias and sometimes pacemakers are needed to provide a strong and steady heartbeat.

The Correct Answer is E

This anatomical continuity predisposes to thrombosis as a result of turbulence.

The correct answer is E.

 
page 1669 harri 16 -

"ABO incompatibilities are hazardous because of the presence of natural anribodies in recipients and the normal expression of A and B blood group substances on endothelium, resulting in immediate vascular injury."

Types of graft rejection:

Hyperacute -extremely rapid rejection (hours) occlusion of graft vessels
Hyperacute rejection is mediated by pre-existing antibodies against donor antigens

Acute - days to weeks after transplant cell-mediated immune response
Acute rejection is based on development of an adaptive immune response


Chronic -months to years after transplant graft vascular disease


The patient is suffering from hyperacute rejection due to the preformed anti-B ABO blood group antibody found in all type A positive individuals. Hyperacute rejection occurs within minutes to a few hours of the time of transplantation, and is due to the destruction of the transplanted tissue by preformed antibodies reacting with antigens found on the transplanted tissue that activate complement and destroy the target tissue. Preformed antibodies can also be due to presensitization to a previous graft, blood transfusion, or pregnancy.


Acute rejection due to antibody-mediated immunity (choice A) is incorrect because this patient suffered from hyperacute rejection (immediate) occurring within minutes to hours, rather than days.

Acute rejection due to cell-mediated immunity (choice B) will not occur until several days or a week following transplantation. Acute rejection is due to type II and type IV reactions.


Chronic rejection, due to the presence of cell-mediated immunity to minor HLA antigens (choice C), occurs in allograft transplantation months to even years after the transplant. Chronic rejection is generally caused by both humoral and cell-mediated immunity.

An accelerated acute rejection, occurring in 3-5 days, can be caused by tissue infiltration and destruction by presensitized T lymphocytes and macrophages (choice D) and/or antibody-dependent, cell-mediated cytotoxicity (ADCC). Note that this is not a hyperacute reaction.

The correct answer is A.

Acute pyelonephritis is an infectious disease involving the kidney parenchyma and the renal pelvis. Gram-negative bacteria, such as Escherichia coli, Proteus, Klebsiella, and Enterobacter, are the most common causative organisms in acute pyelonephritis. Laboratory evaluation will often reveal leukocytosis with a left shift, and urinalysis typically shows pyuria, varying degrees of hematuria, and white cell casts. Since bacteremia is present, the patient should be hospitalized and empirically started on IV ampicillin and gentamicin. This regimen may be need to be changed, however, once the sensitivity results are available.

Erythromycin (choice B) and tetracycline (choice E) are both bacteriostatic antibiotics and would not be recommended in a patient with a severe infection, such as acute pyelonephritis with bacteremia. Vancomycin (choice C) is primarily used in the treatment of severe gram-positive infections. Phenazopyridine (choice D) is a urinary analgesic, and nitrofurantoin (choice D) is a urinary tract anti-infective. Although nitrofurantoin is indicated for the treatment of "mild" cases of pyelonephritis, as well as cystitis, this patient's condition is severe and should be treated with appropriate antibiotics.

The correct answer is E.

Beta-adrenergic blockade may blunt or prevent the premonitory signs and symptoms (e.g., tachycardia, blood pressure changes) of acute episodes of hypoglycemia. Non-selective beta-blockers, such as propranolol, may even potentiate insulin-induced hypoglycemia. Even though this effect is less likely with cardioselective agents, the use of either cardioselective or non-selective beta-blockers in diabetics is not recommended due to their "masking" effect of the normal warning signs and symptoms of hypoglycemia. None of the drugs listed in the othe r choices will blunt the premonitory signs and symptoms of hypoglycemia.

Captopril (choice A) is an angiotensin-converting enzyme (ACE) inhibito r that can be safely used for the treatment of hypertension in diabetic patients. Diltiazem (choice B) is a calcium channel blocker that is also considered to be safe and effective for the treatment of hypertension in diabetic patients. Both methyldopa (choice C), a centrally acting alpha-adrenergic agonist , and prazosin (choice D), an alpha1-adrenergic antagonist, can be safely used to treat hypertension in diabetic patients. However, due to the side effect profile of these medications, they are generally used only in diabetic patients who are unresponsive to ACE inhibitors and calcium channel blockers.

The Correct Answer is C

Small thrombi that develop on cardiac valves are termed vegetations. Vegetations may be seen in bacterial infection of the valves (bacterial endocarditis) also seen with IV drug users, systemic lupus erythematosus, and in chronic wasting states.

Please see Figure 1 (Figure 12-22 in Robbins 5^th edition).

This figure diagrammatically compares the lesions of the four major forms of vegetative endocarditis:
RHD (Rheumatic Heart Disease) – Notice what looks like a string of beads which are small verrucae or small vegetations, sterile deposits of fibrin tend toward a predilection for the closing margin of the valve (not the free edge). This is where the trauma is occurring as the valve closes.

IE (Infective Endocarditis) – The damage may start on the closing margin of the valve, particularly if the valve is already damaged. Unlike RHD, they tend to be larger and bulkier. Particularly with fungal infective endocarditis as compared to bacterial, the vegetations become very large. The larger they are, the greater the risk of breaking off and embolizing.

NBTE (non-bacterial thrombotic endocarditis) – tend to be localized and also tend to be at the closing margin. They can grow large enough to break off and embolize depending on the circumstances.

SLE (Libman-Sacks endocarditis) – Lesions also tend to occur at the closing margin. One of the distinctive features here is that the vegetations can be on either or both sides of the valve leaflets (notice how the artist shows the leaflet partially lifted to demonstrate the underside of the leaflet).

The correct answer is D


RISK FACTORS FOR ATHEROSCLEROSIS


I: Immutable

1. Heredity: - ↑ed risk if close relative has AS before 65 years

- however, not direct transmission in obvious pattern

2. Sex: - males have ↑ed risk (LDL:HDL ratio)

- however, female ‘advantage’ ends with menopause

3. Age: - AS ↑es with age

II: Mutable

1. Hyperlipidaemia:

• lipids transported in blood as lipoproteins
• HDLs (good guys)
• LDLs (bad guys) ratio important re AS
• liver secretes cholesterol as VLDLs

↓ capillary enzymes
LDLs
↓
taken up by e.g. arterial ECs
macrophages
VSM
↓
surplus cholesterol returned
to liver as HDLs

• ↑ HDLs → lower risk of MIs
• can be modified by exercise, diet, drugs

2. Smoking: (leading toxic public health hazard)

• possible hypoxaemia (Hb-CO) → EC injury
• nicotine → vasoconstriction → MI / EC injury
• ↑ platelet aggregation

3. Hypertension:

• EC damage ??
• can be modified by drug therapy / diet

4. Diabetes Mellitus:

?

• ↑ [glucose]plasma → glycosylation of LDLs → AS
• OR
• ↑ [glucose]plasma → oxidation of LDLs → AS

[Controversial Factors]

5. Obesity: only circumstantial evidence for link with CHD
6. Inactivity:
7. Personality: Type A / Type B controversy
8. Diet: - ↓ed risk in vegetarian communities (but other problems)

- ?? protection from red wine and fish oils (inhibit platelets)

e.g. Finland had 4x CHD cf. France, yet similar

fat/cholesterol diets

DIETARY CONSIDERATIONS

AS reflects deteriorative interactions between:

plasma lipids lipoproteins

endothelium
VSM

platelets monocytes

• butter ≡ saturated fats (FAs with single bonds)
• margarine ≡ unsaturated fats (FAs with double bonds)
• saturated FAs and cholesterol → ↑ plasma LDLs → plaque development
• eating unsaturated fats (veg. oils) → ↑ HDLs

↓
transport cholesterol to liver
↓
bile
↓
excreted ⇒ ↓ plasma LDLs

• i.e. proteins important ⇒ genetic predisposition ??
• low rate of CHD in Mediterraneans
• ?? due to high intake of olive / veg. oils (linoleic acid)
• excellent at reducing LDLs
• fish oils also hypolipidaemic
• very low rates of CHD in Eskimos
• Japanese population 6 x less likely to develop CHD cf. USA

The correct answer is C

• Troponin is the inhibitory or contractile regulating protein complex of striated muscle. It is located periodically along the thin filament of the muscle and consists of three distinct proteins: troponin I, troponin C, and troponin T.
• Likewise, the troponin I subunit exists in three separate isoforms; two in fast-twitch and slow-twitch skeletal muscle fibers, and one in cardiac muscle.
• The cardiac isoform (cTnI) is about 40% dissimilar, has a molecular weight of 22,500 daltons, and has 31 additional amino acid residues that are not present on the skeletal isoforms.
• Cardiac troponin I (cTnI) has been useful in the differential diagnosis of patients presenting to Emergency Departments (ED) with chest pain.
  
• Myocardial infarction is diagnosed when blood levels of sensitive and specific biomarkers, such as cardiac troponin, the MB isoenzyme of creatine kinase (CK-MB), and myoglobin, are increased in a clinical setting of acute ischemia.
  

• The most recently described and preferred biomarker for myocardial damage is cardiac troponin (I or T). The cardiac troponins exhibit myocardial tissue specificity and high sensitivity.
  
• Likewise, cardiac TnI and CK-MB have similar release patterns (4-6 hours after the onset of pain), but the level of cTnI remains elevated for a much longer period of time (6-10 days), thus providing for a longer window of detection of cardiac injury.

Normal levels of cTn I in the blood are very low. After the onset of an AMI, cTnI levels increase substantially and are measurable in serum within 4 to 6 hours, with peak concentrations reached in approximately 12 to 24 hours after infarction.24-28 The fact that cTnI remains elevated in serum for a much longer period of time, added to its enhanced diagnostic sensitivity and cardiac specificity, allows for the detection of AMI much earlier after the onset of ischemia (4 hours), as well as the diagnosis of peri-operative infarction in situations where a high serum level of skeletal muscle proteins are expected.

• Additionally, recent data have identified a measurable relationship between cardiac troponin levels and long-term outcome after an episode of chest discomfort.
  
• The studies suggest that the use of the cTnI demonstrates high predictive value in delineating the high risk group of unstable angina patients, and that these tests may be particularly useful in evaluating patient condition prior to discharge from the ED.

The Correct Answer is D

The lesion is a malignant melanoma. Melanomas can develop either de novo or in an existing mole. Sunlight exposure is a significant risk factor and fair-skinned persons are at increased risk of developing melanoma. The most significant factor for long term prognosis is the depth of the lesion, since the superficial dermis lies about 1 mm under the skin surface, and penetration to this depth is associated with a much higher incidence of metastasis than is seen with a more superficial location.

The circumference of the lesion (choice A) is much less important than depth , since one form of melanoma (superficial spreading) can still have good prognosis despite large size, if it has not extended to the depth of the superficial dermal lymphatic bed. The darkness (choice B) or degree of variation in color (choice C) do not have prognostic significance once melanoma is diagnosed. Irregularity, or fuzziness at the border (choice E) of a mole-like lesion is a good clue to potential malignancy, but does not affect prognosis once a melanoma is diagnosed.

The Correct Answer is A

Acute rheumatic fever is triggered by infection with specific strains of group A streptococci which possess antigens that cross-react with human connective tissue, particularly heart valve glycoprotein...

the condition usually affects children or young adults, and there is a familial variation in susceptibility...its prevalance in Western Europe and North America has progressively declined to very low levels, but it remains common in parts of asia, africa and south america, where it is still the most common cause of acquired heart disease in childhood adolescence...

rheumatic fever is a systemic illness typically presenting with fever, anorexia, lethargy and joint pains...

arthritis occurs in approximately 75% of patients and other features include skin rashes, carditis and neurological features...

anti-streptococcal antibody, anti-streptolysin antibody, positive culture for group A streptococcus, recent scarlet fever...

erythema marginatum (the expanding erythematous rash) and sydenham chorea (rapid, purposeless movements) also accompany this disorder...

carditis is the most important manifestation of rheumatic fever...carditis presents as breathlessness, palpitations or chest pain...

other features consist of tachycardia, cardiac enlargement and new or changed cardiac murmurs...

a soft systolic murmur is common but non-specific...a soft mid-diastolic murmur is often due to valvulitis, with nodules forming on the mitral valve leaflets...

there is a pericardial friction rub which is often intermittent...cardiac failure may result either from impaired function of ventricular muscle or from mitral or aortic incompetence and tends to occur in a 'fulminant' form of rheumatic fever that is more common in developing countries...

electrocardiographic changes include ST or T wave changes; conduction defects sometimes occur and may cause syncope...

mitral valve becomes thickened with fused chorda tendinea...

aortic regurgitation occurs...

Complications of rheumatic fever include

• cardiac arrhythmias
• pericarditis
• rheumatic pneumonitis
• pulmonary embolism
• pulmonary infarction
• valve deformity, and
• in extreme cases, congestive heart failure.

The correct answer is A.

The space constant of an axon reflects the amount of passive or electrotonic spread of current within an axon. The larger the space constant, the further the current can spread, allowing action potentials to propagate faster. This is why myelin increases the conduction velocity of action potentials down an axon. Conversely, demyelination decreases the space constant and slows action potential conduction

The Correct Answer is D

When muscles contract during exercise, blood flow can increase more than 20-fold. This increase in blood flow is termed active hyperemia. If muscle contraction is occurring during whole body exercise (e.g., running), more than 80% of cardiac output can be directed to the contracting muscles. Therefore, skeletal muscle has a very large flow reserve (or capacity) relative to its blood flow at rest, indicating that the vasculature in resting muscle has a high degree of vascular tone.

This resting tone is brought about by the interplay between vasoconstrictor (e.g., sympathetic adrenergic and myogenic influences) and vasodilator influences (e.g., nitric oxide production, and interstitial adenosine and K+ concentrations).

In the resting state, the vasoconstrictor influences dominate, whereas during muscle contraction, vasodilator influences dominate to increase oxygen delivery to the contracting muscle fibers and to remove metabolic waste products (e.g., lactate, H+, CO2) that accumulate.

The Correct Answer is B

The word "condyloma" comes from the Greek word meaning "knob." Any knob-like or warty growth on the genitals is known as a condyloma. Venereal warts caused by human papilloma virus are known as "condyloma accuminata" (venereal warts).

The skin lesions caused by Molitor hominus are known as "condyloma subcutaneum" (molluscum contagiosum). The skin lesions associated with secondary syphilis are called "condyloma lata." They have in common with veneral warts the fact that they are both raised lesions on the vulva (or penis), but there ends the similarity.

• Condyloma accuminata are cauliflower-like, while condyloma lata are smooth.
• Condyloma accuminata are dry, while condyloma lata are moist.
• Condyloma accuminata are bulky while, condyloma lata are flat.

Surface scrapings of condyloma lata under darkfield microscopy will show spirochetes. Serologic test for syphilis (VDRL, RPR) will be positive.

The correct answer is B


More information on Endocrinology of the male reproductive system.

The Correct Answer is d

The Correct Answer is E

The Papanicolaou (Pap) smear was developed by George Papanicolaou in the early 1900s to study the estrous cycle of the guinea pig. Papanicolaou believed the screening also could have useful applications for women. Pap smears can detect abnormal cellular changes before more serious problems develop, such as cervical cancer.

A 65 year old male with a 20 pack/year smoking history and a 4 centimeter peripheral lung nodule on chest X-ray presents to your primary care practice. You should


a. schedule him for bronchoscopy
b. schedule him for an open thoracotomy
c. schedule him for a computerized tomography guided needle aspiration
d. send his sputum for analysis as sputum is positive in greater than 95% of cases of cancer
e. start antibiotics

Answer

The Correct Answer is E

The Correct Answer is B

The Correct Answer is C

Single-donor plasma / fresh frozen plasma

“Plasma transfusion.” Rich in the clotting factors, proteins C and S, complement, and immunoglobulins. It reverses coumarin effect, replaces clotting fators, and is okay for HUS/TTP.

It takes about 30 minutes to thaw. Of course there is an infection risk.

“Universal donor” for plasma is group AB; “universal recipient” is group O. This seldom comes up in practice. Since there are no red cells in fresh-frozen plasma, Rh does not matter.

The Correct Answer is C

The dose of platelets should be individualized. A number of simple rules can be used to calculate the appropriate dose.

• A dose of 1 random donor platelet concentrate per 10 kg body weight can be expected to increase the platelet count by 5000/uL in a non-refractory patient.
• One random donor platelet concentrate is expected to increase the platelet count by 5000 to 10,000/uL in a 70 kg patient who is not refractory.
• Generally, a pool of 6 to 8 platelet concentrates or a single apheresis unit is sufficient to correct or prevent bleeding in a normal sized adult weighing up to 90 kg.
• One apheresis product is equivalent to 6 to 8 random donor platelet concentrates and therefore should increase the platelet count by 30,000/uL to 40,000/uL in a 70 kg patient.
• For pediatric patients, 5 mL/kg body weight of a random donor platelet concentrate should increase the platelet count by 5000/uL. A single platelet concentrate contains about 45 to 50 mL and should supply the needs of patients up to 8 kg. If the entire platelet concentrate is not used for a given patient, it is not practical to salvage the remainder of the unit.
• For children >8 kg, a standard dose of 1 unit/10 kg should be used.
• In the absence of increased platelet destruction, platelet transfusion will usually need to be repeated every 3-5 days.
• If increased platelet destruction or consumption is present, daily administration may be required.

Source

The Correct Answer is B

Thyroid stimulating hormone (TSH)-this hormone is produced by the pituitary gland in the brain and stimulates the thyroid gland to produce T4. When the thyroid gland is not producing enough T4, the pituitary gland produces more TSH, signaling the thyroid gland to work harder. If the T4 level is low, the TSH level is usually high.

• a glycoprotein.
• Stimulates thyroid gland.
• Secretion regulated by thyroxine in blood.
• Secretion regulated by hypothalamic hormones.
• TSH secretion is stimulated by the hypothalamic tripeptide TRH.

The Correct ANSWER is C

HIV/AIDS is a communicable yet preventable disease, which can lead to serious social and economic repercussions. India's national adult HIV prevalence rate of less than 1% offers little indication of the serious situation facing the country. An estimated 4 million people were living with HIV at the end of 2003—the second-highest figure in the world, after South Africa.

While HIV/AIDS was once considered a "white gay man's disease," a larger proportion of new HIV diagnoses in several Western European countries is occurring through heterosexual intercourse. For example, more than half of the new HIV infections diagnosed in the UK in 2001 resulted from heterosexual sex, compared with 33% of new infections in 1998.

Confusion about the body fluids that can transmit HIV is a common cause of fear and misunderstanding about HIV and contributes to the discrimination against Persons Living with AIDS (PLWAs). Body fluids that contain HIV in sufficient concentrate to be implicated in HIV transmission are blood, semen, pre-ejaculate, vaginal fluids, and breast milk.
HIV cannot be transmitted through body fluids such as saliva, sweat, tears, or urine.

The Correct Answer is D

Raised intracranial pressure could be the result of the following:

1 Increase of the volume of the normal content of the intracranial cavity, as increase in the volume of CSF as in hydrocephalus ,increase in the volume of the brain tissue itself as in brain oedema or increased cerebral blood volume.

2 Extra volume added to the intracranial cavity as in tumours or haematomas.

Where an extra volume is added to the intracranial cavity this has to be at the expense of the normal contents. To start with the cerebrospinal fluid is squeezed out, we find that the ventricles become compressed and displaced. There will be paucity of subarachnoid spaces and the basal cisterns become less discernible. Once a state is reached where no more CSF could be expulsed, a change in the cerebral blood flow occurs. As mentioned cerebral blood perfusion is related to intracranial pressure. With the rise of intracranial pressure there is diminished cerebral blood flow and more space is provided for the extra volume. However a state would be reached where any further decrease in cerebral blood flow would lead to cerebral ischaemia. In this situation the brain itself starts to herniate through the hiatus of the tentorium and foramen magnum. At this stage the patient’s condition is precarious and needs urgent action to reduce the intracranial pressure.

Increase blood volume can occur as a result of a blockage to venous drainage from the cranial cavity or due to vasodilatation. It is very important to appreciate that cerebral blood vessels are very sensitive to changes in blood gases especially carbon dioxide. High pco2 results in vasodilatation and increase in cerebral blood volume.

The Correct Answer is B

Definition of Dementia

Acquired decline in memory and in at least one other cognitive function (e.g., language, visual spatial, executive) sufficient to affect daily life in an alert person.

Dementia is a broad category of disorders that is broken down into subgroups based on the presumed etiology. Alzheimer's disease, a neurodegenerative brain disease, is the most common cause of dementia.

The cause of nerve cell death in Alzheimer’s disease is unknown. Inheritance plays some role:

• Five percent strongly inheritable (autosomal dominant).
• Twenty to 60% of patients may have a genetic vulnerability.
• There is no fool-proof genetic test for Alzheimer’s disease.
• Damage may result from accumulation of a toxic brain protein called amyloid.

Multi-infarct dementia (dementia due to atherosclerosis) may be misdiagnosed as Alzheimer's or found in addition to Alzheimer's disease. Since the difference cannot always be determined without brain biopsy and since there is little effective treatment for either condition, the distinction is mainly useful to researchers, not patients.

The Correct Answer is C

Most strokes involve the middle cerebral artery and the symptoms of middle cerebral artery stroke include hemiparesis, hemisensory loss, aphasia, and hemineglect. The regions of the brain responsible for being alert are not affected.

At least 25% of stroke patients experience aphasia, or problems understanding or using language. Some lose the ability to speak, while others lose the ability to write, and some lose the ability to understand written or spoken language.

Broca’s Apahsia denotes a lost ability or difficulty in expressing thoughts in words or writing, often resulting in grammatically incorrect communication.

In contrast, receptive aphasia (Wernicke’s area) denotes a difficulty in understanding words or speech, and can result in grammatically correct but meaningless communication.

Anomic or amnesic aphasia consists of the selective forgetting of interrelated groups of words, and global aphasia denotes the loss of almost all linguistic ability.

The Correct Answer is C

Embolic stroke refers to a situation in which a clot is formed in an artery outside the brain and subsequently travels to and lodges in the brain. Risk factors for embolic stroke are atrial fibrillation, myocardial infarction, and heart valve abnormalities.

The Correct Answer is B

Concussion is a physical injury to the brain that causes a disruption of normal functioning just like any other physical injury disrupts normal functioning.

Brain injury can be viewed along a continuum that incorporates concussion, mild brain injury, moderate brain injury and severe brain injury. Each type of brain injury varies depending upon: 1) whether the person was unconscious, 2) how long he/she was unconscious, 3) the length of their amnesia, 4) the resulting cognitive, behavioral and physical problems and 5) the recovery.

Concussion as detailed by guidelines developed by the American Academy of Neurology (AAN) and the Brain Injury Association (BIA), commonly is divided into three different types.

Grade 1 Concussion

• Person is confused but remains conscious.
• SIGNS: Temporarily confused, dazed, unable to think clearly, has trouble following directions
• TIME: Symptoms clear within 15 minutes

Grade 2 Concussion

• Person remains conscious, but develops amnesia
• SIGNS: Similar to Grade 1
• TIME: Symptoms last more than 15 minutes

Grade 3 Concussion

• Person loses consciousness
• SIGNS: Noticeable disruption of brain function exhibited in physical, cognitive and behavioral ways.
• TIME: Unconsciousness for seconds or minutes

It is important to note that a person can sustain a concussion (Grades 1 & 2) without losing consciousness. A Grade 3 concussion involves the loss of consciousness, even if only briefly.

As defined by the American Congress of Rehabilitation Medicine, MTBI is a traumatically induced physiological disruption of brain function as manifested by some or all of the following:

• Any period of loss of consciousness
• Any loss of memory for events immediately before or after the incident
• Any alteration in mental state at the time of incident
• Focal neurological deficits that may or may not be transient but does not exceed:

1. Loss of consciousness of approximately 30 minutes or less
2. An initial Glasgow Coma Scale score of 13-15 after 30 minutes
3. Post-traumatic amnesia (PTA) of no more than 24 hours

Why does cortical bone produce no signal on Magnetic Resonance Imaging?


a. signal production depends on the absence of significant pathology
b. osteoid contains no free hydrogen
c. mineralized bone contains no free hydrogen
d. bone marrow contains no free hydrogen
e. articular cartilage contains no free hydrogen

Answer

Tags: MCQ, Radiology, MRI, Magnetic Resonance Imaging

A primary tumor arises in the medullary cavity of the cortex of the tibia. It fills the tibial diaphysis, but does not erode the cortex significantly. If the tumor is less radio-dense than skeletal muscle but more radiodense than fat, what will be seen on the X-ray?

a. a permeative lesion with indistinct borders
b. a geographically circumscribed lesion with perilesional sclerosis
c. a circumscribed lesion without sclerosis and a sharp transition zone
d. an ill-defined lesion with unclear amounts of bony destruction
e. virtually no abnormality

Answer

Which of these produces the least dense image radiographically?

a. inflated lungs
b. subcutaneous fat
c. rectus femoris muscle
d. bone
e. diamond from an engagement ring

Answer

Tags: MCQ, Radiology, Radiography

The correct Answer is C

Bowel infarction results from ischemia of the intestines, caused either by mechanical obstruction to blood flow (eg, arterial thrombosis or embolism from the heart, volvulus, stricture) or by reduced perfusion (eg, cardiac failure, shock).

Transmural infarction (all layers of the gut wall) usually follows mechanical obstruction to blood flow.

Occlusion of the origin of any of the three main arterial supplies (Coeliac, Superior Mesenteric, Inferior Mesenteric) will lead to transmural infarction.

The superior mesenteric artery is most prone to thrombosis and embolism. Disease leads to transmural infarction which accounts for about 50% of mesenteric ischaemia .

Regarding venous thromboembolic disease,

a. Deep venous thrombosis and pulmonary emboli cannot be diagnosed using MRI.
b. D-dimer assays have a high positive predictive value in suspected venous thromboembolic disease.
c. Duplex ultrasound is highly sensitive and specific investigation for symptomatic proximal leg deep venous thrombosis.
d. The more distal the leg venous thrombosis, the more risk for pulmonary embolism.
e. The dose of VQ (ventilation perfusion) scan is more than that for a CTPA (CT pulmonary angiogram).

Answer

Regarding thalassaemia,

a. Skeletal changes are unusual before 6 months of age.
b. 'Hair-on-end' skull appearance is characteristic for thalassaemia.
c. Ethmoid air cells are usually present.
d. Earliest changes are seen in the hand/feet bones.
e. MRI is sensitive in the early diagnosis of chelator toxicity in the skeleton

Answer

Regarding the injuries of the knee joint,

a. In pivot shift injury, the PCL is commonly injured.
b. Dashboard injury commonly results in the disruption of the ACL.
c. In lateral patellar dislocation, the oedema is seen in the inferolateral patella and the anterior aspect of the lateral femoral condyle.
d. In lateral patellar dislocation, the lateral patello-femoral ligament may be injured.
e. 'Kissing contusions' on the anterior aspects of the femur and tibia are seen in hyperextension injury.

Answer

Tags: MCQ, Radiology, Knee Injury

Regarding imaging of the gestational trophoblastic neoplasia (GTN),

1. Complete hydatidiform moles are more premalignant than the Partial hydatidiform moles.
2. GTNs are almost always curable.
3. In GTNs, the uterine artery pulsatility index (PI) has been shown to predict methotrexate resistance.
4. Metastases typically occur in the peritoneum.
5. Uterine artery embolization (UAE) has a proven therapeutic effect in the management of post GTN vascular malformations.

Answer

Tags: MCQ, Radiology, Gestational Trophoblastic Neoplasia

Regarding the benign bone tumours of the ribs,

1. Enchondroma (EC) are the most common benging tumours of the ribs.
2. Fibdrous dysplasias (FD) are usually seen in the posterior or lateral aspects of the ribs.
3. MRI is not sensitive in diagnosing the non-calcified cartilage of enchondroma.
4. In osteochondromas (OC), cartilage cap of less than 10mm is highly suspicious for malignant transformation.
5. Aneurysmal bone cysts (ABC) are commonly seen in the anterior aspect of the ribs.

Answer

Tags: MCQ, Radiology, Ribs, Tumors

Regarding central neurocytoma (CN) true is

a. CN are typically located within the fourth ventricle.
b. Light microscopic appearance is similar to meningioma.
c. Most of the CNs present after 60 years of age.
d. The attachment to the lateral wall of the lateral ventricle is charactersitic for CN.
e. Intratumoral calcification is common.

Answer

Tags: MCQ, Radiology, Neurocytoma

Regarding endometrial carcinoma,

a. CT is less accurate than endovaginal ultrasound in the diagnosis of myometrial invasion.
b. Zonal uterine anatomy is best seen on the T1WI.
c. Endometrial carcinoma is typically of low signal on the T2WI.
d. Endometrial carcinoma is of high signal compared to cervical stroma on the T2WI.
e. Lung is the most common site of distant metastasis

Answer

Tags: MCQ, Radiology, Endometrial Cancer

Regarding the endometrial carcinoma,

a. In Europe, endometrial carcinoma is second most common gynaecological malignancy, following cervical carcinoma.
b. In the UK, most of the endometrial carcinomas present late
c. FIGO Staging is based on MRI the of the pelvis and CT scan of the abdomen.
d. Endometrial carcinoma accounts for approximately 10% of postmenopausal bleeding
e. The incidence of nodal metastasis is 3% with deep myometrial invasion (stage IC).

Answer

Tags: MCQ, Radiology, Endometrial Cancer

Regarding posterolateral corner injuries of the knee all are true except

a. Posterolateral corner injuries are less common than medial knee injuries
b. Arcuate fracture is a strong indicator of posterior cruciate ligament tear
c. Segond fracture is a strong indicator of posterior cruciate ligament tear
d. Popliteus myotendinous injury is usually associated with other posterolateral corner injuries
e. Lateral collateral ligament injury is a part of posterolateral corner injuries

Answer

Tags: MCQ, Radiology, Knee Injuries

Regarding traumtic diaphragmatic rupture (TDI),

A. TDIs most commonly occur after penetrating trauma
B. Left diaphragm is less commonly ruptured than the right
C. About 50% of TDI are diagnosed acutely
D. The most commonly herniated organ is spleen
E. 'Dependent viscera sign' is a very sensitive CT sign in the diagnosis of TDI

Answer

Tags: MCQ, Radiology, Diaphragm, Blunt Trauma Abdomen

Regarding Angiomyolipomas (AML),

A. AMLs associated with tuberous sclerosis are more common than sporadic ones
B. Males are more commonly affected than Females in both sporadic type and in those with tuberous sclerosis
C. AMLs are associated with neurofibromatosis
D. The most common complication is malignant transformation
E. AMLs are not suitable for embolization

Answer

Regarding epidermoid cysts of the testis,

A. Epidermoid cysts are one of the common cysts of the testis
B. Epidermoid cysts are commonly associated infertility
C. Epidermoid cysts are commonly multiple
D. The ultrasonic appearances are characteristic for epidermoid cysts
E. On Gd administration, epidermoid cysts usually enhance

Answer

Tags: MCQ, Radiology, Testis, USG, Epidermoid cyst

Regarding splenic injury,all are true except

A. Spleen is the most commonly injured abdominal organ in blunt trauma
B. 40% of rib fractures are associated with splenic injuries
C. 40% of splenic injuries are associated with rib fractures
D. Splenic lacerations are seen as an area of low attenuation on contrast enhanced CT scan
E. Most of the splenic injuries are managed conservatively

Answer

Tags: MCQ, Radiology, splenic Trauma, Spleen

Regarding blunt injury of the kidney,

A. Nearly 50% of renal injuries are treated surgically
B. Presence of hematuria is an idication of serioud renal injury
C. Absence of hematuria excludes renal injury
D. Cortical rim sign on CT scan suggests devascularization
E. Hypertension is an early complication of renal trauma

Answer

Tags: MCQ, Radiology, Renal Trauma

Regarding neuroinfections in HIV/AIDS correct is

A. HIV encephalitis preferentially shows white matter changes in the centrum semiovale
B. CMV encephalitis rarely involves brain stem and periventricular white matter
C. CMV encephalitis typically heals by periventricular calcifications
D. Cryptococcus usually causes ring enhancing lesions in the basal ganglia
E. PML (progressive multifocal leucoencephalopathy) typically shows mass effect and contrast enhancement

Answer

Tags: MCQ, Radiology, HIV Encephalitis