NYU 2004 Written Board Recalls224 SBA questions, 4 hours.

Nuclear Medicine

Parathyroid imaging is used with Tc99 sestamibi- which is false?

a) sestamibi works on the principle that parathyroid is hypervascular(FALSE:delayed washout…if persists…then adenoma)

b) confused with thyroid cancer (True: use pertech or iodine to subtract)

Ans. A. Sestamibi works on principle of delayed washout of partathyroid.

Dual phase: early (15min and late 4 hours); if persists then parathyroid adenoma….can give thyroid suppression agent

Subtraction:First….pertech or iodine given..subtract from sestamibi……..

3. Repeat about patient contamination with some type of nuclear medicine agent- what do you do?

a) address the patient’s medical concernsb) clear the area and get nuclear medicine consult before touching patientc) decontaminate patient before treating

Ans. A. Address the medical concerns.

4) FDG Pet and seizure what is false?

a) 90% sensitivity for diagnosing seizure focus ictally

b) if basal ganglia hypometabolic next to hypermetabolic seizure focus, then more likely to get more seizures after surgery

c) the brighter the uptake, the better the outcome after resection

d) Seizure foci demonstarte-hyperperf and hypermetabolism during seizures and hypo and hypo in interictal period

e) PET with FDG for metabolism and HMPAO or ED for perfusion

http://www.auntminnie.com/index.asp?sec=ref&sub=ncm&pag=cns&itemid=53613

Ans. B (A is correct- Nuc Med Requisites states that PET has >90% sensitivity for dx seizure ictally)

5) Thyroid cancer- resected papillary cancer, treated with I 131, then came back with increasing thyroglobulin. Whole Body I 131 scan negative. What is most appropriate next step?a) repeat Body scanb) repeat Therapeutic I 131c) FDG Pet scand) chemoe) radiation

Detectable Tg Levels: When patients have had cancerous growths that make Tg, the absence of Tg in a blood sample is usually good news for a patient who has had thyroid surgery to remove their thyroid gland containing a cancerous growth. However, many patients still have measurable levels of Tg in their blood after surgery. Often this Tg is coming from a small amount of normal thyroid left behind. This means that a measurable level of Tg does not necessarily indicate the presence of tumor. Often physicians will give a small dose of radioiodine to get rid of the last remaining part of the normal thyroid gland in order to make later Tg measurements a better marker for any tumor left behind. 

Ans. C. need an imaging study (ideally) before repeat therapy. Dr. Tiu says they used to just give another therapeutic dose of I 131, but in the new age of PET scans, need to do PET to see if there are any abnormalities.

6) Xenon vs. Tc99m DTPA. DTPA does all of the following except:a) more dose to lungs b) easier for patient c) no need for special back ventilation roomd) stays in lungs longere) shorter half life

Xe:higher dose, longer t ½, retained longer, requires back ventilation room

Ans: A. 30 mCi of Tc99m DTPA in 3 ml Saline delivers 100K counts in 2 minutes on a standard gamma camera with low energy collimation. The typical radiation exposure to the lungs is 100 mrads. This is less than the several hundred millirad exposure from a typical Xe133 rebreathing ventilation exam. Additionally, Xe has a longer half-life, and is retained longer (esp in COPD/asthma), without washing out.

8) What happens to DISIDA in liver?a) passive uptake by hepatocytes, conjugated b) active uptake by RES, conjugated

c) active uptake by hepatocytes, excreted unchanged

Ans: C. DISIDA competes for uptake by the liver, but is not conjugated by the hepatocytes.

9) Prostate cancer, increasing PSA, gets bone scan. Single posterior rib lesion- most likely cause?a) metastasesb) traumac) Eosinophilic Granuloma

Ans. B. trauma is by far most likely.

11) FDG Pet; what is false-a) staging of non small cell is never better with FDG than with CTb) it is less accurate for small cell than non-small cellc) granulomas can give false postivesd) lesions smaller than 1 cm can give a falsely low SUVe) SUV > 2.5 highly suspicious for malignancy (except in the liver)

Ans. A. Non-small cell staging with PET is superior to CT staging.

FDG PET: nonsmall > small cell; >1cm lesions; >2.5 SUV highly susp; granulomas false positive

12) nodules over one side of lung, patient with decreasing feeling in handsa) thymoma b) mesotheliomac) fibrous tumor of pleurad) adenocarcinoma

Ans: A, invasive thymoma with drop mets and myasthenia gravis. Remember relationship b/w myasthenia gravis and thymoma: 15% of pts with myasthenia have thymoma, and 30% of thymomas assoc with myasthenia.

13) For which of the following do you NOT need to decrease amount of particles in V/Q scan?a) prior PEb) pregnancyc) childd) s/p pneumonectomy

Ans. A. prior PE.

14) tibial stress fractures- what is most characteristic for them on bone scan?

a) normal on first two, hot on delayed b) hot on all threec) hot, hot, then slightly decreased uptake on delayedd) cold on all three

Ans. B Stress fractures are hot on all three Shin splints- normal on flow and blood pool, increased activity on delayed in long linear distr at least along 1/3rd of length in postmed tibial cortex at insertion of soleus Stress fracture: stress fractures are more focal, and not in the postmed tibial cortex (classic for shin splints).

15) which test and result go together?a) intrinsic: integral functionb) extrinsic: collimator malfunctionc) Center of rotation: spatial axisd) e) Line bar: linearity

Ans: B. Measures of performance of a scintillation scanner with the collimator attached are called system or extrinsic measurements (Bushberg pg 678).

16) calcification at junction of optic nerve a) drusenb) retinoblastoma

Ans: A. (Repeat).

17) Gallium vs. Indium, what is Indium better for?a) disc infectionb) otitis media c) acute inflammatory bowel diseased) splenic abscess

Ans: C. Acute inflammatory bowel disease. (Repeat).

18) what is a characteristic of hemangioma?a) increased uptake on delayed Tc99m sulfur colloid scanb) hyperechoic with increased acoustic enhancementc) hyperechoic peripherally with hypoechoic center is a variant presentation

Ans: C. This is an atypical appearance of hemangiomas that is only rarely seen in metastatic disease (pg 54 Ultrasound Case Review). Increased uptake is seen on delayed Tc99m RBC scan. The typical ultrasound appearance is hyperechoic WITHOUT increased acoustic enhancement (it can happen, but it is not typical). Answer A is wrong, b/c Tc99m RBC scan is used.

20) Which of following does not uptake octreotide?a) renal cell carcinomab) pheoc) medullary carcinoma thyroidd) carcinoid

Ans: A. RCC does not uptake (Nuc Med Reqs).

21) if a test is sensitive, which of the following DECREASES?a) false negativesb) false positivesc) positive predictive value

Ans: A. you are increasing your positives (false and true), so won’t leave much behind!

22) What will cause your LVEF in MUGA to increase?a) including spleen in background countsb) including field outside patient in background countsc) including diaphragm in background countsd) including the rt atrium in both diastole and systolee) including rt atrium in systole

Ans: A. Remember the formula: LVEF= [(ED-B)-(ES-B)]/(ED-B) which is equivalent to: (ED-ES)/(ED-Background). The spleen has very high counts. (So does the right atrium, but it is so small it really doesn’t affect the counts).

23) Which is false about difference b/w Thallium and Sestamibi?a) sestamibi will redistributeb) sestamibi passively taken up by mitochondria

Ans: A. Sestamibi does not redistribute, this is a property of thallium.

24) What is absolute contraindication to administration of adenosine?a) third degree heart blockb) CABGc) asthma

Ans: A. Contraindications to adenosine myocardial perfusion imaging: a. Severe bronchospastic pulmonary disease b. Hypotension c. Recent Ml (within 6 weeks) or CVA - relative contraindication, requires consultation with nuclear medicine staff d. Sick sinus syndrome e. Second or 3rd degree AV block f. Severe CHF g. Low left ventricular ejection fraction h. Theophylline containing preparations within 48 hours of scheduled exam i. Caffeine-containing products within 6 hours of scheduled exam

j. Oral dipyridamole within 48 hours of scheduled exam k. Inability to give informed consent l. Inability to lie still for imaging

25) A bright nodule, rest of gland relatively suppressed, what is true?a) RAIU will be >40%b) this is an autonomous adenomac) Grave’s disease

Ans: B. autonomous adenoma.

184) Regarding gastric emptying studies, which is true?a) solids more sensitive than liquids. b) liquids more sensitive than solids

Ans: A. (Repeat).

STATS

if high (99.9%) sensitivity, 50% specificity test for Alzheimer’s come out, and your patient tests positive:a) they have Alzheimer’s diseaseb) you need another testc) not sensitive for diagnosisd) negative predictive value is a coin flipe) need to know prevalence in population

Ans: B. you need another test

70) How to correct for aliasing artifact on ultrasound?a) increase pulse repetition frequency

Ans: A (repeat)

86) What is power determination (? Power analysis)a) determining the sample sizeb) changing the coincidence interval c) something about biasd) something about subgroup analysis

Ans: A (repeat)

OB/GYN

33) Which is true?

a) if b-hcg= 2000, should see a gestational sacb) b-hcg should double every dayc) gestational sac should increase by 3mm/dayd)

Ans. A. (repeat)

If the patient's BHCG is > 1500, a gestational sac should always be seen if the pregnancy is developing normally.    If no sac is seen and the value is above this "discriminatory level" a normal pregnancy can be ruled out with fairly high confidence, and the diagnosis is either ectopic pregnancy or completed abortion.  The concept of a "discriminatory level" does not mean that ultrasound is of no value if the BHCG is < 1500.  A normal gestational sac is often seen at lower levels, ruling out ectopic pregnancy. Also, other

obvious signs of ectopic pregnancy may be present at lower levels.  Bhcg doubles every two days. 1.2 mm per day growth is ok.

35) Post menopausal bleeding, not on hormone replacement tx, when would you biopsy?a) 5 mmb) 3 mmc) 7 mmd) 9 mme) 11mm

Ans. A. (Repeat) Ultrasound Requisites: postmenopausal women should have a double layer thickness less than 5 mm. Patients on tamoxifen therapy are allowed a normal thickness up to 8 mm (BUT WITHOUT BLEEDING…..IF BLEEDING THEN back to 5mm.. On a sonohysterogram. the single layer thickness should be normally less than 3 mm.

65) Which is associated with choroid plexus cyst?a) Trisomy 13b) Trisomy 18c) Down’s syndromed) cleidocranial dysplasia

Ans: B (repeat)

66) Which do you NOT see elevated AFP in a) Neural tube deficienciesb) c) Down’s syndrome

Ans: C (repeat)

160) A corpus luteum cyst will usually resolve by:a) 5 weeksb) 10 weeks

c) 15 weeksd) 20 weekse) 25 weeks

Ans: C (repeat)

177) Precocious puberty, ovarian mass, most likely:a) granulosab) Brenner c) Krukenberg

Ans: A. (repeat)

Three major types of ovarian neoplasms are described, with epithelial cell tumors (70%) comprising the largest group of tumors. Germ cell tumors occur less frequently (20%), while sex cord–stromal tumors make up the smallest proportion, accounting for approximately 8% of all ovarian neoplasms.

Granulosa-theca cell tumors, more commonly known as granulosa cell tumors (GCTs), belong to the sex cord–stromal group and include tumors made up of granulosa cells, theca cells, and fibroblasts in varying degrees and combinations. GCTs account for approximately 2% of all ovarian tumors and can be divided into adult (95%) and juvenile (5%) types based on histologic findings.

Patients usually present with precocious pseudopuberty (70-80%) and have secondary sex characteristics at a very early age. These may include increased linear growth, breast enlargement, clitoral enlargement, pubic hair development, increased vaginal secretions, and vaginal bleeding.

178) pathology reveals sheets of Beta cells:a) amyloidb) PVNS

Ans: A (repeat from 1998)

RENAL

42) typical of adrenal aldosteromaa) low renin levelsb) high renin levelsc) hyperkalemia

Ans: A (repeat). The diagnosis of primary aldosteronism is based on the typical biochemical findings of hypokalemia, hypernatremia, depletion of magnesium, elevated bicarbonate levels, low plasma pH, and elevated aldosterone levels in both the serum and urine. However, this biochemical pattern is not unique to primary aldosteronism, and it may be seen in secondary aldosteronism as well.

The demonstration of suppressed renin levels is vital to the diagnosis. Hypertension associated with primary aldosteronism is usually benign, but, in rare cases, malignant hypertension may develop.

43) what is likely cause of alkalosis, hypernatremia and hypertensiona) adrenal aldosteromab) pheo

Ans: A. (repeat)

46) Calcification in testicles:a) meconium peritonitisb) traumac) tumor

Ans: A (repeat)

59) What is true regarding multilocular cystic nephroma:a) protrudes into collecting systemb) cysts connect to each otherc) central stellate regiond) homogenous enhancemente) spreads to renal hilar nodes

Ans: A (repeat)

61) What is not true about mesoblastic nephroma?a) can invade adjacent structuresb) is malignantc) most common renal mass of infancyd) can diagnose on prenatal ultrasound

Ans: B (repeat)

69) What type of stone do you get in bowel resection?a) calcium phosphateb) uric acidc) calcium oxalate \Ans: C. (Repeat)

76) MCDK, what associated with?a) pelvic and ureteral atresiab) contralateral MCDK

Ans. B (Bilateral MCDK is fatal. But this emphasizes the need to check the other kidney when doing a fetal ultrasound and see unilateral MCDK. There is also an increased

incidence of contralateral UPJ or reflux- need to check both kidneys so can potentially save the kidney!- AFIP notes, Woodward)

79) what is true about urethra in male?a) female get diverticula at same rate as malesb) adenocarcinoma more common than SCC in urethra. (This is false. Scc>transitional>adeno)

Ans: B. (more women than men get diverticula).

80) Urethra in female:a) diverticula needs to be marsupalizedb) diverticula located posteriorly – correct, http://www.emedicine.com/med/topic3331.htmc) develops after long term catheterizationd) causes stress incontinence

Ans: )

Female urethral diverticulum is a localized outpouching of the urethra into the anterior vaginal wall. Most often present in the mid or distal urethra, it results from enlargement of obstructed periurethral glands. Although urethral diverticulum is often difficult to diagnose, it has been identified with increasing frequency over the past several decades because of increased physician awareness of the condition.

Although symptoms are highly variable, the most common symptoms are irritative (i.e., frequency, urgency and dysuria) lower urinary tract symptoms (LUTS). Dyspareunia will be noted by 12 to 24 percent of patients and approximately five to 32 percent of patients will complain of post-void dribbling. Recurrent cystitis or urinary tract infection is also a frequent symptom in one-third of patients. Other complaints include pain, hematuria, vaginal discharge, obstructive symptoms or urinary retention and incontinence (stress or urge).

Occasionally, urethral carcinoma and calculi may be present. The most widely accepted theory as to etiology implicates repeated infections of the periurethral glands with subsequent obstruction eventually evolving into urethral diverticula.

Although often highly symptomatic, not all urethral diverticula require surgical excision (removal). Surgical options include transurethral incision of the diverticular neck, marsupialization (creation of permanent opening) of the diverticular sac into the vagina [often referred to as a Spence procedure], and surgical excision.

84) What is typical of epidermoid of the testicle?a) can do a transcrotal biopsyb) has classic findings of increased through transmission with increased echogenicity within itc) lamellated appearance of concentric rings

Ans: C. This is filled with keratin, and although it is benign, cannot definitely distinguish from a tumor, so it must come out. But, instead of doing an orchiectomy

you can just pop the little epidermoid out, and preserve the testicle. (AFIP notes, Woodward).Well defined ring appearance.

102) Pregnant woman, 2 weeks postpartum, enlarged kidney, flank pain, delayed nephrogram?a) Renal Vein thrombosisb) ATNc)

Ans: A. (Repeat).

116) Infant with hyperechoic kidneys, most likely cause?a) Furosemide toxicityb) Medullary sponge (young to middle aged adults)

http://www.emedicine.com/radio/topic470.htm

Ans. A. (Repeat). Nephrocalcinosis has been described in premature infants treated with high doses of furosemide for prolonged periods because of congestive heart failure secondary to patent ductus arteriosus or pulmonary disease. Both nephrocalcinosis and nephrolithiasis may occur. These complications occur 11-50 days after the commencement of furosemide therapy. The addition of chlorothiazide to furosemide prevents further calculi formation, and it may also lead to the dissolution of existing stones. Therefore, preterm infants who are taking furosemide should be regularly screened with renal ultrasonography. Long-term furosemide abuse can also cause medullary nephrocalcinosis in adults.

105) Torsion of ovary, what do you see?a) if see peripheral perfusion, then it is not torsedb) torsed ovary usually larger than other side (swelling, edema)c) usually associated with malignant mass

Ans. B. (Bennett, Radiographics).

114) Adenomyosis, what is false? – a) sharply definedb) may be focalc) may be diffused) can get areas of high signal intensitye) widened junctional zone

Ans: A (repeat)

130) What is true about lymphoma of the kidney?a) get posterior acoustic enhancement and hypoechoic massb) associated with other lymphomas

Ans: A (repeat). Primary lymphoma is rare. Hypoechoic masses with lack of acoustic enchancement distinguishing it from a cyst. However , posterior acoustic enhancement can be seen rarely.

142) Where is cancer in prostate?a) peripheral zoneb) transitional zone

Ans. A. (repeat).

143) Which is not a cause of a small thickened bladder:a) Diabetes with neurogenic bladderb) Detrusor spinchter dysenergia

Ans: A. (repeat) This is a large bladder. Diabetes and sacral spinal cord injuries result in flaccid thin large bladder.

149) Which is not associated with retroperitoneal fibrosis?a) lymphomab) xanthogranulomatos pyelonephritisc) aortic aneurysmd) radiation

Ans: B XGP

167) Pseudodiverticulosis in the ureter in men:a) associated with TBb) most commonly in the distal portion of the ureterc) congenitald) may be malignant

Ans: D. There is an association with malignancy in 30% of patients with ureteral pseudodiverticulosis. This makes close follow-up prudent.

181) What is true about hydrosonography?a) used to evaluate cause of endometrial thickeningb) best done tranabdominallyc) uses iodinated contrast

Ans: A.

193) Regarding splenic artery aneurysms, which is true? a) more likely to rupture in pregnancy

Ans. A (repeat).

195) The location of Cowper’s glands are at what level?a) membranous urethra

Ans. A (Repeat)

196) Which is false about para-ovarian cysts?a) undergo cyclic changeb) are located in the broad ligamentc) undergo torsion

Ans. A (repeat).

197) Urethra:a) anterior urethra defined as the distance to the penoscrotal junction (+ bulbous urethra)b) penoscrotal junction is where most catheter induced trauma occursc) gonococcal strictures are short segment

Ans. B. Foley catheter may injure penoscrotal junction. (Repeat).

198) On fetal ultrasound there is a cyst in the upper pole of the kidney. What is the most likely cause?a) simple cystb) obstruction with dilated calyxc) adult PCKDd) duplicated collecting system with obstructed upper pole

Ans: D.

199) What is not cause of non-immune hydrops? (ie, what causes immune hydrops)a) Erythroblastosis fetalis

Ans. A (repeat).

201) Regarding renal ostial lesions, what is true?a) risk of hypotension s/p dilatationb) better results than lesions elsewherec) should not be performed if renin levels do not lateralize

Ans. A. (repeat)

******************One day old female with mass between her bladder and rectum. Cause?a) hydrometrocolposb) saccrococcygeal teratomac) neuroblastomad) rhabdomyosarcomae) duplicated rectum

Ans. A. (repeat) Dilatation of uterus and vagina secondary to congenital obstruction

accumulation of secretions in the vagina and uterus dilatation of the vagina proximal to a congenital obstruction (e.g., imperforate hymen) produces a palpable, fixed midline mass may cause hydronephrosis AXR: abdominal mass extending from pelvis US: cystic mass posterior to bladder with scattered echoes due to cellular material and blood

Cf: hydrometros = uterine dilatation only (obstruction at cervix)

Precocious puberty, non tender ovarian mass, most likely:a) granulosa cell tumorb) Brenner c) Krukenberg

Ans. A. (repeat)

What is true about hydrosonography?a) used to evaluate cause of endometrial thickeningb) best done transabdominallyc) uses iodinated contrastd) best performed during the secretory phase of cyclee) not to be done post menopausal

Ans. A. (repeat)

Which is not associated with retroperitoneal fibrosis?a) lymphomab) xanthogranulomatos pyelonephritisc) aortic aneurysmd) radiatione) methysergine

Ans: B. In 68% of patients with RPF no cause is found. In the remainder, implicated causes include drugs, abdominal aortic aneurysm, ureteric renal injury, infection, retroperitoneal malignancy (lymphoma – Dahnert), postirradiation therapy, and chemotherapy. (e-medicine).

What is true about lymphoma of the kidney?a) get posterior acoustic enhancement and hypoechoic massb) most commonly associated with other lymphomasc) most commonly Hodgkin’s

Ans. A. (Repeat)

Torsion of ovary, what do you see?

a) if see peripheral perfusion, then it is not torsedb) torsed ovary usually larger than other sidec) usually associated with malignant massd) doesn’t occur in post-menopausal patients

Ans. B.

Patient 6 hours post renal transplant has a decrease in urine output. On ultrasound see reversal of flow in segmental renal artery:a) Renal Vein Thrombosis b) Hyperacute rejectionc) ATN

Ans: A. RVT

*********************MAMMO

48) Get bx back with ADH, what do now?a) excisional bx

Ans: A (repeat).

49) Which is highest grade DCIS?a) comedob) medullaryc) micropapillary d) mucinous

Ans: A (Repeat).

50) Lesion at 9 in right breast, best approach?a) lateral

Ans: A (Repeat).

51) Lesion superior breast, rises from MLO to ML, where is it?a) upper innerb) upper outerc) lower innerd) lower outer

Ans; A. (Repeat). Muffins (medial) rise and lead (lateral) drops.

52) 1 cm, well defined, circumscribed, non-palpable mass, what is chance of malignancy?

a) <2%b) 5%c) 10%d) 50%e) 90%

Ans: A (repeat).

53) If see calcifications on CC but not on MLO, could be all of the following e/c:a) Milk of Calciumb) artifactc) dermal calcificationsd) area not included on MLO view

Ans: A. This is seen on MLO but not CC.

54) what area on MLO film is most subject to motion?a) medial

Ans. A (Repeat).

58) A patient has a bx, gets sclerosing adenosis and LCIS, what is next step?a) repeat Mammo in 1 year

Ans: A (Repeat). Sclerosing adenosis is a benign condition and LCIS/lobular neoplasia has no mammographic or clinical correlate. It just increases your risk of developing real breast cancer in the future.

118) What is not a cause of incomplete visualization of calcs?a) vkp peakb) mAsc) motion d)

Ans: ?Not listed. All of these choices can cause problems- too low kvp for a big breast will give poor visualization, low mAs can do the same, and motion can do the same.

119) s/p biopsy, what is true?a) scar associated with increased chance of malignancyb) skin thickening over area for yearsc) suture calcifications are commond) if see ill defined mass at biopsy site after 2 years, suspicious for malignancy

Ans. B. You commonly will see skin thickening over the area for years. Scars are not associated with increased malignancy, e/c in the lung. Suture calcifications are not common unless assoc with radiation. The last choice, d, is too vaguely worded to

be correct. An ill-defined mass would more commonly be fat necrosis, and this is in fact why patients are followed for 6 months, 1 year, 1 yr 6 mo, and 2 years- not to screen for re-development of breast cancer (which is statistically unlikely), but to watch the changes of fat necrosis, which can go from oil cysts to spiculated appearing lesions- that way, you don’t bx this area unnecessarily. (As per Dr. Glassman, AFIP).

*161) What is not a QA requirement for mammographers?a) 15 CME credits every 3 yearsb) active method for contacting patients within 30 days of abnormal resultc) method to deal with complaints

Ans: ? All of the above are requirements. Answer is not listed. Interpreting Physician Initial Training 60 hours of CMECitation:900.12(a)(1)(i)(C): The interpreting physician shall have a minimum of 60 hours of documented medical education in mammography, which shall include: Instruction in the interpretation of mammograms and education in basic breast anatomy, pathology, physiology, technical aspects of mammography, and quality assurance and quality control in mammography. All 60 of these hours shall be category I and at least 15 of the category I hours shall have been acquired within 3 years immediately prior to the date that the physician qualifies as an interpreting physician. Hours spent in residency specifically devoted to mammography will be considered as equivalent to category I continuing medical education credits and will be accepted if documented in writing by the appropriate representative of the training institution.

162) Core needle biopsy- what is true?a) cheaper than sterotactic b) 18 G needlec) need to radiograph specimen block – (is this not true??)

Ans: A (Repeat).

176) Patient with negative mammogram, develops cancer within the year. This would be classified as a:a) false negativeb) false positivec) true negatived) false negative

Ans: A (Repeat).

182) After patient gets radiation and after biopsy, returns for mammo. Why?a) re-establish baseline

Ans: A (repeat).

183) MRI of breast lesions: a) if malignant, shows early intense enhancementb) plateau of curve

c) needs fat suppression to diagnose

Ans: A. Malignant lesions classically show early intense enhancement, with early washout. This was originally thought to be helpful in distinguishing malignant from benign lesions, but some benign variants behave this way. The other types of enhancement are: Gradual enhancement, with low slope and continual increase in enhancement throughout scan. This is a benign characteristic.Plateau enhancement- early enhancement which plateaus off. This is an indeterminate pattern. (Body MRI, pg 437).

208) Mammography of implants:a) mammography can only diagnose extracapsular ruptureb) MRI needed to diagnose intracapsular rupturec) d) e)

Ans: B. Cannot see intracapsular rupture on Eklund (mammo) views. Linguini sign on MRI.

211) Breast localization wire, where should the final position be?a) 1 cm deep to lesionb) 1.5-3.0 cm deep to lesionc) 1 cm proximal to lesiond) 1.5-3.0 cm proximal to lesion

Ans: A is the best answer here, but 1-1.5 cm deep is fine. 3 cm is way too deep. (AFIP notes- Dr. Glassman).

185) MRI of breast lesion:a) cysts will be T2 bright

Ans: A.

204) Tubular carcinoma of the breast presents as:a) spiculated lesion

Ans: A (repeat) good prognosis.

206) Flow dynamics on MRI are best evaluated using:a) phase contrastb) TOFc) gradient echo

Ans: A (repeat)

95) Inflammatory carcinoma is most classically described as:a) tumor cells blocking lymphatics

Ans: A. (Repeat).

Pulmonary

72) P02:PC02 with hyperventilation:a) 98: 30b) 98:40c) 90:90d) 80:40

Ans: A (repeat).

73) Pt. with hemoptysis from right lung, what to do immediately?a) put in LL decubb) put in RL decubc) put in trendelenburg

Ans: B (Repeat)

82) What is anterior to the right upper lobe bronchus?a) superior pulmonary vein – (check this!)b) superior interlobular pulmonary artery

Ans: A. (Repeat).

191) ?Something about bronchial transection and pneumothorax?

92) High intensity on Chest CT (125 HU)a) Amiodarone toxicity

Ans: A.

93) lymphangitic spread, what is most likely:a) nodular beading along interlobular septab) bronchovascular lymphatic thickening

Ans: A Can see both, but see around periphery (secondary lobules) first, b/c drainage of lymphatics follows veins, periphery to central. (Dr. Galvin, AFIP notes).

94) sarcoid granulomas deposit where in lungs?a) in bronchovascular lymphaticsb) interstitium c) alveoli

Ans: A. The granulomas are deposited along the center and periphery of the secondary lobule, along the lymphatics (Dr. Galvin, AFIP notes pg 6).

97) 23 yo male brought in unconscious with Chenye Stokes breathing; CXR shows diffuse bilateral upper lobe opacities:

a. septic embolib. aspirationc. neurogenic pulmonary edema

Answer: C

167) See bilateral lower lobe multifocal opacities, biopsy reveals necrosing angitisa) Wegener’s b) Goodpasture’sc) TB

Ans: A. Although according to Dr. Galvin, all 5 lobes are equally affected in Wegener’s. Differential diagnosis of necrotizing angitis includes Churg Straus (fleeting infiltrates), Necrotizing Sarcoid Granulomatosis (which is not caused by Sarcoid, but by aspergillous, and has hilar adenopathy), and Lymphomatoid Granulomatosis (a pre-B cell lymphoma, with multiple bilateral nodules and rapid death).

120) What is NOT true about pulmonary embolism?a) usually multipleb) central less likely to result in infarct than peripheral c) presents with classic triad of hemoptysis, chest pain, cough

Ans: C. It is rare to get this “classic” triad, which was seen back when PE’s were diagnosed after they infracted the lung.

Pulmonary Embolism:I. Symptoms

A. Classic Triad 1. Chest Pain (80-90%)

a. Pleuritic Chest Pain (74%) b. Non-pleuritic Chest Pain (14%)

2. Cough (40-53%)

3. Hemoptysis (13-20%) B. Dyspnea (75-85%) C. Apprehension or anxiety (50-65%) D. Syncope (5-13%) E. Diaphoresis (27-36%)

II. Signs A. Tachypnea (80-90%)

1. Respiratory Rate over 16 (92%) 2. Respiratory Rate over 20 (70%)

B. Rales (50-58%) C. Tachycardia (40-50%) D. Fever (40%)

1. Temperature usually 37.8 to 38.5 C 2. Temperature rarely over 38.5 C (102.5)

E. Gallup rhythm (34%) F. Phlebitis (32%) G. Edema (24%) H. Cardiac murmur (23%) I. Adventitious breath sounds J. Cyanosis (19%) K. Circulatory collapse (8%) L. Lower extremity swelling, tight cords, or tenderness

M. Homan's Sign not helpful

134) What is most associated with rounded atelectasis?a) pleural effusionb) lymphadenopathy

Ans: A (Repeat). Of note, Johnny adds that other things are associated with rounded atelectasis, specifically: pleural thickening, volume loss and effusion.

136) If have parietal involvement of chest wall, then at least stage:a) Ib) IIc) IIbd) IIIae) IV

Ans: C

Lung Cancer Staging: Primary tumor

o Tis - Carcinoma in situ o TX - Positive malignant cytologic findings, no lesion observed o T1 - Diameter of 3 cm or smaller and surrounded by lung or visceral pleura or

endobronchial tumor distal to the lobar bronchus o T2 -Diameter greater than 3 cm extension to the visceral pleura, atelectasis, or obstructive

pneumopathy involving less than 1 lung; lobar endobronchial tumor; or tumor of a main bronchus more than 2 cm from the carina

o T3 - Tumor at the apex total atelectasis of 1 lung; endobronchial tumor of main bronchus within 2 cm of the carina but not invading it; or tumor of any size with direct extension to the adjacent structures such as the chest wall mediastinal pleura diaphragm, pericardium parietal layer, or mediastinal fat of the phrenic nerve

o T4 - Invasion of the mediastinal organs, including the esophagus trachea, carina great vessels and/or heart; obstruction of the superior vena cava; involvement of a vertebral body; recurrent nerve involvement; malignant pleural or pericardial effusion; or satellite pulmonary nodules within the same lobe as the primary tumor

Regional lymph node involvement o N0 - No lymph nodes involved o N1 - Ipsilateral bronchopulmonary or hilar nodes involved o N2 - Ipsilateral mediastinal nodes or ligament involved

Upper paratracheal lower paratracheal nodes Pretracheal and retrotracheal nodes Aortic and aortic window nodes Para-aortic nodes Para-esophageal nodes Pulmonary ligament Subcarinal nodes

o N3 - contralateral mediastinal or hilar nodes involved or any scalene or supraclavicular nodes involved

Metastatic involvement o M0 - No metastases o M1 - Metastases present

Stage groupings are as follows:

IA - T1N0M0 IB - T2N0M0 IIA - T1N1M0 IIB - T2N1M0 or T3N0M0 IIIA - T1-3N2M0 or T3N1M0 IIIB - Any T4 or any N3M0 IV - Any M1

For each stage, the prognoses or estimated 5-year survival rates, in the United States are as follows:

Stage IA - 75%

Stage IB - 55%

Stage IIA - 50%

Stage IIB - 40%

Stage IIIA - 10-35% (Stage IIIA lesions have a poor prognosis, but they are technically resectable.)

Stage IIIB - 5% (Stage IIIB lesions are nonresectable.)

Stage IV - Less than 5%

137) What is most common cause of pneumomediastinum?a) alveolar ruptureb) pneumothorax

Ans: A (repeat).

168) HIV positive, asymptomatic child with multiple bilateral pulmonary nodules:a) Lymphoid Interstitial Pneumoniab) PCP

Ans: A (repeat).

203) Surfactant is given:a) to enlarge alveoli that are already ventilatedb) to open closed alveoli

Ans: A. (Repeat).

PEDS

159) Young kid with tumor in testicle, most likely:a) seminomab) yolk sac tumorc) mixed germ cell tumord) choriocarcinomae) embyronal tumor

Ans: B. This is a tricky question. The most common tumor in child for boys is a yolk sac tumor. Other tumors that occur in childhood are Sertoli and Leydig (the hormone-producing tumors). Then, the most common tumor in young men (20’s) is the Mixed Germ Cell Tumor. Finally, Seminoma is most common in older men (30’s). In old men (70’s) lymphoma is most common. Additionally, most tumors in the testicles are mixed, with a predominant component of one type or the other. Of the tumors that are NOT mixed at all, seminoma is the most common. (Woodward, AFIP notes pg 535).

MSK Recalls

156) Osteomalacia is associated with:a) pseudofractures

Ans. A (Repeat).

1. Which of the following is associated with SLAC lesion?

a) uric acid depositionb) calcium pyrophosphate depositionc) scapholunate ligament dissociation

Ans: B. CPPD (Repeat). Both b and c can result in SLAC wrist.

2. Posterior shoulder dislocation is associated with which of the following?

a) Hill Sachsb) Bankart lesionc) Lesser tuberosity fractured) SLAP lesion

Ans. C (Repeat). pure avulsions of the lesser tuberosity are rare;- presence of this frx raises possibility of assoicatted posterior dislocation.

81) young female with x-ray and calcification around shoulders and hips:a) tumoral calcificationb) myositis ossificans progressive

Ans: A. (Repeat).

3. Which is anisotropic?a) muscleb) tendonc) boned)cartilagee) ligaments

Ans: B. tendon

4. Pain with ulnar deviation, cystic lucencies in lunate, positive ulnar variance:

TFCC tearUlnar impaction

Ans: B.

5. Findings NOT associated with meniscal tear?

increased linear signal extending to surfaceglobular signal in meniscustruncated meniscusdecreased size of posterior horn medial meiscus compared to anterior horn

Ans: B. (repeat).

6. Most severe wrist dislocation?a) lunateb) midcarpalc) perilunated) rotatory scaphoid

Ans: A (Repeat). –

Stage 1 – scapholunate ligament disruptionStage 2 – capitolunate lig disrupt (perilunte dislocation)Stage 3 – lunotriqui disruption (midcarpal dislocation)Stage 4 – lunate dislocation volarly

*7. Air in which location is most likely associated with infection?a) musclesb) IV disk spacec) Public symphysisd) Glenohumeral joint

Answer:?A

8. Associated with dislocation of the long head of the biceps?a) supraspinatus tearb) infraspinatus tearc) subscapularis teard) teres minor tear

Ans: C. Torn subscap. (Repeat).

9. Associated with horizontal fractures of the superior and inferior pubic rami?a) vertical shearb) AP compressionc) Lateral compression

Ans: c. Horizontal overlapping fractures of the superior and inferior pubic rami areassociated with lateral compression (www.emedicine.com/radio/topic546.htm).

10. Best location for pathological fracture in adult?a) lesser trochanterb) greater trochanterc) ischial tuberosityd) femoral shaft

Ans: A. (Repeat).

11. Increased T2 signal in the femoral head and neck, with associated joint effusion and a crescent of decreased T2 signal in the femoral head. Most likely?

a) Transient osteoporosis of the hipb) Osteonecrosisc) Stress fracture

Ans: B. AVN is diagnosed when a peripheral band of low signal intensity is present on all imaging sequences, typically in the superior portion of the femoral head, outlining a central area of marrow. http://www.mri.jhu.edu/~dbluemke/Avascular_necrosis.html

12. T1 with fat saturation post Gd best to distinguish between:a) benign and malignant tumorsb) edema from abscessc) lipoma from fatty atrophy

Ans: B

13. Chronic foot pain, pes planus, medial malleolar periosteal reaction associated with:

a) PTT tearb) Charcot jointc) Acute trauma

Ans: A. (Repeat).

14. Persistent hip dislocation s/p total hip replacement is associated with?

a) inadequate gluteal reattachmentb) femoral component resorptionc) malpositioned acetabular componentd) ruptured capsule

Ans. C. The treatment for someone with multiple (or recurrent) dislocations is nearly always surgery, and is geared towards identifying and treating the cause of the dislocation. Common causes include:

Unsatisfactory position of the component parts of the hip replacement (either the cup or

the stem); this is by far the most common problem

Incorrect soft-tissue tension of or poor functioning of the muscles around the hip

Impingement (levering) of the thigh bone or the component in it against the pelvis

Infection

Severe soft-tissue deficiencies around the hip joint

15. Telangiectatic osteosarcoma associated with:

a) diaphyseal locationb) elderly patientc) looks like ABC

Ans: C. (Repeat).

16. Fracture of the dorsal aspect of the growth plate of the distal phalanx of the big toe is associated with:

a) osteomyelitisb) exostosisc) growth disturbance

Ans: A. (Repeat). Some prior recalls state growth disturbance, and this is one of those difficult questions, but Wheeless Orthopaedics says osteomyelitis.

17. Posterior elbow dislocation in an adult … most likely entrapped fragment?

a) coronoid process b) medial epicondylar

Ans. A. (repeat). For kids it is medial epicondylar.

18. Increased T2 signal in the posterior compartment of the forearm is associated with injury to which nerve?

a) medianb) ulnarc) radiald) interosseouse) axillary

Ans: D. Posterior Interosseous passes thru supinator muscle in its course from anterior to the posterior surface of the forearm;

30) periostitis most common when?a) one monthb) 3 monthsc) 12 monthsd) at the onset of puberty

Ans: A. Infants commonly get periostitis (in the first 6 months of life is physiological).

PERIOSTITIS IN ADULT 5Hypertrophic OsteoarthropathyFamilial PachydermoperiostitisThyroid AcropachyVenous StasisSarcoidPERIOSTITIS IN CHILD 8IdiopathicCaffey's Dz - involves mandibleHypervitaminosis AProstiglandinSyphilisLeukemiaScurvyRicketts

124) Medial patellar fracture, a) avulsion at insertion of infrapatellar tendonb) lateral patellar retinaculum injuryc) quadriceps tendon avulsion

Ans: B. (Repeat).

173) What is cause of increased diffuse uptake around femoral component?a) looseningb) infection

Ans: B (Repeat). Loosening will only extend around proximal aspect.

Which is not true?a) hypertension will give a higher flow through a stenosis than normotensive pt with same degree of stenosisb) bradycardia will give reduced flowc) contralateral ICA occlusion will give increased flow on opposite sided) proximal stenosis causes distal flow to have decreased velocity (baseline carotid velocities can be decreased by proximal stenosis at the carotid origin falsely overestimating an ica stenosis if one uses ratios.

Ans: B is false. Bradycardia can increast flow secondary to higher EF to maintain constant cardiac output.

Carotid duplexIncrease in velocity at or just distal to stenosis125-250cm/s=50-75% stenosis

>250cm/s=75-80% stenosisocclusion- unilat damped flow in CCANo flow or reversed flow prox to ICA occlusionCarotid endarterectomy more beneficial than medical therapy in sx pts with 70-99% ICA stenosis

Pitfalls in carotid US-Hypertension- higher velocitiesReduction in cardiac output- decreased sys and diastolic velocitiesAltered velocities- cardiac arrythmias, aortic valve lesions, severe cardiomyopathies, aortic balloon pumpBradycardia- increased stroke volincreased sys vel -prolonged diastolic runoffdecreased end diastolic velaortic stenosis- prolonged acceleration time, decreased peak velocity, delayed upstroke, rounded waveformobstr lesions in one carotid artery- affects vel in contralat vessel- severe unialt ICA stenosi/occlusion shunting of increased flow thru c/l system artifically increased velocities esp in areas of stenosisTandem lesionAliasing Can use PSV ICA/PSV CCA to avoid some pitfalls

GI recalls

10 ) EG- what is not associated?a) renal failureb) thymusc) lytic lesionsd) vertebral planae) pituitary

Ans: Can effect any cell of the RES A. renal failure. Can get thymic enlargement (Dahnert pg 415). See diabetes insipidus, lytic bone lesions, vertebra plana, pituitary stalk involvement.

Low density in right lower quadrant with calcifications:a) mucocele of the appendixb) pseudomyxoma peritoneic) chronic appendicitisd) teratomae) meconium peritonitis

Ans: A. (Only other thing this would be would be an aneurysm or calcified lymph node).

What is not associated with post bone marrow transplant complications:adrenal hemorrhagegraft versus host diseasehepatic veno-occlusive diseaseCMV

Ans: A. side effects include graft-vs-host disease (GvHD), graft rejection, bacterial infections, fungal infections, viral infections, gastrointestinal and hepatic complications, neurologic complications, pulmonary complications, and late effects after stem cell / bone marrow transplant.

1. Pt. with VHL has a lesion in the pancreas. What is the most likely pathology?a) microcystic adenomab) islet cell tumorc) pancreatic cystd) pancreatic adenocarcinoma

Ans: A. (Repeat). Pancreatic cyst is the most common pancreatic lesion.

2. Which of the following syndromes is most associated with malignancy?Gardner’s syndrome (colon polyps, osteomas, desmoids, hamartomas of stomach)Peutz-Jeugers (mucocutaneous pigmentations, hamartomas excluding esophagus,

no malignant potential)Menetrier’s (giant hypertrophic gastritis, achlorhydria, hypoprotenemia, edema,

10% gastric malignancy)

Ans: A. GI polyps may progress to malignancy in almost 100% of patients in Gardner’s.

3. 34 yo female with hepatosplenomegaly and RLQ pain. Liver biopsy demonstrates liver necrosis. What is the diagnosis?

a) autoimmune hepatitisb) Primary Biliary Cirrhosisc) Budd Chiarid) Ascending cholangitis

Ans. A. The chronic hepatitis associated with autoimmune hepatitis may range in severity from a subclinical illness without symptoms and with abnormal results on liver chemistries to a disabling chronic liver disease. Symptoms and physical examination findings may stem from the various extrahepatic diseases associated with autoimmune hepatitis. Common symptoms include the following:

Fatigue Upper abdominal discomfort Mild pruritus Anorexia Myalgia Diarrhea Cushingoid features Arthralgias Skin rashes (including acne) Edema Hirsutism Amenorrhea Chest pain from pleuritis Weight loss and intense pruritus (unusual)

If not treated patients die within 10 years of onset. Overlap with many other disorders is common, including Lupus/Scleroderma, Pernicious Anemia, Coombs disease, etc. http://www.emedicine.com/med/topic366.htm

4. Regarding angiodysplasia of the colon, which of the following is false?

a) Commonly see bleeding with angiography (contrast extrav is usually not seen)

b) Located on the antimesenteric borderc) Early filling vein

Ans: A is false.

The most frequent and earliest sign is that of a densely opacified, dilated, and slowly emptying draining vein within the intestinal wall. This vein is detected during the venous phase of the study and is present in more than 90% of lesions.

As the lesion progresses, a vascular tuft may become apparent during the arterial phase of the study. This is observed in as many as 70-80% of patients. It represents an extension of the dilation process to the mucosal venules.

The latest sign, an early-filling vein, may be observed in the arterial phase, indicating a more developed arteriovenous communication through the angiodysplastic lesion. It is observed in only 60-70% of cases of angiodysplasia.

5.What of the following is a function of Gastrin?

a) Incr. bicarbonate secretion of the pancreasb) Incr. polypeptide secretion of the pancreasc) Incr. gastric acid secretion.

Ans: C. (Repeat)

Hormones

regulation of exocrine pancr secretion-Gastric acid- secretin secrn pancr juice rich in water and electrolytesVIP secretin agonistCCK enzyme rich secretion from pancreasGastrin weak stim for pancr enzyme outputSomatostatin- inhibitor of pancr secretion CCK: a 33 amino acid polypeptide hormone secreted by the mucosa of the upper intestine and by the hypothalamus; it stimulates contraction of the gallbladder and secretion of pancreatic enzymes.

Secretin: secretin a strongly basic polypeptide hormone secreted by the mucosa of the duodenum and upper jejunum when acid chyme enters the intestine. It stimulates the pancreatic acinar cells to release bicarbonate and water which are excreted into the duodenum and change pH from acid to alkaline, thereby facilitating the action of digestive enzymes. leads to increased output of pancreatic juice and HCO3

Gastrin: a polypeptide horomone released from peptidergic fibers in the vagus nerve and from G cells in the pyloric glands in the gastric antrum. Stimulates secretion of gastric acid , pepsin, and weakly stimulates secretion of pancreatic enzymes and gallbladder secretion

VIP: vasoactive intestinal polypeptide: A potent stimulant of secretion of small and large bowel. Relaxes GI smooth muscle, and gall bladder, inhibitory effect on gastric acid secretion

Glucagon: a polypeptide hormone secreted by the alpha cells of the islets of Langerhans in response to hypoglycemia or to stimulation by the growth hormone of the anterior pituitary: parenteral administration of glucagons produces relaxation of the smooth muscle of the stomach, duodenum, small bowel, and colon. (PDR) no mention of esophagusDistal SB> prox SB> duo> stomach> colon

6. Which of the following are characteristics of a hemangioma?a) Able to detect flow in the lesionb) Hyperechoic, well-defined lesionc) Incr. uptake on sulfur colloid

Ans. B. (will not show flow, and will have decreased uptake on sulfur colloid).

At ultrasonography, hemangiomas appear as well-circumscribed, uniformly hyperechoic lesions. The increased echogenicity is postulated to be caused by multiple interfaces between the walls of the cavernous spaces and the blood within them (McArdle, 1978). According to Taboury et al, more than 75% of hemangiomas also have posterior acoustic enhancement that is correlated with hypervascularity at angiography. In large hemangiomas, heterogeneous areas are interspersed within the hyperechoic mass. Atypical features include hypoechoic lesions with a thin hyperechoic rim or a thick rind and scalloped borders (Vilgrain, 2000). Hemangiomas may appear hypoechoic in fatty livers (Marsh, 1989).

7. For which of the following would obtaining a CT with arterial and PV imaging be useful?

a) Metastatic transitional cell cab) HCCc) FNHd) Lymphoma

Ans: HCC. Want to show early arterial enhancement and rapid washout.

8. Most common cause of a colovesical fistulaa) Diverticulitisb) Crohn’s diseasec) Colon cad) Pelvis radiation

Ans. A. diverticulitis.

9. On CT scan, small bowel is seen protruding lateral to the rectus abdominus muscle.

a) Spigelian herniab) Richer’s hernia (one wall of the bowl enters the hernia orifice)c) Obturator herniad) Other types of hernias

Ans. A. A Spigelian hernia is an acquired ventral hernia through the linea semilunaris, the line where the sheaths of the lateral abdominal muscles fuse to form the lateral rectus sheath.

10. Asymtomatic 60 yo with a 3cm mobile mass in the distal ileum. What is the most likely diagnosis?

a) Carcinoidb) Lymphomac) Adenocarcinomad) Melanoma

Ans: B. Lymphoma (Repeat). (? Carcinoid??)

11. Pt. with nonbloody diarrhea, abd pain. UGI with SBFT shows dilated loops with increased secretions.

a) Sprueb) Yersinia infectionc) Sclerodermad) Crohn’s dz.

Ans. A. Signs of celiac disease: thickening of the primary mucosal folds, lumen dilatation, barium segmentation or flocculation, transient intussusception, prolonged transit time, thickening of duodenal mucosal folds, decreased number of duodenal mucosal folds, asymmetry of duodenal mucosal folds, contrast-agent dilution, “bubbly bulb” duodenal nodules, and reversal of the jejunoileal fold pattern.

12. Which are the following are characteristics of a hepatic hydrothorax?a) Occurs more commonly on the leftb) Can occur even with minimal ascitesc) The presence of cirrhosis is not necessary (peritoneal dialysis)

Ans: C. Can see this with continuous ambulatory peritoneal dialysis (see below).A pleural effusion noted in cirrhotic patients in the absence of primary cardiac or pulmonary disease is most likely a hepatic hydrothorax. This complication is noted in approximately 6% of cirrhotic patients and is also an infrequent complication of continuous ambulatory peritoneal dialysis.1,2 Although the effusion may be bilateral or left-sided, the majority (67%) are right-sided.1,3 Unidirectional transdiaphragmatic defects allowing peritoneopleural communication are believed to play a role in the transit of the transudative ascites into the thorax, and there is debate as to whether these communications are congenital or acquired.1,3,4 Along with the identified diaphragmatic defects, other proposed etiologies are transdiaphragmatic lymphatics and hypoalbuminemia.1

13 Least likely to be affected by ischemia.a) Rectumb) Hepatic flexurec) Splenic flexured) Cecum

Ans. A. Dual blood supply.

14. MR imaging- lesion is isointense to spleen on T1 and T2- what is it?

a) hemangiomab) adenomac) metastasesd) HCCe) FNH

Ans. C, metastases. Apparently, this is written in Primer in some chart in the back (new version). Vivian and Gary didn’t think this was a good question at ALL, and both had to look it up. If brighter than spleen think focal fatty sparing.

15. What is a characteristic on IMPT on CT?

a) diffuse pancreatic dilatationb) unilocular massc) multilocular massd) hypodense mass

Ans: A.

16. Most specific sign of acute mesenteric ischemiaa) PV gasb) Bowel wall edema (double halo sign)c) Ascitesd) Pneumoperitoneume) Occlusion of the SMA

Ans: E. Angiography is the criterion standard for diagnosis and presurgical planning and is often an important part of treatment. To promptly diagnose patients with true AMI, a low threshold for obtaining early angiography should be adopted for patients at risk. Sensitivity is reported to be 88% for AMI.

o An embolus appears as a sharp cutoff of flow near the origin of the middle colic artery. Thrombus appears as a more tapered occlusion near the origin of the SMA. NOMI is characterized by narrowing of the origins of multiple SMA branches, alternating dilation and narrowing of the intestinal branches (ie, “string of sausages” sign), spasm of the mesenteric arcades, and impaired filling of the intramural vessels.

17. Which of the following structures does not abut the caudate lobea) ligamentum teresb) Left lobec) Ligamentum venosumd) Right lobe

Ans. A

18. MRCP is good for evaluating all of the following except.a) CBD stoneb) Dilation of the biliary treec) Pancreatic divisumd) Pancreatic pseudocystse) Primary Biliary Cirrhosis (usually spare large bile ducts and may be

misses with mrcp)

Ans: E.

MRCP IndicationsCurrently, principal indications for MRCP include:

1) Screening for patients with low to intermediate probability of bile duct stones. MRCP has a 95 -100% accuracy for this application and is particularly useful in patients with suspected gallstone pancreatitis and in patients with non-specific abdominal pain and normal liver enzymes. In these cases, a normal MRCP can prevent an unnecessary diagnostic ERCP.

2) Failed or incomplete ERCP or for patients who are not ERCP candidates due to conditions

such as surgical diversion of the biliary tree.

3) Variant ductal anatomy. MRCP can effectively demonstrate anatomic variants and congenital anomalies. It may also have a role prior to laparoscopic cholecystectomy in identifying and defining variant anatomy that could complicate the surgical procedure.

4) Patients with surgically altered biliary or upper gastrointestinal anatomy in which ERCP may be difficult or impossible.

5) Primary Sclerosing Cholangitis (PSC). MRCP can show ductal irregularities, strictures and stones that characterize PSC—including the ducts' proximity to a complete obstruction—and avoids the risk of ERCP-induced sepsis.

6) Complications of chronic pancreatitis. MRCP can demonstrate ductal dilatation, strictures, intraductal stones, fistulas and pseudocysts and can serve as a planning tool prior to surgical drainage procedures.

In patients for whom the probability of therapeutic intervention is low, or in whom one of the above conditions exist, MRCP is an excellent and safe alternative to ERCP and a useful diagnostic technique. www.cpmc.org/advanced/liver/ news/newsletter/newsletter-vol6.html

88) Diabetic mom, kid:a) caudal regression syndrome

91) ERCP fills acini, what does that tell you?a) proximal obstruction of ductsb) diagnostic for IPMTc) diagnostic of chronic pancreatitisa

101) Which metastases is not typically hypervascular?a) Melanomab) Islet Cellc) Bronchogenic Carcinomad) Thyroide) Renal

c

104) What happens in Boorhave’s syndrome?a) early finding is pneumomediastinum on plain filmb) use barium to diagnosec)

a150) Which is not in anterior pararenal space?a) duodenal bulbb) fourth portion of duodenum

a (duodenum2,3,4; pancreas, ascending and descending colon)

170) Linitis plastica is most likely secondary to which of the following:a) breast cancer

171) Which is not a cause of a left sided pleural effusion?a) Meigs syndrome

False meigs syndrome is benign ovarian tumor/process, ascites, and pleural effusions

188) Child with phleboliths in skeletal muscle, lesion best defined as:a) venous malformationb) capillary hemangiomac) arterial hemangiomad)cavernous hemangioma

d

200) What is the most common cause of inherited hypercoagulability?a) Factor V Leidenb) Protein Cc) Protein S

157) True of Crohn’s disease?a) asymmetric involvement of lesions

194) Which is most specific sign of malrotation?a) inferomedial displacement of the duodeno-jejunal junction

NYU 2004 Neuro recalls

16) CT scan demonstrates focal calcifications at the junction of the optic nerve and the globe in a patient with unilateral papilledema. Which of the following is the most likely diagnosis?

a. Retinoblastomab. Choroidal osteomac. Drusend. Hemangioma with phleboliths

Answer: C (repeat)

29)A diagram of the intracerebral venous system and structures were labeled from A through E. Which is the Vein of Galen?

44) An MRI of the spine demonstrates a mass lesion which is extradural and located posterolaterally. It is similar to fluid in signal intensity and demonstrates peripheral gadolinium enhancement. This likely represents

a) extruded disc fragmentb) Tarlov cystc) Arachnoid cystd ) Synovial cyst

Answer: D (repeat)

62)70 yo male status post fall. Lateral film of cervical spine shows prevertebral soft tissue swelling and widening of C4/5 disk space anteriorly.

a. hyperflexion sprainb. hyperextension sprainc. UID

Answer: B

63)Cspine injury most associated with neurologic deficit in kids:a. Jefferson’s fxb. UIDc. Hangman’s fxd. C5 anterior teardrop (exact wording)

Answer: D

64) Hepatocerebral degeneration causes what on an MRI a. Low intensity of basal ganglia on T1b. Low intensity of basal ganglia on T2c. High intensity of basal ganglia on T1d. High intensity of basal ganglia on T2

Answer: C (repeat)

65)Although they can be isolated entities, which chromosomal abnormality has been associated with choroid plexus cysts?

a.Trisomy 21 b.Trisomy 13c.Trisomy 18

Answer: C (repeat)

67) On prenatal ultrasound, which is most commonly associated with myelomeningocele.a. hydronephrosisb. gastroschisisc. obliterated cisterna magna

Answer: C (Chiari II)

68) Most characteristic of tethered cord:a. diarrheab. recurrent UTI’sc. back paind. scoliosise. leg paralysis

Answer: D

78) Which artery is associated with Wallenberg syndrome?a) Ipsilateral PICAb) Contralateral PICAc)Superior cerebellar

Answer: A (repeat)

83) What is the most likely etiology of a lytic skull lesion with sclerotic borders?a.Venous lake.b.Epidermoid.c.Fibrous dysplasia.d.Hemangioma.

Answer: B (repeat)

97) 23 yo male brought in unconscious with Chenye Stokes breathing; CXR shows diffuse bilateral upper lobe opacities:

a. septic embolib. aspiration

c. neurogenic pulmonary edema

Answer: C

103) Woman is post partum, headache; lab studies show panhypopituitarism. MRI demonstrates pituitary mass which is low signal on T1 and homogenously contrast enhancing. Diagnosis:

a. pituitary apoplexyb. lymphocytic hypophysitis - http://www.emedicine.com/med/topic3264.htmc. Rathke’s cleft cystd. Craniopharyngioma

Answer: B

111) Ultrasound of carotid artery demonstrates slow upstroke and low systolic peak (parvus tardus waveform). This is consistent with:

a. Aortic insufficiencyb. Aortic stenosis

Answer: B (repeat)

115) Patient found unconscious, lesion in brain is hypo on T2 with bright rim, isointense on T1:

a) cavernous angiomab) hemorrhagic contusionc)herpesd)abcess

Answer: B (repeat)

121) What is associated with NF2a) Meningiomab) optic tract gliomasc)Chromosome 17d)café au lait spots

Answer: A (NF2=MISME: Multiple Inherited Schwannomas, Ependymomas and Meningiomas)

122) Acetozolamide (Diamox) is used in cerebral perfusion study to determine---a. Assessment of cerebrovascular reserveb. direction of flow

Answer: A (repeat)

125) Intraaxial mass with significant restricted diffusion and peripheral enhancement

a) abscessb) glioblastoma multiformec) chronic lacunar infarct

Answer: A. Tumors can also demonstrate restricted diffusion, but less typical.

126) MRI demonstrates area of bright signal on diffusion, low signal on ADC and normal T2 in insular cortex.

a. Herpesb. Acute infarct (minutes to hours)c. Subacute infarct (days to weeks)d. Chronic infarct (months to years)

Answer: B

127) The most medially located cranial nerve in the cavernous sinus is:a. IIb. IIIc. IVd.VI

Answer: D (repeat)

180) What part of the brain is most characteristically involved with Wernicke’s encephalopathy ?

a. Hippocampusb. Mamillary bodiesc. Caudate nucleus

Answer: B (repeat)

202) Latex allergy is associated witha) myelomeningocele

Ans: A (repeat). This is thought to happen secondary to the repeated surgeries that these kids get, with subsequent sensitization to the latex in the gloves.

205) A patient has bilateral retinoblastomas. The patient most likely has a third lesion located in a) the hypothalamusb) the anterior portion of the pituitaryc) the posterior portion of the pituitaryd) the pineal gland e) the suprasellar region

Answer: D (repeat). Note that suprasellar lesions are also common, but less so than pineal.

1)Most common location of intraventricular meningiomaa. atria of lateral ventriclesb. 4th ventriclec. posterior 3rd ventricled. frontal horns of the lateral ventricles

Answer: A (repeat)

2)Which of the following is most characteristic of neurocystercercosis?a. Seizures are a common complicationb. Females are more often affected than malesc. Associated with immunocompromised patients

Answer: A

3) Which is the 2nd most common takeoff the left vertebral artery?a. left carotidb. aorta proximal to left carotidc. aorta between left carotid and left subclaviand. aorta distal to left subclaviane. thyrocervical trunk

Answer: C.

Cardiac:

Atrial myxoma (repeating since 1989)Regarding left atrial myxoma :a) it most commonly arises from the mitral valveb) it has increased echogenicity on ultrasoundc) it can embolized) it mimics aortic stenosise) enlargement can mimic mitral valve pathology on CXR

Ans: C.

The symptoms and signs of left atrial myxomas often mimic mitral stenosis

One complication of untreated myxoma is embolization (tumor cells breaking off and traveling with the bloodstream), which can obstruct a blood vessel or plant a myxoma in another part of the body where it can cause symptoms. Myxoma fragments can embolize to the brain, eye, or limbs.

A left atrial myxoma is a benign tumor located in the left upper chamber of the heart (atrium) on the wall that separates the left chamber from the right (the atrial septum).

Characteristic findings on M-mode and 2-dimensional echocardiography of the most common primary cardiac tumor (ie, left atrial myxoma) demonstrate an echogenic mass in the left atrium during ventricular systole, which is seen prolapsing through the mitral valve during diastole (see Images 9-13).

The mass may be mobile or relatively sessile. Myxomas may demonstrate variable echogenicity and can cause atrial enlargement

Best MRI sequence to evaluate flow direction and dynamic vascular abnormalities… (or something like that).

Phase contrast MRI (Repeat): flow

Septal defect, perfusion is bya. LADb. Right coronaryc. Circumflexd. Main Left coronarye. Marginal artery

Ans: LAD supplies the (majority)septum in the majority of patients.

27) What is a branch of the Left Circumflex? a) posterolateral branchb) acute marginal c) obtuse marginal

Ans. Both obtuse and posterolateral arteries are branches of the circumflex coronary artery

2. Ulcerated aortic plaque is associated with, except…a. Increased diameter of the aortab. Intimal flapc. Increased thickness of the aortic wall

Ans: ?B I would say decreased thickness of the aortic wall

3. Type B dissection is associated with all, except:A. It is a surgical emergency (F)

4. True about endothelium:a. proliferation of muscular cells by heparan sulfate. b. Vasa vasorum in outer portion… c. Multiple layers of endothelial cellsd. Histiocytes in the adventitia producing prostaglandins?

Ans: B.

31) which is most likely to present with CHF? a) Tet

b) anomalous left coronary (ischemia leads to left ventricular dysfunction and CHF)c) absent pulmonary valve

Ans: B. didn’t give pdA as answer, which was on prior recalls.

5. Delayed Gadolinium uptake in the myocardium in MRI is related to:a. Correlates with functional prognosis after acute coronary ischemia b. Predicts response to revascularization c. Mitral valve response to surgery

a

6. What is the most common cause of left ventricular failure in a patient with COPD?A. Coronary artery diseaseB. Pulmonary hypertension

C. Reversal of Left to right shunt

Ans: A. It is important to realize that COPD does not directly cause left ventricular failure, nor is it a late complication from right ventricular failure (it is not like Eisenmenger’s disease). Left ventricular failure in a patient with COPD is due to the same risk factors that a patient without COPD has: coronary artery disease>diabetes>hypertension> valve disease. (Up-to-Date).

7. Young patient with aortic stenosis. What is the most likely association:A. Bicuspid valve.

Ans. A.

55) What is associated with cardiac valve disease?a) carcinoid

Ans: A.

56) Which plane is best to image tricuspid and mitral valves?a) coronalb) sagittalc) vertical long axisd) horizontal long axise) short axis

Ans. D Horizontal Long axis.

57) Which plane is best to measure LV function quantitatively on MR?a) coronalb) sagittalc) vertical long axis

d) horizontal long axise) short axis

Ans: E. short axis.

41) Where does thoracic duct lie in lower thorax?a) to the left of the azygousb) to the left of the IVCc) next to the diaphragmatic crural attachmentd) anterior to the heart

Ans: A. In human anatomy, the thoracic duct is an important part of the lymphatic system - it is the largest lymphatic vessel in the body. It collects most of the lymph in the body (except that from the head and right arm) and drains into the systemic (blood-) circulation. In adults, the thoracic duct typically is 38-45cm in length. It usually starts from the level of the second lumbar vertebra and extends to the neck. It originates in the abdomen from the confluence of various abdominal lymph vessels. It extends vertically in the chest and curves posterior to the left carotid artery and left jugular vein to empty into the junction of the left subclavian vein and left jugular vein, near the shoulders. It traverses the diaphragm at the aortic aperture and ascends the posterior mediastinum between the descending thoracic aorta (to its left) and the azygos vein (to its right).

8. Regarding the origin of the vertebral artery. The second most common location is: In 6% of individuals it arises from the aortic arch most commonly between the left common carotid artery and left subclavian arteries.

17) Myocardial ischemia/infarction with an aberrant left coronary artery is due toa) deoxygenated blood from the pulmonary arteriesb) steal c) spasm/intermittent flowd) small caliber of the vessele) abnormal distribution of the left coronary artery.

Answer: b (blood preferentially flows to the lower resistence pulmonary bed)

9. Aortic stenosis clinical presentation:a. Angina

10. What condition most commonly causes restrictive cardiomyopathy:a. Amyloidosisb. Sarcoidosisc. Subaortic hypertrophic stenosis.

Ans: A. The most common causes of restrictive cardiomyopathy are amyloidosis and idiopathic myocardial fibrosis (a scarring of the heart of unknown cause). It frequently occurs after a heart transplant.

Other causes of restrictive cardiomyopathy include sarcoidosis, hemochromatosis, radiation fibrosis, and various tumor infiltrations of the heart. More rarely, restrictive cardiomyopathy is caused by diseases of the endocardium (the lining of the heart) such as endomyocardial fibrosis and Loeffler's syndrome.

11. Regarding coronary calcifications: a. Absence of calcifications likely not associated with significant

atherosclerotic disease. b. Angioplasty contraindicated in calcified plaques. c.

Ans. A.

12. TAPVR I. Head of snow man. Left vertical vein.

85) Cardiac scan, delayed images are useful for what reason (MRI)?a) to determine future risk of ischemiab) to determine future risk of MIc) to calculate

89) MRI which is false statementa) chemical shift artifact is in phase encoded direction (F- occurs during frequency encoding)b) chemical shift is from in and out of phase

98) What is true about aortic dissection?a) in elderly, systemic hypertension likely etiologyb) Stanford B is operative

112) Systolic dysfunction:a) alcoholicsb) sarcoidc) amyloid

144) What is dose of Gad:a) 0.1 mmol/kgb) 1 mmol/kgc) patient with gad contrast same likihood of reaction as to iodine contrast

145) Regarding heart size in CXR, which is not true?a) related to phase of cardiac cycleb) related to kvp peakc) related to PA vs. AP technique

151) Regarding mitral valve calcifications:a) stenosis associated with annuloplasty x

152) For which of the following are the right associations together?a) AS and systolic jet

b) MI and diastolic jetc) TS and diastolic jetd) pulmonary stenosis and diastolic jet

163) Aberrant left coronary, recurrent episodes of myocardial ischemia- what is cause?a) perfusion with venous bloodb) “steal” from retrograde flow in LCA

164) 47 year old male with shortness of breath while lying on his right side, what is best initial diagnostic test?a) echocardiogramb) stress test

165) Atrial myxoma- what is true?a) CXR will show similar findings as with mitral valve diseaseb) attached to septum but will not prolapsec) most commonly arises from anterior leaflet of mitral valve

166) Regarding true aneurysms:a) usually located at cardiac apexb) are secondary to contained rupture

169) What is appropriate placement of intraaortic balloon pump:a) just distal to aortic knobb) in the mid-thoracic aorta

169) Which of the following statements is true about cardiac vessels?a) Vasa vasorum supply outer wall of vesselb) dissection is b/w the media and adventia

172) What is associated with aortic stenosis?a) anginab) enlargement of the aortic knob

190) Regarding the snowman appearance in TAPVR, what forms the head of the snowman? a) vertical veinb) duplicated SVC

192) Which is true of repair of cardiac lesions?a) graft is on low pressure side in right ventricle for VSDsb) Jantene switch operation

96) 40 year old man, new diagnosis of AS:a) bicuspid valve

b) age related ASc) IHSSd) rupture of chordae tendinae

Interventional

74) What is not an indication for TIPS?a) splenic vein thrombosis (splenectomy….splenic coils)

75) What is an established indication for TIPS?a) failed esophageal sclerotherapy of bleeding varices

34) Patient with swelling of left leg- a) May-Thurner syndrome- compression of left iliac vein by right iliac artery

28) patient with injection of thoracic aorta, get filling of left hepatic from gastroduodenal artery. What is going on?

a) cruciate ligament syndromeb) thrombus in celiacc) spasm

Ans: A (repeat)

A lung biopsy in a 35 y/o female shows alveolar hemorrhage and small vessel vasculitis:

a. Wegener’s granulomatosisb. Goodpasture’s syndromec. Idiopathic pulmonary hemosiderosisd. Needle contamination with cat feces

Ans. A.

Pt undergoes a right lung biopsy, and soon after develops hemoptysis. Your best option is to:

a. Place patient on left sideb. Place patient on right sidec. Sit patient upd. Place pt in Trendelenberge. Hold plastic bag over pt’s head until hemoptysis stops.

Ans: B.

Which is TRUE regarding TIPS:

a.should be done for prevention of bleeding varices or failed esophageal sclerotherapy.

b.Should be done for treatment of ascites in pt NOT undergoing medical tx for said ascites.

c.Should be done for DEFINITIVE tx of ascites d.Should be done for tx of hepatic encephalopathy.

Ans: A. (Repeat)

Which is FALSE regarding TIPS:

a. For treatment of gastric varices due to splenic vein thrombosis.

Failure of an AV fistula is most often due to:

a. Outflow tract stenosis b. Arterial stenosisc. Infectiond. Thrombosis

Ans: A. (Venous end stenoses- Repeat).

22.A pt gets a percutaneous gastrostomy in IR. On the CXR the next day, free air is noted under the diaphragm. Choose the best answer.

This is a normal finding in the first 24-48 hrs, and you should continue with fluids (not food) thru the PEG for a day or so.

Pt should undergo removal of the PEG and laproscopic placement of a new PEG by surgery.

Check the position of the side-holes.Place PEG to wall suction.Replace PEG with one of 1-2 French larger diameter.

Ans. A. In patients with free air after PEG placement exploratory celiotomy is not indicated in the absence of other clinical findings of peritonitis. Routine antibiotics after PEG placement is used routinely by gastroenterologists, not radiologists (e/c in kids), and no study has compared the difference in infection rate b/w the two.

Best placement for a nephrostomy tube is:a. posterior calyxb. anterior calyxc. infundibulumd. something about lateral renal cortex (????)e. corticomedullary junction

Ans: A (repeat)

If a patient is referred for nephrostomy placement in the setting of obstructing ureteral stone with pyleo/pyonephrosis:

a. you should do the procedure but warn the referring clinician that the pt’s sepsis may initially worsen.

b. Attempt to disempact the stonec. Refuse the procedure.d. Upon entering the calyx, immediately distend the renal pelvis with contrast.e. Enter the anterior calyx, thus avoiding traversing much of the renal parenchyma

with the needle (something similar to this).

Ans: A.

39) A Brescia-Cimino fistula anastomosis which vessels?a) Brachial artery to cephalic veinb) Brachial artery to basilic veinc) radial artery to basilic veind) radial artery to cephalic vein

Ans: D. This is an arteriovenous fistula for hemodialysis, consisting of a side-to-side anastomosis of the cephalic vein and radial artery.

Radiocephalic wrist fistula (Brescia-Cimino fistula):  This is the most common fistula and is created at the wrist (primary radiocephalic fistula).  A small vein (cephalic vein) and a small artery (radial artery) are joined together using very fine stitches (see below).

It is possible to create this sort of fistula in any part of the lower half of the forearm.  Above this level the muscles of the forearm become too bulky and it is better to use blood vessels around the elbow.  A particular type of wrist fistula can be created in some patients at the base of the thumb (snuffbox fistula).

Brachio-cephalic fistula: a brachio-cephalic fistula is formed at the elbow by connecting the cephalic vein and the brachial artery at the elbow.  The cephalic vein is found towards the outside of the upper arm and as it enlarges this vein can be used for dialysis.

Brachio-basilic fistula: a brachio-basilic fistula is formed at the elbow by connecting the basilic vein and the brachial artery at the elbow.  The basilic vein is found on the inside of the upper arm but it is also quite deeply placed and so it needs to be transposed (moved) to a more superficial position.  This involves extra incisions along the inside of the upper arm.

Once a brachio-basilic fistula has been formed it is more difficult to form a brachio-cephalic fistula and so surgeons will usually attempt to create a brachio-cephalic fistula first if possible.  Fortunately, if the brachio-cephalic fistula fails it is still possible to create a brachio-basilic fistula

117) Patient with hypocardia, etc after tunneling a mediport- cause?a) air embolism b) hemorrhage

131) What is false regarding angiodysplasia?a) can see bleed during angiography(NEED SCINTIGRAPHY)b) large draining veinc) usually right side

138) When doing a nephrostomy in sick patient, what is true:a) need to warn of possibility of sepsis after procedure

(sepsis may worsen, posterior calyx)

139) nephrostomy tube placement;a) use posterior calyx

207) Ankle Brachial Index; which of the following is true?a) numerator contains arm readingsb) denominator contains ankle readingsc) in patients with peripheral vascular disease, ABI decreases after exercised) with patients who have peripheral vascular disease, increases after exercisee) in patients without peripheral vascular disease, increases after exercise

ABI ….the higher… the better or at least close to 1…. therefore decreses is BAD…PVD…..worse with exercise

Ans: C. A lower ABI is worse. You want the ABI to be > 0.95 (ie, blood flow to your arms is equal to blood flow to your piggy-wiggys). The ankle-brachial index is an effective screening tool. The tools required to obtain an ankle-brachial index include a blood pressure cuff and a continuous wave Doppler. Blood pressure is measured in both upper extremities, and the highest systolic reading--the first return of Doppler sound as the cuff is deflated--is recorded. The ankle systolic pressure is similarly measured using the dorsalis pedis or posterior tibial arteries. The ankle-brachial index is calculated by dividing the ankle pressure (the higher of the posterior tibial artery pressures) by the brachial systolic pressure (the higher of the two arm pressures). An ankle-brachial index below 0.95 at rest or following exercise is considered abnormal. An ankle-brachial index between 0.8 and 0.5 is consistent with intermittent claudication, and an index of less than 0.5 indicates severe disease.11 In patients with an abnormal ankle-brachial index, testing with segmental arterial pressures and a pulse volume recording before and after exercising to the point of absolute claudication are indicated. http://www.aafp.org/afp/20000215/1027.html

110) Embolization, which is true:a) need to permanently embolize varicoceles b/c associated with infertility

113) AVM’s what is true?

a) embolize feeding artery peripherallyb) pulmonary AVM need to coil