I am done Guys! - drmaxdias

[ArchivalUser]

yes, TOF.

[ArchivalUser]

I agree with lymphoma.

pt. under immunosuppressive agents can have complication called PTLD (Posttransplant Lymphoproliferative Disease)

But I am not sure if it is the most common or not.

( http://www.emedicine.com/med/topic3506.htm )

[ArchivalUser]

drmaxdias, i just need help. my exam is coming up, and i have to choose between reading the kaplan notes or doing the kaplan qbank. which do you think would be more helpful?

thanx.. and gudluck, wishing u a great score!!

[ArchivalUser]

Have a great score!!!

[ArchivalUser]

This is excellent stuff drmaxidas n others who substantiated his questions..........

This shows how our preparation should be.......

drmaxi...one more question...what according to u is better?reading kaplan material 5 to 7 times
or

reading kaplan material 2 to 3 times n do UW n Q bank many times???

I Wish u good luck for a good score.

[ArchivalUser]

ABS: ( Pla. Accreta or abruption??...)
The developing embryo sits within two cavities: the amnion and the chorion. As development occurs, the amnion presses against the extracoelomic space, eventually obliterating it and bringing the amnion up to and supported by the chorion. This phenomenon occurs on or about the 12th week of gestation. Incomplete obliteration of the extracoelomic space renders the amnion fragile and subject to spontaneous or traumatic rupture. After the rupture, a transient oligohydramnios occurs due to extravasation of amniotic fluid. Until the chorion adjusts to the permeability, the developing fetus has very little room in which to move. This may contribute to the severity of clubfeet deformities seen with ABS.
This decrease in space also allows the resultant floating amniotic bands to easily ensnare a developing body part. Early in gestation, the encircling bands may result in spontaneous abortions. If the constriction occurs after development is nearly complete, only fissures, acrosyndactylization, and/or intrauterine amputation are noted on the extremities as typical manifestations. If the amniotic bands are swallowed while still partially attached to the placenta, the tether may lead to bizarre facial clefts and palate deficiencies.

[ArchivalUser]

drmaxdias, about the amniotic band syndrome Q, were there choices like "Disruption" ?

I think I saw the ABS in Robbins textbook and they say something like 'ABS is the example of disruption'.

Just wanted to check~

Thanks...

[ArchivalUser]

drafted the thing for myself..just posting if some one seeing the thread new will have all things in a place...hope it helps atleast a few


some crazy Pathophys questions like

1)mechanism of cough in Sarcoidosis (alveolar inflammation v. increased pulmonary pressure; I chose the latter)
for sarcoidosis...the mech of cough shud be airway inflammation....pul HTN is late in course

Pulmonary function in sarcoidosis characteristically reveal a restrictive pattern with a reduction in the diffusing capacity for carbon monoxide, although it is not unusual for lung function to be normal Endobronchial sarcoidosis may lead to impairment of airflow and obstructive respiratory physiology.

2) mechanism causing agranulocytosis with PTU (destruction v. inactivation of precursors of CFUs; again I chose the latter one).
for PTU induced neutropenia....i think it wud be destruction...as other SE are also immune mediated..rash hepatitis...and it resolves by stopping the drug
A couple of questions on
3)study designs; in kids (newborns - 18 years), use of NSAIDS v. Opiods in Pain Management (they had asked about the defect in study design; I picked it is difficult to measure pain in kids; other options were assessment difficulties; not enough comparisons in drugs; and low sample size [it was 300]). I do not know the answer to this question, and the two written above. Therefore, kindly contribute.
agree upon the pain study design q...

4)One another study where they asked about single v. double contrast enemas in ruling out colon cancers, and all the subjects were FOBT positive, with sample size in thousands. The defect I picked; there are no controls in here (other option that was close was the absence of a confirmatory study, but the former looked better to me)

5)one question asked about the therapy one gives in Turner's (the picture of turner's described with small breasts, small uterus, infertility). Estrogen replacement, and GH were not in the choices. I could zero in on to Danazol v. GRH agonists, and I picked the former.
, GnRH is used to prepare the uterus environemnt for the donated egg.... it is a weird question though..
i think both wont help...was there any anabolic steroids in the option coz that can be used alongwith GH for stimulating growth.... gnrh wont help even with egg donation as ovary non functional.....1st 8-10 weeks need a funtional ovary with progesterone..

for the turner's syndrome treatment q (Danazol v. GRH agonists), nomal rx includes estrogen and growth hormone. Danazol is angrogen analog so I am not very positive it should be the answer. GRH agonist maybe correct when treating infertility problem along with donated egg.

I think if we have reviewed Goljan Pathology for Step 1 through his notes, and audios; we stand fair for the Pathophys in the examination.

Also, do Asthma classification, Milestones, and Tanner stages really well.

6)There was a question where distinction b/w Flail Chest, and Ruptured Bronchus was to be made. The key I think was crepitus, and air in the tissues, mentioned in the question stem. Although paradoxical breathing was also mentioned, it rules more in favour of Ruptured Bronchus
ruptured bronchus....subcut empysema

hey guys in flail chest cutaneous emphyesma may be present and he is having paradoxical breathing the hall mark sign of flail chest
Well, I checked Kaplan notes bondjamesbond, and it specifically mentions subcutaneous emphysema with Ruptured Bronchus; not Flail Chest.

...i do agree with your argument.....this is what u get in step 2...I did mention it in my exam experience....there will be 2 answers in most of the q....and depending on the q u have to choose most appropriate answer....when drmaxdias has choosen ruptured bronchus....he must have read few more things suggestive of it.....subcut emphysema is very highly suggestive of tracheobronchial injury....although agreed that flail chest u get paradoxical movement....u can never reach to a conclusion unless u read the whole q....I would be inclined to choose ruptured bronchus
The Flail chest question, paradoxical breathing is very confirmatory. Often it will also have crepitus over the fracture site so it does not necessiate the Ruptured Bronchus dx


7)A question about phobias in which we can zero in on two options; CBT v. Dialectical Behavioral Therapy; I picked the former one


8)another question was about pain when the person lies on his right side; and options included Paget's, and Trochanteric bursitis amongst others. These were the two reasonable ones to be picked.
probably troch bursitis....patient avoids the inflammed side

9)another weird one was a teenage boy with a medial femoral condyle swelling, and groin LNs. They had asked about first step in management; options included X-ray of the joint; MRI; LN FNA amongst others. Can you picture this?
I do not remember about the time of presentation of the child with medical femoral condyle swelling.

...possibly infection..depends on duration....MRI if presented early...x-ray if late...
MRI if late >2weeks, X ray if <2 weeks (could be osteomyelitis from local infection).

The boy, with medica femoral condyle swelling, and LNs in the groin question, it sounds like osteomyelitis, if the pt presents in one weeks, MRI or bone scan is the choice due to their high sensitivity. X-ray will pick up the changes after 2-3 weeks.

10)One question where a guy marries a Hep C positive person, and uses condoms consistently; they had asked about what else can he do to save himself from the disease (relevant ones were nothing else v. hepatitis B vaccine). I picked the former. Kindly discuss this one as well Sir! I am not sure of this one.
Agree on Hepatitis C; what about the medial condyle swelling question?

they said that what else he must do that he does not have Hepatitis C. One of the options was to do nothing else, so I picked that.

˜HCV negative persons with ongoing risk factors require counseling concerning ways to reduce their risk for infection, referral to substance abuse treatment if appropriate, and immunization with hepatitis A and hepatitis B vaccines™
It is from CDC website so it should be pretty convincing

For hepatitis Qs, do they ask how to save the pt from Hep C or Hepatitis in general? Do you remember the other options?


11)question in where the new born had not urinated since birth, and there was a midline abdominal mass; the closest option I could see was Posterior Urethral Valve, so I picked it. Wilms was also one option. I do not know if I am correct on this one.
midline abdo mass is a full bladder i presume


12)Also, an Alzheimer setting, wherein the patient presents with incontinence. Residual volume is less than 100 ml, and it is NOT brought on by coughing, or other causes of increased intraabdominal pressure. They asked the pathophys here. I picked Detrusor Atony. Comments on this please.

Dementia produces incontinence through several mechanisms. Frontal lobe damage can make a patient indifferent to the need for continence. Parietal and occipital lobe damage will diminish the person™s capacity to recognize bathroom features, e.g., the shape of the toilet or sink, and frontal/parietal damage will reduce the patient™s ability to manage the mechanics of disrobing, sitting, and using the toilet. Damage to deep cortical structures, i.e., the insula cortex may diminish the patient™s ability to interpret internal sensations of bladder distention, i.e., the sense of a full bladder.
As the brain damage done by Alzheimer's progresses, a confused person can forget to go to the bathroom, or he may not remember what to do once he gets there.


Retinal lesions, and hyperdensity on CT in a newborn (Congenital Toxoplasmosis?)

13)Stress fracture treatment (rest, and repeat in 2 weeks v. short-leg cast?)
For stress fracture, I think should be rest and ice , pain reliever first . If more severe cases, do splint or cast.
FOR THE Stress fracture treatment (rest, and repeat in 2 weeks v. short-leg cast?) question,
where this stress fracture is located to?

For most of the stress frature, rest is the only treatment to completely heal a stress fracture.
(drmaxdias, I am sorry.... but maybe that is an experimental q)
it was a stress fracture of the most common bones otherwise involved (I think one amonst the metatarsals, or the tibia maybe).
short leg cast just treat the stress fractures man no wait


14)A newborn with torticollis (is facial asymmetry the right option for long-term complication?)

15)3 cm dentate line growth with bleeding in HIV patient (Surgical resection of rectum and anus v. wide excision of the mass?)
3 cm dentate line growth with bleeding in HIV patient (Surgical resection of rectum and anus v. wide excision of the mass?),

Was the cancer above the dentate line 3 cm??? if so the LN drainage will rationalize the wide excision of the mass....

if below the line, yes, local resection is sufficient...

The lesion was 3 cm in size; ON THE DENTATE LINE. Therefore, that makes it < 7cm from the ANAL VERGE. That is why I picked Surgical Excision. Although, we have bondjamesbond with the Nigro regimen. That makes us ponder on the answer again.

extension of the mass can be assesed first of all local radiotherapy and chemotherapy (nigro protocol ) then surgery shd be done because radiotherapy will reduce the size of tha mass



16)Appendicits in pregnancy (CT v. Paracentesis?)
wud go with lap for appendix...but one thing to keep in mind is that most radiological investigations are relative contraindications in preg.. not absolute and risk benefit scenario decides their use..
ct in eqivocal case of appendicitis

17)Carpal tunnel in pregnancy (I think I picked the wrong one for this :-( It should have been splints; I picked local steroid injections!)

18)No response to vaccine; recurrent bacterial infections
(this is B cell def. right?)

19) It had pain on 30 degrees flexion and extension, with medial joint line involvement (sounds like meniscal tear; right?)

20)retinal lesion and hyperdensities on ct
if hyperdensities are periventricular then cmv and if only intracranial word is used then can be toxo,both of these can be others factors will also leads to some conclusion

agreed with above....toxo...short period of cast....facial asymmetry....splint for carpal tunnel

21)febrile transfusion reaction
; I picked leukocyte-depleted packed RBCs (other close one was irradiated blood products).

22)one weird question; they asked about AS, and said what must be true for it to be referred to as immune-mediated:

A. HLA B27 positivity
B. Decreased CRP
C. Decreased Acute Phase Reactants
It could be A..(HLA B27 for reactive arthritis including cardiac involvement)

23)about the question on Contraction bands, and absent limbs in the fetus.
I got that one as well; I think I picked Placenta Accreta for this one.
contraction bands absent limbs will be amniotic band syndrome....

just looked up ABS-
amniotic....its not genetic mostly:)
it occurs due to traumatic rupture of one side of amnion thus unilat limb defects... though can be seen with oligo...as amniotic membrane more likely to rupture..
so i think accreta may be rt....

myometric distortion shud lead to it....its also assoc with oligohydramnios due to renal agenesis and also a genetic component...

ABS: ( Pla. Accreta or abruption??...)
The developing embryo sits within two cavities: the amnion and the chorion. As development occurs, the amnion presses against the extracoelomic space, eventually obliterating it and bringing the amnion up to and supported by the chorion. This phenomenon occurs on or about the 12th week of gestation. Incomplete obliteration of the extracoelomic space renders the amnion fragile and subject to spontaneous or traumatic rupture. After the rupture, a transient oligohydramnios occurs due to extravasation of amniotic fluid. Until the chorion adjusts to the permeability, the developing fetus has very little room in which to move. This may contribute to the severity of clubfeet deformities seen with ABS.
This decrease in space also allows the resultant floating amniotic bands to easily ensnare a developing body part. Early in gestation, the encircling bands may result in spontaneous abortions. If the constriction occurs after development is nearly complete, only fissures, acrosyndactylization, and/or intrauterine amputation are noted on the extremities as typical manifestations. If the amniotic bands are swallowed while still partially attached to the placenta, the tether may lead to bizarre facial clefts and palate deficiencies

24)One question where in the blood was backing off from the vertebral artery, as well as the subclavian artery (as in the patient presented with claudication symptoms on exercise of the left limb, and pressures were significantly reduced in the left limb compared to the right).
I picked the answer where they mentioned the common origin of the two is affected. One another option was anomalous origin, but that did not fit into the picture.

It was not Subclavian Steal Syndrome; no Hx of lightheadedness with exercise.
no basilar insuff means...just post verterbal origin of subclavian a . atheroma....


whats the ans for HIV anal ca?

26)An elderly with AS (but grade 1 murmur, not at all compensated), and he had postural hypotension; had to choose b/w splanchnic pooling (common cause of postural hypotension in elderly) v. AS.
I picked the former, as the AS was too premature to have caused syncope. When AS causes syncope, it means we need to change the valve. Right guys?

27)One another question was why is postural hypotension so common in the Geriatric Population. I picked decreased baroreceptor reflex.

They are big on Geriatric Medicine guys!

28)There was a patient on tacrolimus, azathioprine, and cyclosporine I guess, and they had asked the risk of cancer development, as in what cancer is he liable to develop. The only relevant option was Lymphoma. I just corroborated this info from Google too.

most likly it is skin cancer. It is very well know about one third organ transplant pt under immunosuppressive therapy develop skin cancer within 10-20 years....

But I do not know whether that is in your options.... lymphoma may be the next one in the line...
pt. under immunosuppressive agents can have complication called PTLD (Posttransplant Lymphoproliferative Disease)

But I am not sure if it is the most common or not.

( http://www.emedicine.com/med/topic3506.htm )


29)One question where a man presents with abdominal pain; we find a mass in the adrenals I guess. Then, he has never had any history of any abnormalities with blood pressure, nor are his labs deranged. They asked us the next step;

I do not remember the other options (I do not think reassurance was an option; I have fainting evidence about follow-up in few weeks; not sure). Anyways, the options I do remember are serum (not urine) metanephrine levels, and PET scanning. I picked the latter one, as I believe we use that to decipher whether the lesion is autonomous, and secretes endogenous substances. Comments please!

did get EKGs; did not require them actually to make a diagnosis. There were 3-4 of them. Yes, I did read FA, and it did help me in a few questions.

30)One question where in the mammogram was negative, but the mass was suspicious (firm; non-tender). I do not remember the age, but we still biopsy it. So that is what I picked.
. mammogram has about 10-20% false negative rates and it is one of the big reasons why many pts sued their ob/gyn doctors after discovering CA with a normal mammogram... further work up is requird for a mass with negative mammogram....

31)One another question where in there was an adnexal mass in a postmenopausal woman, I think with a hyperechogenic focus, and/or a septation. So next step shall be USG guided-biopsy; I picked that.
adnexal mass in a postmenopausal woman question, you are correct. you have to rule out ovarian ca via biopsy i dont think we do USG guided percutaneous biopsy for ovarian masses.....we do laparoscopy or explaratory lap and do a biopsy and immd frozen section.....though they might not have been in the options
I think both Laparotomy, and Laparoscopy were in the choices. But aren't we to make a diagnosis first?

for the ovarian mass question, please see reference here at Mayo Clinic...

http://www.mayoclinic.org/adnexal-tumors/diagnosis.html

Biospy could be done with fine needle aspiration under U/S guidance..
the diagnosis is made in the OR drmaxdias....with the histopathologist there examining the frozen section right there and letting them know the diagnosis.....im not sure what to pick though betn laparoscopic or laprotomy..will go with laparoscopic visualization and biopsy

sorry, found another one here . I think Ronaldo is correct. we use laproscopy to biopsy of ovarian mass..

Biopsy and staging
Ovarian cancer is diagnosed by taking a sample of the tumor (biopsy). The tumor material is examined by a pathologist, a physician who specializes in diagnosing diseases by looking at the cells under a microscope. There are several ways to collect a biopsy of an ovarian mass.


"Laparoscopy is the usual first step in confirming the presence of a mass and obtaining a tissue sample for biopsy. Laparoscopic surgery uses small incisions and specially designed instruments to enter the abdomen or pelvis. (This type of operation is widely used to remove the gallbladder.)


If the mass is small, it may be possible to remove the entire mass during laparoscopy. Usually, the surgeon removes the entire ovary.


If the mass is larger that 2.75 inches (complex mass) or 3.5 inches (solid mass) on ultrasound, removal will probably be through conventional surgery. This procedure, called exploratory laparotomy, involves making a larger incision in the skin and abdominal muscles to gain access to the pelvic region.

" http://www.emedicinehealth.com/ovarian_cancer/page5_em.htm

The adnexal mas on postmenopausal woman, need to be ruled out ovarion CA by U/S and biopsy

32)One question where in a young man has multiple sexual partners; uses condoms consistently; and does not use a seat belt. We had to decide b/w advising him seat belt advice or HIV testing. I picked latter.

33)One question where I think the patient was post LSCS; 4 weeks; there was abdominal pain; it was not Endometritis, or other inflammatory cause cause there was no fever (98.6 F). There were two
shotty Lymph Nodes. I picked Incisional Seroma as the answer. The rest did not fit.

Questions on Pathophys;
34) Pathophys of septic shock (CO was increased; PCWP normal; MVO2 was not given, but it was septic shock indeed).I think they asked about Pathophys of hypoxia in here. Is there a backup of blood to the lungs also in septic shock, due to increased venous return, and increased volume?

, the tissue hypoxia is due to cytokines induced vasodilation and endothelial damage, which then leads to both hypoperfusion of the tissue and also capillary leak (which inhibits the O2 diffusion..)
I think increased venous return is the answer as peripheral BVs are dilated and blood goes back to the heart at a faster rate..
; I agree with increased venous return; but I do not think that kind of an explanation was there in the options.

35)One was a hypertensive patient with hypertension, now presenting with new S3, bibasilar rales, and pedal edema; I think the answer to this one was decreased ventricular compliance.

36)A question where in a 42 y/o comes for a health maintenance after 4 years; he has had no problems thus far; cholesterol exam at last visit was 180 mg/dl. I think that was total cholesterol. So now we had to suggest him some tests;
I picked non-fasting total cholesterol levels. Other significant option was Pneumococcal vaccine, but that is not indicated.

the total cholesterol screening test, you do fasting lipid profile study (which includes LDL, VLDL, TG, and et al). There is a similar q in both kaplan qbank and UW.
That total cholesterol was done at his last visit; so I guess we got to repeat it. Remember for men > 35 years, we have to do it annually. This guy is coming after 4 years. And the fasting tests were not an option there.
fasting levels only done if high non fasting TC and/or if multiple risk factors present when risk stratification done.....even if fasting was an option it wud be the wrong one

. I did not see that the last test was done four years ago...probably he was advised for some conservative rx at the time such as life style changes...so now yeah we do another total cholesterol screening test....



37)Ok, one question with ST depression; V3-V6 I think. They asked about the next step.
I do not remember if coronary angiography was there. We do not do Echo for sure; I picked cardiac enzymes (Troponin is done for ischemia, and infarction, and is ordered in acute coronary syndromes). That was my rationale. Comments!

for ST elevation, for further dx, yes, you need to order cardiac enzyme profile after abnormal findings in EKG. but for ST depression, you may not see anything abnormal in enzyme profile... angiography and echo are not indicated at this moment...I do not know, hard to tell before seeing the complete q. setting...

The scenario was that of an ischemic acute coronary episode; ST depression in V3-V6, and they asked for the next best step, and the options included no treatment.

rest often leads to a reversal and is not a sign of infarction
it may be caused by hypokalaemia or endocardia hypoperfusion... I do not see the role of cardiac enzyme profile here, unless the pain persists after rest and sublingual nitraglycerol...and EKG now shows more prominent changes...

ST depression-> need to do Cardiac enzyme to rule out Subendocardiol infraction.


if non responsive and persistent pain even on giving NTG then wud be NSTEMI/USA......enzymes wud be ordered if no rx option


the ovarian mass one. Anyways, did you check on ABS, and Placenta Accreta? And how about that left subclavian, and left vertebral question. Could you reach some conclusion there?

38)One matching set to choose b/w TOF, and TAPVR I guess. One stem had cyanosis comes, and goes since birth, and giving O2 does not improve symptoms. The other stem had severe cyanosis from birth, and pulmonary fields prominent. I think the first one is TOF, and the latter TAPVR.

Did you read that immunosuppressive therapy question? You guys agree with lymphoma?

39)Another one where in there was an alcohol consumer; previous biopsy showed hepatitis without cirrhosis, and this time, it showed the labs as PT 12 seconds INR 1, and Albumin of 4; liver enzymes were elevated in hundreds, not thousands (and AST > ALT). They asked what if the patient is asked to stop alcohol now.
There were options saying that there shall be progression to cirrhosis, and one said reversal. I picked the latter, as his synthetic symptoms are still preserved. This is Alcoholic Fatty Liver I guess, when it is reversible.

Yes, agree with risk of lymphoma. For other Q, I pick the Flail Chest instead of Ruptured Bronchus .
Agree with: Alcoholic hepatitis is reversible if the patient stops drinking, but it usually takes months to resolve.

[ArchivalUser]

Thanks for the inputs hope08; quansar; jeanbaptiste

Thanks for the wishes pinaymd; usmleshka; coool. I really appreciate it! My suggestions shall be not to spend time on things one already knows. Spend time on newer concepts, and then, consolidate prior to examination.

nautilus, your compilation is excellent!

Guys, I agree skin cancers are the most common cancers in immunosuppression. They weren't in the options though! Regards!

[ArchivalUser]

nautilus, thanks for great summary.

4)One another study where they asked about single v. double contrast enemas in ruling out colon cancers, and all the subjects were FOBT positive, with sample size in thousands. The defect I picked; there are no controls in here (other option that was close was the absence of a confirmatory study, but the former looked better to me).

I think answer is absence of a confirmatory study. we need colonoscopy with biopsy or surgery with pathology to confirm if samples are cancer positive or not. there is control (single vs double) there. so this is not defect.