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Transcript of 18 - aim4aiims.in · C. Pseudopterygium secondary to chemical burn 5. Identify the refractive...
Ans. 1. (a) Hyper secreting Adenoma
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RADIOLOGY
1. What is the most probable diagnosis of the given investigation?
Thyroid cartilage
Sternal Notch
Right
a. Hyper secreting Adenoma b. Graves diseasec. Aberrant thyroid d. Papillary Carcinoma
Ref: Essentials of Nuclear Medicine Imaging, 6th Edition
The given image is of Thyroid ScanThyroid Scan
• Functional Scan• Agent used – Tc-99m Pertechnetate• Dose - 3--5 mCi
Patterns of Thyroid Scan1. Normal Scan –
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2. Mutli-nodular Goiter
3. Hypersecreting Adenoma
217RADIOLOGY
Ans. 2. (a) Pulmonary venous hypertension
4. Cold nodule
2. Which of the following is not a finding in the given chest X-ray?
a. Pulmonary venous hypertensionb. Narrow vascular pediclec. Decreased pulmonary blood flowd. Right atrial enlargement
Ref: Chest X-ray Made Easy, Pg – 108
Findings in the given CXR – • Narrow vascular pedicles
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Ans. 3. (c) Renal Angiomyolipoma
• Cardiomegaly• Hyperlucent lung fields• Oligaemic lung fields
The above given findings are suggestive of Pulmonary Arterial HypertensionNote :Pulmonary Venous Hypertension is suggested by Plethoric lung fields with prominent hilar vessels.
3. A 50 year old banker female underwent a routine workup for insurance purposes. The USG showed complex exophytic mass in her kidney. A CT Scan abdomen was done to further evaluate the mass as given below. Which of the following is the most probable diagnosis?
a. Parapelvic Cystb. Renal Cell Carcinomac. Renal Angiomyolipomad. Renal Cyst
Ref :Genitourinary Imaging By Satomi Kawamoto, Katarzyna J. Macura; P – 108• Renal angiomyolipomas (AMLs) are a type of benign renal neoplasm and are
composed of vascular, smooth muscle and fat elements.• Angiomyolipomas are often found incidentally when the kidneys are imaged for
other reasons, or as part of screening.• Angiomyolipomas are members of the perivascular epithelioid cells tumour group
(PEComas) and are composed of variable amounts of three components; blood vessels (-angio), plump spindle cells (-myo) and adipose tissue (-lipo).
219RADIOLOGY
Ans. 4. (c) Toxic megacolon
• Radiologic Findings –◊Mostly small lesions <5 cm in diameter◊Many have a large exophytic component (25%)◊Calcifications not common (6%)◊Plain film findings ◊Mass of fat lucency is lesion is large enough◊CT findings Well-marginated, cortical-based, heterogeneous tumor predominantly of
fat density (<-20 HU)Variable enhancement (smooth muscle, vessels)
4. A patient presented to the emergency department with fever and pain abdomen. He had a history of diarrhea with fever and pain abdomen. There was associated prolonged history of diarrhea and abdominal distension on examination was present. An X-ray abdomen was performed which is given below. Which of the following is the most probable diagnosis?
a. Volvulus b. Intestinal perforationc. Toxic megacolon d. Pneumatosisintestinalis
Ref :Fundamentals of Diagnostic Radiology - Page 678; Schwartz Principles of Surgery 10th Ed; P-1197
The given case is of Toxic Megacolon which is evident by a presentation of acute abdominal pain associated with fever and a past history of diarrhea for several months along with the given radiograph showing dilated entire colon with loss of haustrations
www.aim4aiims.in 220with increased diameter.Toxic Megacolon
• Toxic megacolon is the clinical term for an acute toxic colitis with dilatation of the colon.
• The dilatation can be either total or segmental.• The affected area of bowel loses all tone and contractility.• The patient will have progressive abdominal distension, significant discomfort
and fever.NOTE:Perforation – X-ray will show gas under the diaphragm.
Pneumatosis intestinalis – X-ray will show gas within the bowel wall.
Ans. 1. (b) PDR
10OPTHALMOLOGY
1.Which of the given disease correctly corresponds to the given fluoresceinangiography image:
a. NPDR b. PDRc. Familial dominant drusen d. Birdshot retinopathy
Explanation:This picture shows Fundus Fluorescein Angiography (FFA) of a patients.
Features seen in this picture are
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73OPTHALMOLOGY
Ans. 2. (c) Staphyloma
a. Diffuse leak along superior arcade ( red circle) suggestive of NVEb. Multiple CNP (capillary non perfusion ) areas (yellow circle) c. Multiple pin pointed leaks ( green circle) suggestive of dot and blot hemorrhage
Above all findings suggestive of PDRIn NPDR, there will be no diffuse leak as circled in red circle.
PathologicPatternsofFluorescence
Pattern Cause Example Appearance on an-giogram
Hyper fluorescence Leakage AMD (CNVM)Neovascular tissueCSCR
Hyperfluorescence in-crease with time (both intensity of dye and size of lesion)
Staining Scar
Scleral show
Amount of dye visible increasesSize of lesion stays constant
Pooling Pigment epithelial defectTumor
Dye accumulating in a fluid-filled space (well-defined border, elevation o clinical exam)
Window defect Loss of RPERPE tear Drusen
Normal fluorescence of choroid accentuated (most apparent early, fades late)
Hypo fluorescence Blockage BloodPigmentFibrous tissue
Fluorescence of dye blocked by opaque medium
Nonperfusion Vascular occlusion
Coloboma
Vessels do not fill properly Absence of tissue/vessels
AMD, age-related macular degeneration; CNVM, chorodial neovascular membrane; CSCR, central serous chorioretinopathy; RPE, retinal pigment epithelium.
2.Themost likelycauseofbulgingofcornea inapatientofacutecongestiveglaucomais?a. Keratoconus b. Descemetocelec. Staphyloma d. Decreased corneal thickness
www.aim4aiims.in74Explanation:A staphyloma is an abnormal protrusion of the uveal tissue through a weak point in the eyeball. The protrusion is generalily black in colour, due to the inner layers of the eye. It occurs due to weakening of outer layer of eye (cornea or sclera) by an inflammatory or degenerative condition. It may be of 5 types, depending on the location on the eyeball (bulbus oculi). ANTERIOR (corneal) staphyloma In the anterior segment of the eye, involving the cornea and the nearby sclera. It is an ectasia of pseudocornea ( the scar formed from organised exudates and fibrous tissue covered with epithelium) which results after sloughing of cornea with iris plastered behind, it is known as anterior staphyloma. INTERCALARY staphyloma It is the name given to the localised bulge in limbal area, lined by the root of the iris. It results due to ectasia of weak scar tissue formed at the limbus, following healing of a perforating injury or a peripheral corneal ulcer. There may be associated secondary angle closure glaucoma, may cause progression of the bulge if not treated. Defective vision occurs due to marked corneal astigmatism. Treatment consists of localised staphylectomy under heavy doses of oral steroids. CILIARY Staphyloma As the name implies, it is the bulge of weak sclera lined by ciliary body, which occurs about 2–3 mm away from the limbus. Its common causes are thinning of sclera following perforating injury, scleritis & absolute glaucoma. it is part of anterior staphyloma EQUATORIAL staphyloma On the equator of the eye (region circumferencing the largest diameter orthogonal to the visual axis). Its causes are scleritis & degeneration of sclera in pathological myopia. It occurs more commonly in the regions of sclera which are perforated by vortex veins. POSTERIOR staphyloma Posterior staphyloma beneath the optic disc (right eye) In the posterior segment of the eye, typically diagnosed at the region of the macula, deforming the eye in a way that the eye-length is extended associated with myopia (nearsightedness). It is diagnosed by ophthalmoscopy, which shows an area of retinal excavation in the region of the staphyloma.
Ciliary
Anterior
Intercalary
Equatorial
Posterior
lens
75OPTHALMOLOGY
Ans.3.(d)Intraocularantibniotic
3.Apatient onpost opday 5 after cataract surgerydeveloped the followingcomplication.Treatmentincludea/e:
a. Pars plana vitrectomy b. Topical antibioticc. Intravenous antibiotic d. Intraocular antibiotic
Explanation:Signs present in this picture are,
• Diffuse congestion• Corneal edema• Hypopyon
All this signs along with recent history of cataract surgery suggestive of endophthalmitis
EndophthalmitisIt is an inflammation of the internal layers of the eye resulting from intraocular colonization of infectious agents and manifesting with an exudation into vitreous cavity.It can be exogenous or endogenous.ClassificationPost surgical endophthalmitis
a. Fulminant (<4 days) • Gram negative bacteria• Streptococci• Staphylococcus Aureus
b. Acute (5-7 days)• Staph. Epidermidis• Coagulase negative cocci
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1. Delayed entry• Bleb related
2. Delayed onset• P. acne• Fungi• Staph epidermidis
Symptoms and signs in endophthalmitis• Pain• Rapid diminution of vision • Absent fundus glow• Anterior chamber reaction• Pupillary membrane• Hypopyon
ConfirmationofdiagnosisAll unexpected inflammatory response following intraocular surgery should be considered endophthalmitis unless proven otherwise.
Treatment Three most important determinant in outcome following endophthalmitis are-
a. Duration b. Virulence and loadc. Pharmacokinetics and spectrum of activity1. ANTIMICROBIAL THERAPY
a. Intravitreal antibiotics in post-surgical endophthalmitisb. Intravenous antibiotics in post-surgical bacterial endophthalmitis found to be
poor intraocular penetration.c. Topical and subconjunctival antibiotic can be considered
2. ANTI-INFLAMMATORY THERAPY: ROLE OF CORTICOSTEROIDS3. PARS PLANA VITRECTOMY
Close differential of endophthalmitis in a post surgical patient is TASS (Toxic Anterior Segment Syndrome)
77OPTHALMOLOGY
Ans.4.(a)Pterygium
TASS ENDOPHTHALMITISTiming The day after sx, 12-48 hrs Usually >2 day after surgery,
commonly 4-7 daysMild to moderate pain More pain (25% no pain)
Discharge Watery PurulentLid edema No Yes
Conjunctival chemosis
No Yes
Corneal edema Limbus to limbus Localized or segmental
4. Identify the given pathology:
a. Pterygium b. Pinguiculac. Chemical injury d. Fibrodysplasia
Explanation:PINGECULA
A
A. Pinguecula B. Pinguecula with calci�cation
B
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Ans. 5. (a) Myopia
C. Pinguculitis
C
PTERYGIUM
A. Pterygium showing cap, head and body B. Stockers line in pterygium
C. Pseudopterygium secondary to chemical burn 5. Identify the refractive error:
a. Myopia b. Hypermetropia c. Compound astigmatism d. Mixed astigmatism
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79OPTHALMOLOGYExplanation:
Myopia corrected by minus lens Hyperopia correct by plus lens
(A) Simple hyperopic astigmatism; (B), (E) simple myopic astigmatism; (C) compound hyperopic astigmatism; (D) compound myopic astigmatism; (E) mixed astigmatism
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Ans. 6. (b) Myasthenia Gravis
6.ApatientpresentedwithdroopingofrightuppereyelidasshowninimageA.ThepatientwasgivenacertaindrugafterwhichtheconditionimprovedasshowninimageB.Whichofthefollowingisthepossiblediagnosis?
BeforeDrug AfterDrug
a. Tolosa-Hunt syndrome b. Myasthenia gravisc. Trigeminal neuralgia d. Multiple sclerosis
Explanation:
The image shows the Tensilon test used for the diagnosis of Myasthenia Gravis. The Tensilon test is used to diagnose Myasthenia Gravis. Patients positive for the disease should show an improvement in muscular strength following administration of Tensilon - Edrophonium - IV. Edrophonium is a very short acting Anticholinesterase and therefore increases the effective amount of acetylcholine at the neuromuscular junction in patients with Myasthenia Gravis.
Pathogenesis of Myasthenia Gravis
Axon
Mitochondria
Vesicle
A Normal
Nerve
terminal
Muscle
AChE
AChR
B MG
THE NEUROMUSCULAR JUNCTION
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81OPTHALMOLOGYImportant points in myasthenia gravis
1. Most sensitive test: EMG (decremental response)
2. Most specific test: Antibody against Ach Esterase antibody
3. Treatment of Myasthenic crisis: Plasmapheresis and IVIG
4. Indications for thymectomy in MG
a. Anti < 15 years and > 55 years
b. Anti MuSK positive
c. Generalized MG
OssermanclassificationofMyastheniaGravis(MG)
● Occular MG ● Generalized MG
● Bullbar weakness ● Respiratory weakness/ crisis