USMLE images

[Zuhal]

68 yo male patient presents to your clinic with postprandial pain. X-ray below, whats the dx?

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[Jamiu22]

I think this is would be a problem with the adrenal, while de la chappelle would a problem in the actual sex differentiation. An XX male because one of the Xs has the SRY fragment and they have no MIF so theres no inhibition of development of the mullerian structures

Dude you know this crap... just straight of the dome? that's impressive

 

[addo]

Dude you know this crap... just straight of the dome? that's impressive

lol thanks, just been reviewing....

 

[SLC]

Good one! I wonder if this is the same thing as de la chapelle?

Nope, De-la-Chapelle is a situation where there's abnormal crossing-over between X and Y chromosomes, generating a sperm with an X chomosome that also contains the SRY-gene.

This is a congenital mutation of the 3-beta-hydroxysteroid dehydrogenase enzyme, which leads to a deficiency in all the end-products of normal adrenal steroid biosynthesis.

In the diagram from FA, it takes out all but the top row. Leaving DHEA present, which being a weak androgen, virilizes female fetuses, but undervirilizes male fetuses.

You end up with phenotypically similar babies either way. They sorta meet in the middle with respect to the mechanism for ambiguous genitalia development.

I thought it was a cool mutation...

 

[Zuhal]

Interesting, thank you!

 

[Suncrusher]

will this patient most likely have:

a) diarrhea
b) elevated ESR
c) anemia
d) musculoskeletal pathologies
e) infertility

 

[SLC]

will this patient most likely have:

a) diarrhea
b) elevated ESR
c) anemia
d) musculoskeletal pathologies
e) infertility

Musculoskeletal Pathologies. Pancoast's Tumor, can get at the brachial plexus.

 

[Jamiu22]

will this patient most likely have:

a) diarrhea
b) elevated ESR
c) anemia
d) musculoskeletal pathologies
e) infertility

D... musculoskeletal pathologies... it's too close to the brachial plexus

 

[Suncrusher]

Musculoskeletal Pathologies. Pancoast Tumor.

good. which nerve is most common

 

[Jamiu22]

good. which nerve is most common

That'd be anything on the bottom - lower trunk - ulnar nerve?

 

[JP2740]

esr?

edited: ****

 

[Suncrusher]

That'd be anything on the bottom - lower trunk - ulnar nerve?

heehee I don't actually know. I chose that too so I'm hoping someone here can confirm that ulnar is correct

 

[SLC]

That'd be anything on the bottom - lower trunk - ulnar nerve?

Yup, this.

Also Horners syndrome, from invasion of the superior sympathetic chain

 

[Jamiu22]

heehee I don't actually know. I chose "numbness of 5th digit" on my step so I'm hoping someone here can confirm that ulnar is correct

sounds right to me!..

On a real though, good luck tomorrow.

 

[addo]

Dx?

 

[SLC]

Dx?

Volvulus

 

[addo]

Volvulus

which side?

 

[SLC]

which side?

Right.

 

[addo]

Right.

left- sigmoid volvulus.... or the patient might have ingested a giant coffee bean

 

[JP2740]

pregnancy

 

[SLC]

left- sigmoid volvulus.... or the patient might have ingested a giant coffee bean

Thanks, yeah I can see it's coming from the sigmoid region. But I am (or at least was) unfamiliar with the convention for describing them (GI was last year and haven't hit it in FA yet). I assumed right since it's occupying most of the right upper abdomen.

Now I know, thanks to this question.

 

[Jamiu22]

Dx?

How would you differentiate this from Hirshprungs (below)?

management of hirshprung.... looks painful

 

[addo]

How would you differentiate this from Hirshprungs?

coffee bean sign

 

[Jamiu22]

coffee bean sign

crap, i thought you were jokin earlier... it is a coffee bean sign.

 

[SLC]

How would you differentiate this from Hirshprungs?

Biopsy would be diagnostic (Hirschsprung has absent inntervation, causing backup). It would also present shortly after birth.

It would also be more like megacolon due to impaction rather than volvulus I'd think.

I think of volvulus as a twisting off of a loop of bowell.

 

[addo]

crap, i thought you were jokin earlier... it is a coffee bean sign.

lol yea its like a perfect coffee bean outline

 

[Jamiu22]

Biopsy would be diagnostic (Hirschsprung has absent inntervation, causing backup). It would also present shortly after birth.

It would also be more like megacolon due to impaction rather than volvulus I'd think.

I think of volvulus as a twisting off of a loop of bowell.

cool thanks for the reminder!

 

[tiedyeddog]

management of hirshprung.... looks painful

dude, exactly what in the **** is going on here? Are they removing segments of rectal canal and distal colon.... intra-anusly..?

why is the gapping hole at 1 mo. a good thing? They can poop now but they are totally incontinent?! why not just do a colostomy?

 

[SLC]

dude, exactly what in the **** is going on here? Are they removing segments of rectal canal and distal colon.... intra-anusly..?

why is the gapping hole at 1 mo. a good thing? They can poop now but they are totally incontinent?! why not just do a colostomy?

I gotta think the anus and rectum are spared, and that it will heal up well in the long run.

But those are some pretty intense photographs!

 

[sharklasers]

That'd be anything on the bottom - lower trunk - ulnar nerve?

yeah this is correct, i have it written into my first aid, presumably from uworld, that it would mess with the lower trunk!

 

[JP2740]

i want to post more but all the pics have the names in the link lol

 

[addo]

i want to post more but all the pics have the names in the link lol

upload them to tinypic or some other image site

 

[loveoforganic2]

It's amazing how much book knowledge I've obtained for studying for this test but when used in a practical setting I'm just as likely to diagnose Lyme disease for Endocarditis for SJS for Crohn's if someone doesn't tell me what I'm looking at in words. Good job USMLE

Our tests were 50% images for path (w/thousands of images over the semester), and it still didn't cover what a lot of the buzz word stuff looks like / descriptions of how buzz word things actually manifest. I think UW has done a really good job of filling that info in, and hopefully the NBME's will round it out

 

[addo]

what are we looking at and what is it associated with?

 

[loveoforganic2]

porcelain GB, chronic cystitis?

 

[addo]

porcelain GB, chronic cystitis?

too easy? yea youre right! and as a side note, there was thought to be a strong association between gallbladder cancer and porcelain ballbladder, but as it turns out the association is not that significant.

 

[JP2740]

swallowed pouch. intestinal obstruction

 

[addo]

swallowed pouch. intestinal obstruction

yea dont swallow your change pouch

 

[loveoforganic2]

yea dont swallow your change pouch

 

[tiedyeddog]

lol

 

[tiedyeddog]

alright, I have a good one.

30 y/o man, recently traveled to south-east asia within the last year where he remembers riding elephants and swimming in local lakes. has a hx of upper right quadrant pain and now presents with noted enlarged liver and spleen along with abdominal fluid wave on abdominal palpation.

Here is a liver biopsy. dx?

 

[SLC]

33 yo female presents with "a lump in my throat"

ROS positive for: weight loss, increased appetite, and diarrhea.
PE: DTR's 3+ in upper and lower extremities, skin is warm and moist. A mass is palated in her neck lateral to the right and left of the cricoid cartilage.

Biopsy of the mass is performed and is shown in the attached image.

What is the most likely diagnosis?

Edit, wait for the image, I have to resize it...

 

[JP2740]

alright, I have a good one.

30 y/o man, recently traveled to south-east asia within the last year where he remembers riding elephants and swimming in local lakes. has a hx of upper right quadrant pain and now presents with noted enlarged liver and spleen along with abdominal fluid wave on abdominal palpation.

Here is a liver biopsy. dx?

shistomosomaoa mansoni, is that the portal triad?

 

[JP2740]

33 yo female presents with "a lump in my throat"

ROS positive for: weight loss, increased appetite, and diarrhea.
PE: DTR's 3+ in upper and lower extremities, skin is warm and moist. A mass is palated in her neck lateral to the right and left of the cricoid cartilage.

Biopsy of the mass is performed and is shown in the attached image.

What is the most likely diagnosis?

Edit, wait for the image, I have to resize it...

grave's disease. nvm lol answered w/o pic

 

[SLC]

grave's disease

Try again...

 

[tiedyeddog]

shistomosomaoa mansoni, is that the portal triad?

damn, that was fast.

apparently, it can be S. Japanoicum or S. Masoni. UW said this is pipestem fibrosis and is pathonomonic for it?

edit: I dunno if that's the triad or not, your guess is as good as mine (naw, yours is probably better)

 

[JP2740]

damn, that was fast.

apparently, it can be S. Japanoicum or S. Masoni. UW said this is pipestem fibrosis and is pathonomonic for it?

All I know from FA was that masoni causes portal hypertension, which i got from the symptoms. from the pic I saw that the triad area was messed up (I think it's the portal area lol) and thats the only organism i associate w/ portal problems

 

[addo]

33 yo female presents with "a lump in my throat"

ROS positive for: weight loss, increased appetite, and diarrhea.
PE: DTR's 3+ in upper and lower extremities, skin is warm and moist. A mass is palated in her neck lateral to the right and left of the cricoid cartilage.

Biopsy of the mass is performed and is shown in the attached image.

What is the most likely diagnosis?

Edit, wait for the image, I have to resize it...

im going to guess cancer... and since shes hyperthyroid it must be follicular thyroid cancer

 

[SLC]

im going to guess cancer... and since shes hyperthyroid it must be follicular

That's not it either, though the cells shown in the image can become malignant.

I've made this one super tough; I couldn't answer it if I didn't write it...

 

[addo]

That's not it either, though the cells shown in the image can become malignant.

I've made this one super tough; I couldn't answer it if I didn't write it...

sorry, I wikied follicular cell thyroid carcinoma and theres apparently a hurthle cell variant showing the exact same cytology...

 

[SLC]

sorry, I wikied follicular cell thyroid carcinoma and theres apparently a hurthle cell variant showing the exact same cytology...

Well then my attempt to make this tough, just made it a convoluted and poor question...

But now you're on the right track...