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Step I USMLE images

Started by Zuhal
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Zuhal

Zuhal

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

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MLT2MT2DO said:
27 y/o male just immigrated from Africa shows up with painless ulcerations on his penis that he first noticed 1 week ago. Patient was started on a course of Penicillin G but returned 10 days later when there has been no improvement of his condition.

One of the ulcers is swabbed and the slide below is what is seen in the lab.


What is the arrow pointing to?
What is the disease?
What is the cause of the disease?
Why didn't Penicillin G cure the disease?

(sorry for the Giant picture, especially those of you on phones, but it's a good one and the smaller version lacked)
Click to expand...

Going to say,after >6k questions I have never seen a question on this so I was surprised to see this in FA. Had to google this when I saw it because I'd never heard or seen it
 
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I just got this question wrong, see if you can figure it out
You're looking at an obstructed heart vessel that arises from the left coronary artery and supplies the anterior IV septum. What valvular lesion is likely to result from this occlusion?
heart01p.jpg
 
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Zuhal said:
I just got this question wrong, see if you can figure it out
You're looking at an obstructed heart vessel that arises from the left coronary artery and supplies the anterior IV septum. What valvular lesion is likely to result from this occlusion?
heart01p.jpg
Click to expand...

Ruptured Chordae Tendinae? Leading to Regurgitation?
 
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Zuhal said:
never mind. It's def not chlamydia lol
Click to expand...

the only other differential diagnosis i could think of beside syphilis is that infection where you get donovon something bodies? I forgot the name and I have no idea why penicillin wouldn't work here. I'm gonna read up on it!
 
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Zuhal said:
the only other differential diagnosis i could think of beside syphilis is that infection where you get donovon something bodies? I forgot the name and I have no idea why penicillin wouldn't work here. I'm gonna read up on it!
Click to expand...

Yeah you got the donovan body part correct. These are mentioned in rapid review, and it was the first I'd ever heard of them
 
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Zuhal said:
Good job. Only 23% got the right answer so that's something 😎
Click to expand...

To be honest without a murmur or anything I would have probably been just as likely to pick aortic valve, it would have probably been like a 60:40 split in my head (MV vs AV) where I woulda second guessed myself and picked aortic valve
 
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MLT2MT2DO said:
To be honest without a murmur or anything I would have probably been just as likely to pick aortic valve, it would have probably been like a 60:40 split in my head (MV vs AV) where I woulda second guessed myself and picked aortic valve
Click to expand...

I hear ya and that's exactly what I picked! but FA2012 pg. 285 says that MR often happens due to ischemic heart disease...
 
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MLT2MT2DO said:
To be honest without a murmur or anything I would have probably been just as likely to pick aortic valve, it would have probably been like a 60:40 split in my head (MV vs AV) where I woulda second guessed myself and picked aortic valve
Click to expand...

Same here... that's why I only wrote regurg....although I remember goljan saying this in his audio
 
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Jamiu22 said:
It looks like the wall of the vessls may have been thickened... so I'm guessing maybe mitral stenosis?
Click to expand...

You guys are on a roll today :clap:

Follow up question: Same pt returns to your clinic complaining of weakness and numbness in her R arm. What could have caused this?
 
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Zuhal said:
You guys are on a roll today :clap:

Follow up question: Same pt returns to your clinic complaining of weakness and numbness in her R arm. What could have caused this?
Click to expand...

this could be way off... but I'm thinking due to the slower blood movement in the left atrium, the patient is predisposed to clots that would travel to the brain... causing MCA occlusion / stroke - could present like this - don't know how likely that is though.
 
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SLC said:
Wouldn't it be ruptured papillary muscle?
Click to expand...

My thinking was that you could rupture both and it's primarily through ischemia... but the tendinae was more susceptible since its thinner (but I could be wrong here since I don't know where I got this specific info from).... anyone else wanna chime in?

EDIT: I just looked it up... and I found an article that says it's more likely papillary muscles - oh the details I got to remember....

http://circ.ahajournals.org/content/23/1/42.full.pdf

AMONG THE LESIONS responsible for insufficiency of the mitral valve is rupture of the chordae tendineae. It is our purpose to describe the significant clinical and pathologic findings in 20 cases of insufficiency of the mitral valve due to rupture of the chordae tendineae. This report is based on those cases in which ruptured mitral chordae tendineae were found at necropsy at the Mayo Clinic during the years 1934 to 1958 inclusive. The important etiologic factors claimed for rupture of the mitral chordae tendineae are bacterial endocarditis,15 rheumatic valvular disease,6 7 and trauma.8 9 Cases have been encountered, however, in which conclusive evidence of these conditions has not been demonstrated. In those cases in which evidence for a specific etiologic factor is lacking, so-called spontaneous rupture10' 11 must be considered. Though myocardial infarction is the prominent cause of mitral insufficiency due to ruptured papillary muscles,12' 13 it has not been demonstrated to be of importance in rupture
of the chordae tendineae
Click to expand...
 
Last edited:
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Jamiu22 said:
My thinking was that you could rupture both and it's primarily through ischemia... but the tendinae was more susceptible since its thinner (but I could be wrong here since I don't know where I got this specific info from).... anyone else wanna chime in?
Click to expand...

You could be right, I've only ever heard of ruptured papillary muscle. But I'm a little less than average in the intelligence dept.
 
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Jamiu22 said:
this could be way off... but I'm thinking due to the slower blood movement in the left atrium, the patient is predisposed to clots that would travel to the brain... causing MCA occlusion / stroke - could present like this - don't know how likely that is though.
Click to expand...

Well the fact they have stenosis leads me to think it's due to some form of endocarditis (plus it looks like there's something else besides muscle in the histo slide).
 
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MLT2MT2DO said:
27 y/o male just immigrated from Africa shows up with painless ulcerations on his penis that he first noticed 1 week ago. Patient was started on a course of Penicillin G but returned 10 days later when there has been no improvement of his condition.

One of the ulcers is swabbed and the slide below is what is seen in the lab.



What is the arrow pointing to?
What is the disease?
What is the cause of the disease?
Why didn't Penicillin G cure the disease?

(sorry for the Giant picture, especially those of you on phones, but it's a good one and the smaller version lacked)
Click to expand...

As Zuhal pointed out this is a donavan body (really gj)
Disease is Granuloma inguinale
Caused by Klebsiella Granulomatis
Penicillin G doesn't work due to the shear size of it, outside of the neiserra species it is ineffective against Gram Negatives

This is probably not in the HY category but someone thought it important enough to put it into FA rapid review (donovan bodies)

MLT2MT2DO said:
Since it's vWF what else could be used to treat this? Straight from UW (I'm pretty sure, at very least 1 of my 4 qbanks).
Click to expand...

I know we all use UW but there is a solid chance I didn't get this question from UW but a less well known bank.
Estrogen can also be used in vWF deficiency as it causes an increase in endothelial cell turnover causing more vWF to be released
 
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Jamiu22 said:
this could be way off... but I'm thinking due to the slower blood movement in the left atrium, the patient is predisposed to clots that would travel to the brain... causing MCA occlusion / stroke - could present like this - don't know how likely that is though.
Click to expand...

Good job!
Patient with chronic RHF:
Mitral stenosis---> Left Atrial dialation--> Stais---> Mural thrombus--> Stroke
Mitral stenosis---> Left atrial dialation--> blood backs up to pulmonary vessels--> increase in Hydorstatic pressure in pulmonary vessels---> transudate--> Edema+ Heart failure cells.
 
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MLT2MT2DO said:
As Zuhal pointed out this is a donavan body (really gj)
Disease is Granuloma inguinale
Caused by Klebsiella Granulomatis
Penicillin G doesn't work due to the shear size of it, outside of the neiserra species it is ineffective against Gram Negatives

This is probably not in the HY category but someone thought it important enough to put it into FA rapid review (donovan bodies)



I know we all use UW but there is a solid chance I didn't get this question from UW but a less well known bank.
Estrogen can also be used in vWF deficiency as it causes an increase in endothelial cell turnover causing more vWF to be released
Click to expand...

Thank you for this!
 
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MLT2MT2DO said:
Well the fact they have stenosis leads me to think it's due to some form of endocarditis
Click to expand...

That's a good point actually but I don't think it would cause stroke. Yesterday I had a question (either Uworld or Kaplan, can't remember) where they described an IVDA+ dyspnea/fatigue and a "murmur" and then they told you that he had "ring enhancing lesions" on CT. They wanted to know the organism responsible for the CT findings. At first I thought it had to be Staph but then I changed my mind because up until yesterday, I didn't think you could have that with endocarditis so I changed my answer to Toxo.

Wrong.

Turns out that vegetaitons (due to staph/strep v./psudo/candida etc) can fly off into the blood stream and eventually the brain and show up as 'ring enhancing lesions'

I thought that was really cool!
 
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A 32 year old woman gives birth to a child with ambiguous genitalia:

013_01_13_fig_01.jpg


The infant is hypotensive. Lab values are as follows:

Renin (High)
Aldosterone (Low)
DHEA (High)
Testosterone (Low)
Pregnenolone (High)

Most likely diagnosis?
 
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SLC said:
A 32 year old woman gives birth to a child with ambiguous genitalia:

013_01_13_fig_01.jpg


The infant is hypotensive. Lab values are as follows:

Renin (High)
Aldosterone (Low)
DHEA (High)
Testosterone (Low)
Pregnenolone (High)

Most likely diagnosis?
Click to expand...

Congenital Adrenal Hyperplasia - wait I take that back...it's the 3-beta hydroxylase or something (i initially thought 21-alpha watever, but that didn't add up with your lab values)
 
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Zuhal said:
That's a good point actually but I don't think it would cause stroke. Yesterday I had a question (either Uworld or Kaplan, can't remember) where they described an IVDA+ dyspnea/fatigue and a "murmur" and then they told you that he had "ring enhancing lesions" on CT. They wanted to know the organism responsible for the CT findings. At first I thought it had to be Staph but then I changed my mind because up until yesterday, I didn't think you could have that with endocarditis so I changed my answer to Toxo.

Wrong.

Turns out that vegetaitons (due to staph/strep v./psudo/candida etc) can fly off into the blood stream and eventually the brain and show up as 'ring enhancing lesions'

I thought that was really cool!
Click to expand...

How are you to know the IVDA didn't get HIV from a needle stick and it wasn't toxo? That sounds like a BS question if you ask me
 
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MLT2MT2DO said:
How are you to know the IVDA didn't get HIV from a needle stick and it wasn't toxo? That sounds like a BS question if you ask me
Click to expand...

True but toxo doesn't develop until the CD4 count drops below 200 I believe so it is a late complication and I think they mentioned that he had no other problems/was on no other meds
 
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Zuhal said:
Good one! I wonder if this is the same thing as de la chapelle?
Click to expand...

I've never heard of de la chapelle syndrome...... I just looked it up on wiki...

XX male syndrome (also called de la Chapelle syndrome ,for a researcher who characterized it in 1972[1]) is a rare sex chromosomal disorder. Usually it is caused by unequal crossing over between X and Y chromosomes during meiosis in the father, which results in the X chromosome containing the normally-male SRY gene. When this X combines with a normal X from the mother during fertilization, the result is an XX male.
Click to expand...
 
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Zuhal said:
Good one! I wonder if this is the same thing as de la chapelle?
Click to expand...

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
 
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