IMAGE BASED QUESTIONS ( July 2024 ) .pdf

This presentation contains 10 image based questions , prepared for discussing with Internal Medicine residents.

All are based on Harrison's Principles of Internal Medicine.

1. IMAGE BASED QUESTIONS
JULY 2024

2. Instructions
●There are 10 image based questions in this set.

●Each question has 3 subquestions.

●The figure number in the Harrison’s Principles of Internal
Medicine 21st edition is mentioned with each image.

●Send your answers to 9496720759 /
[email protected] before August 5 , 2024

3. Fig 13-1

4. Q1 ( Fig 13-1 )

A.In the image shown , which are the nerve fibres involved in pain
transmission ?

B.When primary afferents are activated by noxious stimuli, they release
neurotransmitters from their terminals that excite the spinal cord
neurons. Which are the neurotransmitters released by the primary
afferent nociceptor terminals ?

C.Which is the major ascending pathway for pain in the spinal cord ?

5. ANSWERS
A.A delta ( Aδ ) & C fibres.
These fibers are present in nerves to the skin
and to deep somatic and visceral structures.
Some tissues, such as the cornea, are innervated
only by Aδ and C fiber afferents. Most Aδ and C
fiber afferents respond maximally to intense
(painful) stimuli and produce the subjective
experience of pain when they are activated; this
defines them as primary afferent nociceptors
(pain receptors). The ability to detect painful
stimuli is completely abolished when conduction
in Aδ and C fiber axons is blocked.
B. The major neurotransmitter
released is glutamate, which
rapidly excites the second-order
dorsal horn neurons. Primary
afferent nociceptor terminals also
release substance P and CGRP,
which produce a slower and
longer-lasting excitation of the
dorsal horn neurons.
C. Spinothalamic tract

6. Fig 90-6

7. Q2 ( Fig 90-6 )
A.The image shows ?

B.What are the common symptoms of this tumour ?

C.If a patient has this lesion bilaterally , which genetic
disorder should be considered ?

8. ANSWERS
A.Right vestibular schwannoma
( Post gadolinium MRI )
B.Vestibular schwannomas may
be found incidentally on
neuroimaging or present with
progressive unilateral hearing
loss, dizziness, tinnitus, or,
less commonly, symptoms
resulting from compression
of the brainstem and
cerebellum.
C. Neurofibromatosis type 2
The ice cream cone sign refers to
the appearance of a medium-sized
(1.5 to 3.0 cm) vestibular
schwannoma. The intracanalicular
component represents the cone
and the cerebellopontine angle
(CPA) (cisternal) component
representing the ice cream ball.

11. Fig 100-8 ( The peripheral smear of a G6PD patient experiencing
hemolysis )

12. Q3 ( Fig 100-8 )
A. What is the arrow marked structure ?

B.Which are the triggers for hemolysis in G6PD deficiency ?

C.What are the peripheral smear findings seen in G6PD
deficiency ?

13. ANSWERS
A.Bite cells
B.Fava beans , infections , drugs
C.
●Anisocytosis, Polychromasia, and Spherocytes;
●Hemighosts
●Blister cells , Bite cells
●Heinz bodies

14. The most typical feature of G6PD deficiency is the presence of bizarre
poikilocytes, with red cells that appear to have unevenly distributed
hemoglobin (“hemighosts”) and red cells that appear to have had
parts of them bitten away (“bite cells” or “blister cells”) .
A classical test, now rarely carried out, is supravital staining with
methyl violet, which, if done promptly, reveals the presence of Heinz
bodies (consisting of precipitates of denatured hemoglobin and
hemichromes), which are regarded as a signature of oxidative damage
to red cells (they are also seen with unstable hemoglobins).

16. A peripheral blood smear showing occasional hemolyzed cells (thick arrow), many blister cells
(short arrow), and a few bite cells (long arrow) (Wright–Giemsa stain)

17. Fig 270-1 B

18. Q4 ( Fig 270-1B )
A.What does this ECG show ?

B.Mention the various clinical examination findings
in this condition.

C.What is the treatment of choice ?

19. ANSWERS
A.Electrical alternans , seen in pericardial effusion

B.The three principal features of tamponade (Beck’s triad) are
hypotension, soft or absent heart sounds, and jugular venous
distention with a prominent x (early systolic) descent but an absent y
(early diastolic) descent. Additional signs of tamponade may also
include tachypnea and Pulsus Paradoxus

C.Pericardiocentesis

20. ●In a patient with cardiac tamponade ,
pericardiocentesis using an apical, parasternal,
or, most commonly, subxiphoid approach must
be carried out at once because if left untreated,
tamponade may be rapidly fatal.
●Whenever possible, this procedure should be
carried out under echocardiographic guidance.
Intravenous saline may be administered as the
patient is being readied for the procedure, but
the pericardiocentesis must not be delayed.
●If possible, intrapericardial pressure should be
measured before fluid is withdrawn, and the
pericardial cavity should be drained as
completely as possible.
●A small, multiholed catheter may be advanced
over the needle inserted into the pericardial
cavity and left in place to allow draining of the
pericardial space if fluid reaccumulates.

21. Fig 290-1

22. Q5 ( Fig 290-1)
A.What does this CT show ?

B.Which are the genetic causes of this condition ?

C.How is this condition classified ?

23. ANSWERS
A.Many severely dilated airways are seen , suggestive of
bronchiectasis

B.Cystic fibrosis, Kartagener’s syndrome, α1 antitrypsin
deficiency

C.Cylindrical ( tubular ) , Varicose , Cystic

26. Fig 301-3

27. Q6 ( Fig 301-2)
The image shows a normal alveolus (left) and the injured
alveolus in the acute phase of acute lung injury and the acute
respiratory distress syndrome (right).


A.What is the diagnostic criteria for ARDS ?

B.Mention a few clinical disorders associated with ARDS.

C.What is the structure marked by the red box in the image ?

28. ANSWERS
A.

30. Reference :

Matthay MA, Thompson BT, Ware
LB. The Berlin definition of acute
respiratory distress syndrome:
should patients receiving high-flow
nasal oxygen be included? Lancet
Respir Med. 2021
Aug;9(8):933-936. doi:
10.1016/S2213-2600(21)00105-3.
Epub 2021 Apr 27. PMID:
33915103; PMCID: PMC8075801.

31. B.
C. Hyaline membrane

32. Fig 309-3C

33. Q7 ( Fig 309-3C )

Bartter syndrome is a genetically heterogeneous autosomal recessive
disorder of salt reabsorption in the thick ascending limb of loop of Henle.
A.Which are the causative genes associated with Bartter syndrome ?

B.What are the clinical features of classic Bartter syndrome ?

C.Which gene mutation results in Bartter syndrome with sensorineural
deafness ?

34. ANSWERS
A. Currently four causative genes have been associated with Bartter
syndrome:

●NKCC2 for Bartter syndrome type 1 (BS1),
●ROMK (renal outer medullary potassium) for type 2 (BS2),
●ClCKNB, type 3 (BS3), and
●BSND for type 4 (BS4)

36. B. Classic Bartter syndrome is typically associated with mutations in CLCNKB
(BS3).
These patients present mostly in the first decade of life with vomiting,
polyuria, recurrent episodes of dehydration, and hypokalemic metabolic
alkalosis. Hypomagnesemia with renal Mg2+ wasting is common

C. β subunit of CIC-Kb , known as barttin

37. FIG 339-3 ( Compact genomic structure of Hepatitis B virus )

38. Q8 ( Fig 339-3 )
A.Which gene encodes the major envelope protein ?

B.Which gene encodes the DNA polymerase ?

C.What is the significance of HBxAg ?

39. ANSWERS
A.S gene

B.P gene

C.HBxAg is encoded by X gene. It can transactivate the
transcription of cellular and viral genes. It may contribute to
carcinogenesis by binding to p53.

40. Fig 380-2
Coronal T1-weighted post
contrast magnetic resonance
image shows a homogeneously
enhancing mass (arrowheads)
in the sella turcica and
suprasellar region compatible
with a pituitary adenoma; the
small arrows outline the carotid
arteries.

41. Q9 ( Fig 380 -2 )
A.Mention a few of the local effects of sellar mass lesions.

B.Which is the most common pituitary hormone
hypersecretion syndrome in both men and women ?

C.What are the tests to be done if you suspect Cushing’s
disease ?

42. ANSWERS
A.
Clinical manifestations of sellar lesions
vary, depending on the anatomic
location of the mass and the direction
of its extension .

The dorsal sellar diaphragm presents
the least resistance to soft tissue
expansion from the sella;
consequently, pituitary adenomas
frequently extend in a suprasellar
direction. Bony invasion may occur as
well, especially through the sellar floor
to the sphenoid sinus.

43. B. Hyperprolactinemia
C.
●24-h urinary free cortisol ( Ensure urine collection is total and
accurate )
●Dexamethasone (1 mg) at 11 p.m. and fasting plasma cortisol
measured at 8 a.m. [ Normal subjects suppress to less than 5
mcg/dL )
●Late night salivary cortisol
●ACTH assay [ Distinguishes adrenal adenoma (ACTH suppressed)
from ectopic ACTH or Cushing’s disease (ACTH normal or
elevated)]

44. Fig 449-4

45. Q10 ( Fig 449-4)
A.Which is this sign ?

B.Mention any two conditions where this is seen.

C.Mention a few examples of LGMDs

46. ANSWERS
A.Gowers sign

B.Muscular dystrophies ( Duchenne muscular dystrophy , Becker
muscular dystrophy ) , Spinal muscular atrophy

In 1879, neurologist Sir William Richard Gowers described Gowers sign
as the characteristic patterns observed in patients with Duchenne
muscular dystrophy wherein they 'climb up' their thighs with the aid of
their hands to overcome the weakness of their pelvic and proximal lower
limb muscles.

47. C. The most common types of adult-onset LGMD are
●calpainopathy (LGMD2A/LGMDR1),
●Fukutin-related protein (FKRP) deficiency (LGMD2I/LGMDR9), and
●anoctaminopathy (LGMD2L/LGMDR12).
The traditional classification of LGMD is based on autosomal dominant
(LGMD1) and autosomal recessive (LGMD2) inheritance. Superimposed on
the backbone of LGMD1 and LGMD2, the classification uses a sequential
alphabetical lettering system (LGMD1A, LGMD2A, etc.) based on genotype.

48. The limb-girdle muscular dystrophies (LGMDs)
●Males and females are affected equally
●Typical onset ranging from late in the first decade to the fourth decade.
●Typically manifest with progressive weakness of pelvic and shoulder girdle
musculature
●Respiratory insufficiency from weakness of the diaphragm may occur, as may
cardiomyopathy.
●Serum CKs are elevated, and the EMG is myopathic.
●Muscle biopsy reveal dystrophic features, but the findings are not specific to
differentiate subtypes from one another unless immunohistochemistry is
employed (e.g., immunostaining for various sarcoglycans, dysferlin,
alpha-dystroglycan, merosin) or there are features to suggest one of the
myofibrillar myopathies.
●Definitive diagnosis requires genetic testing