USG

USG

Q. 1

To detect a 4 mm nodule in the pancreas, the investigation of your choice would be?

 A

PET scan

 B

Endoscopic USG

 C

CECT

 D

MRI

Q. 1

To detect a 4 mm nodule in the pancreas, the investigation of your choice would be?

 A

PET scan

 B

Endoscopic USG

 C

CECT

 D

MRI

Ans. B

Explanation:

In detection and staging of small tumors EUS (Endoscopic ultrasound) is reliable.

EUS is used in the detection of tumors smaller than 2 cm.

EUS has a high sensitivity and specificity for pancreatic cancer, with an overall staging accuracy higher than 80%.

The possibility of performing EUS-guided FNA significantly improves both diagnostic and staging capability of EUS

Contrast enhanced CT is generally accepted as first line of investigation for suspected pancreatic cancer.

MRI appears to be more valuable for staging the extent and spread of pancreatic carcinoma than for tumor detection of lesions smaller than 2 cm.

PET scan is usually reserved, to confirm malignancy, to differentiate between carcinoma and a focal nodular pancreatitis and to recognize distant metastasis. In general, the sensitivity of PET is high in the detection of lesions more than a centimeter in diameter.


Q. 2

USG examination of an 8 weeks pregnant female shows a gestational sac with absent fetal parts. The diagnosis is:

 A

Ectopic pregnancy

 B

Missed abortion

 C

Threatened abortion

 D

Blighted ovum

Q. 2

USG examination of an 8 weeks pregnant female shows a gestational sac with absent fetal parts. The diagnosis is:

 A

Ectopic pregnancy

 B

Missed abortion

 C

Threatened abortion

 D

Blighted ovum

Ans. D

Explanation:

Anembryonic pregnancy (previously called blighted ovum) is an ultrasound diagnosis. It is a pregnancy in which the embryo fails to develop or is resorbed after loss of viability. On ultrasound, an empty gestational sac, smaller mean gestational sac diameter, absent fetal echoes and absent fecal cardiac movements is seen. Clinical presentation is similar to that of a missed or threatened abortion: Mild pain or bleeding may be present; however, the cervix is closed, and the nonviable pregnancy is retained in the uterus.

Ref: Textbook of Obstetrics D C Dutta, 6th edition, Page 162.


Q. 3

Basanti, a 28yrs aged female with a history of 6 weeks of amenorrhea presents with pain in abdomen; USG shows fluid in pouch of douglas. Aspiration yields dark colour blood that fails to clot. Most probable diagnosis is:

 A

Ruptured ovarian cyst

 B

Ruptured ectopic pregnancy

 C

Red degeneration of fibroid

 D

Pelvic abscess

Q. 3

Basanti, a 28yrs aged female with a history of 6 weeks of amenorrhea presents with pain in abdomen; USG shows fluid in pouch of douglas. Aspiration yields dark colour blood that fails to clot. Most probable diagnosis is:

 A

Ruptured ovarian cyst

 B

Ruptured ectopic pregnancy

 C

Red degeneration of fibroid

 D

Pelvic abscess

Ans. B

Explanation:

Aspiration of blood clots or dark coloured blood that fails to clot, signifies collection of intraperitonial blood.

Pain in abdomen and blood in pouch of doglas in a woman of child bearing age (28yrs) with history of 6 weeks amenorrhea suggests a diagnosis of ruptured ectopic pregnancy.

 
Ref: Ultrasound in Obstetrics and Gynecology, Volume 1 By Eberhard Merz, F. Bahlmann, 2004, Page 73 ; Management of Common Problems in Obstetrics and Gynecology Edited By T. Murphy Goodwin, Martin N. Montoro, Laila Muderspach, Richard Paulson, Subir Roy, 2010, Page 275 ; Textbook of Obstetrics By D.C.Dutta, 5th Edition, Page 197

Q. 4

Young lady presents with acute abdominal pain and history of 1 1/2 months amenorrhoea. On USG examination there is collection of fluid in the pouch of douglas and empty gestational sac. Diagnosis is:

 A

Ectopic pregnancy

 B

Pelvic hematocele

 C

Threatened abortion

 D

Twisted ovarian cyst

Q. 4

Young lady presents with acute abdominal pain and history of 1 1/2 months amenorrhoea. On USG examination there is collection of fluid in the pouch of douglas and empty gestational sac. Diagnosis is:

 A

Ectopic pregnancy

 B

Pelvic hematocele

 C

Threatened abortion

 D

Twisted ovarian cyst

Ans. A

Explanation:

With sonographic absence of a uterine pregnancy, a positive assay for beta-hCG, fluid in the cul-de-sac, and an abnormal pelvic mass, ectopic pregnancy is almost certain.
 
Without early diagnosis, the natural history of “classical” cases is characterized by variably delayed menstruation followed by slight vaginal bleeding or spotting.

With rupture, there is usually severe lower abdominal and pelvic pain that is frequently described as sharp, stabbing, or tearing.  

There is tenderness during abdominal palpation, and bimanual pelvic examination, especially cervical motion, causes exquisite pain.
 
Ref: Leveno K.J., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 10. Ectopic Pregnancy. In K.J. Leveno, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.

 


Q. 5

USG sign of fetal death :

 A

‘Halo’ sign ol head

 B

Heart beat absent

 C

Spalding sign

 D

b and c both

Q. 5

USG sign of fetal death :

 A

‘Halo’ sign ol head

 B

Heart beat absent

 C

Spalding sign

 D

b and c both

Ans. D

Explanation:

Ans. is b and c i.e. Heart beat absent; and Spalding sign

  • Intrauterine fetal death is death of the fetus in utero after the period of viability (after 28 weeks in developing countries and 20 weeks in developed countries or when fetus weighs more than 500 gms).

IUD can be diagnosed clinically by

  • The size of the uterus less than the period of gestation.
  • Liquor decreased.
  • FHS absent.
  • Fetal movements abscent.
  • Egg-shell crackling feel of the fetal head (late feature).

Ultrasound : Earliest diagnosis is possible by USG.

Diagnostic features :

  • Absence of fetal cardiac activity on ultrasound scan (diagnostic).
  • Decreased liquor amnii.
  • Spalding’s sign i.e., overlapping of fetal skull bones due to shrinkage of cerebrum after fetal death.

Radiology :

  • Roberts sign : Presence of gas in the fetal large vessels(earliest sign-seen 12 hours after fetal death).
  • Ball sign : Crumpled up spine of the fetus or hyperflexion of the spine.
  • Spalding’s sign: Overlapping of fetal skull bones seen due to shrinkage of cerebrum after death of fetus. Crowding of the ribs shadow with loss of normal parallelism.

Note: Spalding sign is seen both on USG and radiology.


Q. 6

Contrasts used in USG:

 A

Urograffin

 B

Ultragraffin

 C

Sonavist

 D

Conray

Q. 6

Contrasts used in USG:

 A

Urograffin

 B

Ultragraffin

 C

Sonavist

 D

Conray

Ans. C

Explanation:

C i.e. Sonavist

Ultrasound contrast agents (UCAs)

It consists of microbubbles filled with air or gases, which acts as echo – enhancer by increasing acoustic impedence at the interface b/w gas & blood.

The ideal USCA, should have:no biological effect with repeat doses.

low : attenuation, blood gas solubility & diffusivity. high : echogenicity & ability to pass through pulmonary circulation.


Q. 7

USG is sensitive in

 A

Ureteric colic

 B

Gall stone

 C

Blunt abdominal trauma

 D

b and c

Q. 7

USG is sensitive in

 A

Ureteric colic

 B

Gall stone

 C

Blunt abdominal trauma

 D

b and c

Ans. D

Explanation:

B, C i.e. (Gall Stone), (Blunt abdominal trauma)


Q. 8

Piezoelectric crystals are made use of that is safe from radiation also:

 A

MRI

 B

US

 C

CT

 D

All

Q. 8

Piezoelectric crystals are made use of that is safe from radiation also:

 A

MRI

 B

US

 C

CT

 D

All

Ans. B

Explanation:

B i.e. US

Type of USG

USG frequency

– Trans abdominal USG for

3-5 MHzQ

obstetric purpose

5- 7.5 MHzQ

– Trans vaginal USG for

obstetric purpose

 

– USG for breast

15 MHz

– Endoscopic USG for gutwall

7.5 – 20 MHz

– To image vessel wall via

20 MHz

– cathater

 


Q. 9

A new born presents with congestive heart failure resistant to treatment, on examination has bulging anterior fontanelle with a bruit on auscultation. Transfontanellar USG shows a hypoechoic midline mass with dilated lateral ventricles. Most likely diagnosis is

 A

Encephalocele

 B

Medulloblastoma

 C

Arachnid cyst

 D

Vein of Galen malformation

Q. 9

A new born presents with congestive heart failure resistant to treatment, on examination has bulging anterior fontanelle with a bruit on auscultation. Transfontanellar USG shows a hypoechoic midline mass with dilated lateral ventricles. Most likely diagnosis is

 A

Encephalocele

 B

Medulloblastoma

 C

Arachnid cyst

 D

Vein of Galen malformation

Ans. D

Explanation:

D i.e. Vein of Galen malformation

Midline hypoechoic mass with dilated lateral ventricles (on USG), bruit on auscultation, hydrocephalus and high output cardiac failure in neonates/ infantsQ is diagnostic of vein of galen malformation.


Q. 10

All correlates with USG findings of congenital pyloric stenosis except:

 A

> 95% accuracy

 B

Segment length >16mm

 C

Thickness >4mm

 D

High gastric residues

Q. 10

All correlates with USG findings of congenital pyloric stenosis except:

 A

> 95% accuracy

 B

Segment length >16mm

 C

Thickness >4mm

 D

High gastric residues

Ans. D

Explanation:

D i.e. High gastric residues

Ultrasonography is the investigation of choice to confirm diagnose of hypertrophic pyloric stenosis with accuracy > 95% (approching almost 100%)Q. USG visualizes thickened and elongated pyloric canalQ. USG criteria for diagnosis include >16 mm pyloric length and >4mm pyloric muscle wall thicknessQ. Gastric residues are low b/o recurrent emesisQ.

The hypertrophied muscle project into gastric antrum. There is a constant assocaition with hyperplasia of antral mucosa.

It is a common developmental condition (3 in 1000 live births), affecting boys more than girls (M:F = 4/5 :1)Q. There is a familial predisposition.

Affected infant usually presents between 2-6 weeks of age, with projectile non bilious vomiting (D/D include pylorospasm, hiatus hernia & preampullary duodenal stenosis). HPS is never seen beyond 3 months of age except in premature infants in whom enteral feeding has been started late.

– Despite the recurrent vomiting, child has a voracious appetite that leads to cycle of feeding & vomiting that invariably results in severe dehydration, hypochloremic­hypokalemic metabolic alkalosis with eventual decrease in urine PH

Diagnosis can be made clinically on the basis of history and palpation of an olive mass in the subhepatic region (right upper quadrant) and presence of visible gastric (antral peristaltic) wavesQ.

Diagnosis of the HPS can be established (confirmed) by either USG (method of choice)Q or barium study.

Pyloric signs include

  1. String sign, is passing of thin barium streak through narrowed & elongated pyloric canal. It is most specific sign.
  2. Pyloric canal is almost always curved upward posteriorly
  3. Double/triple track sign or double string sign is produced by barium caught between crowded mucosal folds in pyloric canal overlying the hypertrophied muscle & parallel lines may be seen.
  4. Diamond sign or twining recess is transient triangular tent like cleft/niche in midportion of pyloric canal with apex pointing inferiorly secondary to mucosl bulging between two seperated hypertrophied muscles on the greater curvature side of pyloric canal.
  5. Apple core lesion, pyloric segment looks like apple core with under cutting of distal antral & proximal duodenal bulb.

Antral signs include

  1. Pyloric teat sign is out pouching along lesser curvature b/o disruption of antral peristalsis.
  2. Shoulder sign is impression of hypertrophied muscle on distended gastric antrum.
  3. Antral beaking is noted as thick muscle narrows the barium column as it enters the pyloric canal.
  4. Olive pit sign is impression of pyloric muscle upon antrum seen as tiny amount of barium at orifice.
  5. Caterpillar sign is gastric hyperperistaltic waves.
  6. Kirklin mushroom sign is indentation of base of duodenal bulb.

Ultrasonography (USG)

It is the method of choice to directly visualize the HPS. The examination is typically performed with a high frequency linear transducer (>5MH2) (as the pylorus & duodenum are very superficial in an infant) with infant in right posterior oblique position (to move any fluid present in fundus into antral & pylorus region. The stomach should not be emptied prior to examination as this makes identification of antropyloric area difficult. If fluid is administered to make visualization better, it should be removed at the end of examination to prevent vomiting/aspiration. Features include)

  1. Doughnut appearance/Bull’s eye or target sign is hypoechoic (black) ring of hypertrophied pyloric muscle around echogenic (reflective) mucosa & submucosa on cross /transverse section images.
  2. Shoulder/cervix-sign is indentation of hypertrophied muscle on fluid filled gastric antrum on longitudinal section.
  3. Antral nipple sign is protrusion (evagination) of redundant pyloric mucosa into distended antrum.
  4. Double tract sign refers to fluid trapped in center of elongated pyloric canal is seen as two sonolucent streaks in center.
  5. Exaggerated peristattic waves & delayed gastric emptying of fluid into duodenum
  6. Elongated pylorus with thickened muscles (most specific) is indicated by Length > 15mm, muscle thickness >3mm and transverse serosa to serosa diameter >15mm is consistent with HPS. At least 2 values should be positive. A thickness <2mm is unequivocally normal and between 2 & 2.9mm is abnormal but non specific & can be seen in pylorospasm & gastritis also. Though pylorospasm is transient & mostly resolve in 30 minutes and there is considerable variation in measurement or image appearance with time during thickness. (GI imaging) Pyloric canal length  16-17min, muscle wall thickness 2 3-3.2mmQ, pyloric volume > 1.4cm3, pyloric transverse diameter 13mm with pyloric canal closed and length (mm) + 3.64x + 3.64 x thickness (mm) >25 (Wolfgang) Pyloric length >16mm & muscle thickness > 4mm (Swartz)

Q. 11

Thickened gall bladder wall in USG seen in‑

 A

Acute cholecystitis

 B

Mucosal thickening

 C

Cholesterosis

 D

All

Q. 11

Thickened gall bladder wall in USG seen in‑

 A

Acute cholecystitis

 B

Mucosal thickening

 C

Cholesterosis

 D

All

Ans. D

Explanation:

A i.e. Acute cholecystitis; B i.e. Mucosal thickening; C i.e. Cholesterosis


Q. 12

True about features of cholecystitis on USG :

 A

Thick fibrosed gallbladder wall

 B

Stone impacted at neck of gall bladder

 C

Perigallbladder halo

 D

All

Q. 12

True about features of cholecystitis on USG :

 A

Thick fibrosed gallbladder wall

 B

Stone impacted at neck of gall bladder

 C

Perigallbladder halo

 D

All

Ans. D

Explanation:

A i.e. Thick fibrosed gall bladdar wall; B i.e. Stone impacted at neck of gall bladder; C i.e. Perigall bladdar halo


Q. 13

Focal and diffuse thickening of gall bladder wall with high amplitude reflections and ‘comet tail’ artifacts on USG suggest the diagnosis of:

 A

Xanthogranulomatous cholecysitis

 B

Carcinoma of gall bladder

 C

Adenomyomatosis

 D

Cholesterolosis

Q. 13

Focal and diffuse thickening of gall bladder wall with high amplitude reflections and ‘comet tail’ artifacts on USG suggest the diagnosis of:

 A

Xanthogranulomatous cholecysitis

 B

Carcinoma of gall bladder

 C

Adenomyomatosis

 D

Cholesterolosis

Ans. C

Explanation:

C i.e. Adenomyomatosis

–  Adenomyomatosis of gall bladder is chracterized by diffuse (generalized), segmental (annular) or localized hyperplastic muscular wall thickeningQ, mucosal overgrowth and intramural diverticula/crypts/or sinus tracts (so called Rokitansky-Aschoff Sinuses). It characteristically pesents with comet tail artifacts/sign (on USG), pearl necklace sign (on oral cholecystogram or MR cholangiogr, am) and string of beads sign (on MRCP T2WI).

Most thyroid carcinomas are hypoechoicQ. Whereas most thyroid adenomas are hyperechoic or isoechoic at ultrasound.

Adenomyomatosis of Gall bladder

  • ·Adenomyomatosis is a special case of Gall Bladder cholesteatosis and belongs to the group of Hyperplastic Cholecystoses.
  • ·It appears as a hyperechoic tumerous thickening of the gall bladder wall (generalized or focal) originating from hypertrophied Rokitanski-Aschoff Sinuses (Intramural Diverticulae).

Q. 14

All are signs /features of ectopic pregnancy on USG except

 A

Pseudo sac

 B

Hyprechoic ring

 C

Adenexal mass

 D

Echogenic mass with multicystic spaces within endometrial cavity

Q. 14

All are signs /features of ectopic pregnancy on USG except

 A

Pseudo sac

 B

Hyprechoic ring

 C

Adenexal mass

 D

Echogenic mass with multicystic spaces within endometrial cavity

Ans. D

Explanation:

D i.e. Echogenic mass with multicystic spaces within endometrial cavity


Q. 15

Ectopic pregnacny, characteristic finding in USG is:

 A

Absence of gestational sac in uterus 

 B

Complex adenexal mass

 C

Resistance in coloured Doppler

 D

Free fluid in peritoneal cavity

Q. 15

Ectopic pregnacny, characteristic finding in USG is:

 A

Absence of gestational sac in uterus 

 B

Complex adenexal mass

 C

Resistance in coloured Doppler

 D

Free fluid in peritoneal cavity

Ans. A

Explanation:

A i.e. Absence of gestational sac in uterus

Best method of diagnosing unruptured ectopic pregnancy is combination of transvaginal sonography & quantitative B-HCG valuesQ.


Q. 16

Most accurate assessment of gestational age by USG is done by

 A

Femur length

 B

Gestational sac size

 C

Menstrual history

 D

Crown rump length

Q. 16

Most accurate assessment of gestational age by USG is done by

 A

Femur length

 B

Gestational sac size

 C

Menstrual history

 D

Crown rump length

Ans. D

Explanation:

D i.e. Crown rump length


Q. 17

20 yr old man with progressive proptosis which increases on bending forward. It is compressible and has no bruit or thrill. USG showed “hyperintense” mass with shadowing of mass. The diagnosis is: 

 A

Orbital varix

 B

AV malformation

 C

Neurofibromatosis

 D

“Orbital” encephalocele

Q. 17

20 yr old man with progressive proptosis which increases on bending forward. It is compressible and has no bruit or thrill. USG showed “hyperintense” mass with shadowing of mass. The diagnosis is: 

 A

Orbital varix

 B

AV malformation

 C

Neurofibromatosis

 D

“Orbital” encephalocele

Ans. A

Explanation:

A i.e. Orbital varix

  • Plexiform neurofibroma (exclusively associated with NF 1) presents in early childhood with peri­orbital swelling, diffuse involvement of orbit with disfiguring hypertrophy of periocular tissue, S-shaped mechanical ptosis (d/t lid involvement). On palpation involved tissue feel like a bag of worms. Pulsation without a bruit & thrill (best detected on applantation tonometry)Q may be present if there is an associated congenital defect of greater wing of sphenoid. Other features of NF like Lisch (iris) nodules, prominent corneal nerves, optic nerve glioma, uveal NF may be present.
  • Isolated neurofibroma (less common) presents in 3rd to 4th decade with insidious mildly painful proptosis unassociated with visual impairment or ocular motility dysfunction.

Q. 18

A patient has a surgical cause of obstructive jaundice. He is advised USG. All of the following can be detected on USG, except:

 A

Biliary tree obstruction

 B

Peritoneal deposits

 C

Gall bladder stones

 D

Ascites

Q. 18

A patient has a surgical cause of obstructive jaundice. He is advised USG. All of the following can be detected on USG, except:

 A

Biliary tree obstruction

 B

Peritoneal deposits

 C

Gall bladder stones

 D

Ascites

Ans. B

Explanation:

Ans is ‘b’ i.e. Peritoneal deposits 

Ultrasound is the first radiological investigation done to evaluate obstructive or any jaundice. It is both sensitive and specific for diagnosing gallbladder stones and biliary tract dilatation.

It is able to detect the level of biliary obstruction and most of other causative pathologies. It is also very sensitive for ascites and even minimal fluid can be detected.

Peritoneal deposits could also be detected on USG, but with difficulty. CECT and MR are the preferred investigation for peritoneal deposits in that order.


Q. 19

In acute pyelonephritis, which of the following is not a USG finding:

 A

Increased vascularity

 B

Renal enlargement

 C

Compression of the renal sinuses

 D

Increased echogenecity

Q. 19

In acute pyelonephritis, which of the following is not a USG finding:

 A

Increased vascularity

 B

Renal enlargement

 C

Compression of the renal sinuses

 D

Increased echogenecity

Ans. A

Explanation:

Ans is ‘a’ i.e. Increased vascularity 

Acute bacterial infection causes constriction of peripheral arterioles and reduces perfusion of the affected renal segments. Perfusion defects can be segmental, multifocal, or diffuse.

Ultrasound findings of acute pyelonephritis:

At ultrasound, the majority of kidneys with acute pyelonephritis appear normal. However, ultrasound findings of pyelonephritis include the following:

  • Renal enlargement
  • Compression of the renal collecting system
  • Decreased echogenicity (secondary to edema) or increased echogenicity (potentially from hemorrhage)
  • Loss of corticomedullary differentiation
  • Poorly marginated mass(es)
  • Gas within the renal parenchyma
  • Focal or diffuse absence of color Doppler perfusion corresponding to the swollen inflamed areas

If the pyelonephritis is focal, the poorly marginated masses may be echogenic, hypoechoic, or of mixed echogenicity. Sonography, including power Doppler, is less sensitive than CT, magnetic resonance imaging (MRI), or technetium-99m single-photon emission computed tomography ( 99m Tc-DMSA SPECT) renal cortical scintigraphy for demonstrating changes of acute pyelonephritis.

However, ultrasound is more accessible and less expensive and thus an excellent screening modality for monitoring and follow-up of complications, as well as in the assessment of pregnant patients with acute pyelonephritis because of its lack of ionizing radiation.

Acute pyelonephritis is defined as inflammation of the kidney and renal pelvis.

Two routes may lead to inflammation: ascending infection (85%; e.g., Escherichia coli) and hematogenous seeding (15%; e.g., Staphylococcus aureus).

Most adults present with flank pain and fever and can be diagnosed clinically with the aid of laboratory studies (bacteriuria, pyuria, and leukocytosis). With appropriate antibiotics, both clinical and laboratory findings show rapid improvement.

Imaging is only necessary when symptoms and laboratory abnormalities persist: Imaging is useful to identify potential causes of insufficiently treated infection, including renal and perirenal abscesses, calculi, and urinary obstruction.


Q. 20

Pseudo kidney is –

 A

Thickened bowel loop on USG

 B

Hydronephrosis

 C

Unascended kidney

 D

Undescended testes

Q. 20

Pseudo kidney is –

 A

Thickened bowel loop on USG

 B

Hydronephrosis

 C

Unascended kidney

 D

Undescended testes

Ans. A

Explanation:

Ans. is ‘a’ i.e., Thickened bowel loop on USG 

Pseudokidney sign or target sign is ultrasonographic findings of Intussusception.


Q. 21

A 3 year old girl presents with recurrent UTI. On USG shows hydronephrosis with filling defect and negative shadow of bladder with no ectopic orifice‑

 A

Vesicoureteric reflux

 B

Hydronephrosis

 C

Ureterocele

 D

Sacrococcygeal teratoma

Q. 21

A 3 year old girl presents with recurrent UTI. On USG shows hydronephrosis with filling defect and negative shadow of bladder with no ectopic orifice‑

 A

Vesicoureteric reflux

 B

Hydronephrosis

 C

Ureterocele

 D

Sacrococcygeal teratoma

Ans. C

Explanation:

Ans. is ‘c’ i.e., Ureterocele 


Q. 22

Investigation of choice for blunt trauma abdomen in unstable patient –

 A

X-ray abdomen

 B

USG

 C

Diagnostic Peritoneal lavage (DPL)

 D

MRI

Q. 22

Investigation of choice for blunt trauma abdomen in unstable patient –

 A

X-ray abdomen

 B

USG

 C

Diagnostic Peritoneal lavage (DPL)

 D

MRI

Ans. B

Explanation:

Answer is ‘b’ i.e. USG 

The prime aim of investigations in a pt. of blunt trauma abdomen is to determine whether the patient needs an exploratory laparotomy or not.

Previously DPL was the inv. of choice to determine the presence of infra-abdominal hemorrhage, but currently Ultrasound has replaced DPI.

  • U/S is the investigation of choice in both stable as well as unstable patients.

Schwartz writes- “Blunt abdominal trauma initially is evaluated by FAST examination in most major trauma centers, and this has largely supplanted DPL. FAST is not 100% sensitive, however, so diagnostic peritoneal aspiration is still advocated in hemodynamically unstable patients without a defined source of blood loss to rule out abdominal hemorrhage. Patients with fluid on FAST examination, considered a ‘positive FAST’, who do not have immediate indications for laparotomy and are hemodynamically stable undergo CT scanning to quantify their injuries.”

Sabiston writes – Hemodynamically stable patients sustaining blunt trauma are adequately evaluated by abdominal ultrasound or CT unless other severe injuries take priority and the patient needs to go to the operating room before the objective abdominal evaluation. In such instances, DPL or focussed abdominal sonography for trauma (FAST) is usually performed in the operating room to rule out intra-abdominal bleeding requiring immediate surgical exploration.

Also know

Use of U/S in trauma pts. is now k/a FAST examination (i.e. Focussed Assessment with Sonography for Trauma) – In this examination the goal is not to evaluate the whole abdomen but to look for free intraperitoneal fluid at specific sites

  • The diagnostic approach in penetrating abdominal injuries (i.e. stab wounds & Gunshot wounds) differs from that in blunt injuries.
  • In Gun shot wounds (GSW)

– exploratory laprotomy is mandatory, as chances of internal injury are high (-90%) in GSWs to abdomen

  • In stab wounds (SW)

–   in contrast to GSW, SWs that penetrate the peritoneal cavity are less likely to injure intra-abdominal organs.

SWs should be explored under local anesthesia in the emergency department whether the peritoneum has been violated.

Injuries that do not epnetrate the peritoneal cavity do not require further evaluation.

DPL can also be done to detect intraperitoneal injuries.


Q. 23

Which of the following statement about ascitis is true:

 A

Hemorrhagic ascitis is diagnosed when RBC count > 1,000/mm3

 B

SBP is diagnosed when Neutrophil count > 500/mm3

 C

Large volume paracentesis is indicated in SBP

 D

USG can detect as little as 100 ml of peritoneal fluid

Q. 23

Which of the following statement about ascitis is true:

 A

Hemorrhagic ascitis is diagnosed when RBC count > 1,000/mm3

 B

SBP is diagnosed when Neutrophil count > 500/mm3

 C

Large volume paracentesis is indicated in SBP

 D

USG can detect as little as 100 ml of peritoneal fluid

Ans. D

Explanation:

Answer is D (USG can detect as little as 100 ml of peritoneal fluid):

Abdominal ultrasound may detect as little as 100 ml of ascitic fluid ultrasound is thus a useful investigation for the diagnosis of minimal ascitis –CCDT 3rd/717

Hemorrhagic Ascitis is diagnosed NI hen RBC count >10, 000 / mm3 (Not >1000/mm3)

An RBC count of 10,000 / nun3 is the thresholdfior pink appearance and hemorrhagic ascitis is thus diagnosed when ascitic RBC count is > 10,000 / mm3Schiff ‘s diseases of the Liver 101h/ 996

Spontaneous Bacterial peritonitis (SBP) is diagnosed when Neutrophil count > 250/mm3

The diagnosis of SBP is made when the absolute neutrophil count > 250 / nun3 – Harrisons 17th/1979

The drug of choice for treatment of SBP are cephalosporins & not Norfloxacin Celbtaxime is considered the drug of choice Pr emperic therapy of SBP

Large volume Therapeutic Paracentesis is not recommended for SBP

Diagnostic paracentesis is indicated in SBP Pr establishing the diagnosis but large volume paracentesis should be avoided – Schiff’s Diseases of the Liver 10′”/561


Q. 24

Investigation of choice for screening of proximal internal carotid artery stenosis is :

 A

Doppler flow USG

 B

CT substraction angiography

 C

MRI

 D

Angiography (DSA)

Q. 24

Investigation of choice for screening of proximal internal carotid artery stenosis is :

 A

Doppler flow USG

 B

CT substraction angiography

 C

MRI

 D

Angiography (DSA)

Ans. A

Explanation:

Answer is A (Doppler flow USG):

‘Stenosis at the origin of the internal carotid Artery can be identified and quantified reliably by ultrasonography that combines B mode ultrasound image with a Doppler ultrasound assessment of flow velocity.’


Q. 25

Gold standard investigation for diagnosing cystic echinococcus is:     

September 2009

 A

USG

 B

X-ray

 C

ELISA

 D

CT scan

Q. 25

Gold standard investigation for diagnosing cystic echinococcus is:     

September 2009

 A

USG

 B

X-ray

 C

ELISA

 D

CT scan

Ans. A

Explanation:

Ans. A: USG

For cystic echinococcosis, imaging is the main method that is relied on for diagnosis while serology tests (such as indirect hemogglutination, ELISA (enzyme linked immunosorbent assay), immunoblots or latex agglutination) that use antigens specific for E. granulosus are used to verify the imaging results.

The imaging technique of choice for cystic echinococcosis is ultrasonography since it is not only able to visualize the cysts in the body’s organs but it is also inexpensive, non-invasive and gives instant results.

In addition to ultrasonography, both MRI and CT scans can and are often used although an MRI is often preferred to CT scans when diagnosing cystic echinococcosis since it gives better visualization of liquid areas within the tissue.

As with cystic echinococcosis, ultrasonography is the imaging technique of choice for alveolar echinococcosis and is usually complemented by CT scans since CT scans are able to detect the largest number of lesions and calcifications that are characteristic of alveolar echinococcosis. MRIs are also used in combination with ultrasonography though CT scans are preferred. Like cystic echinococcosis, imaging is the major method used for the diagnosis of alveolar echinococcosis while the same types of serologic tests (except now specific for E. multilocularis antigens) are used to verify the imaging results. It is also important to note that serologic tests are more valuable for the diagnosis of alveolar echinococcosis than for cystic echinococcosis since they tend to be more reliable for alveolar echinococcosis since more antigens specific for E. multilocularis are available.


Q. 26

Initial investigation for an amoebic liver abscess is

September 2009

 A

USG

 B

Exploratory laparotomy

 C

CT scan

 D

Technetium-99 scan

Q. 26

Initial investigation for an amoebic liver abscess is

September 2009

 A

USG

 B

Exploratory laparotomy

 C

CT scan

 D

Technetium-99 scan

Ans. A

Explanation:

Ans. A: USG

Ultrasonography is the preferable initial diagnostic test.

It is rapid, inexpensive, and is only slightly less sensitive than CT scan (75-80% sensitivity vs 88-95% for CT scan). Ultrasonography simultaneously evaluates the gallbladder and avoids radiation exposure.

As opposed to scanning with technetium-99m, sonography often can distinguish an abscess from a tumor or other solid focal lesion.

The lesions tend to be round or oval, with well-defined margins, and hypoechoic.

  • CT scan is sensitive but the findings are not specific.

The abscess typically appears low density with smooth margins and a contrast-enhancing peripheral rim. The use of injected contrast may differentiate hepatic abscesses from vascular tumors.

  • MRI is sensitive, but the findings are not specific. This test provides information comparable with less expensive imaging procedures.
  • Technetium-99m liver scanning is useful for differentiating an amebic liver abscess from a pyogenic abscess; however, it is not used as a first-line test.

Because amebic liver abscesses do not contain leukocytes, they appear as cold lesions on hepatic nuclear scanning, with a typical hot halo or a rim of radioactivity surrounding the abscess.

In contrast, pyogenic liver abscesses contain leukocytes and, therefore, typically appear as hot lesions on nuclear scanning.

  • Gallium scanning is helpful in differentiating pyogenic abscess (similar to technetium-99m nuclear hepatic scanning) but requires delayed images, which makes the test less helpful.
  • Hepatic angiography is only useful to differentiate liver abscesses from vascular lesions.
  • Plain chest or abdominal films may show elevation and limitation of motion of the right diaphragm, basilar atelectasis, and right pleural effusion or gas within the abscess cavity.

None of the imaging tests can definitely differentiate a pyogenic liver abscess, an amebic abscess, or malignant disease. Clinical, epidemiological, and serological correlation is needed for diagnosis.


Q. 27

In acute congestive glaucoma, pupil is: 

 A

Mid-dilated, vertically oval and fixed

 B

Sluggishly reacting to light

 C

Small and irregular

 D

Horizontally oval

Q. 27

In acute congestive glaucoma, pupil is: 

 A

Mid-dilated, vertically oval and fixed

 B

Sluggishly reacting to light

 C

Small and irregular

 D

Horizontally oval

Ans. A

Explanation:

Ans. A: Mid-dilated, vertically oval and fixed

On examination in acute primary angle closure glaucoma, a vertically oval, mid-dilated pupil is present

Glaucoma

  • It can be divided roughly into two main categories, “open angle” and “closed angle” glaucoma.
  • Closed angle glaucoma can appear suddenly and is often painful; visual loss can progress quickly, but the discomfort often leads patients to seek medical attention before permanent damage occurs.
  • Open angle, chronic glaucoma tends to progress at a slower rate and patients may not notice they have lost vision until the disease has progressed significantly.
  • Glaucoma has been nicknamed the”silent thief of sight” because te loss of vision normally occurs gradually over a long period of time, and is often recognized only when the disease ihs quite advanced.
  • Once lost, this damaged visual field cannot be recovered.
  • Worldwide, it is the second leading cause of blindness after cataracts
  •  Open-angle glaucoma accounts for 90% of glaucoma cases in the developed countries.
  • About 10% of patients with closed angles present with acute pain, seeing halos around lights, red eye, very high intraocular decreased vision, and a fixed, mid-dilated pupil.
  • Acute angle closure is an ocular emergency.

Normal aqueous pathway

  • The major risk factor for most glaucomas and focus of treatment is increased intraocular pressure.
  • Intraocular pressure is a function of production of liquid aqueous humor by the ciliary processes of the eye and its drainage through the trabecular meshwork.
  • Aqueous humor flows from the ciliary processes into the posterior chamber, bounded posteriorly by the lens and the zonules of Zinn and anteriorly by the iris.
  • It then flows through the pupil of the iris into the anterior chamber, bounded posteriorly by the iris and anteriorly by the cornea.
  • From here the trabecular meshwork drains aqueous humor via Schlemm’s canal into scleral plexuses and general blood circulation.

Pathology

  • In open angle glaucoma, there is reduced flow through the trabecular meshwork; in angle closure glaucoma, the iridocorneal angle is completely closed because of forward displacement of the final roll and root of the iris against the cornea resulting in the inability of the aqueous fluid to flow from the posterior to the anterior chamber and then out of the trebecular network.

Screening

  • Testing for glaucoma should include measurements of the intraocular pressure via tonometry, changes in size or shape of the eye, anterior chamber angle examination or gonioscopy, and examination of the optic nerve to look for any visible damage to it, or change in the cup-to-disc ratio and also rim appearance and vascular change.
  • A formal visual field test should be performed.
  • The retinal nerve fiber layer can be assessed with imaging techniques such as optical coherence tomography (OCT), scanning laser polarimetry (GDx), and/or scanning laser ophthalmoscopy, also known as Heidelberg retina tomography (HRT3).
  • Owing to the sensitivity of all methods of tonometry to corneal thickness, methods such as Goldmann tonometry should be augmented with pachymetry to measure central corneal thickness (CCT).
  • A thicker-than-average cornea can result in a pressure reading higher than the ‘true’ pressure, whereas a thinner-thanaverage cornea can produce a pressure reading lower than the ‘true’ pressure.
  • Because pressure measurement error can be caused by more than just CCT (i.e., corneal hydration, elastic properties, etc.), it is impossible to ‘adjust’ pressure measurements based only on CCT measurements.
  • The Frequency Doubling Illusion can also be used to detect glaucoma with the use of a frequency doubling technology (FDT) perimeter.
  • Examination for glaucoma also could be assessed with more attention given to sex, race, history of drug use, refraction, inheritance and family history

Management

  • The modern goals of glaucoma management are to avoid glaucomatous damage and nerve damage, and preserve visual field and total quality of life for patients with minimal side effects.
  • Although intraocular pressure is only one of the major risk factors for glaucoma, lowering it via various pharmaceuticals and/or surgical techniques is currently the mainstay of glaucoma treatment.

Medication

  • Prostaglandin analogs, such as latanoprost, bimatoprost and travoprost, increase uveoscleral outflow of aqueous humor.
  • Bimatoprost also increases trabecular outflow.
  • Topical beta-adrenergic receptor antagonists, such as timolol, levobunolol, and betaxolol, decrease aqueous humor production by the ciliary body.
  • Alpha2-adrenergic agonists, such as brimonidine and apraclonidine, work by a dual mechanism, decreasing aqueous humor production and increasing trabecular outflow.
  • Less-selective alpha agonists, such as epinephrine, decrease aqueous humor production through vasoconstriction of ciliary body blood vessels.
  • Epinephrine’s mydriatic effect, however, renders it unsuitable for closed angle glaucoma.
  • Miotic agents (parasympathomimetics), such as pilocarpine, work by contraction of the ciliary muscle, tightening the trabecular meshworkers and allowing increased outflow of the aqueous humour.
  • Ecothiopate is used in chronic glaucoma.
  • Carbonic anhydrase inhibitors, such as dorzolamide, brinzolamide, and acetazolamide, lower secretion of aqueous humor by inhibiting carbonic anhydrase in the ciliary body.
  • Physostigmine is also used to treat glaucoma.

Surgery

  • Surgery is the primary therapy for those with congenital glaucoma.
  • Generally, these operations are a temporary solution, as there is not yet a cure for glaucoma.

Canaloplasty

  • Canaloplasty is a nonpenetrating procedure using microcatheter technology.
  • Enlarging the main drainage channel and its smaller collector channels
  • By opening the canal, the pressure inside the eye may be relieved

Laser surgery

  • Laser trabeculoplasty may be used to treat open angle glaucoma.
  • It is a temporary solution, not a cure.
  • An 50 pm argon laser spot is aimed at the trabecular meshwork to stimulate opening of the mesh to allow more outflow of aqueous fluid.
  • Traditional laser trabeculoplasty uses a thermal argon laser in a procedure called argon laser trabeculoplasty (ALT).
  • A newer type of laser trabeculoplasty uses a “cold” (nonthermal) laser to stimulate drainage in the trabecular meshwork.
  • This newer procedure, selective laser trabeculoplasty (SLT) uses a 532 nm frequency-doubled, Q-switched Nd:YAG laser, which selectively targets melanin pigment in the trabecular meshwork cells.

Nd:YAG laser peripheral iridotomy (LPI)

  • It may be used in patients susceptible to or affected by angle closure glaucoma or pigment dispersion syndrome.
  • During laser iridotomy, laser energy is used to make a small, full-thickness opening in the iris to equalize the pressure between the front and back of the iris, thus correcting any abnormal bulging of the iris.
  • In people with narrow angles, this can uncover the trabecular meshwork.
  • Laser iridotomy reduces the risk of developing an attack of acute angle closure.
  • In most cases, it also reduces the risk of developing chronic angle closure or of adhesions of the iris to the trabecular meshwork.
  • Diode laser cycloablation
  • It lowers IOP by reducing aqueous secretion by destroying secretory ciliary epithelium.

Trabeculectomy

  • The most common conventional surgery performed for glaucoma is the trabeculectomy.
  • Here, a partial thickness flap is made in the scleral wall of the eye, and a window opening is made under the flap to remove a portion of the trabecular meshwork.
  • The scleral flap is then sutured loosely back in place to allow fluid to flow out of the eye through this opening, resulting in lowered intraocular pressure and the formation of a bleb or fluid bubble on the surface of the eye.

Glaucoma drainage implants

  • Several different glaucoma drainage implants include the original Molteno implant (1966), the Baerveldt tube shunt, or the valved implants, such as the Ahmed glaucoma valve implant or the ExPress Mini Shunt and the later generation pressure ridge Molteno implants.
  • These are indicated for glaucoma patients not responding to maximal medical therapy, with previous failed guarded filtering surgery (trabeculectomy).
  • The flow tube is inserted into the anterior chamber of the eye, and the plate is implanted underneath the conjunctiva to allow flow of aqueous fluid out of the eye into a chamber called a bleb.

Laser-assisted nonpenetrating deep sclerectomy

  • The most common surgical approach currently used for the treatment of glaucoma is trabeculectomy, in which the sclera is punctured to alleviate intraocular pressure.
  • Nonpenetrating deep sclerectomy (NPDS) surgery is a similar, but modified, procedure, in which instead of puncturing the scleral wall, a patch of the sclera is skimmed to a level, upon which, percolation of liquid from the inner eye is achieved and thus alleviating IOP, without penetrating the eye.
  • NPDS is demonstrated to cause significantly less side effects than trabeculectomy.
  • However, NPDS is performed manually and requires great skill to achieve a lengthy learning curve.

Q. 28

Investigation of choice for varicose veins:

March 2012, March 2013

 A

Duplex ultrasound imaging

 B

Standard Doppler examination

 C

Varicography

 D

Venography

Q. 28

Investigation of choice for varicose veins:

March 2012, March 2013

 A

Duplex ultrasound imaging

 B

Standard Doppler examination

 C

Varicography

 D

Venography

Ans. A

Explanation:

Ans: A i.e. Duplex ultrasound imaging

Investigation of varicose veins

  • Many now believe that all patients with varicose veins should undergo an assessment by duplex scan
  • Standard Doppler examination is not an accurate method of establishing incompetence of the lesser saphenous incompetence. In all cases of short saphenous incompetence a further investigation is desirable; this is usually carried out by duplex scanning
  • Varicography is an extremely useful investigation in patients with recurrent varicose veins or those with complex anatomy
  • Venography is not used as a standard investigation in patients with varicose veins but is useful if the duplex scan indicates, but cannot confirm, the presence of post-thrombotic change.

Q. 29

Investigation of choice for hydatid disease is:

September 2009

 A

CT scan

 B

Elisa

 C

Biopsy

 D

USG

Q. 29

Investigation of choice for hydatid disease is:

September 2009

 A

CT scan

 B

Elisa

 C

Biopsy

 D

USG

Ans. D

Explanation:

Ans. D: USG

Laboratory Studies

The results of routine laboratory blood work are nonspecific.

Liver involvement may be reflected in an elevated bilirubin or alkaline phosphatase level. Leukocytosis may suggest infection of the cyst.

Eosinophilia is present in 25% of all persons who are infected, while hypogammaglobinemia is present in 30%. Almost every serodiagnostic technique has been evaluated for echinococcosis, with variable results.

– The indirect hemagglutination test and the enzyme-linked immunosorbent assay (ELISA) have a sensitivity of 80% overall (90% in hepatic echinococcosis, 40% in pulmonary echinococcosis) and are the initial screening tests of choice.

–  Immunodiffusion and immunoelectrophoresis demonstrate antibodies to antigen 5 and provide specific confirmation of reactivity.

– The ELISA test is useful in follow-up to detect recurrence.

Imaging Studies

– Plain films

Findings from plain films of the chest, abdomen, or any other involved site are, at best, nonspecific and mostly nonrevealing. A thin rim of calcification delineating a cyst is suggestive of an echinococcal cyst.

– Ultrasound

Ultrasonography helps in the diagnosis of hydatid cysts when the daughter cysts and hydatid sand are demonstrated.

The accuracy of ultrasound evaluations remains operator-dependent.

CT scan

CT scan has an accuracy of 98% and the sensitivity to demonstrate the daughter cysts.

It is the best test for the differentiation of hydatid from amebic and pyogenic cysts in the liver.

– MRI: Images show the cysts adequately, but MRI offers no real advantage over CT scan.

Other Tests

–  Casoni test

Historically, an intradermal skin test (Casoni test) was used and had a sensitivity of 70%.

It is now largely abandoned because of its low sensitivity, low accuracy, and potential for severe local allergic reaction.

 


Q. 30

Investigation of choice for acute cholecystitis:

March 2010

 A

Plain Radiography

 B

USG

 C

CT scan

 D

Barium studies

Q. 30

Investigation of choice for acute cholecystitis:

March 2010

 A

Plain Radiography

 B

USG

 C

CT scan

 D

Barium studies

Ans. B

Explanation:

Ans. B: USG

Plain Radiography:

– Abdominal radiographs are usually not indicated, as most gallstones are not radio-opaque.

– Chest radiographs may be performed to exclude a thoracic cause of pain and bowel perforation.

Ultrasound:

Initial investigation of choice for suspected acute cholecystitis.

Ultrasonographic signs of acute gallbladder inflammation include gallbladder wall thickening/oedema, pericholecystic fluid, gallstones, and positive ultrasonic Murphy’s sign.

– >90% diagnostic accuracy and varies with the morphologic criteria used.

– Colour/power Doppler increases accuracy over Gray-scale sonography.

–  Advantages: allows evaluation of other abdominal structures (can identify an alternative diagnosis), provides preoperative information such as gallbladder size, stone size, gallbladder wall status, and the presence of biliary dilatation.

Tc-IDA Radionuclide Scan:

– Superior diagnostic accuracy and specificity compared to ultrasound.

Used to clarify a negative, equivocal or technically difficult ultrasound in the presence of continued clinical suspicion of acute cholecystitis.

– The hallmark of acute cholecystitis (acalculus as well as calculus) is persistent gall bladder non-visualisation 30 minutes post morphine or on the 3-4 hour delayed image.

– False positives can occur in alcoholics, intensive care unit patients, patients on prolonged fasting, cystic fibrosis and chronic cholecystitis.

– Morphine augmentation reduces false positives and is superior to delayed imaging.

– In critically ill patients in whom acalculous cholecystitis is suggested on US, Tc-IDA scan with pretreatment cholecystokinin to empty gallbladder prior to Tc-IDA scan, or percutaneous cholecystostomy may be indicated. Post treatment Cholecystokinin can be used to evaluate gallbladder function in chronic cholecystitis. Limitations: longer examination time, unreliable in severe hepatocellular disease or at serum bilirubin levels >340-500 mmol/L, and inability to diagnose extra-biliary causes of acute right upper quadrant abdominal pain and to provide anatomical information.

Other Imaging:

Endoscopy or Barium studies may be indicated in certain patients to identify alternative diagnoses which may clinically simulate acute cholecystitis.

– Computed Tomography

  • CT is useful when the clinical picture is non-specific as it can detect other intra-abdominal inflammatory processes, and when complications of acute cholecystitis are suspected.
  • Sensitivities for CT diagnosis of acute cholecystitis have not been established
  • CT features of acute cholecystitis include
  1. Pericholecystic inflammatory changes, including contrast enhancement of the liver adjacent to the gallbladder, inflammatory stranding of pericholecystic tissues, and pericholecystic fluid.
  2. Loss of distinction between walls of the gallbladder and adjacent liver.
  3. Gallbladder wall thickening, contrast enhancement.
  4. Gallbladder distension.
  5. Presence of gallstones.
  • Advantages: allows other diagnoses, able to identify complications of acute cholecystitis.
  • Limitations: exposure to ionising radiation, less sensitive (57%-88%) for detection of gallstones compared to ultrasound.

Q. 31

Investigation of choice for diagnosing intra abdominal bleeding in an unstable patient:

September 2007

 A

CT scan omit

 B

MRI scan

 C

USG

 D

Diagnostic peritoneal lavage

Q. 31

Investigation of choice for diagnosing intra abdominal bleeding in an unstable patient:

September 2007

 A

CT scan omit

 B

MRI scan

 C

USG

 D

Diagnostic peritoneal lavage

Ans. C

Explanation:

Ans. C: USG


Q. 32

Investigation of choice for gall bladder stone is:

March 2010

 A

OCG

 B

USG

 C

PTC

 D

X-ray

Q. 32

Investigation of choice for gall bladder stone is:

March 2010

 A

OCG

 B

USG

 C

PTC

 D

X-ray

Ans. B

Explanation:

Ans. B: USG

Investigation for gall stones:

  • Ultrasound is the initial investigation of choice
  • Diagnostic features on ultrasound include

–            Presence of gallstones

–            Distended thick-walled gallbladder

–            Pericholecystic fluid

–            Murphy’s sign demonstrated with ultrasound probe

  • If diagnostic doubt a HIDA scan may be useful-Will show failure of isotope (hydroxyiminodiacetic acid) uptake by gallbladder

Q. 33

Congenital anomalies that can be identified by USG are all except:     

September 2009

 A

Hydrops fetalis

 B

Esophageal atresia

 C

Anencephaly

 D

Cystic hygroma

Q. 33

Congenital anomalies that can be identified by USG are all except:     

September 2009

 A

Hydrops fetalis

 B

Esophageal atresia

 C

Anencephaly

 D

Cystic hygroma

Ans. D

Explanation:

Ans. D: Cystic Hygroma

Common anomalies that can be seen in USG are:

  • Cranial anomalies-anencephaly, hydrocephalus.choroid plaexus cysts
  • Spinal anomalies-Spina bifida occulta and Spina bifida aperta
  • Fetal heart
  • Fetal abdomen and abdominal wall-Esophageal atresia, omphalocoele, gastroschisis
  • Hydrops f etalis

Q. 34

Best time for diagnosing fetal abnormalities by USG:

September 2009

 A

6-12 weeks of pregnancy

 B

13-19 weeks of pregnancy

 C

20-26 weeks of pregnancy

 D

27-32 weeks of pregnancy

Q. 34

Best time for diagnosing fetal abnormalities by USG:

September 2009

 A

6-12 weeks of pregnancy

 B

13-19 weeks of pregnancy

 C

20-26 weeks of pregnancy

 D

27-32 weeks of pregnancy

Ans. B

Explanation:

Ans. B: 13-19 weeks of pregnancy


Q. 35

Embryonic structure, identified earliest on USG, for confirmation of pregnancy is:

March 2011, March 2013

 A

Fetal pole

 B

Fetal Heart activity

 C

Gestation sac

 D

Fetal skeleton

Q. 35

Embryonic structure, identified earliest on USG, for confirmation of pregnancy is:

March 2011, March 2013

 A

Fetal pole

 B

Fetal Heart activity

 C

Gestation sac

 D

Fetal skeleton

Ans. C

Explanation:

Ans. C: Gestation sac

Gestation sac and embryonic yolk sac is identified at menstrual age of 5 weeks Fetal pole and cardiac activity is identified on USG at menstrual age of 6 weeks Lower limb buds, upper limb buds and spine at 7, 8 and 9 weeks respectively Remember:

  • Total duration of pregnancy: 280 days
  • Earliest detection of pregnancy by USG: Gestational sac
  • Pregnancy is confirmed by:

–        Fetal heart rate

–        Fetal sac on USG

–       Fetal movements

  • Transvaginal sonography detects gestational sac: at 14 days after ovulation

Q. 36

Best time to do USG in pregnancy, if it is to be done once in entire pregnancy, would be:         

March 2011

 A

6-8 weeks

 B

10-12 weeks

 C

18-22 weeks

 D

34-36 weeks

Q. 36

Best time to do USG in pregnancy, if it is to be done once in entire pregnancy, would be:         

March 2011

 A

6-8 weeks

 B

10-12 weeks

 C

18-22 weeks

 D

34-36 weeks

Ans. C

Explanation:

Ans. C: 18-22 weeks

Routine USG at 18-22 weeks gestation has the following effects 1) reduces the incidence of post-term pregnancy (39%) and rates of induction of labour for post-term pregnancy, 2) increases early detection of multiple pregnancy (92%), 3) increases early detection of major fetal anomalies when termination is possible, 4) no significant differences in the clinical outcomes such as perinatal mortality and 5) reduces neonatal admission to special care baby unit (14%)


Q. 37

Non invasive method for locating an expelled Cu-T:

March 2013

 A

Hysteroscopy

 B

Laparoscopy

 C

USG

 D

Laparotomy

Q. 37

Non invasive method for locating an expelled Cu-T:

March 2013

 A

Hysteroscopy

 B

Laparoscopy

 C

USG

 D

Laparotomy

Ans. C

Explanation:

Ans. C i.e. USG


Q. 38

Snow storm appearance of USG is seen in:

March 2013

 A

Dysgerminoma

 B

Carcinoma cervix

 C

Carcinoma endometrium

 D

H. mole

Q. 38

Snow storm appearance of USG is seen in:

March 2013

 A

Dysgerminoma

 B

Carcinoma cervix

 C

Carcinoma endometrium

 D

H. mole

Ans. D

Explanation:

Ans. D i.e. H. mole


Q. 39

Initial IOC for intussesception is:  

March 2003

 A

X-ray

 B

USG

 C

Barium enema

 D

CT scan

Q. 39

Initial IOC for intussesception is:  

March 2003

 A

X-ray

 B

USG

 C

Barium enema

 D

CT scan

Ans. B

Explanation:

Ans. B i.e. USG


Q. 40

Gold standard investigation for diagnosing cystic echinococcus is:     

September 2009

 A

USG

 B

X-ray

 C

ELISA

 D

CT scan

Q. 40

Gold standard investigation for diagnosing cystic echinococcus is:     

September 2009

 A

USG

 B

X-ray

 C

ELISA

 D

CT scan

Ans. A

Explanation:

Ans. A: USG

For cystic echinococcosis, imaging is the main method that is relied on for diagnosis while serology tests (such as indirect hemogglutination, ELISA (enzyme linked immunosorbent assay), immunoblots or latex agglutination) that use antigens specific for E. granulosus are used to verify the imaging results.

The imaging technique of choice for cystic echinococcosis is ultrasonography since it is not only able to visualize the cysts in the body’s organs but it is also inexpensive, non-invasive and gives instant results.

In addition to ultrasonography, both MRI and CT scans can and are often used although an MRI is often preferred to CT scans when diagnosing cystic echinococcosis since it gives better visualization of liquid areas within the tissue.

As with cystic echinococcosis, ultrasonography is the imaging technique of choice for alveolar echinococcosis and is usually complemented by CT scans since CT scans are able to detect the largest number of lesions and calcifications that are characteristic of alveolar echinococcosis. MRIs are also used in combination with ultrasonography though CT scans are preferred. Like cystic echinococcosis, imaging is the major method used for the diagnosis of alveolar echinococcosis while the same types of serologic tests (except now specific for E. multilocularis antigens) are used to verify the imaging results. It is also important to note that serologic tests are more valuable for the diagnosis of alveolar echinococcosis than for cystic echinococcosis since they tend to be more reliable for alveolar echinococcosis since more antigens specific for E. multilocularis are available.


Q. 41

Transvaginal USG can detect fetal cardiac activity in:        

DNB 10; MAHE 12

 A

5 weeks

 B

6 weeks

 C

7 weeks

 D

8 weeks

Q. 41

Transvaginal USG can detect fetal cardiac activity in:        

DNB 10; MAHE 12

 A

5 weeks

 B

6 weeks

 C

7 weeks

 D

8 weeks

Ans. A

Explanation:

Ans. 5 weeks


Q. 42

Investigation of choice for diagnosis of congenital hypertrophic pylori stenosis:

 A

USG

 B

Barium meal

 C

Barium meal follow through

 D

CT scan with contrast

Q. 42

Investigation of choice for diagnosis of congenital hypertrophic pylori stenosis:

 A

USG

 B

Barium meal

 C

Barium meal follow through

 D

CT scan with contrast

Ans. A

Explanation:

Ans. USG


Q. 43

Best parameter by USG to assess fetal maturity:

 A

Crown rump length at 16 weeks

 B

Head circumference at 36 weeks

 C

Biparietel diameter at 12 weeks

 D

Femur length at 12 weeks

Q. 43

Best parameter by USG to assess fetal maturity:

 A

Crown rump length at 16 weeks

 B

Head circumference at 36 weeks

 C

Biparietel diameter at 12 weeks

 D

Femur length at 12 weeks

Ans. C

Explanation:

Ans. Biparietel diameter at 12 weeks


Q. 44

Pseudokidney sign’ on USG is seen in

 A

Trichobezoar

 B

CA stomach

 C

CA kidney

 D

Polycystic kidney

Q. 44

Pseudokidney sign’ on USG is seen in

 A

Trichobezoar

 B

CA stomach

 C

CA kidney

 D

Polycystic kidney

Ans. B

Explanation:

Ans. CA stomach


Q. 45

An elderly man presents with a history of jaundice and pain abdomen. The investigation of choice is:

 A

Ultrasound

 B

4-quadrant aspiration

 C

CT scan

 D

X-ray abdomen

Q. 45

An elderly man presents with a history of jaundice and pain abdomen. The investigation of choice is:

 A

Ultrasound

 B

4-quadrant aspiration

 C

CT scan

 D

X-ray abdomen

Ans. A

Explanation:

Ans. Ultrasound


Q. 46

Antenatal diagnosis of hydrocephalus is done by:

 A

USG

 B

AFP estimation

 C

Foetoscopy

 D

Aminocentesis

Q. 46

Antenatal diagnosis of hydrocephalus is done by:

 A

USG

 B

AFP estimation

 C

Foetoscopy

 D

Aminocentesis

Ans. A

Explanation:

Ans. USG


Q. 47

Acoustic shadow on USG is due to:

 A

Reflection

 B

Refraction

 C

Artefact

 D

Absorption of waves

Q. 47

Acoustic shadow on USG is due to:

 A

Reflection

 B

Refraction

 C

Artefact

 D

Absorption of waves

Ans. A

Explanation:

Ans. Reflection


Q. 48

The earliest congenital malformation that can he detected on USG:

 A

Anencephaly

 B

Hydrocephalus

 C

Sacral agenesis

 D

Down’s syndrome

Q. 48

The earliest congenital malformation that can he detected on USG:

 A

Anencephaly

 B

Hydrocephalus

 C

Sacral agenesis

 D

Down’s syndrome

Ans. A

Explanation:

Ans. Anencephaly


Q. 49

An ideal imaging method for diagnosing hydro-cephalus in an infant is:

 A

Plain X-ray

 B

CT scan

 C

Ultrasound

 D

MRI

Q. 49

An ideal imaging method for diagnosing hydro-cephalus in an infant is:

 A

Plain X-ray

 B

CT scan

 C

Ultrasound

 D

MRI

Ans. C

Explanation:

Ans. Ultrasound


Q. 50

A neonate presents with congestive heart failure, on examination enlarging fontanelIae, bruit on auscultation, on USG shows midline hypoechoeic lesion, most likely diagnosis:

 A

Malformation of vein of galen

 B

Aqueduct stenosis

 C

Arachnoid cyst

 D

Medulloblastoma.

Q. 50

A neonate presents with congestive heart failure, on examination enlarging fontanelIae, bruit on auscultation, on USG shows midline hypoechoeic lesion, most likely diagnosis:

 A

Malformation of vein of galen

 B

Aqueduct stenosis

 C

Arachnoid cyst

 D

Medulloblastoma.

Ans. A

Explanation:

Ans. Malformation of vein of galen


Q. 51

Lactating women with painful breast, 1st investigation to be done should be:

 A

USG

 B

Mammography

 C

CT

 D

MR1

Q. 51

Lactating women with painful breast, 1st investigation to be done should be:

 A

USG

 B

Mammography

 C

CT

 D

MR1

Ans. A

Explanation:

Ans. USG


Q. 52

A 14 year old obese child is referred from an endocrinologist for painful limping of hip.Which of the following investigation is least useful in this clinical setting?

 A

CT

 B

USG

 C

MRI

 D

X-ray PBH

Q. 52

A 14 year old obese child is referred from an endocrinologist for painful limping of hip.Which of the following investigation is least useful in this clinical setting?

 A

CT

 B

USG

 C

MRI

 D

X-ray PBH

Ans. B

Explanation:

Ans. USG


Q. 53

Appearance of Ovaries on USG Photograph is found in

 A

 Ovarian cyst

 B

 PCOD 

 C

Ovarian cancer

 D

Teratoma cyst

Q. 53

Appearance of Ovaries on USG Photograph is found in

 A

 Ovarian cyst

 B

 PCOD 

 C

Ovarian cancer

 D

Teratoma cyst

Ans. B

Explanation:

PCOD (UsG feature: String of pearls/ Necklace appearance


Q. 54

If a lump is found in pregnancy as shown in the photograph below, Initial investigation of choice is ? 

 A

Mammography.

 B

USG.

 C

MRI.

 D

Biopsy.

Q. 54

If a lump is found in pregnancy as shown in the photograph below, Initial investigation of choice is ? 

 A

Mammography.

 B

USG.

 C

MRI.

 D

Biopsy.

Ans. B

Explanation:

If a lump is found in pregnancy as shown in the photograph above, USG is the initial investigation of choice as there is possibility of breast cancer.


Q. 55

A patient has a surgical cause of obstructive jaundice. USG can tell all of the following except

 A

Biliary tree obstruction

 B

Peritoneal deposits

 C

Gall bladder stones

 D

Ascites

Q. 55

A patient has a surgical cause of obstructive jaundice. USG can tell all of the following except

 A

Biliary tree obstruction

 B

Peritoneal deposits

 C

Gall bladder stones

 D

Ascites

Ans. B

Explanation:

Ans. b. Peritoneal deposits

  • Peritoneal deposits are not detected by ultrasound. Even CECT can miss the peritoneal deposits. Best investigation for diagnosis of peritoneal deposits is diagnostic laparoscopy.

Ultrasound:

  • Initial imaging modality of choice in obstructive jaundiceQ
  • It can identify intra- and extrahepatic biliary dilatationQ
  • Ascites can be detected by ultrasound.
  • USG is IOC for acute calculous cholecystitis, chronic cholecystitis and cholilithiasis

Ultrasonography

  • Initial imaging modality of choice in obstructive jaundice°
  • It is operator dependent and maybe suboptimal due to excessive body fat and intraluminal bowel gasp

USG can demonstrate

Size of GB and CBDQ Biliary calculiQ
Thickness of GB wall Occasionally, presence of stones within the biliary treeQ
Presence of inflammationQaround GB  

Ultrasonography

USG in obstructive jaundice

  • Initial imaging modality of choice in obstructive jaundiceQ
  • It can identify intra- and extrahepatic biliary dilatationQ
  • Identify the level of obstructionQ
  • Cause of the obstruction’) may also be identified (gallstones in the gall bladder, common hepatic or CBD stones or lesions in the wall of the duct suggestive of a cholangiocarcinoma or enlargement of the pancreatic head indicative of a pancreatic carcinoma)Q

Q. 56

A female presents with 8 weeks amenorrhea with pain left lower abdomen. On USG, there was thick endometrium with mass in lateral adnexa. Most probable diagnosis

 A

Ectopic pregnancy

 B

Torsion of dermoid cyst

 C

Tubo-ovarian mass

 D

Hydrosalpinx

Q. 56

A female presents with 8 weeks amenorrhea with pain left lower abdomen. On USG, there was thick endometrium with mass in lateral adnexa. Most probable diagnosis

 A

Ectopic pregnancy

 B

Torsion of dermoid cyst

 C

Tubo-ovarian mass

 D

Hydrosalpinx

Ans. A

Explanation:

Ans. a. Ectopic pregnancy

  • A female with 8 weeks amenorrhea with pain left lower abdomen and on USG, thick endometrium with mass in lateral adnexa is suggestive of ectopic pregnancy

Q. 57

Investigation of choice forF’acute appendicitis in children:

 A

CT scan

 B

Ultrasound

 C

MRI

 D

X-ray

Q. 57

Investigation of choice forF’acute appendicitis in children:

 A

CT scan

 B

Ultrasound

 C

MRI

 D

X-ray

Ans. B

Explanation:

Ans. b. Ultrasound


Q. 58

First trimester USG finding in Down syndrome‑

 A

Nuchal thickening

 B

Nuchal translucency

 C

Cardiac anomalies

 D

GI anomalies

Q. 58

First trimester USG finding in Down syndrome‑

 A

Nuchal thickening

 B

Nuchal translucency

 C

Cardiac anomalies

 D

GI anomalies

Ans. B

Explanation:

Ans. is ‘b’ i.e., Nuchal translucency



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