Judy Choe Oral Boards remembrances 2004 This is a long handout I’m sorry, but I tried to be as complete as possible. As I was studying, I realized that many of the old board recalls were not very helpful when no description was presented. So I tried to remember the images that were presented to me. I’m actually quite impressed that I remembered almost all of my cases .As I started the exam I thought to myself that this was going to be the longest 4.5 hours ever and there would be no way I could remember all the cases but I was wrong on both accounts. My number one advice: if you get totally confused on your first case in your first section (which I did), don’t dwell on it. Move on! I was luckily able to do this and felt confident for the remaining sections. Advice number two: don’t stay in the Executive West if you go a day early because it is the most depressing brown hotel ever. A. Nuclear Medicine—think I may have conditioned this section. The lady examiner was by far the most stern and unnerving of anyone else there that I had. What a way to start out my test! 1. I123 thyroid study post thyroidectomy for cancer. Couldn’t even tell what the first study was. Thought it was a gallium study except there was very little liver activity. Multiple masses of increased activity over the neck and increased activity in the lungs. After stumbling along, I was finally told that the lady had thyroid cancer and then I was able to piece together that this was an Iodine study. She had metastatic lesions in her lungs and multiple residual masses in her neck and involved lymph nodes. Ex: what dose would you give to treat. Me: 100-200 mCi. Ex: Which do you favor of the two? Me: 200 given the extensive metastasis. 2. Metastatic colon cancer. Bone scan with increased activity involving the right scapula. Focal increased activity in the left lumbar spine. Talked about Paget’s disease at first. Examiner pointed me to the area of the liver which had heterogeneously subtle increased activity. Also noted another focal rib abnormality after that. Examiner then told me patient had history of colon cancer. Me: Mets 3. UPJ obstruction in an infant.Renogram in a newborn demonstrating normal right kidney activity. Left kidney was enlarged with peripheral activity but no central activity. Delayed scan showed activity in the central previously photopenic area but no clearance in either kidney. Me: Worried about obstruction, but also considering a mass such as a mesoblastic nephroma. However, a lasix exam is necessary to differentiate between functional vs. mech obstx. She showed me a lasix renogram which showed no clearance on the left (nl on the right). Me: This looks like a mechanical obstruction. I favor a UPJ obstruction causing hydronephrosis. 4. Reversible myocardial ischemia. Cardiac perfusion study showing decreased activity in the inferior lateral and posterior wall on stress which reversed with rest. Me: This is consistent with reversible ischemia, in the L Cx and RCA distribution. I also commented on mild left ventricular dilatation with stress compared to rest. She asked me what that meant. I said, this is seen with myocardial dysfunction. She asked me a couple more questions about that which I kind of stumbled on. 5. FDG PET demonstrating a hypermetabolic ring lesion in the posterior fossae.PET FDG study through the brain. Initially shown coronal images and no history given. I couldn’t seen anything abnormal at first and started talking about how these studies are sometimes done for people with seizures but I didn’t see anything abnormal in the medial temporal lobes. She then told me the patient had ataxia and showed me axial images. There was a “ring” lesion with peripheral increased activity and central photopenia. Me: I was thrown off because the finding was not expected since I thought we were looking for an interictal focus. Anyway, I think I talked about metastatic disease and neoplasm. 6. Metastatic esophageal carcinoma on PET.FDG PET cine study showing a large mass in the mediastinum which looked posterior. Also a focal area of focal increased activity in the region of the anterior aspect of left lobe of the liver. I talked about lymphoma with possible metastatic disease in the liver. She asked me to look at the mediastinal mass again and then provided axial images. Me: looks like it may be middle mediastinum, possible esophageal with metastatic disease. She asked me where can esophageal cancer metastasize to? Me: direct to the aorta and adjacent structures. Examiner: where else should we be looking for metastasis? Me: Said I wasn’t sure but gave some guesses. 7. Tc99m MIBI cardiac study. Showed a planar 180 degree study of the heart with markedly decreased activity. Only a focal area of increased activity, not conforming to the heart. Had a hard time determining what the study was. She told me the patient had chest pain. She then showed me an axial which showed decreased activity in the heart with increased activity in the gallbladder. She asked me what pharmaceuticals can be used for cardiac studies. Me : Tc 99m sestamibi. The bell than rang and I had to go. 8. VQ scan with RUL mismatch and abnormal CXR. ULTRASOUND—nice guy. Straightforward cases with histories up front. The cine images were actually very good and they would play them for you several times. I was not shown any normal anatomy type of question. 1. Classic ectopic pregnancy with free fluid. Me: mentioned ruptured ectopic pregnancy since there was free fluid. He asked me what I would do. Me: if no heart beat, nonruptured, or less than 3.5 cm, would give methotrexate. Otherwise can do surgery. 2. Retroperitoneal lymph nodes. Abdominal ultrasound through the aorta and retroperitoneum with multiple low density lymph nodes. Me: Differential includes lymphoma, metastatic disease, TB. 3. Intussusceptions 4. Multiple small bowel loops will wall thickening. Mentioned HSP, HUS, ischemia, infectious colitis. 5. Choroid plexus cysts.Transabdominal pregnancy: Fetal head with bilateral choroids plexus cysts. Talked about association with Trisomy 18 and other findings. 6. Omphalocele. Also showed cardiac abnormality. Me: looks like a VSD or an endocardial cushion defect. Omphalocele can be associated with other abnormalities and so I recommended complete careful fetal anatomic survey. 7. Mild stenosis in the ICA. Carotid CCA and ICA ultrasound showing a calcified plaque. No Doppler aliasing. Pulsed Doppler waveform shows max velocity of 70 cm/s. Me: mild stenosis but not significant. Ex: would you treat this? Me: No. 8. Testicular ultrasound with septated fluid collection. It didn’t look like a classic hydrocele which would surround the entire testicle, because it was centered in the epididymis .but it seemed to be too big for a spermatocele or epididymal cyst. I mentioned the epididymal ddx and then a pyocele or post traumatic hydrocele. He let me go early. MSK—quiet guy but did his best to try to answer any pertinent questions to help me cinch my diagnosis. I had problems with one of the cases (elbow MRI) and after waffling through it and thinking outloud of possible ddx’s, he didn’t prolong the agony. 1. ABC. Lytic expansile lesion in the distal fibula with a satellite lesion just above it, cortically based, in a child. Me: talked about ABC, UBC, NOF, or infection. E: no fever or leukocytosis. Just pain. Me: favor ABC. He showed me an MRI which showed fluid fluid levels. Me: ABC 2. Sarcoidosis.Bilateral hand xrays with multiple lytic lace-like lesions in the hands. Me: sarcoidosis. 3. Tarsal coalition on plain films. He then showed me a confirmatory CT after I mentioned the pertinent findings on xray. 4. Pagets of the proximal tibia. Permeative subtle lytic lesion in the proximal tibia with a flame shaped border. Me: favor Paget’s disease. Would like to see a bone scan to see if there are other lesions. 5. Elbow MRI. Shown a plain film radiograph of the elbow in a child. Not told the age but shown irregularity along the medial growth plate and olecranon 2ndary ossification center. Me: avulsion fx of the medial epicondyle. Next shown an elbow MRI which did not really help me. Actually saw increased signal in the capitellum. I talked about avulsive fractures, though this was on the opposite side than the plain film findings. No increased signal in the medial or lateral epicondyle or associated inserting muscle fibers. 6. Juvenile RA. Lateral radiograph of the cervical spine in a teenager. Marked enlargement in the atlantoaxial space. I talked about JRA but said it would be more typical to have facet joint fusion. He asked me what else I wanted to do. I mentioned flexion/ext views but would be slightly scared to do it in this patient. Next shown a flex/ext without any change (no subluxation). I recommended an MRI to see if there was a pannus that enhanced. 7. Talar insufficiency fracture?Ankle xray showing sclerosis of the talar bone. No narrowing of the joint space or erosions. Associated soft tissue swelling. Me: suggested possibility of a stress fracture. Ankle MRI with dark signal on T1 in the lateral talar dome. T2 lengthening in this area with surrounding joint fluid. Me: may represent a fracture though I don’t see a hypodense linear line on T1 as would be expected in a fracture. Less likely considerations are a benign tumor such as a chondroblastoma. He then reminded me the patient was old. I went back to my stress fracture with surrounding edema. 8. Gout. (Rob and James say they got a Reiter’s case—which this may have been). frontal and oblique views of the forefoot and midfoot. Small erosions along the 5th PIP and elsewhere. Soft tissue swelling along the 1st toe. Me: Gout. Was not given a history to lead me one way or another. 9. Anterior labral tear.MRI gadolinium arthrogram: No rotator cuff tear but there was irregularity in the anterior labrum. Me: anterior labral tear. Not sure if this is what it was. He didn’t say much. Rob says he got the same case and he said SLAP lesion. PEDIATRICS—very nice guy with good histories and good answers to any pertinent questions I had to help me narrow my differential. Got a history before every case. 1. Intussuception via ultrasound. 2. Grade IV germinal matrix hemorrhage via US 3. UBC or ABV in the mandible. Frontal radiogram of the jaw showing a lytic lesion in the inferior left mandible, adjacent to the root of several molars with mild thinning of the adjacent cortex. Me: fibrous dysplasia, ABC or UBC, or odontogenic keratocyst. Ex: the boy had jaw pain. I requested other imaging to evaluate the matrix or if there is a soft tissue mass. Ct showed a lytic lesion with soft tissue mass. No ground glass matrix. Me: UBC or ABC or EG.. 4. VSD. Frontal Chest xray with acyanotic history. Mild edema with mild enlargement of the LA. I mentioned VSD and mitral stenosis, less likely. 5. Hemangioblastoma. Abdominal Ct showing a calcified heterogeneous mass in the liver in a child. Me: hemangioblastoma. Less likely NB mets 6. Arnold Chiari II.Lateral radiograph with a large soft tissue mass arising from the lumbar spine. Me: myelomeningocele. I’d like to image the brain to look for a chiari malformation. Shown a MRI with classic findings of chiari II. Then shown a plain radiograph of the skull showing deformity with convolutional markings. E: what is that finding called? Me: luckanshadel skull. 7. Rib lesion.Frontal chest xray with an opacity in the RUL with lytic expansion of one of the posterior ribs and widening of the adjacent upper two rib spaces. Me: Ewing’s sarcoma or PNET tumor. Recommend CT. 8. NAT—was shown a pancreatic transection with diffuse ascites and bowel wall thickening and abnormal enhancement. After talking about the findings, I suggested trauma and given the pancreatic transaction, wanted to evaluate the head for possible NAT. Was shown classic subdural hematomas of varying ages. I was shown several other cases, but can’t remember them. CHEST—Examiner just whipped through the cases without any feedback or any significant secondary questions. She said she wanted to try to go through as many cases as possible. 1. Alveolar proteinosis. Ground glass opacities in the mid and lower lung zones bilaterally. Went into a diff dx and asked for a CT. Classic alveolar proteinosis. Also included hypersensitivity pneumonia or pulmonary edema/hemorrhage or PCP if immunocompromised. 2. Annuloaortic ectasia. MRI demonstrated aneurysmal dilatation of the asc. aorta. Me: AS, CTD such as Marfans or Ehler’s danlos, or syphilis. 3. Post trauma pulmonary contusion. Post trauma CXR with left upper lobe consolidation with air bronchograms. No shift if mediastinal NGT or EGT which were midline. Wide mediastinum. Me: Aortic injury though the classic signs are not all there including midline shift, depressed mainstem bronchus. Ex: what else would you include in your diff for the lung findings? Me: pulmonary contusion. She then showed me a follow-up xray 3 days later with near complete resolution. Me: pulm contusion, but the aorta was still wide so I recommended a CT with contrast. 4. Mediastinal cyst. Non contrast CT showing a fluid density mass anterior to the pericardium. Me: pericardial cyst, bronchogenic cyst though it is an unusual location, and thymic cyst. If this were a younger patient, I would also include a lymphangioma. 5. Pancoast tumor. Right apical opacity. Me: either TB if the patient is symptomatic or bronchogenic cancer causing a pancoast tumor. I recommended an MRI for further evaluation if pancoast was a consideration. 6. Miliary infection such as TB.Diffuse random military nodules in a febrile patient. Me: Miliary TB or fungal disease such as histoplasmosis. If patient is not febrile I would also consider silicosis or sarcoid. 7. Cystic fibrosis. Classic cystic fibrosis on plain radiograph. 8. IPF. Bilateral lower lung zone and peripheral zone reticular opacities: IPF. No shoulder changes visible to suggest RA or pleural plaques to suggest asbestosis, though they are in the differential. 9. I was shown a case with normal heart size but enlargement of the main pulmonary artery segment and maybe the bilateral central arteries. The history however was of cyanosis or something totally not concordant with pulmary hypertension. Not sure what this case was. 10. Double aortic arch. Plain film with fullness in the mediastinum (difficult to tell if there was only 1 right arch or a double arch). Pt with wheezing. Me: worry about a double aortic arch or vascular ring with a right arch and aberrant L subclavian. Recommend MRI for further eval. Shown MRI with classic double aortic arch on multiple projections. GI—probably the nicest examiner. He loved my differentials and never really asked me for my number one dx. In fact, he would let me give 3-4 differentials, and then would give me pertinent follow up history so that I could cinch the number one diagnosis. 1. Thumbprinting in the transverse colon. Me: ischemia, infection ( he asked me which), pseudomembranous colitis. 2. Metastatic breast CA to the stomach. Multiple nodular filling defects in the stomach almost looked like thick nodular gastric fold thickening. Me: polyposis syndromes such as Peutz jegher, lymphoma, zollinger Ellison syndrome though I commented that there were no ulcers in the duodenum, Kaposi’s sarcoma if immunocompromised. He then mentioned the lady had breast cancer. On further eval of the polypoid lesions, I saw one bull’s eye lesion: I said definitely metastatic disease. 3. SBFT with a focal small area of aneursymal dilatation in the RLQ. Me: lymphoma. E: what else? Me: maybe peritoneal metastasis or endometriosis. 4. Pseudomyoma peritonii on CT. Wanted to know what could cause it. Also, is there an infectious cause? 5. Intussuception on CT. CT showing marked dilatation of the 2nd portion of the duodenum but with decompression distally past the SMA with what looked like intussuception. He asked me about intussuception in adults. Talked a little about that. 6. Nonenhancing liver lesions. Axial Ct with multiple low density small nonenhancing lesion in the liver. Me: metastatic disease, abscesses. He asked me a couple questions about that. 7. Colon cancer with calcified or hemorrhagic mets to the liver. Axial CT with high density areas in the liver with surrounding low edema. Lower images showed a right lower quadrant mass with wall thickening. Me: Primary consideration is cecal carcinoma with hemorrhagic mets. He then told me the high density areas were calcification. So I said, calcified mets can be seen with mucinous carcinoma of the colon. 8. CMV or HIV esophagitis. Single contrast esophagram with a large ulcerating lesion at the distal esophagus. Me: Large esophageal carcinoma or leiomyoma or spindle cell tumor with ulceration. Ex: what if the pt has AIDs? Me: could also represent a giant ulcer seen with CMV or HIV esophagitis. 9. Small bowel diverticulosis. Single contrast SBFT with multiple moderately sized outpouchings/diverticula. Hx of diarrhea. Mentioned jejunal and ileal diverticulosis or scleroderma. 10. Focal nodular hyperplasia on CT. Talked about differentiating it from fibrolamellar carcinoma by looking at the signal of the central scar on T2WI as well as doing a sulfur colloid study. GU—my second hardest section. Nice guy but very business like who informed me upfront that he wanted to do as many cases as possible. Other than giving me the initial 1 sentence history, if I asked secondary questions he’d look on his sheet of paper and say, all I’m told is that this is a 67 year old female with abdominal pain ..not helpful at all. 1. RUG showing normal cowper’s gland with a more proximal stricture in the region of the prostatic urethra, adjacent to the normal appearing posterior urethra. Not exactly sure what I was looking at or for .don’t worry, this wasn’t my first case. So, after nailing a couple of cases beforehand I basically made some stuff up about what I saw, and basically told him I really didn’t know what the meaning of the findings were in this case. He asked me a couple of secondary questions about anatomy on the RUG and then moved on. 2. ADPCKDContrast Ct with multiple bilateral renal cysts, renal enlargement, hepatic cysts, and pancreatic cysts. Me: ADPCK, VHL, or TS. I favored the polycystic disease. We talked about the disease and whether all the cysts looked simple. There was one that had a single enhancing lesion within it. Me: can’t exclude cystic RCC. Recommend biopsy. 3. Post radiation vesico-enteric(rectal) fistula. Plain xray of the pelvis with clips in the pelvis near the symphysis pubis. After being led, finally discovered these clips were secondary to radiation seeds for history of prostate cancer. Then showed a voiding cystogram. HE asked me what the study was. Demonstrated a fistula between the bladder and rectum . Me: Enteric vesicular fistula secondary to radiation therapy. He asked me a couple questions about prostate cancer and whether I knew what it was about the rectum that made it pretty resilient to radiation change. Me: don’t know. 4. Medullary calcinosis. plain xray showing calcification within the collecting systems of both kidneys. Looked like medullary nephrocalcinosis. Talked about the diff dx. Then was shown a retrograde pyelogram showing filling defects in the collecting system. Talked a bit about how the appearance looked like papillary necrosis but the filling defects may have been secondary to the collecting system stones. 5. Contrast nephropathy. Axial noncontrast CT in a patient s/p cardiac cath 24 hours previously. H/o diabetes. Kidneys showed a striated nephrogram pattern. I mentioned that since there was no contrast given in this exam, this was consistent with retained contrast secondary to renal dysfunction. I gave a differential including ATN and AIN. I mentioned that if this patient was symptomatic during the injection of contrast during her procedure, this could represent an allergic reaction but the patient would have had symptoms. He asked me to elaborate on that. James C had the same exact case. I don’t recall exactly using the words contrast nephropathy but in retrospect that is what this was. 6. Adenomyosis and filling defects in the uterus (ddx).Hysterosalpingogram. He asked me what the exam was. Saw multiple filling defects within the pelvis and the fallopian tubes were very small and kind of elongated. Not sure of the significance of that. I talked about polyps, synechia, blood clots, or endometrial carcinoma. He didn’t seem that impressed. So I also noted some outpouchings from the endometrium resembling adenomyosis, so I also mentioned that but didn’t know how to tie the two findings together. He went on to the next case. 7.Adrenal adenoma. Small homogeneous mass in the right adrenal with HU of -4. Me: adrenal adenoma. Examiner: Anything else you want to include in your differential. Me: I guess you could include an adrenal myelolipoma. He said, with that fat density? I said, well, the lesion does have fat. But I favored adrenal adenoma. He said how sure are you. I said I’m positive given the HU less than 10. Perhaps I should have mentioned that if there was a question, you could get in phase and out of phase MRI chemical shift imaging. 8. Duplicated left kidney or crossed fused ectopia post trauma with a urinoma.Axial post contrast through the kidneys showing absence of the right kidney with a duplicated left kidney or crossed ectopic kidneys on the left. Superior kidney had normal enhancement with a focal area of irregularity anterior wall with perinephric fluid of low density. More inferiorly, the inferior kidney had poor enhancement with a high density fluid collection anteriorly. Me; Urinoma with active contrast extravasation into the perinephric fluid. Lower pole kidney moiety does not function as well as the upper and went on with that for awhile. He asked me what I would do to treat the urinoma. Me: perc drainage as well as double J stent. 9. Emphysematous cystitis Axial post contrast CT through the bladder showing a focal outpouching anteriorly from the bladder which was half filled with contrast and urine. The focal outpouching was smooth and thin walled and had a small amount of gas within it. I started talking about a urachal diverticulum but given the air was wondering about a urachal sinus though the images didn’t include that. I asked if the patient had had a foley catheter. He said no. I questioned the air in the bladder. Examiner: what if this pt had fevers and chills? I said, possible emphysematous cystitis. He asked me what would cause that. I had a brain fart and started talking about H. influenza and clostridium. He asked me what was the most common infectx agent in the bladder. Me: E coli! 10. Polyarteritis nodosa. Large ill defined kidney on a noncontrast study with surrounding perirenal fluid and fat stranding. Large amount of fluid surrounding the kidney. Later got an angio which showed multiple small microaneurysms at the distal branches. Me: polyarteritis nodosa or microabscess is hx of IVDA/fevers. EX: no hx of IVDA. What else? Me: other vasculitis. Ex: such as? Me: (oh great .just started guessing. Don’t go down this path unless you have an answer). VIR—nice guy but very intense and serious about what he was doing there. A no nonsense kind of guy. By far, he asked me the most management and follow up type of questions and quite a lot of them. 1. Atherosclerosis involving the left subclavian artery and internal carotid. Also talked about takayasu’s if the patient were younger. There also was stenosis of the internal carotid artery. He asked me the workup for treatment and what would be the indication for stenting versus endarterectomy. 2. Aortoenteric fistula on CT. Aortic aneurysm with saccular aneurysm on Ct. Mentioned possible post traumatic etiology or mycotic aneurysm given the saccular configuration. There also was contrast in the adjacent duodenum which was a non-GI contrast study: Aortoenteric fistula on CT. 3. Chronic PE. Pulmonary angiogram with attenuation of lower lung zone pulmonary arteries. Later given hx of LE DVT. Me: chronic PE. What would you do to help treat? The answer he wanted was IVC filter placement. 4. Renal artery ostial atherosclerosis. Renal artery ostial smooth narrowing. Talked about atherosclerosis and disease causing renin induced HTN. Also about FMD. Anyways, asked about treatment. I said stent with a balloon expandable stent. 5. Bleeder off the popliteal artery post trauma. Trauma with comminuted femoral fracture with extravasation from a small branch of the popliteal artery with delayed arterial phase showing a large amount of hemorrhage. There was a small pseudoaneurysm. Asked treatment. Me: embolize. 6. Acute embolic obstx of the SMA. History given first of a lady in the ER with acute excruciating abd pain. Asked me what I was thinking of and how I would work it up. Me: acute embolic occlusion of the SMA. Recommended an abdominal aortogram. He asked me what projection I wanted to do. Me: Lateral. SMA embolism noted with collateral circulation. Asked me treatment and tried to talk me out of going to the OR. But I didn’t buy it. 7. Right aortic arch with diverticulum of Kommerell at the origin of the aberrant left subclavian artery. 8. There was another case with a pseudoaneurysm where he asked me how I would treat and where I would place my coils. I think it was a bleeding GDA or one of the mesenteric vessels. 9. Proximal common duct stricture on ERCP with intrahepatic duct dilatation.ERCP showing a focal narrowing in the proximal common duct but distal to the convergence of the R and L hilar ducts, so not a typical klatskin location (more hilar). I talked about extrinsic impression by LAN or cholangiocarcinoma in this location. I also talked about the more typical klatskin tumor location and what kinds of things could happen distally. (he then said the patient had had lymphoma with radiation and asked me if radiation could cause this appearance). MAMMO—nice straightforward guy with typical histories for each case. He asked a lot of management questions in terms of how to biopsy, how many cores would I take, etc. 1. Malignant calcifications. 2. Simple cyst 3. Birads 4 lesion on Mammo and US. 4. Radial scar, fat necrosis, or invasive DC differential. 5. Dense breast with fat necrosis type of lucent round calcifications. Later given hx of lumpectomy. Me: hematoma with fat necrosis. 6. Wanted to know how to do a ductogram (know Contrast—I was asked! CONRAY 60) and how to manage multiple papillomas type of lesions. 7. Another birads 2 lesion 8. Another birads 4 lesion with US and plain films. 9. Nonspecific lesion on Mammo. On US it was low density with multiple septations that were echogenic. Diff included PASH, complex FA, but cannot exclude malignancy so I recommended biopsy. Birads 4. 10. Some ancillary questions having to deal with atypical ductal hyperplasia and management, radial scar and its management. NEURO—nice guy with zero feedback. No history provided in any of the images. 1. Arachnoid cyst in the lower thoracic spine. Ex asked me what are the classic locations for an arachnoid cyst. 2. Epidermoid cyst along the lateral aspect of the medulla. Bright on T1 with diffusion weighted images later shown. 3. Partially thrombosed aneurysm with a hemosiderin and bright blood fluid level in the posterior fossae. Kind of a tricky case b/c all I was initially given was a T1 which showed a round bright lesion near the medulla which was uniform in signal. I initially thought it was an dermoid/epidermoid. 4. PICA infarct with vertebral artery dissection. I suggested an angio should be done to evaluate for vertebral artery dissection. Was then shown an MRA with absence of the right vertebral. 5. Neurosarcoid. Started with lateral T1 and T2 WI of the spine with slightly iso and hypointense signal posterior to the cord. Actually quite subtle with change in the CSF bright signal only seen on the superior aspect of the film. Asked for contrast enhancement before offering a differential. Was then shown multiple views of the brain which included markedly enhancing bicerebral hemisphere extraaxial densities (dark on T2). 6. Moya moya with flow voids in the basal ganglia. Asked for an angio to clinch the diagnosis. 7. Weird case with axial CT showing slightly hyperdense well circumb round lesions adjacent to the frontal horn, bilaterally, as well as along the medial aspect of the left lateral atria. Enhanced on contrast. Initially suggested tuberous sclerosis but the examiner said the patient was not retarded. Then went into an intraventricular /periventricular tumor ddx in an adult including meningioma or ependymoma/subependymoma. He asked me what my #1 diagnosis was. 8.Bilateral paragangliomas. Lytic lesion in the left jugular fossae in the skull base on CT. Talked about mets, MM. Asked for a post contrast study or soft tissue windows to evaluate for a soft tissue component. Was given a MRI which didn’t show a classic but somewhat salt and pepper appearing mass. I suggested paraganglioma/glomus tumor. He said what else do you want to do? I asked for an angio which he showed me and asked what vessel would you inject or be concerned about (ECA) and what other vessels? What he was getting at is the contralateral side which he later showed me which also had a carotid body tumor. I guess there is a bilateral association which I did not know about. I think I was shown about 2 other cases ..can’t remember them. Start studying early ..i went through the case review books at least twice. I also did some ACR discs but there were just too many of them. (The nucs, peds, and MSK are very good). Cardenosa’s book is all you need for mammo. The UCSD and UCSF review notes were actually very good for certain sections (Cardiovascular disease at UCSF, Ben Yeh’s UCSF renal review, the UCSF unknown conferences with picture handouts—though photocopies, UCSD obstetric US, Doppler US, and RUG/Hysterosalpingogram lectures by Meg Richman). I actually bought Eisenberg’s full text GI book: a pattern approach because we don’t see very many UGI/SBFT/BE pathology and it has a great approach with DDX’s at the beginning. You can check this book out from our library. Felix Chew’s book of MSK unknowns was also awesome. Dr. Smith’s lecture is all you need for VIR, but make sure you see some pictures—I used the new requisites series text in the Coleman library and just flipped through the pictures of the pertinent topics. Finally also read Duke’s case review as well as the Aunt Minnie text book. Felt like we were the least prepared for nucs and GU because we don’t have dedicated reviews for these subjects among other things, so perhaps pay more attention to those subjects .good luck!