1) ENDOCRINE SYSTEM Flashcards by Syed Shah

Which of the following features of Graves disease does not improve with Antithyroid therapy?

a) Tremor
b) Anxiety
c) Graves Dermopathy
d) GIT Disturbances
e) Exophthalmos

E) Exophthalmos

Exophthalmos is the only symptom that is resistant to ATDs.

o RAI is contraindicated in patient’s with Exophthalmos.
o Recommended therapy:
Steroids —- ATDs —- Surgery.

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A 40-year-old female presents with a large thyroid nodule. Workup & subsequent resection demonstrate a 4 cm papillary thyroid CA with positive lymph nodes and local extension but no evidence of Distant disease. What stage is her cancer?

a) Stage 1
b) Stage 2
c) Stage 3
d) Stage 4
e) Stage 5

A) Stage 1

Age is the most important factor in thyroid cancer. According to 8th edition of AJCC, the patients with age <55 can only be classified as Stage 1 or Stage 2:

Stage 1: No distant Metastasis
Stage 2: Distant Metastasis.

Thus, lymph node status & size of the tumor are not taken into consideration.

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A 46-year-old female with a 3 cm palpable right sided thyroid nodule has a FNA performed, which is reported as Non-diagnostic. What is the next best step?

a) Repeat FNA
b) Core Needle Biopsy
c) Right thyroid Lobectomy
d) Total Thyroidectomy
e) Ultrasound in 6 Months

A) Repeat FNA.

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A 51-year-old male with a 2 cm palpable right sided thyroid nodule has a FNA performed, which is reported as Follicular Lesion of Undetermined Significance [FLUS]. Which of the following is true about this condition?

a) Repeat FNA is not recommended.
b) Molecular testing does not influence management.
c) Right Thyroid Lobectomy is an acceptable option.
d) Total Thyroidectomy is the Next Best Step.
e) Ultrasound follow-up in 6 months in the best option.

c) Right Thyroid Lobectomy is an acceptable option.

The current recommendation is to perform A Repeat FNA.

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The thyroid gland is derived from which embryologic structure?

a) 1st Pharyngeal arch
b) 2nd Pharyngeal pouch
c) 3rd Pharyngeal arch
d) 4th Pharyngeal arch
e) 4th Pharyngeal pouch

a) 1st Pharyngeal arch

Thyroid gland = 1st & 2nd Pharyngeal Arches.
Superior Parathyroid Glands = 4th Pharyngeal Pouch
Inferior Parathyroid Glands = 3rd Pharyngeal Pouch

[ P = Parathyroid = Pouch]

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Which of the following cancers most commonly metastasises to the thyroid?

a) Parathyroid gland
b) Kidney
c) Lung
d) Breast
e) Esophageal CA

B) Kidney

Renal Cell Carcinoma is the most commonly metastasised tumor to the thyroid gland.

Parathyroid gland doesn’t metastasise to thyroid gland.

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Which of the following is true regarding Hurthle Cell Carcinoma?

a) It contains an abundance of oncocytic or oxyphilic cells.
b) Lymph node metastasis is exceedingly rare.
c) Diagnosis of malignancy is usually made by FNA.
d) Residual disease is effectively treated with Iodine 131.
e) Histologically they demonstrate Orphan Annie Cells.

a) It contains an abundance of oncocytic or oxyphilic cells.

Following are the important points regarding Hurthle Cell Carcinoma:
1. Subtype of Follicular Carcinoma & accounts for <10% of thyroid malignancies.
2. Like Follicular Carcinoma, the presence of malignancy is demostrated by Capsular or Vascular Invasion.
3. Like Follicular Carcinoma, FNA doesn’t establish the diagnosis.
4. Residual disease is not effectively treated with RAI because Hurthle Cell CA do not take up radioactive iodine.
5. Hurtle Cell CA is different from Follicular CA as they are highly aggressive and more likely to spread to lymph nodes as compaered to follicular CA.

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Which of the following is true regarding follicular thyroid cancer?

a) It is the most common thyroid malignancy.
b) Commonly spreads via a hematogenous route.
c) Prophylactic nodal dissection is recommended.
d) It is best managed by Hemithyroidectomy.
e) Multicentricity is common.

b) Commonly spreads via a hematogenous route

Following are the important points regarding follicular CA:
1. Multicentricity is uncommon.
2. The presence of malignancy is demostrated by Capsular or Vascular Invasion.
3. If FNA demostrates Follicular Neoplasm, NBS Lobectomy. If histology confirms the diagnosis of Malignancy, then the patient should undergo Total Thyroidectomy.
4. Lymph node dissection is not recommended as the follicular carcinoma doesn’t have lymph nodal spread.

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The most common type of thyroid cancer in children is?

a) Papillary
b) Follicular
c) Medullary
d) Hurthle Cell
e) Anaplastic

a) Papillary

Papillary CA is the most common thyroid malignancy in both children & adults.

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Calcified clumps of cells on histology are consistent with?
a) Papillary
b) Follicular
c) Medullary
d) Hurthle Cell
e) Anaplastic

a) Papillary

Psammoma bodies = Calcified clumps of cells

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A 65-year-old woman with a history of Hashimoto thyroiditis presents with fever, dysphagia and a painless thyroid mass that has enlarged over a short period of time. This most likely represents?

a) Lymphoma
b) Follicular CA
c) Anaplastic CA
d) Acute Suppurative Thyroiditis
e) Medullary Thyroid CA

A) Lymphoma

Hashimoto thyroiditis is the most common cause of Hypothyroidism.
Hashimoto thyroiditis is associated with Lymphoma.
Patient additionally can develop fever, dysphagia and hoarseness of voice.
In a patient with Hashimoto thyroiditis, Lymphoma should be suspected in the setting of a rapidly enlarging thyroid mass.

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After total thyroidectomy & postoperative iodine ablation for a 5 cm follicular thyroid cancer, the best test to monitor for recurrent disease is?

a) Serum TSH
b) Serum Calcitonin
c) Serum Thyroglobulin
d) 131 Iodine Scan
e) U/S Neck

C) Serum Thyroglobulin levels are the most useful modality to monitor patients for recurrence of differentiated thyroid cancer [Papillary & Follicular] after total thyroidectomy & RAI.

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Malignancy within a thyroglossal duct cyst is typically?

a) Follicular CA
b) Papillary CA
c) Squamous CA
d) Anaplastic CA
e) Hurthle Cell CA

B) Papillary CA

Papillary CA is associated with cyst formation.

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After a total thyroidectomy, the right vocal cord is noted to be fixed in a paramedian position. This most likely represents:

A. Injury to the recurrent laryngeal nerve (RLN)
B. Injury to the external branch of the superior laryngeal nerve C. Injury to the internal branch of the superior laryngeal nerve D. Trauma from endotracheal intubation
E. Compression from hematoma

A. Injury to the recurrent laryngeal nerve (RLN)

The RLN innervates the intrinsic muscles of the larynx, except the cricothyroid muscles, which are innervated by the external branch.
Injury to one RLN leads to paralysis of the ipsilateral vocal cord. The cord becomes fixed in either the paramedian position or the abducted position. If the cord becomes fixed in the paramedian position, the patient will have a weak voice, whereas if it becomes fixed in the abducted position, the patient will have a hoarse voice and an ineffective cough.
If both RLNs are injured, an airway obstruction may develop acutely in the patient. of the superior laryngeal nerve.

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During thyroidectomy the superior thyroid arteries were ligated a centimeter away from the thyroid capsule as opposed to immediately adjacent to it. This technical error would most likely result in which of the following complications?

A. Voice fatigue
B. Hoarseness
C. Loss of airway
D. Aspiration
E. Ineffective cough

A. Voice fatigue

The external branch of the superior laryngeal nerve lies on the inferior pharyngeal constrictor muscle and descends alongside the superior thyroid artery before innervating the cricothyroid muscle. Injury to the external superior laryngeal nerve results in an inability to tense the ipsilateral vocal cord and difficulty hitting high notes, projecting the voice, and voice fatigue during a prolonged speech.

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A 45-year-old woman with a history of a goiter presents to the emergency department with a high fever, heart rate of 130 beats per minute, tremors, sweating, and exophthalmos. Which of the following can exacerbate symptoms?

A. Aspirin
B. Propylthiouracil
C. Beta-blocker
D. Methimazole
E. Steroids

A. Aspirin

Aspirin is contraindicated in thyroid storm because it is
thought to decrease protein binding of thyroid hormones. Thus, it may increase the levels of unbound T3 and T4.

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Which of the following is true regarding substernal goiter?

A. Surgical resection should be reserved for patients with tracheal deviation.
B. Most are primary mediastinal goiters with a blood supply arising from intrathoracic vessels.
C. Most can be resected by a cervical incision.
D. Most are highly responsive to prolonged thyroid suppression.
E. Because of the risk of tracheomalacia, most patients should have a prophylactic tracheostomy at the time of resection.

C. Most can be resected by a cervical incision.

Substernal goiter is divided into primary and secondary forms. Primary forms, defined as ones that originate in the mediastinum with blood supply from intrathoracic vessels, are very rare. Most substernal goiters are extensions from cervical goiters. Most surgeons recommend resection for the mere presence of a substernal goiter because most are symptomatic, and those that are not can cause progressive compression of the trachea.

The majority can be successfully removed with a cervical collar incision. Sternotomy is very rarely needed nor is tracheostomy because most can be intubated, even in the face of tracheal compression, with a pediatric endotracheal tube

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The most accurate test for hyperthyroidism is:

A. Free thyroxine (T4)
B. Total T4
C. Total triiodothyronine (T3)
D. Thyroid-stimulating hormone (TSH)
E. Thyroid scan

D. TSH is the most accurate test in hyperthyroidism

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Which of the following is true regarding the blood supply to the thyroid/parathyroid glands?

A. The parathyroid glands are usually supplied by the superior thyroid arteries.
B. The inferior thyroid artery is the first branch of the external carotid artery.
C. The RLNs are at risk of injury during ligation of the superior thyroid arteries.
D. The external branch of the superior laryngeal nerve is at risk of injury when the inferior laryngeal arteries are ligated
E. The thyroidea ima artery usually arises from the aorta.

E. The thyroidea ima artery usually arises from the aorta.

The thyroid gland is supplied by paired superior thyroid arteries from the external carotid arteries and the inferior thyroid arteries from the thyrocervical trunk. The superior thyroid artery is the first branch of the external carotid artery.
During thyroidectomy, care must be taken when ligating the superior thyroid arteries to avoid injury to the external branch of the superior laryngeal nerve.
When ligating the inferior thyroid arteries, care must be taken to avoid injury to the RLNs.
The inferior thyroid arteries usually supply the parathyroid glands (A). Ligation of the main trunk of the inferior thyroid arteries during total thyroidectomy can lead to parathyroid gland ischemia.

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Which of the following is true regarding the laryngeal nerves?

A. The external branch of the superior laryngeal nerve provides sensation to the larynx.
B. Bilateral injury to the superior laryngeal nerves often results in acute airway obstruction.
C. The right RLN separates from the vagus after crossing the subclavian artery.
D. The recurrent laryngeal nerve is both motor and sensory to the larynx.
E. The RLNs provide motor function to the cricothyroid.

C. The right RLN separates from the vagus after crossing the subclavian artery.

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A non-RLN:

A. Does not exist
B. Is more common on the left
C. Can occur in conjunction with a recurrent nerve on the right
D. Loops around the aorta on the right side
E. Is less prone to injury during surgery than a recurrent nerve

C. Can occur in conjunction with a recurrent nerve on the right.

Following are the important points regarding non-RLN:
1. A non-RLN is rare and occurs much more commonly on the right.
2. It branches off the vagus nerve in the neck and heads directly to the larynx, as opposed to arising from the vagus after passing the subclavian artery.
3. The anomalous location, as opposed to its normal position in the tracheoesophageal groove, makes it more prone to injury.
4. On the right, a patient can have both a nonrecurrent nerve and a recurrent nerve.

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Lateral aberrant thyroid in most instances represents:

A. Metastatic papillary carcinoma
B. Metastatic follicular carcinoma
C. Metastatic Hürthle cell carcinoma
D. A congenital lesion related to thyroid descent E. An extension of a thyroglossal duct cyst

A. Metastatic papillary carcinoma

Lateral aberrant thyroid is a term used to denote what appears to be ectopic thyroid tissue found within the neck. In most instances, it actually represents metastatic thyroid cancer within a lymph node, most often of the papillary type.

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A 45-year-old woman presents with a 1.5-cm right thyroid nodule. FNA findings are consistent with papillary carcinoma. Her history is significant for radiation therapy for lymphoma as a child. Optimal management of this patient would consist of:

A. Right hemithyroidectomy
B. Right hemithyroidectomy plus central lymph node dissection
C. Total thyroidectomy
D. Total thyroidectomy with postoperative 131I
E. Total thyroidectomy plus right modified radical neck dissection

C. Total thyroidectomy

TOC for Papillary CA is Total Thyroidectomy.

Following are the indications of RAI:
1. Tumors larger than 4 cm
2. Gross extrathyroidal extension of the tumor regardless of size.
3. Lymph node metastases
4. For high-risk features including tall-cell or columnar-cell variant.

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A 35-year-old woman with a history of previous right thyroidectomy for a benign thyroid nodule now undergoes completion thyroidectomy for a suspicious thyroid mass. Several hours postoperatively, she develops progressive swelling under the incision, stridor, and difficulty breathing. Orotracheal intubation is successful. Which of the following is the most appropriate next step?

a. Fiberoptic laryngoscopy to rule out bilateral vocal cord paralysis
b. Administration of intravenous calcium
c. Administration of broad-spectrum antibiotics and debridement of the wound
d. Wound exploration
e. Administration of high-dose steroids and antihistamines

d. Wound exploration

The clinical presentation is consistent with a wound hematoma and necessitates exploration of the wound, drainage of the hematoma, and identification and control of any bleeding vessels.

If airway compromise is impending, the wound should be opened at the bedside and not delayed until endotracheal intubation or transport to the operating room has been obtained.

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A 55-year-old woman presents with a slow-growing painless mass in her neck. A complete neck ultrasound demonstrates a 1-cm nodule in the right thyroid without masses in the contralateral lobe or lymph node metas- tasis in the central and lateral neck compartments. A fine-needle aspiration of the nodule shows a well-differentiated papillary carcinoma. With regards to this patient, which of the following is associated with a poor prognosis? a. Age b. Sex c. Grade of tumor d. Size of tumor e. Lymph node status

a. Age is a very important prognostic indicator in well-differentiated thyroid cancer (papillary and follicular). Age >55 years is associated with a worse prognosis.

A 55-year-old woman presents with a 6-cm right thyroid mass and palpable cervical lymphadenopathy. Fine-needle aspiration (FNA) of one of the lymph nodes demonstrates the presence of thyroid tissue. Which of the following best describes the management of this thyroid disorder? a. Screening for pancreatic endocrine neoplasms and hypercalcemia b. Total thyroidectomy with modified radical neck dissection c. Total thyroidectomy with frozen section intraoperatively, with modified radical neck dissection reserved for patients with extra-capsular invasion d. Right thyroid lobectomy followed by iodine 131 (131I) therapy e. Right thyroid lobectomy

b. Total thyroidectomy with modified radical neck dissection. Treatment of high-risk papillary carcinomas consists of total thyroidectomy. If patients have lymph node metasta- ses in the lateral neck, concomitant modified radical neck dissection should be performed with total thyroidectomy.

A 29-year-old woman with a history of difficulty becoming pregnant presents to her primary care physician and is diagnosed with Graves disease on iodine uptake scan; her thyrotropin (TSH) level is markedly suppressed and her free thyroxine (T4) level is elevated. She desires to conceive as soon as possible and elects to undergo thyroidectomy. After she is rendered euthyroid with medications preoperatively, which of the following manage- ment strategies should also be employed to reduce the risk of developing thyroid storm in the operating room? a. Drops of Lugol iodine solution daily beginning 10 days preoperatively b. Preoperative treatment with phenoxybenzamine for 3 weeks c. Preoperative treatment with propranolol for 1 week d. Twenty-four hours of corticosteroids preoperatively e. No other preoperative medication is required

a. Drops of Lugol iodine solution daily beginning 10 days preoperatively. Drops of Lugol iodide solution daily beginning 10 days preoperatively should be prescribed to decrease the likeli- hood of postoperative thyroid storm, a manifestation of severe thy- rotoxicosis. Lugol helps to decrease the vascularity of the thyroid itself. Propylthiouracil or methimazole can also be used preoperatively but are contraindicated in pregnant women. In addition, radioactive iodine cannot be used during pregnancy. If thyroid storm occurs, treatment is β-blockade, eg, propranolol.

A 58-year-old man presents with tachycardia, fever, confusion, and vomiting. Workup reveals markedly elevated (triiodothyronine) T3 and (thyroxine) T4 levels. He is diagnosed as having a thyroid storm. Which of the following is the most appropriate next step in the management of this patient? a. Emergent subtotal thyroidectomy b. Emergent total thyroidectomy c. Emergent hemodialysis d. Administration of fluid, antithyroid drugs, b-blockers, iodine solution, and steroids e. Emergent radiation therapy to the neck

d. Administration of fluid, antithyroid drugs, b-blockers, iodine solution, and steroids.

A 36-year-old woman, 20 weeks pregnant, presents with a 1.5-cm right thyroid mass. FNA is consistent with a papillary neoplasm. The mass is cold on scan and solid on ultrasound. Which of the following methods of treatment is contraindicated in this patient? a. Right thyroid lobectomy b. Subtotalthyroidectomy c. Total thyroidectomy d. Total thyroidectomy with lymph node dissection e. 131I radioactive ablation of the thyroid gland

e. Radioactive 131I is contraindicated in pregnancy and should be used with caution in women of childbearing age.

A 63-year-old woman notices lumps on both sides of her neck. A fine- needle aspirate is nondiagnostic, and she undergoes total thyroidectomy. Final pathology reveals a 4-cm Hürthle cell carcinoma. Which of the follow- ing is the most appropriate postsurgical management of this patient? a. No further therapy is indicated b. Chemotherapy c. External beam radiotherapy d. Radioiodine ablation e. Chemotherapy, external beam radiotherapy, and radioiodine ablation

d. Radioiodine ablation The treatment of Hürthle cell carcinoma follows the same principles as follicular carcinoma. Primary treatment is surgical followed by radioiodine ablation. Hürthle cell cancer is a type of follicular cancer, but differs from follicular neoplasms in that it is more often multifocal and bilateral, and is more likely to spread to local nodes and distant sites.

A 51-year-old man presents with a 2-cm left thyroid nodule. Thyroid scan shows a cold lesion. FNA cytology demonstrates follicular cells. Which of the following is the most appropriate initial treatment of this patient? a. External beam radiation to the neck b. Multidrug chemotherapy c. TSH suppression by thyroid hormone d. Prophylactic neck dissection is indicated along with a total thyroidectomy e. Thyroid lobectomy

e. Thyroid lobectomy For lesions less than 4 cm in size, thyroid lobectomy is adequate because at least 80% of follicular lesions are adenomas. For confirmed carcinomas or lesions greater than 4 cm in size, total thyroidectomy should be performed.

Following surgical resection of a large thyroid mass, a patient complains of persistent hoarse- ness and a weak voice. What is the most likely cause of these symptoms? (A) Traumatic intubation (B) Prolonged intubation (C) Injury to the recurrent laryngeal nerve (D) Injury to the superior laryngeal nerve (E) Scar tissue extending to the vocal cords

A 40-year-old woman presents with weight loss, palpitations, and exopthalmos. On phys- ical examination, the thyroid gland is diffusely enlarged. Blood tests reveal primary hyper- thyroidism. Which one of the following is not the treatment of hyperthyroidism? (A) Methimazoli (B) Lugols iodine (C) I131 (D) Subtotal thyroidectomy (E) Steroids

(E) Steroids

After undergoing a left thyroid operation, a 42-year-old opera singer notes no change in speech, but she has difficulty in singing high- pitched notes. Which nerve is most likely to be injured? (A) Recurrent laryngeal (B) Internal laryngeal (C) External laryngeal

A 23-year-old Pacific Islander female is referred to you for evaluation for a left neck mass. She rarely receives any medical care. She has noticed the neck mass for the past 6 months.The lump is increasing in size with time. She states that otherwise, she feels normal. On physical exam, she has a palpable lump on her left thyroid gland as well as left neck lymphadenopathy. She is very thin with long limbs and round, firm lumps in her lips. You suspect she has multiple endocrine neoplasia (MEN) 2B syndrome. What potential abnormalities would you suspect and work up? A. Papillary thyroid cancer B. Pituitary adenoma C. Pheochromocytoma D. Parathyroid hyperplasia

C. Pheochromocytoma

What is the recommended initial surgical approach if the 1.1 cm lesion was non-diagnostic on initial and repeat FNA, and no lymphadenopathy is seen, and the patient desires a limited surgical procedure? A. Repeat FNA again B. Left thyroid lobectomy C. Near-total thyroidectomy D. Total thyroidectomy

B. Left thyroid lobectomy Per the 2015 ATA guidelines, For patients with an isolated indeterminate solitary nodule, thyroid lobectomy is the recommended initial surgical approach. Total thyroidectomy is recommended for indeterminate nodules which are: a) Large (> 4 cm) b) Show marked atypia present on biopsy c) In patients with a family history of thyroid cancer d) In patients with a history of radiation exposure.

What would be your treatment option if the 1.1 cm lesion showed suspicion of a papillary thyroid cancer on FNA and no lymphadenopathy on the thyroid ultrasound? A. Follow-up with repeat ultrasound in 6 months B. Left thyroid lobectomy C. Left thyroidectomy with isthmusectomy D. Total thyroidectomy

D. Total thyroidectomy For Papillary CA, treatment of choice is Total Thyroidectomy

A 43-year-old female presented with a neck swelling. The ultrasound reveals a 0.4 cm circular, smooth, solid, intracapsular lesion. What would be your next step in management or this lesion? A. Fine-needle aspiration (FNA) B. Repeat lab work C. Observation D. Subtotal thyroidectomy

C. Observation

A 43-year-old female presented with a neck swelling. What would your next step be if the lesion were 1.1 cm on imaging and palpable? A. FNA B. Repeat lab work C. Follow-up with repeat ultrasound in 6 months D. Subtotal thyroidectomy

A. FNA

A 56-year-old man presents to clinic for evaluation of a small anterior right neck mass at the level of the thyroid. He has no significant past medical history and denies any history of smoking. The mass has been slowly enlarging over the last 2 years but is not painful. The patient is normotensive with a negative review of systems, and he denies any dyspnea, choking sensations, or hoarseness. What is the first diagnostic study that should be performed in the workup of this mass? a. Ultrasonography of the thyroid b. Serum thyroid-stimulating hormone (TSH) level c. Fine-needle aspiration (FNA) d. Computed tomography (CT) scan of the neck and chest e. Thyroid scintigraphy

b. Serum thyroid-stimulating hormone (TSH) level TSH level is the first study performed on an asymptomatic patient with a thyroid nodule >1 cm. Imaging is the next diagnostic step.

Following total thyroidectomy, a 50-year-old male presents for his 1-year follow-up visit. He is currently on daily levothyroxine therapy. The best method to monitor the adequacy of replacement therapy is: a. Radioactive iodine (RAI) uptake b. Thyroglobulin c. Triiodothyronine resin uptake (RT3U) d. Serum TSH level e. Total thyroxine level (total T4)

d. Serum TSH level Adequacy of thyroid hormone replacement is assessed 6 to 12 weeks after therapy initiation by measuring TSH and free T4.

Which of the following patients with thyroid gland enlargement is LEAST likely to have a diagnosis of thyroid cancer? a. A 5-year-old boy with two family members with medullary thyroid carcinoma b. A 75-year-old man with a solitary nodule and hoarseness c. A 56-year-old woman with a solitary nodule and a history of radiation therapy to the neck d. A 43-year-old woman with a diffuse goiter and tremor e. A 14-year-old girl with an asymptomatic solitary nodule

d. A 43-year-old woman with a diffuse goiter and tremor Thyroid cancer arising in the setting of Graves disease is uncommon

A 47-year-old woman presents to clinic for evaluation of weight gain, thinning hair, constant fatigue, constipation, and muscle weakness over the past year. She denies any prior history of thyroid disorders and currently takes no medications. Serum TSH level is elevated at greater than 30 mIU/L. What is the most likely cause of the patient’s symptoms? a. Thyroid adenoma b. Self-administration of thyroid hormone c. Papillary thyroid carcinoma d. Radioactive iodine administration e. Hashimoto thyroiditis

e. Hashimoto thyroiditis The clinical scenario classically describes the symptoms and biochemical findings of hypothyroidism. In the areas of the world with sufficient dietary iodine, the most common cause is Hashimoto thyroiditis.

A 75-year-old female is taken to the operating room for surgical excision of a 4- × 5-cm papillary thyroid cancer of the right lobe. Which of the following would be an indication for a right lateral compartment lymph node dissection? a. Tumor size b. History of radiation exposure c. Positive central node on frozen section d. Patient’s age e. None of the above

e. None of the above There is currently no role for lateral compartment lymph node dissection (LND) in papillary thyroid cancer if the nodes are not involved by imaging, biopsy, or clinical examination, that is, prophylactic LND. Prophylactic central compartment LND should be considered, however, in patients with high-risk features.

A 43-year-old female presents with a 2.5-cm thyroid nodule. Her serum TSH level is normal and FNA cytology is consistent with atypia of undetermined significance (AUS). Molecular testing reveals a somatic BRAF V600E mutation. What is the appropriate next step? a. Germline genetic testing b. Repeat fine-needle aspiration c. Initiate vemurafenib therapy d. Total or near-total thyroidectomy e. Complete dermatologic examination to search for a melanoma primary

d. Total or near-total thyroidectomy For indeterminant cytology on FNA (Bethesda categories III to V), molecular testing can add significant diagnostic value. In one series, 100% of thyroid FNA samples with either a BRAF V600E, RET/PTC, or PAX8/PPARγ mutation were malignant by postoperative histology; those with RAS mutations harbored malignancy in 85% of cases. These findings support total or near- total thyroidectomy in patients with Bethesda categories III to V cytology and a positive somatic mutation

A 16-year-old female presents with early satiety, postprandial vomiting, and epigastric distension for 3 weeks. She has presented to the ED multiple times. She endorses nervousness, difficulty sleeping, and unintentional weight loss for 3 months. CT of the abdomen and pelvis reveals a proximal small bowel obstruction with transition point at the third portion of the duodenum. What other findings is she most likely to have? a. Cold sensitivity and bradycardia b. Diffuse goiter and exophthalmos c. Low serum iodine level d. Increased urinary phosphate e. Kidney stones and constipation

b. Diffuse goiter and exophthalmos The CT findings described above are consistent with superior mesenteric artery syndrome, an uncommon disorder typically caused by abrupt weight loss, thinning of mesenteric fat, and subsequent compression of the duodenum at the aortomesenteric angle. In the majority of patients, particularly children and adolescents, a metabolic or behavioral cause should be sought. The catabolic state of Graves thyrotoxicosis can lead to such rapid involuntary weight loss. Most cases are treated by correcting the underlying disorder. Surgery is rarely indicated, but laparoscopic duodenojejunostomy is the operation of choice

Which of the following is the most common cause of Acute Thyroiditis? a) Bacterial b) Viral c) Fungal d) Protozoal e) Autoimmune

a) Bacterial Bacterial infections are the most common cause of acute thyroiditis with S. Aureus the most common bacterial organism.

To which of the following molecules do thyroxine esp. binds in serum? a) Albumin b) Thyroxine Binding Pre-Albumin c) Thyroxine Binding Alpha-globulin d) Thyroxine Binding Beta-globulin e) Thyroxine Binding Gamma-globulin

c) Thyroxine Binding Alpha-globulin Thyroxine mainly binds with the Thyroxine binding Alpha-globulin.

A middle aged female presented with swelling in front of neck that has developed over past few months. On examination, the swelling is unilateral and is of thyroid in origin. There are also few lymph nodes palpable along the side of swelling. What is your clinical diagnosis? a) Metastatic Carcinoma b) Non - Hodgkin Lymphoma c) TB d) Papillary Carcinoma e) Medullary Carcinoma

d) Papillary Carcinoma

A 36-year-old female who underwent subtotal thyroidectomy complains of SOB 2hours after operation. What is the most likely cause? a) Tension Hematoma b) B/L RLN Injury c) Tracheomalacia d) Injury to Trachea e) Pulmonary Embolism

a) Tension Hematoma Tension Hematoma is the reactionary haemorrhage usually occurs 4-6 hours after surgery.

A 50-year-old female patient having huge multi-nodular goitre for past 14 years underwent total thyroidectomy. Just after extubation, patient developed dyspnea with visible supraclavicular and intercostal retractions. What is the most likely cause of patient's respiratory distress? a) Tracheomalacia b) Tension Hematoma c) Right RLN Injury d) Injury to Parathyroid Glands e) SLN Injury

a) Tracheomalacia Long standing goitre [MNG] causes a chronic pull on tracheal rings. Following thyroidectomy, the release of chronic pull causes the tracheal rings to collapse when the ETT is removed. This is manifested as sudden onset of SOB immediately following extubation.

A young patient in her 3rd Trimester is found to have Graves Disease. What is the best treatment option for her? a) Total Thyroidectomy b) PTU c) Methamizole d) RAI e) Subtotal Thyroidectomy

c) Methamizole PTU is preferred in 1st Trimester. Methamizole is preferred in 2nd & 3rd Trimester.

A female presents to OPD with complaints of midline neck swelling. On examination, the swelling is non-tender and can be moved side to side but not up and down. What is your diagnosis? a) Lipoma b) Cervical Lymph node c) Thyroglossal Cyst d) Sebaceous Cyst e) Dermoid Cyst

c) Thyroglossal Cyst They can move side to side but not up and down.

What is correct regarding position of thyroglossal duct cyst? a) They are most commonly located just to the lateral of midline between thyroid isthmus above and hyoid bone below. b) They are most commonly located in midline between thyroid isthmus and hyoid bone. c) They are most commonly located in midline above the hyoid bone. d) They are most commonly located at the base go tongue.

b) They are most commonly located in midline between thyroid isthmus and hyoid bone.

A patient with laboured breathing who has developed tension hematoma shortly after thyroidectomy will have which type of Acid-Base Disorder? a) Respiratory Acidosis b) Respiratory Alkalosis c) Metabolic Acidosis d) Metabolic Alkalosis e) Metabolic Acidosis & Respiratory Acidosis

a) Respiratory Acidosis Hematoma formation ----- Upper Airway Obstruction ----- CO2 Retention ------ Respiratory Acidosis

A middle aged female presented with a solitary thyroid swelling. Which of the following is best investigation to be carried out for solitary thyroid swelling? a) U/S b) CT Scan c) MRI d) FNA e) Isotope Scan

d) FNA FNA is the single most important test used in evaluation of thyroid masses.

Which of the following is the most sensitive to detect recurrence of papillary carcinoma? a) Serum T3 Levels b) Serum T4 Levels c) Serum TSH Levels d) Serum thyroglobulin Levels e) Serum Calcitonin Levels

d) Serum thyroglobulin Levels

Which of the following is most useful in monitoring response of thyroxine therapy? a) Serum T3 Levels b) Serum T4 Levels c) Serum TSH Levels d) Serum thyroglobulin Levels e) Serum Calcitonin Levels

c) Serum TSH Levels

Levels of which of the following is most useful and accurate in thyroid profile? a) Serum T3 Levels b) Serum T4 Levels c) Serum TSH Levels d) Serum thyroglobulin Levels e) Serum Calcitonin Levels

c) Serum TSH Levels

Which of the following clinical feature is indicative of thyroid malignancy? a) Dyspnea b) Dysphagia c) Hard neck mass with mobile skin d) Irregularly hard and fixed neck mass e) Productive coUGH

d) Irregularly hard and fixed neck mass

A 39-year-old female underwent subtotal thyroidectomy for large toxic MNG. She presents 2 years later with development of nodularity at the site of operation. O/E, she is tachycardia with slightly raised BP and there is a nodular swelling palpable over the previous neck scar mark of previous operation. A diagnosis of recurrence of primary disease is suspected. H/P reports of previous specimen showed no malignant changes. Which of the following is appropriate treatment option in this patient? a) RAI b) Propanolol c) ATDs d) Near-total thyroidectomy e) Total thyroidectomy

a) RAI Subtotal thyroidectomy = Partial resection of each lobe, removing the bulk of the gland and leaving up-to 8 g of relatively normal tissue in each remnant. Re-operation of recurrent nodular goitre is more difficult & dangerous. Therefore the most safer alternative is RAI. RAI can reduce the size of recurrent goitre.

A 36-year-old female presented with signs of hyperthyroidism with a large nodular goitre. A diagnosis of toxic MNG is made. What is the appropriate treatment in her case? a) Radiotherapy b) RAI c) ATDs d) Immediate total thyroidectomy e) Preoperative preparation of patient with ATDs + BB & then perform total thyroidectomy.

e) Preoperative preparation of patient with ATDs + BB & then perform total thyroidectomy.

Young female presented with Medullary Carcinoma of thyroid gland. Her history is also suggestive of mother suffering from Breast Cancer. What genetic test will be appropriate? a) RET b) BRCA 1 c) BRCA 2 d) P53 e) PTEN

a) RET

A patient underwent near-total thyroidectomy now presents with Buffalo cough & voice change. Nerve injury? a) RLN b) ELN c) ILN d) SLN

A) RLN

During thyroidectomy, RLN is injured and identified per-operatively. What is the best management? a) Nothing b) Primary Repair c) Nerve Graft

b) Primary Repair

Female patient with Painless gradual enlargement of hard thyroid gland. FNA is -ve for malignancy. X - Ray shows Tracheal Compression. Diagnosis? a) De-quervain's thyroiditis b) Reidal thyroiditis c) Follicular Adenoma d) Autoimmune e) Hurtle Cell

b) Reidal thyroiditis Tracheal Compression is a feature of Reidal Thyroiditis

26 Year old female presented with Fever, severe neck pain. O/E, tender & firm neck mass can be appreciated. Thyroid Scan shows no uptake. a) De-quervain's Thyroiditis b) Riedal thyroiditis c) Hashimoto's thyroiditis

a) De-quervain's Thyroiditis

Retrosternal extension of thyroid. Best approach: a) Transcervical b) Median Sternotomy

a) Transcervical

26 Year-old female presented with goitre with retrosternal extension. Underwent surgery. RLN was identified & preserved during surgery. Post-operatively, she is breathless. Drain output is few cc. What is the cause of Breathlessness? a) Pneumothorax b) RLN Injury c) Tension Hematoma d) Tracheomalacia

d) Tracheomalacia If breathlessness occurs immediately then; Tracheomalacia. If it occurs after couple of hours, then; Tension Hematoma

A 55-year-old female presented with H/O Diarrhea, dysphagia & hoarseness of voice. On examination, there is B/L Cervical lymph nodes are enlarged. What biochemical investigation will you order to confirm your diagnosis?

Medullary CA. Order Calcitonin levels. R/O MEN 2 syndrome

Medullary CA with MEN Syndrome: a) Prophylactic Total Thyroidectomy b) Subtotal Thyroidectomy c) Lobectomy + Isthumesectomy

a) Prophylactic Total Thyroidectomy

Thyroid Surgery with Antibiotic prophylaxis % of wound infection? a) 1% b) 0.5% c) 2-3 % d) 5 -10% e) 20%

a) 1%

Medullary CA on FNAC. Treatment: a) Total Thyroidectomy b) Total Thyroidectomy + Central Neck Dissection c) Subtotal Thyroidectomy

b) Total Thyroidectomy + Central Neck Dissection

H/P of thyroid tissue shows same cell pattern. Most likely diagnosis? a) Anaplastic CA b) Medullary CA c) Papillary CA d) Follicular CA e) None of the above

d) Follicular CA

Suspicion of Malignancy in thyroid Management. Management: a) Lobectomy b) Total Thyroidectomy c) Lobectomy + Isthumusectomy

c) Lobectomy + Isthumusectomy

Papillary CA with 2 cm nodule. Management: a) Total Thyroidectomy b) Total Thyroidectomy + RAI

a) Total Thyroidectomy

Post total-thyroidectomy, on the evening of procedure, patient is agitated with BP 140/90, Tachypnea & Tachycardia. What is the initial management? a) 100% O2 b) Lugol Iodine c) Fluids d) Antithyroid drugs e) BB

a) 100% O2

Total thyroidectomy done for huge MNG. After 48 hours, patient became dyspneic with stridor. What is the most likely cause? a) Tension Hematoma b) B/L RLN Paralysis c) Hypocalcemia d) Hypovolemia

a) Tension Hematoma

A patient presented with 2 cm mass in the right lobe of thyroid. Diagnosis of Medullary CA was done. What is the most appropriate management? a) Total Thyroidectomy with Central Node Dissection b) Right lobectomy + RAI c) Chemoradiation d) Surveillance

a) Total Thyroidectomy with Central Node Dissection

Patient with Medullary CA + Hypertension + Long fingers. Most likely diagnosis? a) MEN 1 b) MEN 2A c) MEN 2B

c) MEN 2B

10th POD after total thyroidectomy. Patient is on thyroxine. How to know if dose is enough or not? a) Serum TSH b) T3 c) T4 d) Serum Thyroxine Levels

a) Serum TSH

Patient presented with all signs & symptoms of hyperthyroidism. What is the best initial investigation? a) Serum TSH b) T3 & T4 c) U/S d) FNA

a) Serum TSH

Female patient presented with weight loss, appetite increases & enlarged thyroid. Diagnosis? a) Graves Disease b) Toxic Adenoma c) MNG

a) Graves disease

A patient with diffuse goitre with anti-thyroglobulin & anti-peroxidase antibodies +ve. Family history is positive for thyroid disease. What is the most likely diagnosis? a) Graves disease b) Hashimoto thyroiditis

b) Hashimoto thyroiditis

A 40-year-old female presented in OPD with neck swelling. O/E, there is enlarged thyroid swelling that is firm & compressing the trachea. On further investigations, it is noted that the cold nodule biopsy was negative for malignancy. The most likely diagnosis is: a) Riedels thyroiditis b) Granulomatous thyroiditis

a) Riedels thyroiditis

Invasive mass in the right lobe of the thyroid that is extending into surrounding tissues. Biopsy shows Spindle cells. Patient died within one year of the disease. The most likely diagnosis? a) Papillary CA b) Follicular CA c) Anaplastic CA d) Medullary CA e) Hurtle Cell CA

c) Anaplastic CA

Thyroid goitre with lymphadenopathy + Diarrhea. Family history of similar disease was noted on further inquiry. What is the most likely diagnosis? a) Medullary CA b) Papillary CA c) Follicular CA

a) Medullary CA

A 55-year-old female had 25 years H/O retrosternal goitre. On X-ray cervical region, the trachea was shifted to the opposite side. After extubation, the patient desaturates. Anesthetist says air entry is equal on both sides. After re-intubation, what is the most likely diagnosis? a) Hematoma b) B/S RLN Injury c) Tracheomalacia d) Pneumothorax

c) Tracheomalacia

A patient underwent surgery for a thoracic mass. Intra-operatively, the thoracic mass is involving the nerves. Frozen section says its a benign mass. What will be the next step in the management of this patient: a) Resect as much as possible b) Close wound wait for detailed pathological report c) Resect all

a) Resect as much as possible

A thyroid mass with compression features. On examination, there is fixed & hard mass. Diagnosis? a) Anaplastic b) Follicular c) Medullary d) Papillary

a) Anaplastic

After right lobectomy, H/P shows papillary CA in a single nodule. The treatment of this patient most likely will be: a) Lobectomy + Isthumectomy b) Total Thyroidectomy c) Lobectomy

b) Total Thyroidectomy Papillary CA can be multi-centric. As the patient is undergoing 2nd surgery so its better to undergo Total Thyroidectomy. For Papillary CA = Total Thyroidectomy

Most likely location of thyroglossal cyst is: a) Beneath foramen ceaucm b) Suprahyoid c) Subhyoid

c) Subhyoid

A patient presented with a cystic swelling in midline of neck. It doesn't move with swallowing or protrusion of tongue. Most likely diagnosis? a) Thymus Cyst b) Cystic Hygroma c) Cold Abscess

a) Thymus Cyst

A patient with renal failure on dialysis. Parathyroid hormone level is noted to be increased with Hypercalcemia & Hypophosphatemia. Treatment is: a) 3 Glands Removal b) 4 Glands Removal + 50 mg Reimplant c) Adenoma Removal Only

b) 4 Glands Removal + 50 mg Reimplant

Thyroglossal Cyst is best managed by: a) Sistrunk Procedure b) Total Thyroidectomy c) Lobectomy

a) Sistrunk Procedure

Patient presented with the swelling in the neck. U/S shows thyroid nodule with the laboratory report of thyroid toxic nodule. Best Management: a) Total Thyroidectomy b) Sub-total Thyroidectomy c) Near Total Thyroidectomy

b) Sub-total Thyroidectomy

Inferior Thyroid Artery is related with the: a) Recurrent Laryngeal Nerve b) Superior Laryngeal Nerve c) External Laryngeal Nerve

a) Recurrent Laryngeal Nerve

Patient presented with profuse watery diarrhoea, hypokalaemia & hypochloremia. Most likely diagnosis: a) VIPoma b) ZES

a) VIPoma

Recurrent epigastric pain despite of H2 Antagonist is most likely: a) ZES b) Pancreatitis c) Gastrinoma d) H. Pylori Infection

a) ZES

Patient 4 hours after the meal becomes Hypoglycemic and deteriorates. Diagnosis? a) Insulinoma b) ZES

a) Insulinoma

Patient presented with Hypercalcemia. Treatment will be: a) Charchol b) Fluids c) FFP d) Platelets

b) Fluids

A midline lesion on neck. O/E, the lesion doesn't move with tongue or swallowing. Endoscopy & contrast study does not show any connection with oesophagus or trachea. Most likely diagnosis: a) Dermoid Cyst b) Thyroglossal Cyst c) Brachial Cyst

a) Dermoid Cyst

A patient presented with H/O trauma to the neck. She is a known case of goitre. She now complaints of sweating, palpitation, tachycardia and have an episode of diarrhoea. Diagnosis?

Thyroid Crisis

ZES that is not improving with Omeprazole is best treated with: a) HSV + Pyloroplasty b) Partial Pancreatectomy c) Truncal Vagotomy d) PPPD

d) PPPD Mostly in the duodenum

A patient presented with recurrent gastric ulcer. Although he uses PPIs on regular bases. Diagnosis: a) ZES b) Insulinoma c) H. Pylori Infection

a) ZES

A patient presented with episodes of heart burn, regurgitation. Although he uses PPIs & H2 blockers on regular base. On CXR, there is air just above the diaphragm. Diagnosis: a) Hiatal Hernia b) ZES c) Gastrinoma d) Insulinoma e) Chronic H. Pylori Infection

A) Hiatal Hernia

Patient presented with Recurrent gastric ulcers + Hypercalcemia & raised PTH. Diagnosis? a) APUdoma 2 b) APUdoma 1 c) PHPT d) THPT

a) APUdoma 2 Apudoma 1: gastric carcinoid with pernicious anemia and hyper gastrinemia Apudoma2: gastric carcinoid with ZES and MEN1 Apudoma3: gastric carcinoid independant of hyper gastrinemia

Hyperthyroid Crisis. Initial Management: a) ATDs b) Corticosteriods c) BB

C) BB ABC is always first.

Localization of Parathyroid Gland: a) Sestimibi scan b) CT c) MRI d) U/S

A) Sestimibi scan

Most common Pituitary Tumor?

Prolactinoma

Best Initial Management of Hypercalcemic Crisis? a) IVF b) Bisphosphonates c) Prednisolone d) Calcitonin e) Parathyroidectomy

a) IVF

A 46-year-old female presents with palpitations. Serum glucose 48 mg/dl & C-peptide level is elevated. Her symptoms resolve with administration of glucose. Diagnosis? a) Pheochromocytoma b) VIPoma c) Glucagonoma d) Insulinoma

d) Insulinoma

Hyperparathyroidism + Tender finger swelling? a) Melanoma b) Osteochondral hypertrophy c) Brown Tumor

C) Brown Tumor

Hyper-secreting parathyroid adenoma. Best Initial investigation? a) U/S b) Sestimibi scan c) CT - Scan

a) U/S

A young female with recurrent hypoglycaemic attacks. Best initial investigation? a) Urinary VMA b) C-peptide levels c) IGF -1 d) Fasting Glucose Level

d) Fasting Glucose Levels

High Gastrin level. Best way to localise pancreatic source? a) EUS b) CT -Scan c) MRI d) U/S e) Octreotide Scan

e) Octreotide Scan

Gastrinoma at the level of head of pancreas. Treatment: a) Enucleation b) Pancreaticoduodenectomy

a) Enucleation with peripancreatic LN Dissection

A patient with recurrent ulcers + Diarrhoea. Diagnosis? a) Insulinoma b) Pancreatic Hematoma c) ZES d) Duodenal Atresia

C) ZES

A patient presented from hilly area having Carpo-pedal spasm, rapid breathing & drowsy. Investigations: Ca: 8.8. MgL 1.1. She needs urgent? a) Phosphate b) Calcium c) Magnesium

c) Magnesium Normal Mg: 1.7 - 2.2 Normal Ca: 8 - 10

Hypersecreting Parathyroid Adenoma: a) Total Parathyroidectomy b) Radiation c) Targeted Parathyroidectomy

c) Targeted Parathyroidectomy

A 21-year-old female initially being diagnosed with fibroadenoma. The biopsy proved it to be lobular carcinoma with enlarged lymph nodes in the axilla that are mobile. Treatment will be: a) Mastectomy b) Wide Excision c) Radial Mastectomy

a) Mastectomy. Modified Radial or Simple Mastectomy

a) Mastectomy

A female presented with recurrence of Breast CA & Femur Fracture. Treatment will be: a) IM Nailing & Chemotherapy b) Chemotherapy c) Radiotherapy d) Hormonal

a) IM Nailing & Chemotherapy

Mammographic findings show suspicious lesion. Best way to proceed is: a) FNAC b) Tru-cut Biopsy c) Sterio-biopsy

c) Sterio-biopsy

A female presents with 4 cm breast mass. FNAC shows widespread DCIS. Treatment: a) Radical Mastectomy b) Mastectomy with Axillary Clearance c) Chemotherapy d) Radiotherapy e) Mastectomy + Radiotherapy

E) Mastectomy + Radiotherapy

A patient with breast cancer underwent BCS. Survival is reduced if which of the following modality is not given? a) Tamoxifen b) Radiotherapy c) Chemotherapy

b) Radiotherapy

After MRM, Biopsy reported 3 lymph nodes +ve. The best treatment option: a) Adjuvant Chemotherapy b) Adjuvant Chemo + Radio c) Radiotherapy

b) Adjuvant Chemo + Radio

A 30-year-old female operated for CA Breast. She has now presented with polydipsia, dizziness & disorientation. The most likely cause is: a) Cerebral Mets b) SIADH c) Tamoxifen

b) Cerebral Mets. These symptoms are due to hypercalcemia..

Which chemical is used to identify Tumor & SLNB and also persists for a long time: a) Technetium b) Methylene blue c) Metallic Clips

a) Technetium

A patient with breast carcinoma underwent chemotherapy. She has now presented with Invasive Candidiasis. Treatment of choice: a) Capsofungin b) Fluconazole c) Amphotericin B

a) Capsofungin

Features of Breast CA on mammography: a) Micro-calcification b) Cluster-calcification c) Sauser Shaped d) Larger than 2 cm calcification

a) Micro-calcification

A 25-year-old female with Breast CA involving Outer Lower Quadrant Mass is 4x5 cm + No lymphadenopathy. She wants normal cosmetic appearance: a) Skin Sparing Mastectomy + Implant b) MRM + Implant c) MRM + Prothesis d) MRM + TRAM Flap e) Skin Sparing Mastectomy + TRAM Flap

e) Skin Sparing Mastectomy + TRAM Flap

Young female with Breast CA T1N0. Sx, ER & PR are positive. Treatment will be: a) Adjuvant Chemo + Radiotherapy b) Adjuvant Chemotherapy c) Adjuvant Radiation d) Surveillance e) Immune Modulator Therapy

c) Adjuvant Radiation

A 40 year-old-female had a lump in her left breast. She underwent Simple Mastectomy and axillary Dissection. Biopsy shows ER & PR +ve, Her2 -ve. Now develops a nodule at the scar that is fixed. Next best step in management of this patient: a) Biological Therapy b) Chemotherapy c) Radiotherapy d) Wide Excision e) Wide Excision & Chemotherapy

e) Wide Excision & Chemotherapy followed by Radiation.

A 26-year-old lactating mother developed Red, Hot, Tender left breast swelling. Her swelling is fluctuating & U/S shows hypo-echoic. NBS in management of this patient: a) Aspiration + Antibiotics b) Incision & Drainage c) Antibiotics d) Conservative Management e) Express Milk

a) Aspiration + Antibiotics

A 16-year-old female complains of a lump in her right breast with greenish discharge from her nipple. O/E, there is a lump in UOQ & U/S showed lobulated mass with cystic component. Most likely diagnosis: a) Breast Abscess b) Fibroadenoma c) Carcinoma Breast d) Paget Disease e) Ductal Evolution

e) Ductal Evolution

A 53-year-old female post Neo-adjuvant underwent Mastectomy & Axillary Clearance. H/P showed Invasive Ductal CA with ER/PR +ve & Her2 +ve. Next Management option will be: a) Chemotherapy b) Radiotherapy c) Chemo-Radiation d) Targeted therapy

d) Targeted Therapy

A 60-year-old female has been diagnosed with Right Breast Carcinoma for which She underwent Neo-adjuvant. Her H/P shows ER & Her2 +ve. Next Management option: a) Chemotherapy b) Radiotherapy c) Chemo-Radiation d) Estrogen Antagonist e) Progesterone Antagonist

d) Estrogen Antagonist

A young patient presented with Medullary CA of thyroid. Her history also suggest of mother having breast cancer. What genetic test will be appropriate? a) RET b) BRCA 1 c) BRCA 2 d) P53 e) PTEN

A) RET

A 3 year old boy developed fixed nodule behind the nipple. Treatment of Choice: a) Conservative Management b) Wide Local Excision c) Radiation d) Follow up

d) Follow up

Patient presented with hard breast mass that is not mobile over underlying structure & has fixed nodes with no metastasis. Treatment of Choice: a) Chemotherapy b) Chemo-Radiotherapy c) MRM d) Chemo-Radiotherapy followed by MRM e) Chemo-Radiotherapy followed by SM

d) Chemo-Radiotherapy followed by MRM Locally advanced tumor: Neo-adjuvant ---- MRM --- Chemo & Radio

A young female with breast abscess on antibiotics. Next step in management: a) Conservative Management b) Incision & Drainage c) Aspiration d) Drain Placement

c) Aspiration

Recurrent Breast CA with metastasis in femur. Treatment of Choice: a) IM Nailing b) Radiotherapy c) Chemotherapy d) Immune Therapy

a) IM Nailing

Breast Cystic Swelling increase in size with menstural cycle: Diagnosis: a) Fibrocystic Disease b) Fibroadenoma

a) Fibrocystic Disease

A male presented with Recurrent Breast CA over scar with pectoralis major involvement. Next best step in management of this patient: a) Radiation b) Re-excision c) Radical Mastectomy d) Chemotherapy e) Radical Mastectomy + Chemotherapy

e) Radical Mastectomy + Chemotherapy. If chemotherapy is not in option, then go for Radical Mastectomy

In female patient, FNAC of left axillary lymph node shows adenocarcinoma with ER +ve. Mammogram & MRI are normal. What is the treatment for this patient: a) MRM b) Radiotherapy c) Chemotherapy d) Axillary Dissection & Observation

a) MRM Axillary dissection should be done along with Radiation.

Post-mastectomy, patient with Grade 2 Lymphedema with recurrent lymphangitis. The treatment of choice: a) Liposuction b) Limb Reduction Surgery c) Lymph Venous Bypass

c) Lymph Venous Bypass OR Limb Reduction Surgery

A 44-year-old female smoker presented with recurrent discharge from breast. Recurs again & last attack 2 months back with foul smelling discharge. Treatment: a) Microdochectomy b) Cone Excision c) Simple Mastectomy

b) Cone Excision Ductal Ectasia

A 20-year-old female with multiple fibroadenomas. She wants to remove all. What is the ideal incision: a) Circum-areolar Radial b) Sub-areolar c) Transverse d) Sub-mammary fold

d) Sub-mammary fold

A female in kitchen trapped in fire. Now drowsy with hoarseness of voice. Failed intubation. What is the immediate step: a) Cricothyroidectomy b) Needle Cricothyroidectomy c) Tracheostomy d) Face Mask

a) Cricothyroidectomy

A lady with a post-operative case of breast cancer with NPI 6.4 with grade 1 Tumor of size 2 cm. What does it shows: a) No lymph node Involvement b) Liver Metastasis c) Lung Metastasis d) Lymph Node Involvement

d) Lymph Node Involvement NPI = [0.2 x Size in cm] + Grade + Nodal Stage Good Prognosis: <3.4 Moderate Prognosis: 3.4 to 5.4 Bad Prognosis: >5.4 Nodal Stage: 1: No Lymph Node 2: 1-3 Lymph Node 3: >3 Lymph Nodes

A female patient with Breast CA who underwent MRM. Now presented with refractory edema of the left upper limb. What is the treatment: a) Diuretics b) Compression Garments c) Lymphovenous bypass d) Limb Reduction Surgery

d) Limb Reduction Surgery In patients with refractory lymphedema, Limb Reduction Surgery is indicated.

A 38-year-old female presented with bloody nipple discharge. O/E, there is a palpable subareolar breast mass. What is the possible pathology: a) Papilloma b) Ductal Ectasia c) Fibroadenoma d) Carcinoma

a) Papilloma

Breast Carcinoma with fixed nodes. Treatment will be: a) Chemotherapy b) MRM + Chemotherapy c) Axillary Dissection

b) MRM + Chemotherapy

After breast cancer surgery, shoulder contour is changed. Which nerve has been damaged: a) Long Thoracic Nerve b) Thoracodorsal Nerve c) Axillary Nerve d) Intercosto-brachial Nerve

c) Axillary Nerve

Mammography showed micro-calcification. This feature is for the: a) Malignancy b) Adenoma c) Abscess

a) Malignancy

DCIS with size 2 cm with no lymph nodes palpable. TOC: a) Mastectomy & SLNB b) Lumpectomy & Axillary Clearance c) MRM d) Radiotherapy e) Chemotherapy

a) Mastectomy & SLNB

A female with H/O RTA presented with trauma to the breast. She has now presented with retraction of nipple. Most likely diagnosis: a) Fibro-adenosis b) Breast Abscess c) Fat Necrosis

c) Fat Necrosis

Paget's disease of Nipple. Investigation of choice: a) MRI b) Needle Biopsy c) Punch Biopsy d) U/S e) Mammogram

c) Punch Biopsy

A 4 cm breast mass + Fixed Lymph nodes + no Metastasis. Stage? a) Stage IIIA b) Stage IIC c) Stage IIIC d) Stage IIIB e) Stage IIB

c) Stage III C

A female underwent Neo-adjuvant chemotherapy followed by mastectomy & axillary clearance. H/P showed IDC & is triple positive. NBS in management of this patient: a) Chemotherapy b) Radiotherapy c) Chemo + Radio d) Targeted Therapy

d) Targeted Therapy Hormonal therapy should be given before chemo or radio.

A 40 year old patient underwent simple mastectomy for breast cancer. H/P showed ER +ve & Her2 -ve. Now she has presented with a nodule at the scar. BNS? a) Chemotherapy b) Radiotherapy c) Wide Excision d) Wide Excision & Chemotherapy e) Hormonal Therapy

d) Wide Excision & Chemotherapy

A patient presented with 2.5 cm breast lump in UOQ. O/E, there are mobile axillary lymph nodes. H/P shows ER & PR +ve. Best management option? a) Chemotherapy b) Radiotherapy c) BCS + Hormonal Therapy d) MRM

c) BCS + hormonal Therapy

A young female diagnosed with Breast CA [T1N0M0] underwent lumpectomy. H/P shows ER & PR +ve. NBS? a) Chemo + Radio b) Chemotherapy c) Radiotherapy d) Surveillance e) Immune Modulator Therapy

c) Radiotherapy

A 20 year old girl with firm lump in the breast for last 2 months. She recalls that she had trauma on his breast 6 months ago. No history of nipple discharge. O/E, the swelling is firm and mobile. Diagnosis? a) Fibroadenoma b) Fat Necrosis c) Carcinoma d) Ductal Ectasia

b) Fat Necrosis

A female patient operated for CA Breast. Now developed lymphedema. Best initial management: a) Lymph-venous Bypass b) Amputation c) Tight Dressing

c) Tight Dressing

Breast pain with a mass that is not fixed to underlying structure & puckered skin on movement of the lump is seen. Diagnosis: a) Fibroadenoma b) Carcinoma c) ANDI d) Papilloma

c) ANDI [Mastalgia + Breast Mass] Breast pain is not a feature of carcinoma. So [A] & [B] are ruled out. Fibroadenoma won’t cause mastalgia, unless huge Mastlagia hints against carcinoma No discharge - so chances of papilloma are less

Young female with huge size breast with dilated veins over the breast & skin is moveable over it: a) Phyllodes Tumor b) Carcinoma c) Papilloma d) Giant Fibroadenoma

Young female with huge breast and dilated veins - Giant fibroadenoma (juvenile fibroadenoma) 40 + female with huge breast , bosselated surface with ulceration - phyllodes-

After BCS, patient on radiotherapy develops recurrence on scar. How to investigate? a) MRI b) CT c) Mammogram d) U/S

a) MRI

Skin nodules seen in a patient with limb edema that is years after MRM. Diagnosis? a) Lymph angiosarcoma b) Fat nodules c) SCC d) Lymphoma

a) Lymph Angiosarcoma

Patient presented with a mass in the left breast with the size of 5x3 cm in the UOQ and have the 3 fixed mated lymph nodes at the age of 45. The next best step in the management of this patient: a) BCS b) MRM c) Simple Mastectomy

b) MRM

Breast CA + Metastasis & Hypercalcemia. What to do next: a) MRI b) Bone Scan c) MIBG d) CT

a) MRI

Mastectomy done for CA Breast. Biopsy report shows 3 Lymph nodes positive. Next treatment will be: a) Adjuvant Chemo b) Adjuvant Chemo + Radio c) Radiotherapy only

b) Adjuvant Chemo + Radio

Phyllodes Tumor with low mitotic rate & less differentiation of nuclei on H/P. Best management: a) MRM b) BCS

b) BCS Treatment for Benign Phyllodes: Enucleation or WLE Treatment for Massive, Recurrent or Malignant Phyllodes: Mastectomy. MRM is not recommended in Phyllodes Tumor because it has Hematogenous Spread.

A child presented with left side chest muscle atrophy with I/L fused short fingers. Diagnosis: a) Poland Syndrome b) Khlinefelter Syndrome c) Syndadyctle d) Congenital Amastia

a) Poland Syndrome

A young lady presented with great massive enlargement of the left breast. How will you assess: a) Triple Assessment b) FNAC c) Mammography d) Clinical Examination

a) Triple Assessment

Inflammatory Breast CA Management: a) MRM + Chemo & Radio b) Chemo & Radio c) Surveillance

b) Chemo & Radio followed by salvage surgery. Inflammatory Breast CA is a stage 4 Breast CA. Best initial management for such patients is Chemotherapy & Radiotherapy. It is then followed by Salvage Surgery if possible.

A patient presented with Headaches, Sweating & Palpitations. Diagnosis: a) Pheochromocytoma b) Cushing Syndrome

A) Pheochromocytoma

Serum Tumor Marker for Carcinoid Tumor: a) CEA b) Chromogranin A c) Chromogranin B d) Serotonin

C) Chromogranin B

A patient with mass in the rectum & Chromogranin B is positive. The most likely diagnosis is: a) Carcinoid b) Adenocarcinoma

a) Carcinoid Tumor

A patient presented with 3 cm incidenteloma. Next step in the management of this patient: a) Surveillance b) Removal c) Biopsy

a) Surveillance Any non-functioning adrenal tumor >4cm in diameter & smaller tutors that increase in size over time should undergo surgical resection. Non-functioning adrenal tumors <4 cm should be followed after 6, 12 & 24 months by MRI & Hormonal Evaluation.

A patient with sweating & hypertension & hyperglycaemia. The most likely diagnosis is: a) Pheochromocytoma b) Cushing Syndrome

b) Cushing Syndrome

A female patient due for cholecystectomy. During surgery, she is found of having Pheochromocytoma. Next Best Step in the management of this patient: a) Explore for Pheochromocytoma b) Alpha Blockers & shift the patient to ICU

B) Alpha Blockers & Shift the patient to ICU

A middle aged female with abdominal pain. Her work up was done & CT Scan showed a small mass above the kidney. What is the next best step in management of this patient: a) Functional Work up b) Excision of Mass c) No intervention d) Radiation

a) Functional Work Up Following 6 tests much be performed: ● Morning and midnight plasma cortisol measurements; ● A 1-mg overnight dexamethasone suppression test; ● 24-hour urinary cortisol excretion; ● 12- or 24-hour urinary excretion of metanephrines or plasma-free metanephrines; ● Serum potassium, plasma aldosterone and plasma renin activity; ● Serum DHEAS, testosterone or 17-hydroxyestradiol (virilising or feminising tumour).

A patient presents with asymptomatic gallstones. He also has adrenal gland mass. Your next step in the management of this patient: a) Laparoscopic Cholecystectomy + Adrenalectomy b) Open Cholecystectomy + Adrenalectomy c) Laparoscopic Cholecystectomy Only d) Functional Work up of Adrenal Gland Tumor

d) Functional Work up of Adrenal Gland Tumor Following 6 tests much be performed: ● Morning and midnight plasma cortisol measurements; ● A 1-mg overnight dexamethasone suppression test; ● 24-hour urinary cortisol excretion; ● 12- or 24-hour urinary excretion of metanephrines or plasma-free metanephrines; ● Serum potassium, plasma aldosterone and plasma renin activity; ● Serum DHEAS, testosterone or 17-hydroxyestradiol (virilising or feminising tumour).

A patient underwent CT-Scan for Dyspepsia. There is a 4 cm Adrenal Mass. Next Step in the management of this patient: a) Urinary VMA b) Serum Catecholamine c) Resection

b) Serum Catecholamine Following 6 tests much be performed: ● Morning and midnight plasma cortisol measurements; ● A 1-mg overnight dexamethasone suppression test; ● 24-hour urinary cortisol excretion; ● 12- or 24-hour urinary excretion of metanephrines or plasma-free metanephrines; ● Serum potassium, plasma aldosterone and plasma renin activity; ● Serum DHEAS, testosterone or 17-hydroxyestradiol (virilising or feminising tumour).

A 30-year0old female with Primary Amenorrhea. Her workup reveals 3.5 cm Adrenal Mass. What is the next step in the management of this patient: a) Hormonal Assasy then CT Scan follow up b) Biopsy c) Adrenalectomy d) Observation

a) Hormonal Assasy then CT Scan follow up Following 6 tests much be performed: ● Morning and midnight plasma cortisol measurements; ● A 1-mg overnight dexamethasone suppression test; ● 24-hour urinary cortisol excretion; ● 12- or 24-hour urinary excretion of metanephrines or plasma-free metanephrines; ● Serum potassium, plasma aldosterone and plasma renin activity; ● Serum DHEAS, testosterone or 17-hydroxyestradiol (virilising or feminising tumour).

A patient with Cushing syndrome, having truncal obesity & hypertension. Initial treatment will be: a) Excision b) B/l Adrenalectomy c) Observation d) Metyrapone

d) Metyrapone 1) Medical therapy with metyrapone or ketoconazole reduces steroid synthesis and secretion and can be used to prepare patients with severe hypercortisolism preoperatively or if surgery is not possible. 2) ACTH-producing pituitary tumours are treated by trans-sphenoidal resection or radiotherapy. 3) If an ectopic ACTH source is localised, resection will correct hypercortisolism. 4) A unilateral adenoma is treated by adrenalectomy. 5) In cases of bilateral ACTH-independent disease, bilateral adrenalectomy is the primary treatment. 6) Patients with an ectopic ACTH-dependent Cushing’s syndrome and an irresectable or unlocalised primary tumour should be considered for bilateral adrenalectomy as this controls hormone excess. 7) Subclinical Cushing’s syndrome caused by unilateral adenoma can be treated by unilateral adrenalectomy.

Cushing syndrome patient with a) Dexamethasone Suppression Test Negative b) ACTH & Cortisol: Elevated Diagnosis: a) Pituitary Adema b) Ectopic SCC c) Adrenal Adenoma

b) Ectopic Small cell Carcinoma

Gastrinoma in the head of Pancreas. The best treatment option: a) Enucleation b) Pancreaticodudenectomy

a) Enucleation [With Peripancreatic Lymph nodes Dissection] - Most pancreatic gastrinomas are solitary, located in the head of the gland or uncinate process, and can be identified at operation. - Enucleation with peripancreatic lymph node dis- section is the procedure of choice. - Rarely, tumours are situated in the body or tail and should be treated by enucleation or distal resection. - Even if a tumour is found in the pancreas, duodenotomy is recommended to detect additional tumours, if the patient has MEN 1.

Carcinoid Tumor of Small Bowl. H/O Diarrhea, Flushing, Cramping Abdominal Pain. Best Investigation: a) 24 Hour Urinary 5-HIAA levels b) Octreotide Scan c) Chromogranin A

A) 24 Hour Urinary 5 - HIAA Levels

Profused Watery Diarrhea, Hypotension & Abdominal Pain. Diagnosis: a) VIPOMA b) Carcinoid Tumor

a) VIPoma Presents with: 1) Profused Watery Diarrhea ---- Hypotension 2) Hypokalaemia 3) Abdominal Pain 4) Flushing

Patient presented with recent onset of Temporal Hemianopia. Most likely diagnosis: a) Glioma b) ACTH c) Amerox Fuguax d) Pituitary Adenoma

d) Pituitary Adenoma

High Gastrin level was noted in a patient having H/O regular use of PPI but still have severe dyspepsia. Best way to localise pancreatic source is: a) EUS b) CT c) MRI d) US e) Octreotide Scan

e) Octreotide Scen

CT Scan shows a 4 cm mass in the adrenal & patient has dyspepsia. Next step: a) Urinary VMA b) Blood VMA c) Serum Calcitonin

a) Urinary VMA

Patient with Pheochromocytoma. Best Initial Investigation for diagnosis? a) Urinary Metanephrines b) MRI c) Plasma Metanephrines d) U/S e) CT

C) Plasma Metanephrines

Pheochromocytoma localization: a) MIBG Scan b) CT Scan c) MRI Scan

c) MRI Scan For Extra-renal, MIBG Scan

Elevated VMA levels in urine. Most Likely Diagnosis?

Pheochromocytoma

18 Weeks pregnant lady presented with severe headache, dizziness, tremors, tachycardia with BP 200/110 refractory to drugs. Next best step: a) U/S Abdomen b) Terminate the pregnancy c) CT Abdomen

a) U/S Abdomen

The male patient presented with complaints of whitish discharge from both breasts & was diagnosed as Pituitary Tumor. The most likely diagnosis:

Prolactinoma

Lady with sharp changes of hand, face & hypertension. Next step in management of this patient: a) Serum Prolactin b) GH Levels c) TSH d) Cortisol Levels

b) GH Levels

Fibrocystica is managed by: a) Hypoparathyroidism b) Hyperparathyroidism

b) Hyperparathyroidism Osteitis fibrosa cystica is the result of unchecked hyperparathyroidism, or the overactivity of the parathyroid glands, which results in an overproduction of parathyroid hormone (PTH). PTH causes the release of calcium from the bones into the blood, and the reabsorption of calcium in the kidney.

A female presented to ER unit in hypotensive state, tachycardia, sweating, diarrhoea & have a state of delirium. The patient also have MNG for 5 years. the most likely cause is: a) Graves Disease b) Toxic MNG c) Thyroid Crisis

c) Thyroid Crisis

A patient underwent near total thyroidectomy. Now presents with Buffalo cough & voice change. Which of the following is the most likely injury: a) RLN b) ELN c) SLN d) ILN

a) RLN

Patient presented with Hyperthyroid Crisis. Best Initial Treatment: a) Anti-thyroid Drugs b) Corticosteroids c) Beta Blockers

c) Beta Blockers

Inferior Thyroid Artery is related to:

RLN

Total Thyroidectomy done for huge MNG. After 48 hours, patient presented with dyspnea with Stridor. Most likely diagnosis: a) B/L RLN paralysis b) Hypocalcemia c) Hypovolemia d) Tension Hematoma

d) Tension Hematoma

A patient presented with swelling in the neck. U/S shows thyroid nodule with laboratory report of Thyroid Toxic Nodule. Best management: a) Total Thyroidectomy b) Sub-total Thyroidectomy c) Near-total Thyroidectomy

b) Sub-total Thyroidectomy. Ideally, Lobectomy should be done.

Patient presented with Medullary Thyroid CA, Acromegaly & Hypertension. This syndrome is called: a) MEN 2B b) MEN 2A c) MEN 1

b) MEN 2A

Post-thyroidectomy on the evening of procedure, the patient is agitated with BP 140/90, Tachypnea & Tachycardia. What is the initial management? a) 100% Oxygen b) Lugols Iodine c) IV Fluids d) Antithyroid Drugs e) Beta blockers

a) 100% Oxygen then IVF then Beta Blockers

Goitre with Retrosternal Extension underwent surgery. RLN identified in surgery but post-op there is breathlessness & in drain there is 10 ml of Blood. The most likely diagnosis? a) Pneumothorax b) RLN Injury c) Tracheomalacia d) Tension Hematoma

d) Tension Hematoma Drains not always drain. It can get blocked.

Papillary thyroid CA of 2 cm was found in one lobe but the LN status was negative. The treatment option for this patient: a) Near Total thyroidectomy b) Total Thyroidectomy c) Lobectomy & Isthumectomy

b) Total Thyroidectomy Lobectomy & Isthumectomy is recommended if <1 cm in size.