Clinical Medicine

Question 1

On neck inspection, where do you most commonly see a thyroglossal duct cyst?

Answer 1

Midline, above the level of the thyroid gland

Usually assoicated with the hyoid bone too (moves with tongue extension)

Question 2

Do thyroidal neck masses usually move with swallowing?

Answer 2

Yes

(fixed masses are likely not thyroid)

Question 3

Describe the presenting characteristics of a breast fibroadenoma (5)

Answer 3

• Firm
• Round
• Mobile
• Nontender
• Age <35 years old

Fibroadenoma = benign

Question 4

List 3 non-endocrine signs of a thyroid mass

Answer 4

Dysphonia, dysphagia, dyspnea

(Usually develop in this order)

Question 5

List 3 possible causes of bloody nipple discharge

What other nipple findings would make you concerned for a malignant etiology?

Answer 5

• Nipple trauma
• Intraductal papilloma (benign)
• Carcinoma (malignant)

Concerning findings: new nipple retraction, unilateral discharge

Question 6

List 3 possible causes of breast erythema and warmth

Answer 6

• Inflammatory breast cancer*
• Abscess
• Mastitis

*malignant

Question 7

What is Modigliani syndrome?

Answer 7

Patients who have pronounced neck lordosis may look like they have a goiter

Question 8

What is the single best time of day to measure cortisol in a case of cortisol excess?

Answer 8

12 am (midnight)

(8am in cortisol deficiency)

Question 9

What is the single best time of day to measure cortisol in a case of cortisol deficiency?

Answer 9

8 am

(12am for cortisol excess)

Question 10

What anatomical landmark lies just superior to the thyroid isthmus?

Answer 10

Hyoid Bone

Thyroid Cartilage (most prominent)

Cricoid Cartilage

Thyroid Isthmus

Question 11

In Cushing’s syndrome, 24h free cortisol will be ___ times the normal amount

Answer 11

In Cushing’s syndrome, 24h free cortisol will be 3 times the normal amount

Question 12

List 3 things that can cause decreased cortisol binding globulin

What is the effect on free cortisol?

Answer 12

• Genetic deficiency
• Nephrotic syndrome
• Androgens
• > increased free cortisol
• In these cases, measure total cortisol instead*

Question 13

List 2 things that can cause increased cortisol binding globulin

What is the effect on free cortisol?

Answer 13

• OCPs (estrogen)
  
  • Increases CBG production
• Hyperthyroid

Question 14

What findings on a breast exam would be concerning for Paget’s disease of the breast?

Answer 14

Rash and ulceration of the nipple

Malignant

Note: Paget’s disease of the breast is not related to Paget’s disease of the bone ¯_(ツ)_/¯

Question 15

Which nerve is most likely to be injured during thyroid surgery?

Answer 15

Left recurrent laryngeal nerve

Supplies all intrinsic muscles of the larynx except the cricothyroid m.

Question 16

List 4 findings from the visual breast exam that would be concerning for malignancy

Answer 16

• Abnormal contours (lumps)
• Nipple retratction
• Dimpling
• Orange peel skin (Peu d’orange)→ inflammatory carcinoma

Question 17

Answer 17

A - Urine or saliva

Question 18

Describe the low dose dexamethasone suppression test

Answer 18

• Give 1mg dexamethasone at 12am
• Measure serum cortisol at 8am
  
  • Should be LOW in normal states
  • Cortisol at 8am will be elevated in Cushing’s

Question 19

A 58 year old patient presents with itching, burning, and a scaly rash on the nipple.

What is the most likely diagnosis?

Answer 19

Paget’s disease of the breast

Question 20

What is the circled structure?

Answer 20

Esophagus

Question 21

A 27 year old women presents with a 1cmx1cm mass in the right breast. The mass is mobile, rubbery, and nontender with no overlying skin changes

What is the most likely diagnosis?

Answer 21

Fibroadenoma

Question 22

What are the 4 positions for inspection during a breast exam

Answer 22

1. Arms at sides
2. Arms over head
3. Hands on hips
4. Leaning forward

Different positions to show possible dimpling/different countours. Hands on hips activates pectoralis muscle.

Question 23

When should you do a breast exam?

Answer 23

When the chief complaint is related to the breast! Breast exams ARE NOT recommended for screening.

• breast pain
• mass
• nipple discharge

Question 24

Where should you examine the lymph nodes during a breast exam?

Answer 24

• Axillary
• Supraclavicular
• Infraclavicular

Question 25

What are characteristics of a likely benign breast mass?

Answer 25

• soft/rubbery
• regular
• well-circumscribed
• mobile
• changes in size with menses

Question 26

What are characteristics of a breast mass that suggest MALIGNANCY?

Answer 26

• hard
• irregular
• poorly circumscribed
• fixed to skin/tissues (immobile)
• no change in size

Question 27

Answer 27

B - Lower inner quardrant

DON’T MIX UP LEFT AND RIGHT!!

Question 28

Answer 28

B- FIBROADENOMA

Mobile, rubbery, most common in young women 20-35

Question 29

Answer 29

B- Mastitis

Common infection while breast-feeding

Question 30

Answer 30

D- All of the above

Clear or bloody discharge, unilateral or unilobular are all concerning for malignancy

Question 31

Answer 31

C- Newly identified breast cancer

An infection would present with more erythema.

This is a long-standing cancer that is now eroding through the skin. :(

Question 32

A 28 year old with palpitations, sweating and unintended weight loss. Also eyes have proptosis and lid lag. On exam, you expect the thyroid to be:

Answer 32

Diffusely enlarged

This is Grave’s disease (hyperparathyroidism). Diffuse, symmetrical enlargement