Dr. Pestana's Notes--Skin, Opth, ENT, Neuro

Question 1

Describe the characteristics of patient most likely to get skin cancer.

Answer 1

blonde, blue-eyed, fair-skinned people who live where the sun is fierce and who by virtue of occupation or hoppy are exposed to rays all day

Question 2

Basal cell carcinoma accounts for ____ of skin cancers, Squamous cell accounts for ___ and melanoma accounts for ____. These often coexist.

Answer 2

50%; 25%; 15%

Question 3

_____ carcinoma may show up as a small, raised waxy lesion or as a nonhealing ulcer on the upper face.

Answer 3

Basal cell

Question 4

Basal cell rarely mets to LN. If waxy, lesions can be _____. If nonhealing ulcer, lesion must be _____.

Answer 4

removed in toto; full-thickness biopsied at edge of lesion (differentiate from squamous and melanoma)

Question 5

The most dangerous basal cell ulcer is known as a _____ b/c it can kill by relentless local invasion. Removal requires ____ margins.

Answer 5

rodent ulcer; 1mm

Question 6

Typical location of rodent ulcer is in ____, which makes it cosmetically difficult, therefore surgeons use ____ surgery, which uses microscopic sections and tissue dx as excision is being done.

Answer 6

upper face; Mohs surgery

Question 7

_____ cancer is usually seen on the lower lip and territories below the horizontal live drawn across the mouth. This cancer CAN mets to _____.

Answer 7

Squamous cell; regional LNs

Question 8

Excision of Squamous cell carcinoma requires _____ margins. _____ may need to be biopsied or dissected; radiation is another treatment option

Answer 8

0.5 to 2cm; Sentinel LNS

Question 9

Name the ABCDEs of melanoma

Answer 9

asymmetric, irregular borders, different colors, diameter >0.5cm, evolution

Question 10

Pathology of melanoma MUST include the presence of cancer and _____

Answer 10

depth of invasion

Question 11

Melanoma: _____ have good prognosis. ____ have bad prognosis and can be lethal.

Answer 11

superficial invasions; deep invasions

Question 12

Melanomas less than ___ deep require local excision only. Those between _____ require 2cm margins and attention to LNs. Those greater than ____ have a terrible prognosis despite therapy.

Answer 12

1mm; 1 to 4mm; 4mm

Question 13

MC locations of mets malignant melanoma

Answer 13

LNs, liver, lung, brain, bone, other “weird” places

Question 14

Metastatic malignant melanoma has no predictable timetable. _____ is the current preferred adjuvant systemic therapy.

Answer 14

Interferon

Question 15

____ is a vision impairment resulting from interference with the processing of images by the brain during the first 6 or 7 years of life. Most common presentation is a child with _____.

Answer 15

Amblyopia; strabismus

Question 16

If strabismus not surgically corrected in a child with amblyopia, permanent ____ of the suppressed eye could occur. A ____ can also cause the same issue.

Answer 16

cortical blindness (even though technically the eye can see); congenital cataract

Question 17

Strabismus is verified by showing that the reflection from a light comes from ______ in each eye.

Answer 17

different areas of the cornea

Question 18

When strabismus not diagnosed right away, there can be exaggerated convergence caused by refraction difficulties. _____ instantly resolve the issue.

Answer 18

corrective glasses

Question 19

A ____ in a baby is indicative of retinoblastoma and is an ophthalmologic emergency. It could also be a _____, but you must treat it right away to prevent amblyopia.

Answer 19

white pupil; congenital cataract

Question 20

___ is a common source of blindness and is silent in nature so it is rarely discovered by PCP unless eye exam is done.

Answer 20

Glaucoma

Question 21

_____ glaucoma shows up at very severe eye pain or frontal headache typically starting in the evening when the pupils have been dilated for several hours. Pt might say they are seeing ____ around lights.

Answer 21

Acute angle closure; halos

Question 22

Acute angle closure glaucoma on physical exam shows a _____ pupil that [DOES/DOES NOT] react to light; the cornea has a _____ hue and the eye feels hard as a rock.

Answer 22

mid-dilated; does not; greenish

Question 23

Emergency surgery for Acute angle closure glaucoma includes ______ to allow drainage of fluid trapped in the [ANTERIOR/POSTERIOR] chamber.

Answer 23

drilling a hole in the iris; anterior

Question 24

While waiting for sx for Acute angle closure glaucoma, give ______ and apply topical ____. Mannitol and pilocarpine may also be used.

Answer 24

carbonic anhydrase inhibitors (Diamox); beta blockers and alpha2-selective adrenergic agonists

Question 25

____, another ophthalmologic emergency, is when the eyelids are hot, tender, red and swollen and the patient is febrile. The key finding is a ___ pupil when the eyelids are pried open.

Answer 25

Orbital cellulitis; dilated and fixed

Question 26

Dx and tx Orbital cellulitis [emergency!]

Answer 26

CT scan and drainage

Question 27

Chemical burns of eye require _______ immediately for about _____. ____ is tested to assure no harmful chemicals remain in the conjunctival sac.

Answer 27

irrigation (water or saline); 30 minutes; pH

Question 28

[ACID/ALKALINE] burns of the eye are worse than [ACID/ALKALINE] burns of the eye

Answer 28

alkaline; acid

Question 29

_____ is another emergency recognized by patients reporting "flashes of light" and "floaters". The number of floaters tells you about the magnitude of the problem.

Answer 29

Retinal detachment

Question 30

In retinal detachment, the person with one or two floaters may only have ______ of the retina, whereas a "snowstorm" of floaters or a big dark cloud at the top of the visual field indicates _______.

Answer 30

vitreous tugging; big horseshoe piece of retina pulling away and at risk for ripping of rest

Question 31

Emergency tx Retinal detachement

Answer 31

laser "spot welding" to protect remaining retina

Question 32

_____ is seen when an elderly patient describes sudden vision loss from one eye. In _______ the damage is irreversible.

Answer 32

embolic occlusion of retinal artery; 30 minutes

Question 33

Intermittent tx for embolic occlusion of retinal artery

Answer 33

breathe into paper bag and have someone repeatedly press hard on eye and release [to vasodilate and shake clot into more distal location to prevent ischemia]

Question 34

_____ patients MUST have an ophthalmologic evaluation. ___ damage may have already occurred at this time.

Answer 34

Type 2 DM [type I have about 20yrs before developing eye problems]; retinal

Question 35

_____ neck masses are usually seen in young people and typically have been present for years before they become symptomatic (get infected) and medical help is sought.

Answer 35

Congenital

Question 36

____ is a neck mass is 1-2cm and located on the midline at the level of the hyoid bone and seems to be connected to the tongue.

Answer 36

Thyroglossal duct cyst

Question 37

Surgical removal of thyroglossal duct cyst includes 3 things. [Sometimes nml thyroid location identified via radionuclide scan before sx]

Answer 37

cyst, middle segment of hyoid, track that leads to base of tongue

Question 38

_____ are neck masses that occur along the anterior edge of the SCM anywhere from front of tragus to base of neck.

Answer 38

Branchial cleft cysts

Question 39

____ is a neck mass found at the base of the neck as a large, mushy, ill-defined mass that occupies the entire supraclavicular area.

Answer 39

Cystic hygroma

Question 40

Cystic hygromas usually extend into the ____ and therefore must be worked up with a _____ before surgical removal

Answer 40

mediastinum (deep into the chest); CT

Question 41

Most new enlarged neck LNs are benign. F/U should be ____ later and only if the LNs are still there, should a workup be done. A history of wks/months of enlarged LNs are indicative of a ____ or _____.

Answer 41

3 to 4 weeks; infection; neoplasm

Question 42

_____ is typically in young people with multiple enlarged LNs in neck and elsewhere; usually suffer low-grade fever and night sweats.

Answer 42

Lymphoma

Question 43

Dx and tx Lymphoma

Answer 43

FNA and node removal for pathology; chemotherapy

Question 44

Metastatic tumor to the supraclavicular nodes usually comes from below the clavicles, primarily ____ and ____ tumors. The node should be removed for pathology.

Answer 44

lung; intraabdominal

Question 45

______ of the head and neck is usually seen in old men who smoke and drink and have rotten teeth. Patients with ____ are also prime candidates.

Answer 45

Squamous cell carcinoma of mucosae; AIDS

Question 46

Squamous cell carcinoma of mucosae usually shows up first as a ______ in the neck, typically the jugular chain. Workup includes ____, looking for primary tumor/tumors first.

Answer 46

metastatic LN; triple endoscopy (aka panendoscopy)

Question 47

For Squamous cell carcinoma of mucosae, ____ of the primary(ies) establishes the diagnosis, and ____ demonstrates the extent. Sometimes ____ of the mets node is done.

Answer 47

biopsy; CT; FNA [NEVER open bx]

Question 48

For Squamous cell carcinoma of mucosae, treatment involves (4) things.

Answer 48

resection, radical neck dissection, +/- radiotherapy, +/- platinum-based chemo

Question 49

Name a few presentations of Squamous cell carcinoma of mucosae.

Answer 49

persistent hoarseness, persistent painless ulcer in floor of mouth, persistent unilateral earache

Question 50

____ should be suspected in an adult who has sensory hearing loss in one ear. ___ is best diagnostic modality.

Answer 50

Acoustic neuroma; MRI

Question 51

_____ produce GRADUAL unilateral face paralysis, affecting both the forehead and lower face. [Sudden-onset suggests ____.] _____ is the best diagnostic study.

Answer 51

Facial nerve tumors; Bells-palsy; Gadolinium-enhanced MRI

Question 52

____ tumors are visible and palpable in front of the ear or around the angle of the mandible. Most are _______, which are benign but have potential for malignancy. They [DO/DO NOT] produce pain or facial nerve paralysis

Answer 52

Parotid; pleomorphic adenomas; DO NOT

Question 53

___ is used to both diagnose and treat parotid tumors, preventing recurrences and sparing the facial nerve. ____ alone leads to recurrence and in malignancy, the ____ is sacrificed and a graft is done.

Answer 53

superficial parotidectomy (+/- FNA [open biopsy contraindicated]); Enucleation; facial nerve

Question 54

____ are the cause of unilateral ENT problems in toddlers. Earache, rhinorrhea or unilateral wheezing can be indicative. ____ is the appropriate tx.

Answer 54

Foreign bodies; endoscopy under anesthesia + extraction

Question 55

_____ is an abscess of the floor of the mouth, often the result of a bd tooth infection. The problem here is a threat to the _____ and therefore incision and drainage are done. (Occasionally intubation/tracheostomy may be needed.)

Answer 55

Ludwig angina; airway

Question 56

Tx Bell's palsy

Answer 56

antivirals (prompt and early admin) and steroids

Question 57

Facial nerve injuries are _____ if paralyzed right away and ____ if later develop paralysis due to swelling.

Answer 57

permanent; reversible (spontaneously resolved)

Question 58

_____ is suspected when pt develops diplopia (from paralysis of extrinsic eye muscles) in patient suffering from frontal or ethmoid sinusitis. Emergency that requires these things...

Answer 58

Cavernous sinus thrombosis; IV abx, CT/MRI, draingage of affected sinuses

Question 59

Epistaxis in children is typically from ____; the bleeding comes from the _____, and phenylephrine spray and local pressure controls the problem.

Answer 59

nosepicking; anterior septum

Question 60

An 18yo with epistaxis suggests ____ (especially with septal perforation), treated via ______, or _____ (benign but eats away at nearby structures), treated with surgical resection.

Answer 60

cocaine abuse; posterior packing; juvenile nasopharyngeal angiofibroma

Question 61

Elderly HTN pts can have epistaxis that are copious and life-threatening. _____ and ____ are usually required. Sometimes surgical ligation of feeding vessels can be done.

Answer 61

Control of HTN; posterior packing

Question 62

Dizziness can be caused by either _____ or ____.

Answer 62

inner ear dz; cerebral dz

Question 63

When dizziness is caused by inner ear dz, the patient describes the room as _______. These 3 medications may help alleviate the problem.

Answer 63

"spinning around them"; meclizine, promethazine, diazepam

Question 64

When dizziness is caused by cerebral dz, the patient describes the room as _______. The pt may require _____ for further evaluation.

Answer 64

stable (patient himself is unsteady); neurologic workup

Question 65

_____ includes vertigo, tinnitus and hearing loss and is primarily treated with _____.

Answer 65

Ménière disease; diuretics

Question 66

Vascular problems have ____ onset, without headache when they are _____ and with headache when they are ____.

Answer 66

sudden; occlusive; hemorrhagic

Question 67

As ICP increases due to obstruction from tumor over months, severe headaches (worse in the _____), ____ and ____ can be seen.

Answer 67

AM; blurred vision; projectile vomiting

Question 68

TIAs are sudden, transitory losses of neuro function that come on [WITH/WITHOUT] headaches and resolve spontaneously, leaving no neurologic sequela. Sxs depend on area of brain affected.

Answer 68

without

Question 69

MCC TIAs is high-grade (>70%) stenosis at the _____ or ulcerated plaque at the _____.

Answer 69

internal carotid; carotid bifurcation

Question 70

TIAs are predictive of ____ and therefore elective ____ may prevent and minimize that possibility.

Answer 70

stroke; carotid endartectomy

Question 71

Workup of TIAs include noninvasive Duplex studies. Surgery is indicated if the lesions are found _____. Angioplasty and stent can be done if a _______ first.

Answer 71

in locations where neurological deficits occur; filter is deployed to prevent embolization

Question 72

Ischemic strokes that have been present for longer than _____ are not amenable to revascularization procedures, although ___ can be started (best w/in 90 min).

Answer 72

3 hours; tPA

Question 73

Assessment of ischemic stroke is done via _____ to confirm extent and rule out hemorrhage, and therapy is centered on _____.

Answer 73

CT scan; rehabilitation

Question 74

Ischemic strokes may be complicated by a _____ if blood supply to the brain is suddenly increased.

Answer 74

hemorrhagic infarct

Question 75

Hemorrhagic stroke is seen in pts w/ ____ who complain of severe headache of sudden onset and go on to develop neuro deficits. ___ is used to evaluate the location and extent and therapy is focused on ___ and ___.

Answer 75

HTN; CT scan; control of HTN; rehabilitation

Question 76

Subarachnoid bleeding from intracranial aneurysms may present with no _____ because ______, and the pt may be sent home prematurely. Luckier patients have _____ and ______.

Answer 76

neuro findings; no hematoma pressing on the brain; meningeal irritation and nuchal rigidity

Question 77

Patients with subarachnoid bleeding that were not diagnosed right away may come back to ED with a much worse ____ bleed.

Answer 77

sentinel

Question 78

Workup for subarachnoid hemorrhage is ____ followed by a _____ to locate a potential aneurysm. Sometimes a ___ is done to identify old blood in the spinal fluid. Tx includes ____ in surgery or ___, a radiological alternative.

Answer 78

CT; ateriogram; spinal tap; clipping; endovascular coiling

Question 79

Most intracranial tumors are mets. About half come from the _____; next most common are ____ and ____.

Answer 79

lungs; breast; melanoma

Question 80

About half of primary brain tumors in adults are _____; about 20% are ____.

Answer 80

gliomas; meningiomas

Question 81

The most malignant intracranial tumor is a ____. _____ are usually benign.

Answer 81

glioblastoma multiforme {glioma}; Meningiomas

Question 82

Most intracranial tumor treatment includes ___ and ____ but not ____ because it's hard to breach the blood-brain barrier.

Answer 82

surgery; radiotherapy; chemotherapy

Question 83

Brain tumors can be located in a "silent" area of the brain and therefore don't suggest a location. Only sxs of these tumors can be _____ and ______.

Answer 83

severe, progressively worsening headaches (worse in AM); increased ICP

Question 84

Clinical presentation of increased ICP

Answer 84

blurred vision, papilledema, projectile vomiting, Cushing reflex

Question 85

What is the Cushing reflex, seen in increased ICP?

Answer 85

bradycardia and HTN (pressing on baroreceptors in brain)

Question 86

Brain tumors can be seen on ____, but ___ gives better detail and is preferred. Increased ICP is treated with ____ while waiting for surgery to treat tumor.

Answer 86

CT; MRI; high-dose steroids (dexamethasone)

Question 87

Tumors at the ______ produce inappropriate behavior, optic nerve atrophy on side of tumor, papilledema on contralateral side of tumor and anosmia [Foster-Kennedy syndrome]

Answer 87

base of the frontal lobe

Question 88

____ occur in children who are short for their age; show bitemporal hemianopsia and a calcified lesion above the sella on CT scan.

Answer 88

Craniopharyngiomas

Question 89

_____ produce amenorrhea and galactorrhea in young women. Tx with ____. ____ is reserved for those who wish to become pregnant.

Answer 89

Prolactinomas; bronocriptine; transnasal, trans-sphenoidal surgical removal

Question 90

Prolactinoma: must rule out ____ by testing for hCG, rule out ____ by testing TSH, determine ____ levels and get an ____ of the sella.

Answer 90

pregnancy; hypothyroidism; prolactin; MRI

Question 91

Atypical symptoms of ____ include HTN, diabetes, sweaty hands, headache and history of wedding bands/hats that no longer fit. Workup includes ____ and ____.

Answer 91

acromegaly; somatomedin C levels; pituitary MRI

Question 92

Tx of Acromegaly includes ____ (preferred) or ____. Somatic changes are irreversible.

Answer 92

surgery (transnasal or trans-sphenoidal); radiotherapy

Question 93

_____ occurs when bleeding into a pituitary tumor causes subsequent destruction of the gland. Hx includes chronic pituitary tumor problems followed by an acute episode, starting with _____ and signs of increased compression due to _____.

Answer 93

Pituitary apoplexy; severe headache; hematoma of nearby structures

Question 94

Signs of pituitary apoplexy/damage includes ___ and ____. Tx immediately with _____ and eventually other hormones. Can diagnose with ____ or ____.

Answer 94

stupor; hypotension; steroid replacement; CT; MRI

Question 95

Tumors of the _____, aka _____, produce loss of upper gaze and physical finding known as "sunset eyes"

Answer 95

pineal gland; Parinaud syndrome

Question 96

Brain tumors in children are usually in the _____. _____ is the most common and arises in the _____, producing stumbling/truncal ataxia.

Answer 96

posterior fossa; Medulloblastoma; cerebellum

Question 97

The second MC child brain tumor is a _____. Affected children often assume the ______ position in order to open the flow of cerebrospinal fluid and relieve their headache.

Answer 97

Ependymoma; knee-chest

Question 98

Brain abscesses usually develop in ______. There is fever and an obvious source of infection nearby like ____ or _____. Can visualize on CT. Tx includes _____.

Answer 98

one to two weeks; otitis media; mastoiditis; surgical resection

Question 99

_____, aka ______, produces extremely severe, sharp shooting pain in face brought about by touching a specific area and lasting about 60 seconds. Pts normally ___ years old and have a ____ neurologic exam.

Answer 99

Trigeminal neuralgia; tic douloureux; 60; normal

Question 100

____ is done for patients with trigeminal neuralgia to rule out other causes. Tx includes ____ (med) or ___ (procedure). Some surgeons believe the process is caused by pounding from a nearby vessel, and suggest an operation.

Answer 100

MRI; carbamazepine; radiofrequency ablation

Question 101

_____, aka _____, develops several months after a crushing injury; there is a constant, burning, agonizing pain that doesn't respond to usual analgesics.

Answer 101

Reflex sympathetic dystrophy; causalgia

Question 102

In reflex sympathetic dystrophy (causalgia), extremity is usually _____ and ____. Dx includes successful ____ and curative tx includes ____.

Answer 102

cold; moist; sympathetic block; surgical sympathectomy