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Surgery NBME > Endocrine Disorders > Flashcards

Endocrine Disorders Flashcards

1
Q

what are you concerned about in a patient with a past history of radiation to the neck?

A

low dose ionizing radiation exposure (< 2000rad) carries 40% risk of thyroid cancer (MC - papillary ca)

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2
Q

what do you do in a pt who presents with nodule on thyroid with previous history of neck radiation?

A

proceed straight to thyroidectomy

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3
Q

what is special about diagnosis of medullary thyroid cancer?

A

AD Inheritance via mutation in RET Oncogene

  • measure calcitonin levels, if high screen for RET mutation
  • if mutation found, evaluate for MEN prior to surgery
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4
Q

patient has no identifiable risk factors for thyroid cancer but has a solitary nodule that is not hard nor fixed - what do you do next?

A

FNAB

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5
Q

when should you remove a cyst from the thyroid gland?

A

if it is > 4 cm big OR if it recurs several times following aspiration
- determined by USG

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6
Q

standard of care for diagnosing thyroid nodules

A

FNAB

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7
Q

what do you do with a FNAB result of “colloid nodule”

A

benign result

- medical management with thyroid suppression and routine F/U

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8
Q

what do you do with a FNAB result of “papillary carcinoma” or “medullary carcinoma?”

A

thyroidectomy

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9
Q

psammoma bodies on FNAB of thyroid

A

marker of papillary carcinoma - do thyroidectomy

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10
Q

amyloid deposits on FNAB of thyroid

A

suggest medullary cancer - do thyroidectomy

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11
Q

undifferentiated cells on FNAB of thyroid

A

suggests anaplastic cancer

- do either chemotherapy or radiation OR salvage operative therapy

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12
Q

Hurthle cells on FNAB of thyroid

A

signifies either adenoma or low grade cancer

- do lobectomy; if turns out to be cancer, total thyroidectomy indicated

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13
Q

follicular cells on FNAB of thyroid

A

does not rule out cancer, therefore must do a lobectomy for diagnostic purposes

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14
Q

lymphocytic infiltrate on FNAB of thyroid

A

suggests either lymphoma or chronic lymphocytic thyroiditis

- can differentiate by flow cytometry

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15
Q

tx. of thyroid lymphoma

A

radiation

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16
Q

tx. of chronic lymphocytic thyroiditis

A

no surgical tx. necessary

- may require thyroid hormone replacement therapy

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17
Q

major serious complications following thyroid surgery

A
  1. recurrent laryngeal N. paralysis - hoarseness or cord palsy (bilateral)
  2. external branch of superior laryngeal N. paralysis - high pitched singing voice
  3. hypoparathyroidism
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18
Q

MC type of thyroid cancer

A

papillary cancer

- MC between age 30 and 40

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19
Q

tx. of pt with papillary cancer lesion < 1 cm and no history of previous radiation

A

thyroid lobectomy and isthmusectomy

- had the pt had a previous history of neck irradation, you would do a total thyroidectomy

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20
Q

tx. of pt with papillary cancer lesion > 1.5 cm

A

total thyroidectomy

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21
Q

which thyroid ca. is more prevalent in iodine-deficient regions?

A

follicular cancer

- MC between ages 40-50

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22
Q

Tx. of microinvasive follicular carcinoma

A

lobectomy and isthmusectomy

- unless it is > 4 cm, then do total thyroidectomy

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23
Q

Tx. of clear follicular cell ca.

A

total thyroidectomy for any lesion > 1 cm

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24
Q

tx of medullary carcinoma

A

total thyroidectomy with removal of central neck LNs - lateral neck dissection usually needed for palpable nodes or large primary lesions

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25
Q

post op management of papillary thyroid ca.

A

thyroid suppression with thyroid hormone

I-131 ablation

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26
Q

post op management of follicular thyroid ca.

A

I-131 ablation

- allows successful monitoring for recurrent thyroid ca.

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27
Q

post op management of medullary thyroid ca.

A

radioactive ablation is NOT useful bc tumors come from C-cells
- external irradiation may be beneficial

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28
Q

what can you use to monitor pts with medullary thyroid ca. post-op?

A

serum calcitonin and CEA levels

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29
Q

what additional tests should you order in symptomatic hypercalcemia?

A

PTH
serum ALP
phosphate levels

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30
Q

MC lesions causing primary hyperparathyroidism

A

parathyroid adenomas

31
Q

how do you tx. a parathyroid adenoma?

A

exploratory surgery of neck

- surgeon examines the parathyroid and excises the adenoma with biopsy of one other gland to ensure normalcy

32
Q

when would you do a radical resection of parathyroids?

A

carcinoma

33
Q

how can you do minimally invasive parathyroid surgery?

A

do sestamibi scan first to determine site of adenoma, make small neck incision and remove only adenoma w/o exploration of remaining glands

34
Q

what do you do if there is a “missing” parathyroid gland on surgery?

A

must find it

- MC locations are thymus (inferior glands), intrathyroidal, tracheoesophageal groove and in carotid sheath

35
Q

what do you do if you find a persistent intrathymic parathyroid?

A

thymectomy through cervical incision or median sternotomy

36
Q

at what calcium level is parathyroid exploration warranted?

A

> 11 mEq/L

37
Q

initial management of acute hypercalcemia

A

rehydration with Normal Saline

- once rehydrated, give furosemide which leads to brisk diuresis high in Calcium

38
Q

MC benign cause of hypercalcemia

A

parathyroid adenoma

39
Q

tx. scheme of acute hypercalcemia with symptoms

A
  1. IVF - normal saline
  2. furosemide
  3. bisphosphonates
  4. tx. underlying cause
40
Q

tx. of secondary hyperparathyroidism (for ex. due to renal failure)

A

surgical removal of all but 50g of parathyroid tissue (transplantation into forearm)

41
Q

indications for surgical management of secondary hyperparathyroidism

A

bone pain
fractures
intractable pruritus
ectopic calcifications in soft tissues

42
Q

you are undergoing neck exploration for a parthyroid adenoma in a patient with hypercalcemia- during operation he develops huge spike in BP - what should you do? what do you suspect?

A

terminate operation immediately, admit pt to ICU, give patient both alpha and beta blockers – evaluate for pheochromocytoma

43
Q

what is important during resection of a pheochromocytoma?

A
  1. pt should be on alpha blockers for atleast 10 days prior to surgery
  2. must ligate venous drainage from tumor before manipulating tumor
  3. minimal manipulation of tumor
    - to prevent surge of catecholamines during surgery
44
Q

where do extra-adrenal pheochromocytomas usually occur?

A

along abdominal aorta in a distribution similar to symphathetic chain

45
Q

if h.pylori test is negative with basal serum gastrin > 00 pg/mL - what do you suspect

A

gastrinoma (Zollinger-Ellison) syndrome

46
Q

diagnostic tests for Zollinger-Ellison

A
  1. serum gastrin > 1000 pg/dL
  2. positive calcium or secretin stimulation test
  3. localize lesion with CT or MRI
47
Q

Tx. of sporadic, solitary gastrinoma

A

surgical resection

48
Q

Whipple triad

A
  1. fasting hypoglycemia (< 60)
  2. sympomatic hypoglycemia
  3. relief by administration of glucose
    - seen in pts with insulinoma
49
Q

if an insulinoma is non-resectable, what medical therapy can be used?

A

diazoxide - inhibitor of insulin release

50
Q

MEN2a

A

medullary thyroid cancer
parathyroid hyperplasia
pheochromocytoma

51
Q

management of incidentally discovered adrenal mass

A

lesions > 5 cm: surgery recommended
lesions < 5 cm: full biochemical workup; if nonfunctioning, can monitor with serial CT scans but if it changes in size, removal is necessary

52
Q

worrisome features of a thyroid nodule

A
  1. young/male
  2. history of radiation to the neck
  3. solid mass on USG
  4. cold nodule on scan
53
Q

diagnostic test of choice for thyroid nodule

A

FNA and cytology

54
Q

next step if a FNAB of a thyroid nodule turns up indeterminate?

A

surgery

- usually lobectomy first

55
Q

tx of follicular cancer of thyroid

A

total thyroidectomy

- mets tx. with radioactive iodine ablation

56
Q

next step when lab results show you high Calcium and low phosphate levels

A

PTH determination

sestamibi scan to localize adenoma

57
Q

first test in someone with Cushing features

A

overnight dexamethasone suppression test

58
Q

diagnostic W/U for Cushing’s

A
  1. overnight dexamethasone suppression test
    - no suppression at low dose –> 24 hr urinary cortisol level
  2. high dose suppression test
    - if suppresses: do MRI of head (pituitary)
    - if she does not suppress: do MRI/CT of adrenals
59
Q

pt comes in bc of virulent PUD; she has multiple duodenal ulcers in first and second portions of duodenum as well as watery diarrhea - dx?

A

Zollinger Ellison

60
Q

dx. of Zollinger-Ellison

A

first: serum gastrin levels
- may add secretin stimulation test
second: CT scans with vascular and GI contrast of pancreas

61
Q

baby with extremely low blood sugar is found to have high levels of insulin in the blood - dx and tx?

A

nesidioblastosis

- tx. pancreatectomy

62
Q

tx of insulinoma if inoperable

A

diazoxide

- inhibits insulin release

63
Q

48 yo woman with severe migratory, necrolytic dermatitis; she is thin, has mild stomatitis and mild DM - dx?

A

glucagonoma

- determine glucagon levels and CT scan

64
Q

tx. of glucagonoma

A

surgery

  • if inoperable, Somatostatin can help sx
  • streptozocin: chemotherapy agent
65
Q

CF of hyperaldosteronism

A

female with HTN
hypokalemia, hypernatremia
metabolic alkalosis

66
Q

initial diagnostic tests for hyperaldosteronism

A

determine aldosterone and renin levels

- will show high aldosterone, low renin

67
Q

how can you differentiate adrenal hyperplasia from an adenoma producing aldosterone?

A

adrenal hyperplasia shows postural changes (more aldsterone when upright than when lying down)

68
Q

tx. of adrenal hyperplasia vs adenoma

A

hyperplasia - medically with spironolactone

adenoma - surgically

69
Q

dx of pheochromocytoma

A

24 hr urinary metanephrine or VMA; if elevated, get a CT scan of adrenals

70
Q

what test has high sensitivity and specificity for pheochromocytoma

A

MIBG scan

71
Q

you find a young man to have elevated BP in both arms; in his legs, the BP is normal

A

dx. coarctation of aorta

72
Q

first test to order in coarctation of aorta

A

CXR

- then CT-angio

73
Q

first test for renal artery stenosis

A

Duplex scan of renal arteries

74
Q

tx of renal artery stenosis due to fibromuscular dysplasia

A

angiographic balloon dilation with stenting

Surgery NBME (16 decks)

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