Lumps, Bumps, Skin and Hernias Flashcards
An 18-year-old school student of East African origin presents with a 2-week
history of lethargy, myalgia, rigors with hot flushes and intermittent pyrexia.
Neither she nor any close contacts have been travelling recently. Examination
reveals enlarged anterior and posterior chain lymph nodes in the neck. A blood
film reveals the presence of Downey bodies, thrombocytosis and an increase in the
lymphocyte count to 50 per cent of total leucocytes. This girl is likely to have:
A. Tuberculosis
B. Toxoplasmosis
C. Human immunodeficiency virus infection
D. Lymphoma
E. Infectious mononucleosis
E. Infectious mononucleosis
Lymph nodes are the most common next swelling in a clinical setting, accounting for around 85% of presentations. Cervical lymphadenopathy can be a part of a local or generalised lymphadenopathy.
Infectious mononucleosis (Pfeiffer’s disease/glandular fever) (E) is a viral illness resulting from EBV infection. It commonly affects young adults and teenagers, leading to fever, sore throat, lethargy, and myalgia. A blood film will typically show a reactive lymphocytosis of between 35% and 70% of total leucocyte count and atypical ‘Downey’ bodies, a form of T-cell.
Infectious mononucleosis is usually definitively diagnosed by a positive monospot/Paul Bunnell test. Treatment is rest and analgesia.
A 16-year-old girl presents with a smooth, round and painless lump in the midline
of the neck, of which she feels very self conscious. On examination, it is firm,
transilluminates and is painless to touch. In addition, it moves up when the patient
is asked to take a sip of water. This is likely to be a:
A. Papillary carcinoma of the thyroid
B. Goitre
C. Thyroglossal cyst
D. Lingual thyroid
E. Sebaceous cyst
C. Thyroglossal cyst
The description is that of a thyroglossal cyst (C). These are persistent
remnants of the thyroglossal duct, which guides the passage of the
thyroid gland during development. Typically these cysts are smooth,
round and 2–3 cm in diameter. They occur more commonly in females,
especially teenagers and young adults. On examination the lump tends to
move up with swallowing and tongue protrusion. Definitive management
is by excision of the lump. Lingual thyroid (D) occurs when residual tissue is
left on the base of the tongue as the thyroid migrates along its tract
during development.
Thyroid malignancy (A) is seriously unlikely in a teenager, and the description of a cystic lump doesn’t fit with a goitre (B). It is tethered to the deeper structures, and not the skin, so it cannot be a sebaceous cyst (E).
A 45-year-old female business executive presents with a swelling in the midline of
the neck and features of hyperthyroidism secondary to Graves’ disease. Following
a course of antithyroid medication, a subtotal thyroidectomy is performed. Raised
titres of which immunoglobulin would be expected in this individual?
A. Anti-thyroglobulin antibody
B. Rheumatoid factor
C. Antinuclear antibody
D. Antineutrophil cytoplasmic antibody
E. Anti-thyroid-stimulating hormone receptor antibody
E. Anti-thyroid-stimulating hormone receptor antibody
Graves’ disease is an autoimmune disorder that occurs most commonly in
women (10:1) between the ages of 20 and 50 years. It is associated with
signs of hyperthyroidism.
In Grave’s disease there is an increase in antibodies to TSH receptors (E), resulting in pathological stimulation of the thyroid, leading to increased fre T3/T4. There is an association with other autoimmune disorders such as pernicious anaemia, DM1, and Addison’s. Treatment is medical with Carbimazole, propylthiouracil, propranolol, and radioiodine therapy or surgical (partial or total thyroidectomy).
Anti-thyroglobulin antibody (A), although raised in some patients with
Graves’ disease, is most commonly associated with Hashimoto’s
thyroiditis.
Rheumatoid factor (B) is commonly raised in
patients with rheumatoid arthritis, Sjögren’s syndrome and Felty’s
syndrome.
Raised antinuclear antibody (C) titres occur in SLE, RA, chronic
active hepatitis and systemic sclerosis.
Antineutrophil cytoplasmic antibody (D) is a marker of vasculitis and occurs in two forms: cANCA directed against serine protease 3 is usually elevated in patients with
Wegener’s disease, whereas pANCA is directed against myeloperoxidase
and elevated in systemic vasculitides such as microscopic polyangiitis.
You are asked to assess a 25-year-old patient who returned from theatre 2 hours
ago following a thyroidectomy for a large, hyperplastic goitre and is now
complaining of difficulty swallowing sips of water. On examination you note that
she is very short of breath with a respiratory rate of 30 breaths/min, using her
accessory muscles of respiration and only able to answer your questions in two or
three words. In addition, there appears to be a fluctuant mass in the midline of the
neck underlying the surgical clips. Immediate management of this patient would
be:
A. High-flow oxygen via Hudson mask
B. Removal of surgical clips at the bedside
C. Intravenous access with two large-bore cannulae and fluid resuscitation
D. Removal of surgical clips in theatre under general anaesthesia
E. Call your senior and wait for him/her to remove the clips
B. Removal of surgical clips at the bedside
In this scenario there is a haemorrhage following throidectomy and there is a developing tension haematoma leading to airway compromise. This is an emergency situation and requires immediate removal of the clips at the bedside (B), and then returning the patient to theatre to explore the area and control the haemorrhage.
Other complications of thyroidectomy;
• immediate – haemorrhage, laryngeal oedema, recurrent/superior
laryngeal nerve damage, tracheal damage and thyroid storm
• early – reactionary haemorrhage, hypocalcaemia (secondary to
parathyroid insufficiency) and infection
• late – hypothyroidism, keloid scar, disease recurrence.
A 28-year-old secretary presents with a lump in the midline of the neck that has
grown progressively larger over the past several months. On examination, there is
a palpable lymph node in the left submandibular region. An aspirate is taken,
confirming a malignant cancer of the thyroid gland. The origin of this is most
likely to be:
A. Follicular
B. Anaplastic
C. Medullary
D. Lymphoma
E. Papillary
E. Papillary
A 37-year-old patient is diagnosed with medullary carcinoma of the thyroid gland.
The concentration of which electrolyte could be reduced in this patient?
A. Sodium
B. Potassium
C. Chloride
D. Calcium
E. Magnesium
D. Calcium
Medullary carcinoma of the thyroid gland makes up less than 10 per cent
of all thyroid cancers and occurs equally in men and women. These
cancers arise from the parafollicular C cells, which secrete calcitonin.
Calcitonin acts to reduce the serum calcium and phosphate level. As a
result, the calcium level could be low in this patient. Medullary carcinoma
also occurs as part of the MEN 2 syndrome. Metastasis is via the
lymphatic system.
A 68-year-old man presents with a 10-week history of a rapidly growing swelling
in the midline of the neck. Prior to this problem developing he has been in
excellent health. Over the past 10 weeks, he has begun to feel more worn out and
is unable to complete his daily 3 mile walk without getting short of breath, which
he was previously able to manage comfortably. His wife also reports that his voice
has become increasingly hoarse in the last 2 weeks. The presentation is likely to be
consistent with:
A. Recurrent laryngeal nerve damage
B. Tracheal trauma
C. Medullary carcinoma of thyroid
D. Anaplastic carcinoma of the thyroid
E. Papillary carcinoma of the thyroid
D. Anaplastic carcinoma of the thyroid
The history of a rapidly growing, agressive tumour that has invaded the patient’s airway, in an elderly patient, is strongly indicative of anaplastic thyroid carcinoma (D).
Anaplastic carcinoma invades rapidly and spreads via the haematological and lymphatic routes. Treatment is with radiotherapy and chemotherapy but is rarely curative due to its extremely agressive nature. When the airway is compromosied, as in this case, a paliative tracheostomy is indicated. 5-year survival is 14%.
A 59-year-old fisherman presents with longstanding weight loss, anorexia and
lethargy. Physical examination reveals a palpable swelling in the left
supraclavicular fossa. A disseminated adenocarcinoma of the stomach is diagnosed
following a gastroscopy and computed tomography scan of the thorax and
abdomen. This patient has presented with:
A. Virchow’s node
B. Battle’s sign
C. Cloquet’s node
D. Troisier’s sign
E. Trousseau’s sign
D. Troisier’s sign
Virchow’s node (A) refers to the specific lymph node in the left supraclavicular fossa. This node drains the abdominal organs and becomes enlarged and palpable in teh case of intra-abdominal (particularly) gastric malignancy. When an enlarged Virchow’s node is found on examination, it is termed Troisier’s sign (D).
Battle’s sign (B) is bruising over the mastoid process, and is indicitive of a base of skull fracture involving the petrous temporal bone.
Cloquet’s node (C) refers to the most superior of the deep inguinal lymph nodes. Enlargement of the inguinal lymph nodes can be a sign of lower limb infection, systemic lymphadenopathy, or lymphatic spread of distal malignancies, such as anal or vulva.
Trousseau’s sign (E) is phlebothrombosis of the superficial leg veins in association with gastric carcinoma.
Which of the following structures does not form a border of the anterior triangle
of the neck?
A. Midline of the neck
B. Anterior border of sternocleidomastoid muscle
C. Lower border of the mandible
D. Investing fascia
E. Middle third of the clavicle
E. Middle third of the clavicle
Borders of the anterior triangle of the neck are as follows:
• medial: midline of the neck (A)
• lateral: anterior border of SCM (B)
• superior: lower border of mandible (C)
• roof: investing fascia (D)
• floor: prevertebral fascia.
Borders of the posterior triangle of the neck are as follows:
• anterior: posterior border of the SCM
• posterior: anterior border of trapezius muscle
• base: middle third of the clavicle
• floor: prevertebral fascia overlying prevertebral muscles (splenius
capitis, levator scapulae, scalenus anterior/middle/posterior).
A 45-year-old woman teacher is diagnosed with a submandibular calculus, having
presented with a tender lump below the jaw on eating. Which structure is likely to
be obstructed?
A. Warthin’s duct
B. Stensen’s duct
C. Biliary duct
D. Lingual nerve
E. Facial nerve
A. Warthin’s duct
80% of salivary stones ocur in the submandibular glands, They are usually seen in young to middle aged adults and present with pain and swelling under the jaw, following obstruction or Warthin’s duct (A), this runs throught the submandibular gland and opens on the the floor of the mouth.
Symptoms then to occur around eating, pressing on the gland may produce a foul tasting fluid in the mouth, but can relieve symptoms.
The calculi are often composed of calcium pyrophosphate or calcium carbonate, which is thought to be secondary to fragments of toothpaste acting as a focus for stone formation. Partial obstruction of the duct will result in swelling and pain lasting from minutes to hours, whereas complete swelling will result in persistant swelling and infection. Stones located within the oral cavity part of the duct will be treated by removal under anaesthesia, those stones within the gland will require the removal of the gland.
Stensen’s duct passes through the parotid gland. The lingual nerve also
passes through the submandibular gland. The trunk of the facial nerve lies
between the deep and superficial parts of the parotid glands.
A 40-year-old man presents with a month-long history of intermittent, left-sided
pain and swelling in the anterior neck below the left jaw. His symptoms are
associated with meal times and regress shortly after completing each meal. In
recent days, however, the pain appears to have become more intense and the
swelling more firm. On examination a firm lump is palpable in the left
submandibular region, bimanual palpation of which causes the patient to complain
of a foul taste in his mouth. The most appropriate diagnostic investigation will be:
A. Plain radiographs of the mouth
B. Blood calcium level
C. Biopsy of submandibular tissue
D. Sialogram
E. None of the above
D. Sialogram
A sialogram (D) is a radiograph of the affected salivary gland followed by the injection of radio-opaque contrast into the duct. The radiographs show any obstructions, and the flushing of the contrast is considered to have a theraputic effect. It is the investigation of choice in this case, and may be theraputic.
A 54-year-old builder attends your outpatient clinic with his wife, reporting an
8-month history of a lump on the left side of his face, in front of his ear. It is
painless and does not trouble him. He has attended on the insistence of his wife,
who is worried that it may be growing larger. On examination, the swelling
appears to lie anterior to the angle of the jaw on the left side. It is non-tender and
approximately 5 cm in diameter with a clear edge. The skin is easily moved on top
of it and the lump itself feels rubbery to touch. There is no cervical
lymphadenopathy or facial droop evident on examination. An aspirate is taken
which shows cells of many different types. A decision is made at a follow-up
appointment to excise the lump under anaesthesia. This is likely to be a:
A. Pleomorphic adenoma
B. Adenolymphoma (Warthin’s tumour)
C. Mikulicz’s syndrome
D. Sjörgen’s syndrome
E. Carcinoma of the parotid gland
A. Pleomorphic adenoma
Pleomorphic adenoma (A) is the most common salivary neoplasm and consists of several different types of tissue. 90% of these occur in the parotid gland and grow slowly over many years. They can be locally invasive and can reoccur, they are treated by superficial parotidectomy.
Adenolymphoma (Warthin’s tumour) (B) is a benign cystic tumour that contains epitheleal lymphoid elements. It occurs in middle to old age leading to a soft cystic lump in the parotid gland, in a similar position to a pleomorphic adenoma.
Sjörgen’s (D) and Mikulicz’s (C) syndromes are autoimmunediseases that result in slow progressive and usually painless enlargement of the salivary glands as a result of lymphoid tissue replacing the glandular tissue. Symptoms include; enlargement of parotid/submandibular glands, enlargement of lacrimal glands causing a bulge at the outer end of the upper eyelids and narrowing of the palpebral fissures, dry mouth, dry eyes and generalized arthritis (last two symptoms are more common in
Sjögren’s syndrome).
Parotid carcinoma (E) can arise without warning orcan originate from long-standing pleomorphic adenoma. There is rapid enlargement and pain, which radiates to the side of the face and ear. There may be mouth asymetry and difficulty in closing the mouth. If the tumour has invaded the gland there may be facial nerve involvement.
A 6-year-old boy presents with his mother to the general practice at which you are
based, with a 3-week history of bilateral cheek swelling. The family are newly
registered and medical records have not yet been transferred to the practice. His
mother informs you that the young boy has not received any of his childhood
vaccinations, as she has been worried about the possible detrimental health effects.
The clinical suspicion is of mumps parotitis. Which class of infectious agent is
responsible for mumps?
A. RNA viruses
B. DNA viruses
C. Gram-negative bacteria
D. Gram-positive bacteria
E. Fungi
A. RNA viruses
The mumps virus is an RNA paramyxovirus spread by droplet infection.
It has an incubation period of 2–3 weeks. Affected individuals are
infective for 7 days before and after onset of parotid swelling. Parotid
swelling is bilateral in 70 per cent of cases. In addition to a viral
prodrome, complications of mumps can include orchitis (enquiry about
testicular pain is necessary), arthritis, meningitis, pancreatitis and
myocarditis. Treatment is for symptoms.
A 39-year-old man of Italian origin presents, complaining of an exquisitely tender
area over his right buttock, which has been present for several weeks. Within the
past few days, the area has begun to weep profusely and his temperature at home
prior to admission was 38 ∞C. He reports having had this problem previously and
was operated on during previous admission. On examination you note that the
man is extremely hairy and that there is an irregular, erythematous, warm and
exquisitely tender shallow lump overlying the top of the right buttock. A small scar
is seen over the lump and, on palpation, it is fluctuant and there is a discharge of
purulent fluid. A pilonidal abscess is suspected. Definitive management would
consist of:
A. Advise to shave the affected area
B. Intravenous antibiotics
C. Drainage of the abscess under local anaesthesia
D. Drainage of the abscess under general anaesthesia
E. Oral antibiotics
D. Drainage of the abscess under general anaesthesia
A 56-year-old priest presents with a lump at the back of his hand that has been
getting larger over the past year. Although it does not trouble him, his parishioners
are increasingly commenting on it after his Sunday service. On examination, there
is a soft, non-tender, irregular lump on the dorsum of the hand 3 cm x 5 cm in size.
It is fluctuant on movement and transilluminates but does not reduce when pressed
down. The skin moves freely over it and no other such lumps are to be found on
either arm. An aspirate produces a dark gelatinous material. This is most likely a:
A. Sebaceous cyst
B. Ganglion
C. Bursa
D. Rheumatoid nodule
E. Cystic hygroma
B. Ganglion
A Ganglion (B) is a cystic degeneration of fibrous tissue that most commonly occurs around joints. They present mostly between the ages of 20 and 0, growing slowly over many months. They are non-tender, spherical and smooth. The overlying skin moves freely and aspiration revels a thick gelatinous material.
Aspiration and injection with hydrocortisone is a common treatment but there will usually be reccurence, there is also reccurence after the more traditional book therapy. The only definitive management is surgical excision.
A sebaceous cyst (A) would be within the skin layers
A bursa (C) is a fluid-filled cavity occuring between tendons, bones and skin to allow ease of movement.
Rheumatoid nodules (D) commonly occur in realtion to rheumatoid arthritis, the presenting history here does not indicate that.
