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Misc Subspecialties Flashcards

0
Q

Child with mushy fluid filled mass at base of neck, occupying supraclavicular area and extending into neck. Nxt?

A

Ct scan-cystic hygromas can extend deep into the neck and to the mediastinum. Electively remove.

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1
Q

Tx of thyroglossal cyst that recently got infected

A

Sistrunk operation- remove cyst, connection to tongue, and midline segment of hyoid bone

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2
Q

Easy way to differentiate an inflammatory vs neoplastic neck mass

A

Check back in 3 weeks! Will go away if inflammatory, if neoplastic then 3 was diff doesn’t make a grew change in course of the disease

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3
Q

Pt who smokes and drinks with a fixed mass medial to scm at level of upper notch of thyroid cartilage which Is growing

A

Mets squamous cell cancer to a jugular chain node. Do not biopsy, do Triple endoscopy looking for origin of cancer (mouth, pharynx, larynx, esophagus, trachea)

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4
Q

Work up for neoplastic process involving facial nerve

A

Gadolinium enhanced MRI

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5
Q

Woman with a 2cm mass in front of left ear, deep to skin and painless. Normal facial nerve function

A

Pleomorphic adenoma- can do fna but biopsy in office is never done. Refer to surgery

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7
Q

Pediatric unilateral ear pain or even lung looking darker on tha side

A

Foreign object

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8
Q

management for child this morning who has developed inspiratory stridor, fever, and is drooling from mouth

A

acute epiglottitis needs to be emergently xray (lateral neck) adn then off to OR for nasotracheal intubation.

also start IV antibiotics for H.infl

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9
Q

Ludwig’s angina

A

abscess of floor of mouth that can occur from a tooth infection. need tracheostomy with incision and drainage of abscess

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10
Q

person develops paralysis the next day on his face after having been treated aggressively after an accident

A

trauma to temporal bone would have caused an immediate lesion on facial nerve, but this is gradual devpt likely from edema, so noting needs to be done

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11
Q

18yo with nose bleed, he hasnt been picking his nose and there is no source of anterior bleeding

A

cocaine abuse or posterior juvenile nasopharyngeal angiofibroma

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12
Q

Nelson’s syndrome

A

pituitary adenoma enlargement after removal of adrenal glands for cushings syndrome. mass affect, hyperpigmentation

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13
Q

man with severe headache, seizures, projectile vomiting. was recently treated for acute otitis media and mastoiditis

A

brain abscess

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14
Q

after accident, develop loss of motor function, and pain and temp on both sides distal to injury, with vibration/position sense ok

A

anterior cord syndrome

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15
Q

which class of meds may minimize permanent damage after a spinal cord injury

A

corticosteroids

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16
Q

causalgia

A

sustained pain due to peripheral nerve injury, does not respond to analgesis medications.
dx: successful sympathetic block
surgical sympathectomy

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17
Q

child that has one hip that can be dislocated posteriorly with a click and then returned with a snap

A

developmental dysplasia of the hip

tx: abduction splinting

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18
Q

boy with limping, decreased hip motion, and knee pain

A

legg-perthes= avascular necrosis of femoral epiphysis.

AP and lateral X ray for dx

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19
Q

cause of hip problem in 13yo boy (limited hip motion, as hip flexed, the lex cannot be rotated internally)

A

slipped capital femoral epiphysis- emergency

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20
Q

child with fever and localized bone pain

A

acute hematogenous osteomyelitis

DONT DO XRAY- wont show for 2 weeks. do bone scan

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21
Q

woman with soft tissue tumor in thigh growing stadily

A

MRI - soft tissue sarcoma as consideration

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22
Q

homeless man with severe pain in forearm. muscles very firm and tender to palpation

A

compartment syndrome

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23
Q

open fracture with femur sticking out of the thigh

A

anything open is an ortho emergency- needs to be cleaned and reduced within 6 hours of injury

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24
Q

xrays dont show origin of a right shoulder pain. patient comes in with arm held close to body, internally rotated.

A

posterior dislocation of shoulder (can be missed on xrays)

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25
patient hit the dashboard with his knees in accident,pain in right hip now with leg internally rotated
emergency- posterior dislocation of hip can lead to avascular necrosis
26
what vessel may be compromised in posterior dislocation of knee
popliteal artery | want to check pulses, and prompt reducation
27
recruit complains of localized pain in tibia after a march. specific point tenderness with normal xray
stress fracture= dont show up radiolofically until 2 wks later. Cast and repeat xray in 2 wks
28
what xrays to order for man with fall with fracture of femur
xrays at 90 degrees to each other (AP and lateral(, include joints above and below, and check other bones in the same line of force
29
how to differentiate testicular torsion from epididymitis
sonogram to rule out twisting
30
man with a ureteral stone develops chills, 104 fever, and flank pain
EMERGENCY- has obstruction and infection. IV abx, and decompression by uretral stent or percutaneous nephrostomy
31
man with chills, fever, dysuria, and very tender prostate on rectal exam
IV abx for acute bacterial prostatitis without doing any more rectal exams- that could lead to septic shock
32
man with erection that hasnt gone away
priapism is an emergency (can damage corpora)- give alpha agonist
33
what to do with a baby scheduled for a circumcision who has a urethral opening on ventral side
dont do the circumcision now----may need foreskin for hypospadias surgery
34
little girl who voids urine normally but also wet with urine all the time
low implantation of one ureter- empties into vagina without the sphincter. IVP for dx
35
16yo boy binge drinks and has colicky flank pain
ureteropelvic junction obstruction (pain esp noticed after drinking a lot of fluids)
36
asx prostate cancer is usually not treated after age
75
37
25yo m with painless, hard testicular mass
testicular cancer- immediate bhcg and afp and then radical orchiectomy. testicular cancers are usually not benign DO NOT DO A TRANS-SCROTAL BIOPSY
38
woman leaks urine whenever she laughs, sneezes, lifts heavy objects
stress incontinence, need surgical repair of pelvic floor
39
test for pt presenting with bubbles of air with urine
sigmoid colon diverticulitis or cancer connecting to bladder | -sigmoidoscopy or cystoscopy usually dont show anything. CT scan
40
what history to check for patient presenting with an isolated thyroid nodule
main concern is thyroid cancer. check family history, but especially hx of LOW DOSE IONIZING RADIATION. If history present, straight to thyroidectomy
41
next step after H&P of fixed thyroid nodule
FNA | Note: radioactive scanning with iodine isnt an initial step, but cold nodules have a higher chance of being malignant
42
nerves and structures at risk during thyroidectomy
``` recurrent laryngeal (hoarseness) external branch of superior laryngeal (high pitched voice altered) parathyroid- hypocalcemia ```
43
how would surgery for papillary cancer differ in pt with previous radiation vs not
previous head/neck radiation= total thyroidectomy | no radiation= limited thyroid lobectomy and isthmusectomy
44
post op management after thyroidectomy | in what case is this management not helpful?
thyroid suppression by giving TH and iodine ablation | not helpful in medullary cancer due to tumor arising from C cells
45
what scan can localize primary hyperPTH effects
preoperative sestamibi scan (shows enlarged parathyroid glands)
46
patient with only 3 glands which are normal while patient has hypercalcemia and high PTH levels
find the missing parathyroid gland! | most common site- thymus
47
initial treatment with acute hypercalcemia
calcium results in osmotic diuresis to first step is rehydration with normal saline. - furosemide- brisk diuresis of calcium (dont use thiazides!) - initiate bisphophonates
48
when is surgical management indicated for secondary hyperPTH
- bone pain and fractures - intractable pruritis - ectopic calcifications of soft tissue
49
what to think about when pt with hyperPTH becomes uncontrollably hypertensive during the procedure
pheochromocytoma
50
scans for pheo
MRI- tumor brightness octrotide scan MIBG scan-accumulates in chromaffin tissue
51
pre-op for pheo
10-14 days of alpha blocker
52
what is given if insulinoma cannot be resected
diazoxide= inhibitor of insulin release
53
management for an incidental adrenal mass found on CT
if lesion more than 5cm= higher incidence of adrenal cortical carcinoma- surgery recommended
54
most significant finding in addition to histo and TNM for prognosis of melanoma
presence of ulceration in primary lesion | even in stage 1 lesions, ulceration reduces survival
55
management of malignant melanoma for clark level 1 and 2 lesions
re-excise lesion with 1cm margin,down to the deep fascia (full thickness)
56
for melanoma, lymph nodes are usually just resected if palpable. when may elective node dissection done?
if do sentinel LN biopsy after and it is positive
57
patient with a brownish discoloration on cheek that has been slowly growing
irregular lentigo maligna melanoma usually more superficial and spreading (better prognosis) excision with narrow margins ok
58
prognosis for pt with melanoma on sole of foot
poorer prognosis- these lesions tend to be thicker
59
type of biopsy based on sarcoma size
smaller than 3cm: excisional | greater than 3cm: incisional
60
surgical management of sarcoma
initial extensive surgery provides best control. ex: total resection of a tissue compartment (spares limb unlike amputation)- muscle length, insertion points, deep fascia
61
lung lesion found on cxr after primary excision of a sarcoma
recurrences usually occur in first 2 yrs after resection - follow up with CT with contrast to find other lesions/characterize lesion - if sarcoma in lung= thoracic wedge resection
62
a firm, tender mass in gron with nausea, vomiting, abdominal distension
loop of intestine could be incarcerated/strangulated in hernia
63
when to start breast examinations if have first degree relative history
age 40 yearly mammograms, 30 if history self breast examinations at 20yo
64
"probably benign" breast lesions | "suspicious" breast lesions
probably benign findings warrant follow up (risk of malignancy less than 2%) suspicious- warrant biopsy `
65
which type of biopsy preferred if mammographic lesion is indeterminate
stereotactic core needle (better histologic diagnosis than FNA
66
a woman has amorphous calcifications indicating DCIS. next step?
surgery is necessary,esp since some lesions diagnosed as DCIS have an infiltrative component when excised
67
which pattern of DCIS has a higher malignant potential?
comedo pattern
68
is nodal dissection needed with DCIS?
no unless comedo pattern
69
how does LCIS differ from DCIS?
usually not picked up by a mass or mamography. has no risk of axillary metastasis. usually tx is close observation with checking every 6 mos
70
followup steps for 60yo female with a breast mass (no FH or SH)
mammogram to look for lesion in both breasts ultasound of mass if mass feels cystic biopsy if mass feels solid core biopsy for diagnosis, FNA for cytology
71
28yo woman presenting with a breast mass
under 30- higher incidence of benign lesions and also more risk of radiation. Ultrasound may precede mammogram, to look for cyst and aspirate it. If solid, high likelihood of fibroadenoma- observation or elective removal
72
35yo f presents with tender breasts before menstrual periods. Breasts lumpy
fibrocystic changes *may be due to increased sensitivity to estrogen* may want to eliminate caffeine from diet take supplemental vit E if doesnt go away, biopsy necessary since some risk of cancer exists
73
14 cm breast mass in 20 yo woman
phyllodes tumor (giant cell fibroadenomas)- large, bulky mass with variable malignant potential. need to widely excise.
74
next steps in woman with bloody breast discharge
mammography to look for other problems | find the single duct that is the source and excise
75
how to assess distant mets from breast cancer
chest xray to detect lung and bone---hes----CT/bone scan of head liver enzymes---yes= CT of abdomen
76
how does woman's age affect prognosis in breast cancer
younger at diagnosis tend to do worse
77
what does an ulcerated breast lesion with an underlying mass indicate
inflammatory carcinoma (worse prognosis than usual infiltrating ductal carcinoma)
78
what does a breast mass fixed to deeper tissues indicate
fixation to chest wall indicates invasion of structures outside breast
79
breast cancer with LN palpable in supraclavicular area
stage 4 disease with distant mets- cant resect anymore
80
N1 vs N2 in breast cancer
N1 is mets to movable nodes while N2 is fixed
81
main arterial supplies to the breast
internal mammary (60%) and lateral thoracic (30%)
82
what is spared in the MRM surgery vs a radical mastectomy
pectoralis major muscle
83
for which patient is local radiation indicated following mastectomy
patients with tumors larger than 5cm, that involve margin of resection or that invade the pectoral fascia or muscle
84
when can a lumpectomy/segmental mastectomy done instead of MRM
solitary tumor less than 5cm provided that pt is a good candidate for postop radiation
85
next step in woman with 1.5 cm breast lesion with no palpable axillary nodes and negative mets workup
still need to sample lymph nodes- usually at levels 1 and 2 or sentinel node sentinel node figured out via radiotracer dye
86
is there a significant difference in survival btwn MRM and lympectomy with radiation
not for stage 1 or 2 patients
87
pros and cons of MRM vs lumpectomy in younger women
younger- lumpectomy may be preferred for cosmetic reasons but MRM more appropriate since younger= more recurrences
88
contraindications to immediate reconstruction of breast
primary lesions involving chest wall extensive local or regional disease stage 3 or 4 cancer
89
followup management for node negative stage 0 and 1 cancer with small vs large tumor
small- radiation and no further therapy if ER neg, and hormonal therapy for ER+ chemotherapy is better tolerated in younger pre-menopausal women and can be used larger (1-2cm)- adjuvant therapy + radiation
90
what should be considered for stag 3 and 4 cancer in addition to surgery
neoadjuvant (prior to surgery) therapy to reduce tumor size
91
a woman who had a MRM for stage 2 cancer of breast has a small lesion in suture line 5 years later
local recurrence- r/o with surgical or core needle biopsy excise lesion if cancer if had lumpectomy before, then do mastectomy
92
woman with previous breast cancer surgery has a mammographic abnormality in opposite breast
new primary cancer likely
93
patient who had a mastectomy now has decreased sensation and motor function in right leg
emergency! extradural mets to spine MRI scan for dx of cord compression Steroids, cord decompression, radiation therapy
94
pregnant woman with stage 1 or 2 breast cancer
mastectomy or lumpectomy is safe. if in 3rd trimester, can delay radiation. Lumpectomy discouraged earlier in pregnancy due to need of radiation
95
a 6yo girl presents with a firm 1cm unilateral breast mass
likely a breast bud- observe, reassure parents | dont excise or biopsy
96
best therapy for BPH
TURP (transurethral prostatectomy)- chips of prostate are carved out from urethra and removed via scope
97
pt with lower abdominal mass constantly dribble urine. next step
put in a foley first to relief obstruction
98
pt with lower abdominal mass constantly dribble urine. next step
put in a foley first to relief obstruction
99
which type of breast cancer has tendency to be negative on mammogram and also presents as focal thickening
invasive lobular
100
screening ductal lavage
for high risk lesions or profiles. aspiration of areola to induce nipple discharge, analyzed through cytology.
101
next step with LCIS found
MRM and mastectomy not yet justifiable since this is indication of subsequent cancer devpt. instead should use tamoxifen and mammogram surveillance
102
man with trauma has bloody urethral meatus, distended bladder, scrotal hematoma, high riding prostate
posterior urethral injury associated with pelvic trauma

Surgery (4 decks)

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