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39 Cards in this Set
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A 62 year old lady was drinking her morning cup of coffee at the same time she was applying her makeup, and she noticed in the mirror that there was a lump in the lower part of her neck, visible when she swallowed. She consult you for this and on physical exam you ascertain that she indeed has a dominant, 2 cm. mass on the left lobe of her thyroid as well as two smaller masses on the right lobe. They are all soft and she has no palpable lymph nodes in the neck. - Management? |
Management: Most thyroid nodules are benign, and surgical removal to ascertain the diagnosis is a big operation...thus surgery has to be reserved for selected cases. Worrisome features include: young, male, single nodule, history of radiation to the neck, solid mass on sonogram and cold nodule on scan. In center with sufficient experience, the last tow tests are omitted in preference for fine needle aspiration and cytology. This case does not sound malignant, but you can not be sure. If given the option among the answers, go for the FNA. |
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A 21 year old college student is found on a routine physical examination to have a singe, 2 cm. nodule in the thyroid gland. The young man had radiation to his head and neck when he was thirteen years old because of persistent acne. His thyroid function tests are normal. - Management? |
This one will need surgery, but if offered FNA is still your first answer. |
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A 44 year old lady has a palpable mass in her thyroid gland. She also describes losing weight in spite of a ravenous appetite, palpitations and heat intolerance. She is a thin lady, fidgety and constantly moving, with moist skin and a pulse rate of 105. - What is it? - Management? |
What is it? – A “hot” adenoma.
Management: confirm hyperthyroidism by measuring free T4. Confirm source of the excessive hormone with radioactive iodine scan. Do surgery after Beta blocking. |
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A 22 year old male has a 2 cm. round firm mass in the lateral aspect of his neck, which has been present for four months. Clinically this is assumed to be an enlarged jugular lymph node and it is eventually removed surgically. The pathologist reports that the tissue removed is normal thyroid tissue. - What is it? - Management? |
What is it? - There is no such thing as “lateral aberrant thyroid”. This is metastatic follicular carcinoma from an occult primary in the thyroid gland.
Management: Look for the primary with a thyroid scan. Eventually surgery. |
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An automated blood chemistry panel done during the course of a routine medical examination indicates that an asymptomatic patient has a serum calcium of 12.1 in a lab where the upper limit of normal is 9.5. Repeated determinations are consistently between 10.5 and 12.6. Serum phosphorus is low. - What is it? - Diagnosis made how? |
What is it? - Parathyroid adenoma. How is the diagnosis made? - Had this question been written 20 years ago, the vignette would have described a patient with a disease of “stones and bones and abdominal groans”, and you would have cleverly asked for a serum calcium as your first test. Nowadays most parathyroid adenomas are identified when they are still asymptomatic, because of the widespread use of automated blood chemistry panels. Across the board most cases of hypercalcemia are due to metastatic cancer, but that would not be the case on asymptomatic people. Your next move here is PTH determination and sistimibi scan to localize the adenoma. Surgery will follow. |
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A 32 year old woman is admitted to the psychiatry unit because of wild mood swings. She is found to be hypertensive and diabetic and to have osteoporosis. (she had not been aware of such diagnosis beforehand). It is also ascertained that she has been amenorrheic and shaving for the past couple of years. She has gross centripetal obesity, with moon fascies and Buffalo hump, and thin, bruised extremities. A picture from 3 years ago shows a person of very different, more normal appearance. - What is it? - How is diagnosis made? |
What is it? - Cushings. The appearance is so typical, that you will probably be given a photograph on the test, with an accompanying brief vignette. The presenting symptom may be any one of those listed.
How is the diagnosis made? - Start with AM and PM cortisol determinations. Later she will get dexamethasone suppression tests and MRI) of the head looking for the pituitary microadenoma, which will eventually be removed by the trans-nasal, trans-sphenoidal route. |
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A 28 year old lady has virulent peptic ulcer disease. Extensive medical management including eradication of H.Pylori fails to heal her ulcers. She has several duodenal ulcers in the first and second portions of the duodenum. She has watery diarrhea. - What is it? - How is diagnosis made? |
What is it? - Gastrinoma (Zollinger-Ellison).
How is the diagnosis made? - Start by measuring serum gastrin. Later CT scans (or MRI) of the pancreas looking for the tumor, and surgery to remove it. |
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A second year medical student is hospitalized for a neurological work-up for a seizure disorder of recent onset. During one of his convulsions it is determined that his blood sugar is extremely low. Further work-up shows that he has high levels of insulin in the blood with low levels of C-peptide. - What is it? - Management? |
What is it? - Exogenous administration of insulin. If the C-peptide had been high along with the insulin level, the diagnosis would have been insulinoma.
Management: In this case, psychiatric evaluation and counseling (He is faking the disease to avoid taking the USMLE). If it had been insulinoma, CT scan or MRI looking for the tumor in the pancreas, to be subsequently removed surgically. |
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A 48 year old lady has had severe, migratory necrolytic dermatitis for several years, unresponsive to all kinds of “herbs and unguents”. She is thin, has mild stomatitis and mild diabetes mellitus. - What is it? - How is the diagnosis made? |
What is it? - Glucagonoma.
How is the diagnosis made? - Determine glucagon levels. Eventually CT scan or MRI looking for the tumor in the pancreas. Surgery will follow. If inoperable, somatostatin can help symptomatically and streptozocin is the indicated chemotherapeutic agent. |
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A 45 year old lady comes to your office for a “regular checkup”. On repeated determinations you confirm the fact that she is hypertensive. When she was in your office three years ago, her blood pressure was normal. Laboratory studies at this time show a serum sodium of 144 mEq/L, a serum bicarbonate of 28 mEq/L, and a serum potassium concentration of 2.1 mEq/L. The lady is taking no medications of any kind. - What is it? - How is the diagnosis made? |
What is it? - Hyperaldosteronism. Possibly adenoma.
How is the diagnosis made? - Start with determinations of aldosterone and renin levels. If confirmatory (aldo high, renin low) proceed with determinations lying down and sitting up, to differentiate hyperplasia (not surgical) from adenoma (surgical). Treat the first with aldactone. Pursue the second with imaging studies (CT scan or MRI) and surgery. |
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A thin, hyperactive 38 year old lady is frustrated by the inability of her physicians to help her. She has episodes of severe pounding headache, with palpitations, profuse perspiration and pallor, but by the time she gets to her doctor’s office she checks out normal in every respect. - What is it? - How to diagnose? |
What is it? – Suspect pheochromocytoma.
How to diagnose it? - Start with 24 hr. urinary determination of metanephrine and VMA (Vanillylmandelic acid). Follow with CT scan of adrenal glands. Surgery will eventually be done, with careful pharmacological preparation with alpha-blockers. |
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A 17 year old man is found t have a blood pressure of 190/115. This is checked repeatedly in both arms and it is always found to be elevated, but when checked in the legs it is found to be normal. - What is it? - Further testing? |
What is it? - Coarctation of the aorta.
Further testing; start with a chest X-Ray, looking for scalloping of the ribs. Eventually aortogram and ultimately surgery. |
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A 23 year old lady has had severe hypertension for two years, and she does not respond well to the usual medical treatment for that condition. A bruit can be faintly heard over her upper abdomen. - What is it? - Management? |
What is it? - Renovascular hypertension due to fibromuscular dysplasia.
Management: I hope they only ask you to identify this one in an extended matching set. How to proceed with the diagnosis is a can of worms. There are a million tests, mostly invasive and expensive, and none with clear-cut reliability. Eventually arteriogram will precede surgical correction (or balloon dilatation). |
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A 72 year old man with multiple manifestations of arteriosclerotic occlusive disease has hypertensin of relatively recent onset, and refractory to the usual medical therapy. He has a fain bruit over the upper abdomen. - What is it? |
What is it? - Renovascular hypertension due to arteriosclerotic plaque at the origin of the renal artery...or arteries (this is usually bilateral). I hope you are not asked to manage it. To the problems outline above, add the difficult, equation of guessing which manifestation of his arteriosclerotic disease is going to kill him first. |
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Within eight hours after birth, it is noted that a baby has excessive salivation. A small, soft nasogastric tube is inserted and the baby is taken to X-Ray to have a “babygram” done. The film shows the tube coiled back upon itself in the upper chest. There is air in the gastrointestinal tract. - What is it? - Management? |
What is it? – Tracheo-esophageal fistula, the most common type with proximal blind esophageal pouch and distal TE fistula.
Management: first, rule out the associated anomalies (“VACTER”: vertebral, anal, cardiac, TE and renal/radial). The vertebral and radial will be seen in the same X-ray you already took, you need echo for the heart, sonogram for the kidneys and physical exam for the anus. Then off to surgery. |
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A newborn baby is found on physical exam to have an imperforate anus. - Management? |
Management: This is part of the “VACTER” group, so look for the others as mentioned above. For the imperforate anus, look for a fistula nearby (to the vagina in little girls, to the perineum in little boys), which will help determine the level of the blind pouch and the timing and type of surgery (primary repair versus colostomy and repair later). |
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A newborn baby is noted to be tachypneis, cyanotic and grunting. The abdomen is scaphoid and there are bowel sounds heard over the left chest. An X-Ray confirms that there is bowel in the left thorax. Shortly thereafter, the baby develops significant hypoxia and acidosis. - What is it? - Management? |
What is it? - Congenital diaphragmatic hernia.
Management: The main problem is the hypoplastic lung. It is better to wait 36 to 48 hours to do surgery to allow transition from fetal circulation to newborn circulation. Meanwhile the trick is to keep the kid alive with endotracheal intubation, hyperventilation (careful not to blow up the other lung), sedation and NG suction. |
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At the time of birth it is noted that a child has a large abdominal wall defect to the right of the umbilicus. There is a normal cord, but protruding from the defect there is a matted mass of angry looking, edematous bowel loops. - What is it? |
What is it? - Gastroschisis.
Medial school professors love to emphasize differential diagnosis of somewhat similar problems. The issue with abdominal wall defects, is which one is the gastroschisis and which one is the omphalocele. Chances are all you’ll be expected t do is to identify the correct one. Management is intuitive: you got to get those chitlins back into the belly, and the technical detail are best left to the pediatric surgeons. They will be on the look-out for atresias, which these babies can have, and they may need to use a silicon “silo” to gradually close the abdominal wall defect. |
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A newborn baby is noted to have a shiny, thin, membranous sac at the base of the umbilical cord. Inside the sac one can see part of the liver, and loops of normal looking bowel. - What is it? - Management? |
What is it: This one is the omphalocele.
Management: These kids can have a host of other congenital defects. After those are looked for, repair is as noted above. |
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A newborn is noted to have a moist medallion of mucosae occupying the lower abdominal wall, above the pubis and below the umbilicus. It is clear that urine is constantly bathing this congential anomaly. - What is it? - What is the point? |
What is it? - Exstrophy of the urinary bladder.
What’s the point of the vignette? - These are very rare anomalies that only very highly specialized centers can repair. The problem is that unless the repair is within the first 48 hours, it will not have a good chance to succeed. It takes time to arrange for transfer of a newborn baby to a distant city. If a day or two are wasted before arrangements are made, it will be too late. |
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Half an hour after the first feed, a baby vomits greenish fluid. The mother had polyhydramnius and the baby has Down’s syndrome. X-Ray shows a “double bubble sign”: a large air fluid level in the stomach, and smaller one in the first portion of the duodenum. There is no gas in the rest of the bowel. - What is it? - Management? |
What is it? - It can be two things, but first some general points. Kids vomit, bur and regurgitate all the time (ask any parent), but the innocent vomit is clear-whitish. Green vomiting in the newborn is bad news. It means something serious. The two conditions that this could be are duodenal atresia and annular pancreas
Management: with complete obstruction, emergency surgery will be needed, but these kids have lots of other congenital anomalies, look for them first. |
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Half an hour after the first feed, a baby vomits greenish fluid. X-Ray shows a double bubble sign”: a large air fluid level in the stomach, and a smaller one in the first portion of the duodenum. There is air in the distal bowel, beyond the duodenum, in loops that are not distended. - What is it? - Management? |
What is it? - Now you have three choices: it could be incomplete obstruction from duodenal stenosis or annular pancreas, or it could be malrotation.
Management: If you are dealing with incomplete obstruction you have time to do what’s needed, i.e. it is a lesser emergency. But if it is malrotation the bowel could twist and die, so that one is super-emergency. How can you tell? Do a contrast enema, and if not diagnostic order a water-soluble 9gastrographin) upper GI study. |
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PD.9. – A newborn baby has repeated green vomiting during the first day of life, and does not pass any meconium. Except for abdominal distention, the baby is otherwise normal. X-Ray shows multiple air fluid levels and distended loops of bowel. - What is it? - Management? |
What is it? - Intestinal atresia.
Management: This one is due to a vascular accident in uteru, thus there are no other congenital anomalies to look for, but there may be multiple points of atresia. |
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A very premature baby develops feeding intolerance, abdominal distention and a rapidly dropping platelet count.. The baby is four days old, and was treated with indomethacin for a paten ductus. - What is it? - Management? |
What is it? - Necrotizing enterocolitis.
Management: Stop all feedings, broad spectrum antibiotics, IV fluids/nutrition. Surgical intervention if they develop abdominal wall erythema, air in the biliary tree or pneumoperitoneum. |
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A three day old, full term baby is brought in because of feeding intolerance and bilious vomiting. X-Ray shows multiple dilated loops of small bowel and a “ground glass” appearance in the lower abdomen. The mother has cystic fibrosis. - What is it? - Management? |
What is it? - Meconium ileus.
Management: Gastrografin enema my be both diagnostic and therapeutic, so it is the obvious first choice. If unsuccessful, surgery may be needed. The kid has cystic fibrosis, and management of the other manifestations of the disease will also be needed. |
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A three week old baby has had “trouble feeding” and it is not quite growing well. he now has bilious vomiting and is brought in for evaluation. X-Ray shows a classical “double bubble”, along with normal looking gas pattern in the rest of the bowel. - What is it? - Management? |
What is it? - Malrotation. The vignette is repeated here because not all of them will show up on day one. They can “twist” at any time later.
You know what to do: contrast enema to verify the malrotation and emergency surgery. |
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A 3 week old first-born, full term baby boy began to vomit three days ago. The vomiting is projectile, has no bile in it, follows each feeding and the baby is hungry and eager to eat again after he vomits. He looks somewhat dehydrated and has visible gastric peristaltic waves and a palpable “olive size” mass in the right upper quadrant. - What is it? - Management? |
What is it? Hypertrophic pyloric stenosis.
Management: Check electrolytes: hypokalemic, hypochloremic metabolic alkalosis may have developed. Correct it, rehydrate and do Ramsted Pyloromyotomy. |
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An 8 week old baby is brought in because of persistent, progressively increasing jaundice. The bilirubin is significantly elevated and about two thirds of it is conjugated, direct bilirubin. Ultrasound rules out extrahepatic masses, serology is negative for hepatitis and sweat test is normal. - What is it? - Management? |
What is it? - Biliary atresia.
Management: HIDA scan, percutaneous liver biopsy and exploratory laparotomy. |
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A two month old baby boy is brought in because of chronic constipation. The kid has abdominal distention, and plain X-Rays show gas in dilated loops of bowel throughout the abdomen. Rectal exam is followed by expulsion of stool and flatus, with remarkable improvement of the distention. - What is it? - How to diagnose? |
What is it? - Hirschsprungs’s disease (aganglionic megacolon)
How do you diagnose it? - Barium enema will define the normal-looking aganglionic distal colon and the abnormal-looking thickness biopsy of the rectal mucosa. |
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A 9 month old, chubby, healthy looking little boy has episodes of colicky abdominal pain that make him double up and squat. The pain lasts for about one minute, and the kid looks perfectly happy and normal until he gets another colick. Physical exam shows a vague mass on the right side of the abdomen, an “empty” right lower quadrant and currant jelly stools. - What is it? - Management? |
What is it? - Intussusception.
Management: Barium enema is both diagnostic and therapeutic in most cases. It should be your first choice. If reduction is not achieved radiologically, exploratory laparotomy and manual reduction will be needed. |
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PD.17. – A one year old baby is referred to the University Hospital for treatment of a subdural hematoma. In the admission examination it is noted that the baby has retinal hemorrhages.
PD.18. – A three year old girl is brought in for treatment of a fractured humerus. The mother relates that the girl fell from her crib. X-Rays show evidence of other older fractures at various stages of healing in different bones.
PD.19. – A one year old child is brought in with second degree burns of both buttocks. The stepfather relates that the child fell into a hot tub.
What are these???? |
Classical vignettes of child abuse. Notify the proper authorities. |
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A 7 year old boy passes a large bloody bowel movement. - What is it? - What d you do? |
What is it? - Meckel’s diverticulum . |
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A 15 year old girl has a round, 1 cm. cystic mass in the midline of her neck at the level of the hyoid bone. When the mass is palpated at the same time that the tongue is pulled, there seems to be a connection between the two. The mass has been present for at least 10 years, but only recently bothered the patient because it got infected and drained some pus. - What is it? - Management? |
What is it? - Thyroglossal duct cyst.
Management: - Sistrunk operation (removal of the mass and the track to the base of the tongue, along with the medial segment of the hyoid bone). |
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An 18 year old woman has a 4c., fluctuant round mass on the side of her neck, just beneath and in front of the sternomastoid. She reports that is has been there at least 10 years, although she thinks that it has become somewhat larger in the last year or two. A CT scan shows the mass to be cystic. - What is it? - Management? |
What is it? - A branchial cleft cyst.
Management: Elective surgical removal. |
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A 6 year old child has a mushy, fluid filled mass at the base of the neck, that has been noted for several years. The mass is about 6 cm. in diameter, occupies most of the supraclavicular area and seems by physical exam to go deeper into the neck and chest. - What is it? - Management? |
What is it? - Cystic hygroma.
Management: Get a CT scan to see how deep this thing goes. They can extend down into the chest and mediastinum. Surgical removal will eventually be done. |
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A 22 year old lady notices an enlarged lymph node in her neck. The node is in the jugular can, measures about 1.5 cm, is not tender, and was discovered by the patient yesterday. The rest of the history and physical exam are unremarkable. - What is it? - Management? |
What is it? - It’s large lymph node...and that’s all we know so far. These could be inflammatory (the vast majority) or neoplastic (the rare ones that need something done). So, how do we tell?
Management: before you spend a ton of money doing a million tests, let time be your ally. Schedule the patient to be rechecked in three weeks. If the node has gone away by then, it was inflammatory and nothing further is needed. If it’s still there, it could be neoplastic and something needs to be done. Three weeks of delay will not significantly impact the overall course of a neoplastic process. |
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A 22 year old lady seeks help regarding an enlarges lymph node in her neck. The node is in the jugular chain, measures about 2cm, is firm, not tender, and was discovered by the patient six weeks ago. There is a history of low grade fever and night sweats for the past three weeks. Physical examination reveals enlarged lymph nodes in both axillas and in the left groin. - What is it? - Management? |
What is it? - Lymphoma most likely.
Management: Tissue diagnosis will be needed. You can start with FNA of the available nodes, but eventual node biopsy will be needed to establish not only the diagnosis but also the type of lymphoma. |
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A 72 year old man has 4 cm. hard mass in the left supraclavicular area. The mass is movable, non tender and has been present for three months. The patient has had a 20 pound weight loss in the past two months, but is otherwise asymptomatic. - What is it? - How to make the diagnosis? |
What is it? - Malignant mets to a supraclavicular node from a primary tumor below theneck.
How do we make the diagnosis? - Look for the obvious primary tumors: lung, stomach, colon, pancreas, kidney. The node itself will eventually be biopsied. |
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A 69 year old man who smokes and drinks and has rotten teeth has a hard, fixed, 4 cm. mass in his neck. The mass is just medial and in front of the sternomastoid muscle, at the level of the upper notch of the Thyroid cartilage. It has been there for at least six months, and it is growing. - What is it? - Management? |
What is it? – Metastatic squamous cell carcinoma to a jugular chain node, from a primary in the mucosa of the head and neck (oro-pharyngeal-laryngeal territory).
Management: Don’t biopsy the node! FNA is OK, but the best answer is to do a triple endoscopy (examination under anesthesia of the mouth, pharynx, larynx, esophagus and tracheobronchial tree). |
