Endo surgery

Question 1

Bilateral enlargement of breasts in man.
Soft tissue enlargement without clearly defined palpable borders or nodules no other findings. Next step in management?

Answer 1

Weight loss !! Patient has pseudo Gynaecomastia

In true Gynaecomastia, A central mobile rubbery mass is felt. Sometimes tender.

Question 2

Tertiary hyperparathyroidism = parathyroid hyperplasia = CKD cause

Question 3

Surgical procedures especially induction of anaesthesia and also beta blockers can trigger phaeochromocytomas

Question 4

Episodic headaches, hypertension, hyperglycaemia, blurry vision during episodes can be seen with phaechromocytomas

First step in management

Answer 4

Urine or plasma metanephrines

Question 5

Patient with no medical history of chronic conditions. However after trauma and broken bones, elevated finger stick glucose at 156. But normal HBA1c. Diagnoses and next step in management?

Answer 5

Stress hyperglycaemia

No treatment as mild elevation!!

Over 180 = treatment with short acting insulin!!!

Other risk factors = infection, hypoxia, ICU admission

Question 6

Painless loss of vision in right eye and headaches. Blood pressure is 190/100. Retinal and cerebellar hemangioblastomas. Father had very high blood pressure, significant hearing impairment. Most likely cause of elevated blood pressure?

Answer 6

Catecholamine secretion!! = pheaochromocytoma h

Patient has von hippel Lindau disease = retinal and cns hemangioblastomas which can hemorrhage, renal cancer, pancreatic neuroendocrine tumour, tumour of middle ear causing hearing loss, phaeochromocytomas!!

Note causes of phaeos include:
VHL
MEN syndromes
NF type 1
Just sporadic on its own

Question 7

Hypercalcemia can occur in cases of bprolonged immobilisation eg a quadriplegic. PTH will be low. Treat with bisphosphonates

Answer 7

PTH high and high calcium = Primary or tertiary hyperparathyroidisjm, lithium

PTH low and high calcium. Malignancy, vitd toxicity immobilisation

Question 8

Delirium , tachycardia, hypertension tremor nausea lid lag. Patient had just undergone surgery for bone fracture. Next step in management p?

Answer 8

Thyroid function tests and propanolol

Concerning for thyroid storm

Risk factors = surgery in a patient with undiagnosed hyperthyroidism, trauma, infection, iodine contrast, childbirth

Arrhythmias eg a fib may occur

Question 9

Irregular periods and amenorrhea, slightly raised prolactin and MRI with 7mm pituitary microadenoma. Most important reason for treating the patient now?

What are the indications for treatment of prolactinoma?

How do you treat

Answer 9

To prevent bone loss!!,

Prolactin suppresses gnrh = less fsh and lh = estrogen deficiency = oligo/amenorrha and infertility

But ALSO

Estrogen deficiency causes bone loss -> osteoporosis

Indications for treatment =
Macroprolactinoma so at least 10mm
Risk or presence of neurological symptoms
Hypogonadism
Galactorrhea

Dopamine agonists = cabergoline, bromocriptine

if drugs don’t work = surgery

Question 10

Euthyroid sick syndrome
Labs and presentation?
Management

Answer 10

Low T3 and normal T4 and TSH

Severe acute illness

Observation no treatment

Question 11

Subclinica, hypothyroidism presentation and labs? Management?

Answer 11

Elevated TSH, Normal T3 and T4

Question 13

Solitary thyroid nodule + signs of toxicosis. Elevated T4. Most likely diagnosis?

Answer 13

Tóxic adenoma!!!

Not thyroid cancers as don’t secrete thyroxine.

Question 14

Post surgery. Woman experiencing oliguria. Serum urea and creatinine are normal (helps rule out hypovolemia as cause). Her oliguria is most likely causes by increased concentración of which hormone?

Answer 14

ADH!!!!/Vasopressin.

Surgery can increase secretion of ADH secondary to pain. SIADH type picture.

Question 15

Large irregular non functioning thyroid module or thyroid nodules with solid and Cystic components. Next step following ultrasound?

Answer 15

fine needle aspiration biopsy

Question 16

Woman with plantar úlcer on first metatarsal. Type 1 diabétic. Dorsalis pedis pulses are normal bilaterally!!!!! Most likely underlying cause of the ulcer?

Answer 16

Peripheral neuropathy!!!

Not arterial insufficiency as typically causes PAD, and pulses would be abnormal

Question 17

Newly diagnosed acute páncreatitis. Serum studies show high Calcium, low phosphorus. Urinalysis shows hematuria and calcificación in RUQ. Most likely cause of condition?

Answer 17

Parathyroid adenoma!!!

STONES!!! (Hematuria) Bones, psychic groans, abdominal moans, or whatever.

High calcium can lead to acute pancreatitis

Question 18

51 YO man nontender mass in neck. Father and 2 older brothers diagnosed with thyroid cancer at 46,46, and 49. 2Cm nodule in the right love of the thyroid gland. Most likely diagnosis?

Answer 18

(M)edullary carcinoma!!

It is associated with (M)EN 2A and 2B
So familial Association is common!!!