Term
| What are the symptoms of myasthenia gravis? |
|
Definition
| weakness that worsens after exercise and improves after rest; other symptoms include ptosis, diplopia, dysarthria, dysphagia, and respiratory complications |
|
|
Term
| How do diagnose myasthenia gravis? |
|
Definition
| edrophonium-tensilon test |
|
|
Term
| How do you classify how bad myasthenia gravis is? |
|
Definition
| the osserman classification |
|
|
Term
| What medications are used to treat myasthenia gravis? |
|
Definition
| anticholinesterase drugs, glucocorticoids (prednisone), and immunosuppressive drugs (azathioprine, cyclophosphamide) |
|
|
Term
| How do you treat myasthenia gravis acute crisis? |
|
Definition
| treat medically and with plasmapheresis |
|
|
Term
| T/F Thymectomy should be avoided during an acute crisis of myasthenia gravis. |
|
Definition
|
|
Term
|
Definition
| most are benign but they can locally invade and systemic spread |
|
|
Term
| How strong is the association between myasthenia gravis and thymoma? |
|
Definition
| MG is identified in 30-50% of patients with thymoma wherease 15% of myasthenic partientshave thymoma |
|
|
Term
| T/F It is necessary to diagnose anterior mediastinal masses to confirm diagnosis of thymoma before going to surgery. |
|
Definition
| false;you can go ahead and take it out |
|
|
Term
| When should you biopsy an anterior mediastinal mass? |
|
Definition
| may be useful for patietns with very extensive anterior mediastinal masses causing invasion of adjacent viral structures and for patients in whom lymphoma is suspected |
|
|
Term
| What is the treatment of thymoma? |
|
Definition
| surgical resection via a median sternotomy |
|
|
Term
|
Definition
| occular involvement only (diplopia, ptosis) |
|
|
Term
|
Definition
| generalized muscle weakness without respiratory impairment |
|
|
Term
|
Definition
| more bulbar manifestation than in class IIA |
|
|
Term
|
Definition
| rapid onset and progression of bulbar and generalized weakness including respiratory muscle weakness |
|
|
Term
|
Definition
| muscle atrophy requiring mechanical ventilation |
|
|
Term
| What is involved in a complete thymectomy? |
|
Definition
| removal of the entire thymus gland, pericardial fat, and thymoma en bloc |
|
|
Term
| What should you do if during a thymectomy you discover that the thymoma extends into other structures? |
|
Definition
| the best prognosis relies on a complete resection so you can sacrifice adjacent structures like pericardium, lung, a single phrenic nerve, great vessels, etc. |
|
|
Term
|
Definition
| completely encapsulated, no invasion; surgery is the tx; 90% 5 yr survival |
|
|
Term
| What is stage II thymoma? |
|
Definition
| macroscopic invasion to fat or pleura or microscopic invasion through capsule; treat with surgical resection; 70-80% 5yr survival |
|
|
Term
| What is stage III thymoma? |
|
Definition
| macroscopic invasion to adjacent structure: pericardium, great vessels, lung, or intrathoracic metastasis; treatment is radiacl resection and/or XRT; 50-60% 5 yr prognosis |
|
|
Term
| What is stage IV thymoma? |
|
Definition
| extrathoracic metastasis; treatment is chemo/XRT; 20-30% 5 yr prognosis |
|
|
Term
| How does MG lead to decreased muscle strength? |
|
Definition
| reduction in number of ACh receptors in response to antibiodies to the nicotinic receptor causes recovery of muscle strength following a period of rest |
|
|
Term
| What autoimmune diseases are associated with thymoma? |
|
Definition
| myasthenia gravis, red cell aplasia, or hypogammaglobulinemia |
|
|
Term
| Does thymectomy cure myasthenia gravis? |
|
Definition
| 25-30% of patients show complete remission of MG; 35-60% have an improvement in symptoms with a decrease in their medication requirement; 20% show no change in status; 10-15% have a worsening of their symptoms |
|
|
Term
| What are the parts of the mediastinum? |
|
Definition
| anterior/superior, middle, posterior |
|
|
Term
| What are the most common mediastinal tumors? |
|
Definition
| 20% neurogenic tumor in posterior mediastinum; thymomas (15-20%) in anterior mediastinum |
|
|
Term
| What percent of mediastinal masses are malignant? |
|
Definition
|
|
Term
| How should you work up a mediastinal mass? |
|
Definition
| symptoms/finding to indicate thyroid pathology and to detect presence of diffuse adenopathy suggesting possibility of lymphoma; a CT scan of the chest; alpha feto protein and HCG if germ cell tumor is suspected |
|
|
Term
| How do you diagnose lymphoma? |
|
Definition
| open mediastinotomy video-assisted thoracoscopy if fine needle aspiration biopsy is equivocal |
|
|
Term
| How do you treat mediastinal lymphoma? |
|
Definition
| chemo or XRT depending on cell type |
|
|
Term
| Sestaimibi scan is used to diagnose... |
|
Definition
|
|
Term
| What is in the differential for mediastinal mass? |
|
Definition
| thymoma, lymphoma, germ cell tumor (teratoma, seminoma, nonseminoma), parathyroid adenoma, aberrant thyroid, lipoma, hemangioma, thymic cyst |
|
|
Term
| T/F FNA is seldom helpful for diagnosing mediastinal masses. |
|
Definition
|
|
Term
| WHen is open biopsy via anterior mediastinotomy or VATS indicated for a mediastinal mass? |
|
Definition
| lymphoma or stage III or IV thymoma is suspected |
|
|
Term
| Likely diagnosis of a 35 yoa man with HIV and a large ill defined anterior mediastinal mass? |
|
Definition
|
|
Term
| What is the typical presentation of testicular tumor? |
|
Definition
| nontender, nontransilluminating testicular mass in a man younger than 40 yoa |
|
|
Term
| What is the most common malignancy in men between 15 and 35 yoa? |
|
Definition
| testicular cancer (3 to 5 per 100,000) |
|
|
Term
| What is the best therapy for testicular tumor? |
|
Definition
|
|
Term
| What is involved in a radical orchiectomy? |
|
Definition
| testis, epididymis, andspermatic cord taken at theinteral iliac ring; care is taken notto incise the scrotum itself during the surgical procedure |
|
|
Term
| What percent of testicular tumors are derived from the germinal epithelium? |
|
Definition
|
|
Term
| Name some subtypes of germ cell tumors? |
|
Definition
| choriocarcinoma, embryonal carcinoma, serminoma, teratoma, and yolk sac tumor |
|
|
Term
| Where else can testicular tumors come from besides germ cells? |
|
Definition
| gonadal stromal tumors, secondary tumors of the testis such as lymphoma nd metastatic tumors |
|
|
Term
| How do you evaluate a testicular mass? |
|
Definition
| character of the mass, painful versus painless, hard versus soft, and transilluminating versus nontransilluminating |
|
|
Term
| What is the preoperative testing for orcheictomy for solid testicular tumor? |
|
Definition
| Beta-HCG, AFP, Lactic acid dehydrogenase, placental alkaline phosphatase, chest radiograph to rule out metastatic disease |
|
|
Term
| What kinds of tumors have elevations in beta HCG and AFP? |
|
Definition
| elevated in 80-85% of nonseminomatous germ cell tumors |
|
|
Term
| What should you do once testicular tumor is confirmed by orchiectomy? |
|
Definition
| CT scan of the abdomen and chest is warranted; therapeutic decisions depend first on an accurate pathologic diagnosis of ceell type; other factors determining treatment include extent of disease, risk factors and compliance of the pt |
|
|
Term
| Why is it important to differentiate between pure seminoma and other germ cell tumors? |
|
Definition
| exquisite sensitivity to radiation therapy and its reponse to chemotherapy when the disease is bulky and advanced |
|
|
Term
| What followup do pts with testicular tumors in remission need? |
|
Definition
| lifelong surveillance of their remaining testicle because the incidence of carcinoma becomes greater by a manyfold factor |
|
|
Term
| What is XY gonadal dysgenesis? |
|
Definition
| intraabdominal male gonads with Y chromosomes; tends to become malignant |
|
|
Term
| T/F Androgen insensitivity has an increase risk of testicular cancer. |
|
Definition
|
|
Term
| T/F A testicular tumor can metastasize to the left supraclavicular lymph node. |
|
Definition
|
|
Term
| T/F Needle biopsy should be performed for solid testicular masses to rule out malignancy. |
|
Definition
| false; needle biopsy is contraindicated and orchiectomy should be performed instead |
|
|
Term
| Why is it important to make an inguinal incision to remove a testicle? |
|
Definition
| to avoid disruption of the lymphatic drainage of the testicle, which normally does not involve the scrotum itself |
|
|
Term
| What causes anal fissures? |
|
Definition
| trauma to theanal canal from thepassage of large firm stool and regional ischemia of the mucosa related to a hypertonic internal sphincter |
|
|
Term
| T/F Anal fistulae are usually painless. |
|
Definition
|
|
Term
| Where are anal fissures usually located? |
|
Definition
| posterior midline position |
|
|
Term
| What other symptoms are associated with a anal fissure? |
|
Definition
|
|
Term
| What medical treatment can be attempted for acute anal fissure? |
|
Definition
| sitz baths, bulking agents, a stool softener, and topical nitroglycerine ointment |
|
|
Term
| How does nitroglycerine help relieve pain from anal fissures? |
|
Definition
| vasodilates and improves blood flow to the ischemic posterior portion of the anal canal |
|
|
Term
| What is the risk of incontinence with lateral internal sphincterotomy? |
|
Definition
| 35% (botulinum toxin can be used instead) |
|
|
Term
| What can you do to reduce the resting sphincter tone without resorting to lateral internal sphincterotomy? |
|
Definition
| local injection of botulinum toxin |
|
|
Term
| What is a grade I hemorrhoid? |
|
Definition
| prominent hemorrhoids on inspection or on anoscopy |
|
|
Term
|
Definition
| constipation, diarrhea, obesity and increased intraabdominal pressure |
|
|
Term
| What is a class II internal hemorrhoid? |
|
Definition
| hemorrhoids that prolapse but reduce spontaneously |
|
|
Term
| What is a class III hemorrhoid? |
|
Definition
| hemorroids that require manual reduction |
|
|
Term
| What are grade IV hemorrhoids? |
|
Definition
|
|
Term
| What is a fistula-in-ano? |
|
Definition
| abnormal communication between teh anal canal and the perineum |
|
|
Term
| How does a fistula-in-ano form? |
|
Definition
| fistulas are draining sinuses that represent the end result of perianal abscesses that form when crypts at the dentate line become obstructed; most fistulas arise several weeks to months after the abscess is drained adn track into different spaces and planes in the perianal region |
|
|
Term
| How are fistulae-in-ano named? |
|
Definition
| according to their relationship to the anal sphincter muscles (intersphincteric, transphincteric, suprasphincteric, extrasphincteric) |
|
|
Term
| What's the difference between extrasphincteric and suprasphincteric? |
|
Definition
| suprasphincteric originates above teh sphincter complex at teh dentate line; extrasphincteric originates above teh sphincter complex but still in the rectum |
|
|
Term
|
Definition
| rule used to find the internal opening of a fistula in the anus; most fistulas located anteriorly tarck straight directly to the dentate line while posterior fistulas track in a curved line towards the posterior midline or commissure of the anal canal |
|
|
Term
|
Definition
| a loop of plastic or silicone, commonly called a vascular "vessel loop" which is placed through a fistula when there is a significant amount of sphincter muscle involved; the seton spares the sphincter muscle and remains in place for weeks to months until the drainage resolves and teh fistula closes |
|
|
Term
| What are the best positions to perform an anorectal exam in? |
|
Definition
| left lateral decubitus position with knees flexed or in the prone jackknife position |
|
|
Term
| What two serious diagnoses should you consider in any patient who presents with chronic or recurrent anorectal complaints? |
|
Definition
| malignancy and inflammatory bowel disease |
|
|
Term
| The dentate line marks the end of the ____ and the beginning of the ____. |
|
Definition
| end of the anus and beginning of the rectum |
|
|
Term
| What will you find on palpation of an anal fissure? |
|
Definition
| tear; increased sphincter tone, hypertrophic anal papilla |
|
|
Term
| What does a fistula in ano look like on anoscopy? |
|
Definition
| small rough areas in anus |
|
|
Term
| What are teh symptoms of anal fissure? |
|
Definition
| severe anal pain with defecation; bleeding, itching and minimal drainage |
|
|
Term
| What are anal symptoms unique to fistula-in-ano? |
|
Definition
| drainage of pus or mucus or minimal stool soilage on undergarments |
|
|
Term
| What is the symptomatic treatment for anal fissures? |
|
Definition
| sitz baths, stool softeners, suppositories, bulking agents and nitroglycerin ointment |
|
|
Term
| What kinds of hemorroids are indicated for band ligation? |
|
Definition
| class II and III internal hemorrhoids |
|
|
Term
| How do you treat a thrombosed external hemorrhoid? |
|
Definition
| if it is not responding to medical therapy, you should treat it by excisional thrombectomy instead of incession and drainage |
|
|
Term
| What should you think if the anal fissure is chronic and isn't located in teh posterior wall of the anus? |
|
Definition
| must r/o crohns and malignancy |
|
|
Term
| What percent of people have adrenal incidentalomas? |
|
Definition
| 0.7-4.3% of patients undergoing abdominal CTscans and in 1.4 to 8.7% of peopleat autopsy |
|
|
Term
| What percent of adrenal incidentalomas are non-functioning? |
|
Definition
|
|
Term
| What might an adrenal mass be? |
|
Definition
| pheochromocytoma, aldosterone producing, cortisol producing, ganglioneuromas, adrenocortical carcinoma, and metastases; could also be a myelolipoma, cyst, or hemorrhage |
|
|
Term
| T/F Adrenal hematomas are uncommon after trauma. |
|
Definition
|
|
Term
| What is the risk of an adrenal mass being metastasis in a patient with a prior history of malignancy? |
|
Definition
|
|
Term
| What are some labs you can get to work up an adrenal mass? |
|
Definition
| 24 hr urine collection for detection of vanillyl-mandelic acid, metanephrine, and normetanephrine to evaluate for pheochromocytoma; a serum potassium test; measurement of aldosterone and plasma renin activity to evaluate for an aldosterone producing adenoma and an overnight 1 mg dexamehtasone suppression test |
|
|
Term
| Once you determine whether an adrenal mass if functioning or nonfunctioning what is the next step? |
|
Definition
| anatomic assessment preferably with nonenhanced CT or MRI; PET scanning is used for the evaluation of an adrenal mass in a patient with known extra-adrenal cancer because it is of value in separating benign lesions from metastases |
|
|
Term
| What adrenal masses can be diagnosed by CT? |
|
Definition
| mylolipomas, cysts and hemorrhage; certain characteristics on CT can suggest a malignancy |
|
|
Term
| T/F Primary adrenocortical carcinomas are rare. |
|
Definition
|
|
Term
| The majority of adrenocortical carcinomas are around what size? |
|
Definition
|
|
Term
| When is surgery recommended for an adrenal incidentaloma? |
|
Definition
| all functioning tumors, nonfunctioning tumors more than 4 cm tumors less than 4 cm that are enlarging, tumors of any size with imaging characteristics suggestive of carcinooma, and a solitary adrenal metastasis |
|
|
Term
| What is the most common tumor that metastasizes to the adrenal glands? |
|
Definition
|
|
Term
| Name some cancers that commonly metastasize to the adrenal gland? |
|
Definition
| lung, breast, kidney, colon, and stomach, and melanoma |
|
|
Term
| How should you work up a patient with a history of malignancy and a newly found adrenal incidentaloma? |
|
Definition
| they should undergo a biochemical assessment to exclude a functioning tumor; whole body PET scanning is performed in aptients with a non-functioning tumor to exclude the presence of other metastases; surgery for solitary lesions 4 cm or greater; FNA biopsy for solitary nonfunctioning lesions smaller than 4 cm because the result will alter treatment; neg result= nonoperative |
|
|
Term
| What is the followup for a patient with a nonfunctioning adrenal incidentaloma smaller than 4 cm? |
|
Definition
| CT scan at 3 and 15 months; if no change in the size of the mass, the patient is followed annually by reviewing the history and performing a physical examination |
|
|
Term
|
Definition
| pheochromocytoma because 10% are bilateral, extraadrenal, multiple, malignant, or familial |
|
|
Term
| T/F Pheochromocytomas can cause hypertension that is either paroxysmal or sustained. |
|
Definition
|
|
Term
| What are the symptoms of pheochromocytomoa? |
|
Definition
| HTN, headache, palpitations, profuse sweating, anxiety, abdominal pain |
|
|
Term
| T/F There's no point in getting a 24 hr urine collection with testing for metanephrines in a patient who is asympomatic for pheochromocytoma. |
|
Definition
| false; because of biochemical testing for clinically silent adrenal incidentaloma, up to half of patients with pheochromocytoma are identified before they get symptoms |
|
|
Term
| What do you do pre op after you have identified an adrenal mass as a pheochromocytoma? |
|
Definition
| exclude multiple, bilateral or extra-adrenal pheochromocytoma with pre op imaging studies such as abdominal CT or MRI; an iodine-131 MIBG scan is usually obtained for confirmation of pheochromocytoma because of its superior specificity of 90-100%; PET imaging can be used when conventional imaging sutides cannot localize the tumor; you should also get a preop CXR because the lung is one of the most common sites for metastasis; good to get an ECG and echo to rule out associated cardiomyopathy |
|
|
Term
| How does pheochromocytoma look on MRI? |
|
Definition
| it is bright on T2 weighted MRI |
|
|
Term
| What is the best technique to confirm a pheo? |
|
Definition
| iodine-131 metaiodobenzylguanidine (MIBG) scan |
|
|
Term
| What does a 24 hr urine test for pheo measure? |
|
Definition
| metanephrines, normetanephrines, and vanylmandelic acid |
|
|
Term
| Besides doing a 24 hr urine collection, you can also measure what to test for pheo? |
|
Definition
| plasma free metanephrine levels |
|
|
Term
| How do you control blood pressure before attempting pheo removal? |
|
Definition
| administer an alpha adrenergic blocking agent 1 to 2 weeks before surgery; a beta adrenergic blocking agent is added to oppose the reflex tachycardia associated with alpha blockade; start the alpha blocker first to prevent recipitating a hypertensive crisis |
|
|
Term
| What complications do you avoid by administering an alpha blocker before removing a pheo? |
|
Definition
| prevent hypertensive crisis and also to allow for relaxation of the constricted vascular tree and correction of the reduced plasma volume to prevent hypotension that can occur following tumor removal |
|
|
Term
| What alpha blocker should you use to control pre op pheo bp? |
|
Definition
| phenoxybenzamine is the traditional choice; alpha methyl-p-tyrosine is often used in combination with phenoxybenzamine, because it competitively inhibits tyrosine hydroxylase; newer, selective alpha blocking agents have also been used with good results |
|
|
Term
| How should you monitor/manage pts during operative removal of a pheo? |
|
Definition
| arterial line, central venous catheter, foley catheter, IV nitroprusside continuous infussion is often given for control of hypertension and a short acting beta blocker (esmolol) can be used to control any tachycardia; after removal of pheo you can give neosynephrine when bp fails to respond to fluid administration |
|
|
Term
| What is the followup after removal of pheo? |
|
Definition
| histopathology can not always identify whether a tumor is benign or malignant so all patients are followed for life; plasma free metanephrine levels are measured 1 month after surgery and at yearly intervals thereafter |
|
|
Term
| What is the differential diagnosis of groin pain +/- mass? |
|
Definition
| inguinal hernia, femoral hernia, muscle strain, and adenopathy |
|
|
Term
| Is it more common for suddenly painful/incarcerated hernias to have been previously recognized as an asymptomatic hernia or do they happen all of a sudden? |
|
Definition
| depends; inguinal hernia will probably have a history of hernia but femoral hernias are more likely to present with acute incarceration |
|
|
Term
| Where does a femoral hernia herniate through? |
|
Definition
| the femoral canal bounded superiorly by the inguinal ligament, laterally by the femoral vein, and medially by the pyriformis and pubic ramus |
|
|
Term
| How can you tell a femoral hernia from a inguinal hernia by looking at it in the operating room? |
|
Definition
| femoral hernia will be below the inguinal ligmanet; inguinal hernia will be above the inguinal ligament |
|
|
Term
| How common is it for umbilical hernias to close on their own? |
|
Definition
|
|
Term
|
Definition
| a groin hernia that contains a Meckel diverticulum or the appendix |
|
|
Term
| What is a richter hernia? |
|
Definition
| herniation of part of the bowel wall through a defect in the anterior abdominal wall; bowel obstruction does not occur, although the constricted bowel wall may become ischemic and subsequently necrotic |
|
|
Term
| What is a spigelian hernia? |
|
Definition
| a hernia just lateral to the rectus sheath at the semilunar line, the lower limit of the posterior rectus sheath |
|
|
Term
| What is an obturator hernia? |
|
Definition
| herniation through the obturator canal alongside the obturator vessels and nerves |
|
|
Term
| What are the demographics of people with obturator hernias? |
|
Definition
| women, particularly multiparous women with a histoory of recent weight loss |
|
|
Term
| What is a sliding hernia? |
|
Definition
| a hernia in which one wall of the hernia is made up of an intra abdominal organ, most commonly thesigmoid colon, ascending colon, or bladder |
|
|
Term
| What are the borders of the hesselbach triangle? |
|
Definition
| rectus sheath medially; inguinal ligament inferolaterally, and the inferior epigastric vessels superolaterally |
|
|
Term
| What are 2 names for the ligament that extends from the pubic tubercle laterally and passes posteriorly to the femoral vessels? |
|
Definition
| cooper ligament or the pectineal ligament |
|
|
Term
| How do you perform a primary repair of an inguinal hernia? |
|
Definition
| transversus abdominus is sutured to either thecooper ligament or the shelving edge of the inguinal ligament |
|
|
Term
| How do you surgical repair a femoral hernia? |
|
Definition
| cooper ligament repair must be used |
|
|
Term
| What hernia compication is also a contraindication for mesh? |
|
Definition
| compromised bowel (risk of infection of mesh) |
|
|
Term
| T/F Laparoscopic repair for hernia has better outcomes. |
|
Definition
| false; neither open or lap is better |
|
|
Term
| What is the term for the obturator neuralgia produced by nerve compression by an obturator hernia. |
|
Definition
|
|
