‫دورة اﻟﺗﺣﺿﯾر ﻟﻼﻣﺗﺣﺎن اﻟوزاري ﻟﻠطب اﻟﻌﺎم‬

‫‪2018/9‬‬
• Adrenal- 12 questions
• Hernia- 12 questions
• Thyroid -24 questions
ADRENAL
1. A 36-year-old man has an abdominal CT scan after a motor vehicle
crash , no injuries are found but his pressure is 160/100 mmHg , the CT
shows a 3-cm adrenal mass. Appropriate initial biochemical evaluation
should include all of the following EXEPT:

A. Plasma metanephrines
B. Plasma aldosterone level
C. Low dose overnight dexamethasone suppression test
D. Plasma Renin level
E. Serum Adrenocorticotropic hormone level

9.2015
 Adrenal incidentaloma
• Incidentally discovered adrenal masses.
• discovered through imaging performed for unrelated nonadrenal
disease

• The differential diagnosis of adrenal incidentaloma is wide and

includes secreting and non-secreting neoplasms

• In patients with a history of malignancy, metastatic disease is the most

likely cause of adrenal masses, particularly when bilateral.

• In those without a clear history of malignancy, at least 80% of

incidentalomas will turn out to be nonfunctioning cortical adenomas
or other benign lesions, which do not require surgical management.

• The workup of the adrenal incidentaloma integrates hormonal

evaluation with size criteria.
1. A 36-year-old man has an abdominal CT scan after a motor vehicle
crash , no injuries are found but his pressure is 160/100 mmHg , the CT
shows a 3-cm adrenal mass. Appropriate initial biochemical evaluation
should include all of the following EXEPT:

A. Plasma metanephrines
B. Plasma aldosterone level
C. Low dose overnight dexamethasone suppression test
D. Plasma Renin level
E. Serum Adrenocorticotropic hormone level
2. A 20 years old man has a 2 cm right adrenal mass found during a
work up for low back pain. the left adrenal is of normal size .the next
step should be:

A. Repeat imaging study in 6 months

B. 24 -hour urine collection for catecholamines
C. CT - guided fine -needle aspiration
D. High -dose dexamethasone test
E. Elective right laparoscopic adrenalectomy
2. A 20 years old man has a 2 cm right adrenal mass found during a
work up for low back pain. the left adrenal is of normal size .the next
step should be:

A. Repeat imaging study in 6 months

B. 24 -hour urine collection for catecholamines
C. CT - guided fine -needle aspiration
D. High -dose dexamethasone test
E. Elective right laparoscopic adrenalectomy
3. The most common adrenal mass incidentally found on CT scan
(adrenal incidentaloma) is

A. Adrenal cyst
B. Adrenal hemorrhage
C. Cortical adenoma
D. Myelolipoma

2.2014
 Adrenal incidentaloma
• Incidentally discovered adrenal masses.
• discovered through imaging performed for unrelated nonadrenal
disease

• The differential diagnosis of adrenal incidentaloma is wide and

includes secreting and non-secreting neoplasms

• In patients with a history of malignancy, metastatic disease is the most

likely cause of adrenal masses, particularly when bilateral.

• In those without a clear history of malignancy, at least 80% of

incidentalomas will turn out to be nonfunctioning cortical adenomas
or other benign lesions, which do not require surgical management.

• The workup of the adrenal incidentaloma integrates hormonal

evaluation with size criteria.
3. The most common adrenal mass incidentally found on CT scan
(adrenal incidentaloma) is

A. Adrenal cyst
B. Adrenal hemorrhage
C. Cortical adenoma
D. Myelolipoma

2.2014
4. A 45-year-old woman with a history of hypertension undergoes CT of
the abdomen and pelvis after presentation to the ER with Right Lower
Quadrant pain , the study is negative except for an incidentally found 3-
cm-mass in the right adrenal. Evaluation reveals elevated urine
metanephrines, the lesion is most likely located in the?

A. Zona glomerulosa
B. Zona fasciculata
C. Zona reticularis
D. Medulla
E. Para-adrenal tissues

9.2015/ 3.2015
 Pheochromocytoma
• Tumor of Adrenal medulla.
• affects approximately 0.2% of hypertensive individuals.
• Men and women are affected equally.
• The peak incidence : sporadic cases ages 40 - 50 y. familial cases
manifest earlier.

• classic triad : headache, diaphoresis, and palpitations.

• almost all patients will display at least one of these symptoms.
• Hypertension is present in 90% of cases and (episodic or
sustained).

the 10% tumor:

• 10% bilateral, 10% malignant, 10% extraadrenal, 10% familial.
 Pheochromocytoma

• Measurements of 24-hour urine levels of catecholamines and

their metabolites have long been the cornerstone of biochemical
testing, and the most reliable tests available.

• measurement of free (unconjugated) metanephrines in plasma

was introduced as an alternative screening tool for
pheochromocytoma.
– high sensitivity, approaching 99%,
– specificity of 89% at best. High false negative
– Therefore, the primary usefulness exclude pheochromocytoma
when the test is negative
 Pheochromocytoma
• Clonidine suppression testing, the measurement of plasma-free
normetanephrine levels after the oral administration of 0.3 mg
clonidine, may help clarify equivocal test results.

Anatomic localization :
• MRI is slightly more sensitive,.
• CT often yields better anatomic definition for operative planning
• Scintigraphy with 131I- or 123I-labell metaiodobenzylguanidine
(MIBG)
– multifocal disease is suspected.
– highly specific for pheochromocytoma.
– sensitivity of only 77% to 90%.
• (PET) and PET-CT highly sensitive and superior to MIBG.
4. A 45-year-old woman with a history of hypertension undergoes CT of
the abdomen and pelvis after presentation to the ER with Right Lower
Quadrant pain , the study is negative except for an incidentally found 3-
cm-mass in the right adrenal. Evaluation reveals elevated urine
metanephrines, the lesion is most likely located in the?

A. Zona glomerulosa
B. Zona fasciculata
C. Zona reticularis
D. Medulla
E. Para-adrenal tissues
5. A 52-year-old woman complains of headaches, palpitations,and
excessive sweating. Her blood pressure is 182/91 mmHg, her Heart
rate of 110 with no other findings. 24 hour urinary and plasma
metanephrines are elevated. Abdominal CT scan demonstrates a 5-
cm right adrenal mass. She is scheduled for a laporoscopic right
adrenalectomy. What medical therapy should be initiated in this
patient ?

A. Atenolol
B. Prednisone
C. Spironolactone
D. Furosemide
E. Phenoxybenzamine
Pheochromocytoma- treatment

• The adverse perioperative hemodynamic changes most commonly

observed with pheochromocytoma are intraoperative hypertension
and postoperative hypotension.

• As soon as the biochemical diagnosis of pheochromocytoma has

been confirmed, α-adrenergic blockade should be initiated to
protect against hemodynamic lability

• The period of preoperative conditioning should last at least 2 weeks

to allow for adequate reversal of α-adrenergic receptor
downregulation.
Pheochromocytoma- treatment

• Phenoxybenzamine - nonspecific, noncompetitive (irreversible),

long-acting α-adrenergic antagonist.
• side effects: postural hypotension and significant nasal congestion .
• phenoxybenzamine provides the most complete alpha blockade.

• Beta blockers may be administered after adequate alpha blockade

has been achieved for the subset of patients with persistent
tachycardia.

• Beta blockers should never be the first agent administered,

because a decrease in peripheral vasodilatory beta receptor
stimulation results in unopposed α-adrenergic tone, which may
exacerbate hypertension.
5. A 52-year-old woman complains of headaches, palpitations,and
excessive sweating. Her blood pressure is 182/91 mmHg, her Heart
rate of 110 with no other findings. 24 hour urinary and plasma
metanephrines are elevated. Abdominal CT scan demonstrates a 5-
cm right adrenal mass. She is scheduled for a laporoscopic right
adrenalectomy. What medical therapy should be initiated in this
patient ?

A. Atenolol
B. Prednisone
C. Spironolactone
D. Furosemide
E. Phenoxybenzamine

9.2015
6. A 36-year-old woman presents with palpitations, anxiety, and
hypertension. Workup reveals a pheochromocytoma. Which of the
following is the best approach to optimizing the patient
preoperatively?

A. Fluid restriction 24 hours preoperatively to prevent intraoperative

congestive heart failure
B. Initiation of an α-blocker 24 hours prior to surgery
C. Initiation of an α-blocker at 1 to 3 weeks prior to surgery
D. Initiation of a β-blocker 1 to 3 weeks prior to surgery
E. Escalating antihypertensive drug therapy with β-blockade followed by α-
blockade starting at least 1 week prior to surgery

10.2013/ 10.2014/ 02.2016

7. Which of the following statements is true about surgery for
pheochromocytoma?

A. Patient should receive preoperative alfa-blockade for 1 to 4 weeks

prior to surgery.
B. The adrenal vein should be taken only after the arterial supply is
isolated and ligated.
C. Intravenous fluids should be restricted until the tumor is removed.
D. Preoperative beta-blockade should precede any alfa-blockes to
avoid the precipitation of malignant hypertension
E. Bilateral adrenalectomy should be performed for patients with
MEN2a

9.2012
8. Which of the following is the most sensitive test for a
pheochromocytoma?

A. 24 h urine vanillymandelic acid

B. 24 h urine metanephrine
C. 24 h urine epinephrine
D. 24 h urine norepinephrine

10.2010
8. Which of the following is the most sensitive test for a
pheochromocytoma?

A. 24 h urine vanillymandelic acid

B. 24 h urine metanephrine
C. 24 h urine epinephrine
D. 24 h urine norepinephrine

10.2010
9. A 49-year-old obese man has become irritable, his face has
changed to a round configuration, he has developed purplish lines on
his flanks, and he is hypertensive. CT scan shows 3cm right adrenal
mass. What is true regarding this patient?

A. A surgical intervention is indicated only for lesions more than 6cm

B. MRI and scintigraphic scan is not useful in distinguishing adenoma from
carcinoma preoperatively
C. Operative exploration of both adrenals is indicated
D. Preoperative CT guided biopsy of adrenal lesion should be performed
E. Steroid therapy maybe required for up to 6-12 months postoperative

10.2014
 Cushing syndrome

• Cushing syndrome is an endocrine disorder caused by prolonged

exposure of the body to elevated levels of cortisol, independent of
the source.
 Cushing syndrome
ETIOLOGY
• The most common cause of Cushing’s syndrome is pharmacologic
glucocorticoid use for the treatment of inflammatory disorders.
Cushing syndrome

Clinical manifestations

• hypertension
• Personality changes
• Obesity
• moon face
• buffalo hump
• purple abdominal striae
• hirsutism.
 Cushing syndrome

• For patients undergoing adrenalectomy for Cushing’s

syndrome, perioperative stress dose steroids are recommended.

• In the most common scenario of resection of a solitary adrenal

Cushing’s adenoma, steroids can usually be tapered to physiologic
replacement levels over the course of several weeks.

• However, a subset of patients with Cushing’s syndrome of longer

duration and severity will demonstrate lasting HPA axis suppression,
requiring glucocorticoid supplementation for longer periods,
sometimes longer than 1 year.
9. A 49-year-old obese man has become irritable, his face has changed
to a round configuration, he has developed purplish lines on his flanks,
and he is hypertensive. CT scan shows 3cm right adrenal mass. What is
true regarding this patient?

A. A surgical intervention is indicated only for lesions more than 6cm

B. MRI and scintigraphic scan is not useful in distinguishing adenoma from
carcinoma preoperatively
C. Operative exploration of both adrenals is indicated
D. Preoperative CT guided biopsy of adrenal lesion should be performed
E. Steroid therapy maybe required for up to 6-12 months postoperative
10. A 49-year-old obese man has become irritable, his face has
changed to a round configuration, he has developed purplish lines on
his flanks, and he is hypertensive. A 24-hour urine collection
demonstrates elevated cortisol levels. This is confirmed with bedtime
cortisol measurements of 700 ng/mL. Which of the following findings
is most consistent with the diagnosis of Cushing disease?

A. Decreased ACTH levels

B. Glucocorticoid use for the treatment of inflammatory disorders
C. A 3 cm adrenal mass on computed tomography (CT) scan
D. Suppression with high dose dexamethasone suppression testing
E. A 1 cm bronchogenic mass on magnetic resonance imaging (MRI)

2.2014
 Cushing syndrome
ETIOLOGY
• The most common cause of Cushing’s syndrome is pharmacologic
glucocorticoid use for the treatment of inflammatory disorders.
10. A 49-year-old obese man has become irritable, his face has
changed to a round configuration, he has developed purplish lines on
his flanks, and he is hypertensive. A 24-hour urine collection
demonstrates elevated cortisol levels. This is confirmed with bedtime
cortisol measurements of 700 ng/mL. Which of the following findings
is most consistent with the diagnosis of Cushing disease?

A. Decreased ACTH levels

B. Glucocorticoid use for the treatment of inflammatory disorders
C. A 3 cm adrenal mass on computed tomography (CT) scan
D. Suppression with high dose dexamethasone suppression testing
E. A 1 cm bronchogenic mass on magnetic resonance imaging (MRI)

2.2014
11. A 32-year-old woman has a 5-year history of poorly controlled
hypertension. She is taking three different medications, including a
diuretic, β-blocker, and potassium supplements. What should be the
next step in establishing the diagnosis of surgically correctable
hypertension?

A. CT of the abdomen and pelvis

B. Urine catecholamines
C. Serum aldosterone and renin levels
D. Renal US
E. Saline suppresion testing

9.2012
 primary hyperaldosteronism
• Unregulated release of excess aldosterone from one or both adrenal
glands.
• Mean age - 50
• Most patients are asymptomatic
• Classically presentation: hypertension and hypokalemia.
• (most patients may be normokalemic, depending on the population
screened). Hypokalemia is likely a manifestation of severe or late-stage
disease.
• Hypokalemia: muscle cramps, weakness, or paresthesias.
• hypertension :
– moderate to severe
– refractory to medical therapy.
– It is common for them to require two to four antihypertensive
medications.
– Responsiveness to spironolactone may be seen.
 primary hyperaldosteronism

The most common causes of

primary hyperaldosteronism
• unilateral aldosterone-
producing adenomas
(aldosteronomas) .
• bilateral adrenal hyperplasia
primary hyperaldosteronism
11. A 32-year-old woman has a 5-year history of poorly controlled
hypertension. She is taking three different medications, including a
diuretic, β-blocker, and potassium supplements. What should be the
next step in establishing the diagnosis of surgically correctable
hypertension?

A. CT of the abdomen and pelvis

B. Urine catecholamines
C. Serum aldosterone and renin levels
D. Renal US
E. Saline suppresion testing

9.2012
12. A patient with hypertension is diagnosed with
hyperaldosteronism. A CT scan shows bilaterally enlarged adrenals
without a mass. The most appropriate next intervention is

A. Unilateral adrenolectomy
B. Bilateral adrenolectomy
C. Selective venous catheterization
D. Medical management

medical therapy with

spironolactone, amiloride, or triamterene is the mainstay of management.
primary hyperaldosteronism
Hernia
13. A 43 years old man with history of long standing umbilical hernia comes
to the emergency room with abdominal pain, vomiting and a painful
protrusion at the umbilical hernia sight that appeared 24 hours ago. On
exam he is tachycardic 120/min, fever 38, his abdomen is distended with
peritoneal signs and there is a protrusion at the umbilical sight with
redness. Which of the following is true regarding the treatment of this
patient?

A. The patient needs an emergent surgery

B. A manual attempt to reduce hernia can be done and if hernia returns the
patient can be operated in elective manner
C. The patient may be treated conservatively with NPO, nasogastric tube
liquids and antibiotics
D. An aspiration of the protrusion should be done to rule out an abscess
E. The patient should be admitted to the department and surgery should be
planned for next day.

3.2015
 Hernia
• reducible: its contents can be replaced within the surrounding
musculature.
• irreducible or incarcerated: when it cannot be reduced.
• strangulated
– hernia has compromised blood supply to its contents.
– serious and potentially fatal complication.
– Strangulation occurs more often in large hernias that have small
orifices. In this situation, the small neck of the hernia obstructs arterial
blood flow, venous drainage, or both to the contents of the hernia sac.

A more unusual type of strangulation is a Richter’s hernia.

Richter’s hernia, a small portion of the antimesenteric wall of the intestine is
trapped within the hernia, and strangulation can occur without the presence of
intestinal obstruction.
Strangulated Hernia
13. A 43 years old man with history of long standing umbilical hernia comes
to the emergency room with abdominal pain, vomiting and a painful
protrusion at the umbilical hernia sight that appeared 24 hours ago. On
exam he is tachycardic 120/min, fever 38, his abdomen is distended with
peritoneal signs and there is a protrusion at the umbilical sight with
redness. Which of the following is true regarding the treatment of this
patient?

A. The patient needs an emergent surgery

B. A manual attempt to reduce hernia can be done and if hernia returns the
patient can be operated in elective manner
C. The patient may be treated conservatively with NPO, nasogastric tube
liquids and antibiotics
D. An aspiration of the protrusion should be done to rule out an abscess
E. The patient should be admitted to the department and surgery should be
planned for next day.
 Hernia
abnormal protrusion of an organ or tissue through a defect in its
surrounding walls.
 Direct vs. indirect hernia
• Inguinal hernias are classified as direct or indirect.

Indirect inguinal hernia:

the sac of hernia passes from the internal inguinal ring obliquely
toward the external inguinal ring and ultimately into the scrotum.

Direct inguinal hernia:

The sac of hernia protrudes outward and forward and is medial to the
internal inguinal ring and inferior epigastric vessels.

• The operative repair of these types of hernias is similar.

A pantaloon-type hernia occurs when there is an indirect and direct

hernia component.
 Hernia
• ~ 75% of all hernias occur in the inguinal region.
• Two thirds of these are indirect and the remainder are direct
inguinal hernias.
• Femoral hernias comprise only 3% of all groin hernias.
• An indirect inguinal hernia is the most common hernia.
• Indirect inguinal and femoral hernias occur more commonly on the
right side.
• femoral hernias have the highest rate of strangulation (15% to
20%) of all hernias.
• It is recommended that all femoral hernias be repaired at the time
of discovery.
14. A 22-year-old college student notices a bulge in his right
groin. It is accentuated with coughing, but is easily reducible.
Which of the following hernias follows the path of the spermatic
cord within the cremaster muscle?

A. Femoral
B. Direct inguinal
C. Indirect inguinal
D. Spigelian
E. Interparietal
 Direct vs. indirect hernia
• Inguinal hernias are classified as direct or indirect.

Indirect inguinal hernia:

the sac of hernia passes from the internal inguinal ring obliquely
toward the external inguinal ring and ultimately into the scrotum.

Direct inguinal hernia:

The sac of hernia protrudes outward and forward and is medial to the
internal inguinal ring and inferior epigastric vessels.

• The operative repair of these types of hernias is similar.

A pantaloon-type hernia occurs when there is an indirect and direct

hernia component.
14. A 22-year-old college student notices a bulge in his right
groin. It is accentuated with coughing, but is easily reducible.
Which of the following hernias follows the path of the spermatic
cord within the cremaster muscle?

A. Femoral
B. Direct inguinal
C. Indirect inguinal
D. Spigelian
E. Interparietal
15. A 75-year-old man comes to clinic with complaints of testicular
pain. Examination reveals a right inguinal swelling that protrudes to
the scrotum. Which of the following hernias is the most characterize
by the findings?

A. femoral
B. spigelian
C. direct inguinal
D. indirect inguinal
E. Incisional

02.2016
16. An 84-year-old male is admitted for elective left inguinal hernia
repair. During surgery a hernia is identified protruding from the
posterior wall of the inguinal canal medial to the inferior epigastric
vessels and lateral to the rectus sheath. Which of the following
correctly describes the hernia?

A. Indirect Hernia
B. Direct Hernia
C. Femoral Hernia
D. Richter’s Hernia
17. Which of the following hernias represent incarceration of a limited
portion of the small bowel?

A. Spigelian hernia
B. Grynfeltt hernia
C. Petit hernia
D. Richter hernia
E. Littre hernia

9.2015
 A spigelian hernia; through the spigelian fascia
at the lateral border of the rectus at the linea semicircularis.
 Richter and Littre hernias
represent incarceration of a limited portion of the small bowel.
• Littre hernia has an incarcerated Meckel diverticulum or the appendix
as its contents.
• Richter hernia - characterized by noncircumferential incarceration of
the small bowel, usually only the antimesenteric portion.
A Richter's hernia can result in strangulation and necrosis in the absence of
intestinal obstruction
17. Which of the following hernias represent incarceration of a limited
portion of the small bowel?

A. Spigelian hernia
B. Grynfeltt hernia
C. Petit hernia
D. Richter hernia
E. Littre hernia
18. Spigelian hernias occur:

A. On the lateral border of the rectus abdominis

B. In the lines alba.
C. In the medial wall of the inguinal canal
D. In the femoral triangle
E. In the epigastrium

3.2010/ 10.2010
 A spigelian hernia; through the spigelian fascia
at the lateral border of the rectus at the linea semicircularis.
18. Spigelian hernias occur:

A. On the lateral border of the rectus abdominis

B. In the lines alba.
C. In the medial wall of the inguinal canal
D. In the femoral triangle
E. In the epigastrium

3.2010/ 10.2010
19. Which is the most common cause of incisional hernia:

A. Obesity
B. Diabetes
C. Immune deficiency medications
D. Advanced age
E. Surgical site infection
F. Answers A + E
G. All are correct

3.2015
 incisional hernia
occur as a result of excessive tension and inadequate healing of a
previous incision, which may be associated with surgical site infection.

Risk Factors for Incisional Hernia:

• Obesity
• advanced age
• Malnutrition
• Ascites
• Pregnancy
• conditions that increase intra-abdominal pressure Obesity can
cause an incisional
• Medications: corticosteroids, chemotherapeutic agents.
19. Which is the most common cause of incisional hernia:

A. Obesity
B. Diabetes
C. Immune deficiency medications
D. Advanced age
E. Surgical site infection
F. Answers A + E
G. All are correct

3.2015
20. All of the following are risk factors for developing incisional
hernia, except?

A. Morbid Obesity
B. Malnutrition
C. Ascites
D. Ischemic Heart
E. Wound Infection

2.2016
 incisional hernia
occur as a result of excessive tension and inadequate healing of a
previous incision, which may be associated with surgical site infection.

Risk Factors for Incisional Hernia:

• Obesity
• advanced age
• Malnutrition
• Ascites
• Pregnancy
• conditions that increase intra-abdominal pressure Obesity can
cause an incisional
• Medications: corticosteroids, chemotherapeutic agents.
20. All of the following are risk factors for developing incisional
hernia, except?

A. Morbid Obesity
B. Malnutrition
C. Ascites
D. Ischemic Heart
E. Wound Infection

2.2016
21. A 22-year-old woman is seen in a surgery clinic for a bulge in the right
groin. She denies pain and is able to make the bulge disappear by lying
down and putting steady pressure on the bulge. She has never experienced
nausea or vomiting. On examination she has a reducible hernia below the
inguinal ligament. Which of the following is the most appropriate
management of this patient?

A. Observation for now and follow up in surgical clinic in 6 months

B. Observation for now and follow up in surgical clinic if she develops
further symptoms
C. Elective surgical repair of the hernia
D. Emergent surgical repair of the hernia
E. Emergent surgical repair of hernia with exploratory laparotomy to
evaluate the small bowel

10.2014
Which type of Hernia?
Femoral Hernia
Anatomy:
• occurs through the femoral canal.
• Femoral Canal vorders:
– superior: iliopubic tract.
– inferior: Cooper’s ligament.
– lateral: femoral vein
– Medial: the junction of the iliopubic tract and Cooper’s ligament
(lacunar ligament).
• A femoral hernia produces a mass or bulge below the inguinal ligament

The incidence of strangulation in femoral hernias is high.

• all femoral hernias should be repaired .
• incarcerated femoral hernias should have the hernia sac contents
examined for viability
21. A 22-year-old woman is seen in a surgery clinic for a bulge in the right
groin. She denies pain and is able to make the bulge disappear by lying
down and putting steady pressure on the bulge. She has never experienced
nausea or vomiting. On examination she has a reducible hernia below the
inguinal ligament. Which of the following is the most appropriate
management of this patient?

A. Observation for now and follow up in surgical clinic in 6 months

B. Observation for now and follow up in surgical clinic if she develops
further symptoms
C. Elective surgical repair of the hernia
D. Emergent surgical repair of the hernia
E. Emergent surgical repair of hernia with exploratory laparotomy to
evaluate the small bowel
22. A 53 years old smoker presents with a 3-cm symptomatic umbilical
hernia. Which of the following herniorraphies is least likely to lead to
recurrence?

A. Figure of -8 suture
B. Simple interrupted suture
C. Simple continuous
D. Mesh
E. Vest over pants
 recurrent hernias

• The repair of recurrent hernias is challenging, and

results are associated with a higher incidence of secondary recurrence.

• Recurrent hernias almost always require placement of

prosthetic mesh for successful repair.

• Recurrences after anterior hernia repair using mesh are best managed by
a laparoscopic or open posterior approach, with placement of a second
prosthesis.
22. A 53 years old smoker presents with a 3-cm symptomatic umbilical
hernia. Which of the following herniorraphies is least likely to lead to
recurrence?

A. Figure of -8 suture
B. Simple interrupted suture
C. Simple continuous
D. Mesh
E. Vest over pants
23. What is the appropriate treatment for a patient with type 3
( mixed ) hiatal hernia and iron deficiency anemia ?

A. Observation
B. Acid reducing agent
C. Repairing of the hiatal hernia alone
D. Repairing of the hiatal hernia and fundoplication
hiatal Hernia
 Hiatal hernia/ GERD
Clinical presentaion:
• intermittent dysphagia for solids- results from episodes of acute
gastric or esophageal obstruction.
• abdominal and chest pain- secondary to visceral torsion.
• gastrointestinal bleeding from mucosal ischemia
• heartburn.

Diagnosis:
• contrast study or
• endoscopy is performed for proximal gastrointestinal tract
complaints.
 Hiatal hernia/ GERD
Complications:
Gastrointestinal bleeding
• caused by ulceration of the mucosa at an area where the stomach
folds back onto itself.
• often the cause of iron deficiency anemia.

• In cases of anemia in the setting of a paraesophageal hernia,

especially without another source, repair of the hernia results in
resolution of the anemia.
 Hiatal hernia/ GERD
indications for surgical therapy :

• patients with evidence of severe esophageal injury (e.g., ulcer,

stricture, Barrett’s mucosa).
• Incomplete resolution of symptoms or relapses while on medical
therapy are appropriate.
• patients with a long duration of symptoms.
• symptoms persist at a young age are initially considered for surgery.
Fundoplications types
23. What is the appropriate treatment for a patient with type 3 (
mixed ) hiatal hernia and iron deficiency anemia ?

A. Observation
B. Acid reducing agent
C. Repairing of the hiatal hernia alone
D. Repairing of the hiatal hernia and fundoplication
24. An 84-year-old male underwent right inguinal repair. On the
morning after surgery he complains of right testicular pain and
tenderness with scrotal erythema. What is the next step in the
management of this patient?

A. Pain killers
B. Doppler ultrasound of the testes
C. Urgent surgery
D. Antibiotic treatment
E. Pressure dressing
F. B or/and C

02.2016
 Ischemic Orchitis and Testicular
Atrophy
• Ischemic orchitis is an established complication after open inguinal
hernia repair.
• usually occurs from thrombosis of the small veins of the
pampiniform plexus within the spermatic cord.
• This results in venous congestion of the testis, which becomes
swollen and tender 2 to 5 days after surgery.
• The process may continue for an additional 6 to 12 weeks and
usually results in testicular atrophy.
• Ischemic orchitis also can be caused by ligation of the
testicular artery.
• It is treated with anti-inflammatory agents and analgesics.
• Orchiectomy is rarely necessary.
• Classically, the diagnosis of testicular ischemia is clinically
established and confirmed by color or power Doppler when there is
no detectable flow within the testicular parenchyma.
Thyroid & parathyroid
1. A 33-year-old man had a total thyroidectomy at age 20 for
medullary thyroid cancer. His father and sister were both treated for
medullary thyroid cancer. His father died of a hypertensive crisis. His
sister died during biopsy of an adrenal mass. The patient had a CT
scan for flank pain. Which of the following is the most likely
diagnosis?

A. Familial Medullary thyroid cancer

B. Conn Syndrome
C. Cushing disease
D. MEN2a (Multiple endocrine neoplasia 2a)
E. Metastatic medullary thyroid cancer
 Multiple Endocrine Neoplasia
Type 1 MEN1
• autosomal dominant
• characterized phenotypically by:
– tumors of the parathyroid gland - 98 – 100% (leading to
hyperparathyroidism – Hypercalcemia)
– Tumor of pancreatic islet cells 30-80%
– Tumor of pituitary gland. 15-50%

• Affected individuals can also develop:

– lipomas, adenomas of the of adrenal and thyroid glands.
– cutaneous angiofibromas.
– carcinoid tumors.
 Multiple Endocrine Neoplasia
Type 2- MEN2:
All affected individuals with MEN 2 develop MTC.

MEN 2A characterized by
• pheochromocytoma (50%)
• and hyperparathyroidism (25%).

MEN2B is characterized by:

• MTC and pheochromocytoma .
• mucosal neuromas on the tongue, lips, and subconjunctival areas,
• intestinal ganglioneuromatosis
• Marfanoid body habitus.
Both types are caused by germline mutations in the RET proto-oncogene, located on
chromosome 10q11.
1. A 33-year-old man had a total thyroidectomy at age 20 for
medullary thyroid cancer. His father and sister were both treated for
medullary thyroid cancer. His father died of a hypertensive crisis. His
sister died during biopsy of an adrenal mass. The patient had a CT
scan for flank pain. Which of the following is the most likely
diagnosis?

A. Familial Medullary thyroid cancer

B. Conn Syndrome
C. Cushing disease
D. MEN2a (Multiple endocrine neoplasia 2a)
E. Metastatic medullary thyroid cancer
2. A 42-year-old woman complains to her physician of symptoms
associated with hyperthyroidism. On examination she has a palpable
nodule but no evidence of exophthalmos. She does have pretibial
myxedema. Her laboratory work-up reveals a suppressed TSH level with
elevated free T3. What is the next step in the management of this
patient?

A. Radioactive 123I uptake scan

B. Neck ultrasound
C. PTU
D. FNA
E. Cervical ultrasound
F. A or B
2. A 42-year-old woman complains to her physician of symptoms associated
with hyperthyroidism. On examination she has a palpable nodule but no
evidence of exophthalmos. She does have pretibial myxedema. Her
laboratory work-up reveals a suppressed TSH level with elevated free T3.
What is the next step in the management of this patient?

A. Radioactive 123I uptake scan

B. Neck ultrasound
C. PTU
D. FNA
E. Cervical ultrasound
F. A or B
3. 44 years old woman was diagnosed with 2.5 cm nodule in the left thyroid
lobe. She underwent an FNA of the nodule which was compatible with a
follicular neoplasm. Which of the following is true regarding these
cytological findings?

A. Confirm follicular thyroid carcinoma.

B. Rules out papillary thyroid carcinoma.
C. Associated with 20-30% risk of malignancy.
D. Necessitates a repeat FNA.
E. Given this findings the patient may be followed with a repeat neck
exploration US in 6 month.

3.2015
 Follicular carcinoma
• Diagnosis of follicular cancer is based on the demonstration of
capsular or vascular invasion by follicular cells, not on cellular
cytology alone.

• When FNA reveals follicular cells, although most of these cases are
benign (follicular adenoma), the diagnosis or exclusion of follicular
carcinoma ultimately depends on complete histologic examination
of the resected specimen.

• Large series have shown malignancy in 6% to 20% of thyroid lesions

when follicular cells are demonstrated on FNA.
3. 44 years old woman was diagnosed with 2.5 cm nodule in the left
thyroid lobe. She underwent an FNA of the nodule which was
compatible with a follicular neoplasm. Which of the following is true
regarding these cytological findings?

A. Confirm follicular thyroid carcinoma.

B. Rules out papillary thyroid carcinoma.
C. Associated with 20-30% risk of malignancy.
D. Necessitates a repeat FNA.
E. Given this findings the patient may be followed with a repeat neck
exploration US in 6 month.

3.2015
04. A 70-year-old female arrives to clinic following and ultrasound
guided fine needle aspiration of a thyroid nodule. The cytology result
is positive for malignancy. All of the following are possible cytology
results, except?

A. Papillary Carcinoma
B. Follicular Carcinoma
C. Medullary Carcinoma
D. Anaplastic Carcinoma
E. Melanoma Metastasis

2.2016
04. A 70-year-old female arrives to clinic following and ultrasound
guided fine needle aspiration of a thyroid nodule. The cytology result
is positive for malignancy. All of the following are possible cytology
results, except?

A. Papillary Carcinoma
B. Follicular Carcinoma
C. Medullary Carcinoma
D. Anaplastic Carcinoma
E. Melanoma Metastasis
05. A 51-year-old man presents with a 2-cm left thyroid nodule.
Thyroid scan shows a cold lesion. FNA cytology demonstrates
follicular cells. Which of the following is the most appropriate initial
treatment of this patient?

A. External beam radiation to the neck

B. Multidrug chemotherapy
C. TSH suppression by thyroid hormone
D. Prophylactic neck dissection is indicated along with a total thyroidectomy
E. Thyroid lobectomy

10.2014
 Types of Thyroid Cancer:
q Primary:
• Follicular epithelium – well differentiated
papillary
follicular
• Follicular epithelium – undifferentiated
Anaplastic
• Parafollicular cells
Medullary
• Lymphoid cells
lymphoma
q Secondary : metastatic
 Classification:

1.Well-differentiated malignant neoplasms (85% of thyroid

cancer)

• *Papillary thyroid carcinoma (PTC)

• *Follicular thyroid carcinoma (FTC)
• *Hurthlecell carcinoma (HCC)
2. Poor differentiated malignant neoplasms
• *Medullarythyroid carcinoma (MTC)
• *Anaplasticthyroid carcinoma (ATC)
• *Insular thyroid carcinoma (ITC)

3. Other malignant tumors:

• *Lymphoma
• *Metastatictumors
 follicular carcinoma

• 5%-10% of thyroid cancers, 15% of WDTC

• Peak in 50s

• Female:male ratio is 3:1

• 10-year survival rate: 86% in non-invasive tumors, 44% in

invasive tumors
 follicular carcinoma
• It is unifocal, thickly encapsulated and shows invasion of both
capsule and blood vessels

• Spread by the blood stream and rarely

through lymphatic

• It is unusual tumor (5 -10%)

Presentation:
As a single lump in the thyroid:
This is the common mode of presentation.
As pain in a bone or a spontaneous fracture:
in case of metastases to bone through the blood stream
 follicular carcinoma
• Treatment of follicular carcinoma is primarily surgical.
• The diagnosis of the carcinoma cannot be determined by preoperative FNA or
intraoperative frozen section diagnosis of a follicular lesion.

• If the lesion is 2 cm or smaller and well contained within one thyroid lobe, an
argument may be made for thyroid lobectomy and isthmusectomy.

• If the lesion is larger than 2 cm, the surgeon may well proceed with total
thyroidectomy.

• For lesions less than 4 cm in size, thyroid lobectomy is adequate because at

least 80% of follicular lesions are adenomas

• If the follicular lesion is larger than 4 cm, the risk for cancer is higher than 50%,
and total thyroidectomy is an obvious choice.
 Papillary Thyroid Carcinoma (PTC)

• Most common WDTC -75%-85%

• 80%-90% of radiation-induced TC
• Peak incidence: 30s-40s
• 10 year-survival: 84%-90%
• associated with an excellent prognosis,
• Female:male ratio is 3:1
 PTC – pathology variants
• Microcarcinoma • Diffuse Follicular
• Macrocarcinoma • Diffuse Sclerosing
• Encapsulated • Tall Cell
• Follicular • Columnar
• Oncocytic • Dedifferentiated
• Solid
 well-differentiated cancers
• The primary treatment of differentiated thyroid cancer, including
papillary and follicular thyroid cancer, is surgical ablation.

• although well-differentiated cancers generally have a good

prognosis, there are high rates of multicentricity within the
thyroid and high rates of lymph node metastases and
recurrence.

• Several factors enter into surgical decision making.

 well-differentiated cancers
Appropriate surgical options and terminology for known or
suspected thyroid malignancy include the following:

• hemithyroidectomy or thyroid lobectomy, with or without

isthmusectomy;

• near-total thyroidectomy, defined by leaving less than 1 g of

tissue adjacent to the recurrent laryngeal nerve at the ligament
of Berry on one side.

• total thyroidectomy, defined by removal of all visible thyroid

tissue.
 well-differentiated cancers
Because of the higher likelihood of malignancy, the following patients with
undiagnosed nodules should undergo a total or near-total thyroidectomy as
their initial resection:

• patients with larger than 4-cm tumors.

• those with marked atypia on biopsy.
• those with FNA results suspicious for papillary cancer.
• those with a family history of thyroid cancer, patients with a history of
radiation exposure,
• men older than 50 years.

• In patients without these high-risk findings and without a diagnosis of

malignancy, thyroid lobectomy is an appropriate initial resection and
serves as a diagnostic biopsy.
 lobectomy total thyroidctomy lymph node - Lymph node +
If lesion is invasive or
high risk:
(1) lesion > 4-cm.
(2) With marked
atypia on biopsy.
diagnostic after FNA, central neck
(3) With a family
follicular for lesion not − dissection (level
history of thyroid
invasive and < 4 cm VI)
cancer, patients with
a history of radiation
exposure,
men older than 50
years.
central neck
low risk lesion < 1
papillary lesion > 1 cm − dissection (level
cm
VI)
central neck Modified radical
medullary − all lesions dissection (level lymph node
VI) dissection
 Lymph node dissection
• The management of central and lateral neck lymph nodal
basins has been a topic of active debate in the multidisciplinary
literature.

it is currently recommended that all patients with known or

suspected papillary cancer undergo a thorough physical
examination and complete ultrasound of the central and lateral
neck prior to resection of the thyroid lesion.
• If clinically positive adenopathy is detected
in the central neck, a therapeutic level VI or central neck lymph
node dissection should be performed at the time of total or near-
total thyroidectomy.

• consensus supports a practice of ipsilateral therapeutic lateral

neck dissection for patients who have biopsy-proven metastatic
lateral cervical disease.
• completion thyroidectomy should be performed, except
• patients with small (<1 cm), unifocal, intrathyroidal, node-
negative and otherwise low-risk papillary cancers.

• In patients that meet these low-risk criteria, thyroid lobectomy

may be considered an adequate resection and no further
surgical intervention is required.
05. A 51-year-old man presents with a 2-cm left thyroid nodule.
Thyroid scan shows a cold lesion. FNA cytology demonstrates
follicular cells. Which of the following is the most appropriate initial
treatment of this patient?

A. External beam radiation to the neck

B. Multidrug chemotherapy
C. TSH suppression by thyroid hormone
D. Prophylactic neck dissection is indicated along with a total
thyroidectomy
E. Thyroid lobectomy
06. A 63-year-old woman notices lumps on both sides of her neck. A
fine-needle aspirate is nondiagnostic, and she undergoes total
thyroidectomy. Final pathology reveals a 2-cm Hürthle cell carcinoma.
Which of the following is the most appropriate postsurgical
management of this patient?

A. No further therapy is indicated

B. Chemotherapy
C. External beam radiotherapy
D. Radioiodine ablation
E. Chemotherapy and External radiotherapy and radioiodine ablation

10.2014
 Hurthle cell carcinoma
• Hurthle cell carcinoma is a subtype of FTC that closely resembles FTC, both
grossly and on microscopic examination.

• The tumor contains an abundance of oxyphilic cells, or oncocytes.

• Hurthle cell carcinoma appears in an older age group and is very unusual
in children.

• Hurthle cell carcinoma is manifested in much the same fashion as follicular

cell neoplasms.
 Hurthle cell carcinoma
Prognosis and Treatment
• Treatment is surgical, following the same general principles as for the
workup of a follicular neoplasm.

• There is debate as to whether patients with a predominance of Hurthle

cells on FNA of a dominant thyroid nodule should undergo total
thyroidectomy, or if lobectomy may be appropriate.

• Spread to local lymph nodes in Hurthle cell carcinoma is a poor prognostic

event, associated with almost 70% mortality.

• There is a significantly higher rate of recurrence than that seen in FTC.

 Hurthle cell carcinoma
• Accepted postsurgical management of well-differentiated papillary and
follicular thyroid cancers involves the use of radioiodine ablation and
long-term monitoring of Tg.

• 131I contains highenergy (gamma rays) and medium-energy (beta

particles), which enhances the therapeutic effect.

• Patients are usually withheld from thyroid replacement therapy so that

TSH levels may become elevated, rendering the thyroid iodine avid and
thus maximizing the effect of 131I.
06. A 63-year-old woman notices lumps on both sides of her neck. A
fine-needle aspirate is nondiagnostic, and she undergoes total
thyroidectomy. Final pathology reveals a 2-cm Hürthle cell carcinoma.
Which of the following is the most appropriate postsurgical
management of this patient?

A. No further therapy is indicated

B. Chemotherapy
C. External beam radiotherapy
D. Radioiodine ablation
E. Chemotherapy and External radiotherapy and radioiodine ablation
07. A 55-year-old woman presents with a slow-growing painless mass on the
right side of the neck. A fine-needle aspiration of the nodule shows a well-
differentiated papillary carcinoma. A complete neck ultrasound
demonstrates a 1-cm nodule in the right thyroid without masses in the
contralateral lobe or lymph node metastasis in the central and lateral neck
compartments. With regards to this patient, which of the following is
associated with a poor prognosis?

A. Age
B. Sex
C. Grade of tumor
D. Size of tumor
E. Lymph node status
• Age at diagnosis is the most important prognostic factor in well-
differentiated thyroid cancer.

• Diagnosis at an age younger than 40 years is associated with

excellent survival. In women, this age benefit is extended to 50
years.
07. A 55-year-old woman presents with a slow-growing painless mass on
the right side of the neck. A fine-needle aspiration of the nodule shows a
well-differentiated papillary carcinoma. A complete neck ultrasound
demonstrates a 1-cm nodule in the right thyroid without masses in the
contralateral lobe or lymph node metastasis in the central and lateral neck
compartments. With regards to this patient, which of the following is
associated with a poor prognosis?

A. Age
B. Sex
C. Grade of tumor
D. Size of tumor
E. Lymph node status
08. A 44 years old woman has papillary thyroid carcinoma of the right
lobe confirmed by fine-needle aspiration. Ultrasound study stages the
tumor as T1 (1,5 cm). What should bet he surgical procedure?

A. Right thyroid lobectomy, selective node dissection of the right side.

B. Right thyroid lobectomy, level 6 node dissection
C. Total thyroidectomy, selective node dissection of the right side.
D. Total thyroidectomy, level 6 dissection and selective dissection of the
right side.
E. Total thyroidectomy

10.2011/ 3.2012
09. A 23-year-old woman has a 2.0 cm right thyroid nodule , she is
asymptomatic. Her Thyroid-stimulating-hormone level is normal, Fine
needle aspiration shows Papillary thyroid cancer. at the time of surgery a
5-mm black lymph node is detected in the right Paratracheal area.
Frozen section of lymph node confirms metastatic Papillary thyroid
cancer. what is the most appropriate surgical management of this
patient?

A. Total thyroidectomy
B. Right thyroid lobectomy with ipsilateral paratracheal node dissection
C. Total thyroidectomy with central neck dissection
D. Total thyroidectomy with right modified radical neck dissection
E. Right thyroid lobectomy
10. A patient with a 1-cm medullary carcinoma of the right thyroid
and no clinically significant adenopathy is best treated with

A. Right thyroid lobectomy and isthmusectomy

B. Right thyroid lobectomy and subtotal left thyroidectomy
C. Total thyroidectomy
D. Total thyroidectomy with central lymph node dissection

9.2012
 MTC
• Most patients with MTC or a syndromic predisposition to MTC
should undergo at least a total thyroidectomy. Total
thyroidectomy allows complete removal of the gland and a
search formulticentricity.

• Central compartment nodes frequently are involved early in the

disease process, so that a bilateral central neck node dissection
should be routinely performed.
• In patients with palpable cervical nodes or involved central neck
nodes, ipsilateral or bilateral, modified radical neck dissection is
recommended.
 MTC

Surgery:
• Thyroidectomyand SLND (level II, III, IV), anterior compartment
ND (include level VI, and/or VII).

• 10-year survival rate is 90%

• Recurrent MTC: resistant to chemo and XRT

 ATC

• Dx: FNA or open biopsy

• Usually unresectable
• Tracheotomy for airway obstruction
• Ttreatment with the combination:
• * Surgery: thyroidectomy/ND, debulkingsurgery
• * Chemotherapy: Adriamycinand Cisplatin
• * XRT: only external beam, tumor does not
concentrate I-131,
11. An 11-year-old girl presents to your office because of a family
history of medullary carcinoma of the thyroid. Physical examination is
normal. Which of the following tests should you perform?

A. Urine vanillylmandelic acid (VMA) level

B. Serum insulin level
C. Serum gastrin level
D. Serum glucagon level
E. Serum somatostatin level

10.2013
 Familial Medullary carcinoma
• In MEN2B kindreds, RET testing should be performed
shortly after birth and before age 5 years in FMTC and
MEN2A kindreds.

• If MTC is suspected, the presence of other components of MEN2

syndrome must be considered:
serum calcium and urinary catecholamine levels must be measured to
evaluate for hyperparathyroidism and pheochromocytoma
11. An 11-year-old girl presents to your office because of a family
history of medullary carcinoma of the thyroid. Physical examination is
normal. Which of the following tests should you perform?

A. Urine vanillylmandelic acid (VMA) level

B. Serum insulin level
C. Serum gastrin level
D. Serum glucagon level
E. Serum somatostatin level

10.2013
12. Which of the following is the most useful in identifying patients at
high risk for familial medullary thyroid cancer?

A. RET oncogene
B. Calcitonin levels
C. Calcium levels
D. K-ras oncogene
E. Urine metanephrines
Both types are caused by germline mutations in the RET proto-oncogene, located on
chromosome 10q11.
12. Which of the following is the most useful in identifying patients at
high risk for familial medullary thyroid cancer?

A. RET oncogene
B. Calcitonin levels
C. Calcium levels
D. K-ras oncogene
E. Urine metanephrines
13. Calcitonin is produced by the parafollicular cells of the thyroid gland.
Measurement of calcitonin is essential in what disease process?

A. Graves disease
B. Follicular thyroid cancer
C. Hashimoto disease
D. Medullary thyroid cancer
E. Papillary thyroid cancer
 Calcitonin
• a 32–amino acid polypeptide.
• secreted by the parafollicular cells, or C cells.
• inhibit calcium absorption by osteoclasts and thereby to lower
peripheral serum calcium levels.
• Increased peripheral levels of serum calcium stimulate calcitonin
secretion.
• Calcitonin secretion can be stimulated by the infusion of calcium,
pentagastrin, and alcohol.

• Basal or stimulated calcitonin levels are sensitive markers for

primary or recurrent MTC.
13. Calcitonin is produced by the parafollicular cells of the thyroid gland.
Measurement of calcitonin is essential in what disease process?

A. Graves disease
B. Follicular thyroid cancer
C. Hashimoto disease
D. Medullary thyroid cancer
E. Papillary thyroid cancer
14. The most common cause of primary hyperparathyroidism is:

A. Parathyroid adenoma
B. Multiple parathyroid adenomas
C. Parathyroid hyperplasia
D. Parathyroid carcinoma
15. Which of the following patients with primary
hyperparathyroidism should undergo parathyroidectomy?

A. A 62-year-old asymptomatic woman

B. A 54-year-old woman with fatigue and depression
C. A 42-year-old woman with a history of kidney stones
D. A 59-year-old woman mildly elevated 24-hour urinary calcium
excretion
E. A 60-year-old woman with mildly decreased bone mineral density
measured at the hip of less than 2 standard deviation below peak
bone density
15. Which of the following patients with primary hyperparathyroidism
should undergo parathyroidectomy?

A. A 62-year-old asymptomatic woman

B. A 54-year-old woman with fatigue and depression
C. A 42-year-old woman with a history of kidney stones
D. A 59-year-old woman mildly elevated 24-hour urinary calcium
excretion
E. A 60-year-old woman with mildly decreased bone mineral density
measured at the hip of less than 2 standard deviation below peak
bone density
16. Surgery is indicated in which of the following asymptomatic
patients with primary hyperparathyroidism?

A. Mildly elevated urinary calcium excretion (>100mg/dl).

B. Reduction in creatinine clearance by 10%
C. Serum calcium > 0.8 above the upper limits of normal
D. Age < 50 years

9.2012
17. A 52-year-old woman sees her physician with complaints of fatigue,
headache, flank pain, hematuria, and abdominal pain. She undergoes a
sestamibi scan that demonstrates persistent uptake in the right superior
parathyroid gland at 2 hours. Which of the following laboratory values is
most suggestive of her diagnosis?

A. Serum acid phosphatase above 120 IU/L

B. Serum alkaline phosphatase above 120 IU/L
C. Serum calcium above 11 mg/dl
D. Urinary calcium below 100 mg/day
E. Parathyroid hormone levels below 5 pmol/l
18. A 56 years old postmenopausal woman has serium calcium of 10.9
mg/dl (normal 7.5 to 9.5) and a serum PTH of 85 pg/ml(normal 20 to 60
pg/ml) . She has no family history and is asymptomatic .she is an avid
jogger . Bone densitometry (DEXA scan) shows minimal osteoporosis.
Which of the following is true?

A. Calcium supplementation will decrease her risk of stress facture.

B. The NIH consensus conference recommends observation
C. 24 -hour urine collection for calcium will be diagnostic
D. She is a candidate for parathyroidectomy
E. Treatment with biphosphonates is warranted
19. A 53-year-old woman presents with complaints of weakness, anorexia,
malaise, constipation, and back pain. While being evaluated, she becomes
somewhat lethargic. Laboratory studies include a normal chest x-ray, serum
albumin 3.2 mg/dL, serum calcium 14 mg/dL, serum phosphorus 2.6 mg/dL,
serum chloride 108 mg/dL, blood urea nitrogen (BUN) 32 mg/dL, and
creatinine 2.0 mg/dL. Which of the following is the most appropriate initial
management?

A. Intravenous normal saline infusion

B. Administration of thiazide diuretics
C. Administration of intravenous phosphorus
D. Use of mithramycin
E. Neck exploration and parathyroidectomy

2.2014/ 3.2015
 hypercalcemic crisis
Management involves urgent medical and surgical strategies.

1. Pharmacologic agents associated with or adversely affected by

hypercalcemia need to be discontinued (digoxin potentiates
arrhythmias in the setting of hypercalcemia).

2. Hydration with normal saline.

3. Medical management promotes the renal excretion of calcium.

 hypercalcemic crisis
Hydration:

• IV fluids, preferably normal saline, are administered at a rapid rate

(200 to 300 mL/hr) to reverse the intravascular volume contraction
and promote the renal excretion of calcium.
 hypercalcemic crisis
Medical management

• Loop diuretics : to reduce the risk for volume overload and inhibit calcium
resorption in the loop of Henle.

• hydrocortisone is 200 to 400 mg/day IV for 3 to 5 days

• Calcitonin acts quickly (within 24 to 48 hours) to lower serum calcium

levels and is more effective when used in combination with glucocorticoids.

• Bisphosphonates have a high affinity for hydroxyapatite in bone. They

potently inhibit osteoclast activity for up to 1 month.
19. A 53-year-old woman presents with complaints of weakness, anorexia,
malaise, constipation, and back pain. While being evaluated, she becomes
somewhat lethargic. Laboratory studies include a normal chest x-ray, serum
albumin 3.2 mg/dL, serum calcium 14 mg/dL, serum phosphorus 2.6 mg/dL,
serum chloride 108 mg/dL, blood urea nitrogen (BUN) 32 mg/dL, and
creatinine 2.0 mg/dL. Which of the following is the most appropriate initial
management?

A. Intravenous normal saline infusion

B. Administration of thiazide diuretics
C. Administration of intravenous phosphorus
D. Use of mithramycin
E. Neck exploration and parathyroidectomy
20. A 23-year-old woman undergoes total thyroidectomy for carcinoma of
the thyroid gland. On the second postoperative day, she begins to complain
of a tingling sensation in her hands. She appears quite anxious and later
complains of muscle cramps. Which of the following is the most appropriate
initial management strategy?

A. 10 mL of 10% magnesium sulfate intravenously

B. Oral vitamin D
C. 100 μg oral Synthroid
D. Contentious infusion of calcium gluconate
E. Oral calcium gluconate
 Post procedure hypocalcemia

The most significant complications are:

1. postprocedure hypocalcemia secondary to de-vascularization

of the parathyroid.
2. significant hoarseness caused by recurrent laryngeal nerve
injury, induced by traction or division.
 Post procedure hypocalcemia

• Rates of are approximately 5%.

• It resolves in 80% of cases in approximately 12 months.

• Intravenous calcium infusion is the treatment for severe, symptomatic

hypocalcemia.
• oral calcium supplementation (up to 1-2 g every 4 hours) is sufficient in
patients with mild symptoms.
• in most cases the problem is resolved in several days.

• In cases of persistent hypocalcemia, vitamin D preparations may be

necessary.
20. A 23-year-old woman undergoes total thyroidectomy for carcinoma of
the thyroid gland. On the second postoperative day, she begins to complain
of a tingling sensation in her hands. She appears quite anxious and later
complains of muscle cramps. Which of the following is the most appropriate
initial management strategy?

A. 10 mL of 10% magnesium sulfate intravenously

B. Oral vitamin D
C. 100 μg oral Synthroid
D. Contentious infusion of calcium gluconate
E. Oral calcium gluconate

2.2014/ 3.2012
21. Preoperative biochemical evaluation of patient for parathyroidectomy is
dune for PHPT (primary hyperparathyroidism) show Ca+ 12 and intact PTH
(200pg/ml). 1cm hypercellular parathyroide adenoma is resected .
Postoperatively the patient complaint on perioral tingling, numbness and
carpopedal spasm. The ECG will show:

A. Atrial fibrillation
B. Prolong QT
C. Pecked T wave
D. Torsa des pointes
E. U wave
 hypocalcemia
Signs & Symptoms:

• Neuromuscular excitability
• Carpopedal spasm
• Tetany
• Chvostek’s sign
• Trousseau’s sign
• Seizures

ECG changes:
QTc prolongation primarily by prolonging the ST segment.
21. Preoperative biochemical evaluation of patient for parathyroidectomy is
dune for PHPT (primary hyperparathyroidism) show Ca+ 12 and intact PTH
(200pg/ml). 1cm hypercellular parathyroide adenoma is resected .
Postoperatively the patient complaint on perioral tingling, numbness and
carpopedal spasm. The ECG will show:

A. Atrial fibrillation
B. Prolong QT
C. Pecked T wave
D. Torsa des pointes
E. U wave
22. A 35-year-old female underwent total thyroidectomy for grave's disease
one week ago. She now complains of muscle cramps sinus rhythm with
prolonged QT on ECG. What is the most likely diagnosis?

A. Hypercalcemia
B. Hypocalcemia
C. Hyponatremia
D. Hypermagnesemia
E. Hypophosphatemia
23. A 35-year-old woman with a history of previous right thyroidectomy for
a benign thyroid nodule now undergoes completion thyroidectomy for a
suspicious thyroid mass. Several hours postoperatively, she develops
progressive swelling under the incision, stridor, and difficulty breathing.
Orotracheal intubation is successful. Which of the following is the most
appropriate next step?

A. Fiberoptic laryngoscopy to rule out bilateral vocal cord paralysis

B. Administration of intravenous calcium
C. Administration of broad-spectrum antibiotics and debridement of the
wound
D. Wound exploration
E. Administration of high-dose steroids and antihistamines

3.2012/ 2.2016
23. A 35-year-old woman with a history of previous right thyroidectomy for
a benign thyroid nodule now undergoes completion thyroidectomy for a
suspicious thyroid mass. Several hours postoperatively, she develops
progressive swelling under the incision, stridor, and difficulty breathing.
Orotracheal intubation is successful. Which of the following is the most
appropriate next step?

A. Fiberoptic laryngoscopy to rule out bilateral vocal cord paralysis

B. Administration of intravenous calcium
C. Administration of broad-spectrum antibiotics and debridement of the
wound
D. Wound exploration
E. Administration of high-dose steroids and antihistamines

2.2016
24. After a total thyroidectomy, the right vocal cord is noted to be fixed
in a paramedian position. The most likely represents:

A. Injury to the RLN (Recurrent laryngeal nerve)

B. Injury to the external branch of the superior laryngeal nerve
C. Injury to the internal branch of the superior laryngeal nerve
D. Trauma from endotracheal intubation
E. Compression from hematoma

/2.2016