A 38 year old lady presents with a recent episode of renal colic. As part of her
investigations the following results are obtained:
Corrected Calcium 3.84 mmol/l
PTH 88pg/ml (increased)
Her serum urea and electrolytes are normal.
What is the most likely diagnosis?
A. Carcinoma of the bronchus
B. Secondary hyperparathyroidism
C. Primary hyperparathyroidism
D. Tertiary hyperparathyroidism
E. Carcinoma of the breast
Theme from September 2012 exam
Theme from September 2011 exam
In this situation the most likely diagnosis is primary hyperparathyroidism. The
question mentions that serum urea and electrolytes are normal, which makes tertiary
hyperparathyroidism unlikely.
Primary hyperparathyroidism
In exams primary hyperparathyroidism is stereotypically seen in elderly females with
an unquenchable thirst and an inappropriately normal or raised parathyroid hormone
level. It is most commonly due to a solitary adenoma
Causes of primary hyperparathyroidism
• 80%: solitary adenoma
• 15%: hyperplasia
• 4%: multiple adenoma
• 1%: carcinoma
Features - 'bones, stones, abdominal groans and psychic moans'
• Polydipsia, polyuria
• Peptic ulceration/constipation/pancreatitis
• Bone pain/fracture
• Renal stones
• Depression
• Hypertension
,Associations
• Hypertension
• Multiple endocrine neoplasia: MEN I and II
Investigations
• Raised calcium, low phosphate
• PTH may be raised or normal
• Technetium-MIBI subtraction scan
Treatment
• Parathyroidectomy, if imaging suggests target gland then a focused approach
may be used
• Theme: Head and neck lumps
A. Branchial cyst
B. Cystic hygroma
C. Carotid body tumour
D. Lymphadenopathy
E. Adenolymphoma of the parotid
F. Pleomorphic adenoma of the parotid
G. Submandibular tumour
H. Thyroglossal cyst
I. Thoracic outlet syndrome
J. Submandibular gland calculus
•
Please select the most likely lesion to account for the clinical scenario given.
Each option may be used once, more than once or not at all.
2. A 60 year old Tibetan immigrant is referred to the surgical clinic with a painless
neck swelling. On examination it is located on the left side immediately anterior
to the sternocleidomastoid muscle. There are no other abnormalities to find on
examination.
You answered Branchial cyst
The correct answer is Carotid body tumour
Carotid body tumours typically present as painless masses. They may compress
the vagus or hypoglossal nerves with symptoms attributable to these structures.
Over 90% occur spontaneously and are more common in people living at high
, altitude. In familial cases up to 30% may be bilateral. Treatment is with
excision.
3. A 40 year old women presents as an emergency with a painful mass underneath
her right mandible. The mass has appeared over the previous week with the pain
worsening as the lump has increased in size. On examination there is a 4cm mass
underneath her mandible, there is no associated lymphadenopathy.
Submandibular gland calculus
The sub mandibular gland is the most common site for salivary calculi. Patients
will usually complain of pain, which is worse on eating. When the lesion is
located distally the duct may be laid open and the stone excised. Otherwise the
gland will require removal.
4. A 73 year old male smoker is referred to the clinic by his GP. On examination he
has a 3cm soft mass immediately anterior to his ear. It has been present for the
past five years and is otherwise associated with no symptoms.
You answered Pleomorphic adenoma of the parotid
The correct answer is Adenolymphoma of the parotid
Warthins tumours (a.k.a. adenolymphoma) are commoner in older men
(especially smokers). They are the second commonest benign tumour of the
parotid gland, they may be bilateral. They are soft and slow growing and
relatively easy to excise. Pleomorphic adenomas typically present in females
aged between 40 - 60 years.
•
• Neck lumps
•
The table below gives characteristic exam question features for conditions
causing neck lumps:
Reactive By far the most common cause of neck swellings. There may
lymphadenopathy be a history of local infection or a generalised viral illness
Lymphoma Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very
uncommon
There may be associated night sweats and splenomegaly
Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing
Thyroglossal cyst More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the
hyoid bone
, Moves upwards with protrusion of the tongue
May be painful if infected
Pharyngeal pouch More common in older men
Represents a posteromedial herniation between
thyropharyngeus and cricopharyngeus muscles
Usually not seen, but if large then a midline lump in the neck
that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration
and chronic cough
Cystic hygroma A congenital lymphatic lesion (lymphangioma) typically
found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years
of age
Branchial cyst An oval, mobile cystic mass that develops between the
sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial
cleft in embryonic development
Usually present in early adulthood
Cervical rib More common in adult females
Around 10% develop thoracic outlet syndrome
Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing
A 12 year old child is admitted with a 12 hour history of colicky right upper quadrant
pain. On examination the child is afebrile and is jaundiced. The abdomen is soft and
non tender at the time of examination. What is the most likely cause?
A. Infectious hepatitis
B. Acute cholecystitis
C. Cholangitis
D. Hereditary spherocytosis
E. Gilberts syndrome
Theme from September 2012 Exam
The child is most likely to have hereditary spherocytosis. In these individuals there
may be disease flares precipitated by acute illness. They form small pigment stones.
These may cause biliary colic and some may require cholecystectomy.
Hereditary Spherocytosis
Most common disorder of the red cell membrane, it has an incidence of 1 in 5000.
The abnormally shaped erythrocytes are prone to splenic sequestration and
destruction. This can result in hyperbilirubinaemia, jaundice and splenomegaly. In
older patients an intercurrent illness may increase the rate of red cell destruction
investigations the following results are obtained:
Corrected Calcium 3.84 mmol/l
PTH 88pg/ml (increased)
Her serum urea and electrolytes are normal.
What is the most likely diagnosis?
A. Carcinoma of the bronchus
B. Secondary hyperparathyroidism
C. Primary hyperparathyroidism
D. Tertiary hyperparathyroidism
E. Carcinoma of the breast
Theme from September 2012 exam
Theme from September 2011 exam
In this situation the most likely diagnosis is primary hyperparathyroidism. The
question mentions that serum urea and electrolytes are normal, which makes tertiary
hyperparathyroidism unlikely.
Primary hyperparathyroidism
In exams primary hyperparathyroidism is stereotypically seen in elderly females with
an unquenchable thirst and an inappropriately normal or raised parathyroid hormone
level. It is most commonly due to a solitary adenoma
Causes of primary hyperparathyroidism
• 80%: solitary adenoma
• 15%: hyperplasia
• 4%: multiple adenoma
• 1%: carcinoma
Features - 'bones, stones, abdominal groans and psychic moans'
• Polydipsia, polyuria
• Peptic ulceration/constipation/pancreatitis
• Bone pain/fracture
• Renal stones
• Depression
• Hypertension
,Associations
• Hypertension
• Multiple endocrine neoplasia: MEN I and II
Investigations
• Raised calcium, low phosphate
• PTH may be raised or normal
• Technetium-MIBI subtraction scan
Treatment
• Parathyroidectomy, if imaging suggests target gland then a focused approach
may be used
• Theme: Head and neck lumps
A. Branchial cyst
B. Cystic hygroma
C. Carotid body tumour
D. Lymphadenopathy
E. Adenolymphoma of the parotid
F. Pleomorphic adenoma of the parotid
G. Submandibular tumour
H. Thyroglossal cyst
I. Thoracic outlet syndrome
J. Submandibular gland calculus
•
Please select the most likely lesion to account for the clinical scenario given.
Each option may be used once, more than once or not at all.
2. A 60 year old Tibetan immigrant is referred to the surgical clinic with a painless
neck swelling. On examination it is located on the left side immediately anterior
to the sternocleidomastoid muscle. There are no other abnormalities to find on
examination.
You answered Branchial cyst
The correct answer is Carotid body tumour
Carotid body tumours typically present as painless masses. They may compress
the vagus or hypoglossal nerves with symptoms attributable to these structures.
Over 90% occur spontaneously and are more common in people living at high
, altitude. In familial cases up to 30% may be bilateral. Treatment is with
excision.
3. A 40 year old women presents as an emergency with a painful mass underneath
her right mandible. The mass has appeared over the previous week with the pain
worsening as the lump has increased in size. On examination there is a 4cm mass
underneath her mandible, there is no associated lymphadenopathy.
Submandibular gland calculus
The sub mandibular gland is the most common site for salivary calculi. Patients
will usually complain of pain, which is worse on eating. When the lesion is
located distally the duct may be laid open and the stone excised. Otherwise the
gland will require removal.
4. A 73 year old male smoker is referred to the clinic by his GP. On examination he
has a 3cm soft mass immediately anterior to his ear. It has been present for the
past five years and is otherwise associated with no symptoms.
You answered Pleomorphic adenoma of the parotid
The correct answer is Adenolymphoma of the parotid
Warthins tumours (a.k.a. adenolymphoma) are commoner in older men
(especially smokers). They are the second commonest benign tumour of the
parotid gland, they may be bilateral. They are soft and slow growing and
relatively easy to excise. Pleomorphic adenomas typically present in females
aged between 40 - 60 years.
•
• Neck lumps
•
The table below gives characteristic exam question features for conditions
causing neck lumps:
Reactive By far the most common cause of neck swellings. There may
lymphadenopathy be a history of local infection or a generalised viral illness
Lymphoma Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very
uncommon
There may be associated night sweats and splenomegaly
Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing
Thyroglossal cyst More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the
hyoid bone
, Moves upwards with protrusion of the tongue
May be painful if infected
Pharyngeal pouch More common in older men
Represents a posteromedial herniation between
thyropharyngeus and cricopharyngeus muscles
Usually not seen, but if large then a midline lump in the neck
that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration
and chronic cough
Cystic hygroma A congenital lymphatic lesion (lymphangioma) typically
found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years
of age
Branchial cyst An oval, mobile cystic mass that develops between the
sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial
cleft in embryonic development
Usually present in early adulthood
Cervical rib More common in adult females
Around 10% develop thoracic outlet syndrome
Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing
A 12 year old child is admitted with a 12 hour history of colicky right upper quadrant
pain. On examination the child is afebrile and is jaundiced. The abdomen is soft and
non tender at the time of examination. What is the most likely cause?
A. Infectious hepatitis
B. Acute cholecystitis
C. Cholangitis
D. Hereditary spherocytosis
E. Gilberts syndrome
Theme from September 2012 Exam
The child is most likely to have hereditary spherocytosis. In these individuals there
may be disease flares precipitated by acute illness. They form small pigment stones.
These may cause biliary colic and some may require cholecystectomy.
Hereditary Spherocytosis
Most common disorder of the red cell membrane, it has an incidence of 1 in 5000.
The abnormally shaped erythrocytes are prone to splenic sequestration and
destruction. This can result in hyperbilirubinaemia, jaundice and splenomegaly. In
older patients an intercurrent illness may increase the rate of red cell destruction
