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MyPasTest: MRCS A Online - Jan Exam 201525. Surgical Specialities; General Surgery; Breast & Endocrine Surgery (50Qs)
01. You are assisting in a sentinel node biopsy for a patient with known breast cancer. Which of the
following statements is correct? Select ONE answer only.
At least 10 nodes must be sampled to give an accurate nodal stage« YOUR ANSWER
Sentinel node biopsy involves identifying the first 4 nodes of a basin through which the majority of lymph from
the breast drains
Page
Lymphoscintigraphy can be performed up to one week in advance of the procedure
Blue dye is contraindicated in pregnancy« CORRECT ANSWER
1500
There is a high incidence of brachial plexus traction following sentinel node.
Sentinel node biopsy reduces the number of patients who require a lymph node dissection, thereby
reducing complications such as lymphoedema. However, there is still a false negative result and as such
patients should be counseled accordingly. It involves identifying the first nodes which drain the primary
tumour and is usually 1-2 nodes but can be more. A combination of radioactive colloid and blue dye
(patent blue) can be used but the blue dye is contraindicated in pregnancy.
02. Theme: Complications of thyroidectomy
A Air embolism
B Haemorrhage
C Bilateral complete recurrent laryngeal nerve paralysis
D Bilateral incomplete recurrent laryngeal nerve paralysis
E Hypocalcaemia
F Hypothyroidism
G Superior laryngeal nerve paralysis
H Pneumothorax
I Recurrent hyperthyroidism
J Thyroid crisis
K Tracheal collapse
L Unilateral complete recurrent laryngeal nerve paralysis
M Unilateral incomplete recurrent laryngeal nerve paralysis
N None of the above.
The following are descriptions of patients post-thyroidectomy. Please select the most appropriate
diagnosis from the above list. The items may be used once, more than once, or not at all.
Scenario 1
A 27-year-old woman 2 days post-thyroidectomy has numbness around the mouth and the sensation of ‘pins and
needles’ in her fingers.
A - Air embolism« YOUR ANSWER
E - Hypocalcaemia« CORRECT ANSWER.
E – Hypocalcaemia:
Hypocalcaemia after thyroidectomy may occur for two reasons: metabolic and anatomical. Metabolic
causes are not fully understood but may be secondary to the release of calcitonin during manipulation or
a reduction of renal tubular resorption of calcium without a change in parathormone or calcitonin levels.
Anatomical causes are the result of excision of all parathyroid tissue during total thyroidectomy. If the
calcium is > 2.0 mmol/litre, symptoms usually resolve within 2 days without treatment. If symptoms
persist or worsen treatment with calcium supplementation and synthetic vitamin D will be necessary.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
25. Surgical Specialities; General Surgery; Breast & Endocrine Surgery (50Qs)
Scenario 2
A 50-year-old woman becomes acutely confused 12 h postthyroidectomy. She has been complaining of severe
abdominal pain, palpitations and diarrhoea. An electrocardiogram demonstrates atrial fibrillation.
B - Haemorrhage« YOUR ANSWER
J - Thyroid crisis« CORRECT ANSWER.
J – Thyroid crisis: Page
This is a rare but life-threatening condition precipitated by thyroid surgery, infection, stress, or 1501
radioactive iodine therapy in an unprepared patient. It is caused by the sudden release of massive
amounts of thyroid hormone into the systemic circulation resulting in hyperpyrexia, tachycardia, extreme
restlessness, diarrhoea and vomiting. It may mimic the acute abdomen but needs emergency treatment.
Assessment and appropriate management of the airways, breathing and circulation should be performed.
Fluid resuscitation with normal saline is required with propanolol together with potassium iodide,
carbimazole and dexamethasone.
Scenario 3
A 45-year-old woman returns to outpatients 3 months after thyroidectomy. She complains that her vocal range
appears diminished when she participates in her local amateur dramatics productions.
C - Bilateral complete recurrent laryngeal nerve paralysis« YOUR ANSWER
G - Superior laryngeal nerve paralysis« CORRECT ANSWER.
G – Superior laryngeal nerve paralysis:
Damage to the superior laryngeal nerve can cause voice weakness or fatigue, mild hoarseness and loss
of vocal range. The upper half octave in range is lost, which can be particularly troublesome for singers,
and is unlikely to be recovered.
Scenario 4
A 64-year-old man develops severe difficulty breathing shortly after a total thyroidectomy. Examination reveals
respiratory rate 34 breaths/min and auscultation demonstrates inspiratory stridor.
D - Bilateral incomplete recurrent laryngeal nerve paralysis« CORRECT ANSWER.
D – Bilateral incomplete recurrent laryngeal nerve paralysis:
Recurrent laryngeal nerve damage may be uni- or bilateral secondary to bruising, stretching, division
devascularisation or ligation. In bilateral incomplete recurrent laryngeal nerve paralysis both vocal cords
lie in the midline, unable to abduct, and there is severe dyspnoea with stridor soon after operation.
Tracheal collapse (secondary to tracheomalacia) and haemorrhage into the pre-tracheal space may both
present similarly; however, the former is rare and the latter usually evident on examination. In bilateral
complete recurrent laryngeal nerve paralysis the two vocal cords occupy the cadaveric position, midway
between the normal resting position and the midline.
No abduction or adduction is possible; the voice is lost, but the dyspnoea is not severe. In unilateral
complete recurrent laryngeal nerve paralysis all the laryngeal muscles on the affected side are paralysed
except the cricothyroid and part of the arytenoideus. The affected cord lies in the cadaveric position; the
opposite cord can be adducted, but the differences in vocal cord tension produce a hoarse voice.
Unilateral incomplete recurrent laryngeal nerve paralysis produces slight dyspnoea on exertion and little
or no alteration in the voice.
03. Theme: Endocrine
A Propranolol
B Carbimazole
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
25. Surgical Specialities; General Surgery; Breast & Endocrine Surgery (50Qs)
C Propylthiouracil
D Subtotal thyroidectomy
E Total thyroidectomy.
For each of the clinical scenarios below select the most appropriate treatment of thyrotoxicosis. Each
option may be used once, more than once, or not at all.
Page
Scenario 1 1502
A pregnant woman.
A - Propranolol« YOUR ANSWER
C - Propylthiouracil« CORRECT ANSWER.
Scenario 2
A teenager.
B - Carbimazole« CORRECT ANSWER.
Scenario 3
A 65-year-old individual with cerebrovascular accident (CVA)/atrial fibrillation (AF).
C - Propylthiouracil« YOUR ANSWER
A - Propranolol« CORRECT ANSWER.
Scenario 4
Failed medical treatment.
D - Subtotal thyroidectomy« YOUR ANSWER
E - Total thyroidectomy« CORRECT ANSWER.
Thyrotoxicosis is managed conservatively in the first instance. Propranolol, a blocker, is good for
reducing anxiety and treatment of cardiac arrhythmias such as AF. Care must be taken when prescribing
carbimazole because blood dyscrasias occur in 2% of cases. A pregnant woman should be prescribed
propylthiouracil. Ideally if a woman is attempting conception, then she should be changed from
carbimazole to propylthiouracil. In the instance of failed medical therapy, radio-iodine (i.e. not during
pregnancy) or a total thyroidectomy may be considered. The increasing use of total thyroidectomy (i.e.
versus subtotal thyroidectomy) as a treatment for thyrotoxicosis is due to its lower risk of recurrent
hyperthyroidism; if the patient is euthyroid at the time of surgery, thyroxine is started immediately
postoperatively (please see following references):
Bahn RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management
guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists.
Thyroid. 2011;21:593-646.
Stålberg P, Svensson A, Hessman O, et al. Surgical treatment of Graves' disease: evidence-based
approach. World J Surg. 2008;32:1269-1277.
Barczynski M, Konturek A, Hubalewska-Dydejczyk A, et al. Randomized clinical trial of bilateral subtotal
thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up. Br J Surg.
2012;99:515-522.
04. Theme: Mastalgia
A Acute mastitis
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
25. Surgical Specialities; General Surgery; Breast & Endocrine Surgery (50Qs)
B Aberrations of normal development and involution(ANDI)
C Breast abscess
D Breast carcinoma
E Cyclical mastalgia
F Fat necrosis
G Fibroadenosis
H Mondor’s disease Page
I Tietze’s syndrome. 1503
The following patients have presented to the one-stop breast clinic with mastalgia. Please select the most
appropriate dignosis from the list above. The items may be used once, more than once, or not at all.
Scenario 1
A 33-year-old woman is seen with a 1-day history of painful enlargement of her right breast. Of note, she is
currently breastfeeding and is a smoker. On examination she has generalised enlargement of her right breast.
The overlying skin is erythematous, hot to touch and tender. There are no masses palpable. Breast ultrasound is
normal.
A - Acute mastitis « CORRECT ANSWER.
A – Acute mastitis:
The commonest form of mastitis is that occuring in relation to pregnancy and breastfeeding, the so called
‘lactational mastitis’. The condition is more common among smokers. Most cases are caused by
Staphylococcus aureus when an ascending infection from the nipple, along the lactiferous ducts, initiates
the mastitis. In the early phase the spreading cellulitis produces the classical signs of inflammation. After
a few days an abscess develops, which may give rise to a palpable lump. The time-scale and the absence
of a lump, either clinically or radiologically, differentiates acute mastitis from a breast abscess. Treatment
is with antibiotics alone.
Scenario 2
A 27-year-old woman presents with a 6-month history of intermittent pain along the inner aspect of her left breast.
The pain occurs for a few days before resolving spontaneously. The frequency of ‘attacks’ is increasing. She is an
amateur athlete and complains that the pain prevents her from taking part in any physical activity. Breast
examination is unremarkable apart from some tenderness medially.
B - Aberrations of normal development and involution(ANDI) « YOUR ANSWER
I - Tietze’s syndrome« CORRECT ANSWER.
I – Tietze’s syndrome:
Tietze’s syndrome is an inflammatory condition of the costochondral cartilages. It is characterised by
pain, tenderness and swelling of one or more costal cartilages, typically the first four. The syndrome
usually affects older children and young adults and there are more female cases than male cases. The
pain is usually exacerbated by physical activity, deep inspiration and coughing. Examination reveals the
presence of exquisite tenderness and swelling over the affected joints. Treatment consists of local heat,
analgesics, anti-inflammatory drugs, or local steroid injections. Most often the pain subsides after a few
weeks or months but swelling may persist for longer.
Scenario 3
A 58 year-old woman presents with a 2-week history of a mild ache and prickling sensation in her right breast.
She is worried as she thinks she can now feel a lump in the area of concern. She has had a previous
hysterectomy and bilateral salpingo-oophorectomy at the age of 45 and has been on hormone replacement
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
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