A 14 year old black female presents for a routine evaluation. On examination, you note a rubbery, well-defined, nontender breast mass approximately 2 cm in diameter. The patient denies any history of breast tenderness, nipple discharge, or skin changes.
The most likely diagnosis is:
Correct Answer B: Most breast masses in adolescent girls are benign. Fibroadenoma is the most common, accounting for approximately two-thirds of all adolescent breast masses. It is characterized by a slow growing, nontender, rubbery, well-defined mass, most commonly located in the upper, outer quadrant. Size varies, and is most commonly in the range of 2-3 cm.
Fibrocystic disease is found in older adolescents and is characterized by bilateral nodularity and cyclic tenderness. Benign breast cysts are characterized by a spongy, tender mass with symptoms exacerbated by menses. Cysts are frequently multiple, and spontaneous regression occurs in 50% of patients. Cystosarcoma phyllodes is a rare tumor with malignant potential, although most are benign. It presents as a firm, rubbery mass the may enlarge rapidly. Skin necrosis is usually associated with the tumor,. Intraductal papillomas are usually benign but do have malignant potential. They are commonly subareolar and are associated with nipple discharge. These tumors are rare in the adolescent population.
A 32 year old white female marathon runner presents with persistent pain and tenderness over the pubic symphysis. With exercise, pain is noted in the lower abdomen and medial thighs. There is no fever. A radiograph shows widening of the pubic symphysis.
What is the most likely diagnosis?
Correct Answer C: Osteitis pubis is characterized by the chronic occurrence of pain in the lower abdomen and medial thighs with exercise. It produces tenderness over the pubic symphysis, and widening of the symphysis is often seen on plain radiographs. Pain from osteomyelitis is similar, but usually presents with fever and systemic symptoms, and does not cause widening of the symphysis. A stress fracture of the pubic ramus may occur in distance athletes, but the pain and tenderness are lateral, located over the posterior ramus. Inguinal hernia should not present with symphysis pain.
A 72 year old female is found to have a complex splenic mass on a CT scan done for another reason. Because of concerns regarding possible malignancy and the potential for spontaneous splenic rupture, an elective splenectomy is planned.
Which one of the following immunizations should be given prior to her surgery?
Correct Answer A: Asplenic and functionally asplenic patients are susceptible to overwhelming infection from encapsulated organisms, and should be immunized with pneumococcal, meningococcal, and Hib vaccines. The vaccines’ immunogenicity may be reduced when given after splenectomy or during chemotherapy; thus, they should be given at least 2 weeks before performing elective splenectomy or starting chemotherapy if possible.
A 32-year-old white male undergoes an emergency splenectomy after a motor vehicle accident.
Which one of the following should he receive after the surgery?
Correct Answer A: Pneumococcal and meningococcal vaccines are currently recommended for patients with asplenia. Haemophilus influenzae type b (Hib) vaccine can be considered as well. A Td booster or Tdap also should be considered. Emergency splenectomy for trauma is an indication for vaccination, although splenic remnants may persist.
A 53-year-old white female undergoes abdominal ultrasonography for suspected gallbladder disease. A 3-cm thin walled, fluid-filled cyst is seen on the left kidney.
Which one of the following would be most appropriate at this time?
Correct Answer E: Simple renal cysts are incidentally seen on abdominal imaging studies in over 30% of people over age 50, and are present in up to 50% in some autopsy series. No further evaluation is indicated for cysts that meet ultrasound criteria (i.e., thin-walled, homogeneous, fluid-filled). With cysts that appear to be complex, a renal CT with contrast is indicated. MRI has been shown to be statistically superior to CT in correctly characterizing benign lesions, and may be helpful when results of a CT scan are equivocal. Simple cysts do not require aspiration or other treatment. Referral is indicated for symptomatic or complex cysts or solid masses.
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