A 14-year-old male presents for a routine physical examination. During a genital examination, you note a mass over the left testicle. This mass feels like a bag of worms, but resolves when you examine the patient in the supine position.
The most appropriate course of care would be:
Correct Answer B: This patient has a varicocele, which is not a normal variant but rather a collection of dilated and tortuous veins in the pampiniform plexus around the spermatic cord. The cause is not fully understood, but it has been hypothesized that varicoceles result from increased venous pressure and incompetent valves. Approximately 85%-95% occur on the left side, and if they are found on the right side or occur bilaterally, surgical intervention is recommended. Also, if the varicocele is large or painful, has an acute onset, or does not resolve in the supine position, a surgical referral should be made. Infertility is a problem for only 10%-15% of patients with varicoceles, and hormonal therapy is not recommended. Testicular volumes should be measured, and if the affected testicle has a volume 2 mL less than the normal testicle, referral is prudent.
What is the treatment of an intraductal papilloma?
Correct Answer A: Intraductal papilloma is a small, benign (non-cancerous) tumor that grows within a milk duct of the breast. Symptoms include: breast pain, nipple discharge, sometimes bloody, breast lump and breast enlargement.
Intraductal papilloma is the most common cause of spontaneous nipple discharge from a single duct. A small lump beneath the nipple may be felt by the examiner. A mammogram often does not show papillomas. Ultrasound may be helpful. Cellular (cytologic) examination of discharge may be performed to identify potentially malignant (cancerous) cells. A breast biopsy is necessary to make a definitive diagnosis and rule out cancer.
Treatment involves surgical removal of the involved duct and examination of the tissue to rule out cancer.
A 38 year old woman is to be operated on for carpal tunnel syndrome.
Which one of the following structures is situated in the tunnel along with the median nerve?
Correct Answer D: The carpal tunnel contains the median nerve, FPL and 4 tendons each of the FDP and FDS. Of note, with respect to the FDS tendons, the 3rd and 4th FDS tendons are volar to the 2nd and 5th FDS tendons. Flexor carpi radialis is (FCR) is not a tendon within the carpal tunnel.
A neurosurgeon complains of a 3 week history of awakening at night with right-hand discomfort that resolves after several minutes. On examination, he has mild weakness of thumb abduction and diminished pain sensibility on the palmar aspect of the thumb and index finger.
The most likely diagnosis is:
Correct Answer A: Carpal tunnel syndrome is compression of the median nerve as it passes through the carpal tunnel in the wrist. Symptoms include pain and paresthesias in the median nerve distribution. Diagnosis is suggested by symptoms and signs and confirmed by nerve conduction velocity testing. Treatments include ergonomic improvements, analgesia, splinting, and sometimes corticosteroid injection or surgery.
Note: It is thumb abduction, by the abductor pollicis muscle, which is weak in carpal tunnel syndrome. Weakness of thumb adduction is due to a problem of the adductor pollicis muscle, which is mainly innervated by the ulnar nerve.
A 35-year-old patient is rushed to the ED after an accident. When he comes in he is in hypovolemic shock. Immediate abdomen imaging reveals fluid in the splenorenal recess. The patient is unresponsive to initial management with fluid and blood administration.
What is the most appropriate management?
Correct Answer D: Splenic rupture generally results from blunt abdominal trauma. Significant impact (eg, motor vehicle collision) can rupture a normal spleen. Rupture of the splenic capsule produces marked hemorrhage into the peritoneal cavity. The manifestations, including hemorrhagic shock, abdominal pain, and distention, are usually clinically obvious. However, splenic trauma can also produce a subcapsular hematoma, which may not rupture until hours or even months after the injury.
Rupture is generally preceded by left upper quadrant abdominal pain. Splenic rupture should be suspected in patients with blunt abdominal trauma and hemorrhagic shock or left upper quadrant pain (which sometimes radiates to the shoulder); patients with unexplained left upper quadrant pain, particularly if there is evidence of hypovolemia or shock, should be asked about recent trauma.
Evaluation of the abdominal trauma patient commonly utilizes focused assessment with sonography in trauma (FAST exam), and CT scan. The FAST exam is more useful in hemodynamically unstable patients; however, a negative FAST examination is not adequate to exclude splenic injury, particularly intraparenchymal injury. Diagnostic peritoneal aspiration/lavage (DPA/DPL) is less common, having been largely replaced by the FAST examination in most major trauma centers.
Splenic injury can be initially managed with observation, angiographic embolization, or surgery depending upon the hemodynamic status of the patient, grade of splenic injury, and presence of other injuries and medical comorbidities. The hemodynamically unstable trauma patient with a positive FAST scan or DPA/DPL requires emergent abdominal exploration to determine the source of intraperitoneal hemorrhage. Hemodynamically stable patients with low-grade (I to III) blunt or penetrating splenic injuries without any evidence for other intra-abdominal injuries, active contrast extravasation, or a blush on CT, may be initially observed safely. In general, patients who meet the criteria for observation but who require intervention to manage extra-abdominal injuries (eg, leg fracture stabilization) can also be safely observed.
Note: Splenectomy should be avoided if possible, particularly in children, to avoid the resulting permanent susceptibility to bacterial infections; in which case, treatment is transfusion, as needed.
Click to expand