Archer Step 3 Q-bank Pearls

[steveme]

Disclosure: Most pearls I am posting here are with permission from and using freely available content on Archer blogs and I have not violated any copyrights. Since there is a thread discussing UWOrld Qbank pearls, I would like to post pearls from Archer Q-banks which are very good and additive to UWorld concepts. More questions equates better learning and retention!

Pearl 1:

Testicular Torsion questions:

Recognize that clinical probability of testicular ultrasound can be estimated by history and physical examination ( see the predictive clinical score below). Ultrasound should only be done if the clinical diagnosis is uncertain and if the performance of imaging does not significatntly delay the treatment.

Rapid diagnosis is important in order to salvage a viable testis with prompt surgery. The testicular salvage rate is more than 80% if surgery is performed within 6 hours, but the rate decreases to approximately 20% if surgery is done after 12 hours after the onset of symptoms.

Testicular Torsion: Clinical features include acute onset pain, absence of cremasteric reflex, negative prehn’s sign, tender testicle on palpation and a an elevated or horizontal lie of testis ( changed position of testis). Absent cremasteric reflex is the most sensitive physical finding for diagnosing testicular torsion. Three features in the history can serve as predictors of pre-test clinical probability of Testicular Torsion: 1. Onset of pain less than six hours 2. Absence of Cremasteric reflex 3. Diffuse Testicular Tenderness. Presence of all the three features ( score:3) is assocaited with 87% probability (high probability) of having Testicular Torsion as per a large study. These patients should undergo direct surgical exploration. A score of 1 or 2 indicates moderate to low clinical probabilty and should first undergo diagnostic ultrasound. A score of 0 favors an alternative diagnosis for acute scrotum rather than Testicular Torsion.

Key Concept : Recognize “Testicular Torsion” clinical score and determine the next step as follows : : 1. Onset of pain less than six hours 2. Absence of Cremasteric reflex 3. Diffuse Testicular Tenderness. Presence of all the three features ( score:3) is assocaited high probability of having Testicular Torsion as per a large study –> Next step, direct surgical exploration. A score of 1 or 2 indicates moderate to low clinical probabilty –> next step, diagnostic ultrasound. A score of 0 favors an alternative diagnosis for acute scrotum rather than Testicular Torsion.

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[steveme]

Pearl #2
Thyroid Nodules approach is an important topic tested often.
First determine : Palpable vs. Incidentalomas

A. Approach – Palpable Thyroid Nodule
Cold nodules are more likely to be malignant when compared to hot nodules ( hot/ functioning nodule virtually rules out malignancy)

1. If thyroid nodule palpable –> Get TSH First.
a) If High TSH – suggests cold nodule/ Hashimatos –> Get FNAC (source: NEJM)(AACE recommends ultrasound as the next step here because hashimatos may have benign nodularity that regress with therapy and ultrasound will help to see if there are suspicious features. If U/S suspicious, then FNAC is recommended. This may be optimal approach because hurthle cells of hashimatos may cause false positives on cytology if the FNAC is obtained from such benign nodule –> so, we would recommend that you choose ultrasound as your next step if that is there in your MCQ choices. If the choices have no ultrasound, choose FNAC as answer). Further approach will depend on FNAC results. For hypothyroidism issue – Treat with levothyroxine if overt hypothyroidism or if subclinical hypothyroidism that warrants treatment.
b) If TSH normal – suggests cold nodule – next step, get FNAC.
c) If TSH low – suggests Hot nodule ( toxic adenoma) but not confirmative (What if there is GRAVES in the surrounding tissue and this is a cold nodule?) – so, next step get RAIU scan. If RAIU scan shows Hot nodule treat with I131 ( if there is overt hyperthyroidism from this toxic adenoma) or just observation. If RAIU shows COLD nodule, get FNAC.

Further Approach depends on FNAC results :
a) If FNAC is benign – Suppressive therapy with LT4 in some cases if cosmetically warranted
b) If FNAC is malignant/ suspicious – SURGERY
c) If FNAC is non-diagnostic – repeat FNAC. If repeat FNAC is again non-diagnosotic, surgery

B) Approach – Thyroid Incidentalomas

Thyroid Incidentalomas – These are those nodules ( not the palpable ones) detected on ultrasound such as when ultrasound was done for other purposes such as for other palpable thyroid abnormalities or during carotid artery imaging or ultrasound done for hyperparathyroidism).

The next step in such nodules discovered on the ultrasound depends upon the features of the nodule.
FNAC is indicated in such incidentally discovered thyroid nodules if :
– Nodule > 10 mm in diameter
– On ultrasound, if nodule has suspicious features of malignancy à hypoechoic, microcalcifications, irregular shape, blurred margin or increased vascularity
– If there are risk factors for thyroid cancer ( family history, childhood neck irradiation)

Self-Assessment Questions :

1. A 55-year-old man presented for a regular follow-up to your office 2 weeks ago at which time a palpable nodule of 1.7 cm was noted in the left thyroid lobe. He denies a history of head and neck irradiation, hoarseness, pain, dysphagia, or hemoptysis. His physical exam is otherwise normal, with no lab abnormalities. Most appropriate next step in management?

A. Ultrasound of thyroid

B. TSH level

C. Fine Needle Aspiration ( FNAC)

D. Observation

E. Suppressive therapy with levothyroxine

2. The patient in Q1. subsequently, underwent an FNAC which revealed Papillary Carcinoma of thyroid. Staging work-up revealed no evidence of distant metastases and a neck CT scan does not reveal any lymphadenopathy. The most appropriate management of his thyroid cancer involves:

A. Radio iodine therapy ( RAI)

B. Partial thyroidectomy

C. Total thyroidectomy

D. Life long levothyroxine + Total Thyroidectomy + RAI therapy

E. Total Thyroidectomy + Life long levothyroxine

F. Partial thyroidectomy + life long levothyroxine

3. A 55 year old man was recently found to have a 2.0 cm thyroid nodule on palpation during his annual physical. An ultrasound revealed no suspicious features of malignancy. TSH and free T4 levels were normal. Patient denies any history of neck irradiation, pain, dysphagia or hemoptysis. There is no history of cancer in his family. The next best step in evaluation of the nodule :

A. Suppressive therapy with levothyroxine

B. FNAC

C. Lobectomy with isthmectomy

D. Observation

E. Radio iodine therapy

Answers:

Q1. B

Q2. D

Q3. B