Casefiles 11: adrenal mass, disk herniation, PAD

Question 1

ddx of “adrenal incidentaloma”

most are?

Answer 1

benign functioning and nonfunctioning adrenal adenomas, adrenocortical carcinoma, and metastatic tumors
nonfunctioning adenomas, accounting for 55% to 94% of all cases.

Question 2

Functioning adrenal tumors

Answer 2

pheochromocytoma, aldosterone-producing adenoma, and cortisol-producing adenoma

Question 3

s/s of ? should be actively sought in the history and on physical examination of adrenal incidentaloma pt

Answer 3

excess catecholamines, aldosterone, cortisol, and androgens
history of hypertension, headaches, palpitations, profuse sweating, abdominal pain, anxiety, and prior history of malignancy
features suggestive of Cushing syndrome

Question 4

The functional assessment consists of three main diseases

Answer 4

pheochromocytoma (metanephrine and catecholamine levels, low ACTH or DHEAS)
Conn’s syndrome
hypercortisolism (overnight 1-mg dexamethasone suppression test (DST))

Question 5

What can be measured to evaluate for an aldosterone-producing adenoma (Conn syndrome) where ? is suggestive of hyperaldosteronism

Answer 5

Plasma aldosterone and renin activity
an aldosterone-renin ratio greater than 30
confimatory: Saline salt loading test or captopril challenge

Question 6

After determining whether an adrenal mass is functioning or nonfunctioning, anatomic assessment is performed, preferably with ?
What is used for the evaluation of an adrenal mass in a patient with a known extra-adrenal cancer because of its ability to separate benign from metastatic lesions?

Answer 6

CT or MRI

PET scan

Question 7

Imaging characteristics suggestive of adrenocortical carcinoma include ?

Answer 7

irregular margins, inhomogeneous density, scattered areas of decreased attenuation, local invasion
large size and enlargement over time, majority are 6 cm or greater

Question 8

CT characteristics that are highly specific for adrenal adenomas are ?

Answer 8

Hounsfield units less than 10 during noncontrast CT and early contrast washout during a CT with intravenous contrast (defined as more than 60% contrast clearance at 10-15 minutes after contrast injection)
One/both of these CT features has extremely high negative predictive value for malignancy, and incidentalomas with these findings can be managed with observation only

Question 9

Surgery is recommended for what adrenal masses?

Answer 9

all functioning tumors, nonfunctioning tumors 4 cm or greater, tumors that enlarge (growth of more than 0.8-1.0 cm during a 3- to 12-month period), tumors with imaging characteristics suspicious for carcinoma, or solitary adrenal metastases

Question 10

The adrenal gland is a frequent site of metastasis which include ?

Answer 10

breast, kidney, colon, stomach, melanoma, and most commonly lung cancer

Question 11

Management of patients with nonfunctioning adrenal incidentalomas smaller than 4 cm

Answer 11

follow-up imaging at 3 and 15 months.
A change in size greater than 1 cm may prompt adrenalectomy.
then annual H&Ps

Question 12

Pheochromocytoma is a tumor that arises from the ?

“10% tumor” because ?

Answer 12

chromaffin cells of the adrenal medulla and secretes catecholamines.
10% are bilateral, extra-adrenal, multiple, malignant, and over 10% familial

Question 13

how to localize pheos

Answer 13

CT or MRI
usually appears bright on a T2-weighted MRI
An iodine-131 metaiodobenzylguanidine (MIBG) scan may be obtained for confirmation or evaluation of non localized pheo
PET scan if others fail

Question 14

other screening if dx pheo

Answer 14

CXR for mets (most common site)

EKG and ECHO: chronic catecholamine excess may cause cardiomyopathy

Question 15

what should be given 1 to 2 weeks before surgery to remove pheo?

Answer 15

α-adrenergic–blocking agent: allows for relaxation of the constricted vascular tree and correction of the reduced plasma volume which prevents hypotension that often occurs following tumor removal
-β-adrenergic–blocking agent may be added to oppose the reflex tachycardia associated with α-blockade, but never start first due to potential precipitation of a HTN crisis related to unopposed α-receptor stimulation.

Question 16

the preferred α-adrenergic antagonist is ?

Answer 16

phenoxybenzamine
also, α-Methyl-p-tyrosine, which is often used in combination with phenoxybenzamine, competitively inhibits tyrosine hydroxylase, the rate-limiting enzyme in catecholamine synthesis

Question 17

Intraoperative medical management of pheos is critical because of the danger of ?

Answer 17

large fluctuations in blood pressure, heart rate, and fluids

monitor BP with art line, monitor volume with CVC and foley, IV nitroprusside for HTN control, esmolol for tachycardia

Question 18

Acute hypotension may occur following excision of a pheochromocytoma related to sudden diffuse vasodilatation, so tx with ?

Answer 18

fluid administration, if that fails continuous IV norepinephrine

Question 19

motor weaknesses associated with the affected nerve roots can also be detected with herniated disks (L4: ?; L5: ?)

Answer 19

anterior tibialis

extensor hallicus longus

Question 20

Disc herniation at what level is most common?

Answer 20

L5-S1 level with S1 nerve root compression is most common (40%-50%)
then L4-L5 level herniation with L5 nerve root compression occurs in 40%
L3-L4 disc herniation with L4 nerve root compression occurs in 3% to 10%

Question 21

cauda equina syndrome

Answer 21

Compression of the sacral nerve bundle, which forms the end of the spinal cord. Common symptoms: bladder and bowel dysfunctions, pain and/or weakness in the legs. Important to pick it up early to avoid nerve entrapment that ends up producing long-term dysfunctions

Question 22

back pain red-flag symptoms

Answer 22

older than 50, presence of systemic symptoms such as fever, night sweats, weight loss, hx of malignancy, night pain, immune suppressed status, hx of IV drug use, failure to respond to initial treatments, prolonged corticosteroid use, diagnosis of osteoporosis, and trauma

Question 23

L2 nerve root:
muscle group?
sensory dermatome?
DTR?

Answer 23

hip flexor
anterior medial thigh
no DTR

Question 24

L3 nerve root:
muscle group?
sensory dermatome?
DTR?

Answer 24

quads
anterior thigh to knee
knee jerk

Question 25

L4 nerve root: muscle group? sensory dermatome? DTR?

Answer 25

anterior tibialis medial calf and ankle knee jerk

Question 26

L5 nerve root: muscle group? sensory dermatome? DTR?

Answer 26

extensor hallicus longus lateral ankle to dorsum of foot no DTR

Question 27

S1 nerve root: muscle group? sensory dermatome? DTR?

Answer 27

gastrocnemius/soleus/paroneals plantar and lateral foot ankle jerk

Question 28

lumbar spondylosis presentation

Answer 28

Generalized back pain that is worse immediately after waking up; improves throughout the day; pain fluctuates with activity and is worse with extension of the spine

Question 29

Spinal stenosis/neurogenic claudication presentation

Answer 29

Back pain with radiculopathy worsened by extension /standing; improvement with flexion, sitting

Question 30

spondylolisthesis presentation

Answer 30

Back pain with radiation down one or both legs, exacerbated by flexion/extension

Question 31

ankylosing spondylitis

Answer 31

More common in young males; morning stiffness, low back pain radiating to buttock that improves with exercise

Question 32

conus medullaris syndrome

Answer 32

Same as caudal equina (Urinary retention or fecal incontinence; decreased rectal tone; saddle anesthesia) but also with UMN signs (eg, hyperreflexia, clonus)

Question 33

Imaging studies should be considered in patients with “red flag” symptoms and in patients whose symptoms persist for greater than ? of conservative management. The role of imaging in these patients is to rule out ?

Answer 33

4 to 6 weeks | fracture, tumor, or infections

Question 34

Common recommended interventions for back pain | a more effective but risky combo?

Answer 34

ctivity modification, rest, NSAIDs, PT | combination of oral analgesics, antidepressants, and opioids

Question 35

the indications for surgical treatment for back pain include ?

Answer 35

identifiable anatomic nerve compression, neurologic deficits, and/or intractable pain

Question 36

Surgical treatment for herniated discs involves ? | If several levels of disc spaces are involved, ? is indicated

Answer 36

laminectomy and removal of the protruding disc(s) | posterior spinal fusion in addition to the disc extraction

Question 37

bilateral calf claudication, the locations of the arterial occlusions are most likely in the ?

Answer 37

superficial femoral arteries (SFAs)

Question 38

One of the important initial considerations in the management of a patient with peripheral arterial disease (PAD) is to determine whether the disease falls into the category of ? or ?

Answer 38

intermittent claudication (IC) or critical limb ischemia (CLI)

Question 39

The diagnosis of CLI is characterized by ?

Answer 39

ischemic rest pain lasting greater than 2 weeks in duration, and with the patient often becoming dependent on opiate analgesia for relief ankle-brachial index (ABI) of less than 0.40 toe pressure of less than 30 mm Hg

Question 40

After establishing the diagnosis of IC, the initial management should include ?

Answer 40

life style modifications (smoking cessation, dietary modifications, and weight loss) and pharmacological treatment to reduce his cardiovascular disease risk

Question 41

risk of limb-loss for patients with IC is ? | the combined risk of mortality from cardiovascular and cerebral vascular events are ?

Answer 41

generally quite low (less than 5% over 5 years) | high (42% and 65% at 5 and 10 years, respectively)

Question 42

Fontaine classification for PVD

Answer 42

I Asymptomatic IIa Mild claudication (symptoms onset >200 m) IIb Moderate-severe claudication (symptoms onset <200 m) III Ischemic rest pain IV Tissue loss or ulceration

Question 43

Rutherford classification of PVD

Answer 43

0 I Asymptomatic 1 IIa Mild claudication* 2 IIb Moderate claudication* 3 IIb Severe claudication* 4 III Rest pain 5 IV Ischemic ulceration not exceeding the digits of the foot 6 IV Severe ischemic ulcers or frank gangrene

Question 44

Statin therapy targeting the reduction of LDL levels to ?in average-risk individuals and to ? in high-risk patients with multiple other CV co-morbidities

Answer 44

less than 100 mg/dL | less than 70 mg/dL

Question 45

What have been shown to reduce the risk of MI and strokes in patients with PAD?

Answer 45

Beta-blockers and ACE inhibitors

Question 46

ABI values

Answer 46

ABI greater than 0.9 is normal; ABI less than 0.9 signifies PAD, and ABI less than 0.4 is usually associated with rest pain or tissue loss (CLI)

Question 47

Anatomic assessment of patients with PAD should be reserved only for ? imaging includes ?

Answer 47

individuals for whom invasive interventions are being considered color flow duplex scan, spiral CT, MRI, and arteriography (gold standard)

Question 48

patients with occlusive disease where? may complain of pain in the upper thighs and buttock regions with walking impotence may result from occlusive disease where?

Answer 48

aorto-iliac | in the internal iliac arteries

Question 49

Leriche syndrome

Answer 49

combination of buttock and thigh claudication, impotence, and diminished femoral pulses

Question 50

patients with CLI often have rest pain located predominately ? and is improved or relieved with ? other characteristics?

Answer 50

in the foot and toes dependent positioning of the extremity and will have dependent rub or and elevation pallor chronic ischemic changes of the feet and lower legs including atrophic and shiny skin and loss of leg hairs

Question 51

Arterial occlusive disease can often be divided as ?

Answer 51

``` inflow disease (above the inguinal ligament) or outflow disease (below the inguinal ligament) operative and percutaneous interventions are much more successful and durable for inflow diseases ```

Question 52

neurogenic vs vasculogenic claudication

Answer 52

neurogenic claudication tends to occur inconsistently with positional changes; whereas, claudication from PAD is related to insufficient blood flow to the major lower extremity muscles during exertion. vasculogenic: a function of work load and blood supply, the symptoms are reproducible with the same amount of work load each and every time + changes in skin temperature, capillary refill, and peripheral pulses

Question 53

interventions for occlusive diseases in the ? are associated with greater long-term patency than procedures performed in ?

Answer 53

aorta and iliac arteries | smaller vessels at the below-the-knee level

Question 54

classification of aorto-iliac, femoral/popliteal occlusive disease

Answer 54

TASC based on location and characteristics helpful to determine whether open surgical approaches or endovascular approaches are best

Question 55

Type A lesions (“simple lesions”) in the aorta, iliac, and femoral-popliteal have good results with ?

Answer 55

endovascular treatment techniques (angioplasty and stenting)

Question 56

Type B lesions have good results using the ?

Answer 56

endovascular approaches, unless open revascularization is needed for another lesion in the same anatomic region

Question 57

Type C lesions have better long-term results with ?

Answer 57

open revascularization techniques so endovascular approaches should be used only if the patient is at high risk for open surgery

Question 58

Type D lesions have poor results with ?

Answer 58

endovascular treatment, therefore open surgery is the primary treatment