A 40-year-old man has a subtotal

thyroidectomy performed for Graves' disease.

Several hours later, he complains of difficulty
breathing. On examination, he has stridor and
a markedly swollen, tense neck wound. What
should be one of the first steps in the
management of this patient?
A Intubate with an endotracheal tube
B Perform a tracheostomy
C Control the bleeding site in the operating
room
D Open the wound to evacuate the hematoma
E Aspirate the hematoma
. The answer is D (Chapter 16, I D 2 e [4] [b]
[ii]). Postoperative bleeding after
thyroidectomy can cause airway compromise
due to tracheal compression. The first step
should be to open the wound to evacuate the
hematoma, followed by a return to the
operating room to control the bleeding site.
Attempts to perform either endotracheal
intubation or tracheostomy may be difficult
until the external compression of the
hematoma is relieved
A 50-year-old hypertensive man has definitive
biochemical evidence of a
pheochromocytoma. Computed tomography
(CT) scan and magnetic resonance imaging
(MRI) do not reveal any abnormalities, and m-
iodobenzylguanidine scanning is not readily
available. What should be the next step in the
management of this patient?
A Abdominal exploration
B Continued clinical observation
C Mediastinoscopy
D Selective venous sampling
E Mediastinal exploration
The answer is D (Chapter 16, II G 5 d).
Although 90% of pheochromocytomas are
located in the adrenal glands, they can occur
in any tissue that is derived from
neuroectoderm. When computed tomography
(CT) scan and magnetic resonance imaging
(MRI) do not identify a tumor, m-
iodobenzylguanidine scanning can be helpful;
however, this is not always available. Selective
measurements of catecholamines drawn at
various levels from the vena cava and its major
branches should be obtained before surgical
exploration.
3. A 55-year-old woman with progressive but
episodic muscle weakness is diagnosed as
having myasthenia gravis. Her chest
radiograph is normal and reveals no evidence
of mediastinal mass or tumor. What is the
most definitive treatment that can be offered
this patient?
A Prednisone
B Neostigmine
C Thymectomy
D Plasmapheresis
E Atropine
The answer is C (Chapter 16, IV C 3 b).
Myasthenia gravis is an autoimmune disease
of neuromuscular transmission that causes
skeletal muscle weakness.
Parasympathomimetic drugs have been found
to improve muscle strength in these patients.
Prednisone has also been used with some
success because of the autoimmune nature of
this disease. Plasmapheresis may be effective
in preparing the patient preoperatively. The
treatment of choice for all forms of
myasthenia, except purely ocular, appears to
be thymectomy. An increased percentage of
patients have permanent remission. The
response to medication is improved in patients
who do not achieve a complete remission.
A first-degree relative of a patient found to
have advanced medullary carcinoma of the
thyroid gland is referred for further evaluation.
Which screening measure is the choice for
detection of medullary thyroid pathology?
A Careful physical examination
B Serum calcitonin level
C Stimulated serum calcitonin level (calcium
and pentagastrin)
D Gastrin level
E Carcinoembryonic antigen (CEA) level
The answer is C (Chapter 16, I F 5 c [2] [c]). All
first-degree relatives of patients with
medullary carcinoma of the thyroid gland
should be screened for this disorder because it
can occur in a familial pattern. Physical
examination of the thyroid gland should be
performed for the detection of any nodules.
An increased serum calcitonin or an increased
stimulated serum calcitonin test will also
indicate underlying medullary pathology,
either hyperplasia or carcinoma. The
stimulated tests will detect disease at an
earlier, more curable stage. Increased gastrin
levels are associated with Zollinger-Ellison
syndrome and are not part of this multiple
endocrine adenomatosis (MEN) type 2
syndrome. Carcinoembryonic antigen (CEA) is
elevated in some gastrointestinal
malignancies.
If a first-degree relative of a patient with MEN-
2 A syndrome is found to have medullary
pathology requiring surgical exploration of the
thyroid gland, what should the preoperative
screening include?
A Serum cortisol level
B Fasting glucose and insulin
C CT scan of the head
D Urinary aldosterone and renin
E Urinary vanillylmandelic acid and
metanephrines
The answer is E (Chapter 16, II G 4 a; Chapter
17, I B 2). Medullary carcinoma of the thyroid
gland may present as a sporadic or familial
form associated with MEN type 2A or 2B. Both
are associated with pheochromocytomas. If a
pheochromocytoma is present, it should be
diagnosed and treated first to avoid the
morbidity of cervical exploration in a patient
with untreated pheochromocytoma. Urinary
vanillylmandelic acid and metanephrines
should be evaluated preoperatively.
A 60-year-old female patient has a workup for
episodic symptoms of palpitations,
nervousness, and bizarre behavior, all of which
tend to occur during fasting states.
Biochemically, she is diagnosed as having an
insulinoma. What is the best choice for
localizing this tumor?
A CT scan
B MRI
C Selective arteriography
D Percutaneous catheterization of the portal
vein with selective venous sampling
E Surgical exploration and intraoperative
ultrasound
The answer is E (Chapter 17, II B 4 a [2]). The
patient has had a definitive biochemical
diagnosis of insulinoma. These tumors can be
present anywhere in the pancreas. Because
they are usually small in size, arteriography,
CT, and MRI are less sensitive than they would
be for larger tumors. With careful surgical
exploration and intraoperative ultrasound,
approximately 90% of these tumors can be
localized at the time of surgery.
A 55-year-old female patient is evaluated for
new onset of diabetes mellitus. Her medical
history is largely unremarkable. Her physical
examination is unrevealing except for the
presence of an erythematous skin rash. Her
further evaluation should include an
investigation of the possibility of which of the
following?
A Insulinoma
B Glucagonoma
C Gastrinoma
D Carcinoid tumor
E Pancreatic cholera
7. The answer is B (Chapter 17, II E 1).
Glucagon-producing tumors of the pancreas
secrete glucagon in large amounts. Patients
tend to present with new onset of diabetes
mellitus (hyperglycemia). Affected individuals
also characteristically have a migratory
erythematous skin rash.