Sunday, May 17, 2020

Breast MCQ - Part II - Surgery - with answers

01. 60yrs old lady presented with 2cm painless lump in the left breast for 2 weeks duration. In clinical examination it suggested malignancy which of the following are T/F

a) Tethering with skin indicate poor prognosis 
b) Mammography is done of the triple assessment 
c) FNAC negative no need to go for further investigation 
d) Hormonal treatment compare with CT is best in this patient than young patient with same features 
e) If decided to do breast conservation surgery, radiotherapy should not given

02. Regarding breast carcinoma;

a) Detected by self breast examination is free of metastatic disease 
b) In 80 year old woman can effectively treat with tamoxifen only. 
c) Her-2-neu receptor represents poor prognosis 
d) Micro metastases can be excluded if the isotope bone scan is normal 
e) Treated with mastectomy has better overall survival rather than breast conservative surgery combined with radiotherapy

03. Features of metastatic breast CA

a) Bone pain 
b) High ALP level 
c) Hypocalcaemia 
d) Pathological fractures 
e) Pleural effusions

04. Regarding breast CA

a) Fibro adenoma is an AND! arising from a single terminal duct lobule 
b) Typical hyperplasia of fibrocystic disease has a high risk for developing malignancies c) USS is a method of screening 
d) Hormonal therapy is the first line therapy for elderly patients

05. A 40 year old female presented with pain in both breasts & upper limbs for 6 months. Features favoring the diagnosis of fibrocystic disease are,

a) Cyclical pain 
b) Nodules like feeling in the respective area c) Presence in upper medial quadrant 
d) Bilateral involvement

06. What is the most common complication following simple mastectomy and axillary clearance

a) Bleeding 
b) Thoracodorsal never damage 
c) Seroma formation 
d) Surgical site infection 
e) Flap necrosis mastectomy

07. Risk factors for breast carcinoma 
a) Hormone replacement therapy 
b) Menopause at 35y of age
c) Oral contraceptive pills for 5 years 
d) Null parity 
e) Breast feeding

08. Regarding breast disorders, 

a) Acute mastitis needs incision and drainage. 
b) Female with malignant lump without any metastasis can be treated with lumpectomy. c) Cyclical mastalgia can be treated with cyst aspiration. 
d) 2cm fibro adenoma need wide local excision. 
e) Mastalgia is common at perimenopause age.

09. Breast carcinoma, 

a) Characterized by macro calcifications on mammogram. 
b) Detected on self breast examination stands the best chance of cure. 
c) When locally advanced, best treated with neo adjuvant chemotherapy. 
d) Micro metastasis cannot be excluded if the isotope bone scan is normal. 
e) Survival is superior when treated by modified radical mastectomy comparing with breast conservation surgery combine with radiotherapy.

10. Regarding breast carcinoma 

a) Tumor situated in sub areolar area is the best situation for breast conservative surgery
b) Estrogen receptor positive breast carcinoma has good prognosis
c) Estrogen ,progesterone and HER2 receptors can be identified
d) Usually sensitive to chemotherapy

11. True or False regarding benign breast disease

a) Fibro adenoma has irregular margins
b) Usually grows up to 2-3cm in size
c) Giant fibro adenoma can be seen in pregnancy
d) Well lobulated

12. WOF are true or false

a) Middle thyroid vein drains to the internal jugular vein
b) Clinical features of L5/S1 disc prolapse affecting the S1 root includes parasthesia of the lateral aspect of the foot
c) 80% of blood supply to the liver is from the portal vein
d) Iliohypogastric nerve passes through the external inguinal ring along with the spermatic cord
e) Abductor pollicis brevis muscle is supplied by the ulnar nerve


01. a) T b) T c) F d) F e) F

02. a) F b) F c) T d) F e) F

03. a) T b) T c) F d) T e) T

04. a) T b) F c) T d) F

05. a) T b) T c) F d) T

06. a

07. a) T b) F c) T d) T e) F

08. a) F b) F c) F d) F e) F

09. a) F b) F c) T d) T e) F

10. a) F b) T c) T d) T

11. a) F b) T c) F d) F

12. a) T b) T c) T d) F e) F

Saturday, May 9, 2020

Rickets - Short Note - Paediatrics

Vitamin D deficiency

    • Bony deformity and rickets.
    • Without bone abnormalities but with symptoms of hypocalcaemia, i.e. seizures, neuromuscular irritability (tetany), apnoea, stridor. (common before 2 years of age and in adolescence-high demand for calcium in rapidly growing bone results in hypocalcaemia before rickets develops)


    • Rickets signifies a failure in mineralisation of the growing bone or osteoid tissue.
    • Failure of mature bone to mineralise is osteomalacia.


Nutritional (primary) rickets

Risk factors

• Living in northern latitudes
• Dark skin
• Decreased exposure to sunlight
• Maternal vitamin D deficiency
• Diets low in calcium, phosphorus and vitamin D, e.g. exclusive breast-feeding into late infancy
• Macrobiotic, strict vegan diets
• Prolonged parenteral nutrition in infancy

Intestinal malabsorption
• Small bowel enteropathy (e.g. coeliac disease)
• Pancreatic insufficiency (e.g. cystic fibrosis)
• Cholestatic liver disease
• High phytic acids in diet (e.g. chapattis)

Defective production of 25(OH)D2
• Chronic liver disease

Increased metabolism of 25(OH)D3
• Enzyme induction by anticonvulsants (e.g. phenytoin, phenobarbital)

Defective production of 1,25(OH)2D3
• Hereditary type I vitamin D-resistant (or dependent) rickets (mutation which abolishes activity of renal hydroxylase)
• Familial (X-linked) hypophosphataemic rickets (renal tubular defect in phosphate transport)
• Chronic renal disease
• Fanconi syndrome (renal loss of phosphate)

Target organ resistance to 1,25(OH)2D3
• Hereditary vitamin D-dependent rickets type II
(due to mutations in vitamin D receptor gene).

Clinical manifestations

• Misery
•  Failure to thrive/short stature
•  Frontal bossing of skull
•  Craniotabes (ping-pong ball sensationof the skull elicited by pressing firmly over the occipital or posterior parietal bones)- Earliest sign
•  Delayed closure of anterior fontanelle
•  Delayed dentition
•  Rickety rosary (palpable or visible costochondral junctions)
•  Harrison sulcus (a horizontal depression on the lower chest corresponding to attachment of the softened ribs and with the diaphragm)
    • Pigeon chest / violin case deformity
    • Pot belly
    • Kyphoscoliosis
•  Expansion of metaphyses (especially wrist in crawling individuals, in ankle in walking infants)
•  Bowing of weight-bearing bones
    • Knock knees
•  Hypotonia
    • Proximal myopathy resulting waddling gait
    • Bone pain- axial skeleton, spine, shoulders, ribs & pelvis
    • Localized pain due to green stick fractures
•  Seizures & tetani due to hypocalcaemia


• Dietary history for vitamin and calcium intake
• Blood tests – serum calcium is low or normal, phosphate low, plasma alkaline phosphatase activity greatly increased, 25-hydroxyvitamin D may be low and parathyroid hormone elevated.
• X-ray of the wrist joint – shows cupping and fraying of the metaphyses and a widened epiphyseal plate, looser’s zone


Nutritional rickets is managed by,
    • Balanced diet,
    • Correction of predisposing risk factors
    • Administration of vitamin D3 (cholecalciferol).

Healing occurs in 2–4 weeks and can be monitored from the,
    • Lowering of alkaline phosphatase,
    • Increasing vitamin D levels
    • Healing on X-rays (but complete reversal of bony deformities may take years)