Clinical Rotation 4
Symptoms of prostatitis include all of the following except:
-fever and chills -perineal region pain -microhematuria -urethral discharge -urinary urgency or frequency
Commonly seen in men older than 50 years of age, symptoms of BPH include:
-leaking or dribbling of urine -weak or hesitant urine stream -increased urinary frequency -nocturia
Anatomically, the prostate can be divided into four zones. These include what?
-transition zone -central zone -peripheral zone -anterior fibromuscular zone
Which of the following would be the most worrisome sonographic finding?
A 4 cm, smooth, oval mass with cystic areas in the breast of a 55-year-old woman
A 39 year old man is seen with right-sided painless scrotal swelling. Sonographic examination reveals the appearance shown. What is the most likely explanation for this appearance? Where else should the sonographer investigate?
A large right sided varicocele can be caused by extrinsic compression of the right testicular vein, and examination of the right upper quadrant revealed an occult lower pole renal cell carcinoma.
An 83-year-old man saw his rural family medicine physician with complaints of overall weakness, joint pain, and generally "not feeling well" for the last 9 months. The patient had been quite active for his age before 1 year ago. After taking a careful history and completing a thorough physical examination, the clinician ordered labs including PSA. On receiving the PSA results of 23 ng/mL, the physician also requested a prostate sonogram and a nuclear medicine bone scan. The patient was scheduled for a consultation visit with his physician, who gave the patient what news regarding his current state of health?
Prostate cancer
The PSA density result in an asymptomatic 65 year old African American man is 0.2, and DRE reveals a nodule. What is the likely dx?
Prostate cancer
A 32-year-old man woke up with intense pain, which he described as "a constant, deep, throbbing pain behind his scrotum." The patient's temperature had been elevated for a few days, and he had felt intermittent fever and chills for about the same length of time. The primary care physician ordered routine laboratory tests and TRUS examination of the prostate. His laboratory test results showed an elevated PSA and white blood cell count. The sonogram showed a diffuse increase in color flow Doppler in the prostate gland and an irregular, cystic structure at the junction of a seminal vesicle and prostate. What is the most likely diagnosis?
Prostatitis can cause the "constant, deep, throbbing pain" as described by this patient. The irregular, cystic structure at the junction of the seminal vesicle and prostate coupled with an elevated white blood cell count would lead one to consider abscess.
A 50 year old woman with augmented breasts presents to the U/S department complaining of newly occurring asymmetry of breast size, right smaller than left. Sonographically, the right breast has long, echogenic lines within the internal portion of the implant. Shadowing, resembling bowel gas, is also seen along the external periphery of the implant. Findings are most consistent with?
Right breast "stepladder" and "snowstorm" signs
A 30 year old man undergoes sono examination for a painless mass in the right hemiscrotum. The sonogram reveals multiple punctate hyperechoic nonshadowing foci and a hypoechoic mass within the right testis. What is the most likely dx?
Seminoma with microlithiasis
A 43 year old man is seen with a mobile painless mass at the upper pole of his right testis. Sono exam reveals a 1.5 cm, round anechoic lesion that demonstrates acoustic enhancement. No other abnormalities are apparent. This probably represents a:
Spermatocele
A 15 year old boy is seen in the ED after falling and straddling a bicycle cross-bar. He has pain and swelling of the scrotum. The sonogram reveals heterogeneity of the right testicle and hypervascularity on color Doppler. An area of echogenic material is seen just outside the upper margin of the right testicle. What is the most likely dx?
Testicular rupture
A 25 year old man has a sudden onset of scrotal pain during a soccer game. During examination in the ED, the right hemiscrotum is still painful. A sonogram reveals slight enlargement of the right testicle, and on color Doppler examination, no blood flow can be found in the right testicle. What is the most likely dx?
Testicular torsion
A 25 year old woman is referred for a pelvic exam because of LLQ pain. A preg test is negative. The sonogram reveals a 2.0 cm unilocular, simple cyst adjacent to the left ovary. Which of the following statements is true regarding this finding?
This most likely represents a paraovarian cyst, and no treatment is necessary.
A 49 year old woman who is HIV positive undergoes a sonogram that shows a small mass with multiple, enlarged axillary nodes. What is likely causing the lymph node abnormality?
Thought to be enlarged due to patient's HIV status but results came back positive for cancer cells
A 61 year old man is seen with intermittent pain and swelling of the right scrotum, radiating to the right inguinal canal. A sonogram is ordered because a scrotal hernia is suspected. Which of the following sonographic findings is suggestive of a scrotal hernia?
Tubular structures that demonstrate peristalsis within the scrotum
A 72 year old man is seen in the ED with swelling and pain in the right hemiscrotum of 2 days' duration. His scrotum is red and warm to the touch. Sonography reveals the findings shown. What is the most likely dx?
acute epididymo-orchitis
A 21 year old woman is referred for nonspecific neck discomfort. No neck masses are palpable. A mostly cystic thyroid nodule with a "spongiform" appearance is noted on the sonogram. What is the most likely dx?
benign hyperplastic thyroid nodule
A slender, postmenopausal woman is referred for neck sonogram for evaluation of a palpable, tender right neck nodule. She reports slight pain with palpation; no pain had been noted before the physical examination. Sonographic examination reveals a 1.5 cm, mostly cystic nodule with some solid debris. Uninterrupted, peripheral rim calcification is also noted. What is the most likely dx?
benign hyperplastic thyroid nodule
A 75 year old woman undergoes a pelvic exam because of increasing abdominal girth and complaints of feeling exhausted. Sono evaluation demonstrates a 20 cm, complex, predominantly cystic mass occupying her pelvis and abdomen. Multiple papillary projections and septations are evident within the mass, which demonstrate vascularity on color Doppler imaging. What is the most likely diagnosis?
cystadenocarcinoma
A 19 year old woman was referred for a pelvic sono because of a palpable right adx mass and no other symptoms. The sonographer was unable to identify a normal right ovary but noticed a discrete area with hyperechoic dots and lines, including a rounded echogenic area that produced a shadow. At first, the area was thought to be bowel, but on observation, there was no peristalsis. These findings are most consistent with which type of ovarian mass?
cystic teratoma
A 20-year-old woman is seen for an annual pelvic exam, and the physician palpates an adnexal mass. The patient denies pelvic pain or abnormal bleeding. Serum preg test is negative. Sonographic eval demonstrates an ovarian mass. CT scan demonstrates fat within the mass. What is the likely dx?
cystic teratoma
A 45-year-old patient with a PSA value of 1.5 ng/mL underwent TRUS examination. The patient had been unaware of any prostate or urinary symptoms, and the transrectal sonogram went well for the patient. Sonographic findings are shown. What is the most likely diagnosis?
ejaculatory duct cyst
A 57 year old man presents with general malaise and unintentional weight loss. An abdominal CT scan reveals retroperitoneal masses. He has no palpable scrotal abnormalities, but a sonographic examination is ordered. What is the most likely dx?
germ cell tumor (seminoma)
A 16 year old girl presents with a breast mass that has been palpable for 6 months. Sonographically, a 7 cm, smooth, oval, gently lobulated mass is seen. The findings are most consistent with ?
giant fibroadenoma
Sonographically, prostate cancers are often visualized as focal, hypoechoic nodules most often found:
in the peripheral zone
Benign enlargement of the prostate gland occurs almost exclusively:
in the transition zone
Which of the following is not considered a mass of the breast tissue?
inclusion cyst
A 12 year old girl presents with breast asymmetry and a large palpable mass in her right breast. What is the likely dx?
juvenile fibroadenoma
A 55 year old woman with stomach cancer is referred for a pelvic sono because of pelvic discomfort. The sono reveals bilateral solid ovarian masses. This finding is most consistent with which of the following?
metastatic tumors
A 61 year old man with a biopsy-proven papillary thyroid cancer is also noted to have several oval, flat, elongated masses in the area between the jugular vein and carotid artery. Hyperechogenicity is noted in the hilar regions of these "masses". What is the most likely dx?
normal cervical lymph nodes
A 30 year old woman with a hx of a breast reduction is sent for imaging of palpable masses along the surgical scar. A sonogram reveals three round, smooth, anechoic masses. The findings are most consistent with which of the following?
oil cysts
A 60 year old woman with an elevate CA 125 level is referred for a pelvic sono. A mass is noted in the rt adx. What is the most likely dx?
ovarian cystadenocarcinoma
A 75 year old woman is referred to the U/S department with elevated serum calcium level. The neck sonogram reveals an oblong hypoechoic mass adjacent to the posterior aspect of the lower third of the left thyroid lobe. What is the most likely dx?
parathyroid adenoma
A 16 year old boy is seen in the ED after being awakened by severe scrotal pain in the early morning hours, approx 4 hours earlier. The sonographic exam reveals an enlarged, slightly hypoechoic left testicle compared with the right. Initial color Doppler of the left testis is shown in image, and Doppler eval performed 11 minutes later at the end of the exam is shown. What is the post likely dx?
partial torsion initially; action of transducer detorsed teste
A 45 year old woman with menorrhagia undergoes a pelvic sono that reveals a multiloculated cystic mass adjacent to the right ovary. The patient's medical hx includes prior pelvic sx for endometriosis 15 years ago. The patient denies any RLQ pain. Which of the following is the most likely dx?
peritoneal inclusion cyst
A 43 year old woman with breast CA and a hx of tamoxifan therapy is referred for a pelvic sonogram to rule out endometrial pathology and metastatic ovarian disease. Sonography reveals a normal-appearing uterus. However, a mass is noted in the right adx. FU pelvic exam in 5 weeks demonstrates resolution of the mass.What is the most likely dx?
physiologic ovarian cyst
A 68 yr old woman is referred for pelvic sonography to FU a known adx cycstic mass. This mass has been stable in size for the last 2 years. What is the most likley dx?
serous cystadenoma
Transverse imaging of the prostate gland in a 70 year old man with a hx of urinary obstruction demonstrates an anechoic defect into the base of the prostate. This finding most likely represents which of the following?
surgical defect from TURP
Which of the following is a sonographic feature of advanced prostate cancer?
tumor extension to the periprostatic lymph nodes
A 40 year old man is seen after being involved in an explosion accident. A sonographic eval is ordered because of a contusion on the right hemiscrotum; What is the most likley dx?
tunica rupture
A 67-year-old patient had been coping with increasing urinary fre. quency, increased leaking, and hesitation of the urine stream for more than 3.5 years; he finally scheduled an appointment with his PCP. History, PSA, DRE, and TRUS examination were completed on this patient. DRE and TRUS exam revealed an enlarged prostate. With this patient's clinical history, elevated PSA results, DRE, and sonographic findings, what is the most likely diagnosis?
Benign prostatic hyperplasia
A 73-year-old man in otherwise good health has experienced increasing episodes of the need to urinate during the night over the last year. DRE, urinalysis, and PSA blood test were completed. DRE findings were described as "a generous gland with no palpable nodules," and blood work revealed a high free/total PSA ratio. Given this information, what is likely causing this patient's symptoms?
Benign prostatic hyperplasia
Incidental bilateral thyroid nodules are noted on a 75 year old man who is undergoing carotid artery eval. Because the patient's wife recently died of breast cancer, the patient is concerned about cancer and has asked that these nodules be investigated. The nodule in the right lobe is noted to be mostly cystic but contains debris. The nodule in the left lobe contains multiple microcystic spaces separated by thin septa. These findings almost certainly suggest:
Bilateral benign thyroid nodules
A 10 year old boy is referred for scrotal sonography because on clinical examination only one of his testicles was palpable within the scrotal sac. A homogeneous ovoid mass is identified within the left inguinal canal. Surgical repair is recommended because this condition is associated with an increased risk for which of the following?
Cancer
A 30 year old man with gynecomastia, elevated hCG, and no palpable scrotal mass presents for a sonogram. The most significant sonographic finding includes a 1.5 cm heterogeneous mass within the right testicle. After orchiectomy, the prognosis remains poor because this type of cancer does not respond well to radiation and chemotherapy. the clinical and sonographic findings suggest which type of cancer?
Choriocarcinoma
A young woman presents with a painless, diffusely enlarged thyroid gland on physical examination. The sonographic appearance confirms diffuse enlargement with a micronodular pattern and increased vascularity. Which of the following conditions should the sonographer suggest to the interpreting physician?
Chronic thyroiditis
A 28 year old man undergoes clinical evaluation for a palpable mass in the left testicle. A sonogram reveals a solid, mostly hypoechoic mass including a shadowing calcification within the left testicle. A small amount of fluid also surrounds the left testicle. These findings are most suggestive of:
Embryonal cell carcinoma
Pelvic sonography in a 24 year old woman experiencing cyclic pain reveals a right adx mass. FU exam in 5 weeks demonstrates no change in appearance or size. What is the most likely dx?
Endometrioma
The sonographic images of a unilateral ovarian mass in a 25 year old woman with menstrual irregularities demonstrate a well-defined, 5.0 cm homogeneous unilocular mass containing low-level internal echoes and posterior acoustic enhancement. These findings are consistent with which ovarian pathology?
Endometrioma
The most common reason for elevated PSA is:
Enlarged prostate gland (BPH)
A 45 year old woman with mild pelvic discomfort undergoes a sonographic exam, and a 3.0 cm hypoechoic solid ovarian mass is discovered. The images also demonstrate ascites and marked attenuation posterior to the mass. Which of the following is the most likely dx?
Fibroma with Meigs' syndrome
A 32 year old man undergoes evaluation for infertility, and his physician orders a sonogram. The exam shows a collection of vessels measuring 2.0 to 2.5 mm in the left hemiscrotum. What Doppler findings within this collection of vessels would suggest a primary varicocele?
Further dilation and increased blood flow during Valsalva maneuver
A pediatric patient with elevated estrogen levels is referred for a pelvic sono after receiving a dx of precocious puberty. A solid mass is discovered in the left adx, with no evidence of a normal left ovary. What is the most likely dx?
Granulosa cell tumor
A 35 year old man presents with symptoms consistent with hyperthyroidism. He is referred for a neck U/S. The thyroid appears diffusely hypoechoic with a lobulated contour. No discrete nodules are seen. Color Doppler shows a dramatic increase in flow throughout the gland. What is the most likely cause for these findings?
Grave's disease
A 31 year old woman is referred for a sonogram after bilateral neck fullness is noted during a routine physical examination. The sonographic appearance of the thyroid gland is diffuse, hypoechoic enlargement of both lobes and the isthmus and "coarse" parenchyma. The sonographic features of the mass along with the patient's gender and age are suspicious for:
Hashimoto's thyroiditis
A 29 year old woman with LLQ pain is referred for a pelvic sonogram to rule out ovarian torsion. The images demonstrate a 4.0 cm left ovarian mass containing a reticular pattern of echoes with posterior enhancement and peripheral ovarian flow. A follow up sonogram performed two months later demonstrates a normal left ovary and a 2.5 cm dominant follicle on the right ovary. By the time of the follow up exam, the patient was asymptomatic. Which of the following is the most likely dx for the first exam?
Hemorrhagic ovarian cyst
The goal of PSA testing is to:
Identify early stage prostate cancers
A 10 year old girl presents with a very tender, high-midline neck mass. Her parents report feeling a "small lump" in this location since she was a baby, but it has enlarged and is now painful. The sonogram reveals an oval, 1.0 cm x 1.5 cm cystic mass with a thin wall and some internal debris. It is located approximately 3 cm superior to the thyroid isthmus. What is the most likely cause of this cystic mass?
Infected thyroglossal duct cyst
A 64 year old woman presents with the breast pathology shown. What is the likely dx?
Invasive Ductal Carcinoma
A 65 year old man presents for a mammogram and sonogram of a palpable retroareolar mass. What is the likely dx?
Invasive Ductal Carcinoma
A 65 year old man presents to the U/S department with a palpable RUOQ breast mass. Sonographically, a solid mass with posterior shadowing is seen at 10 OC 3CMFN. The findings are most consistent with which of the following?
Invasive Ductal Carcinoma
A 38 year old pregnant woman presents to the U/S dept with a rapidly enlarging, retroareolar, palpable mass. Sonographically, a microlobulated mass with internal blood flow is identified. The findings are most consistent with which of the following?
Invasive ductal carcinoma
A 32 year old woman in her first trimester of pregnancy presents for a breast sonogram because of a palpable lump. The sonogram reveals a large, predominantly cystic mass with multiple mural nodules. What is the most likely diagnosis.
Invasive ductal carcinoma without metastatic disease
A 53 year old woman is sent for a breast sonogram because of an abnormality seen only in one view of her recent mammogram. The sonogram reveals an area of distortion with thickened Cooper's ligaments and lymphadenopathy but does not show a discrete mass. The findings are most consistent with which of the following?
Invasive lobular carcinoma
A 50 year old woman palpates a compressible, mobile mass in her left breast. Sonographically, the mass, although palpable, is indistinguishable from the surrounding breast tissue. What would be the most likely dx?
Lipoma
An elderly man with a painless, palpable thyroid nodule is referred for thyroid sonography. Previous imaging studies have reported "a thyroid nodule with calcifications." The images are not available for review. A second sonogram is performed and reveals a 2 cm x 3 cm solid, hypoechoic nodule with a hypoechoic halo and disruption of peripheral, eggshell calcification. These findings make this nodule suspicious for:
Malignant nodule
A young man is referred to the U/S department for evaluation of a lateral neck mass that is nontender. The sonogram reveals a solitary thyroid nodule and multiple rounded masses that follow the carotid-jugular areas. Both the intrathyroidal and extrathyroidal masses contain microcalcifications. This should represent:
Metastatic thyroid cancer
A 63 year old man in apparent good health is seeking a second opinion for a thyroid nodule that was dx elsewhere. He was told that the nodule contained "psammoma bodies." This finding refers to:
Microcalcifications in a nodule
A 45 year old woman undergoes a pelvic exam because of a family hx of ovarian CA. Her CA125 levels are not elevated, and she is not experiencing any unusual symptoms other than weight gain. Sonography reveals a 15 cm, predominantly cystic mass with multiple septations, several papillary projections, and low-level echoes within the mass. Color doppler imaging reveals vascularity within the solid components. Given the patient's hx and sono findings, which of the following is the most likely dx?
Mucinous cystadenocarcinoma
A 52 year old man is dx with epididymo-orchitis after a sonographic eval. His clinical signs and symptoms most likely include which of the following?
Painful enlargement of the scrotum
A 55 year old woman undergoes a sonogram that reveals a retroareolar, solid mass within dilated ducts. She has evidence of skin edema and complaints of unilateral pink nipple discharge. What would be the most likely dx?
Papillary carcinoma
A 19 year old man with no significant medical hx is seen with a palpable nodule in the region of the right inferior lobe of the thyroid. On sonographic exam, the corresponding nodule is found to be slightly less echogenic than the surrounding thyroid parenchyma. There is a wide, irregular halo surrounding the nodule and fine punctate internal calcifications throughout the nodule. What is the most likely dx?
Papillary thyroid cancer
A 40 year old woman is referred for a sonogram of a palpable neck nodule that is nontender. High resolution sonography reveals a rounded hypoechoic lymph node that contains microcalcifications and measures 1.0 cm in length and 1.0 cm in AP dimension that correlates with the palpable lesion. A solid hypoechoic thyroid nodule on the same side of the neck also is noted. What is the most likely dx?
Papillary thyroid cancer
A postmenopausal patient with hypercalcemia and hypophosphatasia is referred for sonography of the neck. An oval-shaped, hypoechoic mass is seen posterior to the mid-lower right lobe of the thyroid. The clinical findings of hypercalcemia and hypophosphatasia along with the shape and location of the mass are most suggestive of:
Parathyroid adenoma
