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  • Question 1 - A 65-year-old woman is being evaluated one week after being diagnosed with a...

    Incorrect

    • A 65-year-old woman is being evaluated one week after being diagnosed with a deep vein thrombosis in her left leg. She has been administered low-molecular weight heparin for five days and has now been prescribed warfarin. The patient has a medical history of osteoporosis, breast cancer, type 2 diabetes, and depression. Which medication she is currently taking is most likely to have contributed to her increased risk of developing a deep vein thrombosis?

      Your Answer: Denosumab

      Correct Answer: Tamoxifen

      Explanation:

      Prior to initiating tamoxifen treatment, women should be informed about the elevated risk of VTE, which is one of the most significant side effects of the medication. Additionally, tamoxifen has been linked to an increased risk of endometrial cancer.

      Venous Thromboembolism: Common Risk Factors

      Venous thromboembolism (VTE) is a condition where blood clots form in the veins, which can lead to serious complications such as pulmonary embolism (PE). While there are many factors that can increase the risk of VTE, some are more common than others. These include malignancy, pregnancy, and the period following an operation. Other general risk factors include advancing age, obesity, family history of VTE, immobility, hospitalization, anaesthesia, and the use of central venous catheters. Underlying conditions such as heart failure, thrombophilia, and antiphospholipid syndrome can also increase the risk of VTE. Additionally, certain medications like the combined oral contraceptive pill, hormone replacement therapy, raloxifene, tamoxifen, and antipsychotics have been shown to be risk factors.

      It is important to note that while these factors can increase the risk of VTE, around 40% of patients diagnosed with a PE have no major risk factors.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 2 - A 50-year-old woman with known ovarian cancer presented to the emergency department complaining...

    Incorrect

    • A 50-year-old woman with known ovarian cancer presented to the emergency department complaining of severe right leg pain since yesterday. She had a hysterectomy 1 month ago.
      Which of the following is the most likely cause of her symptoms?

      Your Answer: Air embolus

      Correct Answer: DVT (deep-vein thrombosis)

      Explanation:

      After undergoing surgery, a woman presents with leg pain. Several potential causes are considered, including deep-vein thrombosis (DVT), acute limb ischaemia, air embolus, lumbar disc herniation, and paradoxical embolus. Based on the patient’s risk factors and symptoms, DVT is deemed the most likely diagnosis. Other causes are ruled out due to lack of relevant history or low probability. Understanding the possible causes of leg pain after urological surgery can help healthcare providers make an accurate diagnosis and provide timely treatment.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 3 - The physician is analyzing the routine blood test results for a 65-year-old woman...

    Incorrect

    • The physician is analyzing the routine blood test results for a 65-year-old woman who has a medical history of hypertension, type 2 diabetes mellitus, and giant cell arteritis. The following are some of the findings:
      - Hemoglobin (Hb) level of 133 g/L (normal range for females: 115-160 g/L; males: 135-180 g/L)
      - Mean cell volume (MCV) of 88 fl (normal range: 82-100 fl)
      - Platelet count of 390 * 109/L (normal range: 150-400 * 109/L)
      - White blood cell (WBC) count of 10.7 * 109/L (normal range: 4.0-11.0 * 109/L)
      - Neutrophil count of 8.4 * 109/L (normal range: 2.0-7.0 * 109/L)
      - Lymphocyte count of 1.4 * 109/L (normal range: 1.0-3.0 * 109/L)

      What could be the possible cause of these abnormal results?

      Your Answer: Ramipril

      Correct Answer: Prednisolone

      Explanation:

      The slightly high neutrophil count of 8.4 could be attributed to the use of prednisolone, a corticosteroid commonly used in the treatment of giant cell arteritis. This medication is known to induce neutrophilia. On the other hand, amlodipine, an antihypertensive drug, is not associated with neutrophilia but may cause leucopenia as a rare side effect. Dapagliflozin, a medication used in managing type 2 diabetes mellitus, does not affect white cell count, but it may cause frequent urinary tract infections, dizziness, and rash. Similarly, exenatide, a subcutaneous injection used in managing type 2 diabetes mellitus, is not known to cause changes in white cell count, but it may cause nausea, vomiting, and diarrhea.

      Understanding Corticosteroids and Their Side-Effects

      Corticosteroids are commonly prescribed therapies used to replace or augment the natural activity of endogenous steroids. They can be administered systemically or locally, depending on the condition being treated. However, the usage of corticosteroids is limited due to their numerous side-effects, which are more common with prolonged and systemic therapy.

      Glucocorticoid side-effects include impaired glucose regulation, increased appetite and weight gain, hirsutism, hyperlipidaemia, Cushing’s syndrome, moon face, buffalo hump, striae, osteoporosis, proximal myopathy, avascular necrosis of the femoral head, immunosuppression, increased susceptibility to severe infection, reactivation of tuberculosis, insomnia, mania, depression, psychosis, peptic ulceration, acute pancreatitis, glaucoma, cataracts, suppression of growth in children, intracranial hypertension, and neutrophilia.

      On the other hand, mineralocorticoid side-effects include fluid retention and hypertension. It is important to note that patients on long-term steroids should have their doses doubled during intercurrent illness. Longer-term systemic corticosteroids suppress the natural production of endogenous steroids, so they should not be withdrawn abruptly as this may precipitate an Addisonian crisis. The British National Formulary suggests gradual withdrawal of systemic corticosteroids if patients have received more than 40mg prednisolone daily for more than one week, received more than three weeks of treatment, or recently received repeated courses.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 4 - A 35-year-old woman presents to her GP with complaints of unexplained weight loss...

    Incorrect

    • A 35-year-old woman presents to her GP with complaints of unexplained weight loss and vague symptoms. During the examination, the GP detects a suspicious lump on her neck and refers her urgently to ENT. To expedite the process, the GP conducts several investigations and observes a significant elevation in calcitonin levels. Which type of cancer is associated with calcitonin as a tumor marker?

      Your Answer: Lymphoma

      Correct Answer: Medullary thyroid cancer

      Explanation:

      The presence of calcitonin in the blood can indicate the presence of medullary thyroid cancer, as this type of cancer originates from the parafollicular cells that produce calcitonin. Therefore, calcitonin is considered a tumor marker for medullary thyroid cancer.

      Understanding Tumour Markers

      Tumour markers are substances that can be found in the blood, urine, or tissues of people with cancer. They are often used to help diagnose and monitor cancer, as well as to determine the effectiveness of treatment. Tumour markers can be divided into different categories, including monoclonal antibodies against carbohydrate or glycoprotein tumour antigens, tumour antigens, enzymes, and hormones.

      Monoclonal antibodies are used to target specific tumour antigens, which are proteins or other molecules that are found on the surface of cancer cells. Some common tumour markers include CA 125 for ovarian cancer, CA 19-9 for pancreatic cancer, and CA 15-3 for breast cancer. However, it is important to note that tumour markers usually have a low specificity, meaning that they can also be found in people without cancer.

      Tumour antigens are proteins that are produced by cancer cells and can be detected in the blood or tissues of people with cancer. Some examples of tumour antigens include prostate specific antigen (PSA) for prostatic carcinoma, alpha-feto protein (AFP) for hepatocellular carcinoma and teratoma, and carcinoembryonic antigen (CEA) for colorectal cancer.

      Enzymes and hormones can also be used as tumour markers. For example, alkaline phosphatase and neurone specific enolase are enzymes that can be elevated in people with cancer, while hormones such as calcitonin and ADH can be used to detect certain types of cancer.

      In summary, tumour markers are an important tool in the diagnosis and monitoring of cancer. However, they should be used in conjunction with other diagnostic tests and imaging studies, as they are not always specific to cancer and can also be elevated in people without cancer.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 5 - A 30-year-old man presents approximately 2 weeks after a viral illness with petechiae,...

    Incorrect

    • A 30-year-old man presents approximately 2 weeks after a viral illness with petechiae, easy bruising, gum bleeding and lesions of the oral mucosa and tongue. He has no personal or family history of note and is not taking any medication. Physical examination is normal, except for petechiae, bruising and oral lesions. An image of the patient's tongue is shown below. What is the most appropriate initial investigation/management option for this clinical scenario and image?

      Your Answer: Surgical correction

      Correct Answer: Full blood count

      Explanation:

      Diagnosis and Investigation of Immune Thrombocytopenic Purpura (ITP)

      Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by antiplatelet antibodies and immune-mediated platelet destruction, leading to a decrease in peripheral platelet count and an increased risk of severe bleeding. The following are the recommended diagnostic and investigative measures for ITP:

      Full Blood Count: An urgent first-line investigation with a full blood count is essential to confirm platelet count, which is the hallmark of ITP. Anaemia and/or neutropenia may indicate other diseases. On peripheral blood smear, the morphology of red blood cells and leukocytes is normal, while the morphology of platelets is usually normal, with varying numbers of large platelets.

      Surgical Correction: Surgical management is not the first-line intervention for ITP and is reserved for later use in patients with acute ITP, for whom splenectomy usually results in rapid, complete, and life-long clinical remission. Its results in patients with chronic ITP are typically less predictable.

      Aspiration for Cytology: Further investigations, such as bone marrow aspiration, could be considered for later use in patients with ITP, such as adults older than 60 years, to exclude myelodysplastic syndrome or leukemia.

      Excision Biopsy: Further investigations, such as a biopsy, could be considered further down the line, such as in adults older than 60 years, to exclude myelodysplastic syndrome or leukemia.

      None: If a patient presents with purpura/petechiae on the tongue and buccal mucosa, urgent haematological referral is warranted, and not undertaking any further investigations would be inappropriate.

      Diagnosis and Investigation of Immune Thrombocytopenic Purpura (ITP)

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 6 - A 55-year-old man comes to the Genetic Counselling Clinic after being diagnosed with...

    Correct

    • A 55-year-old man comes to the Genetic Counselling Clinic after being diagnosed with colon cancer through the national bowel cancer screening programme. He was adopted as a child and has no knowledge of his biological family's medical history.
      What is the most suitable genetic disorder to test for in this individual?

      Your Answer: Lynch syndrome

      Explanation:

      Lynch syndrome is a genetic condition that increases the risk of developing colorectal cancer by over 80%. It also raises the risk of other cancers such as endometrial, stomach, breast, ovarian, small bowel, pancreatic, prostate, urinary tract, kidney, and liver cancer. Genetic testing is recommended for anyone diagnosed with colorectal cancer, regardless of age.

      Breast cancer (BRCA) mutations are inherited in an autosomal dominant pattern and significantly increase the risk of developing breast, ovarian, prostate, and pancreatic cancer. These cancers tend to occur at a younger age than in the general population. While there is a possible link to colorectal pathology, other genetic syndromes should be considered first when looking for a genetic cause of cancer.

      Cowden syndrome is a rare genetic condition characterized by benign growths called hamartomas on various parts of the body. It increases the risk of developing breast, thyroid, or endometrial cancer but has no association with colorectal cancer.

      Familial adenomatous polyposis is an autosomal dominant condition that causes widespread colorectal adenomas, with polyps usually developing in late childhood. This greatly increases the risk of colorectal cancer, and prophylactic colectomy is often performed. Screening is recommended for those with an affected first-degree relative or multiple polyps detected on colonoscopy.

      Von Hippel-Landau (VHL) syndrome is an autosomal dominant condition that causes multiple benign tumors and cysts in various parts of the body, including the brain, spinal cord, eyes, adrenals, kidneys, and pancreas. It increases the risk of renal and pancreatic cancer but has no association with colorectal cancer.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 7 - A 30-year-old woman has just been diagnosed with Hodgkin's lymphoma and has started...

    Incorrect

    • A 30-year-old woman has just been diagnosed with Hodgkin's lymphoma and has started her first day of chemotherapy. However, she has been feeling unwell since then and her U&E results show abnormalities such as hyperkalaemia, hyperphosphataemia, and hypocalcaemia. What prophylaxis is used to prevent the complication that this woman has experienced?

      Your Answer: Dexamethasone

      Correct Answer: Allopurinol

      Explanation:

      Tumour lysis syndrome is characterized by high levels of potassium and phosphate, as well as low levels of calcium. This is evident in the case history of a lymphoma patient who has started chemotherapy. Allopurinol is the most commonly used prophylaxis, with rasburicase as an alternative. Diuretics are not recommended due to the potential to exacerbate acute kidney injury. It is important to note that steroids and radiotherapy are not common causes of tumour lysis syndrome.

      Understanding Tumour Lysis Syndrome

      Tumour lysis syndrome (TLS) is a life-threatening condition that can occur during the treatment of high-grade lymphomas and leukaemias. Although it can happen without chemotherapy, it is usually triggered by the introduction of combination chemotherapy. Patients at high risk of TLS should be given prophylactic medication such as IV allopurinol or IV rasburicase to prevent the potentially deadly effects of tumour cell lysis. Rasburicase is a recombinant version of urate oxidase, an enzyme that metabolizes uric acid to allantoin, which is more easily excreted by the kidneys. Patients in lower-risk groups should be given oral allopurinol during chemotherapy cycles to avoid the condition. However, rasburicase and allopurinol should not be given together in the management of tumour lysis syndrome as this reduces the effect of rasburicase.

      TLS occurs when tumour cells break down and release chemicals into the body, leading to high levels of potassium and phosphate and a low level of calcium. It should be suspected in any patient presenting with an acute kidney injury in the presence of high phosphate and uric acid levels. From 2004, TLS has been graded using the Cairo-Bishop scoring system, which considers abnormality in two or more of the following within three days before or seven days after chemotherapy: uric acid, potassium, phosphate, and calcium. Clinical tumour lysis syndrome is when laboratory tumour lysis syndrome is present along with increased serum creatinine, cardiac arrhythmia or sudden death, or seizure.

      In summary, understanding tumour lysis syndrome is critical in the treatment of high-grade lymphomas and leukaemias. Prophylactic medication can be given to prevent the potentially deadly effects of tumour cell lysis, and the Cairo-Bishop scoring system can be used to grade the severity of the condition. Early detection and management of TLS can improve patient outcomes and prevent complications.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 8 - An 88-year-old man with known metastatic prostate cancer is brought to the emergency...

    Incorrect

    • An 88-year-old man with known metastatic prostate cancer is brought to the emergency department confused. He is unable to provide further history but reports feeling generally unwell. Upon examination, his chest is clear, heart sounds normal, and abdomen is soft with no tenderness. The initial blood tests reveal:
      - Na+ 134 mmol/l
      - K+ 4.7 mmol/l
      - Urea 7.8 mmol/l
      - Creatinine 104 µmol/l
      - Adjusted Ca2+ 3.5 mmol/l
      - Mg2+ 0.81 mmol/l

      What would be your initial treatment plan?

      Your Answer: IV hydrocortisone

      Correct Answer: IV fluids

      Explanation:

      Severe cases (>3.0 mmol/l) requiring admission are often caused by malignancy, as seen in this patient. Treatment involves obtaining IV access and conducting appropriate biochemistry tests to check for other electrolyte abnormalities. A chest x-ray and ECG should also be performed. The first intervention should be fluid resuscitation to replace the deficit and maintain hydration, which may require large volumes (3-4 litres in the first 24 hours). If hypercalcaemia persists, IV bisphosphonates like zoledronate or pamidronate can be administered. Specific anticancer therapies can be considered after this.

      Managing Hypercalcaemia

      Hypercalcaemia is a condition where there is an excess of calcium in the blood. The initial management of hypercalcaemia involves rehydration with normal saline, typically 3-4 litres per day. This helps to flush out the excess calcium from the body. Once rehydration is achieved, bisphosphonates may be used to further lower the calcium levels. These drugs take 2-3 days to work, with maximal effect being seen at 7 days.

      Calcitonin is another option for managing hypercalcaemia. It works quicker than bisphosphonates but is less commonly used due to its short duration of action. Steroids may be used in sarcoidosis, a condition that can cause hypercalcaemia.

      Loop diuretics such as furosemide may also be used in hypercalcaemia, particularly in patients who cannot tolerate aggressive fluid rehydration. However, they should be used with caution as they may worsen electrolyte derangement and volume depletion.

      In summary, the management of hypercalcaemia involves rehydration with normal saline followed by the use of bisphosphonates or other medications depending on the underlying cause of the condition. It is important to monitor electrolyte levels and adjust treatment accordingly to prevent complications.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 9 - A 50-year-old woman is found to have a proximal deep vein thrombosis four...

    Correct

    • A 50-year-old woman is found to have a proximal deep vein thrombosis four weeks after undergoing surgery for a broken ankle. She is prescribed warfarin (initially accompanied by low molecular weight heparin) with a desired INR range of 2.0-3.0. What other treatment option should be presented to this patient?

      Your Answer: No additional treatment other than routine care

      Explanation:

      Post-Thrombotic Syndrome: A Complication of Deep Vein Thrombosis

      Post-thrombotic syndrome is a clinical syndrome that may develop following a deep vein thrombosis (DVT). It is caused by venous outflow obstruction and venous insufficiency, which leads to chronic venous hypertension. Patients with post-thrombotic syndrome may experience painful, heavy calves, pruritus, swelling, varicose veins, and venous ulceration.

      In the past, compression stockings were offered to patients with DVT to reduce the risk of post-thrombotic syndrome. However, current recommendations state that elastic graduated compression stockings should not be used to prevent post-thrombotic syndrome or VTE recurrence after a proximal DVT. This recommendation does not cover the use of elastic stockings for the management of leg symptoms after DVT.

      Once post-thrombotic syndrome has developed, compression stockings are a recommended treatment. Other recommendations include keeping the leg elevated. It is important for healthcare providers to recognize the potential complications of DVT and to provide appropriate management to prevent the development of post-thrombotic syndrome.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 10 - A 72-year-old man presents to the Haematology Clinic with symptoms of bone pain...

    Incorrect

    • A 72-year-old man presents to the Haematology Clinic with symptoms of bone pain and anaemia. The medical team suspects multiple myeloma (MM) and orders a set of blood tests, including a full blood count, urea, serum creatinine and electrolytes, serum calcium, albumin, serum protein electrophoresis, serum-free light-chain assay, and serum beta-2 microglobulin. The team also plans to perform an imaging investigation to look for osteolytic lesions. What initial scan should be ordered?

      Your Answer: Whole-body magnetic resonance imaging (MRI)

      Correct Answer: Whole-body low-dose CT (WBLD-CT)

      Explanation:

      When investigating suspected multiple myeloma (MM), it is crucial to use whole-body low-dose CT (WBLD-CT) imaging. This method is more effective than traditional radiology in detecting lytic lesions and should be the first option if available. Lesions with a diameter of 5mm or more are considered positive. If WBLD-CT and MRI fail to show lesions with a strong clinical indication, an FDG-PET or FDG-PET-CT can be used to detect bone lesions. During treatment follow-up, an FDG-PET-CT can detect active lesions and provide prognostic information. While a skeletal survey (X-ray) is less sensitive than WBLD-CT, it can still be useful. If suspicion remains high for MM despite negative WBLD-CT or skeletal survey results, a whole-body MRI should be performed. This method can detect focal lesions and bone marrow infiltration and may also be of prognostic value in asymptomatic patients. The presence of focal lesions is a strong predictor of progression to symptomatic MM.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 11 - A 56-year-old man with a history of epilepsy and ischaemic heart disease presents...

    Incorrect

    • A 56-year-old man with a history of epilepsy and ischaemic heart disease presents to the clinic with a complaint of feeling lethargic for the past 3 months. Upon conducting blood tests, the following results were obtained: Hb 9.6 g/dl, MCV 123 fl, Plt 164 * 109/l, WCC 4.6 *109/l. Which medication is the most likely cause of his symptoms?

      Your Answer: Clopidogrel

      Correct Answer: Phenytoin

      Explanation:

      Phenytoin: Mechanism of Action and Adverse Effects

      Phenytoin is a medication used to manage seizures. Its mechanism of action involves binding to sodium channels, which increases their refractory period. However, the drug is associated with a large number of adverse effects, which can be categorized as acute, chronic, idiosyncratic, and teratogenic. Acute effects include dizziness, diplopia, nystagmus, slurred speech, ataxia, confusion, and seizures. Chronic effects include gingival hyperplasia, hirsutism, coarsening of facial features, drowsiness, megaloblastic anemia, peripheral neuropathy, enhanced vitamin D metabolism causing osteomalacia, lymphadenopathy, and dyskinesia. Idiosyncratic effects include fever, rashes, hepatitis, Dupuytren’s contracture, aplastic anemia, and drug-induced lupus. Teratogenic effects are associated with cleft palate and congenital heart disease. Although routine monitoring of phenytoin levels is not necessary, trough levels should be checked before dosing in cases of dose adjustment, suspected toxicity, or non-adherence to the prescribed medication.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 12 - A 32-year-old man presents to his General Practitioner having been feeling unwell for...

    Incorrect

    • A 32-year-old man presents to his General Practitioner having been feeling unwell for a few days with a persistent cough.
      Investigations:
      Investigation Result Normal value
      Haemoglobin (Hb) 130 g/l 120–160 g/l
      White cell count (WCC) 18 × 109/l 4.5–11.0 × 109/l
      Neutrophils 12 × 109/l 2.0–7.5 × 109/l
      Platelets (PLT) 450 × 109/l 150–400 × 109/l
      A blood film shows atypical lymphocytes.
      What is the most likely diagnosis?

      Your Answer: Cytomegalovirus infection (CMV)

      Correct Answer: Acute bacterial infection

      Explanation:

      Differential Diagnosis for a Patient with Abnormal Full Blood Count Results

      When a patient presents with abnormal full blood count (FBC) results, it is important to consider a range of potential diagnoses. In this case, the patient has neutrophilia and atypical lymphocytes, indicating an acute bacterial infection. Other potential diagnoses, such as chronic myeloid leukaemia, tuberculosis, cytomegalovirus infection, and pregnancy, can be ruled out based on the absence of key symptoms and blood film findings. Clinical prediction scores can be used to aid in antibiotic stewardship. It is important to consider all potential diagnoses and conduct further testing as needed to ensure accurate diagnosis and appropriate treatment.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 13 - A 42-year-old female presents to her primary care physician with a 2-month history...

    Incorrect

    • A 42-year-old female presents to her primary care physician with a 2-month history of progressive fatigue. She has a medical history of type-1 diabetes mellitus. Her doctor orders a full blood count, which reveals a low Hb and high mean cell volume. The platelet and WBC counts are within normal limits. Which antibody test should be performed to assist in the diagnosis?

      Your Answer: Gastric parietal cell antibodies

      Correct Answer: Intrinsic-factor antibodies

      Explanation:

      When investigating vitamin B12 deficiency, intrinsic factor antibodies are more useful than gastric parietal cell antibodies due to the low specificity of the latter. Megaloblastic anaemia, characterized by low haemoglobin and raised mean cell volume, can be caused by B12 or folate deficiency and may indicate pernicious anaemia, an autoimmune condition that impairs B12 uptake. Intrinsic factor antibodies are more specific for pernicious anaemia and are commonly used to confirm the diagnosis along with a blood test. Anti-histone antibodies are involved in drug-induced lupus caused by certain drugs. Anti-TTG antibodies are used to screen for coeliac disease, which can cause microcytic anaemia due to iron deficiency from malabsorption. While gastric parietal cell antibodies are linked to pernicious anaemia, their low specificity makes them less reliable for diagnosis compared to intrinsic factor antibodies.

      Understanding Pernicious Anaemia

      Pernicious anaemia is a condition that results in vitamin B12 deficiency due to an autoimmune disorder affecting the gastric mucosa. The term pernicious means causing harm in a gradual or subtle way, and this is reflected in the often subtle symptoms and delayed diagnosis of the condition. While pernicious anaemia is the most common cause of vitamin B12 deficiency, other causes include atrophic gastritis, gastrectomy, and malnutrition.

      The pathophysiology of pernicious anaemia involves antibodies to intrinsic factor and/or gastric parietal cells. These antibodies can bind to intrinsic factor, blocking the vitamin B12 binding site, or reduce acid production and cause atrophic gastritis. This leads to reduced intrinsic factor production and reduced vitamin B12 absorption, which can result in megaloblastic anaemia and neuropathy.

      Risk factors for pernicious anaemia include being female, middle to old age, and having other autoimmune disorders such as thyroid disease, type 1 diabetes mellitus, Addison’s, rheumatoid arthritis, and vitiligo. It is also more common in individuals with blood group A.

      Symptoms of pernicious anaemia include anaemia features such as lethargy, pallor, and dyspnoea, as well as neurological features such as peripheral neuropathy and subacute combined degeneration of the spinal cord. Neuropsychiatric features such as memory loss, poor concentration, confusion, depression, and irritability may also be present, along with mild jaundice and glossitis.

      Diagnosis of pernicious anaemia involves a full blood count, vitamin B12 and folate levels, and testing for antibodies such as anti intrinsic factor antibodies and anti gastric parietal cell antibodies. Treatment involves vitamin B12 replacement, usually given intramuscularly, and folic acid supplementation may also be required. Complications of pernicious anaemia include an increased risk of gastric cancer.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 14 - A 35-year-old male is diagnosed with macrocytic anaemia. The patient is suspected to...

    Incorrect

    • A 35-year-old male is diagnosed with macrocytic anaemia. The patient is suspected to have a folate deficiency.
      Which of the following statements is most accurate regarding folate deficiency?

      Your Answer: It causes abnormal neurological findings indistinguishable from those associated with vitamin B12 deficiency

      Correct Answer: It increases the risk of a neural tube defect in the foetus.

      Explanation:

      Understanding Folic Acid Deficiency: Causes and Effects

      Folic acid deficiency is a serious condition that can have detrimental effects on fetal development and overall health. In this article, we will explore the causes and effects of folic acid deficiency.

      Causes of Folic Acid Deficiency

      Reduced intake is the most common cause of folic acid deficiency. This can occur due to an inadequate diet or malabsorption. Excessive urinary production, drugs, and excessive requirements can also contribute to folic acid deficiency.

      Effects of Folic Acid Deficiency

      Folic acid deficiency is associated with neural tube defects in the fetus, which can lead to serious developmental issues. It can also increase the risk of abruption of the placenta and spontaneous abortion. In severe cases, megaloblastic anemia can develop, but this typically takes more than two years after complete cessation of folic acid intake.

      Treatment of Folic Acid Deficiency

      Methotrexate-induced folic acid deficiency can be corrected with concomitant folic acid therapy. Folinic acid is also effective in treating toxicity caused by methotrexate. Intestinal bacterial overgrowth is not a common cause of folic acid deficiency.

      Distinguishing Folic Acid Deficiency from Vitamin B12 Deficiency

      Abnormal neurological findings are associated with vitamin B12 deficiency, but not necessarily with folic acid deficiency. Patients with megaloblastic anemia typically do not exhibit neurological symptoms, which suggests that folic acid deficiency is the cause.

      In conclusion, folic acid deficiency is a serious condition that can have significant effects on fetal development and overall health. It is important to understand the causes and effects of this condition in order to prevent and treat it effectively.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 15 - A 14-year-old girl is referred to haematology due to heavy and prolonged periods...

    Incorrect

    • A 14-year-old girl is referred to haematology due to heavy and prolonged periods that have not responded well to tranexamic acid and the combined oral contraceptive pill. Her blood tests reveal Hb of 10.3 g/dl, Plt of 239 * 109/l, WBC of 6.5 * 109/l, PT of 12.9 secs, and APTT of 37 secs. What is the probable diagnosis?

      Your Answer: Disseminated intravascular coagulation

      Correct Answer: Von Willebrand's disease

      Explanation:

      Understanding Von Willebrand’s Disease

      Von Willebrand’s disease is a common inherited bleeding disorder that is usually passed down in an autosomal dominant manner. It behaves like a platelet disorder, with symptoms such as nosebleeds and heavy menstrual bleeding being common, while joint and muscle bleeding are rare. The disease is caused by a deficiency or abnormality in von Willebrand factor, a large glycoprotein that promotes platelet adhesion to damaged endothelium and acts as a carrier molecule for factor VIII.

      There are three types of Von Willebrand’s disease. Type 1 is the most common and is characterized by a partial reduction in von Willebrand factor. Type 2 is further divided into four subtypes, each with a different abnormality in the von Willebrand factor. Type 3 is the most severe form and is caused by a total lack of von Willebrand factor, inherited in an autosomal recessive manner.

      Diagnosis of Von Willebrand’s disease involves tests such as a prolonged bleeding time, APTT, factor VIII levels, and platelet aggregation with ristocetin. Management options include tranexamic acid for mild bleeding, desmopressin to raise levels of von Willebrand factor, and factor VIII concentrate. While there is no clear correlation between symptomatic presentation and type of Von Willebrand’s disease, common themes among patients include excessive mucocutaneous bleeding, bruising in the absence of trauma, and menorrhagia in females.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 16 - A 68-year-old woman presents to her General Practitioner with worsening back pain over...

    Incorrect

    • A 68-year-old woman presents to her General Practitioner with worsening back pain over a period of several months. She also feels generally unwell. She is exhausted, has a dry mouth and is constipated.
      Investigations:
      Investigation Result Normal value
      Haemoglobin (Hb) 93 g/l 115–155 g/l
      White cell count (WCC) 6.4 × 109/l 4.0–11.0 × 109/l
      Platelets (PLT) 380 × 109/l 150–400 × 109/l
      Mean corpuscular volume (MCV) 100 fl 80–100 fl
      Erythrocyte sedimentation rate (ESR) 94 mm/h < 15 mm/h
      Estimated glomerular filtration rate (eGFR) 32 ml/min per 1.73 m2 > 90 ml/min per 1.73 m2
      Corrected calcium (Ca2+) 2.8 mmol/l 2.2–2.6 mmol/l
      What is the most appropriate initial investigation to confirm the diagnosis in this patient?

      Your Answer: Carcinoembryonic antigen (CEA)

      Correct Answer: Serum electrophoresis

      Explanation:

      Tumor Markers and Serum Electrophoresis: Their Role in Diagnosing Multiple Myeloma

      Multiple myeloma is a malignant disease of plasma cells that can cause renal failure, normocytic anemia, hypercalcemia, and raised ESR. To diagnose multiple myeloma, serum electrophoresis, serum-free light-chain assay, and assessment of urinary Bence Jones protein are recommended. Serum electrophoresis confirms the presence of a paraprotein, which may be due to myeloma or MGUS. Further tests, such as bone marrow biopsy, magnetic resonance imaging, and immunofixation of serum and urine, are usually carried out in secondary care to confirm the diagnosis.

      Carcinoembryonic antigen (CEA), CA 19-9, serum lactate dehydrogenase (LDH), and CA125 are tumor markers used to monitor disease progression in various cancers. However, there is no role for these markers in diagnosing multiple myeloma. CEA is mainly used to monitor the progress of treatment for colonic cancer, while CA 19-9 is used to monitor disease progression in pancreatic cancer. LDH is raised in lymphoma and certain types of testicular cancer, and CA125 is used in the diagnosis of ovarian cancer. Therefore, these markers are not useful in diagnosing multiple myeloma.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 17 - A 70-year-old man with metastatic prostate cancer is experiencing increased pain and vomiting...

    Incorrect

    • A 70-year-old man with metastatic prostate cancer is experiencing increased pain and vomiting while taking morphine sulphate 60mg bd. It has been decided to switch to subcutaneous administration. What is the recommended 24-hour dose of morphine for continuous subcutaneous infusion?

      Your Answer: 20mg

      Correct Answer: 60mg

      Explanation:

      In this scenario, the BNF suggests administering half of the oral dose of morphine when using the parenteral route (subcutaneous, intramuscular, or intravenous). If the patient is no longer able to swallow, a continuous subcutaneous infusion of morphine is typically given.

      Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting treatment with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects are usually transient, such as nausea and drowsiness, but constipation can persist. In addition to strong opioids, bisphosphonates, and radiotherapy, denosumab may be used to treat metastatic bone pain.

      Overall, the guidelines recommend starting with regular oral morphine and adjusting the dose as needed. Laxatives should be prescribed to prevent constipation, and antiemetics may be needed for nausea. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and referral to a clinical oncologist should be considered. Conversion factors between opioids are provided, and the next dose should be increased by 30-50% when adjusting the dose. Opioid side-effects are usually transient, but constipation can persist. Denosumab may also be used to treat metastatic bone pain.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 18 - A 78-year-old man with known metastatic prostate cancer presents to his General Practitioner...

    Correct

    • A 78-year-old man with known metastatic prostate cancer presents to his General Practitioner with generalised pain. He states that he has always had aches and pains from old age, but that this is different: he can feel the pain particularly in his back at night.
      What is the most likely site to be involved in bone metastasis in this patient?

      Your Answer: Spine

      Explanation:

      Common Sites of Metastatic Spread in Bone

      Metastatic spread to the bone is a common occurrence in many types of cancer. The following are some of the most common sites of metastases in bone:

      Spine: The spine is the most common site for bony metastases, with spread often found from a range of solid and haematological cancers, as well as infectious diseases such as tuberculosis.

      Ribs: While breast cancer is known to spread to the ribs, this is not the case for many other cancers.

      Pelvis: The pelvis is a prevalent site of metastatic spread occurring mostly from the prostate, breast, kidney, lung, and thyroid cancer.

      Skull: Skull metastases are seen in 15-25% of all cancer patients and tend to include those from the breast, lungs, prostate, and thyroid, as well as melanoma.

      Long bones: Localised bone pain is a red flag for metastatic spread to any of the long bones such as the femur and humerus. Breast, prostate, renal, thyroid, and lung cancers frequently metastasize to these areas.

      Overall, understanding the common sites of metastatic spread in bone can help with early detection and treatment of cancer.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 19 - A 15-year-old Afro-Caribbean girl arrives at the emergency department with complaints of left...

    Correct

    • A 15-year-old Afro-Caribbean girl arrives at the emergency department with complaints of left hip pain. There is no history of recent trauma, but the patient has a medical history of sickle cell disease and has been admitted multiple times in the past with similar symptoms. What is the appropriate management plan for this patient?

      Your Answer: Painkillers, oxygen and IV fluids

      Explanation:

      To effectively manage sickle cell crisis, it is essential to administer analgesia, oxygen, and IV fluids. In addition, antibiotics may be necessary if an infection is suspected, and transfusion may be required if the patient’s Hb levels are low.

      It is not advisable to simply monitor patients without providing any treatment, as this would result in significant pain and discomfort.

      The most effective approach involves a combination of oxygen, fluids, and analgesia. Pain management is crucial, as the blockage of blood vessels by sickle-shaped red blood cells prevents the delivery of oxygen and blood to the tissues, resulting in pain. Oxygen supplementation is necessary to alleviate this pain, and IV fluids can help to slow or halt the sickling process. None of these components alone would be sufficient in managing pain, but together they form a comprehensive approach to pain management.

      Managing Sickle-Cell Crises

      Sickle-cell crises can be managed through various interventions. General management includes providing analgesia, rehydration, and oxygen. Antibiotics may also be considered if there is evidence of infection. Blood transfusion may be necessary for severe or symptomatic anemia, pregnancy, or pre-operative cases. However, it is important not to rapidly reduce the percentage of Hb S containing cells.

      In cases of acute vaso-occlusive crisis, such as stroke, acute chest syndrome, multiorgan failure, or splenic sequestration crisis, exchange transfusion may be necessary. This involves rapidly reducing the percentage of Hb S containing cells. It is important to note that the management of sickle-cell crises should be tailored to the individual patient’s needs and medical history. Proper management can help alleviate symptoms and prevent complications.

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      • Haematology/Oncology
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  • Question 20 - A 72-year-old man visits his doctor complaining of fatigue, back pain, and frequent...

    Incorrect

    • A 72-year-old man visits his doctor complaining of fatigue, back pain, and frequent urination and thirst for the past 3 months. Upon examination, the doctor orders a urine protein electrophoresis and a serum-free light-chain assay, which confirm the diagnosis. What is the most probable result on the patient's blood film?

      Your Answer: Heinz bodies

      Correct Answer: Rouleaux formation

      Explanation:

      Rouleaux formation is a characteristic finding in multiple myeloma, which is a condition that presents with symptoms such as hypercalcaemia, anaemia, and back pain. Diagnosis of myeloma involves urine protein electrophoresis and serum-free light-chain assay. Rouleaux formation is observed as stacked RBCs on a blood film, resulting from an increase in acute-phase proteins that are positively charged and attract negatively charged RBCs. It is important to note that rouleaux formation is not exclusive to myeloma and can be seen in various inflammatory conditions. The erythrocyte sedimentation rate blood test measures this mechanism clinically. Heinz bodies, which are caused by oxidative stress and denaturation of haemoglobin, are not associated with myeloma but are seen in G6PD deficiency. Howell-Jolly bodies, which are present in hyposplenic or asplenic disorders, and an increased number of reticulocytes, which indicate increased RBC turnover, are also not characteristic of myeloma.

      Understanding Multiple Myeloma: Features and Investigations

      Multiple myeloma is a type of blood cancer that occurs due to genetic mutations in plasma cells. It is commonly diagnosed in individuals over the age of 70. The disease is characterized by the acronym CRABBI, which stands for Calcium, Renal, Anaemia, Bleeding, Bones, and Infection. Patients with multiple myeloma may experience hypercalcemia, renal damage, anaemia, bleeding, bone pain, and increased susceptibility to infections. Other symptoms may include amyloidosis, carpal tunnel syndrome, neuropathy, and hyperviscosity.

      To diagnose multiple myeloma, doctors may perform a variety of tests, including blood tests, protein electrophoresis, bone marrow aspiration, and imaging studies. Blood tests may reveal anaemia, elevated levels of M protein in the blood or urine, and renal failure. Protein electrophoresis can detect raised concentrations of monoclonal IgA/IgG proteins in the serum or urine. Bone marrow aspiration confirms the diagnosis if the number of plasma cells is significantly raised. Imaging studies, such as whole-body MRI or X-rays, can detect osteolytic lesions or the characteristic rain-drop skull pattern.

      The diagnostic criteria for multiple myeloma require one major and one minor criteria or three minor criteria in an individual who has signs or symptoms of the disease. Major criteria include plasmacytoma, 30% plasma cells in a bone marrow sample, and elevated levels of M protein in the blood or urine. Minor criteria include 10% to 30% plasma cells in a bone marrow sample, minor elevations in the level of M protein in the blood or urine, osteolytic lesions, and low levels of antibodies not produced by the cancer cells in the blood.

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      • Haematology/Oncology
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  • Question 21 - A 49-year-old homeless man has been admitted to the emergency department after collapsing...

    Incorrect

    • A 49-year-old homeless man has been admitted to the emergency department after collapsing with sudden onset left side hemiparesis and facial droop. A CT scan has revealed a large intracerebral haemorrhage, which is likely to have occurred spontaneously. The patient's medical and family history is unknown, but you suspect that coagulopathy may be the cause of the spontaneous bleed. The clotting profile and specific clotting factor levels are as follows:

      - PT prolonged
      - APTT prolonged
      - Factor VIII high
      - Factor II low
      - Factor V low
      - Factor VII low
      - Factor IX low
      - Von Willebrand factor high

      What is the most probable reason for the coagulopathy?

      Your Answer: Haemophilia B

      Correct Answer: Liver failure

      Explanation:

      It is highly probable that the individual is suffering from liver failure as all clotting factors, except for factor VIII, are below normal levels. In cases of liver failure, both PT and APTT may be prolonged. Haemophilia A and B are unlikely as they result in deficiencies of specific clotting factors, whereas Von Willebrand disease may have low levels of Von Willebrand factor but the other factors remain unaffected. Disseminated intravascular coagulation, on the other hand, leads to depletion of all clotting factors.

      Coagulopathy in Liver Disease: Paradoxical Supra-normal Factor VIII and Increased Thrombosis Risk

      In liver failure, the levels of all clotting factors decrease except for factor VIII, which paradoxically increases. This is because factor VIII is synthesized not only in hepatic endothelial cells but also in endothelial cells throughout the body. Moreover, good hepatic function is required for the rapid clearance of activated factor VIII from the bloodstream, leading to further increases in circulating factor VIII. Despite conventional coagulation studies suggesting an increased risk of bleeding, patients with chronic liver disease are paradoxically at an increased risk of thrombosis formation. This is due to several factors, including reduced synthesis of natural anticoagulants such as protein C, protein S, and anti-thrombin, which are all essential for preventing thrombosis.

      Reference
      Tripodi et al. An imbalance of pro- vs anti-coagulation factors in plasma from patients with cirrhosis. Gastroenterology. 2009 Dec;137(6):2105-11.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 22 - A 67-year-old woman presents to the breast clinic with an abnormal mammogram and...

    Incorrect

    • A 67-year-old woman presents to the breast clinic with an abnormal mammogram and a small fixed lump in her right breast. What type of breast cancer is most frequently encountered?

      Your Answer: Inflammatory breast cancer

      Correct Answer: Invasive ductal carcinoma (no special type)

      Explanation:

      The most prevalent form of breast cancer is invasive ductal carcinoma, without any distinctive features.

      Breast Cancer: Understanding Types and Classification

      Breast cancer can be classified based on the type of tissue it originates from, namely duct or lobular tissue. Ductal carcinoma and lobular carcinoma are the two main types of breast cancer, which can further be classified as either carcinoma-in-situ or invasive. Invasive ductal carcinoma, also known as No Special Type, is the most common type of breast cancer. Lobular carcinoma and other rare types of breast cancer are classified as Special Type.

      Apart from the common types, there are several rarer types of breast cancer, including medullary breast cancer, mucinous breast cancer, tubular breast cancer, adenoid cystic carcinoma of the breast, metaplastic breast cancer, lymphoma of the breast, basal type breast cancer, phyllodes or cystosarcoma phyllodes, and papillary breast cancer. Paget’s disease of the nipple is another type of breast cancer that is associated with an underlying mass lesion. Inflammatory breast cancer is a rare type of breast cancer that results in an inflamed appearance of the breast due to cancerous cells blocking the lymph drainage.

      Understanding the different types and classifications of breast cancer is crucial for accurate diagnosis and treatment. It is important to note that some types of breast cancer may be associated with underlying lesions seen in the common types, rather than being completely separate subtypes.

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      • Haematology/Oncology
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  • Question 23 - A 49-year-old woman receives a red blood cell transfusion in the emergency department...

    Incorrect

    • A 49-year-old woman receives a red blood cell transfusion in the emergency department after a car accident. She develops a fever and becomes anxious after 30 minutes. The transfusion is stopped and the following observations are made: respiratory rate 21 breaths per minute, heart rate 74 bpm, saturations 98% (room air), blood pressure 125/85 mmHg, temperature 39ºC. The patient is comfortable at rest and chest auscultation reveals no wheezing. What is the most appropriate treatment for this patient's reaction?

      Your Answer: Adrenaline IM

      Correct Answer: Paracetamol

      Explanation:

      Complications of Blood Product Transfusion: Understanding the Risks

      Blood product transfusion can lead to various complications that can be classified into different categories. Immunological complications include acute haemolytic reactions, non-haemolytic febrile reactions, and allergic/anaphylaxis reactions. Infective complications may also arise, including the transmission of vCJD. Other complications include transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), hyperkalaemia, iron overload, and clotting.

      Non-haemolytic febrile reactions are thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage. On the other hand, allergic reactions to blood transfusions are caused by hypersensitivity reactions to components within the transfusion. TRALI is a rare but potentially fatal complication of blood transfusion, while TACO is a relatively common reaction due to fluid overload resulting in pulmonary oedema.

      It is important to understand the risks associated with blood product transfusion and to be aware of the different types of complications that may arise. Proper management and prompt treatment are crucial in preventing further harm to the patient.

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      • Haematology/Oncology
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  • Question 24 - A 32-year-old woman presents to her General Practitioner with a 1-week history of...

    Incorrect

    • A 32-year-old woman presents to her General Practitioner with a 1-week history of epistaxis and bleeding gums. She recently recovered from influenza and has a history of hypothyroidism for which she takes levothyroxine. On examination, she has multiple bruises and petechiae over her lower limbs and trunk. Her investigations reveal a low platelet count and normal coagulation parameters. What is the most likely diagnosis?

      Your Answer: Thrombotic thrombocytopenic purpura (TTP)

      Correct Answer: Immune thrombocytopenic purpura (ITP)

      Explanation:

      The patient is likely suffering from immune thrombocytopenic purpura (ITP), a condition where the immune system destroys platelets. This can be caused by autoantibodies targeting glycoprotein IIb/IIIa or Ib–V–IX complexes, and is often seen in patients with autoimmune diseases. Acute cases can occur in children following a viral infection or vaccination, and symptoms typically include bleeding from the skin and mucous membranes. Given the patient’s history of hypothyroidism, ITP is a more likely diagnosis than other conditions such as Factor V Leiden, thrombotic thrombocytopenic purpura (TTP), or von Willebrand’s disease (VWD). Disseminated intravascular coagulation (DIC) is also unlikely, as the patient’s coagulation profile is normal aside from the low platelet count.

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      • Haematology/Oncology
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  • Question 25 - A 38-year-old man presents to the infertility clinic with a low sperm count...

    Incorrect

    • A 38-year-old man presents to the infertility clinic with a low sperm count and suspected left varicocele, as noted by his GP. He also has a history of hypertension treated with ramipril and has been experiencing night sweats intermittently over the past few months. His FBC shows anaemia and his ESR is markedly raised. Additionally, haematuria is present on urinalysis. What is the most likely diagnosis for this clinical presentation?

      Your Answer: Chronic urinary tract infection

      Correct Answer: Renal cell carcinoma

      Explanation:

      Renal Cell Carcinoma: Symptoms, Diagnosis, and Prognosis

      Renal cell carcinoma is a type of kidney cancer that often presents with haematuria, loin pain, and a flank mass. However, other symptoms such as weight loss, fatigue, and pyrexia may also occur. In some cases, paraneoplastic symptoms like a raised ESR may be present. Diagnosis involves FBC to check for anaemia or polycythaemia. Left-sided varicocele may also occur due to tumour invasion of the left renal vein. Prognosis depends on the tumour stage at diagnosis, with a 5-year survival rate of 60-70% for tumours confined to the renal parenchyma, 15-35% for lymph node involvement, and only 5% for distant metastases. It is important to differentiate renal cell carcinoma from other conditions such as lymphoma, multiple myeloma, testicular carcinoma, and chronic urinary tract infection.

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      • Haematology/Oncology
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  • Question 26 - A 5-year-old boy has been diagnosed with sickle cell disease following his routine...

    Incorrect

    • A 5-year-old boy has been diagnosed with sickle cell disease following his routine heel-prick screening test. His mother contacts the General Practitioner to discuss the implications of this diagnosis and would like more information about treatment.
      Which of the following is the best choice of management?

      Your Answer: Lifelong iron supplementation

      Correct Answer: Lifelong antibiotic prophylaxis with penicillin

      Explanation:

      Management of Sickle Cell Disease: Antibiotic Prophylaxis, B12 and Iron Supplementation, and Malaria Prophylaxis

      Sickle cell disease is a condition that increases the risk of infections, particularly pneumococcal infections, respiratory tract infections, urinary tract infections, and osteomyelitis. To prevent severe infections or sepsis, the National Institute for Health and Care Excellence (NICE) recommends lifelong antibiotic prophylaxis with penicillin V or amoxicillin for people with sickle cell disease, starting ideally at three months of age. Pneumococcal vaccination every five years is also crucial. Co-amoxiclav is not the antibiotic of choice for prophylaxis. B12 supplementation is indicated only if a person with sickle cell disease has B12 deficiency. Folate supplementation is recommended for all people with sickle cell anaemia due to high folate turnover associated with haemolysis. Lifelong iron supplementation is not recommended unless there is proven iron deficiency that would require 3-month supplements rather than lifelong treatment. Finally, sickle cell disease does not protect against malaria, and people with sickle cell disease planning to travel to an area where malaria is endemic should take the standard recommended malaria prophylaxis for that area.

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      • Haematology/Oncology
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  • Question 27 - A 65-year-old woman is diagnosed with a DVT 2 weeks after undergoing a...

    Incorrect

    • A 65-year-old woman is diagnosed with a DVT 2 weeks after undergoing a hip replacement surgery, despite being on prophylactic dose LMWH. She has a history of osteoarthritis but no other significant medical history. The treatment for her DVT is started with LMWH. What is the best anticoagulation plan for her?

      Your Answer: Continue on treatment dose LMWH for 6 months

      Correct Answer: Switch to direct oral anticoagulant for 3 months

      Explanation:

      For cases of venous thromboembolism that are provoked, such as those resulting from recent surgery, a standard length of warfarin treatment is 3 months. However, for unprovoked cases, the recommended length of treatment is 6 months.

      NICE updated their guidelines on the investigation and management of venous thromboembolism (VTE) in 2020. The use of direct oral anticoagulants (DOACs) is recommended as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. Routine cancer screening is no longer recommended following a VTE diagnosis. The cornerstone of VTE management is anticoagulant therapy, with DOACs being the preferred choice. All patients should have anticoagulation for at least 3 months, with the length of anticoagulation being determined by whether the VTE was provoked or unprovoked.

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      • Haematology/Oncology
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  • Question 28 - A 63-year-old patient presents for follow-up. He underwent aortic valve replacement with a...

    Correct

    • A 63-year-old patient presents for follow-up. He underwent aortic valve replacement with a prosthetic valve five years ago and is currently on warfarin therapy. He has been experiencing fatigue for the past three months and a recent full blood count revealed the following results: Hb 10.3 g/dl, MCV 68 fl, Plt 356 * 109/l, and WBC 5.2 * 109/l. The blood film showed hypochromia and his INR was 3.0. An upper GI endoscopy was performed and was reported as normal. What would be the most appropriate next step in investigating this patient's condition?

      Your Answer: Colonoscopy

      Explanation:

      Lower gastrointestinal tract investigation should be conducted on any patient in this age group who has an unexplained microcytic anaemia to rule out the possibility of colorectal cancer.

      Referral Guidelines for Colorectal Cancer

      Colorectal cancer is a serious condition that requires prompt diagnosis and treatment. In 2015, the National Institute for Health and Care Excellence (NICE) updated their referral guidelines for patients suspected of having colorectal cancer. According to these guidelines, patients who are 40 years or older with unexplained weight loss and abdominal pain, 50 years or older with unexplained rectal bleeding, or 60 years or older with iron deficiency anemia or change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients who test positive for occult blood in their feces should also be referred urgently.

      An urgent referral should also be considered for patients who have a rectal or abdominal mass, unexplained anal mass or anal ulceration, or are under 50 years old with rectal bleeding and any of the following unexplained symptoms/findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anemia.

      The NHS offers a national screening program for colorectal cancer, which involves sending eligible patients aged 60 to 74 years in England and 50 to 74 years in Scotland FIT tests through the post. FIT is a type of fecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.

      The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, under 60 years old with changes in their bowel habit or iron deficiency anemia, or 60 years or older who have anemia even in the absence of iron deficiency. Early detection and treatment of colorectal cancer can significantly improve patient outcomes, making it important to follow these referral guidelines.

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      • Haematology/Oncology
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  • Question 29 - A 55-year-old woman presents with weight loss and anaemia. She has no significant...

    Incorrect

    • A 55-year-old woman presents with weight loss and anaemia. She has no significant medical history. Upon examination, she has massive splenomegaly and pale conjunctivae. Her full blood count shows a Hb of 10.9 g/dl, platelets of 702 * 109/l, and a WCC of 56.6 * 109/l. Leucocytosis is noted on her film, with all stages of granulocyte maturation seen. What is the most probable diagnosis?

      Your Answer: Myelodysplasia

      Correct Answer: Chronic myeloid leukaemia

      Explanation:

      Massive splenomegaly can be caused by myelofibrosis, chronic myeloid leukemia, visceral leishmaniasis (kala-azar), malaria, and Gaucher’s syndrome. Among these, chronic myeloid leukemia is the most probable diagnosis, as it is the most common cause.

      Understanding Chronic Myeloid Leukaemia and its Management

      Chronic myeloid leukaemia (CML) is a type of cancer that affects the blood and bone marrow. It is characterized by the presence of the Philadelphia chromosome in more than 95% of patients. This chromosome is formed due to a translocation between chromosomes 9 and 22, resulting in the fusion of the ABL proto-oncogene and the BCR gene. The resulting BCR-ABL gene produces a fusion protein that has excessive tyrosine kinase activity.

      CML typically affects individuals between 60-70 years of age and presents with symptoms such as anaemia, weight loss, sweating, and splenomegaly. The condition is also associated with an increase in granulocytes at different stages of maturation and thrombocytosis. In some cases, CML may undergo blast transformation, leading to acute myeloid leukaemia (AML) or acute lymphoblastic leukaemia (ALL).

      The management of CML involves various treatment options, including imatinib, which is considered the first-line treatment. Imatinib is an inhibitor of the tyrosine kinase associated with the BCR-ABL defect and has a very high response rate in the chronic phase of CML. Other treatment options include hydroxyurea, interferon-alpha, and allogenic bone marrow transplant. With proper management, individuals with CML can lead a normal life.

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      • Haematology/Oncology
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  • Question 30 - A 25-year-old man presents to his doctor with a complaint of a lump...

    Incorrect

    • A 25-year-old man presents to his doctor with a complaint of a lump in his testicle. During the examination, the lump disappears when he lies down. The scrotum shows dilated veins, while the abdominal examination is unremarkable. He expresses concern about his inability to conceive despite trying. What is the most probable diagnosis?

      Your Answer: Testicular teratoma

      Correct Answer: Varicocoele

      Explanation:

      Common Causes of Testicular Lumps: Varicocele, Epididymitis, Hydrocele, Inguinal Hernia, and Testicular Teratoma

      Testicular lumps can be a cause for concern and require medical attention. Here are some common causes of testicular lumps:

      Varicocele: This is a painless swelling of the testes on the left side, which can be described as a bag of worms within the spermatic cord above the testis. It tends to occur in those aged 12+ years and is rare in pre-pubertal boys. Varicoceles are associated with male infertility, and a quarter of men with abnormal semen parameters will have a varicocele.

      Epididymitis: This is inflammation of the testis and epididymis caused by infection such as chlamydia infection, gonorrhoea, mumps, bacterial coliforms or syphilis. It may present as acute testicular pain, swelling and tenderness, and associated symptoms include urethritis, increased urinary frequency and dysuria. Systemic symptoms may include fever and rigors.

      Hydrocele: This is a non-tender, painless, cystic scrotal swelling below and anterior to the testes. It will normally transilluminate and does not tend to reduce on lying flat. Although hydroceles can fluctuate in size and are affected by movement, they are not usually a cause for concern.

      Inguinal hernia: This is a condition where a part of the intestine or other tissue protrudes through a weak spot in the abdominal muscles, causing a lump in the groin or scrotum. If reducible, the lump may disappear on lying flat.

      Testicular teratoma: This is a solid testicular lump within the testis, which is suggestive of a tumour. Testicular cancers can be subdivided into seminomas, teratomas and yolk-sac tumours. Over 95% of testicular cancers arise from the germ cells. Teratomas typically present at age 20–30 years, whereas seminomas typically present at age 35–45 years.

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      • Haematology/Oncology
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  • Question 31 - An 82-year-old man presents to his General Practitioner (GP) with fatigue, lethargy, weight...

    Incorrect

    • An 82-year-old man presents to his General Practitioner (GP) with fatigue, lethargy, weight loss and night sweats for the past six weeks. Clinical examination is unremarkable. His past medical history includes ischaemic heart disease and hypertension. His GP orders a set of blood tests. The full blood count results are as follows:
      Investigation Result Normal value
      Haemoglobin (Hb) 135 g/l 135–175 g/l
      White Blood Cells 21.2 × 109/l 4–11 × 109/l
      Neutrophils 2.8 ×109/l 2.5–7.58 ×109/l
      Lymphocytes 18.2 × 109/l 1.5–3.5× 109/l
      Platelets 160 g/l 150–400× 109/l
      What is the most likely diagnosis?

      Your Answer: Human immunodeficiency virus (HIV)

      Correct Answer: Chronic lymphocytic leukaemia (CLL)

      Explanation:

      Differential diagnosis for lymphocytosis in an elderly patient with vague symptoms

      Chronic lymphocytic leukaemia (CLL) is the most likely cause of lymphocytosis in an elderly patient who presents with vague symptoms such as weight loss, night sweats and fatigue for six weeks. CLL is one of the most common types of leukaemia in adults, typically occurring during or after middle age and rarely in children.

      Other possible diagnoses can be ruled out based on additional clinical features. Patients with HIV tend to have lymphopenia, not lymphocytosis. Lymphomas usually present with an enlargement of a lymph node, which is not reported in this case. Patients with polymyalgia rheumatica tend to have a normal leukocyte count, with some cases having increased estimated sedimentation rate and/or C-reactive protein. A transient viral illness would be an unlikely cause of lymphocytosis in an elderly person with persistent symptoms.

      Therefore, CLL should be considered as the most likely diagnosis in this case, and further tests such as flow cytometry and bone marrow biopsy may be needed to confirm the diagnosis and determine the stage of the disease. Treatment options for CLL depend on the stage and other factors such as age and overall health, and may include watchful waiting, chemotherapy, immunotherapy, or targeted therapy.

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      • Haematology/Oncology
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  • Question 32 - A 16-year-old girl comes to the clinic with a palpable purpuric rash on...

    Incorrect

    • A 16-year-old girl comes to the clinic with a palpable purpuric rash on her lower limbs and polyarthralgia after experiencing a recent sore throat. What is the probable diagnosis?

      Your Answer: Idiopathic thrombocytopenic purpura

      Correct Answer: Henoch-Schonlein purpura

      Explanation:

      Understanding Henoch-Schonlein Purpura

      Henoch-Schonlein purpura (HSP) is a type of small vessel vasculitis that is mediated by IgA. It is often associated with IgA nephropathy, also known as Berger’s disease. HSP is commonly observed in children following an infection.

      The condition is characterized by a palpable purpuric rash, which is accompanied by localized oedema over the buttocks and extensor surfaces of the arms and legs. Other symptoms include abdominal pain, polyarthritis, and features of IgA nephropathy such as haematuria and renal failure.

      Treatment for HSP involves analgesia for arthralgia, while management of nephropathy is generally supportive. There is inconsistent evidence for the use of steroids and immunosuppressants.

      The prognosis for HSP is usually excellent, especially in children without renal involvement. The condition is self-limiting, but around one-third of patients may experience a relapse. It is important to monitor blood pressure and urinalysis to detect any progressive renal involvement.

      Overall, understanding Henoch-Schonlein purpura is crucial for prompt diagnosis and management of the condition.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 33 - A 25-year-old man with sickle cell anaemia complains of fatigue, paleness and a...

    Correct

    • A 25-year-old man with sickle cell anaemia complains of fatigue, paleness and a headache. Laboratory findings reveal Hb of 66 g/L and reticulocytes of 0.8%. The patient is suspected to have contracted parvovirus. What is the probable diagnosis?

      Your Answer: Aplastic crisis

      Explanation:

      An aplastic crisis, often caused by parvovirus infection, is characterized by a sudden decrease in haemoglobin levels without a corresponding increase in reticulocytes.

      Sickle cell anaemia is a condition that involves periods of good health with intermittent crises. There are several types of crises that can occur, including thrombotic or painful crises, sequestration, acute chest syndrome, aplastic, and haemolytic. Thrombotic crises, also known as painful crises or vaso-occlusive crises, are triggered by factors such as infection, dehydration, and deoxygenation. These crises are diagnosed clinically and can result in infarcts in various organs, including the bones, lungs, spleen, and brain.

      Sequestration crises occur when sickling occurs within organs such as the spleen or lungs, leading to pooling of blood and worsening of anaemia. This type of crisis is associated with an increased reticulocyte count. Acute chest syndrome is caused by vaso-occlusion within the pulmonary microvasculature, resulting in infarction in the lung parenchyma. Symptoms include dyspnoea, chest pain, pulmonary infiltrates on chest x-ray, and low pO2. Management involves pain relief, respiratory support, antibiotics, and transfusion.

      Aplastic crises are caused by infection with parvovirus and result in a sudden fall in haemoglobin. Bone marrow suppression leads to a reduced reticulocyte count. Haemolytic crises are rare and involve a fall in haemoglobin due to an increased rate of haemolysis. It is important to recognise and manage these crises promptly, as they can lead to serious complications and even death.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 34 - A 5-year-old boy with sickle cell anaemia complains of abdominal pain. During the...

    Incorrect

    • A 5-year-old boy with sickle cell anaemia complains of abdominal pain. During the physical examination, the doctor observes splenomegaly and signs of anaemia. What is the probable diagnosis?

      Your Answer: Thrombotic crisis

      Correct Answer: Sequestration crisis

      Explanation:

      In a sequestration crisis, the sickle cells lead to significant enlargement of the spleen, which causes abdominal pain as seen in this case. This is more prevalent in early childhood as repeated sequestration and infarction of the spleen during childhood can eventually lead to an auto-splenectomy. A sequestration crisis can result in severe anemia, noticeable pallor, and cardiovascular collapse due to the loss of effective circulating volume.

      Sickle cell anaemia is a condition that involves periods of good health with intermittent crises. There are several types of crises that can occur, including thrombotic or painful crises, sequestration, acute chest syndrome, aplastic, and haemolytic. Thrombotic crises, also known as painful crises or vaso-occlusive crises, are triggered by factors such as infection, dehydration, and deoxygenation. These crises are diagnosed clinically and can result in infarcts in various organs, including the bones, lungs, spleen, and brain.

      Sequestration crises occur when sickling occurs within organs such as the spleen or lungs, leading to pooling of blood and worsening of anaemia. This type of crisis is associated with an increased reticulocyte count. Acute chest syndrome is caused by vaso-occlusion within the pulmonary microvasculature, resulting in infarction in the lung parenchyma. Symptoms include dyspnoea, chest pain, pulmonary infiltrates on chest x-ray, and low pO2. Management involves pain relief, respiratory support, antibiotics, and transfusion.

      Aplastic crises are caused by infection with parvovirus and result in a sudden fall in haemoglobin. Bone marrow suppression leads to a reduced reticulocyte count. Haemolytic crises are rare and involve a fall in haemoglobin due to an increased rate of haemolysis. It is important to recognise and manage these crises promptly, as they can lead to serious complications and even death.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 35 - A 7-year-old boy who has haemophilia A presents to the Emergency Department after...

    Incorrect

    • A 7-year-old boy who has haemophilia A presents to the Emergency Department after falling off a skateboard and hitting his head. He is drowsy and confused with a Glasgow Coma Score of 9.
      What would be the next most appropriate step in this patient’s management?

      Your Answer: Transfer to theatre for evacuation of intracranial haematoma

      Correct Answer: Immediate administration of factor VIII

      Explanation:

      Immediate Treatment for Serious Bleeding in Patients with Haemophilia

      Serious or life-threatening bleeding in patients with haemophilia requires immediate evaluation and therapy with replacement factor. The immediate goal is to raise the activity of the deficient factor to a level sufficient to achieve haemostasis. For patients with potentially serious or life-threatening bleeding, treatment should be initiated immediately, even before completing diagnostic assessment.

      In the case of haemophilia A, factor VIII must be replaced. Waiting to find out factor VIII levels prior to administering it could lead to further bleeding. Therefore, immediate administration of factor VIII is the most appropriate option.

      While obtaining imaging of the head may be useful, the main objective is to obtain rapid haemostasis. Thus, transferring the patient immediately for a CT scan of the head is not the first action to take.

      In a patient with haemophilia, evacuation of a clot may lead to further potentially catastrophic bleeding. If surgery is required, the patient must have adequate levels of factor VIII present to achieve haemostasis. Therefore, transferring the patient to the theatre for evacuation of an intracranial haematoma should not be the first action taken.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 36 - A 23-year-old woman with sickle cell disease is admitted to the haematology unit...

    Incorrect

    • A 23-year-old woman with sickle cell disease is admitted to the haematology unit after experiencing increasing fatigue and general malaise for the past week following a recent febrile illness. Upon examination, she appears pale and has multiple petechiae and bruises over her trunk and upper and lower limbs. Blood tests reveal a Hb of 82 g/L (135-180), platelets of 29 * 109/L (150 - 400), and WBC of 1.3 * 109/L (4.0 - 11.0). What is the most likely cause of this patient's presentation?

      Your Answer: Cytomegalovirus infection

      Correct Answer: Parvovirus B19 infection

      Explanation:

      Pancytopenia may occur in patients with underlying haematological conditions who are infected with Parvovirus B19, which can also cause fever and rash.

      Parvovirus B19: A Virus with Various Clinical Presentations

      Parvovirus B19 is a DNA virus that can cause different clinical presentations. One of the most common is erythema infectiosum, also known as fifth disease or slapped-cheek syndrome. This illness may manifest as a mild feverish condition or a noticeable rash that appears after a few days. The rash is characterized by rose-red cheeks, which is why it is called slapped-cheek syndrome. It may spread to the rest of the body but rarely involves the palms and soles. The rash usually peaks after a week and then fades, but for some months afterwards, a warm bath, sunlight, heat, or fever may trigger a recurrence of the bright red cheeks and rash. Most children recover without specific treatment, and school exclusion is unnecessary as the child is not infectious once the rash emerges. However, in adults, the virus may cause acute arthritis.

      Aside from erythema infectiosum, parvovirus B19 can also present as asymptomatic, pancytopenia in immunosuppressed patients, aplastic crises in sickle-cell disease, and hydrops fetalis. The virus suppresses erythropoiesis for about a week, so aplastic anemia is rare unless there is a chronic hemolytic anemia. In pregnant women, the virus can cross the placenta and cause severe anemia due to viral suppression of fetal erythropoiesis, which can lead to heart failure secondary to severe anemia and the accumulation of fluid in fetal serous cavities (e.g. ascites, pleural and pericardial effusions). This condition is treated with intrauterine blood transfusions.

      It is important to note that the virus can affect an unborn baby in the first 20 weeks of pregnancy. If a woman is exposed early in pregnancy (before 20 weeks), she should seek prompt advice from her antenatal care provider as maternal IgM and IgG will need to be checked. The virus is spread by the respiratory route, and a person is infectious 3 to 5 days before the appearance of the rash. Children are no longer infectious once the rash appears, and there is no specific treatment. Therefore, the child need not be excluded from school as they are no longer infectious by the time the rash occurs.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 37 - In the UK, which malignancy is most frequently diagnosed in women? ...

    Incorrect

    • In the UK, which malignancy is most frequently diagnosed in women?

      Your Answer: Bowel cancer

      Correct Answer: Breast cancer

      Explanation:

      Most Common Cancers in Women in the UK

      Breast cancer is the most frequently diagnosed cancer in women in the UK, with approximately 54,800 cases in 2014. Lung cancer follows as the second most common cancer in women, with around 21,600 cases diagnosed in the same year. Bowel cancer ranks third, with approximately 18,400 cases diagnosed in 2014. Uterine cancer is the fourth most common cancer in women, with around 9,300 cases diagnosed. Leukaemia is the eleventh most common cancer in women, with approximately 3,800 cases diagnosed in 2014. These statistics are according to Cancer Research UK.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 38 - Among the following groups of malignant tumours, which one is known for frequently...

    Incorrect

    • Among the following groups of malignant tumours, which one is known for frequently metastasizing to bone?

      Your Answer: Kidney, sarcoma, lung, thyroid

      Correct Answer: Breast, prostate, kidney, lung, thyroid

      Explanation:

      Metastasis Patterns of Common Tumours

      Metastasis, the spread of cancer cells from the primary tumour to other parts of the body, is a major factor in cancer progression and treatment. Different types of cancer have different patterns of metastasis. Here are some common tumours and their predilection for dissemination to specific organs:

      – Breast, prostate, kidney, lung, thyroid: These tumours have a predilection for dissemination to bone.
      – Kidney, sarcoma, lung, thyroid: Sarcoma most commonly metastasises to the lungs.
      – Breast, prostate, kidney, lymphoma: Tumours that commonly metastasise to the brain include those of the breast, lung, prostate, kidney and thyroid.
      – Lung, breast, prostate, thyroid, brain: Primary brain tumours rarely metastasise to other parts of the body.
      – Thyroid, brain, lung, liver, breast: Primary liver tumours most commonly metastasise to the lung, portal vein and portal nodes.

      Understanding the metastasis patterns of different tumours can help in early detection and targeted treatment.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 39 - A 47-year-old woman from Nigeria complains of fatigue, back pain and excessive thirst....

    Incorrect

    • A 47-year-old woman from Nigeria complains of fatigue, back pain and excessive thirst. Her ESR is elevated and she has normocytic/normochromic anemia.
      What is the most probable diagnosis?

      Your Answer: Calcium pyrophosphate arthropathy

      Correct Answer: Multiple myeloma

      Explanation:

      Distinguishing Multiple Myeloma from Other Bone Diseases

      Multiple Myeloma: A Malignant Disease of Plasma Cells

      Multiple myeloma is a type of cancer that affects the plasma cells in the bone marrow. It is more common in black Africans and rare in Asians, with a median age of onset over 60. Patients may not show any symptoms and are often diagnosed through routine blood tests. However, they are more susceptible to infections and may have low white blood cell counts. Elevated levels of ESR and CRP are almost always present. Diagnosis is confirmed when two out of three of the following are present: paraproteinaemia or Bence Jones protein, radiological evidence of lytic bone lesions, and an increase in bone marrow plasma cells. Patients may experience bone pain, lethargy, thirst, and anaemia, which are all signs of multiple myeloma.

      Calcium Pyrophosphate Arthropathy: Shedding of Crystals into Joints

      Calcium pyrophosphate arthropathy, also known as pseudogout, is caused by the shedding of calcium pyrophosphate crystals into the joint. It typically presents as an acute-onset monoarticular arthritis, usually in the knee or wrist. The joint will be hot, red, tender, and swollen. Rhomboid-shaped crystals that are weakly positively birefringent under polarised light will be visible in synovial fluid.

      Osteoporosis: Fragility Fractures

      Osteoporosis is characterised by fragility fractures, such as vertebral crush fractures, Colles fractures, and fractures of the proximal femur. It is uncommon in men at this age, unless associated with hypogonadism. Anaemia and elevated ESR are not seen in osteoporosis.

      Osteoarthritis: Joint Pain and Stiffness

      Osteoarthritis presents with joint pain, stiffness, and reduced function. The weight-bearing joints, such as the hip and knee, and the small joints of the hand are commonly affected. Patients do not experience symptoms such as thirst and lethargy, which are due to hypercalcaemia. Blood biochemistry is normal in osteoarthritis.

      Paget’s Disease of Bone: Bone Remodelling

      Paget’s disease of the bone is rare in individuals under 40 years old. It is characterised by bone pain, deformity, fragility fractures, and complications from nerve compression

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      • Haematology/Oncology
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  • Question 40 - A 32-year-old man is brought to the emergency department by his physician due...

    Incorrect

    • A 32-year-old man is brought to the emergency department by his physician due to bone pain, weakness, and splenomegaly. He has been experiencing increasing fatigue and weakness while performing his daily tasks over the past few weeks. During the examination, he appears extremely pale and has petechiae on his lower limbs. After a bone marrow sample is taken, he is diagnosed with acute promyelocytic leukemia (APML). What is the most probable finding on his blood film?

      Your Answer: 'Tear-drop' poikilocytes

      Correct Answer: Auer rods

      Explanation:

      A finding of Auer rods on a blood film strongly indicates the presence of acute promyelocytic leukemia.

      The correct answer is ‘Auer rods’. This patient has been diagnosed with APML, and the most common finding on a blood film associated with this is Auer rods. These are needle-like structures that are large, pink or red stained and can be seen within the cytoplasm of myeloid blast cells.

      ‘Tear-drop’ poikilocytes are typically found in myelofibrosis, which is characterized by flat, elongated red blood cells that resemble a tear-drop in shape. This occurs due to the squeezing of cells through fibrotic tissue in bone marrow in myelofibrotic disorders.

      Smear cells are usually seen in chronic lymphocytic leukemia (CLL), which are remnants of cells that lack identifiable plasma membrane or nuclear structure.

      Spherocytes are generally found in hereditary spherocytosis or autoimmune hemolytic anemia, which are red blood cells that are sphere-shaped and more fragile than normal red blood cells due to abnormalities in the red cell membrane.

      Acute myeloid leukaemia is a common form of acute leukaemia in adults that may occur as a primary disease or following a myeloproliferative disorder. Symptoms are related to bone marrow failure and include anaemia, neutropenia, thrombocytopenia, splenomegaly, and bone pain. Poor prognostic features include age over 60, >20% blasts after first course of chemo, and deletions of chromosome 5 or 7. Acute promyelocytic leukaemia M3 is associated with t(15;17) and has a good prognosis. The French-American-British classification system includes seven subtypes.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 41 - A 25-year-old woman comes to the clinic complaining of fatigue. Upon conducting blood...

    Incorrect

    • A 25-year-old woman comes to the clinic complaining of fatigue. Upon conducting blood tests, the following results are obtained:
      - Hemoglobin (Hb): 10.4 g/dl
      - Platelets (Plt): 278 * 109/l
      - White blood cell count (WCC): 6.3 * 109/l
      - Mean corpuscular volume (MCV): 65 fl
      - Hemoglobin A2 (HbA2): 4.5% (< 3%)

      What is the most probable diagnosis?

      Your Answer: Hereditary spherocytosis

      Correct Answer: Beta-thalassaemia trait

      Explanation:

      When a female presents with microcytic anaemia, it is important to consider potential causes such as gastrointestinal bleeding or menorrhagia. However, if there is no history of these conditions and the microcytosis is not proportional to the haemoglobin level, beta-thalassaemia trait should be considered as a possible diagnosis, especially if HbA2 levels are elevated.

      Understanding Beta-Thalassaemia Trait

      Beta-thalassaemia trait is a genetic disorder that affects the production rate of beta chains. It is an autosomal recessive condition that results in a mild hypochromic, microcytic anaemia. This condition is usually asymptomatic, meaning that it does not show any noticeable symptoms. However, it is important to note that microcytosis is characteristically disproportionate to the anaemia. Additionally, individuals with beta-thalassaemia trait have raised levels of HbA2, which is typically greater than 3.5%. Understanding beta-thalassaemia trait is crucial for individuals who may be carriers of this genetic disorder.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 42 - A 35-year-old woman comes to her General Practitioner complaining of fatigue, weight loss,...

    Incorrect

    • A 35-year-old woman comes to her General Practitioner complaining of fatigue, weight loss, and palpable lymph nodes in the left supraclavicular fossa.
      What is the most suitable location to investigate for a primary tumor in this patient?

      Your Answer: Corpus uteri

      Correct Answer: Stomach

      Explanation:

      Metastasis and Spread of Common Cancers

      Gastric carcinoma, the fifth most common cancer worldwide, often presents with advanced disease and can affect various parts of the stomach. Troisier’s sign, an enlarged left supraclavicular node, is a telltale sign of gastric carcinoma, but cancers from other gastrointestinal and urogenital sites can also present with this symptom.

      Endometrial cancer, or cancer of the corpus uteri, typically spreads to pelvic and para-aortic nodes, as well as distant organs like the lungs, liver, brain, and bones. Epigastric pain, hepatomegaly, jaundice, and ascites may indicate poor prognosis.

      Lung cancers tend to spread to deep lymph nodes in the mediastinum and thorax, as well as the other lung, pleura, and distant organs.

      Renal carcinoma first spreads to local lymph nodes before invading the aorta and vena cava. It can also spread to more distant lymph nodes, bones, liver, and lungs.

      Prostate cancer can spread to local and regional lymph nodes, but it is also known to spread to the bones, causing severe pain, especially in the femur.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 43 - A 55-year-old man is referred to the Haematology Clinic under the 2-week-wait rule...

    Incorrect

    • A 55-year-old man is referred to the Haematology Clinic under the 2-week-wait rule with significant fatigue and frequent infections over the past six months. His blood results confirm a diagnosis of chronic lymphocytic leukaemia (CLL) with a 17p chromosome deletion.
      Which of the following is the most appropriate first-line treatment?

      Your Answer: Bendamustine plus rituximab

      Correct Answer: Acalabrutinib

      Explanation:

      Treatment Options for Chronic Lymphocytic Leukaemia (CLL)

      The National Institute for Health and Care Excellence (NICE) has released new guidelines for managing newly diagnosed CLL in adults. Acalabrutinib is recommended as a monotherapy option if the patient has a 17p deletion or TP53 mutation, or if fludarabine plus cyclophosphamide and rituximab (FCR) or bendamustine plus rituximab (BR) are unsuitable. Prednisolone, a glucocorticoid commonly used in treating lymphoma, has no role in managing CLL. If there is no 17p deletion or TP53 mutation, FCR or BR would be the most appropriate first-line treatment. Conservative management is not recommended as the patient has developed signs of bone marrow dysfunction. Imatinib, the first-line treatment for CML, would not be useful for CLL.

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      • Haematology/Oncology
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  • Question 44 - A 32-year-old female presents with a purpuric rash on the back of her...

    Correct

    • A 32-year-old female presents with a purpuric rash on the back of her legs, frequent nose bleeds, and menorrhagia. She is currently taking Microgynon 30. A full blood count reveals Hb of 11.7 g/dl, platelets of 62 * 109/l, and WCC of 5.3 * 109/l. What is the probable diagnosis?

      Your Answer: Idiopathic thrombocytopenic purpura

      Explanation:

      A diagnosis of ITP is suggested by the presence of isolated thrombocytopenia in a healthy patient. Blood dyscrasias are not typically caused by the use of combined oral contraceptive pills.

      Understanding Immune Thrombocytopenia (ITP) in Adults

      Immune thrombocytopenia (ITP) is a condition where the immune system attacks and reduces the number of platelets in the blood. This is caused by antibodies targeting the glycoprotein IIb/IIIa or Ib-V-IX complex. While children with ITP usually experience acute thrombocytopenia after an infection or vaccination, adults tend to have a more chronic form of the condition. ITP is more common in older females and may be detected incidentally during routine blood tests. Symptoms may include petechiae, purpura, and bleeding, but catastrophic bleeding is not a common presentation.

      To diagnose ITP, a full blood count and blood film are typically performed. While a bone marrow examination is no longer routinely used, antiplatelet antibody testing may be done, although it has poor sensitivity and does not affect clinical management. The first-line treatment for ITP is oral prednisolone, but pooled normal human immunoglobulin (IVIG) may also be used if active bleeding or an urgent invasive procedure is required. Splenectomy is now less commonly used as a treatment option.

      In some cases, ITP may be associated with autoimmune haemolytic anaemia (AIHA), which is known as Evan’s syndrome. It is important for individuals with ITP to work closely with their healthcare provider to manage their condition and prevent complications.

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      • Haematology/Oncology
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  • Question 45 - A 28-year-old woman visits her GP with concerns about a lump in her...

    Incorrect

    • A 28-year-old woman visits her GP with concerns about a lump in her breast that she discovered three weeks ago. The lump is causing discomfort when she wears a bra. During the examination, the doctor detects a 4 cm, non-tethered, and firm lump in the upper left quadrant of her right breast. The surface and contour are smooth, the skin is intact, and it does not transilluminate. The doctor refers her for a triple assessment, which confirms that she has a fibroadenoma. What is the next step in her treatment plan?

      Your Answer: Discharge and safety netting

      Correct Answer: Refer for surgical excision

      Explanation:

      The appropriate action for a patient presenting with a breast fibroadenoma larger than 3 cm is to refer them for surgical excision. Fibroadenomas are benign masses that develop from the whole lobule and are typically small, firm, and smooth, often referred to as breast mice. While they are usually treated conservatively, surgical excision is necessary if they cause discomfort, as in this case. Checking the mass again in three months, discharge and safety netting, prescribing oral antibiotics, and referring for aspiration are all incorrect management options for a fibroadenoma.

      Understanding Breast Fibroadenoma

      Breast fibroadenoma is a type of breast mass that develops from a whole lobule. It is characterized by a mobile, firm, and smooth lump in the breast, which is often referred to as a breast mouse. Fibroadenoma accounts for about 12% of all breast masses and is more common in women under the age of 30.

      Fortunately, fibroadenomas are usually benign and do not increase the risk of developing breast cancer. In fact, over a two-year period, up to 30% of fibroadenomas may even get smaller on their own. However, if the lump is larger than 3 cm, surgical excision is typically recommended.

      In summary, breast fibroadenoma is a common type of breast mass that is usually benign and does not increase the risk of breast cancer. While it may cause concern for some women, it is important to remember that most fibroadenomas do not require treatment and may even resolve on their own.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 46 - A 25-year-old male comes to the emergency department complaining of cough, fever and...

    Incorrect

    • A 25-year-old male comes to the emergency department complaining of cough, fever and difficulty breathing. During the examination, he is found to be hypoxic and chest x-ray reveals pulmonary infiltrates. He has been experiencing anaemia, jaundice and weakness since he was 6 months old, and also suffers from severe pain when exposed to cold temperatures. What is the probable underlying condition?

      Your Answer: Raynaud's syndrome

      Correct Answer: Sickle cell disease

      Explanation:

      When a patient with sickle cell disease experiences dyspnoea, chest pain, cough, hypoxia, and new pulmonary infiltrates on chest x-ray, it is likely that they are suffering from acute chest syndrome. This is a complication specific to sickle cell anaemia, and is characterized by the presence of these symptoms along with the aforementioned pulmonary infiltrates.

      Sickle cell anaemia is a condition that involves periods of good health with intermittent crises. There are several types of crises that can occur, including thrombotic or painful crises, sequestration, acute chest syndrome, aplastic, and haemolytic. Thrombotic crises, also known as painful crises or vaso-occlusive crises, are triggered by factors such as infection, dehydration, and deoxygenation. These crises are diagnosed clinically and can result in infarcts in various organs, including the bones, lungs, spleen, and brain.

      Sequestration crises occur when sickling occurs within organs such as the spleen or lungs, leading to pooling of blood and worsening of anaemia. This type of crisis is associated with an increased reticulocyte count. Acute chest syndrome is caused by vaso-occlusion within the pulmonary microvasculature, resulting in infarction in the lung parenchyma. Symptoms include dyspnoea, chest pain, pulmonary infiltrates on chest x-ray, and low pO2. Management involves pain relief, respiratory support, antibiotics, and transfusion.

      Aplastic crises are caused by infection with parvovirus and result in a sudden fall in haemoglobin. Bone marrow suppression leads to a reduced reticulocyte count. Haemolytic crises are rare and involve a fall in haemoglobin due to an increased rate of haemolysis. It is important to recognise and manage these crises promptly, as they can lead to serious complications and even death.

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      • Haematology/Oncology
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  • Question 47 - A 35-year-old woman presents to her General Practitioner complaining of fatigue and lack...

    Incorrect

    • A 35-year-old woman presents to her General Practitioner complaining of fatigue and lack of energy. She has a 1-year history of heavy menstrual bleeding with excessive blood loss. She is clinically anaemic.
      Investigations:
      Investigation Result Normal value
      Haemoglobin (Hb) 102 g/l 115–155 g/l
      Haematocrit 28% 36–47%
      Mean corpuscular volume (MCV) 70 fl 80–100 fl
      Mean cell haemoglobin (MCH) 25 pg 28–32 pg
      Mean corpuscular haemoglobin volume (MCHC) 300 g/l 320–350 g/d
      White cell count (WCC) 7.5 × 109/l 4.0–11.0× 109/l
      Platelets (PLT) 400× 109/l 150–400× 109/l
      What is the most appropriate dietary advice for this patient?
      Select the SINGLE advice option from the list below.

      Your Answer: She should drink tea or coffee with meals and when taking supplements

      Correct Answer: She should increase her intake of vitamin C-rich and iron-rich food

      Explanation:

      To address her iron-deficiency anaemia, the patient should consume more foods rich in vitamin C and iron. Vitamin C can increase iron absorption by up to 10 times and maintain iron in its ferrous form. However, she should avoid breakfast cereals and white breads as they are often fortified with iron. Tea should also be avoided during meals or when taking iron supplements as it contains tannin, which reduces iron absorption. While a vegetarian diet can still provide non-haem iron, it is important to consume a variety of iron-rich plant-based foods. A gluten-free diet is only necessary if coeliac disease is present, which is unlikely in this case as the patient’s iron-deficiency anaemia is likely due to menorrhagia.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 48 - A 38-year-old woman comes to see her general practitioner with a lump in...

    Incorrect

    • A 38-year-old woman comes to see her general practitioner with a lump in her right breast. She has no significant medical or family history. During the examination, a small, firm, non-painful lump is found in the upper left quadrant of her right breast. The rest of the breast examination is normal. What is the best course of action for this patient?

      Your Answer: Conservative management, with an urgent referral to breast clinic if the lump grows

      Correct Answer: Urgent referral to breast clinic

      Explanation:

      An urgent referral to a breast clinic is necessary for women over the age of 30 who have an unexplained breast lump, using a suspected cancer pathway referral. This is in accordance with NICE guidelines, as the lump may represent cancerous pathology and should be investigated promptly. Conservative management or routine referral to breast clinic is not appropriate in this case, as the potential for cancerous pathology requires urgent attention.

      In 2015, NICE released guidelines for referring individuals suspected of having breast cancer. If a person is 30 years or older and has an unexplained breast lump with or without pain, or if they are 50 years or older and have discharge, retraction, or other concerning changes in one nipple only, they should be referred using a suspected cancer pathway referral for an appointment within two weeks. If a person has skin changes that suggest breast cancer or is 30 years or older with an unexplained lump in the axilla, a suspected cancer pathway referral should also be considered. For individuals under 30 years old with an unexplained breast lump with or without pain, non-urgent referral should be considered.

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      • Haematology/Oncology
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  • Question 49 - A 30-year-old female patient visits the GP clinic with a tiny lump in...

    Incorrect

    • A 30-year-old female patient visits the GP clinic with a tiny lump in her right breast. Upon examination, a smooth fluctuant lump is found in the right upper quadrant of the breast. The patient is referred to the breast clinic for an ultrasound scan, which reveals a 2cm cyst in the right upper quadrant of the breast. What is the most suitable course of action for management?

      Your Answer: Monitor with 6-monthly ultrasound scan

      Correct Answer: Aspiration of the cyst

      Explanation:

      Aspirating breast cysts is necessary due to the potential risk of breast cancer, particularly in younger women. Merely monitoring the cysts with ultrasound or mammogram without aspiration is not a suitable approach. There is no need for wide local excision at this point. Providing false reassurance to the patient is not advisable.

      Benign breast lesions have different features and treatments. Fibroadenomas are firm, mobile lumps that develop from a whole lobule and usually do not increase the risk of malignancy. Breast cysts are smooth, discrete lumps that may be aspirated, but blood-stained or persistently refilling cysts should be biopsied or excised. Sclerosing adenosis, radial scars, and complex sclerosing lesions cause mammographic changes that may mimic carcinoma, but do not increase the risk of malignancy. Epithelial hyperplasia may present as general lumpiness or a discrete lump, and atypical features and family history of breast cancer increase the risk of malignancy. Fat necrosis may mimic carcinoma and requires imaging and core biopsy. Duct papillomas usually present with nipple discharge and may require microdochectomy.

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      • Haematology/Oncology
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  • Question 50 - A 30-year-old female who is 36 weeks pregnant comes in with a painful...

    Correct

    • A 30-year-old female who is 36 weeks pregnant comes in with a painful and swollen right calf. After a Doppler scan, it is confirmed that she has a deep vein thrombosis. What anticoagulant is recommended?

      Your Answer: Subcutaneous low molecular weight heparin

      Explanation:

      While the first trimester poses a higher risk of teratogenic effects from warfarin, most healthcare providers would opt for low molecular weight heparin in such cases. Additionally, the possibility of peripartum hemorrhage and the difficulty in reversing the effects of warfarin in such a scenario should also be taken into account.

      During pregnancy, the body undergoes changes that make it more prone to blood clots. This is known as a hypercoagulable state and is most common in the last trimester. The increase in factors VII, VIII, X, and fibrinogen, along with a decrease in protein S, contribute to this state. Additionally, the growing uterus can press on the inferior vena cava, leading to venous stasis in the legs.

      When it comes to managing deep vein thrombosis (DVT) or pulmonary embolism (PE) during pregnancy, warfarin is not recommended due to its potential harm to the fetus. Instead, subcutaneous low-molecular-weight heparin is preferred over intravenous heparin as it has a lower risk of bleeding and thrombocytopenia. It is important for pregnant women to be aware of the signs and symptoms of DVT/PE, such as leg swelling, pain, and shortness of breath, and to seek medical attention promptly if they experience any of these symptoms.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 51 - A 26-year-old female patient comes to the clinic after discovering a lump in...

    Correct

    • A 26-year-old female patient comes to the clinic after discovering a lump in her right breast. She is uncertain about how long it has been there and reports no pain or other symptoms. She has no significant medical history. During the physical examination, a smooth, rubbery, mobile mass of approximately 2 cm in diameter is palpated. The patient is immediately referred for imaging, which reveals a small, lobulated lesion measuring about 2.5cm in width, highly suggestive of a fibroadenoma. What is the next step in managing this patient?

      Your Answer: Reassurance and monitoring

      Explanation:

      A young patient has a small fibroadenoma <3 cm, which is highly suggestive on imaging. There is no increase in the risk of breast cancer, so a core-needle biopsy is not necessary. Watchful waiting is appropriate, and cryoablation may be used for larger fibroadenomas. Fine-needle aspiration is only necessary for larger lumps or in older patients. Understanding Breast Fibroadenoma Breast fibroadenoma is a type of breast mass that develops from a whole lobule. It is characterized by a mobile, firm, and smooth lump in the breast, which is often referred to as a breast mouse. Fibroadenoma accounts for about 12% of all breast masses and is more common in women under the age of 30. Fortunately, fibroadenomas are usually benign and do not increase the risk of developing breast cancer. In fact, over a two-year period, up to 30% of fibroadenomas may even get smaller on their own. However, if the lump is larger than 3 cm, surgical excision is typically recommended. In summary, breast fibroadenoma is a common type of breast mass that is usually benign and does not increase the risk of breast cancer. While it may cause concern for some women, it is important to remember that most fibroadenomas do not require treatment and may even resolve on their own.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 52 - A 47-year-old man, currently admitted to a medical ward for acute pancreatitis, experiences...

    Incorrect

    • A 47-year-old man, currently admitted to a medical ward for acute pancreatitis, experiences intermittent episodes of epistaxis. Blood tests are conducted and reveal the following results:
      - Platelets: 52 * 109/L (normal range: 150 - 400)
      - Prothrombin time (PT): 23 seconds (normal range: 10-14 seconds)
      - Activated partial thromboplastin time (APTT): 46 seconds (normal range: 25-35 seconds)
      - Fibrinogen: 0.8 g/L (normal range: 2 - 4)
      - D-Dimer: 1203 ng/mL (normal range: < 400)
      Based on the probable diagnosis, what would be the expected findings on a blood film?

      Your Answer: Spherocytes

      Correct Answer: Schistocytes

      Explanation:

      The presence of schistocytes is indicative of microangiopathic hemolytic anemia, which is associated with disseminated intravascular coagulation (DIC). DIC is a condition where the coagulation pathways are activated, leading to a procoagulant state. It can be triggered by various factors, including acute illness. The patient’s blood tests show a depletion of platelets and coagulation factors, which is typical of DIC. However, elliptocytes, Heinz bodies, and Howell-Jolly bodies are not expected in DIC. Elliptocytes are usually seen in conditions like iron deficiency and thalassemia, while Heinz bodies are associated with alpha-thalassemia and glucose-6-phosphate dehydrogenase deficiency. Howell-Jolly bodies are characteristic of decreased splenic function, such as post-splenectomy.

      Understanding Disseminated Intravascular Coagulation (DIC) Diagnosis

      Under normal conditions, coagulation and fibrinolysis work together to maintain homeostasis. However, in DIC, these processes become dysregulated, leading to widespread clotting and bleeding. One key factor in the development of DIC is the release of tissue factor (TF), a glycoprotein found on the surface of various cell types. Normally, TF is not in contact with the general circulation, but it is exposed after vascular damage or in response to certain cytokines. Once activated, TF triggers the extrinsic pathway of coagulation, which then triggers the intrinsic pathway. DIC can be caused by various factors, including sepsis, trauma, obstetric complications, and malignancy.

      To diagnose DIC, a typical blood picture will show decreased platelets and fibrinogen, increased fibrinogen degradation products, and the presence of schistocytes due to microangiopathic hemolytic anemia. Additionally, both the prothrombin time and activated partial thromboplastin time are prolonged, while bleeding time and platelet count are often low. Understanding the diagnosis of DIC is crucial for prompt and effective treatment.

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      • Haematology/Oncology
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  • Question 53 - A 68-year-old man who is a heavy smoker presents to his General Practitioner...

    Incorrect

    • A 68-year-old man who is a heavy smoker presents to his General Practitioner with shortness of breath and facial flushing.
      On examination, you notice some facial swelling. You suspect a bronchial neoplasm with potential superior vena cava obstruction (SVCO) as a consequence of this.
      Which of the following signs is most likely to be seen in this patient?

      Your Answer: Cranial nerve palsy

      Correct Answer: Venous dilatation over the anterior chest wall

      Explanation:

      Clinical Signs and Symptoms of Bronchial Neoplasm and SVCO

      Bronchial neoplasm is highly likely in a patient presenting with venous dilatation over the anterior chest wall. The presence of facial swelling should alert healthcare professionals to the possibility of superior vena cava obstruction (SVCO), which can cause dilated subcutaneous veins, tissue edema, and shortness of breath. An SVCO is an oncological emergency that requires prompt treatment with steroids and diuretics. Lung carcinoma is the most common cause of SVCO, but it can also be caused by lymphomas and other types of cancer.

      Other clinical signs and symptoms that may indicate lung cancer include expiratory wheeze, supraclavicular or cervical lymphadenopathy, finger clubbing, and cranial nerve palsy. However, these signs and symptoms are non-specific and may also be present in other chronic diseases. It is important to consider the patient’s overall clinical picture and perform appropriate diagnostic tests to confirm the diagnosis and determine the underlying cause of the symptoms.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 54 - A 45-year-old woman, who is a non-smoker, presents with back pain. A bone...

    Incorrect

    • A 45-year-old woman, who is a non-smoker, presents with back pain. A bone scan shows multiple lesions highly suggestive of metastases. Clinical examination is normal apart from unilateral axillary lymphadenopathy. Excision biopsy of an affected lymph node shows adenocarcinoma. Which of the following investigations should be prioritised to find the site of the primary?

      Your Answer: Chest radiograph

      Correct Answer: Mammography

      Explanation:

      When a patient presents with metastatic bone disease from an unknown primary, it is important to identify the primary source in order to guide treatment and determine prognosis. Tumours that commonly metastasize to bone include those of the lungs, prostate, breast, kidney, and thyroid.

      In cases where the patient has unilateral axillary lymphadenopathy, metastatic breast carcinoma is highly likely. Other potential causes of unilateral axillary lymphadenopathy include lymphoma, primary malignancy, melanoma, or metastases from non-breast primary malignancy.

      While there are various investigations that can be performed, mammography should be the first examination of choice. If the mammogram is negative, other investigations may be pursued to identify alternative occult sites.

      It is important to note that identifying the primary source is useful even in cases of metastatic disease, as it can guide treatment and provide insight into prognosis. Therefore, mammography plays a crucial role in the diagnosis of metastatic breast cancer.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 55 - A 19-year-old man is being examined for excessive bleeding after a tooth extraction....

    Incorrect

    • A 19-year-old man is being examined for excessive bleeding after a tooth extraction. The test results show:
      Platelet count: 173 * 109/l
      Prothrombin time (PT): 12.9 seconds
      Activated partial thromboplastin time (APTT): 84 seconds
      Which clotting factor is he most likely deficient in?

      Your Answer: Factor VII

      Correct Answer: Factor VIII

      Explanation:

      Understanding Haemophilia

      Haemophilia is a genetic disorder that affects blood coagulation. It is caused by a deficiency in either factor VIII (Haemophilia A) or factor IX (Haemophilia B), which are essential for blood clotting. Although it is an X-linked recessive disorder, up to 30% of patients have no family history of the condition.

      The symptoms of haemophilia include haemoarthroses, haematomas, and prolonged bleeding after surgery or trauma. Blood tests can confirm the diagnosis, with a prolonged APTT being a common finding. However, the bleeding time, thrombin time, and prothrombin time are usually normal.

      Treatment for haemophilia involves replacing the missing clotting factor through regular infusions. However, up to 10-15% of patients with haemophilia A may develop antibodies to factor VIII treatment, which can make it less effective.

      In summary, haemophilia is a genetic disorder that affects blood coagulation and can cause symptoms such as haemoarthroses and prolonged bleeding. Diagnosis is confirmed through blood tests, and treatment involves replacing the missing clotting factor.

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      • Haematology/Oncology
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  • Question 56 - A 45-year-old woman is referred by her general practitioner due to complaints of...

    Incorrect

    • A 45-year-old woman is referred by her general practitioner due to complaints of headache, fatigue and weakness. Recently, she had a prolonged menstrual bleeding that only stopped after the application of compression for a long time. She also suffered from a urinary tract infection the previous month. She has no family history of a bleeding disorder.
      On examination, she has pallor, hepatosplenomegaly and lymphadenopathy. Investigations reveal that she has a low haemoglobin level, a low white blood cell count and a low platelet count; numerous blast cells are visible on peripheral blood film. Bone marrow biopsy reveals 30% of blast cells. The blood film is shown below.
      Which one of the following is the most likely diagnosis?

      Your Answer: Chronic myeloid leukaemia (CML)

      Correct Answer: Acute myeloid leukaemia (AML)

      Explanation:

      Leukaemia is a type of cancer that affects the blood and bone marrow. There are several types of leukaemia, including acute myeloid leukaemia (AML), acute lymphoblastic leukaemia (ALL), chronic lymphocytic leukaemia (CLL), chronic myeloid leukaemia (CML), and hairy cell leukaemia. AML is characterized by the rapid proliferation of immature myeloid cells called blasts, which can cause anaemia, thrombocytopenia, bleeding problems, and an increased risk of infections. ALL is caused by a clonal proliferation of lymphoid precursors, which can lead to pancytopenia and symptoms such as fever and abdominal pain. CLL is the most common type of leukaemia and is caused by the clonal proliferation of monoclonal B lymphocytes. CML is the rarest form of leukaemia and is caused by a chromosomal translocation involving chromosomes 9 and 22. Hairy cell leukaemia is characterized by the presence of abnormal white cells with hair-like cytoplasmic projections. Treatment for leukaemia typically involves chemotherapy and sometimes a bone marrow transplant, depending on the type of disease present. Prognosis varies depending on the type of leukaemia and the age of the patient.

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      • Haematology/Oncology
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  • Question 57 - A 32-year-old patient who is a vegan and very active has been experiencing...

    Incorrect

    • A 32-year-old patient who is a vegan and very active has been experiencing fatigue and difficulty breathing for the past two months. During examination, she appears to be anaemic.
      What is the most probable vitamin deficiency causing her anaemia?

      Your Answer: Vitamin B6

      Correct Answer: Vitamin B12

      Explanation:

      Vegan Nutrition: Understanding the Availability of Vitamins

      As a vegan, it is important to understand the availability of vitamins in your diet. One vitamin that vegans are at risk of deficiency in is vitamin B12, which is primarily found in animal products such as meat, fish, eggs, and milk. However, there are vegan-friendly sources of vitamin B12 such as fortified cereals and plant-based milks.

      Contrary to popular belief, vitamin B6, vitamin A, vitamin B1, and vitamin C are all readily available in vegan-friendly foods. Vitamin B6 can be found in bread, whole grains, vegetables, peanuts, and potatoes. Vitamin A can be found in yellow, red, and green vegetables as well as yellow fruits. Vitamin B1 can be found in peas, fruit, whole grain bread, and fortified cereals. Vitamin C is predominantly found in fruits and vegetables such as oranges, peppers, strawberries, broccoli, potatoes, and Brussels sprouts.

      By understanding the availability of vitamins in vegan-friendly foods, vegans can ensure they are meeting their nutritional needs and maintaining a healthy diet.

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      • Haematology/Oncology
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  • Question 58 - A 10-year-old girl became acutely ill last week with vomiting, high fevers (maximum...

    Correct

    • A 10-year-old girl became acutely ill last week with vomiting, high fevers (maximum temperature of 39.5 °C) and weakness. Her mother took the girl to the general practitioner (GP) on day two of the illness, and he suggested she had gastroenteritis and that it should resolve itself in a week. However, the girl continues to be very ill and has now developed a non-blanching petechial rash on her abdomen.
      Blood tests show many blasts in the periphery, low platelets and severe anaemia.
      What is the most likely diagnosis?

      Your Answer: Acute lymphoblastic leukaemia (ALL)

      Explanation:

      Types of Leukaemia: Characteristics and Symptoms

      Leukaemia is a type of cancer that affects the blood and bone marrow. There are different types of leukaemia, each with its own characteristics and symptoms. Here are some of the most common types:

      Acute lymphoblastic leukaemia (ALL): This is the most common type of leukaemia in children, usually presenting before the age of five. It is associated with a clonal expansion of immature lymphoid progenitor cells, leading to anaemia, thrombocytopenia, and increased susceptibility to infections. Symptoms include hepatosplenomegaly, generalised lymphadenopathy, new-onset bruising, fatigue, joint and bone pain, bleeding, and superimposed infections. Treatment is with pegaspargase.

      Hairy-cell leukaemia: This is a B-cell leukaemia usually affecting middle-aged men. The malignant cells have cytoplasmic projections that make them look hairy, hence the name.

      Acute myeloblastic leukaemia (AML): This is a type of leukaemia that is most commonly seen in adults. It can be of various types, but one that is commonly assessed is promyelocytic leukaemia M3 that is characterised by cells with dark, pink, needle-like intracytoplasmic inclusions called Auer rods. This is a very aggressive form of leukaemia.

      Chronic lymphocytic leukemia (CLL): This is a disease most commonly seen in the elderly and is usually of B-cell origin. Blood smear findings commonly refer to ‘smudge cells’, which is a result of the fragile cells breaking during preparation of the smear.

      Chronic myelogenous leukemia (CML): This is a disease most commonly seen in middle-aged adults and is associated with the Philadelphia chromosome, a chimeric chromosome formed by the translocation of part of chromosome 9 to chromosome 22.

      In conclusion, leukaemia is a serious disease that requires prompt diagnosis and treatment. Knowing the characteristics and symptoms of each type can help in early detection and management.

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      • Haematology/Oncology
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  • Question 59 - A 57-year-old woman with a long history of sun exposure presents to the...

    Correct

    • A 57-year-old woman with a long history of sun exposure presents to the accident and emergency department after a fracture of her right femur associated with a minor fall. On reviewing the films with the on-call radiographer you are concerned about a lytic lesion possibly being related to the fracture.
      Which of the following primary tumours most commonly metastasises to bone?

      Your Answer: Bronchial carcinoma

      Explanation:

      Metastasis Patterns of Common Carcinomas

      Carcinomas are malignant tumors that can spread to other parts of the body through a process called metastasis. The patterns of metastasis vary depending on the type of carcinoma. Here are some common carcinomas and their typical metastasis patterns:

      Bronchial Carcinoma: This type of carcinoma often spreads to the bone or brain. Symptoms may include difficulty breathing, coughing, chest pain, weight loss, and fatigue.

      Brain Carcinoma: Primary malignant brain tumors rarely spread to other parts of the body, but they can spread to surrounding areas of the brain and spinal cord.

      Renal Carcinoma: Renal cancers commonly metastasize to the lungs, producing lesions that appear like cannonballs on a chest X-ray. They can also spread to the bone, causing osteolytic lesions.

      Gastric Carcinoma: Gastric cancers tend to spread to the liver, lung, and peritoneum. Tumors that have a preference for bone metastasis include those of the lung, prostate, breast, kidney, and thyroid.

      Colorectal Carcinoma: Colorectal cancers commonly metastasize to the liver, lung, and peritoneum. Tumors that have a preference for bone metastasis include those of the lung, prostate, breast, kidney, and thyroid.

      Understanding the patterns of metastasis for different types of carcinomas can help with early detection and treatment. If you experience any symptoms or have concerns, it’s important to speak with your healthcare provider.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 60 - A 56-year-old man who comes to see you concerned about prostate cancer. You...

    Incorrect

    • A 56-year-old man who comes to see you concerned about prostate cancer. You perform a digital rectal exam which reveals an enlarged, firm and irregular prostate. What would be the best course of action for management?

      Your Answer: Reassure Remi as he has a low PSA

      Correct Answer: Refer to urology as 2 week wait referral

      Explanation:

      The appropriate way to address the patient is as a 2-week wait referral. According to the NICE Guidelines for suspected cancer referrals, if a hard, irregular prostate indicative of prostate carcinoma is detected during rectal examination, urgent referral is necessary. Along with the referral, the PSA test result should also be included. It is important to note that the PSA test is not always reliable in detecting prostate cancer, as around 1 in 50 men with fast-growing prostate cancer have a normal PSA level.

      Prostate specific antigen (PSA) is an enzyme produced by both normal and cancerous prostate cells. It is commonly used as a marker for prostate cancer, but its effectiveness as a screening tool is still debated. The NHS Prostate Cancer Risk Management Programme (PCRMP) has released guidelines for handling requests for PSA testing in asymptomatic men. While a recent European trial showed a reduction in prostate cancer deaths, it also revealed a high risk of over-diagnosis and over-treatment. As a result, the National Screening Committee has decided not to introduce a screening programme, but rather allow men to make an informed decision. The PCRMP recommends age-adjusted upper limits for PSA levels, while NICE Clinical Knowledge Summaries suggest a lower threshold for referral. PSA levels can also be raised by factors such as benign prostatic hyperplasia, prostatitis, and urinary tract infections.

      The specificity and sensitivity of PSA testing are poor, with a significant number of men with elevated PSA levels not having prostate cancer, and some with normal PSA levels having the disease. Various methods are used to add meaning to PSA levels, including age-adjusted upper limits and monitoring changes in PSA levels over time. It is also debated whether digital rectal examination causes a rise in PSA levels. It is important to note that PSA testing should be postponed after certain events, such as ejaculation or instrumentation of the urinary tract.

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      • Haematology/Oncology
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