A 50-year-old man presents for a follow-up after being diagnosed with limited-stage small cell lung cancer (SCLC). He underwent four cycles of chemotherapy and concurrent radiation to the tumour site, resulting in significant tumour response as confirmed by CT scan, which showed scarring only in the area of the primary tumour in the right upper lobe and no evidence of recurrence. The patient has a good performance status and physical examination is unremarkable except for decreased breath sounds and crackles in the right upper chest. Neurologic examination results are normal.
What is the most appropriate next step in management?
MRCP2-3633
A 57-year-old woman presents to the Emergency department with complaints of chest pain and shortness of breath after a transatlantic flight from New York. She has a medical history of breast cancer and has undergone treatment with doxorubicin, cyclophosphamide, and radiation therapy. She is currently taking an aromatase inhibitor for oestrogen receptor-positive breast cancer. On physical examination, she is tachycardic at 110/min, has a respiratory rate of 24/min, and a BMI of 24 kg/m2. Her oxygen saturation on ambient air is 92%, and her estimated central venous pressure is 8 cm H2O. Carotid upstrokes are normal, and her x-ray is normal. Which of the following medical interventions is most likely responsible for her current symptoms?
MRCP2-3634
A 55-year-old man presents to the medical admissions unit (MAU) with a two-month history of worsening back pain. His primary care physician initially prescribed simple analgesia, but when the pain persisted, an x-ray of his lumbar spine was ordered. The x-ray revealed a lytic lesion in L2, which is consistent with a metastatic deposit of unknown origin. The patient reports feeling well over the past year, with no symptoms other than his back pain. He is a non-smoker and takes no regular medication. A full clinical examination, including neurological examination, is unremarkable.
The FY1 doctor on MAU has ordered some initial investigations, including FBC, U/E, LFT, bone profile, and LDH, along with urinalysis, chest x-ray, and a myeloma screen. All of these investigations have come back normal. What should be the next course of action?
MRCP2-3635
A 52-year-old woman presents with a right leg deep venous thrombosis (DVT). On further questioning, there is a history of increasing abdominal bloating and discomfort over the past few months. She has had two children and her menses began when she was aged 12. She used the oral contraceptive pill for 10 years. Her mother died of breast cancer at the age of 65. On examination, there is evidence of ascites and a right ovarian mass. Ultrasound confirms the ovarian mass, and raised CA-125 is suggestive of ovarian carcinoma. Which one of the following factors in her history is most associated with risk of ovarian cancer?
MRCP2-3637
A 42-year-old woman with a history of breast cancer is admitted to the hospital with a 3-week history of worsening chest pain and a 2-day history of swelling in her face, neck veins, and left arm. She was diagnosed and treated for breast cancer 3 years ago but has recently experienced a recurrence. A CT scan has revealed a large tumor surrounding her superior vena cava, which is starting to invade her heart muscle. What is the most appropriate initial treatment for this woman?
MRCP2-3638
A 58-year-old man presents with worsening shortness of breath over the past year. He has been using inhalers prescribed by his GP for the past two years, but only intermittently in the last three months. He has a six-year history of hypertension and takes ramipril 10 mg od and bendroflumethiazide 2.5 mg daily. He quit smoking two years ago and drinks approximately 14 units of alcohol per week. On examination, he appears cyanosed with a swollen face and dilated superficial veins over the anterior chest wall, along with fixed dilated neck veins. His blood pressure is 154/88 mmHg, and his pulse is 88 beats per minute. Respiratory examination reveals a hyperexpanded chest with scattered expiratory wheeze, and there is pitting edema of the ankles. Abdominal examination is normal.
Investigations show a hemoglobin level of 148 g/L (130-180), a white cell count of 12.91 ×109/L (4-11), platelets of 488 ×109/L (150-400), serum sodium of 130 mmol/L (137-144), serum urea of 10.8 mmol/L (2.5-7.5), and serum corrected calcium of 2.81 mmol/L (2.2-2.6). The ECG is normal, and a chest x-ray shows hyperexpanded lung fields with left paratracheal shadowing. A CT scan of the thorax reveals an anterior mediastinal mass.
What single investigation would be most useful in making a diagnosis?
MRCP2-3639
A 67-year-old man had undergone right hemicolectomy with adjuvant chemotherapy for stage III colon cancer two years ago. He has been regularly monitored with annual CT scans and serum carcinoembryonic antigen (CEA) level measurements. However, his recent CEA level is 20.1 ng/mL (20.1 µg/L) (normal <2.0 ng/mL [2.0 µg/L]) compared to 2.0 ng/mL (2.0 µg/L) last year. A restaging CT scan of the abdomen and pelvis reveals a 2 cm solitary lesion in the liver, and otherwise, it is unremarkable. What is the most appropriate initial treatment?
MRCP2-3640
A 45-year-old man presents to the Emergency Department with shortness of breath. He was diagnosed with non-Hodgkin lymphoma 8 months ago and has been undergoing chemotherapy. He is waiting for an appointment in haematology outpatients to evaluate his response to treatment.
The patient reports feeling increasingly breathless over the past week and experiencing puffiness in his arms and face. He denies chest pain, cough, or fever. On examination, his oxygen saturation is 92% on air and his heart rate is 112 beats per minute. His chest is clear, but he is unable to lie flat for an abdominal examination due to his breathlessness. He has flushed skin and oedema in his arms and hands, and his neck veins are engorged.
A chest x-ray reveals a widened mediastinum with extensive lymphadenopathy. A CT scan of the thorax confirms superior vena cava obstruction (SVCO). The haematology team reviews the scan and informs the patient that his lymphoma has progressed despite chemotherapy. He is started on steroids and a proton pump inhibitor.
What is the next step in managing this patient’s SVCO?
MRCP2-3641
A 45-year-old woman was diagnosed with breast cancer three years ago. She had a wide local excision with axillary node sampling which showed a grade 3, 19 mm invasive carcinoma of no specific type. The cancer was ER/PR positive and Her-2 negative. Due to one positive lymph node, she received chemotherapy and radiotherapy as adjuvant treatment. After completing the treatment, she started adjuvant endocrine therapy for a planned duration of five years. Recently, she visited the DVT clinic with a swollen and tense left calf. An ultrasound Doppler scan confirmed the presence of a below knee DVT, and she was started on therapeutic enoxaparin. What endocrine agent was likely prescribed to this woman?
MRCP2-3642
A 50-year-old woman with a family history of breast cancer is hesitant to start taking tamoxifen as a preventative measure. However, she has recently been diagnosed with early-stage breast cancer and is now considering tamoxifen as part of her treatment plan. During her follow-up appointment, she expresses concerns about the long-term effects of tamoxifen. What advice can you offer her?