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  • Question 1 - As a medical student working with a geriatric care team, we recently conducted...

    Incorrect

    • As a medical student working with a geriatric care team, we recently conducted a blood test on a patient with a history of microcytic anemia. Our goal was to determine if a blood transfusion was necessary. At what Hb level is a transfusion typically recommended for elderly patients?

      Your Answer: Hb <12 g/dl

      Correct Answer:

      Explanation:

      According to the NICE guidelines, patients who require red blood cell transfusions but do not have major bleeding, acute coronary syndrome, or chronic anemia requiring regular transfusions should receive transfusions with a restrictive threshold. This threshold should be set at 7g/dl, with a target hemoglobin concentration of 7-9 g/dl after transfusion. For patients with acute coronary syndrome, a threshold of 8g/dl and a target hemoglobin concentration of 8-10g/dl after transfusion should be considered. For patients with chronic anemia requiring regular transfusions, individual thresholds and hemoglobin concentration targets should be established.

      Understanding Microcytic Anaemia

      Microcytic anaemia is a condition characterized by small red blood cells that result in a decrease in the amount of oxygen carried in the blood. There are several causes of microcytic anaemia, including iron-deficiency anaemia, thalassaemia, congenital sideroblastic anaemia, and lead poisoning. In some cases, microcytosis may be associated with a normal haemoglobin level, which could indicate the possibility of polycythaemia rubra vera. It is important to note that new onset microcytic anaemia in elderly patients should be urgently investigated to exclude underlying malignancy.

      Beta-thalassaemia minor is a type of microcytic anaemia where the microcytosis is often disproportionate to the anaemia. It is important to identify the underlying cause of microcytic anaemia to determine the appropriate treatment. Iron-deficiency anaemia is the most common cause of microcytic anaemia and can be treated with iron supplements. Thalassaemia may require blood transfusions or bone marrow transplantation. Congenital sideroblastic anaemia may require treatment with vitamin B6 supplements. Lead poisoning can be treated by removing the source of lead exposure and chelation therapy. Overall, early diagnosis and treatment of microcytic anaemia can improve outcomes and prevent complications.

    • This question is part of the following fields:

      • Haematology And Oncology
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  • Question 2 - A 35-year-old male is referred to the medical assessment unit by his physician...

    Correct

    • A 35-year-old male is referred to the medical assessment unit by his physician to investigate the possibility of thrombotic thrombocytopenic purpura (TTP) after presenting with a fever of 38.5ºC. His recent urea and electrolyte results indicate declining kidney function, with a creatinine level three times higher than his usual baseline. What is the pathophysiology underlying TTP?

      Your Answer: Failure to cleave von Willebrand factor normally

      Explanation:

      The absence of a plasma protease responsible for breaking down ultra-large multimers of von Willebrand factor (vWF) is the cause of TTP. This results in the accumulation of unusually large vWF multimers in the plasma of TTP patients. It is important to note that autoimmune destruction of red blood cells is a different form of autoimmune hemolytic anaemia and is not related to TTP. Similarly, autoimmune destruction of platelets is seen in ITP, not TTP.

      Thrombotic Thrombocytopenic Purpura: Understanding its Pathogenesis, Features, and Causes

      Thrombotic thrombocytopenic purpura (TTP) is a rare condition that typically affects adult females. Its pathogenesis involves the abnormal formation of large and sticky multimers of von Willebrand’s factor, which causes platelets to clump within vessels. In TTP, there is a deficiency of ADAMTS13, a metalloprotease enzyme that breaks down these large multimers. This deficiency leads to the formation of microemboli, resulting in fluctuating neuro signs, microangiopathic haemolytic anaemia, thrombocytopenia, and renal failure. TTP overlaps with haemolytic uraemic syndrome (HUS).

      TTP can be caused by various factors, including post-infection (e.g., urinary, gastrointestinal), pregnancy, drugs (such as ciclosporin, oral contraceptive pill, penicillin, clopidogrel, and acyclovir), tumours, SLE, and HIV. It is essential to identify the underlying cause of TTP to provide appropriate treatment and prevent further complications.

      In summary, TTP is a rare condition that affects adult females and is caused by the abnormal formation of large and sticky multimers of von Willebrand’s factor. Its features include fluctuating neuro signs, microangiopathic haemolytic anaemia, thrombocytopenia, and renal failure. TTP can be caused by various factors, and identifying the underlying cause is crucial for proper treatment.

    • This question is part of the following fields:

      • Haematology And Oncology
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  • Question 3 - Which of the following tumors is most likely to cause early para-aortic nodal...

    Correct

    • Which of the following tumors is most likely to cause early para-aortic nodal metastasis in younger patients?

      Your Answer: Ovarian

      Explanation:

      The ovarian vessels directly branch from the aorta to supply ovarian tumours. Meanwhile, the internal and external iliac nodes are responsible for draining the cervix.

      Para-aortic Lymphadenopathy and its Association with Metastasis

      Para-aortic lymphadenopathy is a condition where the lymph nodes located near the aorta become enlarged due to the spread of cancer cells. This condition is commonly associated with the metastasis of cancer cells from various organs, including the testis, ovary, and uterine fundus. In these cases, the cancer cells spread to the para-aortic lymph nodes at an early stage of the disease.

      However, it is important to note that para-aortic nodal disease may also occur as a result of cancer cells spreading from other organs. In these cases, the para-aortic nodal disease represents a much later stage of the disease, as other nodal stations are involved earlier.

      Overall, para-aortic lymphadenopathy is a significant concern for individuals with cancer, as it can indicate the spread of cancer cells to other parts of the body. Early detection and treatment of para-aortic nodal disease can improve the chances of successful treatment and recovery.

    • This question is part of the following fields:

      • Haematology And Oncology
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  • Question 4 - A 65-year-old woman visits the rheumatology clinic complaining of fatigue that has lasted...

    Incorrect

    • A 65-year-old woman visits the rheumatology clinic complaining of fatigue that has lasted for 6 weeks. She reports sleeping more than usual and feeling easily tired while walking her dog. The patient has a medical history of rheumatoid arthritis and is currently taking methotrexate. She smokes 2-3 cigarettes per day and drinks half a bottle of wine per week.

      The following investigations are ordered:

      - Haemoglobin: 88 g/L (normal range: 115 - 160)
      - Mean cell volume (MCV): 105 fL (normal range: 80 - 100)

      What is the most probable cause of this patient's symptoms?

      Your Answer: Alcohol excess

      Correct Answer: Folate deficiency

      Explanation:

      Methotrexate treatment can lead to megaloblastic macrocytic anemia due to a deficiency of folate.

      The patient’s low hemoglobin and high MCV indicate macrocytic anemia, which can be caused by various factors such as alcohol abuse, hypothyroidism, aplastic anemia, and megaloblastic anemia due to a deficiency of vitamin B12 and/or folate. In this case, the patient has a history of rheumatoid arthritis and takes methotrexate weekly, which inhibits dihydrofolate reductase and causes a deficiency of folate. Therefore, folate deficiency is the most probable cause of the patient’s anemia.

      Alcohol excess is an incorrect option as it usually requires larger quantities of alcohol to cause macrocytic anemia.

      Anaemia of chronic disease is an incorrect option as it typically results in normocytic or microcytic anemia, not macrocytic anemia.

      Iron deficiency anemia is an incorrect option as it causes microcytic anemia, and the MCV value would be lower than expected.

      Understanding Macrocytic Anaemia

      Macrocytic anaemia is a type of anaemia that can be classified into two categories: megaloblastic and normoblastic. Megaloblastic anaemia is caused by a deficiency in vitamin B12 or folate, which leads to the production of abnormally large red blood cells in the bone marrow. This type of anaemia can also be caused by certain medications, alcohol, liver disease, hypothyroidism, pregnancy, and myelodysplasia.

      On the other hand, normoblastic anaemia is caused by an increase in the number of immature red blood cells, known as reticulocytes, in the bone marrow. This can occur as a result of certain medications, such as methotrexate, or in response to other underlying medical conditions.

      It is important to identify the underlying cause of macrocytic anaemia in order to provide appropriate treatment. This may involve addressing any nutritional deficiencies, managing underlying medical conditions, or adjusting medications. With proper management, most cases of macrocytic anaemia can be successfully treated.

    • This question is part of the following fields:

      • Haematology And Oncology
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  • Question 5 - A 67-year-old woman visits the oncology clinic after being diagnosed with non-metastatic breast...

    Incorrect

    • A 67-year-old woman visits the oncology clinic after being diagnosed with non-metastatic breast cancer. She is started on neoadjuvant chemotherapy using docetaxel.

      What is the mechanism of action for this form of chemotherapy?

      Your Answer: Inhibits dihydrofolate reductase

      Correct Answer: Prevents microtubule depolymerisation and disassembly

      Explanation:

      Docetaxel, a taxane chemotherapy agent, works by reducing the amount of free tubulin through the prevention of microtubule depolymerisation and disassembly during the metaphase stage of cell division, ultimately hindering mitosis.

      Cytotoxic agents are drugs that are used to kill cancer cells. There are several types of cytotoxic agents, each with their own mechanism of action and potential adverse effects. Alkylating agents, such as cyclophosphamide, work by causing cross-linking in DNA. However, they can also cause haemorrhagic cystitis, myelosuppression, and transitional cell carcinoma. Cytotoxic antibiotics, like bleomycin and anthracyclines, degrade preformed DNA and stabilize DNA-topoisomerase II complex, respectively. However, they can also cause lung fibrosis and cardiomyopathy. Antimetabolites, such as methotrexate and fluorouracil, inhibit dihydrofolate reductase and thymidylate synthesis, respectively. However, they can also cause myelosuppression, mucositis, and liver or lung fibrosis. Drugs that act on microtubules, like vincristine and docetaxel, inhibit the formation of microtubules and prevent microtubule depolymerisation & disassembly, respectively. However, they can also cause peripheral neuropathy, myelosuppression, and paralytic ileus. Topoisomerase inhibitors, like irinotecan, inhibit topoisomerase I, which prevents relaxation of supercoiled DNA. However, they can also cause myelosuppression. Other cytotoxic drugs, such as cisplatin and hydroxyurea, cause cross-linking in DNA and inhibit ribonucleotide reductase, respectively. However, they can also cause ototoxicity, peripheral neuropathy, hypomagnesaemia, and myelosuppression.

    • This question is part of the following fields:

      • Haematology And Oncology
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  • Question 6 - A 75-year-old man has a tumour located in the central area of the...

    Correct

    • A 75-year-old man has a tumour located in the central area of the posterior third of his tongue. Which lymph node group is most likely to be affected by metastasis?

      Your Answer: Bilateral deep cervical nodes

      Explanation:

      Metastasis to the bilateral deep cervical lymph nodes is a common occurrence in tumours located in the posterior third of the tongue. This is particularly true for tumours located near the midline, as lymph vessels may cross the median plane at this location. Additionally, centrally located tumours are also more likely to exhibit early metastasis.

      Lymphatic Drainage of the Tongue

      The lymphatic drainage of the tongue varies depending on the location of the tumour. The anterior two-thirds of the tongue have minimal communication of lymphatics across the midline, resulting in metastasis to the ipsilateral nodes being more common. On the other hand, the posterior third of the tongue has communicating networks, leading to early bilateral nodal metastases being more common in this area.

      The tip of the tongue drains to the submental nodes and then to the deep cervical nodes, while the mid portion of the tongue drains to the submandibular nodes and then to the deep cervical nodes. If mid tongue tumours are laterally located, they will usually drain to the ipsilateral deep cervical nodes. However, those from more central regions may have bilateral deep cervical nodal involvement. Understanding the lymphatic drainage of the tongue is crucial in determining the spread of tumours and planning appropriate treatment.

    • This question is part of the following fields:

      • Haematology And Oncology
      6.8
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  • Question 7 - You are developing a research project to evaluate the impact of a novel...

    Incorrect

    • You are developing a research project to evaluate the impact of a novel anticoagulant on the coagulation cascade. Your focus is on the intrinsic pathway. What parameter will you measure?

      Your Answer: Prothrombin time (PT)

      Correct Answer: aPTT

      Explanation:

      The aPTT time is the most effective way to evaluate the intrinsic pathway of the clotting cascade. If the aPTT time is prolonged, it may indicate haemophilia or the use of heparin.

      To assess the extrinsic pathway, the prothrombin time (PT) is the preferred measurement.

      The thrombin time is a test that evaluates the formation of fibrin from fibrinogen in plasma. It can be prolonged by heparin, fibrin degradation products, and fibrinogen deficiency.

      A 50:50 mixing study is utilized to determine whether a prolonged PT or aPTT is caused by a factor deficiency or a factor inhibitor.

      The Coagulation Cascade: Two Pathways to Fibrin Formation

      The coagulation cascade is a complex process that leads to the formation of a blood clot. There are two pathways that can lead to fibrin formation: the intrinsic pathway and the extrinsic pathway. The intrinsic pathway involves components that are already present in the blood and has a minor role in clotting. It is initiated by subendothelial damage, such as collagen, which leads to the formation of the primary complex on collagen by high-molecular-weight kininogen (HMWK), prekallikrein, and Factor 12. This complex activates Factor 11, which in turn activates Factor 9. Factor 9, along with its co-factor Factor 8a, forms the tenase complex, which activates Factor 10.

      The extrinsic pathway, on the other hand, requires tissue factor released by damaged tissue. This pathway is initiated by tissue damage, which leads to the binding of Factor 7 to tissue factor. This complex activates Factor 9, which works with Factor 8 to activate Factor 10. Both pathways converge at the common pathway, where activated Factor 10 causes the conversion of prothrombin to thrombin. Thrombin hydrolyses fibrinogen peptide bonds to form fibrin and also activates factor 8 to form links between fibrin molecules.

      Finally, fibrinolysis occurs, which is the process of clot resorption. Plasminogen is converted to plasmin to facilitate this process. It is important to note that certain factors are involved in both pathways, such as Factor 10, and that some factors are vitamin K dependent, such as Factors 2, 7, 9, and 10. The intrinsic pathway can be assessed by measuring the activated partial thromboplastin time (APTT), while the extrinsic pathway can be assessed by measuring the prothrombin time (PT).

    • This question is part of the following fields:

      • Haematology And Oncology
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  • Question 8 - You are investigating the impact of HIV on T-cells during their maturation process....

    Incorrect

    • You are investigating the impact of HIV on T-cells during their maturation process. Which organ sample is necessary to meet the criteria of your research?

      Your Answer: Lymph nodes

      Correct Answer: Thymus

      Explanation:

      The thymus is where T-cells undergo maturation, while they are produced in the bone marrow. Once mature, they can be found in the spleen and lymph nodes where they interact with antigen presenting cells. To investigate the impact of HIV on T-cell maturation, a thymus sample is necessary.

      Understanding the Lymphatic System

      The lymphatic system is composed of primary and secondary lymphatic organs, as well as lymph vessels. The primary lymphatic organs are the thymus and red bone marrow, which are responsible for the formation and maturation of lymphocytes. These organs contain pluripotent cells that give rise to immunocompetent B cells and pre-T cells. To become mature T cells, pre-T cells must migrate to the thymus.

      On the other hand, secondary lymphatic organs include lymph nodes, the spleen, tonsils, mucosa-associated lymphoid tissue (MALT), and Peyer’s patches. These organs filter lymphocytes and activate them to mount an immune response. Understanding the lymphatic system is crucial in comprehending how the body’s immune system works. By knowing the different organs and their functions, we can appreciate how the body fights off infections and diseases.

    • This question is part of the following fields:

      • Haematology And Oncology
      6.6
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  • Question 9 - An 80-year-old woman visits her doctor complaining of excessive vaginal bleeding. After undergoing...

    Incorrect

    • An 80-year-old woman visits her doctor complaining of excessive vaginal bleeding. After undergoing an ultrasound scan and uterine biopsy, it is revealed that she has an endometrial tumor located in the uterine fundus. Which group of nearby lymph nodes will be the primary location for lymphatic metastasis of this tumor?

      Your Answer: Obturator lymph nodes

      Correct Answer: Para-aortic lymph nodes

      Explanation:

      The lymphatic drainage of the uterine fundus is similar to that of the ovaries, running alongside the ovarian vessels and draining into the para-aortic lymph nodes. Therefore, option 4 is correct. Options 1, 2, and 5 are incorrect as they refer to the drainage of the cervix and uterine body, which is different from that of the uterine fundus. Option 3 is also incorrect as the external iliac lymph nodes are not involved in the drainage of the uterine fundus.

      Lymphatic Drainage of Female Reproductive Organs

      The lymphatic drainage of the female reproductive organs is a complex system that involves multiple nodal stations. The ovaries drain to the para-aortic lymphatics via the gonadal vessels. The uterine fundus has a lymphatic drainage that runs with the ovarian vessels and may thus drain to the para-aortic nodes. Some drainage may also pass along the round ligament to the inguinal nodes. The body of the uterus drains through lymphatics contained within the broad ligament to the iliac lymph nodes. The cervix drains into three potential nodal stations; laterally through the broad ligament to the external iliac nodes, along the lymphatics of the uterosacral fold to the presacral nodes and posterolaterally along lymphatics lying alongside the uterine vessels to the internal iliac nodes. Understanding the lymphatic drainage of the female reproductive organs is important for the diagnosis and treatment of gynecological cancers.

    • This question is part of the following fields:

      • Haematology And Oncology
      8.1
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  • Question 10 - A 65-year-old woman has been diagnosed with endometrial carcinoma originating from the uterine...

    Incorrect

    • A 65-year-old woman has been diagnosed with endometrial carcinoma originating from the uterine body. Which nodal region will the tumor spread to first?

      Your Answer: Para aortic nodes

      Correct Answer: Iliac lymph nodes

      Explanation:

      In the case of uterine body tumours, the initial spread is likely to occur in the iliac nodes. This becomes clinically significant when nodal clearance is carried out during a Wertheims type hysterectomy, as the tumour may cross different nodal margins.

      Lymphatic Drainage of Female Reproductive Organs

      The lymphatic drainage of the female reproductive organs is a complex system that involves multiple nodal stations. The ovaries drain to the para-aortic lymphatics via the gonadal vessels. The uterine fundus has a lymphatic drainage that runs with the ovarian vessels and may thus drain to the para-aortic nodes. Some drainage may also pass along the round ligament to the inguinal nodes. The body of the uterus drains through lymphatics contained within the broad ligament to the iliac lymph nodes. The cervix drains into three potential nodal stations; laterally through the broad ligament to the external iliac nodes, along the lymphatics of the uterosacral fold to the presacral nodes and posterolaterally along lymphatics lying alongside the uterine vessels to the internal iliac nodes. Understanding the lymphatic drainage of the female reproductive organs is important for the diagnosis and treatment of gynecological cancers.

    • This question is part of the following fields:

      • Haematology And Oncology
      4.3
      Seconds

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Haematology And Oncology (3/10) 30%
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