-
Question 1
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
-
-
Question 2
Incorrect
-
A 68-year-old man presents with complaints of weight loss and fatigue that have been ongoing for several months. Upon examination, the only notable finding is pallor. A blood film reveals the presence of immature blasts, and genetic testing shows the presence of a chromosomal translocation t(9;22) - the Philadelphia chromosome. Further investigations reveal the following results: Hb of 95 g/l (normal range: 135-175 g/l), leukocytes of 62 × 109/l (normal range: 4.0-11.0 × 109/l), and PLT of 101 × 109/l (normal range: 150-400 × 109/l). What is the most likely diagnosis?
Your Answer: Acute lymphocytic leukaemia (ALL)
Correct Answer: Chronic myeloid leukaemia (CML)
Explanation:Chronic myeloid leukaemia (CML) is a rare form of cancer that occurs due to the abnormal growth of myeloid precursors or blasts. This leads to an increase in white blood cells and a decrease in the normal functions of the bone marrow, resulting in anaemia and thrombocytopenia. CML is most commonly seen in people between the ages of 60 and 70 and has a slow onset that can last for months or even years. The majority of cases are caused by a genetic mutation called the Philadelphia chromosome, which produces a protein that promotes the growth of cancer cells. Symptoms of CML include fatigue, weight loss, night sweats, abdominal distension, and left upper quadrant pain. Treatment for CML involves inhibiting the genetic mutation with a drug called imatinib.
Acute lymphocytic leukaemia (ALL) is a type of cancer that occurs due to the abnormal growth of immature lymphocytes, which replace the normal cells of the bone marrow and lead to a decrease in blood cell production. ALL is most commonly seen in children and presents with symptoms such as anaemia, fever, and abdominal pain. Diagnosis is made through bone marrow biopsy and genetic analysis, which can reveal chromosomal abnormalities associated with the disease.
Hodgkin’s lymphoma (HL) is a type of cancer that typically presents with enlarged lymph nodes and is associated with the presence of Reed-Sternberg cells, which are abnormal B cells. Multiple myeloma (MM) is a cancer that affects plasma cells in the bone marrow, leading to a decrease in blood cell production and other symptoms such as hypercalcemia and kidney dysfunction. Non-Hodgkin’s lymphoma (NHL) is a type of cancer that arises from the abnormal growth of B cells, T cells, or natural killer cells and can be caused by genetic mutations, infections, or chronic inflammation. Symptoms of NHL include enlarged lymph nodes throughout the body.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 3
Correct
-
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: 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.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 4
Correct
-
A 63-year-old man presents to the haematology clinic with fatigue, significant weight loss, and easy bruising over the past 2 years. His blood test results are as follows:
- Hemoglobin: 90 g/L (normal range for males: 135-180 g/L; females: 115-160 g/L)
- Platelets: 85 * 109/L (normal range: 150-400 * 109/L)
- White blood cells: 70.5 * 109/L (normal range: 4.0-11.0 * 109/L)
- Neutrophils: 61.8 * 109/L (normal range: 2.0-7.0 * 109/L)
- Lymphocytes: 1.2 * 109/L (normal range: 1.0-3.5 * 109/L)
- Monocytes: 3.0 * 109/L (normal range: 0.2-0.8 * 109/L)
- Eosinophils: 2.5 * 109/L (normal range: 0.0-0.4 * 109/L)
The blood film shows obvious leucocytosis with eosinophilia and basophilia visible. There are also large numbers of immature granulocytes, but no blast cells are visible. What is the most appropriate first-line treatment for this patient?Your Answer: Imatinib
Explanation:The patient’s history and blood results suggest that they have chronic myeloid leukaemia (CML), which is characterized by a high white cell count due to an excess of myeloid cells and a chronic presentation. The absence of blast cells indicates that this is not acute leukaemia. The patient’s anaemia and thrombocytopenia are likely due to bone marrow dysfunction caused by myelofibrosis, indicating a need for treatment. The first-line treatment for CML is imatinib, a tyrosine kinase inhibitor that is taken as a daily tablet and has shown excellent results in treating CML.
Given the patient’s signs of bone marrow dysfunction, conservative management is not appropriate. While there may be a role for no treatment in early disease detected incidentally on a blood test, this patient requires treatment at this point.
It is important to note that fludarabine and cyclophosphamide are chemotherapy agents used in treating chronic lymphocytic leukaemia (CLL) and have no role in managing CML. The blood test abnormalities expected in CLL are similar to those seen in CML, but with a differential showing normal or low neutrophil and high lymphocyte counts.
Prednisolone, a glucocorticoid used to treat various conditions, is often used in treating different forms of lymphoma but is not effective in managing CML.
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.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 5
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: 30mg
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
-
-
Question 6
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:
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
-
-
Question 7
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:
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.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 8
Incorrect
-
A 25-year-old female student attends the blood transfusion service wishing to donate blood. She is currently well, has never had a serious illness and weighs 60 kg. About three months ago she spent the summer doing voluntary work in Nigeria. She also had her ears pierced three years ago and had a tattoo put on her left arm one year ago. She is not acceptable as a donor.
Which of the following is the reason for her rejection to donate blood in the UK?Your Answer:
Correct Answer: Recent travel to an endemic area
Explanation:Blood Donation Eligibility Criteria: Factors to Consider
When it comes to donating blood, there are several factors to consider to ensure the safety of both the donor and the recipient. Here are some examples:
Recent travel to an endemic area: If a person has recently traveled to a country with a high risk of infectious diseases, they may have to wait a certain period before donating blood. For instance, if someone has returned from Nigeria, they must wait at least six months before donating blood in the UK.
Underweight: A person must weigh at least 50 kg to donate blood. If they weigh less than that, they may not have enough blood volume to spare.
Body piercing: If someone has had a body piercing within the last 12 months, they should inform the staff before donating blood. They may have to wait for at least four months before donating.
Tattoo: Similarly, if someone has had a tattoo within the last 12 months, they should inform the staff before donating blood. They may have to wait for at least four months before donating.
Age: To donate blood, a person must be between 17 and 66 years old (or 70 if they have donated blood before). If they are over 70, they can still donate if they have donated blood in the last two years.
By considering these factors, blood donation centers can ensure that the blood they collect is safe and suitable for transfusion.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 9
Incorrect
-
A 45-year-old woman with a 30-pack-year history of smoking visits her General Practitioner with complaints of dark urine, nausea and overall weakness. She reports experiencing a seizure and was admitted to the hospital where she was diagnosed with a 'hormone tumor'. What is the most probable diagnosis?
Your Answer:
Correct Answer: Small-cell carcinoma of the lung (SCLC)
Explanation:Small-cell carcinoma of the lung (SCLC) is a type of lung cancer that is often associated with a condition called syndrome of inappropriate antidiuretic hormone syndrome (SIADH). SIADH is caused by the abnormal release of anti-diuretic hormone (ADH), which leads to impaired water excretion and hyponatremia. This can result in symptoms such as nausea, weakness, confusion, and seizures. While SCLC is the most common cause of SIADH, it can also be caused by other types of cancer, certain drugs, intracranial lesions, and infections. Squamous-cell carcinoma (SCC) of the lung, on the other hand, does not typically result in SIADH as it does not originate from neuroendocrine cells. Pancreatic cancer can also cause SIADH, but it is less common than in SCLC. Prostate cancer, which is the second most common cancer globally, does not usually present with hormonal effects but rather with lower urinary tract symptoms. Bronchial carcinoid tumors, which are neuroendocrine tumors of the lung, can cause hormonal effects such as weight gain, high blood pressure, and hirsutism, but these symptoms are not indicated in the scenario given.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 10
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:
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
-
-
Question 11
Incorrect
-
A 30-year-old man presents with fatigue, joint pain, and abnormal liver function tests. After investigation, he is diagnosed with hereditary hemochromatosis. His wife undergoes genetic testing and is found to not carry the disease. What is the likelihood that their child will develop hemochromatosis?
Your Answer:
Correct Answer: 0%
Explanation:Understanding Haemochromatosis: Symptoms, Causes, and Complications
Haemochromatosis is a genetic disorder that affects iron absorption and metabolism, leading to the accumulation of iron in the body. It is caused by mutations in the HFE gene on both copies of chromosome 6. This disorder is more common in people of European descent, with a prevalence of 1 in 200.
In the early stages of haemochromatosis, symptoms are often non-specific, such as fatigue and joint pain. As the disease progresses, patients may develop bronze skin pigmentation, diabetes mellitus, liver disease, cardiac failure, hypogonadism, and arthritis.
Treatment for haemochromatosis involves regular phlebotomy to remove excess iron from the body. Reversible complications of haemochromatosis include cardiomyopathy, skin pigmentation, liver cirrhosis, diabetes mellitus, hypogonadotrophic hypogonadism, and arthropathy. However, irreversible complications include cirrhosis, which can lead to liver failure and other serious health problems.
In conclusion, haemochromatosis is a genetic disorder that affects iron metabolism and can lead to serious health complications if left untreated. Early diagnosis and treatment can help prevent irreversible damage and improve quality of life for affected individuals.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 12
Incorrect
-
A 68-year-old woman presents to her General Practitioner to discuss some recent blood tests which were taken for tri-monthly monitoring of her methotrexate. She has rheumatoid arthritis (RA) and takes methotrexate, folic acid and co-codamol.
Investigations:
Investigation Result Normal value
Haemoglobin 91 g/l 115–165 g/l
White cell count (WCC) 5.2 × 109/l 4.0–11.0 × 109/l
Platelets 228 × 109/l 150–400 × 109/l
Neutrophils 5.4 × 109/l 2.0–7.5 × 109/l
Mean corpuscular volume (MCV) 96 fl 85–105 fl
Mean corpuscular haemoglobin (MCH) 29 pg 27–32 pg
Sodium 138 mmol/l 135–145 mmol/l
Potassium 4.1 mmol/l 3.5–5.3 mmol/l
Urea 3.2 mmol/l 2.5–7.5 mmol/l
Creatinine 68 µmol/l 53–100 µmol/l
Estimated glomerular filtration rate > 90 ml/min per 1.73m2 > 90 ml/min per 1.73m2
What is the most likely cause of this patient’s anaemia?
Your Answer:
Correct Answer: Anaemia of chronic disease
Explanation:Understanding the Causes of Normocytic Anaemia in a Patient with Rheumatoid Arthritis
The patient in question has been diagnosed with normocytic anaemia, which is characterized by normal MCV and MCH results. There are several potential causes of this type of anaemia, including renal failure, anaemia of chronic disease, and mixed iron and vitamin B12 or folate deficiency. However, given that the patient has rheumatoid arthritis (RA) and normal renal function, the most likely cause of her anaemia is a chronic disease. This is thought to be the result of chronic inflammation associated with diseases such as RA.
One potential complication of RA is Felty syndrome, which is characterized by a triad of conditions: RA, splenomegaly, and neutropenia. However, this patient has a normal WCC and neutrophil count, which rules out this diagnosis.
Vitamin B12 deficiency can also cause anaemia, but it typically results in macrocytic anaemia characterized by a raised MCV. In contrast, this patient has a normal MCV. Vitamin B12 deficiency is typically treated with oral supplements, unless intrinsic antibodies are present, in which case intramuscular B12 is needed.
Folate deficiency can also drive macrocytic anaemia, but this patient demonstrates normocytic anaemia. Methotrexate, which is commonly used to treat RA, is a folate antagonist, which is why the patient is also taking folic acid supplements to reduce the risk of developing folate deficiency.
Iron deficiency is another potential cause of anaemia, but it typically results in microcytic hypochromic anaemia characterized by low MCV and MCH. In contrast, this patient has normal MCV and MCH results. A combination of iron and vitamin B12 or folate deficiencies may result in normocytic anaemia, as can acute blood loss.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 13
Incorrect
-
A 65-year-old man with lung cancer is currently on MST 30 mg bd for pain management. What dosage of oral morphine solution should be prescribed for his breakthrough pain?
Your Answer:
Correct Answer: 10 mg
Explanation:The breakthrough dose should be 10 mg, which is one-sixth of the total daily morphine dose of 60 mg (30 mg taken twice a day).
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
-
-
Question 14
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:
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.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 15
Incorrect
-
A 70-year-old man with a 12-year history of gastro-oesophageal reflux disease presents with dysphagia. Upon endoscopy, an obstructive lesion is observed that is highly suspicious of oesophageal cancer. What is the expected result of the biopsy?
Your Answer:
Correct Answer: Adenocarcinoma
Explanation:Gastroesophageal reflux disease (GORD) or Barrett’s esophagus are linked to the development of oesophageal adenocarcinoma.
Oesophageal Cancer: Types, Risk Factors, Features, Diagnosis, and Treatment
Oesophageal cancer used to be mostly squamous cell carcinoma, but adenocarcinoma is now becoming more common, especially in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett’s. Adenocarcinoma is usually located near the gastroesophageal junction, while squamous cell tumours are found in the upper two-thirds of the oesophagus.
Risk factors for adenocarcinoma include GORD, Barrett’s oesophagus, smoking, achalasia, and obesity. Squamous cell cancer is more common in the developing world and is associated with smoking, alcohol, achalasia, Plummer-Vinson syndrome, and diets rich in nitrosamines.
The most common presenting symptom for both types of oesophageal cancer is dysphagia, followed by anorexia and weight loss. Other possible features include odynophagia, hoarseness, melaena, vomiting, and cough.
Diagnosis is done through upper GI endoscopy with biopsy, endoscopic ultrasound for locoregional staging, CT scanning for initial staging, and FDG-PET CT for detecting occult metastases. Laparoscopy may also be performed to detect occult peritoneal disease.
Operable disease is best managed by surgical resection, with the most common procedure being an Ivor-Lewis type oesophagectomy. However, the biggest surgical challenge is anastomotic leak, which can result in mediastinitis. Adjuvant chemotherapy may also be used in many patients.
Overall, oesophageal cancer is a serious condition that requires prompt diagnosis and treatment. Understanding the types, risk factors, features, diagnosis, and treatment options can help patients and healthcare providers make informed decisions about managing this disease.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 16
Incorrect
-
A 27-year-old man with a medical history of sickle cell disease presents with intense pain in his left hip. He mentions having received antibiotics from his general practitioner for a chest infection. How would you categorize this sickle cell crisis?
Your Answer:
Correct Answer: Thrombotic crises
Explanation:Sickle cell patients may experience thrombotic crises due to factors such as infection, dehydration, or deoxygenation. In this case, the patient’s severe pain and recent infection suggest a thrombotic crisis. Other types of crises, such as sequestration crises that present with acute chest syndrome, aplastic crises caused by parvovirus infection, or haemolytic crises with increased haemolysis, may have different symptoms. A thyrotoxic crisis would not be related to sickle cell disease.
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
-
-
Question 17
Incorrect
-
A 52-year-old man presents to his General Practitioner to discuss worsening symptoms of pruritus and weight loss over the last few weeks. He has a known diagnosis of ulcerative colitis (UC).
On examination, he is jaundiced. His abdomen is soft and nontender and there is a palpable mass in the right upper quadrant.
Investigations:
Investigation Result Normal value
Bilirubin 178 umol/l 0–21 umol/l
Alanine transaminase (ALT) 32 IU/l 10–45 IU/l
Aspartate transaminase (AST) 27 IU/l 15–42 IU/l
Alkaline phosphatase (ALP) 648 IU/l 30–130 IU/l
Gamma-glutamyl transferase (GGT) 1042 IU/l 15–40 IU/l
Alpha-fetoprotein (AFP) 8 IU/l 0–10 IU/l
What is the most likely diagnosis?
Select the SINGLE most likely diagnosis from the options below. Select ONE option only.Your Answer:
Correct Answer: Cholangiocarcinoma
Explanation:Differential Diagnosis for Obstructive Jaundice in a Patient with Ulcerative Colitis
Ulcerative colitis (UC) is a chronic inflammatory bowel disease that increases the risk of developing hepatobiliary cancers. When a patient with UC presents with obstructive jaundice, the most likely diagnosis is cholangiocarcinoma, as evidenced by a raised bilirubin with normal transaminases but raised ALP and GGT.
Other potential causes of obstructive jaundice include gallstones, which typically present with right upper quadrant pain and fever, and gallbladder empyema if the patient is acutely unwell. Haemochromatosis, an inherited condition that causes liver damage due to excessive iron absorption, would present with raised transaminases rather than obstructive jaundice.
Hepatocellular carcinoma (HCC) is another potential diagnosis in a patient with UC, but it is characterized by raised transaminases and ALP. Non-alcoholic fatty liver disease (NAFLD), which results from a build-up of fat in the liver, is more common in individuals who are obese, have type II diabetes, hyperlipidaemia, or metabolic syndrome, and would present with raised transaminases rather than ALP and GGT.
In summary, when a patient with UC presents with obstructive jaundice, cholangiocarcinoma should be the primary consideration, but other potential causes should also be evaluated.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 18
Incorrect
-
A 50-year-old woman, who is currently four weeks into a course of postoperative radiotherapy for locally advanced cervical carcinoma, is admitted with abdominal pain and diarrhoea.
Which of the following is the most likely cause of the clinical picture?Your Answer:
Correct Answer: Radiation enteritis
Explanation:Understanding Radiation Enteritis and Other Possible Causes of Bowel Symptoms
Radiation enteritis is a condition that occurs when the bowel becomes inflamed due to radiation therapy. It can manifest as ileitis, colitis, or proctitis, and can be acute or chronic. Acute radiation enteritis typically occurs during therapy and presents with symptoms such as anorexia, diarrhoea, and abdominal pain. Chronic radiation enteritis, on the other hand, can develop months or years after treatment and may cause weight loss, steatorrhoea, and small bowel obstruction.
While radiation enteritis is a likely cause of bowel symptoms in patients who have undergone radiation therapy, other conditions should also be considered. Bowel obstruction, for example, can cause nausea, vomiting, and bloating, but does not typically cause diarrhoea. Local malignant infiltration to the bowel may present with obstruction, while bowel perforation is a medical emergency that causes peritonitis and sepsis.
In summary, understanding the possible causes of bowel symptoms is important in determining the appropriate treatment for patients. While radiation enteritis is a common consequence of radiation therapy, other conditions such as bowel obstruction, local malignant infiltration, and bowel perforation should also be considered.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 19
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:
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
-
-
Question 20
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:
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
-
-
Question 21
Incorrect
-
A 72-year-old patient with chronic lymphocytic leukaemia presents to the emergency department with haematemesis. Urgent blood tests are taken and blood products ordered from the laboratory.
A full blood count shows:
Hb 76 g/L Male: (135-180) Female: (115 - 160)
Platelets 26 * 109/L (150 - 400)
WBC 21.8 * 109/L (4.0 - 11.0)
Which blood product carries the highest risk for this immunocompromised patient?Your Answer:
Correct Answer: Platelets
Explanation:Platelet transfusions have the highest risk of bacterial contamination due to their short shelf life and refrigeration. This patient requires both red blood cells and platelets, but caution should be taken with platelet transfusions due to the risk of contamination. Cryoprecipitate and plasma have lower contamination risks and can be stored for longer periods. Packed red cells can also be used and have a longer shelf life.
Platelet Transfusion Guidelines for Active Bleeding and Pre-Invasive Procedures
Platelet transfusions are recommended for patients with thrombocytopenia and clinically significant bleeding, such as haematemesis, melaena, or prolonged epistaxis, with a platelet count of less than 30 x 10 9. For severe bleeding or bleeding at critical sites, such as the CNS, platelet thresholds for transfusion are higher, with a maximum of less than 100 x 10 9. However, it should be noted that platelet transfusions have a higher risk of bacterial contamination compared to other types of blood products.
For pre-invasive procedures, platelet transfusions are recommended to maintain platelet levels of greater than 50 x 10 9/L for most patients, 50-75 x 10 9/L for those at high risk of bleeding, and greater than 100 x 10 9/L for surgeries at critical sites. However, if there is no active bleeding or planned invasive procedure, a threshold of 10 x 10 9/L is recommended, unless platelet transfusion is contraindicated or there are alternative treatments available for the patient’s condition.
It is important to note that platelet transfusions should not be performed for chronic bone marrow failure, autoimmune thrombocytopenia, heparin-induced thrombocytopenia, or thrombotic thrombocytopenic purpura. These guidelines aim to provide appropriate and safe platelet transfusion practices for patients with thrombocytopenia.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 22
Incorrect
-
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:
Correct 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
-
-
Question 23
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:
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
-
-
Question 24
Incorrect
-
A 28-year-old man presents to his General Practitioner with pallor, fatigue, weakness, palpitations and dyspnoea on exertion. His symptoms have come on quickly over the last three weeks. A full blood count is ordered and is suggestive of acute lymphoblastic myeloid leukaemia (AML).
What Is the next most appropriate investigation for this patient?
Your Answer:
Correct Answer: Bone marrow biopsy
Explanation:Diagnostic Tests for Acute Myeloid Leukaemia
Acute myeloid leukaemia (AML) is a type of blood cancer that affects the bone marrow. To diagnose AML, several diagnostic tests may be performed. The most common tests include a bone marrow biopsy, ultrasound scan of the abdomen, chest X-ray, computerised tomography (CT) scan of chest, abdomen and pelvis, and lumbar puncture.
Bone Marrow Biopsy: This is the most important test for diagnosing AML. It involves extracting cells from the bone marrow and examining them under a microscope. AML is characterised by the presence of primitive myeloblasts and Auer rods in the bone marrow.
Ultrasound Scan of the Abdomen: This test is used to check for enlarged lymph nodes in the abdomen or spleen. If any enlarged lymph nodes are found, they may be biopsied to determine the extent of the leukaemia.
Chest X-ray: This test is used to check for enlarged lymph nodes in the mediastinum.
CT Scan of Chest, Abdomen and Pelvis: This test is not usually used as a first-line investigation for AML. However, once the diagnosis is confirmed, a CT scan may be used to assess for the presence of enlarged lymph nodes or for planning purposes if radiotherapy is going to form part of the treatment.
Lumbar Puncture: This test is not usually used in the diagnosis of AML unless it is suspected that the leukaemia cells are also present in the cerebrospinal fluid.
In conclusion, a bone marrow biopsy is the most important test for diagnosing AML. Other tests may be used to determine the extent of the leukaemia or for planning purposes if radiotherapy is going to form part of the treatment.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 25
Incorrect
-
Among the following groups of malignant tumours, which one is known for frequently metastasizing to bone?
Your Answer:
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
-
-
Question 26
Incorrect
-
A 60-year-old patient presents with jaundice and an enlarged, nodular liver. A CT scan of the abdomen reveals a cirrhotic liver with a large mass, and CT-guided biopsy of the mass confirms a malignant tumour derived from hepatic parenchymal cells. Which virus is most likely directly related to the development of this tumour?
Your Answer:
Correct Answer: Hepatitis B virus
Explanation:Viral Infections and Their Link to Cancer
Hepatitis B, Epstein-Barr, human herpesvirus type 8, and human papillomavirus are all viral infections that have been linked to the development of cancer. Hepatitis B, for example, can lead to cirrhosis and ultimately hepatocellular carcinoma. Similarly, EBV has been associated with various malignancies, including lymphoproliferative disorders and nasopharyngeal carcinoma. HPV, on the other hand, is a common cause of genital warts and cervical cancer. It is important to recognize the early signs of these viral infections in order to prevent the development of cancer and improve prognosis.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 27
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:
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
-
-
Question 28
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:
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
-
-
Question 29
Incorrect
-
A 78-year-old woman presents to her general practitioner with a painless lump in her groin that she noticed 2 weeks ago. The lump has grown slightly since she first noticed it. On examination, a hard lump is palpable on her left labia majora and she has left inguinal lymphadenopathy. She has no significant past medical history and no known allergies.
What is the most probable diagnosis?Your Answer:
Correct Answer: Vulval carcinoma
Explanation:A possible diagnosis for an older woman with a labial lump and inguinal lymphadenopathy is vulval carcinoma, especially if the lump is firm and has grown rapidly over a short period of time. Risk factors for this condition include advanced age, smoking, and HPV infection. Bartholin’s cyst, condylomata lata, lipoma, and sebaceous cyst are less likely diagnoses, as they do not typically present with the same symptoms or risk factors as vulval carcinoma.
Understanding Vulval Carcinoma
Vulval carcinoma is a type of cancer that affects the vulva, which is the external female genitalia. It is a relatively rare condition, with only around 1,200 cases diagnosed in the UK each year. The majority of cases occur in women over the age of 65 years, and around 80% of cases are squamous cell carcinomas.
There are several risk factors associated with vulval carcinoma, including human papilloma virus (HPV) infection, vulval intraepithelial neoplasia (VIN), immunosuppression, and lichen sclerosus. Symptoms of vulval carcinoma may include a lump or ulcer on the labia majora, inguinal lymphadenopathy, and itching or irritation.
It is important for women to be aware of the risk factors and symptoms of vulval carcinoma, and to seek medical attention if they experience any concerning symptoms. Early detection and treatment can improve outcomes and increase the chances of a full recovery.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 30
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:
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
-
-
Question 31
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:
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
-
-
Question 32
Incorrect
-
A 27-year-old woman with a BMI of 34 kg/m² presents to your GP clinic with a small lump in her right breast. She is worried about the possibility of breast cancer, although she has noticed that the lump has decreased in size over the past two weeks. She denies any direct injury but mentions playing rugby recently. There is no family history of breast or gynaecological cancer. On examination, a small, firm, poorly mobile lump is found in the lower quadrant of the right breast.
What is the most probable diagnosis?Your Answer:
Correct Answer: Traumatic breast fat necrosis
Explanation:Traumatic breast fat necrosis may develop following a minor or unnoticed injury in women with a high body mass index, although it is crucial to investigate any lump to exclude breast cancer. Nipple discharge is a common symptom of mammary duct ectasia, while a tender lymph node in the axilla is likely to be palpable. Paget’s disease is characterized by an eczema-like appearance of the nipple, not a lump. Fibroadenoma, also known as a breast mouse, is not attached.
Understanding Fat Necrosis of the Breast
Fat necrosis of the breast is a condition that affects up to 40% of cases and is often caused by trauma. This condition can be mistaken for breast cancer due to its physical features, such as a mass that may initially increase in size. It is important to understand that fat necrosis is not cancerous and can be treated with proper care.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 33
Incorrect
-
A 65-year-old man who works as a pipe lagger is referred to you with a 6-month history of increasing shortness of breath and weight loss. He is a lifelong non-smoker and has always led a fit, healthy life. Clinical examination indicates a left pleural effusion, which is confirmed on the chest radiograph. Which of the following malignant causes is most likely? Select the SINGLE malignant cause from the list below. Select ONE option only.
Your Answer:
Correct Answer: Mesothelioma
Explanation:Understanding Mesothelioma and Other Possible Malignancies
Mesothelioma is a rare and aggressive form of cancer that is often linked to asbestos exposure. Those who worked as pipe laggers in the past were frequently exposed to asbestos, which can lead to mesothelioma. Symptoms of mesothelioma include cough, shortness of breath, chest pain, and weight loss. While the prognosis for mesothelioma remains poor, some cases can be surgically resected and chemotherapy can provide palliative care.
However, other malignancies can also present with similar symptoms, such as non-small-cell cancer, small-cell lung cancer, squamous-cell lung cancer, and bronchial carcinoid tumors. It is important to exclude these possibilities and properly diagnose the specific type of cancer in order to provide the most effective treatment.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 34
Incorrect
-
A 47-year-old man is seen by his General Practitioner for his annual hypertension review. He agrees to be referred to the local smoking cessation service, as he is currently experiencing chest pain.
Which of the following medications will need to be monitored closely on cessation of smoking?Your Answer:
Correct Answer: Theophylline
Explanation:The Effect of Smoking Cessation on Asthma Medications
Smoking cessation can have a significant impact on the management of asthma and the use of certain medications. Here is a breakdown of how smoking cessation affects different asthma medications:
Theophylline: Smoking induces the hepatic enzyme CYP1A2, which plays a major role in metabolizing theophylline. Therefore, quitting smoking can lead to higher plasma levels of theophylline and potentially fatal arrhythmias. Patients need to have their plasma theophylline concentration levels monitored closely and may require a reduced dose after quitting smoking.
Budesonide/formoterol: Neither budesonide nor formoterol are metabolized by CYP1A2, so there is no need for close monitoring following smoking cessation. Asthma control should improve after quitting smoking, and the inhaler dose should be reviewed as part of stepwise management.
Montelukast: Montelukast is metabolized by the cytochrome P450 system but not CYP1A2, so smoking cessation does not affect its level.
Prednisolone: Prednisolone is metabolized by the cytochrome P450 system, but CYP1A2 is not involved. Therefore, smoking cessation does not affect its metabolism.
Salbutamol: Smoking cessation can improve asthma control, leading to less frequent use of salbutamol or other reliever inhalers. There is no need to monitor this closely as reducing the as-required use of this medication poses no risk.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 35
Incorrect
-
A 42-year-old woman is found to have breast cancer. She has no significant medical history, is premenopausal, and has no family history of breast or ovarian cancer. The cancer is in its early stages and she undergoes a wide-local excision followed by whole-breast radiotherapy. The pathology report reveals that the tumour is positive for oestrogen receptors but negative for HER2. What is the most probable adjuvant treatment that she will be recommended?
Your Answer:
Correct Answer: Tamoxifen
Explanation:The use of Tamoxifen is limited to pre-menopausal women, and there is a continuing discussion regarding the duration of therapy, whether it should be for 5 years or more.
Breast cancer management varies depending on the stage of the cancer, type of tumor, and patient’s medical history. Treatment options may include surgery, radiotherapy, hormone therapy, biological therapy, and chemotherapy. Surgery is typically the first option for most patients, except for elderly patients with metastatic disease who may benefit more from hormonal therapy. Prior to surgery, an axillary ultrasound is recommended for patients without palpable axillary lymphadenopathy, while those with clinically palpable lymphadenopathy require axillary node clearance. The type of surgery offered depends on various factors, such as tumor size, location, and type. Breast reconstruction is also an option for patients who have undergone a mastectomy.
Radiotherapy is recommended after a wide-local excision to reduce the risk of recurrence, while mastectomy patients may receive radiotherapy for T3-T4 tumors or those with four or more positive axillary nodes. Hormonal therapy is offered if tumors are positive for hormone receptors, with tamoxifen being used in pre- and peri-menopausal women and aromatase inhibitors like anastrozole in post-menopausal women. Tamoxifen may increase the risk of endometrial cancer, venous thromboembolism, and menopausal symptoms. Biological therapy, such as trastuzumab, is used for HER2-positive tumors but cannot be used in patients with a history of heart disorders. Chemotherapy may be used before or after surgery, depending on the stage of the tumor and the presence of axillary node disease. FEC-D is commonly used in the latter case.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 36
Incorrect
-
A 30-year-old woman comes to her General Practitioner complaining of fatigue and sudden shortness of breath. An urgent full blood count is performed and the patient is diagnosed with acute lymphoblastic leukemia (ALL).
What is the most probable first-line treatment option for this patient's leukemia?Your Answer:
Correct Answer: Chemotherapy
Explanation:Treatment Options for Acute Leukaemia: Chemotherapy, Stem-Cell Transplant, Blood Transfusion, Intravenous Immunoglobulins, and Radiotherapy
Acute leukaemias, such as acute lymphoblastic leukaemia (ALL), are characterized by an increase in primitive undifferentiated blast cells in the bone marrow and blood, leading to marrow failure. The traditional treatment for ALL involves four components: induction, consolidation, maintenance, and central nervous system (CNS) prophylaxis. The first-line therapy for ALL is combination chemotherapy, which aims to eradicate the blast cells. Once remission is induced, maintenance chemotherapy is given to eliminate the disease that cannot be detected under the microscope.
Stem-cell transplants can be used to treat ALL once remission is induced using chemotherapy. This treatment can be allogeneic (the patient receives stem cells from a matched or partially mismatched related or unrelated donor) or autologous (the patient receives their own stem cells). The goal of a stem-cell transplant is to restore the body’s ability to produce normal blood cells. While it can be a curative treatment for patients with this disease, it is not used as a first-line treatment.
Blood transfusions are not a treatment for acute leukaemia, but they may be necessary to treat anaemia or platelet deficiency. Patients with leukaemia are at risk of graft-versus-host disease, so they are typically given irradiated blood components. Intravenous immunoglobulins are not used to treat acute leukaemia but may be used prophylactically against infection in patients with hypogammaglobulinaemia due to cancer treatment.
Radiotherapy is not a first-line treatment for acute leukaemia, but it may be used to treat the brain or spinal cord if the disease has spread there. Total body radiotherapy may also be used before a stem-cell transplant to suppress the immune system and reduce the risk of transplant rejection.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 37
Incorrect
-
A 12-year-old boy presents acutely with petechiae on his legs, severe abdominal pain, bloody faeces, haematuria and painful joint swelling. The haematology laboratory results are normal.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Henoch–Schönlein purpura
Explanation:Common Pediatric Diseases: Symptoms and Management
Henoch–Schönlein purpura (HSP), Acute lymphocytic leukaemia, Alport’s syndrome, and Juvenile rheumatoid arthritis (JRA) are some of the common pediatric diseases that require prompt diagnosis and management. HSP is an autoimmune hypersensitivity vasculitis that often affects children and is associated with IgA dominant immune complexes. ALL is a type of cancer that affects the blood and bone marrow, causing symptoms such as fatigue, fever, and joint pain. Alport’s syndrome is a hereditary nephritis that can lead to chronic kidney disease, hearing loss, and ocular abnormalities. JRA is characterized by swollen joints, fever, and joint pain. Prompt diagnosis and management are crucial in these diseases, which may require supportive treatment, pain relief, and monitoring for potential complications.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 38
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:
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.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 39
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:
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
-
-
Question 40
Incorrect
-
A 29-year-old female of Afro-Caribbean descent visits the oncology clinic after being referred by her primary care physician. She has observed some painless, asymmetrical lymphadenopathy lumps on her neck. She reports experiencing more night sweats lately and has noticed some discomfort when consuming alcohol.
What characteristic is linked to a negative prognosis for the most probable diagnosis?Your Answer:
Correct Answer: Night sweats
Explanation:Experiencing fever above 38ºC and night sweats in the past 6 months is linked to a poor prognosis if at least one of these ‘B’ symptoms is present. While acute lymphoblastic leukemia has a worse prognosis in individuals of Afro-Caribbean descent, Hodgkin’s lymphoma does not typically present with bone marrow failure and is more common in children. Alcohol-induced pain may be present in some cases of Hodgkin’s lymphoma, but it does not indicate a poor prognosis. While female sex is not linked to a poor prognosis, some studies suggest that males may have a worse outcome. Asymmetrical lymphadenopathy is a characteristic of Hodgkin’s lymphoma but has not been associated with a worse prognosis.
Understanding Hodgkin’s Lymphoma: Histological Classification and Prognosis
Hodgkin’s lymphoma is a type of cancer that affects the lymphocytes and is characterized by the presence of Reed-Sternberg cells. It is most commonly seen in individuals in their third and seventh decades of life. The histological classification of Hodgkin’s lymphoma is based on the type of cells present and their frequency. The most common type is nodular sclerosing, which is more common in women and has a good prognosis. Mixed cellularity is the second most common type and is associated with a large number of Reed-Sternberg cells. Lymphocyte predominant is a rare type with the best prognosis, while lymphocyte depleted is the rarest and has the worst prognosis.
In addition to the histological classification, there are other factors that can affect the prognosis of Hodgkin’s lymphoma. The presence of B symptoms, such as weight loss, fever, and night sweats, is associated with a poor prognosis. Other factors identified in a 1998 NEJM paper include age over 45 years, stage IV disease, low hemoglobin levels, low lymphocyte count, male gender, low albumin levels, and high white blood cell count. Understanding the histological classification and prognosis of Hodgkin’s lymphoma can help guide treatment decisions and improve outcomes for patients.
-
This question is part of the following fields:
- Haematology/Oncology
-
00
Correct
00
Incorrect
00
:
00
:
00
Session Time
00
:
00
Average Question Time (
Mins)