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  • Question 1 - A 25-year-old man presents to his doctor with a complaint of a lump...

    Correct

    • 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: 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
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  • Question 2 - Which of the following may be linked to a higher risk of venous...

    Correct

    • Which of the following may be linked to a higher risk of venous thromboembolism?

      Your Answer: Behcet's syndrome

      Explanation:

      Venous Thromboembolism: Common Risk Factors

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

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

    • This question is part of the following fields:

      • Haematology/Oncology
      75.9
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  • Question 3 - A 65-year-old woman is diagnosed with a DVT 2 weeks after undergoing a...

    Incorrect

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

      Your Answer: Switch to direct oral anticoagulant for 6 months

      Correct Answer: Switch to direct oral anticoagulant for 3 months

      Explanation:

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

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

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 4 - A 32-year-old patient presents with a month-long fever and occasional afebrile episodes. Blood...

    Incorrect

    • A 32-year-old patient presents with a month-long fever and occasional afebrile episodes. Blood cultures and infection screening have yielded negative results. During examination, the patient has a temperature of 38°C and nontender lymph nodes in the neck. What is the most crucial step in reaching a diagnosis?

      Your Answer: Blood cultures

      Correct Answer: Lymph node biopsy

      Explanation:

      The Importance of Lymph Node Biopsy in Diagnosing Hodgkin’s Lymphoma

      When it comes to diagnosing Hodgkin’s lymphoma, a lymph node biopsy is the most reliable method. Fine-needle aspiration should not be used as the sole method for diagnosis. In addition to the biopsy, a thorough evaluation should include a medical history and examination, blood tests, liver function tests, serum protein tests, HIV testing, chest radiograph, CT scans, and bone marrow biopsy. Gallium scans can also be performed to document radioisotope uptake by the tumor. Lymphangiography may be necessary if the presentation of Hodgkin’s lymphoma is subdiaphragmatic. While a raised ESR can indicate Hodgkin’s lymphoma, it is not the most important step in obtaining a diagnosis. Similarly, repeating a CRP test or blood cultures would not be appropriate if the initial results were negative. In summary, a lymph node biopsy is crucial in diagnosing Hodgkin’s lymphoma and should be the first step in the evaluation process.

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 5 - A 42-year-old woman is found to have breast cancer. She has no significant...

    Correct

    • 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: 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
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  • Question 6 - A 32-year-old patient who is a vegan and very active has been experiencing...

    Correct

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

      Your Answer: Vitamin B12

      Explanation:

      Vegan Nutrition: Understanding the Availability of Vitamins

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

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

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

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 7 - A 30-year-old male presents with progressive weakness and fatigue over the past year....

    Incorrect

    • A 30-year-old male presents with progressive weakness and fatigue over the past year. He reports difficulty achieving and maintaining an erection with his new partner, which is a new symptom for him. Laboratory tests reveal elevated ferritin levels. The patient is started on a treatment plan that involves regular phlebotomies.

      What is the most effective way to monitor the patient's response to treatment?

      Your Answer: Serum iron and transferrin saturations

      Correct Answer: Ferritin and transferrin saturation

      Explanation:

      To monitor treatment in haemochromatosis, the most effective combination of iron tests is ferritin and transferrin saturation. These tests can track the response to treatment by measuring total iron stores and the amount of serum iron bound to proteins in the blood. However, serum transferrin and serum iron are not reliable indicators of treatment response as they fluctuate throughout the day and are affected by diet and phlebotomies. Therefore, using ferritin and serum transferrin or serum iron would not be the most useful combination for monitoring haemochromatosis. Similarly, using serum iron and serum transferrin together would not provide any insight into treatment monitoring. The most appropriate and effective combination is ferritin and transferrin saturation.

      Understanding Haemochromatosis: Investigation and Management

      Haemochromatosis is a genetic disorder that causes iron accumulation in the body due to mutations in the HFE gene on both copies of chromosome 6. The best investigation to screen for haemochromatosis is still a topic of debate. For the general population, transferrin saturation is considered the most useful marker, while genetic testing for HFE mutation is recommended for testing family members. Diagnostic tests include molecular genetic testing for the C282Y and H63D mutations and liver biopsy with Perl’s stain. A typical iron study profile in a patient with haemochromatosis includes high transferrin saturation, raised ferritin and iron, and low TIBC.

      The first-line treatment for haemochromatosis is venesection, which involves removing blood from the body to reduce iron levels. Transferrin saturation should be kept below 50%, and the serum ferritin concentration should be below 50 ug/l to monitor the adequacy of venesection. If venesection is not effective, desferrioxamine may be used as a second-line treatment. Joint x-rays may show chondrocalcinosis, which is a characteristic feature of haemochromatosis. It is important to note that there are rare cases of families with classic features of genetic haemochromatosis but no mutation in the HFE gene.

    • This question is part of the following fields:

      • Haematology/Oncology
      74.4
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  • Question 8 - In the UK, which malignancy is most frequently diagnosed in women? ...

    Correct

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

      Your Answer: Breast cancer

      Explanation:

      Most Common Cancers in Women in the UK

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

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 9 - A 42-year-old female presents to her primary care physician with a 2-month history...

    Incorrect

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

      Your Answer: Gastric parietal cell antibodies

      Correct Answer: Intrinsic-factor antibodies

      Explanation:

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

      Understanding Pernicious Anaemia

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

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

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

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

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

    • This question is part of the following fields:

      • Haematology/Oncology
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  • Question 10 - A 55-year-old man is referred to the Haematology Clinic under the 2-week-wait rule...

    Incorrect

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

      Your Answer: Imatinib

      Correct Answer: Acalabrutinib

      Explanation:

      Treatment Options for Chronic Lymphocytic Leukaemia (CLL)

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

    • This question is part of the following fields:

      • Haematology/Oncology
      52.9
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SESSION STATS - PERFORMANCE PER SPECIALTY

Haematology/Oncology (5/10) 50%
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