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Question 1
Incorrect
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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: Dapagliflozin
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.
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This question is part of the following fields:
- Haematology/Oncology
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Question 2
Correct
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A 64-year-old woman presents to the clinic after undergoing a lumpectomy for a cancerous lump in her left breast. The histopathology report indicates that the tissue was oestrogen receptor-positive, and the patient is offered anastrozole therapy as adjuvant treatment. She has no significant medical history and is not currently taking any medications. The patient is eager to begin the recommended adjuvant therapy. What diagnostic tests should be conducted before initiating treatment?
Your Answer: DEXA scan
Explanation:Anastrozole, an aromatase inhibitor, is a recommended adjuvant therapy for patients with oestrogen positive cancer (ER+). However, it may lead to osteoporosis as an adverse effect. Therefore, NICE recommends performing a DEXA scan before initiating therapy. A clotting screen is not necessary before starting anastrozole, as it does not cause coagulopathies. ECGs are not required either, as cardiac changes and arrhythmias are not associated with this medication. Unlike certain medications like statins, anastrozole is not known to commonly affect lipid profiles, so it does not need to be monitored. Liver function tests are also not routinely assessed before starting anastrozole, as it is not known to affect liver function. However, it would have been appropriate to send a clotting screen before the patient’s lumpectomy.
Anti-oestrogen drugs are used in the management of oestrogen receptor-positive breast cancer. Selective oEstrogen Receptor Modulators (SERM) such as Tamoxifen act as an oestrogen receptor antagonist and partial agonist. However, Tamoxifen can cause adverse effects such as menstrual disturbance, hot flushes, venous thromboembolism, and endometrial cancer. On the other hand, aromatase inhibitors like Anastrozole and Letrozole reduce peripheral oestrogen synthesis, which is important in postmenopausal women. Anastrozole is used for ER +ve breast cancer in this group. However, aromatase inhibitors can cause adverse effects such as osteoporosis, hot flushes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.
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This question is part of the following fields:
- Haematology/Oncology
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Question 3
Incorrect
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A 45-year-old woman is referred by her general practitioner due to complaints of headache, fatigue and weakness. Recently, she had a prolonged menstrual bleeding that only stopped after the application of compression for a long time. She also suffered from a urinary tract infection the previous month. She has no family history of a bleeding disorder.
On examination, she has pallor, hepatosplenomegaly and lymphadenopathy. Investigations reveal that she has a low haemoglobin level, a low white blood cell count and a low platelet count; numerous blast cells are visible on peripheral blood film. Bone marrow biopsy reveals 30% of blast cells. The blood film is shown below.
Which one of the following is the most likely diagnosis?Your Answer: Acute lymphoblastic leukaemia (ALL)
Correct Answer: Acute myeloid leukaemia (AML)
Explanation:Leukaemia is a type of cancer that affects the blood and bone marrow. There are several types of leukaemia, including acute myeloid leukaemia (AML), acute lymphoblastic leukaemia (ALL), chronic lymphocytic leukaemia (CLL), chronic myeloid leukaemia (CML), and hairy cell leukaemia. AML is characterized by the rapid proliferation of immature myeloid cells called blasts, which can cause anaemia, thrombocytopenia, bleeding problems, and an increased risk of infections. ALL is caused by a clonal proliferation of lymphoid precursors, which can lead to pancytopenia and symptoms such as fever and abdominal pain. CLL is the most common type of leukaemia and is caused by the clonal proliferation of monoclonal B lymphocytes. CML is the rarest form of leukaemia and is caused by a chromosomal translocation involving chromosomes 9 and 22. Hairy cell leukaemia is characterized by the presence of abnormal white cells with hair-like cytoplasmic projections. Treatment for leukaemia typically involves chemotherapy and sometimes a bone marrow transplant, depending on the type of disease present. Prognosis varies depending on the type of leukaemia and the age of the patient.
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This question is part of the following fields:
- Haematology/Oncology
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Question 4
Correct
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A 65-year-old man with a history of depression and lumbar spinal stenosis presents with a swollen and painful left calf. He is evaluated in the DVT clinic and a raised D-dimer is detected. A Doppler scan reveals a proximal deep vein thrombosis. Despite being active and feeling well, the patient has not undergone any recent surgeries or been immobile for an extended period. As a result, he is initiated on a direct oral anticoagulant. What is the optimal duration of treatment?
Your Answer: 6 months
Explanation:For provoked cases of venous thromboembolism, such as those following recent surgery, warfarin treatment is typically recommended for a duration of three months. However, for unprovoked cases, where the cause is unknown, a longer duration of six months is typically recommended.
NICE updated their guidelines on the investigation and management of venous thromboembolism (VTE) in 2020. The use of direct oral anticoagulants (DOACs) is recommended as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. Routine cancer screening is no longer recommended following a VTE diagnosis. The cornerstone of VTE management is anticoagulant therapy, with DOACs being the preferred choice. All patients should have anticoagulation for at least 3 months, with the length of anticoagulation being determined by whether the VTE was provoked or unprovoked.
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This question is part of the following fields:
- Haematology/Oncology
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Question 5
Correct
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A 47-year-old man, currently admitted to a medical ward for acute pancreatitis, experiences intermittent episodes of epistaxis. Blood tests are conducted and reveal the following results:
- Platelets: 52 * 109/L (normal range: 150 - 400)
- Prothrombin time (PT): 23 seconds (normal range: 10-14 seconds)
- Activated partial thromboplastin time (APTT): 46 seconds (normal range: 25-35 seconds)
- Fibrinogen: 0.8 g/L (normal range: 2 - 4)
- D-Dimer: 1203 ng/mL (normal range: < 400)
Based on the probable diagnosis, what would be the expected findings on a blood film?Your Answer: Schistocytes
Explanation:The presence of schistocytes is indicative of microangiopathic hemolytic anemia, which is associated with disseminated intravascular coagulation (DIC). DIC is a condition where the coagulation pathways are activated, leading to a procoagulant state. It can be triggered by various factors, including acute illness. The patient’s blood tests show a depletion of platelets and coagulation factors, which is typical of DIC. However, elliptocytes, Heinz bodies, and Howell-Jolly bodies are not expected in DIC. Elliptocytes are usually seen in conditions like iron deficiency and thalassemia, while Heinz bodies are associated with alpha-thalassemia and glucose-6-phosphate dehydrogenase deficiency. Howell-Jolly bodies are characteristic of decreased splenic function, such as post-splenectomy.
Understanding Disseminated Intravascular Coagulation (DIC) Diagnosis
Under normal conditions, coagulation and fibrinolysis work together to maintain homeostasis. However, in DIC, these processes become dysregulated, leading to widespread clotting and bleeding. One key factor in the development of DIC is the release of tissue factor (TF), a glycoprotein found on the surface of various cell types. Normally, TF is not in contact with the general circulation, but it is exposed after vascular damage or in response to certain cytokines. Once activated, TF triggers the extrinsic pathway of coagulation, which then triggers the intrinsic pathway. DIC can be caused by various factors, including sepsis, trauma, obstetric complications, and malignancy.
To diagnose DIC, a typical blood picture will show decreased platelets and fibrinogen, increased fibrinogen degradation products, and the presence of schistocytes due to microangiopathic hemolytic anemia. Additionally, both the prothrombin time and activated partial thromboplastin time are prolonged, while bleeding time and platelet count are often low. Understanding the diagnosis of DIC is crucial for prompt and effective treatment.
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This question is part of the following fields:
- Haematology/Oncology
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Question 6
Correct
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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: 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.
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This question is part of the following fields:
- Haematology/Oncology
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Question 7
Correct
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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.
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This question is part of the following fields:
- Haematology/Oncology
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Question 8
Incorrect
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A 32-year-old man is brought to the emergency department by his physician due to bone pain, weakness, and splenomegaly. He has been experiencing increasing fatigue and weakness while performing his daily tasks over the past few weeks. During the examination, he appears extremely pale and has petechiae on his lower limbs. After a bone marrow sample is taken, he is diagnosed with acute promyelocytic leukemia (APML). What is the most probable finding on his blood film?
Your Answer: Target cells
Correct Answer: Auer rods
Explanation:A finding of Auer rods on a blood film strongly indicates the presence of acute promyelocytic leukemia.
The correct answer is ‘Auer rods’. This patient has been diagnosed with APML, and the most common finding on a blood film associated with this is Auer rods. These are needle-like structures that are large, pink or red stained and can be seen within the cytoplasm of myeloid blast cells.
‘Tear-drop’ poikilocytes are typically found in myelofibrosis, which is characterized by flat, elongated red blood cells that resemble a tear-drop in shape. This occurs due to the squeezing of cells through fibrotic tissue in bone marrow in myelofibrotic disorders.
Smear cells are usually seen in chronic lymphocytic leukemia (CLL), which are remnants of cells that lack identifiable plasma membrane or nuclear structure.
Spherocytes are generally found in hereditary spherocytosis or autoimmune hemolytic anemia, which are red blood cells that are sphere-shaped and more fragile than normal red blood cells due to abnormalities in the red cell membrane.
Acute myeloid leukaemia is a common form of acute leukaemia in adults that may occur as a primary disease or following a myeloproliferative disorder. Symptoms are related to bone marrow failure and include anaemia, neutropenia, thrombocytopenia, splenomegaly, and bone pain. Poor prognostic features include age over 60, >20% blasts after first course of chemo, and deletions of chromosome 5 or 7. Acute promyelocytic leukaemia M3 is associated with t(15;17) and has a good prognosis. The French-American-British classification system includes seven subtypes.
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This question is part of the following fields:
- Haematology/Oncology
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Question 9
Correct
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A 55-year-old woman presents with weight loss and anaemia. She has no significant medical history. Upon examination, she has massive splenomegaly and pale conjunctivae. Her full blood count shows a Hb of 10.9 g/dl, platelets of 702 * 109/l, and a WCC of 56.6 * 109/l. Leucocytosis is noted on her film, with all stages of granulocyte maturation seen. What is the most probable diagnosis?
Your Answer: Chronic myeloid leukaemia
Explanation:Massive splenomegaly can be caused by myelofibrosis, chronic myeloid leukemia, visceral leishmaniasis (kala-azar), malaria, and Gaucher’s syndrome. Among these, chronic myeloid leukemia is the most probable diagnosis, as it is the most common cause.
Understanding Chronic Myeloid Leukaemia and its Management
Chronic myeloid leukaemia (CML) is a type of cancer that affects the blood and bone marrow. It is characterized by the presence of the Philadelphia chromosome in more than 95% of patients. This chromosome is formed due to a translocation between chromosomes 9 and 22, resulting in the fusion of the ABL proto-oncogene and the BCR gene. The resulting BCR-ABL gene produces a fusion protein that has excessive tyrosine kinase activity.
CML typically affects individuals between 60-70 years of age and presents with symptoms such as anaemia, weight loss, sweating, and splenomegaly. The condition is also associated with an increase in granulocytes at different stages of maturation and thrombocytosis. In some cases, CML may undergo blast transformation, leading to acute myeloid leukaemia (AML) or acute lymphoblastic leukaemia (ALL).
The management of CML involves various treatment options, including imatinib, which is considered the first-line treatment. Imatinib is an inhibitor of the tyrosine kinase associated with the BCR-ABL defect and has a very high response rate in the chronic phase of CML. Other treatment options include hydroxyurea, interferon-alpha, and allogenic bone marrow transplant. With proper management, individuals with CML can lead a normal life.
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This question is part of the following fields:
- Haematology/Oncology
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Question 10
Correct
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A 35-year-old woman presents to her General Practitioner complaining of fatigue and lack of energy. She has a 1-year history of heavy menstrual bleeding with excessive blood loss. She is clinically anaemic.
Investigations:
Investigation Result Normal value
Haemoglobin (Hb) 102 g/l 115–155 g/l
Haematocrit 28% 36–47%
Mean corpuscular volume (MCV) 70 fl 80–100 fl
Mean cell haemoglobin (MCH) 25 pg 28–32 pg
Mean corpuscular haemoglobin volume (MCHC) 300 g/l 320–350 g/d
White cell count (WCC) 7.5 × 109/l 4.0–11.0× 109/l
Platelets (PLT) 400× 109/l 150–400× 109/l
What is the most appropriate dietary advice for this patient?
Select the SINGLE advice option from the list below.Your Answer: She should 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.
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This question is part of the following fields:
- Haematology/Oncology
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