Cancer

Question 1

A 63-year-old man with sun-damaged skin presents with a small nodule on the left aspect of his forehead. He mentions that it is itchy at times, and he thinks that he may have seen a colleague 2 years previously for removal of some keratoses or scabs. The patient indicates that these were either cauterised or frozen. On examination there is a pearly white nodule with prominent telangiectasia on its surface.

Answer 1

Basal cell carcinoma

Question 2

A woman in her mid-40s with dark, leathery skin and intense wrinkling of the lower neck (signifying excessive sun exposure either in a form of frequent sun tanning beds or perhaps frequent beach visits) presents at your office. She reports she has had multiple facial lifts, to decrease wrinkles. The plastic surgeon she has consulted performed other cosmetic procedures, including botulinum toxin type A injections. She complains about a mole on her jaw that has recently started to bleed.

Answer 2

Basal cell carcinoma

Question 3

A 64-year-old man presents with painless haematuria. He had a similar episode 1 year ago and was given antibiotics for a presumed urinary infection and his bleeding resolved. He has a decreased urinary stream and nocturia twice a night. He has smoked a pack of cigarettes daily for 45 years. Physical examination shows only moderate enlargement of the prostate. Urinalysis is positive for 10 to 15 RBCs and 5 to 10 WBCs per high-power field with no bacteria detected.

Answer 3

Bladder cancer

Question 4

A 26-year-old man presented with progressive paraparesis that had commenced 3 months previously. There were also paresthesia and hyperreflexia in both legs, but no bowel or bladder symptoms. Magnetic resonance images (MRIs) of the thoracic spine demonstrated an enlarged mass, causing spinal cord compression.

Answer 4

CNS tumour (spinal)

Question 5

A 60-year-old man presents with progressive headache and cognitive decline. A MRI of the brain without gadolinium enhancement demonstrates a large extra-axial lesion that is similar intensity to brain on T1 images. After contrast administration, the lesion enhances avidly.

Answer 5

Meningioma

Question 6

A 35-year-old man presents with visual loss in his left eye and diplopia. MRI demonstrates a lesion involving the cavernous sinus.

Answer 6

Meningioma

Question 7

A 40-year-old woman presents with a history of progressively decreased hearing in her left ear over the past few years. She noticed the hearing deficit when trying to use the phone with the left ear. She has recently complained of intermittent dizziness, tinnitus in the left ear, and vague left-sided headaches.

Answer 7

Acoustic neuroma

Question 8

A 45-year-old man has a routine hearing test for work and a sensorineural hearing loss is detected. He has no signs or symptoms.

Answer 8

Acoustic neuroma

Question 9

A 6-year-old boy presents with 3 to 4 weeks of morning headaches and intermittent vomiting without fever. The headaches improve throughout the day. Over the past 2 days, the headaches are lasting longer and the vomiting is more frequent, but after vomiting the headaches are much improved. The headaches are not localised to one side. On the day of presentation, the parents note that he is walking like a ‘drunken sailor’.

Answer 9

Medulloblastoma

Question 10

A 35-year-old right-handed man presents with a partial seizure involving jerky movements of his right arm and the right side of his face. He also reports left-sided headaches for a few months and clumsiness of his right hand. On examination he is awake and orientated. He has a subtle facial droop and pronator drift on the right side.

Answer 10

Astrocytic brain tumours

Question 11

A 65-year-old woman presents with cognitive and memory changes over the past few weeks, associated with headaches over the past week. On examination she is apathetic and has slow mentation and left-sided weakness.

Answer 11

Astrocytic brain tumours

Question 12

A 2-year-old girl presents with a 2- to 3-week history of nausea, vomiting, and an enlarging head. Physical examination reveals megacephaly and poor visual regard (acuity 20/200).

Answer 12

Craniopharyngioma

Question 13

A 16-year-old girl presents with primary amenorrhoea, galactorrhoea, and mild headaches. Ophthalmological examination reveals loss of vision in the right eye (20/40).

Answer 13

Craniopharyngioma

Question 14

A 55-year-old male farmer presents with worsening shortness of breath, night sweats, fevers, bilateral axillary lymphadenopathy, and a 7.7 kg (12%) total body weight loss over 3 months. Recently, he has not been able to work because of fatigue. Physical examination reveals a 3.5 cm left axillary mass; enlarged cervical, axillary, and inguinal lymph nodes; splenomegaly; and no hepatomegaly.

Answer 14

Non-Hodgkin’s lymphoma (N.B. can be a rare primary CNS lymphoma)

Question 15

A 56-year-old woman presents with a painless right neck lump that has been slowly enlarging for the last 2 years. She denies fevers, night sweats, or weight loss. Physical examination reveals bilateral cervical and axillary adenopathy and a palpable spleen.

Answer 15

Non-Hodgkin’s lymphoma (N.B. can be a rare primary CNS lymphoma)

Question 16

A 65-year-old woman presents to her primary care physician with a 4-month history of intermittent abdominal pain localised to the RUQ with radiation to the epigastrium; the pain increases with the ingestion of fatty food and decreases with fasting. In the last 2 weeks the pain has been more frequent and steady. The patient complains of nausea, pruritus, anorexia, and weight loss, which she relates to the lack of appetite. At physical examination, there is RUQ tenderness and jaundice of the conjunctival sclera. No lymphadenopathy or palpable masses are found.

Answer 16

Cholangiocarcinoma

Question 17

A 70-year-old man presents to his primary care physician with a complaint of rectal bleeding. He describes blood mixed in with the stool, which is associated with a change in his normal bowel habit such that he is going more frequently than normal. He has also experienced some crampy left-sided abdominal pain and weight loss. He has previously been fit and well and there was no family history of GI disease. Examination of his abdomen and digital rectal examination are normal.

Answer 17

Colorectal carcinoma

Question 18

A 65-year-old woman presents with unilateral leg pain and swelling of 5 days’ duration. There is a history of hypertension, congestive heart failure, and recent hospitalisation for pneumonia. She had been recuperating at home but on beginning to mobilise and walk, the right leg became painful, tender, and swollen. On examination, the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Superficial veins on the right foot are more dilated than on the left and easily visible. The right leg is slightly redder than the left. There is tenderness on palpation in the popliteal fossa behind the right knee.

Answer 18

DVT

Question 19

A 77-year-old man presents to his general practitioner with weight loss of 6.8 kg (15 lbs) and a 3-month history of dysphagia and abdominal pain. The only abnormal finding on physical examination is stools positive for occult blood. He is referred for an upper endoscopy, which shows an exophytic, ulcerated mass in the cardia of the stomach.

Answer 19

Gastric cancer

Question 20

A 60-year-old Asian man with a long-standing history of chronic hepatitis B virus complicated by cirrhosis presents to his primary care physician with abdominal distension, yellow eyes, right upper quadrant (RUQ) abdominal pain, decreased appetite, weight loss, and change in his sleep pattern for several weeks. Physical examination reveals a cachectic man with jaundice, palmar erythema, ascites, a palpable mass in RUQ, and asterixis.

Answer 20

Hepatocellular carcinoma

Question 21

A 55-year-old black man with a history of intravenous drug use, heavy alcohol drinking, and chronic hepatitis C virus with cirrhosis of the liver is referred to a liver specialist with an elevated serum alpha fetoprotein of 200 micrograms/L (200 ng/mL) and a 2 cm liver mass in the screening ultrasound of the abdomen. Physical examination reveals palmar erythema, bilateral leg oedema, and ascites.

Answer 21

Hepatocellular carcinoma

Question 22

A 58-year-old man presents to his primary care physician with increasing tiredness, accompanied by bruising on his legs. He also complains of aching bones. He has no previous illnesses. On examination, he is pyrexial and pale, has bony tenderness over the sternum and tibia, and has petechiae on his legs. There are no palpable lymph nodes. He has crepitations at the left base. The liver and spleen are not palpable.

Answer 22

Acute myeloid leukaemia

Question 23

A 38-year-old man presents to his primary care physician complaining of generalised weakness, epistaxis, mouth ulcers, and weight loss. He has unremarkable past medical history and takes no medications. Physical examination reveals mild pallor and petechial haemorrhages over his lower limbs. He has multiple, widespread small lymph nodes that are palpable, and mild splenomegaly.

Answer 23

Acute lymphocytic leukaemia

Question 24

A 4-year-old girl presents with lethargy, dyspnoea, fever, and bruising. On examination she has hepatosplenomegaly. Chest x-ray shows a mediastinal mass and pleural effusion.

Answer 24

Acute lymphocytic leukaemia

Question 25

A 54-year-old man presents to his primary care physician with a 2-month history of fever, malaise, and weight loss. He also reports frequent epistaxis, abdominal fullness, and early satiety. On examination, he is found to have splenomegaly.

Answer 25

Chronic myeloid leukaemia

Question 26

A 50-year-old man presents to his primary care physician for a routine physical examination. He is asymptomatic at the time of the visit and the physical examination is normal. Routine baseline bloods showed elevated WBC and platelet counts.

Answer 26

Chronic myeloid leukaemia

Question 27

A 62-year-old man presents to his primary care physician for an annual physical. He denies any complaints such as fever or chills, weight loss, or fatigue. Of note, his blood tests show an elevated WBC count. The WBCs are predominantly lymphocytes, with a differential of 80% lymphocytes and an absolute lymphocyte count of 75 x 10⁹/L (75 x 10³/microlitre).

Answer 27

Chronic lymphocytic leukaemia

Question 28

A 60-year-old man presents with swollen lymph nodes in the cervical and inguinal region that have been present for 2 months and are gradually increasing in size. The lymphadenopathy is painless and has not responded to a course of antibiotics prescribed by the primary care physician. The patient denies any recent history of infection, fever, or chills. A blood test shows an elevated WBC count. The WBCs are predominantly lymphocytes, with a differential of 88% lymphocytes and an absolute lymphocyte count of 80 x 10⁹/L (80 x 10³/microlitre).

Answer 28

Chronic lymphocytic leukaemia

Question 29

A 65-year-old man presents with a 2-month history of a dry persistent cough and 4.5 kg unintentional weight loss. He denies fevers, dyspnoea, sore throat, rhinorrhoea, chest pain or haemoptysis. Medical history is significant for COPD and hypertension. Family history is non-contributory. He smoked 1 pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy is palpable on examination and breath sounds are diminished globally without focal wheezes or crackles.

Answer 29

lung cancer

Question 30

A 25-year-old male presents to his general practitioner with a slowly enlarging, non-painful right neck mass. He denies recent upper respiratory tract infections, fevers, night sweats, or unintentional weight loss. He is otherwise healthy. Social history and family history are unremarkable. On examination he is afebrile with normal vital signs. Pertinent findings include a 3-cm, firm, round, non-tender, mobile mass in the mid-right neck. There is no other peripheral lymphadenopathy. The liver and spleen are not enlarged.

Answer 30

Hodgkin’s lymphoma

Question 31

A 55-year-old male farmer presents with worsening shortness of breath, night sweats, fevers, bilateral axillary lymphadenopathy, and a 7.7 kg (12%) total body weight loss over 3 months. Recently, he has not been able to work because of fatigue. Physical examination reveals a 3.5 cm left axillary mass; enlarged cervical, axillary, and inguinal lymph nodes; splenomegaly; and no hepatomegaly.

Answer 31

Non-Hodgkin’s lymphoma

Question 32

A 56-year-old woman presents with a painless right neck lump that has been slowly enlarging for the last 2 years. She denies fevers, night sweats, or weight loss. Physical examination reveals bilateral cervical and axillary adenopathy and a palpable spleen.

Answer 32

Non-Hodgkin’s lymphoma

Question 33

A 60-year-old previously healthy man presents with 2 to 3 months of back pain. Over the last 3 weeks, he has developed a cough and increasing fatigue. On examination he has evidence of pneumonia and is noted on radiography to have osteolytic lesions. Laboratory data reveals anaemia associated with the presence of a monoclonal protein.

Answer 33

Multiple myeloma

Question 34

A 45-year-old woman presents to the emergency department with nausea, vomiting, and confusion. She has a history of low back pain of 6 months’ duration and increasing sciatic pain in the last 2 weeks. On physical examination, the patient is pale and dehydrated with bone tenderness in the lumbar region. Neurological examination reveals an upgoing plantar reflex on the left with intact power in all muscle groups and at all joints. Magnetic resonance imaging reveals an L5 compression fracture. This is associated with hypercalcaemia and renal insufficiency.

Answer 34

Multiple myeloma

Question 35

A 75-year-old man undergoing chemotherapy for metastatic prostate cancer is rushed to A&E by ambulance with acute confusion and a temperature of 38.2C and HR of 140.

Answer 35

Neutropenic sepsis

Question 36

A 55-year-old man presents with severe dysphagia to solids and worsening dysphagia to liquids. His social history is significant for 40 pack-year cigarette smoking and a 6-pack of beer per day. He has lost over 10% of his body weight and currently is nourished only by milkshake supplements. He complains of some mild odynophagia and is constantly coughing up mucus secretions.

Answer 36

Oesophageal cancer

Question 37

An otherwise healthy 45-year-old male executive complains of heartburn. He has tried over-the-counter medications with no relief. He was tried on a course of proton pump inhibitors for 6 weeks, but still has heartburn. He has no weight loss or dysphagia.

Answer 37

Oesophageal cancer

Question 38

A 70-year-old man who smokes heavily presents with a 6-month history of intermittent abdominal pain and nausea. He has lost 10 kg of weight in the past 2 months, which he thinks is due to a decreased appetite, and he complains of pruritus. On physical examination there is icterus in the conjunctival sclerae and epigastric tenderness but no abdominal mass or lymphadenopathy. Blood tests demonstrate elevated bilirubin and alkaline phosphatase; the rest of the blood tests are within the normal range.

Answer 38

Pancreatic cancer

Question 39

A 45-year-old woman presents to her physician with vague upper abdominal (epigastric) pain. After treatment with proton-pump inhibitors, analgesics, and antacids over a period of 3 months, which were ineffective, the patient also started to experience back pain. This prompted an initial upper gastrointestinal endoscopy, which was normal. Nearly 4 months after initial presentation, an upper abdominal ultrasound reveals a pancreatic mass with liver metastases.

Answer 39

Pancreatic cancer

Question 40

A 65-year-old white man presents to his general practitioner in his normal state of health. He describes nocturia (1 episode per night) and a 3-hour daytime voiding interval. He denies any incontinence, haematuria, dysuria, frequency, or urgency. He has no gastrointestinal complaints. Physical examination reveals his prostate to be smooth and symmetrical, with an approximate volume of 40 mL.

Answer 40

Prostate cancer

Question 41

A 60-year-old black man presents to his general practitioner with complaints of difficulty with urination. He describes a weak stream and a sense of incomplete voiding. He describes nocturia (5 episodes per night) and has been taking an alpha-blocker for this with minimal improvement. He says he can last about 60 to 90 minutes without urinating. He denies any suprapubic tenderness, dysuria, or haematuria. He further denies any back pain or gastrointestinal complaints. Rectal examination reveals his prostate to be approximately 60 mL, asymmetrical, with a large 2-cm nodule at the right base.

Answer 41

Prostate cancer

Question 42

A 65-year-old man presents to the emergency department with acute onset of shortness of breath of 30 minutes’ duration. Initially, he felt faint but did not lose consciousness. He is complaining of left-sided chest pain that worsens on deep inspiration. He has no history of cardiopulmonary disease. A week ago he underwent a total left hip replacement and, following discharge, was on bed rest for 3 days due to poorly controlled pain. He subsequently noticed swelling in his left calf, which is tender on examination. His current vital signs reveal a fever of 38.0°C (100.4°F), heart rate 112 bpm, BP 95/65 mmHg, and an O₂ saturation on room air of 91%.

Answer 42

PE

Question 43

A 56-year-old obese woman presents to the emergency department with a history suggestive of biliary colic, including epigastric discomfort after a heavy meal. Her past medical history includes cholelithiasis, hypertension (treated with an angiotensin-converting enzyme [ACE] inhibitor), and dyslipidaemia (treated with a statin). She is an ex-smoker, drinks alcohol socially, and has no significant family history. On palpation of her abdomen, she has RUQ pain, but there are no other relevant findings on examination. An abdominal ultrasound is performed, which demonstrates the presence of gallbladder stones without obstruction, and an incidental 5-cm, left-sided renal mass.

Answer 43

Renal cell carcinoma

Question 44

A thin 65-year-old man with no significant past medical history presents with a 5-month history of right-sided flank discomfort and abdominal fullness. He finally seeks medical attention because of 2 weeks of lower extremity oedema, and 4 days of gross haematuria with clots. On examination, his blood pressure is 160/90 mmHg, heart rate is 120 bpm and regular, and he is afebrile. He is found to have a palpable right-sided lower abdominal mass, and pitting oedema to the mid-shins bilaterally, which is worse on the right.

Answer 44

Renal cell carcinoma

Question 45

A 70-year-old previously healthy white man presents with multiple, hyperkeratotic, scaly papules on the face, scalp, and hands. Some papules have grown to become larger nodules that sometimes bleed and fail to heal. In the past he has had significant sun exposure including multiple blistering sunburns. Previously, he has had skin cancer on the face.

Answer 45

Squamous cell carcinoma

Question 46

A 60-year-old white woman presents with an enlarging scaly pink plaque on her forearm that is friable and bleeds easily. She has been taking ciclosporin (cyclosporine) for 4 years following a kidney transplant.

Answer 46

Squamous cell carcinoma

Question 47

A 35-year-old man presents with non-specific testicular discomfort and the feeling of a mass in the testis. On examination, a 2 cm by 1 cm smooth, painless mass is palpated in the right testis. The mass does not transilluminate with light. There is no lymphadenopathy.

Answer 47

Testicular cancer

Question 48

A 40-year-old woman is found to have a 2-cm right-sided thyroid nodule during a routine physical examination. She has no history of head and neck irradiation or family history of thyroid cancer. The nodule is firm and mobile in relation to the underlying tissue. Vital signs and the remainder of the examination are normal.

Answer 48

Thyroid cancer

Question 49

A 19-year-old man is diagnosed with a highly proliferating non-Hodgkin’s lymphoma. The disease is bulky, involving lymph nodes above and below the diaphragm, spleen, and bone marrow. Serum lactate dehydrogenase is significantly raised, but renal function and electrolytes are within normal limits. Twenty-four hours after initiation of aggressive chemotherapy he complains of nausea, vomiting, diarrhoea, and lethargy. He has become oliguric and is hypertensive and tachycardic. Biochemistry demonstrates elevated uric acid, potassium, and phosphate, as well as raised urea and creatinine.

Answer 49

Tumour lysis syndrome

Question 50

A 69-year-old woman with a 2-year history of chronic lymphocytic leukaemia presents with a white blood cell (WBC) count of 41 x 10^9/L (41,000/microlitre). She has a past medical history of hypertension and mild renal impairment related to the use of NSAIDs for osteoarthritis. She is started on systemic chemotherapy with fludarabine. At follow-up 7 days after initiation of treatment she complains of fatigue and weakness. Her WBC count has fallen to within normal levels but serum biochemistry reveals hyperuricaemia, hyperkalaemia, hyperphosphataemia, hypocalcaemia, and a significant deterioration in renal function.

Answer 50

Tumour lysis syndrome