Day 5 Flashcards
1
Q
56 year old female presents to the general practitioner with a three month history of a persistent cough, dyspnoea and left-sided pleuritic chest pain.
She works as a teacher and is not aware of any previous exposure to asbestos or other occupational carcinogens.
She has no significant past medical history and is a life-long non-smoker.
Full blood count reveals a thrombocytosis.
A chest X-ray is requested which shows a peripheral opacity in the left lower zone.
Which of the following is the most likely diagnosis?
What is a likely complication?
A
Adenocarcinoma of the lung
Adenocarcinoma is the most common type of lung cancer seen in non-smokers and women.
It arises from mucus cells in the bronchial epithelium and is typically found in the peripheral airways.
It commonly invades the pleura, causing pleuritic chest pain and can present with pleural effusion.
2
Q
A 65 year old woman presents with an episode of haemoptysis to the GP.
She reports that this has happened several times over the past three months and she has noticed some weight loss.
She does not smoke and has worked as a secretary for all her adult life.
Her only significant past medical history was that of breast cancer when she was 40, for which she was treated with wide local excision and radiotherapy.
She has a family history of breast cancer.
What is the single most important risk factor for the development of lung cancer within her history?
A
previous radiotherapy
3
Q
A 75 year old gentlemen with known multiple myeloma presents to the A&E with increasing confusion.
He has an AMTS of 6/10 when you see him and you obtain a collateral history from his carer who reports that over the past two days he has become increasingly disorientated in time, place and person.
His cognition is persistently poor and is not fluctuating.
He complains of pain in his thigh and reports that he has become increasingly constipated over the past week.
There are no signs or symptoms of infection.
What is the single most likely cause of his confusion?
A
Hypercalcaemia
There is a diverse range of causes for confusion in oncology patients:
- Metabolic disturbance (hypoglycaemia, hypercalcaemia)
- Infection (pneumonia, UTI)
- Metastatic spread to the brain
- Anaemia
- Intense pain
- Side effects of pain medication
4
Q
A 21 year old lady visits the GP to discuss contraception. She is three weeks postpartum and is currently breast-feeding. She has no other relevant medical history. Previously, she used the combined oral contraceptive pill and would like to go back to that.
Which is the most appropriate form of contraception to offer?
A
Progesterone only pill
This is the only suitable option for a postpartum woman actively breast-feeding.
5
Q
A 55 year old man presents to A&E with dyspnoea and stridor.
He has a background of bronchial carcinoma.
On examination he has distended veins over his chest, there is inspiratory stridor heard and Pemberton’s test is positive.
What is Pemberton’s sign?
Examination of the chest is otherwise normal.
What is the single most likely diagnosis?
A
Superior vena cava obstruction
The patient presents with classical symptoms of superior vena cava obstruction given his background of bronchial carcinoma with dyspnea and distended veins.
He is Pemberton’s sign positive; the diagnostic test for this condition.
6
Q
A 21 year old woman attends the sexual health clinic requesting emergency contraception after having unprotected sexual intercourse (UPSI) eight days ago. She is currently on day 17 of a regular 30 day cycle.
Which of the following is the most appropriate management option?
A
Copper intrauterine device (IUD)
The IUD is licensed for use either five days post UPSI or five days post earliest possible ovulation - whichever is later. Earliest possible ovulation date is worked out by length of cycle - 14 days. In this patient, it is day 16 (30-14). Therefore, she falls within this five day window.
7
Q
A 73-year-old man with a diagnosis of Stage III non-small cell lung cancer with mediastinal nodal involvement is being followed up in the lung cancer clinic. He has a notable past medical history of chronic kidney disease and is approaching end-stage renal impairment. The patient reports a three month history of gradually worsening headaches and double vision. A neurological exam is performed which reveals an ataxic gait, but no other focal neurology.
What is the most likely diagnosis?
Which investigation is the best investigation to confirm the underlying diagnosis?
A
Magnetic resonance imaging (MRI) of the brain
This patient is presenting with signs and symptoms of raised intracranial pressure (ICP), likely secondary to brain metastases of his lung cancer. More specifically, these are likely cerebellar metastases which have resulted in diplopia and ataxia.
Brain metastases are typically best visualised using a contrast-enhanced computed tomography (CT scan). However, contrast is nephrotoxic, and therefore contraindicated in this patient due to their significant renal impairment.
An MRI is therefore the best option to visualise these intracerebral metastases. MRI scans are particularly effective in delineating at high resolution the soft tissue structure within the cerebellum. As such, they are often used in preference to contrast CT scans for cerebellar metastases, especially when assessing the resectability of a tumour.
8
Q
A 75 year old man presents to his GP with increasingly problematic diarrhoea for the past two weeks.
He complains that it is associated with pain on defecation and there is occasionally blood present on the outside of his stool.
He has tried loperamide over the counter but reports that this has not had any effect.
He denies any fever or vomiting and has not had any unexplained weight loss over the past couple of months.
He reports that he is currently receiving external beam radiotherapy for prostate cancer. He has no other past medical history.
What is the single most likely cause?
A
Radiotherapy
This is the correct answer. A common side effect of radiotherapy to the prostate region would be mucositis in the rectum called proctitis. This can lead to diarrhoea and the presence of blood in the stool.
9
Q
A 48 year old woman attends the sexual health clinic to discuss contraception.
She tells you she thinks she’s going through ‘the change’, as she stopped having periods 12 months ago, and asks whether she still needs contraception.
She has a past medical history of breast cancer, which was successfully treated two years ago.
Her medications include Atorvastatin and Cetirizine as required.
She smokes five cigarettes a day and consumes three units of alcohol a week.
Her observations in clinic today are normal.
Which of the following advice is most appropriate?
A
Copper intrauterine device (IUD)
The IUD is the only suitable option for this patient due to her history of breast cancer.
10
Q
A 30-year old woman presents to the Emergency Department with shortness of breath. She has recently returned from holiday in America.
Clinical examination is unremarkable.
A diagnosis of pulmonary embolism is suspected.
What is the most common ECG finding in a pulmonary embolus?
A
Sinus tachycardia
The most common ECG finding in patients with pulmonary embolism is sinus tachycardia. Other features such as the right axis deviation and right ventricular strain pattern may also be seen. These ECG changes occur due to the dilatation of the right atrium and ventricle, as well as right ventricular ischaemia. Tachycardia can also be secondary to fever and pain.
11
Q
A 69-year-old man with metastatic prostate cancer on the oncology ward is complaining of worsening pain.
He is currently taking modified release oral Morphine 60 mg twice daily, with 10 mg immediate release Morphine solution as required for breakthrough pain.
He is currently taking two doses of immediate release morphine a day.
The medical team decides to convert this to a subcutaneous administration, because he is frequently vomiting.
What is the correct dose of morphine to give over a 24 hour period using a continuous subcutaneous infusion?
A
70mg infusion over 24hr
This patient is requiring a daily dose of 140 mg oral Morphine (60x2 + 10x2) for adequate pain control.
Morphine administered subcutaneously is twice the strength of oral Morphine, and therefore 140/2 = 70mg of subcutaneous Morphine represents an equivalent dose.
12
Q
A 42 year old man with a diagnosis of acute myeloid leukaemia is two days post his initial cycle of chemotherapy.
He presents to A&E with nausea, vomiting and diarrhoea. He is apyrexial and reports that he been going to the toilet less frequently during the past two days.
He reports no headache, dyspnoea or back pain.
He was prescribed no medication prior to the onset of his chemotherapy.
His observations are normal. Routine bloods show that the full blood count is normal.
What is the single most likely diagnosis?
A
Tumour lysis syndrome
This is the correct answer, given his haematological malignancy and his symptoms.
Common symptoms include nausea, vomiting and muscle pain.
13
Q
A 65 year old woman presents to the Accident and Emergency Department with a three month history of persistent cough and bloody sputum.
She has complained that she has lost 2 stones unintentionally over the past few months. She has smoked cigarettes for the past forty years. However, last night she developed a headache and noticed her face was swollen more than usual.
On examination, there is a raised JVP, and stridor when she raises her arm above her head.
What is the most appropriate immediate management?
A
Immediate oral dexamethasone 8mg
The patient has presented with an oncological emergency of Superior Vena Cava obstruction. 75% of lung tumours are responsible for this complication and it can result in facial plethora, raised JVP and inspiratory stridor upon performing Pemberton’s test. Therefore, the most appropriate immediate management would be to give the patient oral dexamethasone first.
14
Q
When is Mannitol prescribed?
A
Mannitol is given for patients with raised intracranial pressure.
Raised intracranial pressure can occur due to metastasis or primary CNS tumours.
15
Q
A 30 year old woman attends the pre-operative assessment clinic for an elective laparoscopic cholecystectomy procedure in eight weeks’ time. She takes no medications other than the combined oral contraceptive pill (OCP).
Which of the following is the most appropriate advice to give regarding her pill and surgery?
A
Stop the pill four weeks before surgery, commence an alternative form of contraception in the interim and then restart 2 weeks after surgery
Both surgery and taking the OCP are risk-factors for venous thromboembolism - stopping the OCP (and replacing it with another method) reduces this risk, and continues to protect from pregnancy.
16
Q
An 89 year old Type 2 diabetic is being treated for a urinary tract infection with IV gentamicin.
He has a small peripheral cannula placed in the back of his hand.
During his admission his capillary blood glucose measurements are repeatedly >15mmol/L.
His gliclazide is therefore increased from 80mg BD to 160mg BD.
The next evening he is noted to become significantly more agitated and confused. A capillary blood glucose measurement returns at 2.9mmol/L.
What is the most appropriate initial management of this patient?
A
Carton of fruit juice
This is an ideal choice for mild hypoglycaemia because it contains plenty of short chain carbohydrates which will rapidly increase blood glucose.
17
Q
A 50-year-old man with a diagnosis of diffuse large B-cell lymphoma is brought into A&E by his wife after experiencing abdominal pain, cramps and vomiting.
He is three days post his second cycle of chemotherapy consisting of Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone.
On questioning, he has no other symptoms apart from not having passed urine in the last 13 hours.
His observations are as follows: Heart rate 110 beats per minute, Blood pressure 90/55, Respiratory rate 25, Oxygen saturation 95% on room air, Temperature 37.4oC.
Which of the following is the most appropriate initial management?
A
Fluid resuscitation with 500 mL 0.9% sodium chloride
This is the correct answer. This man is presenting with symptoms of tumour lysis syndrome. This is a condition which typically presents a few days after chemotherapy and is common for haematological malignancies, particularly non-Hodgkin lymphomas. The administration of chemotherapy can cause significant cell death in mitotically active tumours, resulting in the extravasation of intracellular contents such as nucleic acids into the circulation. These are then broken down into uric acid and phosphate. Uric acid can precipitate in renal tubules leading to an acute kidney injury, which may cause the anuria as reported by this patient. Raised phosphate levels sequester free Ca2+ ions in the bloodstream, leading to hypocalcaemia and its characteristic symptoms, such as tetany (cramps) and vomiting.
This man has significant risk factors for tumour lysis syndrome and combined with anuria means that he may have an acute kidney injury. The most appropriate management for this should be fluid resuscitation in the first instance, particularly given his hypotension.
18
Q
A 85-year-old man with a known diagnosis of Stage II squamous cell lung cancer presents to A&E with a one week history of severe progressive back pain and difficulty walking.
He has a background of severe chronic obstructive pulmonary disease with frequent exacerbations and two previous myocardial infarctions which required stenting.
He is admitted and an urgent magnetic resonance imaging (MRI) scan of the spine reveals metastatic cord compression at multiple vertebral levels.
Which of the following options represent the most appropriate management for this patient’s condition?
A
Refer to the clinical oncology team for radiotherapy
This patient has presented with metastatic spinal cord compression and will require intervening to prevent further cord compression and neurological loss.
As the patient has multiple severe cardiopulmonary co-morbidities, and because the compression is at multiple levels rather than a single level, they are unlikely to be a candidate for neurosurgical intervention.
Radiotherapy is the most appropriate management option to help decompress the spinal metastases and palliate this patient’s symptoms.
19
Q
A 47 year old man with a known adrenal mass presents complaining of severe headache and sweating.
He is mildly pyrexial and his BP is 231/143mmHg.
An ECG shows some sub-criteria ST elevation in the lateral leads.
What is the most likely diagnosis?
What is the most appropriate initial management?
A
Phentolamine
This is the ideal initial management of a symptomatic phaeochromocytoma because it blocks mainly alpha adrenergic receptors leading to vasodilation and reduction in blood pressure.
20
Q
A 74 year old woman presents to the Emergency Department with pain in her upper back.
The pain started four days ago and is often worse at night and when lying flat.
On examination, there is no swelling or deformity but there is tenderness at the T10 level.
There is bilateral impaired sensation below the groin, global weakness and spastic hypertonia in the legs.
Her observations are stable.
Her past medical history includes breast cancer diagnosed two months ago, for which she underwent a surgical resection.
What is the most likely diagnosis?
What are the red flags?
A
Malignant spinal cord compression
Given her recent history of breast cancer and the pain being worse at night and when lying flat, malignant spinal cord compression is the most likely diagnosis.
The characteristic pain is often worse at night and when lying flat, as this allows further compression of the spine which exacerbates the symptoms.
The presence of sensory and upper motor neuron neurology in the legs indicates that the cord is being compressed.
21
Q
A 77-year-old male with a recent diagnosis of Non-Hodgkin lymphoma (NHL) presents to A&E with shortness of breath and stridor.
Pemberton’s test is positive.
The patient is moved into a sitting position and given high-flow oxygen (15L/min via a non-rebreathe mask).
Given the likely diagnosis, what is the next step in management of the patient in the emergency department?
A
Dexamethasone
This is the correct answer. This patient likely has superior vena cava syndrome caused by compression of the superior vena cava by a tumour (Non-Hodgkin lymphoma can cause superior vena cava syndrome). Pemberton’s test involves asking the patient to lift their arms above their head. If this causes facial plethora, the patient has Pemberton’s sign (i.e. a positive Pemberton’s test). Dexamethasone can reduce swelling and oedema associated with the tumour, helping to reduce the external compression of the superior vena cava.
22
Q
A 50-year-old man with Stage I small cell lung cancer presents to his GP with a two week history of tingling in his hands and feet.
He is being treated with chemoradiotherapy consisting of a 30 gray radiation dose, and combination Cyclophosphamide, Doxorubicin, Vincristine and Etoposide.
What is the most likely cause of his current symptoms?
A
Vincristine administration
Peripheral neuropathy is a significant and common side effect of Vincristine, which acts by inhibiting microtubule formation at the mitotic spindle.
Other chemotherapeutic agents that cause peripheral neuropathy include other vinca alkaloids such as Vinblastine (to a lesser extent than Vincristine), platinum-based agents such as Cisplatin, and taxanes such as Paclitaxel and Docetaxel.
23
Q
Classical side effects to be aware of include:
Anthracyclines (doxorubicin, daunorubicin)
anti-HER-2 monoclonal antibodies
Platinum agents (cisplatin, carboplatin)
Cyclophosphamides
Tamoxifen
Bleomycin
Cisplatin
Cytarabine
A
Classical side effects to be aware of include:
Anthracyclines (doxorubicin, daunorubicin) cause cardiomyopathy
anti-HER-2 monoclonal antibodies (e.g. Herceptin)cause cardiomyopathy
Platinum agents (cisplatin, carboplatin) cause peripheral neuropathy and sensorineural hearing loss.
Cyclophosphamides lead to haemmorhagic cystitis and transitional cell carcinoma of the bladder.
Tamoxifen increases the risk of endometrial cancer
Bleomycin can cause lung fibrosis
Cisplatin has a risk of ototoxicity and nephrotoxicity
Cytarabine can cause ataxia
24
Q
A 50 year old man presents to the clinic with a new diagnosis of hepatocellular carcinoma.
He has a past medical history of chronic hepatitis B, pernicious anaemia, ulcerative colitis and a previous infection with hepatitis A. He smokes 20 cigarettes a day and has a past history of drug abuse including IV heroin.
What is the single risk factor that is most likely to have contributed to the diagnosis of hepatocellular carcinoma?
A
Chronic Hepatitis B
chronic hepatitis B increases the risk of hepatocellular carcinoma significantly.
25
An 82-year-old woman is on the ward, two days after a neck of femur fracture repair. She reports sudden-onset shortness of breath and sharp chest pain exacerbated by breathing. Observations are as follows: respiratory rate 22/min, SpO2 93% on high flow oxygen, pulse rate 125/min, blood pressure 88/54, temperature 37.3. A 12-lead ECG is performed which shows sinus tachycardia. Wells' score is calculated as 4, and D-dimer is 1200 ng/mL. A CTPA is ordered.
A diagnosis of massive pulmonary embolism (PE) is suspected.
**Which of the following features indicate that the PE is massive?**
**Systolic blood pressure \< 90 mmHg**
This is the correct answer. Massive pulmonary embolism is characterised by hypotension (systolic blood pressure \< 90 mmHg or a drop in systolic blood pressure of ≥ 40 mmHg for ≥ 15 minutes) or signs of shock. It is associated with significantly higher mortality rates than non-massive PE.
26
A 45 year old man is being treated for non-Hodgkin’s lymphoma.
He attends his outpatient clinic and a questionnaire is completed regarding the side effects of chemotherapy.
He complains that he has reduced sensation in hands bilaterally.
**Which of the following is the most likely cause?**
Vincristine is associated with peripheral neuropathy and is a common therapeutic agent in non-Hodgkin’s lymphoma.
27
A 72 year old man presents with haemoptysis. He states that this has happened on several occasions over the past 2 months. He also reports that he has lost his appetite and some weight during this period. An urgent outpatient CXR is arranged for him and he is referred to the Lung Cancer clinic.
The CXR shows a cavitating lesion within the right middle lobe. He does not report a temperature and the rest of his observations are normal.
What is the single most likely diagnosis?
Squamous cell lung cancer
The history of haemoptysis and ALARM symptoms together with the cavitating lesion in the lung makes this the most likely diagnosis.
28
Important Features of Squamous cell carcinoma
(7)
1. Second most common type of lung cancer in the UK
2. Usually present as obstructive lesions of the bronchus leading to infection.
3. Occasionally cavitates (10% at presentation) Lung Ca that most commonly cavitates
4. On X-ray it is not possible to tell whether it is an abscess or a cancer (the border's definition cannot be easily seen) but on the CT there is obviously a jagged border – indicating cancer.
5. Local spread is common, but metastasis are normally late (but frequent)
6. Often causes hypercalcaemia – by bone destruction or production of PTH analogues (PTHrp).
7. Also associated with clubbing and HPOA (Hypertrophic pulmonary osteoarthropathy)
29
Important Features of Adenocarcinoma
| (6)
1. Most common type of lung cancer in the UK
2. Arises from mucous cells in the bronchial epithelium
3. Commonly invades the mediastinal lymph nodes and the pleura, and spreads to the brain and bones
4. Does not usually cavitate
5. Proportionally more common in non-smokers, women and in the Far Eastleast likely to be related to smoking
6. Most likely to cause pleural effusion (as are mesotheliomas)
30
Important Features of Small cell carcinoma
(4)
1. Arise from endocrine cells (Kulchitsky cells). These are APUD cells, and as a result, these tumours will secrete many poly-peptides mainly ACTH.
2. They can also cause various presentations such as Addison's and Cushing's disease.
3. Small cell carcinoma spreads very early and is almost always inoperable at presentation.
4. These tumours do respond to chemotherapy, but the prognosis is generally poor.
31
How would pulmonary fibrosis present on a chest x-ray
Pulmonary fibrosis characteristically presents with reticulonodular shadowing within the lower zones of the lung.
32
**_How many units in a pint of beer?_**
**_How many units in a glass of wine?_**
**_How many units in a bottle of wine?_**
**_How many units in a pint of beer?_**
2.3
**_How many units in a glass of wine?_**
2.3
**_How many units in a bottle of wine?_**
10 units
33
A 52-year-old woman presents to her GP with a thyroid lump. Which of the following clinical features would you consider an urgent referral for this patient (2-week rule)?
**Unexplained hoarseness or voice changes associated with a goitre**
Urgent referral (2-week rule) to a thyroid surgeon or endocrinologist for the following patient groups: 1) unexplained hoarseness or voice changes associated with a goitre, 2) lymphadenopathy associated with a thyroid lump (usually deep cervical or supraclavicular region), 3) rapidly enlarging painless thyroid mass increasing in size over a period of weeks, or 4) child with thyroid nodule.
34
A 62 year old male presents to the general practitioner complaining of a four week history of increasing shortness of breath, intermittent blood-stained sputum and unintended weight loss of 4kg.
He has no significant past medical history and has not travelled outside the United Kingdom before.
He is an ex-smoker with a 32 pack year history.
On examination his vital signs are in normal range and there is reduced air entry in the right lung.
**Which of the following is the best next step in the management of this patient?**
**Refer to the respiratory clinic under 2 week wait referral**
National Institute for Health and Care Excellence (NICE) guidelines advise that any patient over the age of 40 with unexplained haemoptysis should be referred urgently to the respiratory clinic under a two week wait referral.
Patients should also be referred under the two week wait system if they have a chest X-ray with findings suspicious for lung cancer or if there is a strong clinical suspicion of lung cancer.
Features in this case which increase the suspicion of lung cancer include unexplained weight loss and haemoptysis in a patient with a significant smoking history.
35
A 64 year old female presents to A+E with a 4-day history of night sweats, fever, and malaise. She has advanced breast cancer, for which she has been receiving cycles of cytotoxic chemotherapy through a peripheral line. She says the area around the line has become red and painful over the last week, and on examination, it is discharging green pus.
What is the most likely infective organism?
Staphylococcus epidermitis
This is a coagulase-negative staph, and is a common cause of line infections (particularly in neutropenic patients, from which they can develop neutropenic sepsis)
36
A 25 year old lady attends the sexual health clinic requesting emergency contraception after having unprotected sexual intercourse (UPSI) 4 days ago.
The first day of her last menstrual period was 14 days ago, and she has a regular 28 day cycle.
She is not on any medication or regular contraception. She has no past medical history.
When you counsel her on her options, she expresses that she is not keen on any invasive procedures.
Which of the following is the most appropriate management option?
**Ulipristal acetate (ellaOne)**
ellaOne is the only oral emergency contraception that can be given up to 5 days after UPSI.
37
A 72 year old man with known non-small cell lung cancer presents with difficulty breathing.
He reports that this varies with position.
The patient has normal observations and is apyrexial.
He does not report any other symptoms.
On examination, you notice distended neck veins.
What is the single most appropriate initial action?
Dexamethasone 8mg BD PO
This it the correct answer and most appropriate management plan. This patient has superior vena cava obstruction the most important management is to give steroids (dexamethasone 8mg BD).
38
A 30 year old businesswoman attends the sexual health clinic to discuss contraception.
She previously used a Progesterone only pill but found it difficult to remember to take. She wants to try another method that does not require daily administration. Her main concern is that her periods are long and heavy.
She expresses that she is keen to start a family in the next 2 years.
Which of the following is the most suitable option to offer?
**Contraceptive implant**
* This is the most suitable option as it does not require daily administration, will not cause periods to become heavier, and can be easily reversed by removal compared to other invasive devices.
* Depo-provera injection - An important adverse effect of this method to be aware of is that it causes a delayed return to fertility (approximately by a year) - it therefore should not be given to women who wish to start a family in the next few years.*
39
A 63-year-old woman presents to the General Practice with a 3 month history of persistent cough, unintentional weight loss and shortness of breath.
Over the last week she has noticed that upon bouts of coughing, she now is producing bloody sputum.
She is referred to the local hospital where on examination she has bilateral finger clubbing, and pale conjunctiva.
A chest X-ray is performed and solitary pulmonary nodule is reported in the right middle lung zone adjacent to the mediastinum.
**What is the most appropriate next line investigation?**
CT Chest
This is the correct answer. CT should be performed before a fibreoptic Bronchoscopy or Endobronchial Ultrasound needle aspiration, as it would allow us to identify and localise the lesion.
40
A 67-year-old man is brought into the Emergency Department (ED) after collapsing whilst out shopping.
His wife reports that he suddenly 'blacked out' for about 30 seconds.
He initially went pale and then appeared flushed on regaining consciousness.
On assessment, he is unresponsive.
His blood pressure is 90/65 mmHg and an ECG shows a heart rate of 35 bpm with complete **dissociation between the p waves and QRS complexes**.
**Which of the following is the next best step in management?**
**What would the definitive management be?**
**IV Atropine**
This man's blackout has characteristics of cardiogenic syncope due to bradycardia (also known as a Stokes-Adams attack).
These include sudden onset, short duration and associated facial colour change (due to oxygenated blood in the pulmonary capillaries accumulating and then being released into the systemic circulation during recovery, leading to flushing).
His ECG findings and slow heart rate are indicative of third-degree (complete) heart block. Following initial assessment, in the presence of adverse features (myocardial ischaemia, heart failure, syncope or shock), the initial management of bradycardia is to administer 500 micrograms of atropine IV if the patient is unstable.
The definitive management for complete heart block is the insertion of a permanent pacemaker.
41
A 25 year old lady attends the walk-in sexual health clinic after forgetting to take her combined oral contraceptive pill (OCP).
She has missed days one and two in the packet.
She had unprotected sexual intercourse (UPSI) on day one.
She is due to take day three today.
**Which of the following is the most appropriate course of action?**
**Advise her to take two pills today, prescribe emergency contraception and use condoms for seven days**
This patient has missed the first two pills from Week one.
In a traditional pill-taking regime, the week prior to this would be the pill-free interval - meaning this patient has not been taking pills for nine days.
**The OCP needs to be taken for seven days in a row to be effective**, so she is now at risk of pregnancy due to the UPSI on day one.
She needs emergency contraception, as well as barrier protection as an extra precaution until at least seven days of pill-taking is re-established.
42
A previously well 60-year-old man presents to A&E with a two month history of increasing jaundice, abdominal pain and weight loss.
On examination he has marked right upper quadrant tenderness and the liver edge can be palpated 4 cm below the costal margin.
A computed tomography scan of the chest, abdomen and pelvis reveals multiple round hypoechoic lesions within the liver mass.
No other extra-hepatic abnormalities are reported and he has no background of liver disease or alcohol excess.
**Which of the following additional investigations is the most important to perform in the diagnostic workup of this patient?**
Colonoscopy
This patient has presented with intrahepatic jaundice secondary to multiple liver metastases.
The primary tumour is currently unknown, as the computed tomography (CT) scan has failed to detect the primary tumour in the rest of the body.
Cancers most likely to metastasise to the liver include colorectal (via the portal circulation which drains the gut), breast and lung.
The latter would have been detected on a staging CT scan to find the primary tumour.
Small colorectal tumours are often occult on CT scans, and therefore a colonoscopy would be the best investigation to identify a missed colorectal tumour.
43
You are the F2 working in A&E. A 60 year old male patient is admitted to the emergency department with fever and feeling generally unwell.
8 days ago he completed a cycle of chemotherapy for metastatic bowel cancer.
On physical examination he is tachycardic, hypotensive, and pyrexial.
Full blood count reveals a neutrophil level of 0.2 x 10^9/L.
**Which of the following is the most appropriate management for the most likely diagnosis?**
**Intravenous tazocin**
The patient presents with neutropenic sepsis.
The patient should be managed according to the sepsis 6 guidelines, including intravenous broad-spectrum antibiotics.
44
A 93-year-old man with severe chronic obstructive pulmonary disease (COPD), metastatic lung cancer and mild dementia is deteriorating in hospital following an acute exacerbation of his COPD.
The consultant in charge predicts that he will continue deteriorating and will die within the next few days.
The patient is currently on a continuous subcutaneous infusion of Morphine 50mg and Midazolam 5mg.
However, he has ongoing difficulties managing his copious secretions.
**Which appropriate anticipatory medication to add to this syringe driver?**
**Glycopyrronium**
four main symptoms common in the last days of life are
(1) Respiratory secretions
(2) Nausea and vomiting
(3) Pain
(4) Terminal agitation.
This man has already been prescribed medication to relieve his pain (morphine) and terminal agitation (midazolam). Given his copious secretions, Glycopyrronium is the best medication to add on to his current syringe driver. Glycopyrronium helps to reduce respiratory secretions via its anti-muscarinic actions.
45
A 21 year old patient presents to General Practice after having a seizure.
Whilst undergoing an initial assessment, he has another seizure that lasts more than five minutes.
A nurse has attempted to obtain intravenous access but has had a number of unsuccessful attempts.
**What is the most appropriate initial treatment?**
Buccal midazolam
The first line treatment for seizures and status epilepticus is benzodiazepines.
Since intravenous access is yet to be obtained, the most appropriate initial treatment in this patient is buccal midazolam (which works more quickly than rectal treatment).
This is in keeping with recommendations by NICE.
46
A 25 year old man presents with a midline neck lump related to the thyroid gland.
Over the past three months he has had 5 kg of unexplained weight loss associated with reduced appetite.
A fine needle aspirate is taken from the neck and demonstrates signs consistent with papillary thyroid cancer.
**Which of the following is a histological sign of papillary thyroid cancer?**
**Orphan Annie Cells**
Orphan-Annie cells with their optically clear nuclei are pathognomonic of papillary thyroid cancers
47
What is a Philadelphia chromosome?
Philadelphia chromosome is present within CML and is caused by the
translocation of chromosome 9 and chromosome 22 to form a fusion gene BCR-Abl.
It can be targeted by imatinib.
48
A 78-year-old patient on the ward complains of palpitations and dizziness. She has an extensive past medical history and is currently being treated for community-acquired pneumonia.
A 12-lead ECG is performed and a diagnosis of torsades de pointes is made.
**Which of the antibiotic has most likely contributed to the patient developing this abnormal heart rhythm?**
Erythromycin
Macrolide antibiotics can cause QT prolongation, which increases the risk of developing torsades de pointes.
She has likely been started on this for the treatment of pneumonia.
49
A 33-year-old Afro-Caribbean lady complains of painful loss of vision in her right eye over the last three days.
She reports that she has an **irregular shaped area missing towards the middle of her vision.**
She also complains of **abnormal perception of colours** with reds appearing less distinct than normal.
She is otherwise healthy with no significant past medical history.
She does not take any regular medications and has no allergies.
**Given the underlying diagnosis. (1)**
**Which of the following findings would you most likely find on examination of her eyes? (2)**
**optic neuritis**
**A relatively dilated pupil on the right when the torch is swung towards it**
This lady has features in keeping with a diagnosis of optic neuritis which may be secondary to a demyelinating condition such as multiple sclerosis.
**This option describes a relative afferent pupillary defect (RAPD)** of the right eye, which commonly occurs in patients affected by MS (secondary to optic neuritis).
50
A 55 year old woman being treated for triple negative breast cancer presents with pain in her spine which has progressed over the past three weeks.
However, her pain today is described as excruciating and is not responsive to pain relief.
A whole spine MRI is carried out and reveals the presence of bone metastases within the thoracic spine.
She has received 6 cycles of BEC chemotherapy regimen and there has been no prior surgical intervention related to her breast cancer.
**What is the single most likely route of metastatic spread to the bone?**
Haematogeneous
The most common mechanism of spread of metastasis is haematogeneous through blood vessels to distant sites.
* lung
* liver
* brain
are common sites for breast cancer metastases.
51
A 45 year old woman who is currently being treated for breast cancer completed her second cycle of chemotherapy 6 days ago.
She presents to the A&E with increasing confusion and a temperature of 38.5 degrees.
She reports that she has had a chesty cough for the past three days, which has deteriorated.
She is clinically stable when you see her.
**What is the diagnosis?**
**What is the single most appropriate management plan?**
**IV Tazocin STAT**
Tazocin is the correct antibiotic regimen for neutropenic sepsis.
52
A 66-year-old woman on the oncology ward with metastatic breast cancer is complaining of worsening pain not controlled by regular Paracetamol and as-required Ibuprofen.
She is reviewed by the team who commence her on 15mg Morphine Sulphate tablets twice daily.
**Which set of anticipatory medications would be most important to prescribe? (2)**
**Regular Senna** and **as-required Cyclizine**
Opiate naïve patients who are commenced on strong opioids such as Morphine will invariably experience nausea and constipation.
Although nausea is often transient, constipation persists due to reduced intestinal peristalsis.
Therefore regular pro-kinetic laxatives such as Senna should be prescribed, whereas Cyclizine should be prescribed on an as-required basis.
53
What is Senna?
regular pro-kinetic laxatives such as Senna
54
A 73-year-old man with lung cancer is taking modified release Morphine sulphate tablets 30mg twice daily for pain relief.
## Footnote
**Which of the following options represents an appropriate as required prescription for any additional pain he experiences during the day?**
**10mg immediate release Morphine sulphate solution**
This is the correct answer. The prescription of Morphine for breakthrough pain (defined as additional pain experienced by a patient not controlled by their current regular morphine) is a hot topic and commonly tested. Morphine prescribed for breakthrough pain is stipulated as 1/6 of the total oral Morphine dose, and prescribed as instant release oral Morphine such as "Oramorph" solution. The dose required for breakthrough pain for this patient is (30x2)/6 = 10mg.
55
An 82 year old male presents to the Emergency Department with confusion, muscle weakness, constipation, abdominal pain and nausea.
His past medical history includes squamous cell carcinoma of the lung treated with chemotherapy.
On examination vital signs are in normal range.
His Glasgow Coma Score (GCS) is 14/15.
Blood tests show serum corrected calcium 3.7 mmol/l (normal range 2.1-2.6mmol/l).
**What is the diagnosis?**
**What is the mechanism of his diagnosis?**
**Which of the following is the best next step in the management of this patient?**
**Intravenous 0.9% sodium chloride infusion**
**Intravenous bisphosphonates should be prescribed after the patient has been rehydrated**
Squamous cell carcinoma is associated with ectopic parathyroid hormone-related protein (PTHrP) production which acts like parathyroid-hormone (PTH) to increase bone resorption and renal calcium reabsorption, thereby increasing serum calcium levels.
Hypercalcaemia can also results from bony metastases.
The classic symptoms of hypercalcaemia can be remembered with the mnemonic "stones, bones, groans, thrones, psychiatric overtones".
**Initial management is with intravenous fluid replacement to correct dehydration and increase urinary excretion of calcium.**
56
A 26 year old lady attends her GP practice with elbow pain for the past week followed by a lump appearing on her elbow 2 days ago.
This lump has got bigger and is now stopping her fully extending her arm.
She has not injured her arm and she is frustrated as she has been taking part in a ‘plank competition’ at the gym and she can no longer do this as she can’t lean on her elbow.
On examination there is a lump over the olecranon, it is not painful, red or hot to touch.
She is systemically well and has no other joint abnormalities.
**What is the most likely diagnosis?**
Olecranon Bursitis
The common presentation of pain and swelling localised to the olecranon following a repetitive injury makes this the most likely diagnosis
57
A 28 year old man collapses outside the GP surgery.
The receptionist immediately calls you to come and assess the patient.
On assessing the patient you see that he has a rash on his arms and legs, there is an audible wheeze and his lips are swollen.
His temperature is 36.6, HR is 110, RR is 36, sats 92% blood pressure 82/60. You make the diagnosis of anaphylaxis, place the patient in the recovery position, attach high flow oxygen and call 999.
**Which of the following medication is the most appropriate to administer immediately?**
Adrenaline 1:1000 IM 500micrograms (0.5ml)
This is the correct dose of adrenaline, a life saving medication in anaphylaxis.
58
A 56-year-old female presents to her **GP** 9 days after her second cycle of 5-Fluorouracil, Epirubicin and Cyclophosphamide chemotherapy for breast cancer.
She has a past medical history of Type 2 diabetes mellitus and is allergic to Penicillin. She reports feeling slightly feverish, but is otherwise well, with no rigors, myalgia, cough or urinary symptoms.
On examination, her temperature is 38.2oC with no other clinical findings.
**What is the best initial management for this patient?**
**Refer urgently to the local medical team**
This woman may be presenting with neutropenic sepsis, which is a potentially life-threatening oncological emergency. In neutropenic patients, infections can rapidly progress leading to fulminant sepsis. Therefore, the diagnosis of neutropenic sepsis is often presumptive in any febrile patient having recently received chemotherapy. This patient needs to be urgently assessed by the medical team at her local hospital, and should receive empirical antibiotics with a door-to-needle time of 1 hour, in line with national neutropenic sepsis guidelines. In a hospital setting, she will also be able to receive other supportive treatment such as fluids, oxygen and other investigations to identify the source of infection.
Neutropenic sepsis typically occurs approximately 10 days or more after chemotherapy, as this is when patients typically experience what is known as a "neutrophil nadir". Certain chemotherapeutic agents which work to inhibit DNA synthesis have a significant effect on the mitotically active bone marrow, and can lead to myelosuppression. Examples include alkylating agents such as Cyclophosphamide, anti-metabolites such as 5-Fluorouracil, and topoisomerase inhibitors such as Epirubicin. This patient is receiving combination chemotherapy, which puts her at high risk for neutropenia.
59
A 60-year-old woman presents to her GP with a one week history of worsening abdominal pain, constipation, nausea, and bilious vomiting. She also reports a six month history of bloating and early satiety. She is normally fit and well apart from a recent diagnosis of stress incontinence, for which she is being seen by the local urology team. On examination, her abdomen is distended and diffusely tender.
As part of the diagnostic workup, the GP takes blood to measure serum levels of tumour markers.
**What is the diagnosis?**
**Which of the tumour marker, if raised, would most likely explain her symptoms?**
CA 125
This patient has presented with features of bowel obstruction.
CA 125 is a tumour marker for ovarian cancer, which is the likely cause of this patient's symptoms.
Ovarian cancer often presents late with non-specific symptoms, such as bloating, early satiety, and new onset stress incontinence in middle aged women.
Due to these non-specific symptoms, bowel obstruction can be a first presentation for patients with ovarian cancer, as the tumour spreads into the peritoneum causing bowel obstruction at multiple levels.
Importantly, a raised CA 125 is not diagnostic of ovarian cancer, but increases the likelihood of an ovarian malignancy.
It can also be used to track response to treatment in patients with a confirmed diagnosis, and to monitor recurrence.
This patient will need urgent referral for a computed tomography scan of their chest, abdomen and pelvis for staging.
60
A 70-year-old man with a 20 year smoking history, presents with a four month history of weight loss and a persistent cough with occasional bloody sputum.
He also complains of sweating profusely at night over the past month, requiring a regular change of bed sheets.
He has noticed that he is thirsty more than usual and has been passing urine more than five times a day, yet has been finding it difficult to pass stool.
On examination, he scores 6/10 on the acute mental test, and has noticeable finger clubbing.
**What is this complication?**
**What is the most likely lung malignancy?**
**What would be specifically associated with the diagnosis?**
**Hypertrophic pulmonary osteoathropathy (HPOA) (clubbing)**
The patient has signs of **lung cancer** alongside signs of **hypercalcaemia** (polyuria, polydipsia, constipation and confusion).
**Squamous cell carcinoma** is the most likely malignancy as this is associated with **paraneoplastic** **hyperparathyroidism** (PTHrP).
Additionally, squamous cell cancer is also associated with HPOA affecting the hands and feet.
61
A 22 year old dancer attends the sexual health clinic to discuss contraception.
She is unhappy on her current contraceptive, the Nexplanon implant, as it has made her periods erratic.
She also experiences spotting throughout her cycle.
The irregular bleeding interferes with her work and she requests a method that will bring back regularity of her periods as soon as possible.
Her past medical history includes acne, for which she uses topical Benzoyl peroxide.
There is no relevant family history.
She is a non-smoker and has a normal blood pressure.
**_Which of the following is the most suitable option to offer?_**
**The combined oral contraceptive pill (OCP)**
This is the most suitable option for a young woman with no contraindications, whose main concern is **irregularity**.
The OCP is well known for improving regularity of cycles, as well as lighter, less painful periods (including, sometimes, complete cessation of periods).
**It also has the benefit of improving acne.**
62
A patient has lung cancer.
Their bloodwork shows;
* hypokalaemia
* hypernatraemia
* hypercortisolism
**Ectopic production of which of the following hormones is the most likely cause of this patient's symptoms?**
**Which lung cancer is this associated with?**
**Adrenocorticotrophic hormone (ACTH)**
This is a presentation of Cushing's syndrome secondary to ectopic ACTH production, which is associated with **small cell lung cancer** (neuroendocrine tumours).
The ectopic ACTH production stimulates the adrenal glands to produce excess cortisol. Patients present with proximal muscle weakness, central obesity, hypertension, hypokalaemia and diabetes mellitus. The lack of cortisol suppression with the dexamethasone test indicates an ectopic source of ACTH. If the ACTH was being produced by a pituitary tumour (Cushing's disease) there would be cortisol suppression with the high dose dexamethasone.
63
A 60 year old man presents to the Respiratory Clinic following a three month history of unintentional weight loss, persistent cough and dyspnoea. Over the last few days he developed haemoptysis.
A Chest X-ray performed shows a peripheral nodule. Further investigations are requested, and biopsy shows a **glandular** **architecture** of the lesion, with the PET-CT scan staging the lesion as T1N0M0.
**What type of lung cancer is it?**
**What is the most appropriate definitive management of the patient?**
**Surgical referral for lobectomy**
It is the definitive management of a patient with a curative **adenocarcinoma** (non-small cell lung cancer), patients must undergo pulmonary lung function tests prior to treatment with surgery.
64
How is **non-small cell lung cancer** treated?
(2)
**Cisplatin + Gemcitabine**
Chemotherapy is reserved for patients for whom curative treatment is not an option.
This involves patients with stage III, IV non-small cell lung cancer.
65
A 75 year old man has a known diagnosis of squamous cell carcinoma of the lung.
He is currently undergoing treatment with chemotherapy.
On his blood tests it is shown that he has a **raised calcium level.**
All other investigations are normal including serum electrophoresis.
**What is the single most likely explanation for this result?**
**Parathyroid Hormone related Peptide Production**
Squamous cell carcinoma secretes **parathyroid hormone related peptide** which increases turnover rate of bone.
66
A 40 year old woman attends the sexual health clinic wishing to discuss contraceptive choices.
She was previously using the **combined oral contraceptive pill**, but was advised to stop after being diagnosed with stage 1 breast cancer.
**Which of the following is the most appropriate form of contraception for this woman?**
**Copper intra-uterine device (IUD).**
Non-hormonal methods such as the IUD are the only acceptable form of contraception in women with active breast cancer.
67
A 32-year-old man presents to A&E with chest pain. He describes a two-day history of severe, sharp, central chest pain that is worse on inspiration. He has no past medical history of note.
Observations are as follows:
* respiratory rate 12/min,
* SpO2 96% on room air,
* pulse rate 112/min,
* blood pressure 128/89,
* temperature 37.7.
A 12-lead ECG is performed which shows **global concave ST-elevation.**
**What is the most likely diagnosis?**
Acute pericarditis
The history of a young man with pleuritic chest pain and low-grade fever is highly suspicious of acute pericarditis (acute inflammation of the pericardium).
This is confirmed by the characteristic global concave ST elevation seen on the 12-lead ECG.
**PR depression and T wave changes may also be seen.**
Acute pericarditis may be idiopathic or caused by infection (most commonly viral), inflammatory disorders, cardiac surgery, or drugs.
68
A 35 year old woman attends the sexual health clinic requesting to start the combined oral contraceptive pill.
She has a past medical history of asthma, well-controlled with Salbutamol, and occasional tension headaches.
She smokes 15 cigarettes a day and does not drink alcohol. Her body mass index (BMI) in clinic today is 25. Her only family history is that her mother suffered a deep vein thrombosis at age 75.
**Which of the following in her history, makes the combined oral contraceptive pill an unsuitable option for her?**
Being 35 years old or more and smoking 15 or more cigarettes a day is a UK MEC 4
and the combined pill should not be prescribed in these patients.
69
A 28-year-old man presents to A&E with a six week history of progressive **dyspnoea** and **headaches**.
He reports that the **headaches are worse in the morning** and when bending over.
Over the last 3 months, he reports infrequently awaking at night sweating profusely.
He also thinks that his clothes feel looser than before. On examination, he has marked **facial oedema** and prominent **contiguous cervical lymphadenopathy**. His respiratory rate is 22 and his oxygen saturations are 96% on air.
**Which of the following is likely to be the single most effective treatment option for him?**
* One-off high dose Dexamethasone
* 15L/min oxygen via a non-rebreathe mask
* Percutaneous transcatheter insertion of a central venous stent
* Mannitol infusion
* Systemic therapy with Doxorubicin, Bleomycin, Vinblastine and Dacarbazine
**Systemic therapy with Doxorubicin, Bleomycin, Vinblastine and Dacarbazine**
This is the correct answer. This man is presenting with symptoms and signs of superior vena cava obstruction (SVCO), which commonly include shortness of breath, headaches secondary to raised intracranial pressure, and facial oedema. The condition is commonly associated with malignancies within the mediastinum which invade into the SVC wall. The top three most common malignancies which cause SVCO are non-small cell lung cancer, small cell lung cancer, and lymphomas.
In a patient in this age group, the most likely cause is Hodgkin's lymphoma, also suggested by the patient's night sweats and contiguous cervical lymphadenopathy. The most effective treatment for SVCO is systemic treatment with chemotherapy. The effects of this are most rapid in small cell lung cancers and lymphomas, which are highly chemo-sensitive tumours. Doxorubicin, Bleomycin, Vinblastine and Dacarbazine (abbreviated as ABVD) form the first-line combination chemotherapy regimen for Hodgkin's lymphoma.
70
A 25 year old lady attends the walk-in sexual health clinic after forgetting to take her Progesterone only pill yesterday.
She usually takes **Cerazette** (desogesterel) once a day.
Her last pill was due 15 hours ago. She has not had any unprotected sexual intercourse this month.
**What is the most appropriate advice to give? (3)**
* **Take the missed pill,**
* **continue the pack as usual,**
* **and use condoms for the next two days**
Progesterone only pills are only effective on the day taken - missing even one day reduces effectiveness. Patient should be advised to use condoms for the next two days, and if unprotected sexual intercourse happens in these two days, emergency contraception must be offered.
71
An 18 year old woman attends the sexual health clinic to discuss contraceptive methods.
She is keen for a long-term method as she has no plans for children for at least ten years. She has no preference regarding invasiveness of the method.
Her most recent STI screen tested positive for Chlamydia, for which she is currently on a seven day course of **Doxycycline**.
She has had Chlamydia and Gonorrhoea once in the past previously.
She has no other medical history.
Her mother has 'a blood-clotting condition' and had a clot aged 40.
She is a non-smoker and uses alcohol socially.
A pregnancy test in clinic today is negative.
**Which of the following is the most appropriate method to recommend?**
**Contraceptive implant**
This is the most effective contraceptive method (\>99% effective - more effective than sterilisation).
It is a small device inserted subcutaneously in the arm and lasts three years.
There are no contraindications in the patient's history and it fits her preferences, making it the most appropriate option for her.
*\*Depo-provera injections can lead to an increased risk of fractures later in life, and so is not usually a first-line method in teenagers and young women*
72
A 25 year old man presents to General Practice with a severe sore throat that began two days ago.
He suffers no coryzal symptoms or night sweats.
He has a past medical history of Crohn's disease but hasn't suffered a flare for two years and takes **azathioprine**.
ENT examination is unremarkable.
**What is the most appropriate next step in management?**
**Urgent full blood count**
This man takes an immunosuppressant medication, azathioprine.
In anybody that is immunosuppressed (e.g. taking azathioprine for Crohn's or rheumatoid arthritis, recent chemotherapy or acute leukaemia), **if they present with a sore throat, neutropenia must be excluded using an urgent full blood count.**
This is true even if examination is normal.
73
A 25 year old lady attends the sexual health clinic requesting emergency contraception after having unprotected sexual intercourse (UPSI) last night.
The first day of her last menstrual period was 14 days ago.
She has a regular 28 day cycle.
She has no past medical history.
Her observations are normal, and you note her BMI to be 32.
Whilst counselling her on her options, she expresses she is not keen for any invasive procedures.
Which of the following is the most appropriate management option?
* Levonelle,
* double dose
**In women with a BMI \>26 or a weight \>70kg**, the dose of Levonelle must be doubled in order to be effective.
This patient's BMI is 32 so she falls within this category.
74
A 65 year old woman who has a new diagnosis of metastatic breast cancer presents to the oncology clinic.
She has a past medical history of heart failure and COPD.
She reports that she is able to mobilise for 2-3 hours a day but finds it difficult to carry out activities such as cooking or cleaning.
**What is the WHO performance status of this patient?**
**The WHO performance status classification categorises patients as:**
* **0:** able to carry out all normal activity without restriction
* **1:** restricted in strenuous activity but ambulatory and able to carry out light work
* **2:** ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours
* **3:** symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden
* **4:** completely disabled; cannot carry out any self-care; totally confined to bed or chair.
75
A 65-year-old woman presents to the emergency department with sudden-onset shortness of breath and chest pain.
She has just returned from a trip to South Africa.
On examination chest expansion is symmetrical, trachea is central and breath sounds are vesicular.
Her observations are below:
* HR 120
* BP 80/40
* RR 20
* SaO2 88%
* T 37.50C
**Given the likely diagnosis, what is the most appropriate initial treatment?**
1. 15L of Oxygen therapy via non-rebreathe mask
2. 0.9% sodium chloride 500ml IV
3. LWMH
4. Alteplase IV bolus
76
An 82 year old woman presents to the GP with increasing shortness of breath and difficulty sleeping.
She reports that this has developed alongside an irregular midline neck lump, which on palpation appears hard.
She reports pain on swallowing.
At rest you can hear **intermittent** **stridor**.
She appears to have **lost significant weight** with her clothes being quite loose in clinic.
**What is the single most likely diagnosis?**
**Anaplastic** **carcinoma** commonly presents in elderly patients, particular women, with signs of airway compromise (stridor) and **dysphagia**.
It is a rare but aggressive tumour.
77
A 25 year old lady attends the sexual health clinic requesting emergency contraception after having unprotected sexual intercourse (UPSI) four days ago.
The first day of her last menstrual period was 14 days ago.
She has a regular 28 day cycle.
She has a past medical history of asthma and acne.
Her medications include Salbutamol, Seretide, Montelukast, Prednisolone and topical Benzoyl peroxide.
**Which of the following is the most appropriate management option?**
Copper intrauterine device (IUD)
The IUD is the most effective form of emergency contraception and should always be offered first-line in the absence of contraindications.
Additionally, The Faculty of Sexual and Reproductive Health states that **ellaOne is not recommended for women who have severe asthma**, as this patient appears to have ('severe asthma' is defined here as requiring **oral steroids**).
78
A 55 year old gentlemen has a diagnosis of small cell lung cancer.
He presents to A&E complaining of nausea and vomiting and is acutely confused with an AMTS of 3/10.
He is triaged, IV fluid resuscitation is initiated and bloods taken.
His blood tests show that his plasma sodium is 122 mmol/L.
All other blood results are normal.
**What is the single most likely diagnosis?**
* SIADH (Syndrome of inappropriate antidiuretic hormone secretion)
* SIADH is a well known cause of hyponatraemia in euvolaemic patients.
## Footnote
**The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is one of the paraneoplastic syndrome which has a well-established linkage to small cell lung cancer. It occurs in 7–16% of small cell lung cancer (SCLC) cases and has been linked to worse outcome in patients with SCLC**
79
Lung Cancer paraneoplastic syndromes
| (7)
1. Vascular and haematological complications: Anaemia
2. HPOA (Hypertrophic pulmonary osteoarthropathy)
3. Finger clubbing: 30% of cases – caused by non-small cell carcinoma.
4. Inappropriate ADH secretion – this can cause hyponatraemia
5. Ectopic ACTH secretion – causing Cushing's syndrome
6. Hypercalcemia (squamous)
7. Carcinoid syndrome - This presents with hepatomegaly, flushing and diarrhea
80
A 24-year-old man presents to his general practitioner (GP) complaining of tiredness and fever. He was diagnosed with testicular cancer last month and had his first dose of chemotherapy last week.
On further questioning, he does not report any other symptoms. His blood pressure is 125/80 mmHg and his temperature is 38.3°C.
**Which of the following is the next best step in management?**
**If they present unwell or with a fever, any patient who has recently had chemotherapy should be presumed to have neutropaenic sepsis.**
The neutrophil count typically reaches its lowest point 7-10 days after chemotherapy, however, this may vary.
This patient should be sent urgently to hospital to receive broad-spectrum IV antibiotics.
**This is usually piperacillin with tazobactam (Tazocin).**
In addition, his full blood count should be checked to find out if he is neutropaenic.
81
A 20 year old woman attends the walk-in sexual health clinic after missing a number of combined oral contraceptive pills.
She has missed days 17, 18, and 19 of pill-taking.
There has been no recent unprotected sexual intercourse.
**What is the most appropriate advice?**
**Take the most recently missed pill, continue the rest of the packet, and omit the next pill-free week**
This patient should take the missed pill and today's pill (i.e. two pills), and continue the rest of the pack.
When this pack ends, she should start taking the next pack straight away i.e. without taking a pill-free break.
82
A 70-year-old man with a 40 pack year smoking history presents to A&E with progressive upper limb and facial swelling. The veins in his neck appear distended and his face is plethoric.
What is the most likely cause of his symptoms?
Lung cancer
This gentleman is suffering from superior vena cava obstruction (SVCO).
The most common cause for this presentation is from extrinsic compression by a pulmonary tumour on the superior vena cava.
This is likely given his age and smoking history
83
A 48 year old man presents to hospital with a right upper quadrant pain, jaundice and rigors.
His heart rate is 105bpm, blood pressure 88/63, respiratory rate 28/min, temperature 38.4°C and oxygen saturations 98% on room air.
On examination he is Murphy’s sign positive. A VBG lactate is perform which returns as 5mmol/L.
**What is the most appropriate immediate management of this patient?**
**Fluid challenge with crystalloid**
A fluid challenge is recommended by NICE for any patient with suspected sepsis who displays the signs of shock (SBP\<90mmHg) or has a lactate above 4mmol/L.
This is because these patients are at high risk of failing to adequately perfuse their organs.
84
A 43 year old female presents to A+E with a 12-hour history of fever, which she recorded at home as 39 degrees.
She has a background of Acute Myeloid Leukaemia, for which she has been receiving cycles of chemotherapy in the last month.
Her last cycle was completed three days ago.
On examination, she looks pale and her observations show significant hypotension, tachycardia, and pyrexia.
Systems examinations are grossly normal. Blood cultures are sent along with relevant blood tests.
She is found to have a neutropenia of 0.4x109.
**What empirical antibiotics should be started?**
**Piperacillin** and **tazobactam**
Tazocin is first line empirical therapy for severe neutropenic sepsis, as it covers Staphs, streps, anaerobes, problem gram +ves (e.g. coagulase -ve staph) and problem gram -ves (e.g. Pseudomonas).
85
A 72-year-old man with metastatic prostate cancer is admitted to the oncology ward.
He has a long history of Type 2 diabetes mellitus resulting in significant diabetic retinopathy and nephropathy.
Given his worsening pain, a decision is made to commence regular opioid pain control.
He has never received opiates in the past.
**Which of the following options represent the most appropriate opiate dosing regimen for this patient?**
* Twice-daily modified release Oxycodone 7.5 mg, as-required immediate release Oxycodone 2.5 mg
* Fentanyl 12 mcg/hour patch every 3 days, as-required immediate release Oxycodone 5 mg
* Four-hourly immediate release Oxycodone 2.5 mg, as-required immediate release Oxycodone 5 mg
* Four-hourly immediate release Morphine 5 mg, as-required immediate release Morphine 5 mg
* Twice-daily modified release Morphine 10 mg, as-required immediate release Morphine 3 mg
Twice-daily modified release Oxycodone 7.5 mg, as-required immediate release Oxycodone 2.5 mg
86
A 40-year-old man is brought into the Emergency Department (ED) after being found poorly rousable at home. He has been unwell for the last few weeks complaining of tiredness, weakness, excess thirst and nausea.
**On examination, he has a GCS of 10 and is haemodynamically stable.**
* Blood glucose: 65 mmol/L (4-11 mmol/L)
* Urine glucose: 4+
* Urine ketones: +
* Sodium: 154 mmol/L (135-145 mmol/L)
* Potassium: 5.0 mmol/L (3.5-5.0 mmol/L)
* Urea: 35 mmol/L (2.5-6.7 mmol/L)
* Creatinine: 240 µmol/L (70-130 µmol/L)
**Which of the following is the next best step in management?**
**1L of 0.9% saline over 1 hour**
This patient has **Hyperosmolar Hyperglycaemic State (HHS)**.
It is characterised by marked hyperglycaemia (above 30 mmol/L); absent or mild ketonaemia and raised serum osmolality (\> 320 mOSm/kg).
Osmolality, in this case, should be formally requested but can be estimated by the formula: (2 X sodium) + urea + glucose.
In this case: (2 x 154) + 35 + 65 = 408 mOsm/kg. Compared to diabetic ketoacidosis (DKA), HHS has a more insidious onset and is associated with higher blood glucose levels.
It is also more common in Type 2 diabetics and not usually associated with heavy ketonuria. In this case, mild ketonuria is likely due to starvation.
**First-line treatment for HHS is to hydrate the patient with 0.9% saline. At least 1L should be given in the first hour.**
87
A 50-year-old lady presents to the Emergency Department with a 1-day history of pleuritic chest pain. She has a past medical history of COPD. Her observations are as follows:
HR 88, RR 20, BP 120/85, T 37.0, SO2 89% RA
On examination, she is comfortable at rest.
On palpation, there is no tracheal deviation or crepitus over the chest.
On auscultation, there is decreased air entry over her right lung.
A chest X-ray is ordered which shows evidence of reduced lung markings on the right side with no other findings.
**What is the best management option for this patient?**
**Chest drain insertion**
This patient has features of a **secondary spontaneous pneumothorax** of the right lung, most likely secondary to her underlying COPD.
Patients who have a secondary pneumothorax who are symptomatic or have a pneumothorax measuring **\>2 cm from the chest rim on radiographs should be offered a chest drain.**
88
A 22 year old lady attends the sexual health clinic requesting emergency contraception after having unprotected sexual intercourse (UPSI) four days ago. The first day of her last menstrual period was 14 days ago. She has a regular 28 day cycle.
She has a past medical history of seasonal rhinitis. Her medications include Cetirizine as needed.
She had one other UPSI on day two of this cycle.
She is not keen on an invasive procedure.
**Which of the following is the most appropriate management option?**
Ulipristal acetate (ellaOne)
This is the correct option as it is licensed for use up to five days post UPSI. Note that the previous UPSI in the cycle was very unlikely to result in pregnancy. In the unlikely scenario that it did, ellaOne is not known to harm an existing pregnancy.
89
A **25 year old** man presents to his GP complaining of a lump on his testicle.
He noticed it while having a bath two days ago.
He has not noticed any other symptoms of note.
On examination the GP notices a mass, which appears to be part of the testicle.
No masses are felt posteriorly or superiorly, and there is no sign of effusion.
The GP sends off a range of blood tests including tumour markers.
The patient has a testicular ultrasound, which demonstrates a hyperechoic mass within the testicle.
The blood test results that come back 2 weeks later show a **raised AFP.**
**What is the single most likely diagnosis?**
**Non-seminoma germ cell tumour**
Non-seminoma testicular tumours are more common in this **age group** and the **raised AFP** is supportive of this diagnosis
90
A 36 year old woman attends the sexual health clinic wishing to start contraception.
She is sexually active with one regular partner.
Her main concern is that her periods are long and heavy.
She has a past medical history of asthma and migraine with aura.
She takes Salbutamol and Sumatriptan as needed.
She is keen to avoid any method that could cause her to gain weight.
**Which of the following is the most appropriate contraceptive for her?**
**Mirena coil**
Mirena coils are an effective treatment for heavy periods and do not usually cause weight gain. This is the single best answer in this scenario.
*NB, the progesterone only pill is not good for heavy periods*
91
A 25 year old man presents to the GP with episodes of flushing and sweats.
He describes these occuring intermittently and reports that he has periods of diarrhoea that coincide with these symptoms.
During these episodes he feels that his heart is racing.
He does not report vomiting or a temperature.
On examination of his abdomen a mass is noted in the right upper quadrant.
He is normotensive.
**What is the single most likely diagnosis?**
**Carcinoid Syndrome**
The carcinoid tumour **metastasises to the liver,** leading to systemic symptoms as they do not undergo metabolism in the portal circulation.
92
What dose of oromorph does NICE recommend for opioid-naive patients?
**20-30 mg oral Morphine** is safe and effective for opiate naïve patients
93
A 65-year-old woman presents to A&E with a two week history of progressive dyspnoea and chest pain.
She describes being initially short of breath on exertion, but now she currently struggles to catch her breath even at rest.
She has been in remission for seven years from Stage II oesophageal cancer.
This was treated with neoadjuvant chemoradiotherapy, followed by an oesophagectomy, and adjuvant chemotherapy with Carboplatin and Paclitaxel.
On examination, her jugular venous pressure is raised at 7 cm above the sternal notch, and does not rise on inspiration.
**Which of the following clinical features is most likely to be associated with this patient's presentation?**
**Pericardial rub**
This woman has presented with constrictive **pericarditis, secondary to neoadjuvant radiotherapy** directed at the mediastinum to shrink her oesophageal tumour prior to surgery.
Delayed constrictive pericarditis after radiotherapy for thoracic malignancies is well described, secondary to radiation-induced fibrosis of the pericardium.
Constrictive pericarditis initially presents with features of right heart failure (such as a raised jugular venous pressure) as the right ventricle is less muscular and is first affected. A pericardial rub may be present as a result of the myocardium coming up against the edges of a tightened pericardium.
94
A 22 year old man is currently undergoing treatment for non-Hodgkin’s lymphoma. During his chemotherapy regimen he reports that he has become increasingly nauseous. He would like to be prescribed some medication for this.
**What is the single most appropriate class of anti-emetic to prescribe him?**
* D2 receptor antagonist
* H1 receptor antagonist
* NMDA receptor antagonist
* 5HT3 antagonist
* H2 receptor antagonist
**Ondansetron** is the most frequently agent in chemotherapy to treat nausea and vomiting.
5HT3 antagonist
95
Which receptor does cyclizine target?
H1 receptor antagonist
H1 receptor antagonists can be used in nausea and vomiting (e.g. cyclizine), but are not first line for chemotherapy-induced nausea and vomiting.
96
Which receptor does risperidone target?
**D2 receptor antagonist**
D2 receptor antagonists are used to treat schizophrenia and mania and are examples of anti-psychotics.
They can be used for vomiting and nausea but are not classically first line for patients with chemotherapy induced nausea and vomiting.
97
Which receptor does metoclopramide target?
HT3
98
Confirming death consists of:
| (6)
1. confirming the patients identity
2. checking for any obvious signs of life
3. checking response to verbal and painful stimuli
4. Assessing pupils - they should be fixed and dilated
5. Feeling a central pulse
6. Listening for heart sounds and respiratory sounds for a total of 5 minutes.
99
A 75 year old man presents to the Emergency Department complaining of a two month history of gradual onset weakness in his limbs.
He states the **weakness is worse in his lower limbs and improves with movement.**
He also reports a **dry mouth, fatigue** and a new cough productive of blood-stained sputum.
He has no significant past medical history but reports a 45 pack year smoking history.
On examination his vital signs are in normal range, there is proximal muscle weakness with reduced tendon reflexes.
A chest X-ray shows a left hilar mass.
**Which of the following is the most likely diagnosis?**
**Which syndrome is he presenting with?**
**Small cell lung cancer**
This is a presentation of **Lambert-Eaton myasthenic syndrome (LEMS)**, a paraneoplastic disorder associated with small cell lung cancer.
In LEMS circulating antibodies develop against voltage-gated calcium channels in the peripheral nervous system, inhibiting acetylcholine release into the synaptic cleft and inhibiting neuromuscular transmission.
Patients typically present with limb weakness, predominately affecting the lower limbs.
Classically they will describe the limb weakness initially improving with movement although the weakness will return when exertion is sustained.
They also report autonomic symptoms such as dry mouths, impotence and difficulty urinating.
100
What is Lambert-Eaton myasthenic syndrome?
(3)
* In LEMS circulating **antibodies develop against voltage-gated calcium channels** in the peripheral nervous system,
* **inhibiting acetylcholine release** into the synaptic cleft
* and **inhibiting neuromuscular transmission**
Patients typically present with limb weakness, predominately affecting the lower limbs.
Classically they will describe the limb weakness initially improving with movement although the weakness will return when exertion is sustained.
They also report autonomic symptoms such as dry mouths, impotence and difficulty urinating.
*\*associated with small cell lung cancer*
101
A 33 year old woman attends the GP to discuss ongoing contraception following the recent birth of her child.
She gave birth five weeks ago and is currently breast-feeding.
She plans to breast-feed for at least six months.
She has no other medical history and takes no medication.
She is keen on a long-term method of contraception, expressing that she would like more children in the next few years, but has no immediate plans.
**What is the most appropriate contraceptive method to recommend?**
Intrauterine device (IUD)
This is a very effective long-acting reversible contraceptive (LARC). It can be inserted either 48 hours within giving birth or four weeks postpartum, is effective immediately, and can be reversed with immediate return to fertility, making it suitable for this patient's needs.
102
A 20 year old lady attends the walk-in sexual health clinic after forgetting to take her combined oral contraceptive pill.
She has missed the 12th (yesterday's) pill in the packet, but took all of her preceding tablets.
She had unprotected sexual intercourse two days ago.
**Which of the following is the most appropriate advice to give her?**
**Take yesterday's missed pill, today's pill, then continue the rest of the pack as normal**
One missed pill is not usually a cause for concern. Patients should be advised to take the pill they missed, along with the pill that is due.
103
A 63-year-old man on the Respiratory ward develops sudden respiratory distress.
He is haemodynamically unstable with hypotension and tachycardia.
**The trachea is deviated to the right side of the chest.**
A tension pneumothorax is suspected.
**Which of the following is the next best step in the management of this patient?**
* Insert a 14-16G needle
* into the 2nd intercostal space
* **midclavicular** line of the left side
A needle thoracostomy is the best initial management for tension pneumothorax while awaiting chest x-ray to confirm the diagnosis, and chest drain insertion as definitive management.
In tension pneumothorax the trachea is deviated away from the affected side, therefore in this man, the needle should be inserted into the left lung.
104
A 55 year old female presents with a three month history of dyspnoea and persistent cough.
Over the last few days her cough has progressively worsened and she is now coughing red specks.
She complains that her clothes no longer fit her, and she is having to regularly wear belts.
She works as a receptionist and has never smoked.
**Which of the following is the single most likely diagnosis?**
**Adenocarcinoma**
The patient has a history indicative of lung cancer, with dyspnoea, haemoptysis and weight loss that has progressively worsened.
However, the lack of smoking history makes adenocarcinoma the most likely diagnosis.
105
The medical foundation doctor is called to the cardiac care unit to review an 76 year old lady has just had a witnessed loss of consciousness.
On arrival patient is alert but complaining of feeling dizzy and breathless, no airway or breathing issue is identified.
On assessment of circulation, the patient has a weak radial pulse with a rate of around 40, blood pressure is 98/47, and the cardiac monitor shows complete heart-block.
There is an IV cannula in situ.
The patient’s medication history includes atenolol, ramipril, and amlodipine.
What is the single best initial treatment for this patient?
**IV atropine 500 micrograms**
This patient has symptomatic bradycardia caused by complete heart-block. In an unstable patient with bradycardia, the first line treatment is atropine IV.
It works as an anticholinergic agent, decreasing the parasympathetic input to the heart and thereby causing increased sinoatrial node firing and increased heart rate.
Atropine can be given in 500 micrograms to 1mg boluses, up to a total of 3mg.
106
How does Atropine work?
| (3)
* It works as an **anticholinergic agent,**
* decreasing the **parasympathetic** input to the heart
* and causing increased sinoatrial node firing and increased heart rate
107
A 63-year-old woman with Stage IV ovarian cancer presents with gradual onset abdominal pain and bloating associated with significant bilious vomiting.
Which anti-emetic is most appropriate for controlling her symptoms?
**Cyclizine**
This woman is presenting with symptoms of mechanical bowel obstruction secondary to likely widespread peritoneal metastases of her advanced ovarian cancer.
**Cyclizine is a centrally-acting histamine H1 receptor antagonist and is the anti-emetic of choice in bowel obstruction.**
108
A 37 year old lady attends the walk-in sexual health clinic after forgetting to take her last Progesterone-only pill. She usually takes Micronor (Norethisterone) once a day. Her last pill was due four hours ago. She has not had any unprotected sexual intercourse this month.
## Footnote
**What is the most appropriate advice to give?**
**Take the missed pill, continue the pack as usual, and use condoms for the next two days**
Be aware of the two types of progesterone-only pills (POP): 'traditional' Norethisterone-containing pills, and newer Desogestrel ones.
Desogestrel POPs are considered missed after 12 hours of being late to take them, whilst norethisterone POPs are missed after 3 hours - this patient is four hours late, therefore has missed a pill and needs added protection.
POPs are only effective on the day taken - missing even one day reduces effectiveness. Patient should be advised to use condoms for the next two days.
109
A 19 year old male presents to the Emergency Department with shortness of breath and a headache which started 1 week ago.
He has noted some **swelling of his arms**, **redness of his face**,a cough and a **hoarse voice.**
On further discussion he reports a history of fever, weight loss and night sweats and neck pain on drinking alcohol.
On examination he has distended neck veins and palpable rubbery cervical lymph nodes.
**Given the likely diagnosis.**
**What is the next best step in his initial management?**
Dexamethasone
This patient has the features of an underlying **Hogkin's Lymphoma** - night sweats, fevers, weight loss, alcohol related neck pain and lymphadenopathy.
Over and above this he also has the signs of Superior vena cava obstruction (SVCO) - arm swelling, facial redness, shortness of breath, headache.
Lymphoma accounts for 12% of SVCO, the most common cause being non-small cell lung cancer. If not treated SVCO can lead to catastrophic cardiopulmonary collapse. The first line treatment is dexamethasone which will rapidly shrink the tumour relieving the obstruction.
110
Treatment of tumour lysis syndrome
| (4)
**In general, treatment of TLS consists of**
* intensive hydration
* stimulation of diuresis
* allopurinol
* rasburicase
111
Treatments for hypercalcaemia
| (3)
IV (intravenous, into a vein) fluids.
Medications to reduce the level of calcium in the blood and prevent further bone breakdown (including bisphosphonates and steroids).
In the most severe cases, dialysis may be needed if the hypercalcemia has caused kidney failure.
112
A 25 year old woman attends the sexual health clinic to discuss concerns around her contraceptive method.
She has recently started the oral contraceptive pill but has read online about its association with cancers.
**Which is true regarding the OCP and its association with cancers?**
* reduces risk of ovarian and endometrial cancer
* increases risk of breast and cervical cancer
There is an increased risk (1.2x) of breast cancer and cervical cancer.
The risk reduces to baseline after ten years of stopping the OCP.
It has been shown to be protective against ovarian and endometrial cancer, and this protective effect lasts 30 years. It is important to discuss these small, but serious, risks with patients when counselling them on contraceptive methods.
113
Which triad is
Confusion, ophthalmoplegia and ataxia
This describes the triad seen in Wernicke's encephalopathy due to thiamine deficiency, commonly seen in alcohol misuse.
114
A 67-year-old woman on the Oncology ward being treated for meningioma reports worsening headache.
On examination, she appears drowsy and is irritable.
Her pupils are non-reactive.
Raised intracranial pressure (ICP) is suspected.
**Which of the following clinical features are associated with raised ICP?**
This is the Cushing's triad, which is the physiological response that can be seen in the context of raised ICP.
I**ncreased blood pressure** is an attempt to maintain adequate cerebral blood flow, while the **bradycardia** is a **baroreceptor** **reflex** in response to hypertension.
The respiratory centre is located in the brainstem.
**Increased ICP leads** to increased pressure on the brainstem, leading to **irregular breathing patterns.**
115
Cushings triad
| (3)
116
A 58 year old female presents to the Emergency Department complaining of a ten week history of progressively worsening joint pains, swelling and morning stiffness affecting her wrists, elbows, knees and ankles.
She also reported unintentional weight loss of 9kg over the past three months but otherwise has been well with no recent infective illnesses.
Her past medical history includes irritable bowel syndrome and a smoking history of 30 pack years.
There is no relevant family history.
On examination vital signs were in normal range.
There is evidence of clubbing in the fingers as well as swelling and tenderness to palpation across multiple joints and the anterior shins bilaterally.
X-rays of the affected joints show periosteal thickening.
A chest X-ray was requested which showed a peripheral rounded opacity in the right lower zone.
**What is the diagnosis?**
**Hypertrophic Pulmonary Osteoarthropathy**
This is a presentation of the paraneoplastic syndrome hypertrophic pulmonary osteoarthropathy (HPOA) secondary to an underlying lung malignancy.
The three classic features of HPOA; periostitis (inflammation of the periosteum, the connective tissue layer surrounding bone), digital clubbing and painful arthropathy of large joints are present in the history.
The patient's smoking history alongside the unintended weight loss and chest X-ray finding of a suspicious mass point to an underlying lung malignancy.
A computerised tomography (CT) chest scan would be appropriate to confirm a diagnosis of lung cancer.
The pain from HPOA can be managed with non-steroidal anti-inflammatory medications and treatment of the underlying cancer will significantly improve symptoms for the majority of patients.
117
A 58-year-old man presents to his GP with a six month history of feeling "tired all the time".
On further questioning, he admits to feeling that his clothes are looser and to experiencing occasional cramping central abdominal pain.
The GP performs a focused abdominal examination which is unremarkable.
The patient is otherwise well.
**What is the single most appropriate action for the GP to take?**
**Urgent referral to the local colorectal clinic within 2 weeks**
The National Institute for Health and Care and Excellence (NICE) stipulates that any adult aged 40 and over with unexplained **weight** **loss** and **abdominal pain** should be referred urgently within two weeks using the suspected cancer pathway referral for colorectal cancer.
This patient may also have an iron-deficiency anaemia resulting in fatigue, and a full blood count will need to be performed for this.
118
A 65 year old patient with a long term smoking history presents to the General Practice complaining of a persistent cough over the past four months and night sweats.
She has purple stretch marks along her abdomen, and has gained weight.
She has been attending cognitive behavioural therapy after experiencing anhedonia and low mood.
She is referred to the local hospital.
The results of the most recent investigation an endobronchial ultrasound transbronchial needle aspiration shows cells with dense neurosecretory granules.
**What is the most likely underlying diagnosis?**
**A small cell carcinoma** is the underlying diagnosis.
The persistent cough and night sweats with a background of chronic smoking allude to malignancy.
The paraneoplastic symptoms of Cushing syndrome (weight gain, purple striae, depression) due to ectopic ACTH secretion is attributable to small cell carcinoma.
Additionally, the histology specimen shows small cell lung cancer.
The cells have dense neurosecretory granules.
119
Lung cancer commonly metastasises to the;
(4)
brain
breast
bone
adrenals
120
A 60 year old female presents to the general practitioner reporting new onset drooping of her left eyelid with no associated change in her vision.
On systematic questioning she also reports a five month history of new cough and unintended weight loss.
She has no significant past medical history but a 35 pack year smoking history.
On examination there is unilateral ptosis, miosis and enophthalmos affecting the left eye.
Cranial nerve examination is otherwise unremarkable.
Respiratory examination reveals decreased chest expansion on the left with reduced breath sounds in the left upper-mid zones.
**What is this syndrome called?**
**What type of tumour is present?**
**Invasion of which of the following structures is the most likely explanation for this patient's physical findings?**
**Cervical sympathetic plexus**
**This is a presentation of Horner's syndrome caused by a Pancoast tumour.**
A Pancoast tumour is a tumour of the apex of the lung.
It is a relatively rare presentation of lung cancer and may be due to squamous cell or adenocarcinoma.
When the Pancoast tumour infiltrates the cervical sympathetic plexus, it causes Horner's syndrome - ipsilateral miosis (constricted pupil), ptosis (drooping of the upper eyelid) and enophthalmos (posterior displacement of the eye within its orbit), as seen in this case.
It also causes a unilateral anhidrosis (loss of sweating on one side of the face) but this may be less noticeable to patients and to clinicians on examination.
The patient's smoking history, symptoms of new cough and unintended weight loss alongside the respiratory examination findings point to an underlying lung cancer.
A computerised tomography (CT) chest would be the appropriate investigation to diagnose the Pancoast tumour.
121
A 65 year-old male presents to the emergency department with shortness of breath and fever.
He has a recent diagnosis of acute myeloid leukaemia (AML) for which he completed his first round of chemotherapy 10 days ago.
* Heart rate: 96 beats per minute
* Respiratory rate: 20 breaths per minute
* Oxygen saturations: 95% on air
* Temperature: 38.5°C
* Blood pressure: 118/86mmHg
**What is the most appropriate immediate next step?**
**Prescribe Piperacillin with Tazobactam and administer immediately**
The patient likely has neutropenic sepsis as he has recently completed a course of chemotherapy, which causes a depletion of neutrophils, and he has a temperature over 38°C.
As the neutrophils are depleted, they are unable to fight off the infection effectively, and hence this condition is associated with a high fatality rate and needs to be treated with empirical antibiotics immediately.
122
A 45 year old man presents to the emergency department, he is vomiting large amounts of blood.
The patient is known to misuse alcohol, but has no other significant past medical history.
On assessment, the patient is alert but vomiting, breath and heart sounds are normal.
**Observations show**
* blood pressure of 86/41
* heart rate of 127
* respiratory rate of 22
* oxygen saturations of 96% on 2L/min via nasal cannula
* and a temperature of 36.8 celsius
Two large bore IV cannulae are in situ.
The major haemorrhage protocol has been activated.
**What is the single best initial treatment?**
## Footnote
**Give a 500ml normal saline bolus IV**
This patient is in haemorrhagic shock secondary to a significant upper GI bleed (likely variceal, in the context of profuse haematemesis and history of alcohol misuse) and as such current evidence and guidance suggests that initial resuscitation is done with IV crystalloids, while awaiting blood for transfusion (if required).
A restrictive blood transfusion strategy is advocated in these patients based on available evidence, as this reduces the risk of both on-going and re-bleeding.
123
A 24 year old model attends the sexual health clinic to discuss contraception.
She has a past medical history of acne and polycystic ovary syndrome (PCOS).
There is no relevant family history.
Her main concern is that her periods are heavy and irregular, and she would prefer lighter and regular periods as this is currently interfering with her work.
She is also keen to avoid any method that could cause her to gain weight.
**Which of the following is the most suitable contraceptive to offer her?**
**Combined oral contraceptive pill**
This is the preferred option in women and girls with PCOS - it helps control period regularity, as well as other manifestations of the condition like acne.
124
A 55 year old woman with metastatic melanoma who is receiving palliative care only presents to the A&E agitated, with a high temperature.
She appears confused, is sweating profusely and has diarrhoea.
A history cannot be taken, however on examination there is a tremor present, her pupils are dilated and she has increased reflexes.
She has a bag of medications with her, which include MST Continus, Ibruprofen, Tramadol, Ondansetron, Sertraline and Sodium docusate.
**What is the single most likely diagnosis?**
**Tramadol + Sertraline = Serotonin Syndrome**
This patient presents with the triad of serotonin syndrome: mental state changes, autonomic hyperactivity (diarrhoea and pupil dilatation) and tremor.
