Day 5 Flashcards
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?
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.
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?
previous radiotherapy
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?
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
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?
Progesterone only pill
This is the only suitable option for a postpartum woman actively breast-feeding.
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?
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.
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?
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.
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?
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.
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?
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.
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?
Copper intrauterine device (IUD)
The IUD is the only suitable option for this patient due to her history of breast cancer.
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?
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.
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?
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.
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?
Tumour lysis syndrome
This is the correct answer, given his haematological malignancy and his symptoms.
Common symptoms include nausea, vomiting and muscle pain.
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?
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.
When is Mannitol prescribed?
Mannitol is given for patients with raised intracranial pressure.
Raised intracranial pressure can occur due to metastasis or primary CNS tumours.
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?
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.
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?
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.
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?
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.
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?
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.
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?
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.
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?
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.
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?
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.
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?
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.
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
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
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?
Chronic Hepatitis B
chronic hepatitis B increases the risk of hepatocellular carcinoma significantly.
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.
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.
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.
Important Features of Squamous cell carcinoma
(7)
- Second most common type of lung cancer in the UK
- Usually present as obstructive lesions of the bronchus leading to infection.
- Occasionally cavitates (10% at presentation) Lung Ca that most commonly cavitates
- 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.
- Local spread is common, but metastasis are normally late (but frequent)
- Often causes hypercalcaemia – by bone destruction or production of PTH analogues (PTHrp).
- Also associated with clubbing and HPOA (Hypertrophic pulmonary osteoarthropathy)
Important Features of Adenocarcinoma
(6)
- Most common type of lung cancer in the UK
- Arises from mucous cells in the bronchial epithelium
- Commonly invades the mediastinal lymph nodes and the pleura, and spreads to the brain and bones
- Does not usually cavitate
- Proportionally more common in non-smokers, women and in the Far Eastleast likely to be related to smoking
- Most likely to cause pleural effusion (as are mesotheliomas)
Important Features of Small cell carcinoma
(4)
- Arise from endocrine cells (Kulchitsky cells). These are APUD cells, and as a result, these tumours will secrete many poly-peptides mainly ACTH.
- They can also cause various presentations such as Addison’s and Cushing’s disease.
- Small cell carcinoma spreads very early and is almost always inoperable at presentation.
- These tumours do respond to chemotherapy, but the prognosis is generally poor.
How would pulmonary fibrosis present on a chest x-ray
Pulmonary fibrosis characteristically presents with reticulonodular shadowing within the lower zones of the lung.
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
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.
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.
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)
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.
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).
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.*
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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).
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.
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
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.
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.
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.
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.
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.
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
Lung Cancer paraneoplastic syndromes
(7)
- Vascular and haematological complications: Anaemia
- HPOA (Hypertrophic pulmonary osteoarthropathy)
- Finger clubbing: 30% of cases – caused by non-small cell carcinoma.
- Inappropriate ADH secretion – this can cause hyponatraemia
- Ectopic ACTH secretion – causing Cushing’s syndrome
- Hypercalcemia (squamous)
- Carcinoid syndrome - This presents with hepatomegaly, flushing and diarrhea
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.
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.
Cushings triad
(3)
