EMRCS PATHO 1 Flashcards by yamin bocha

A 40 year old women presented with a mass on her forehead. On examination, she had a fluctuant pulsatile mass on her head. Examination of her neck revealed a mass inferior to the hyoid with a positive Berry’s sign. What is the most likely underlying diagnosis?

	Follicular thyroid cancer
	Medullary thyroid cancer
	Papillary thyroid cancer
	Anaplastic thyroid cancer
	Parathyroid gland cancer

Papillary thyroid cancers will tend to spread via lymphatics and present with disease that is nearly always confined to the neck. Follicular carcinomas may metastasise haematogenously and the skull may be the presenting site of disease in between 2 and 8% of patients.

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What is the most common cause of mesenteric infarction?

Mesenteric vein thrombosis
Acute embolism affecting the superior mesenteric artery
Acute on chronic thrombus of the superior mesenteric artery
Sub intimal dissection of the superior mesenteric artery
Proximal migration of abdominal aortic aneurysm

Acute embolic events account for up to 50% of cases of mesenteric infarcts. These may occur as a result of long standing atrial fibrillation, ventricular anuerysms and post myocardial infarction

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A term neonate is undergoing an open inguinal herniotomy. During the operation, the operating surgeon identifies a small round yellow nodule within the inguinal canal. What is this most likely to represent?

	Ectopic lymphatic tissue
	Adrenal rest
	Encysted hydrocele of the cord
	Yolk sac tumour
	Hamartoma

Adrenal rests are a very common finding in term neonates (50%) and most regress so that by adulthood the population incidence is 1%. The adrenal glands and gonads both develop from the urogenital ridge. In early embryogenesis, the adrenal cortical tissue can migrate with the descending gonads.

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In which of the following conditions is a Ghon complex most likely to be found?

	Actinomycosis
	Infection with mycobacterium tuberculosis
	Mycosis fungoides
	Lewy body dementia
	Chronic lymphocytic leukaemia

Infection with mycobacterium tuberculosis

Ghon focus is primary infection
Ghon complex is primary infection and regional nodal involvement

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A 26 year old man who smokes heavily develops aching, crampy pains in his legs. On examination, distal limb pulses are diminished. What is the most likely cause?

	Vasculitis
	Steal syndrome
	Clot embolus
	Vasospasm
	Arterial injury

Vasculitis

This is likely to represent Buergers disease. It is commonest in young males who smoke heavily.

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A 22 year old female undergoes a thyroidectomy. The resected specimen shows a non encapsulated tumour with papillary projections and pale empty nuclei. What is the underlying diagnosis?

	Papillary carcinoma
	Follicular carcinoma
	Medullary carcinoma
	Anaplastic carcinoma
	B Cell lymphoma

The presence of papillary structures together with the cytoplasmic features described is strongly suggestive of papillary carcinoma. They are seldom encapsulated.

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A 78 year old lady presents 6 years following a successfully treated squamous cell carcinoma of the oesophagus. She has a long history of dysphagia but it is not progressive. What is the most likely diagnosis?

	Recurrent malignancy
	Oesophageal candidiasis
	Radiation stricture
	Globus
	Pharyngeal pouch

Radiation stricture
SCC of the oesophagus is commonly treated with chemoradiotherapy. Fibrosis and dysphagia may occur in survivors. At 6 years post treatment, recurrence would be most unusual.

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A 4 year old boy presents with haematuria and on examination is found to have a right sided renal mass. What is the most likely cause?

	Wilms tumour
	Glomerulonephritis
	Horseshoe kidney
	Renal adenocarcinoma
	Ureteric transitional cell carcinoma

Wilms tumours (nephroblastoma) usually present in the first 4 years of life and may cause lung metastases.

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A 74 year old woman presents with an erythematous rash originating in the nipple. It is spreading to the surrounding areolar area and the associated normal tissue. What is the most likely cause?

	Nipple eczema
	Pagets disease of the nipple
	Fibroadenosis
	Invasive lobular carcinoma
	Radial scar

Paget’s is associated with DCIS or invasive carcinoma. Unlike eczema of the nipple which predominantly affects the areolar region, Pagets will usually affect the nipple first and then spread to the areolar area. Diagnosis is made by punch biopsy.

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A 60 year old man presents with recurrent renal stones. He is found to have a calcium of 2.72 (elevated) and a PTH of 12 (elevated). What is the most appropriate long term management plan?

	Neck exploration and parathyroidectomy
	CT scanning of the neck
	MRI scanning of the neck
	Medical treatment alone
	External beam radiotherapy to the neck

This patient has primary hyperparathyroidism and nephrolithiasis, which is an indication for parathyroidectomy.

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Pagets disease of the nipple is most likely to be associated with which of the lesions listed below?

	Invasive lobular carcinoma
	Ductal carcinoma in situ
	Invasive ductal carcinoma
	Lobular carcinoma in situ
	Inflammatory breast cancer

Most cases of Pagets disease of the nipple are associated with invasive ductal carcinoma.

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A 37 year old lady presents with right upper quadrant pain and nausea. She is otherwise well and her only medical therapy is the oral contraceptive pill which she has taken for many years with no ill effects. Her liver function tests and serum alpha feto protein are normal. An ultrasound examination demonstrates a 4cm non encapsulated lesion in the right lobe of the liver which has a mixed echoity and heterogeneous texture. What is the underlying lesion most likely to be?

	Liver cell adenoma
	Hydatid cyst
	Hepatocellular carcinoma
	Cystadenoma
	Mesenchymal hamartoma

Liver cell adenomas are linked to OCP use and 90% of patients with liver cell adenomas have used the OCP. Liver function tests are often normal. The lesions will typically have a mixed echoity and heterogeneous texture.

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Which of the following events is most classically seen in the arterioles of patients with malignant hypertension?

	Caseous necrosis
	Coagulative necrosis
	Fibrinoid necrosis
	Apoptosis
	Colliquative necrosis

Fibrinoid necrosis is seen in the arterioles of patients with malignant hypertension.

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A 38 year old lady presents with a recent episode of renal colic. As part of her investigations the following results are obtained:
Corrected Calcium 3.84 mmol/l
PTH 88pg/ml (increased)
Her serum urea and electrolytes are normal.
What is the most likely diagnosis?

	Carcinoma of the bronchus
	Secondary hyperparathyroidism
	Primary hyperparathyroidism
	Tertiary hyperparathyroidism
	Carcinoma of the breast

In this situation the most likely diagnosis is primary hyperparathyroidism. The question mentions that serum urea and electrolytes are normal, which makes tertiary hyperparathyroidism unlikely.

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A 24 year old man is diagnosed as having Hodgkins lymphoma. Which subtype is associated with the most favorable prognosis?

	Nodular sclerosing
	Lymphocyte depleted
	Nodular lymphocyte predominant
	Classical lymphocyte predominant
	Mixed cellularity

The classical lymphocyte predominant variant has the most favorable prognosis. Nodular lymphocyte predominant disease is a very different disease entity and does not have the same favorable prognosis

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A 32 year old man who has suffered from Crohns disease for many years presents with intermittent jaundice. When it occurs, it is obstructive in nature. It then usually resolves spontaneously. What is the most likely cause?

	Crigler Najjar syndrome
	Parasitic infection of the liver
	Bile duct stones
	Gilberts syndrome
	Multi cystic liver disease

Bile salts are absorbed in the terminal ileum. When this process is impaired as in Crohns the patient may develop gallstones, if these pass into the CBD then obstructive jaundice will result.

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Which of the tumour markers listed below is most likely to be elevated in a patient with ovarian cancer?

	IgG 4
	CEA
	CA125
	CA19-9
	AFP

CA125
CA 125 Ovarian cancer
CA 19-9 Pancreatic cancer
CA 15-3 Breast cancer

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A 23 year old lady presents with a nodule in the right lobe of the thyroid. Examination of the neck is otherwise unremarkable and clinically she is euthyroid. Imaging shows a solid nodule at the site. What is the correct course of action?

	Image guided core biopsy
	Image guided fine needle aspiration for cytology
	Arrange a hemithyroidectomy
	Perform an incision biopsy
	Perform an excision biopsy

FNAC is the first line investigation in this setting. Whereas FNAC has declined in popularity recently (in breast investigation), it remain a very popular option in the investigation of thyroid masses. It cannot reliably diagnose a follicular tumour.

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A 73 year old lady is admitted with small bowel obstruction and following surgery is diagnosed as having diaphragm disease. Which of the agents listed below is the most likely precipitant?

	Alcohol abuse
	Oral non steroidal anti inflammatory drugs
	Abdominal radiotherapy
	Oral steroids
	Chronic laxative misuse

Diaphragm disease of the small intestine is caused by NSAIDS in most cases and treated by surgical resection

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A 12 year old child is admitted with a 12 hour history of colicky right upper quadrant pain. On examination the child is afebrile and is jaundiced. The abdomen is soft and non tender at the time of examination. What is the most likely cause?

	Infectious hepatitis
	Acute cholecystitis
	Cholangitis
	Hereditary spherocytosis
	Gilberts syndrome

The child is most likely to have hereditary spherocytosis. In these individuals there may be disease flares precipitated by acute illness. They form small pigment stones. These may cause biliary colic and some may require cholecystectomy.
Gilbert’s syndrome is an inherited condition causing unconjugated hyperbilirubinaemia. Patients may have jaundice or be asymptomatic. The other LFTs are normal and Gilbert’s may be confirmed with a fasting test or Nicotinic acid test. There is no need for treatment as it is a benign condition.

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A 78 year old lady presents to the surgical clinic with symptoms of both dysphagia and dyspnoea. On examination, there is a large mass in the neck that moves on swallowing. CT scanning of the neck shows a locally infiltrative lesion arising from the thyroid and invading the strap muscles. What is the most likely diagnosis?

	Lymphoma
	Follicular carcinoma
	Multinodular goitre
	Anaplastic carcinoma
	Papillary carcinoma

Marked local invasion is a feature of anaplastic carcinoma. These tumours are more common in elderly females.

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A 28 year old man has a carcinoid tumour identified in his appendix. Blood testing for which of the substances listed below is likely to be helpful during follow up?

	CA19-9
	Alkaline phosphatase
	AFP
	CEA
	Chromogranin A

It is important to distinguish between blood and urine tests for carcinoid syndrome. Blood tests usually measure chromogranin A,neuron-specific enolase (NSE), substance P, and gastrin. Urine tests usually measure 5 HIAA, which is a metabolite of serotonin. Sometimes blood tests for 5 hydroxytryptamine (serotonin) are also performed.

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A 28 year old female attends the gynaecology unit for a D+C following an incomplete miscarriage. She has previously had recurrent pulmonary embolic events. After the procedure she is persistently bleeding. Her APTT is 52 (increased). What is the most likely cause?

	Antiphospholipid syndrome
	DIC
	Haemophilia B
	von Willebrand disease
	Factor V Leiden deficiency

A combination of thromboembolism and bleeding in a young woman should raise the possibility of antiphospholipid syndrome. Other features may include foetal loss, venous and arterial thrombosis and thrombocytopenia. A Lupus anticoagulant may be present and the APTT is prolonged.

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A 40 year old man presents with obstructive jaundice and dysphagia. Twenty years previously he underwent a right hemicolectomy for a mucinous right sided colonic carcinoma. He was subsequently diagnosed as having Lynch syndrome. A recent colonoscopy was normal. What is the most likely cause of his jaundice?

	Hepatocellular carcinoma
	Liver metastasis from colonic cancer
	Pancreatic carcinoma
	Duodenal carcinoma
	Metastatic gastric carcinoma

Metastatic gastric carcinoma

Lynch syndrome usually results in colonic cancer which is right sided and mucinous. The next most common site to be affected is the uterus. The stomach is at particular risk and this risk is up to 10 times greater in HNPCC (Lynch) patients than the general population. Duodenal adenomas (and rarely carcinoma) are usually seen in association with FAP. Whilst pancreatic carcinoma is associated with HNPCC it is far less likely to occur than gastric cancer.
We are often asked how these patients become jaundiced, this occurs as a result of nodal spread along the hepatoduodenal ligament nodes to occlude the porta hepatis resulting in jaundice

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A 65 year old man presents with a history of progressive dysphagia over the past 4 weeks. For the preceding 5 years he had regularly attended his general practitioner with symptoms of dyspepsia and reflux. What is the most likely cause? ``` Leiomyoma of the oesophagus Plummer Vinson syndrome Squamous cell carcinoma of the oesophagus Adenocarcinoma of the oesophagus Achalasia ```

Adenocarcinoma of the oesophagus A short history of progressive dysphagia in a middle aged man who has a background history of reflux is strongly suggestive of malignancy. Long standing reflux symptoms may be suggestive of a increased risk of developing Barretts oesophagus. Note that not all patients with Barretts transformation alone are symptomatic. In such cases, the tumours are adenocarcinoma.

A 34 year old woman who has previously undergone a colectomy for familial adenomatous polyposis coli presents with a firm lesion at the inferior aspect of her rectus abdominis muscle. Which cell type is most typically associated with such tumours? ``` Myocytes Proliferation of apocrine glands Chondrocytes Lipoblasts Myofibroblasts ```

Desmoid tumours would be the most likely differential here and consist of a clonal proliferation of myofibroblasts. They are usually firm overgrowths of tissue with a propensity to local infiltration. They occur in up to 15% of patients with familial adenomatous polyposis coli. Desmoid tumours usually show bi allelic APC mutations They occur most commonly in women after childbirth in the rectus abdominis muscle

A 68 year old man presents with recurrent episodes of left sided ureteric colic and haematuria. Investigations show some dilatation of the renal pelvis but the outline is irregular. What is the most likely underlying lesion? ``` Transitional cell carcinoma Adenocarcinoma Hamartoma Rhabdomyosarcoma Nephroblastoma ```

These arise from urothelium and necessitate a nephroureterectomy.

A 23 year old woman presents with severe headache, photophobia and neck stiffness. A lumbar puncture is undertaken and cerebrospinal fluid is sent for microscopy and culture. Culture shows a growth of Neisseria meningitidis. What is likely to be the predominant cell type in the cerebrospinal fluid? ``` Eosinophils Basophils Macrophages Lymphocytes Neutrophils ```

In bacterial meningitis, neutrophils are typically present in the CSF. In viral meningitis, a lymphocytosis is said to predominate. Clinically, there can be overlap with a neutrophilia occurring in some cases of viral meningitis. In bacterial meningitis, the neutrophilia can be attenuated by the administration of antibiotics.

A 5 year old boy presents with recurrent episodes of sinusitis. The casualty staff are surprised to find his liver lying in the left upper quadrant of the abdomen. What is the underlying diagnosis? ``` Von Recklinghausen's disease Li Fraumeni syndrome Pierre Robin syndrome Kartagener's syndrome MEN I ```

This is a case of Kartagener's syndrome. The primary problem is of immotile cilia syndrome. When associated with situs inversus Kartagener's syndrome is diagnosed

A 42 year old lady has suffered from hepatitis C for many years and has also developed cirrhosis. On routine follow up, an ultrasound has demonstrated a 2.5cm lesion in the right lobe of the liver. What is the most likely diagnosis? ``` Liver metastasis Liver abscess Hepatocellular carcinoma Mesenchymal hamartoma Liver cyst ```

In patients with cirrhosis the presence of a lesion >2cm is highly suggestive of malignancy. The diagnosis is virtually confirmed if the AFP is >400ng/mL.

A 66 year old lady presents with pain in her right hip. It has been increasing over the previous three weeks and waking her from sleep. On examination, she is tender on internal rotation. Blood tests reveal a markedly elevated serum calcium and alkaline phosphatase levels. What is the likely cause? ``` Metastatic breast cancer Chondrosarcoma Osteoporosis Pagets disease Rickets ```

Metastatic breast cancer Increasing pain at rest, together with increased serum calcium and alkaline phosphatase are most likely to represent metastatic tumour to bone. Chondrosarcomas do occur in the pelvis but are not associated with increased serum calcium and typically have a longer history.

A 40 year old male is found to have multiple colonic polyps during a colonoscopy. He mentions that he has extra teeth. What is the underlying diagnosis? ``` Gardner's syndrome Lynch syndrome FAP Neurofibromatosis Type I Neurofibromatosis Type II ```

Gardner's syndrome is an AD disorder, characterised by: Colonic polyps, supernumerary teeth, jaw osteomas, congenital hypertrophy of retinal pigment. osteomas of the skull, thyroid cancer, epidermoid cysts, fibromas and sebaceous cysts.

A 52 year old man is having a blood transfusion after losing blood from a total knee replacement. He is normally fit and well. Three hours into the transfusion he complains of sudden onset abdominal pain and nausea. His temperature is 39 degrees, Blood pressure 98/42 mmHg, HR 105 bpm and saturations 94% air. His urine appears dark. What is the most likely diagnosis? ``` Delayed haemolytic transfusion reaction Neutrophilic febrile reaction Acute haemolytic transfusion reaction Sickle cell crisis Transfusion associated lung injury ```

Acute haemolytic transfusion reaction Rapid intravascular haemolysis leading to shock, DIC and death can occur with this reaction.

A 20 year old lady is referred to the vascular clinic. She has been feeling generally unwell for the past six weeks. She works as a typist and has noticed increasing pain in her forearms whilst working. On examination, she has absent upper limb pulses. Her ESR is measured and mildly elevated. What is the most likely diagnosis? ``` Polyarteritis nodosa Wegeners granulomatosis Giant cell arteritis Takayasu's arteritis Buergers disease ```

Takayasus arteritis may be divided into acute systemic phases and the chronic pulseless phase. In the latter part of the disease process the patient may complain of symptoms such as upper limb claudication. In the later stages of the condition the vessels will typically show changes of intimal proliferation, together with band fibrosis of the intima and media.

A 22 year old man is investigated for weight loss. A duodenal biopsy taken as part of his investigations shows total villous atrophy and lymphocytic infiltrate. He has a skin lesion that has small itchy papules. What is the most likely underlying diagnosis? ``` Pyoderma gangrenosum Dermatitis herpetiformis Bullous pemphigoid Acanthosis nigricans Pemphigus vulgaris ```

The patient has coeliac disease and this is classically associated with dermatitis herpetiformis.

Which syndrome is likely to be present in a 28 year old man who presents with a locally advanced mucinous carcinoma of the caecum. There are scanty polyps in the remaining colon. His father died from colorectal cancer aged 34. ``` FAP Lynch syndrome Cowden disease MYH associated polyposis Peutz-Jeghers syndrome ```

Lynch syndrome is likely when right sided colonic cancers occur at a young age. These tumours are often poorly differentiated and mucinous. The Amsterdam criteria can be used to identify families at risk who may benefit from genetic testing.

A 2 day old baby is noted to have voiding difficulties and on closer inspection is noted to have hypospadias. Which of the following abnormalities is most commonly associated with the condition? ``` Cryptorchidism Diaphragmatic hernia Ventricular - septal defect Bronchogenic cyst Atrial septal defect ```

Hypospadias most commonly occurs as an isolated disorder. Associated urological abnormalities may be seen in up to 40% of infants, of these cryptorchidism is the most frequent (10%).

A 65 year old male attends surgical out patients with epigastric discomfort. He has recently been diagnosed with diabetes by the GP and is a heavy smoker. An OGD is normal. What is the most likely diagnosis? ``` Pancreatic adenocarcinoma Pancreatic squamous cell carcinoma Pancreatic insulinoma Pancreatic glucaconoma Pancreatic gastrinoma ```

The dominant differential diagnosis should be of pancreatic adenocarcinoma in this setting. Glucagonomas are very rare and may be associated with a bullous rash.

A 48 year old man notices that he is becoming increasingly dizzy when he plays squash, in addition he has also developed cramping pain in his left arm. One day he is inflating his car tyre with a hand held pump, he collapses and is brought to hospital. What is the most likely underlying cause? ``` Aortic coarctation Cervical rib Patent ductus arteriosus Takayasu's arteritis Subclavian steal syndrome ```

Subclavian steal syndrome is associated with a stenosis or occlusion of the subclavian artery, proximal to the origin of the vertebral artery. As a result, the increased metabolic needs of the arm then cause retrograde flow and symptoms of CNS vascular insufficiency.

A 5 year old boy presents to the clinic with short stature suggestive of achondroplasia. What is the genetic basis of this condition? ``` X linked defect Y linked defect YY linked defect Autosomal dominant defect Autosomal recessive defect ```

Achondroplasia usually occurs as a sporadic mutation. It is then transmitted in an autosomal dominant fashion.

A 70 year old lady presents with an upper gastrointestinal haemorrhage. This surprises the surgical team as she has been taking a proton pump inhibitor at high dose since a recent admission with epigastric pain. At endoscopy, the duodenum is found to contain multiple ulcers. What is the most likely explanation? ``` Infection with helicobacter pylori Gastrinoma Duodenal lymphoma Adenocarcinoma of the duodenum Alcoholism ```

Gastrinomas are typically the source of gastrin in Zollinger Ellison syndrome.

A 45 year old patient undergoes a CT scan of the abdomen and is noted to have a 6cm mass in the right adrenal gland. Urinary catecholamines and other endocrine investigations are negative. CT of the chest and remainder of the abdomen is otherwise normal. What is the most appropriate course of action? Image guided FNAC of the adrenal gland Image guided core biopsy of the adrenal gland List the patient for an adrenalectomy Organise surveillance of the lesion with CT scanning Organise surveillance of the lesion with USS

Most surgeons would excise a mass of this size rather than attempt biopsy

A 72 year old man presents with symptoms and signs of benign prostatic hyperplasia. Which of the following structures is most likely to be enlarged? ``` Posterior lobe of the prostate Median lobe of the prostate Right lateral lobe of the prostate Left lateral lobe of the prostate Anterior lobe of the prostate ```

Carcinoma of the prostate typically occurs in the posterior lobe. The median lobe is usually enlarged in BPH. The anterior lobe has little in the way of glandular tissue and is seldom enlarged.

A 38 year old man has been suffering from mechanical back pain for several years. One morning he awakes from sleep and feels a sudden onset of pain in his back radiating down his left leg. Which of the following events is most likely to account for his symptoms? ``` Prolapse of inner annulus fibrosus Prolapse of outer annulus fibrosus Prolapse of nucleus pulposus Rupture of the ligamentum flavum None of the above ```

The symptoms would be most likely the result of intervertebral disk prolapse. In disk prolapse the nucleus pulposus is the structure which usually herniates.

A 34 year old man presents to the surgical clinic 8 months following a laparotomy for a ruptured spleen. He complains of a nodule in the centre of his laparotomy wound. This is explored surgically and a stitch granuloma is found and excised. From which of the following cell types do granulomata arise? ``` Polymorpho nucleocytes Plasma cells Reed- Sternberg cells Platelets Macrophages ```

Macrophages give origin to granulomas.

An unusually tall 43 year old lady presents to the surgical clinic with bilateral inguinal hernias. She develops chest pain and collapses. As part of her investigations a chest x-ray shows evidence of mediastinal widening. What is the most likely underlying diagnosis? ``` Pulmonary embolus Aortic dissection Tietze syndrome Boerhaaves syndrome Myocardial infarct ```

Marfans syndrome may present with a variety of connective tissue disorders such as bilateral inguinal hernia. They are at high risk of aortic dissection, as in this case.

A 72 year old man has just undergone an emergency repair for a ruptured abdominal aortic aneurysm. Pre operatively he was taking aspirin, clopidogrel and warfarin. Intra operatively he received 5000 units of unfractionated heparin prior to application of the aortic cross clamp. His blood results on admission to the critical care unit are as follows: Full blood count Hb 8 g/dl Platelets 40 * 109/l WBC 7.1 * 109/l His fibrin degradation products are measured and found to be markedly elevated. Which of the following accounts for these results? ``` Anastomotic leak Disseminated intravascular coagulation Heparin induced thrombocytopenia Adverse effect of warfarin Adverse effects of antiplatelet agents ```

The combination of low platelet counts and raised FDP in this setting make DIC the most likely diagnosis.

A 53 year old man from Hong Kong presents with symptoms of fatigue, weight loss and recurrent epistaxis. Clinical examination reveals left sided cervical lymphadenopathy and oropharyngeal examination reveals an ulcerated mass in the naso pharynx. Which of the following viral agents is most commonly implicated in the development of this condition? ``` Cytomegalovirus Epstein Barr virus Coxsackie virus Herpes simplex virus None of the above ```

The clinical scenario is most typical for nasopharyngeal carcinoma. An association with previous Epstein Barr Virus is well established. Infection with the other viruses listed is not a recognised risk factor for the development of the condition. Trotter's triad (diagnosis of nasopharyngeal carcinoma) Unilateral conductive hearing loss Ipsilateral facial & ear pain Ipsilateral paralysis of soft palate

An 18 year old male presents with lethargy, night sweats and on examination is found to have left supraclavicular lymphadenopathy. A surgical registrar performs a left supraclavicular lymph node biopsy. The pathologist identifies Reed- Sternberg cells on the subsequent histology sections, what is the most likely diagnosis? ``` Metastatic gastric cancer Hodgkins lymphoma Non Hodgkins lymphoma Tuberculosis None of the above ```

Reed-Sternberg cells are characteristic histological cell type found in Hodgkins disease.

A 25 year old female presents with a lump in her neck. On examination, she has a discrete nodule in the right lobe of the thyroid. A fine needle aspirate shows papillary cells. An adjacent nodule is also sampled which shows similar well differentiated papillary cells. What is the most likely cause? ``` Hashimotos thyroiditis Papillary carcinoma Follicular carcinoma Medullary carcinoma Thyroid B Cell lymphoma ```

Multifocal disease is a recognised feature of papillary lesions. Papillary adenomas are not really recognised and most well differentiated lesions are papillary carcinomas.

A 28 year old man develops an acute paronychia and subsequent spreading sepsis. The tissue exudate has a higher protein content than normal tissue because? Breakdown of tissue cells release protein Capillary walls are more permeable Increased blood flow transports more protein into the area Intracapillary pressure is raised Plasma cells release gamma globulin

The increased permeability allows the exudation of plasma proteins.

A 40 year old man undergoes a complex appendicectomy and the wound fails to heal satisfactorily. The wound site itself is associated with multiple sinuses and fistulas. Pus is sent for microbiology and shows gram positive organisms and sulphur granules. What is the most likely underlying diagnosis? ``` Infection with Staphylococcus aureus Infection with Bacteroides fragilis Actinomycosis Crohns disease Ulcerative colitis ```

The presence of chronic sinuses together with gram positive organisms and sulphur granules is highly suggestive of Actinomycosis. Crohns disease is associated with multiple fistulae, but not gram positive organisms with sulphur granules.

As a busy surgical trainee on the colorectal unit you are given the unenviable task of reviewing the unit's histopathology results for colonic polyps. Which of the polyp types described below has the greatest risk of malignant transformation? ``` Hyperplastic polyp Tubular adenoma Villous adenoma Hamartomatous polyp Serrated polyp ```

Villous adenomas carry the highest risk of malignant transformation. Hyperplastic polyps carry little in the way of increased risk. Although, patients with hamartomatous polyp syndromes may have a high risk of malignancy, the polyps themselves have little malignant potential.

A 23 year old man presents to the surgical clinic with an inguinal hernia. On examination he has a small direct hernia. However, you also notice that he has pigmented spots around his mouth, on his palms and soles. In his history he underwent a reduction of an intussusception aged 12 years. Which of the following lesions is most likely to be identified if a colonoscopy were performed? ``` Hamartomas Tubulovillous adenoma Colorectal cancer Crohns disease Hyperplastic polyps ```

He is most likely to have Peutz-Jeghers syndrome which is associated with Hamartomas.

A 56 year old surgeon has been successfully operating for many years. Over the past few weeks she has begun to notice that her hands are becoming blistering and weepy. A latex allergy is diagnosed. Which of the following pathological processes accounts for this scenario? ``` Type 1 hypersensitivity reaction Type 2 hypersensitivity reaction Type 4 hypersensitivity reaction Type 3 hypersensitivity reaction None of the above ```

Contact dermatitis of a chronic nature is an example of a type 4 hypersensitivity reaction. Type 4 hypersensitivity reactions are cell mediated rather than antibody mediated. Hypersensitivity reactions: ACID type 1 --Anaphylactic type 2 --Cytotoxic type 3 --Immune complex type 4 --Delayed hypersensitivity

A 70 year old lady who has never smoked is identified as having a peripherally sited mass in her left lung. What is the most likely underlying diagnosis? ``` Small cell lung cancer Gastric cancer metastasis Adenocarcinoma Squamous cell carcinoma Lymphoma ```

Adenocarcinomas are the most common tumour type present in never smokers. They are usually located at the periphery.

A 56 year old motorcyclist is involved in a road traffic accident and sustains a displaced femoral shaft fracture. No other injuries are identified on the primary or secondary surveys. The fracture is treated with closed, antegrade intramedullary nailing. The following day the patient becomes increasingly agitated and confused. On examination, he is pyrexial, hypoxic SaO2 90% on 6 litres O2, tachycardic and normotensive. Systemic examination demonstrates a non blanching petechial rash present over the torso. What is the most likely explanation for this? ``` Pulmonary embolism with paradoxical embolus Fat embolism Meningococcal sepsis Alcohol withdrawl Chronic sub dural haematoma ```

This man has a recent injury and physical signs that would be concordant with fat embolism syndrome. Meningococcal sepsis is not usually associated with hypoxia initially. Pulmonary emboli are not typically associated with pyrexia. Triad of symptoms: Respiratory Neurological Petechial rash (tends to occur after the first 2 symptoms)

A 74 year old woman presents with a breast lump. On examination, it has a soft consistency. The lump is removed and sliced apart. Macroscopically there is a grey, gelatinous surface. Which of the following tumour types is most likely? ``` Sarcoma Invasive ductal carcinoma Mucinous carcinoma DCIS Lobular carcinoma ```

Mucinous carcinomas comprise 2-3% of all breast cancers. They are one of the special type of carcinomas. These have a better prognosis than is associated with tumours of Non Special Type (NST) and axillary nodal disease is rare in this group.

A 45 year old man has widespread metastatic adenocarcinoma of the colon. Which of the following tumour markers is most likely to be elevated? ``` CA19-9 Carcinoembryonic antigen Alpha Feto Protein CA 125 Beta HCG ```

Carcinoembryonic antigen is elevated in colonic cancer, typically in relation to disease extent with highest serum levels noted in metastatic disease. It is falsely elevated in a number of non-malignant disease states such as cirrhosis and colitis and for this reason it has no role in monitoring colitics for colonic cancer

A 25 year old man is found to have carcinoid syndrome. Which of the following hormones is released by carcinoids? ``` Serotonin Dopamine Nor adrenaline Adrenaline Aldosterone ```

Carcinoids secrete serotonin. Carcinoid syndrome will only occur in the presence of liver metastasis as the hormone released from primary lesions will typically be metabolised by the liver.

A 43 year old man presents with haemoptysis and is diagnosed as having tuberculosis. Which of the cell types listed below will usually internalise the tubercule bacullis? ``` Fibroblast Neutrophil Erythrocyte Macrophage Eosinophil ```

M. Tuberculosis will reside in macrophages where it will often survive

A cachectic 32 year old man with severe perineal Crohns disease is receiving treatment with intravenous antibiotics. Over the past 72 hours he has complained of intermittent dysphagia and odynophagia. What is the most likely cause? ``` Oesophageal Crohns disease Oesophageal candidiasis Plummer Vinson syndrome Globus Achalasia ```

Treatment with systemic antibiotics may result in development of candidiasis. Patients may present with odynophagia and episodic dysphagia. Endoscopic appearances are usually diagnostic and treatment is with an oral anti fungal agent.

Which of these tumour markers is most helpful in identifying an individual with hepatocellular carcinoma? ``` Serum AFP Serum CA19-9 CEA Beta HCG CA125 ```

Hepatocellular carcinoma is commonly diagnosed with imaging and an elevated alpha fetoprotein. Biopsy may seed the tumour and should be avoided. Up to 80% of hepatocellular carcinoma arise in cirrhotic livers.

A 39 year old man has suffered from terminal ileal Crohns disease for the past 20 years. Which condition is he least likely to develop? ``` Gallstones Malabsorption Pyoderma gangrenosum Amyloidosis Feltys syndrome ```

``` Feltys syndrome is associated with rheumatoid disease. Individuals with long standing Crohns disease are at risk of gallstones because of impairment of the enterohepatic recycling of bile salts. Formation of entero-enteric fistulation may produce malabsorption. Amyloidosis may complicate chronic inflammatory states. Feltys syndrome: Rheumatoid disease Splenomegaly Neutropenia ```