EMRCS PATHO 7 Flashcards
A splenectomy increases the risk of infection from all the following organisms except?
Pneumococcus Klebsiella Haemophilus influenzae Staphylococcus aureus Neisseria meningitidis
Staphylococcus aureus infection following splenectomy is no more common than in non splenectomised individuals. The other organisms are encapsulated, which is why they are more likely to cause overwhelming post splenectomy sepsis.
Which of the following is not an extraintestinal feature of Crohns disease?
Iritis Clubbing Aphthous ulcers Erythema multiforme Pyoderma gangrenosum
Extraintestinal manifestation of inflammatory bowel disease: A PIE SAC
Aphthous ulcers Pyoderma gangrenosum Iritis Erythema nodosum Sclerosing cholangitis Arthritis Clubbing
Which of the following is not considered a risk factor for the development of oesophageal malignancy?
Oesophageal metaplasia Smoking Excessive intake of alcoholic spirits Achalasia Blood group O
Blood group O is not a risk factor for oesophageal cancer. Achalasia is associated with the risk of developing squamous cell carcinoma of the oesophagus.
A 24 year old man from Sub Saharan Africa presents with a lymphadenopathy and weight loss. A diagnosis of tuberculosis is suspected and a lymph node biopsy is performed. Staining with which of the agents below is most likely to facilitate identification of the causative organism?
Gram stain Ziehl-Neelsen stain Von Kossa stain Van Gieson stain Masson Trichrome stain
Ziehl-Neelsen stain is typically used to identify mycobacteria. They are not stained in the Gram staining process. Van Gieson and Masson trichrome are histological staining methods for identification of connective tissues. The Von Kossa technique is useful for identifying tissue mineralisation
Which of the following is not a pathological feature of breast cancer?
Resemblance to ductal epithelial cells Angiogenesis Nuclear pleomorphism Metastatic calcification Vascular invasion
Dystrophic calcification may be present in breast malignancy and is the basis for the breast screening programme. Metastatic calcification is calcification which occurs in otherwise normal tissues, usually as a result of hypercalcaemia. Invasive ductal carcinoma is the most common type of breast cancer, unless the tumour is very poorly differentiated there is usually some resemblance to ductal epithelial cells.
An 18 month old boy presents with recurrent urinary tract infections. As part of the diagnostic work-up he is noted to have abnormal renal function. An ultrasound scan is performed and shows bilateral hydronephrosis and hydroureter. What is the most likely underlying diagnosis?
Posterior urethral valves Meatal stenosis Hydronephrosis Pelvico-ureteric junction obstruction Benign prostatic hyperplasia
A posterior urethral valve is an obstructive, developmental uropathy that usually affects male infants (incidence 1 in 8000). Diagnostic features include bladder wall hypertrophy, hydronephrosis and bladder diverticula.
An 85 year old man presents with a cough and haemoptysis. He has a modest smoking history of 15 pack years. He is found to have a tumour located in the right main bronchus, with no evidence of metastatic disease. He decides not undergo any treatment and he remains well for a further 12 months before developing symptomatic metastasis. What is the most likely diagnosis?
Adenocarcinoma Small cell carcinoma Squamous cell carcinoma Metastatic renal cancer Lymphoma
Squamous cell carcinomas are reported to be more slow growing and are typically centrally located. Small cell carcinomas are usually centrally located. However, small cell carcinomas would seldom be associated with a survival of a year without treatment.
At which of the following anatomical sites does dormant tuberculosis most frequently reactivate?
Apex of the lung Base of the lung Brain Terminal ileum Lumbar spine
TB reactivation most commonly occurs at the lung apex. This site is better oxygenated than elsewhere allowing the mycobacteria to multiply more rapidly and then spread both locally and distantly.
What is the commonest tumour type encountered in the colon?
Squamous cell carcinoma Adenocarcinoma Lymphoma Anaplastic carcinoma Sarcoma
Adenocarcinoma are the most common and typically arise as a result of the adenoma - carcinoma sequence.
What is the process that is most likely to account for a 73 year old lady presenting with a cold pulseless hand 3 days following a myocardial infarct?
Foreign body embolus Rupture of existing atheromatous plaque Steal syndrome Vasospasm Clot embolus
The development of mural or atrial appendage thrombi may occur following a myocardial infarct and co-existing atrial fibrillation may contribute to the formation. They tend to present with classical features of an embolic event.
Which of the following changes are most likely to be identified in the aortic wall of a 38 year old lady with a Marfans syndrome and a dissecting aortic aneurysm?
Transmural aortitis Cystic medial necrosis Foamy macrophages Dense dystrophic calcification None of the above
Cystic medial necrosis ( or cystic medial degeneration) occurs when basophils and mucoid material lie in between the intimal elastic fibres of the aorta. It is typically found in the aortic degeneration of Marfans syndrome, but may also be seen in aortic degeneration in older adults.
A 58 year old man undergoes an upper GI endoscopy for the investigation of odynophagia. At endoscopy a reddish area is seen to extend into the oesophagus from the gastro-oesophageal junction. Which of the following pathological events is most likely to explain this process?
Metaplasia Anaplasia Dysplasia Hypoplasia Hyperplasia
This is most likely to represent Barretts oesphagus and is thus metaplasia. Dysplasia is less likely in this setting although biopsies are mandatory.
A male infant is born by emergency cesarean section at 39 weeks gestation for foetal distress. Soon after the birth the baby becomes progressively hypoxic and on examination is found to have a scaphoid abdomen. What is the most likely underlying diagnosis?
Intestinal malrotation Hiatus hernia Foramen of Bochdalek hernia Foramen of Morgagni hernia Tracheo-oesphageal fistula
The finding of a scaphoid abdomen and respiratory distress suggests extensive intra thoracic herniation of the abdominal contents. This is seen most frequently with Bochdalek hernias. Morgagni hernias seldom present in such a dramatic fashion. The other options do not typically present with the symptoms and signs described.
A 72 year old lady falls and lands on her left hip. She attends the emergency department and is given some paracetamol by the junior doctor and discharged. Several months later she presents with ongoing pain and discomfort of the hip. Avascular necrosis of the femoral head is suspected. Which of the following features is least likely to be present?
Union of the fracture Angiogenesis at the fracture site Increased numbers of fibroblasts at the fracture site Osteochondritis dissecans Apoptosis of osteoblasts
Apoptosis is not a feature of necrotic cell death. By this stage there would usually be attempted repair so angiogenesis and proliferation of fibroblasts would be expected. These cells may differentiate further to become osteoblasts which in turn will lay down new matrix.
What is the urinary diagnostic marker for carcinoid syndrome?
B-HCG Histamine Chromogranin A 5-Hydroxyindoleacetic acid 5-Hydroxytryptamine
Urinary measurement of 5- HIAA is an important part of clinical follow up.
Which one of the following is least associated with the development of colorectal cancer in patients with ulcerative colitis?
Unremitting disease Disease duration > 10 years Onset before 15 years old Poor compliance to treatment Disease confined to the rectum
Disease confined to the rectum
A 78 year old lady presents with a tender swelling in her right groin. On examination there is a tender swelling that lies below and lateral to the pubic tubercle. It has a cough impulse. What is the most likely underlying diagnosis?
Thrombophlebitis of the great saphenous vein Femoral hernia Thrombophlebitis of saphena varix Inguinal hernia Obturator hernia
Whilst a thrombophlebitis of a saphena varix may cause a tender swelling at this site, it would not usually be associated with a cough impulse.
Which of the conditions listed below is an example of heterotopia?
Barretts oesophagus Squamous cell carcinoma of the lung Meckels diverticulum containing gastric mucosa Colonic diverticulum Ectopic testis
In heterotopia, the tissue type that is found in the abnormal location is present there from birth and does not migrate to that site subsequently or arise as a result of metaplasia. The tissue that lines a Meckels diverticulum is determined early in development.
A 73 year old man presents with pain in the right leg. It is most uncomfortable on walking. On examination, he has a deformity of his right femur, which on x-ray is thickened and sclerotic. His serum alkaline phosphatase is elevated, but calcium is within normal limits. What is the most probable underlying diagnosis?
Rickets Pagets disease Metastatic lung cancer Osteoclastoma Chondrosarcoma
Pagets is typically associated with thickened, sclerotic, long bones. Lung carcinoma typically causes lytic bony lesions and hypercalcaemia.
An 18 year old female presents with 3 nodules in the right lobe of the thyroid. Clinically she is euthyroid and there is associated cervical lymphadenopathy. She has no family history of thyroid disease. What is the most likely cause?
Follicular thyroid cancer Follicular thyroid adenoma Papillary thyroid cancer Hashimotos thyroiditis Toxic nodular goitre
Papillary thyroid cancers are the most common type of thyroid cancer and are the more common in females (M:F=1:3). Papillary tumours are more likely to develop lymphatic spread than follicular tumours.
What is the main risk factor for the development of anal cancer?
Smoking Ano-receptive intercourse Immunosuppression Infection with Epstein Barr virus Infection with Human Papilloma virus
Anal cancer is strongly associated with HPV infection
A 3 month old boy is suspected of having hypospadias. At which of the following locations is the urethral opening most frequently located in boys suffering from the condition?
On the distal ventral surface of the penis On the proximal ventral surface of the penis On the distal dorsal surface of the penis On the proximal dorsal surface of the penis At the base of the scrotum
The defect is located ventrally and most often distally. Proximally located urethral openings are well recognised. Circumcision may compromise reconstruction.
Which of the tumour markers listed below is most likely to be elevated in a patient with pancreatic cancer?
CEA CA19-9 AFP PSA CA15-3
Tumour marker Association
CA 125 Ovarian cancer
CA 19-9 Pancreatic cancer
CA 15-3 Breast cancer
A 52 year old male attends for a preoperative assessment for an inguinal hernia repair. You notice that the chest x-ray shows a loculated left pleural effusion. On further questioning the patient reports that he worked as a builder 30 years ago. What is the most likely cause for the effusion?
Asbestosis Pneumonia Mesothelioma Silicosis Left ventricular failure
This patient has a risk of asbestos exposure through his occupation as a builder. As there a is latent period of 30 years and a complicated effusion, the most likely cause is mesothelioma.
A 64-year-old woman is reviewed due to multiple non-healing leg ulcers. She reports feeling generally unwell for many months. Examination findings include a blood pressure of 138/72 mmHg, pulse 90 bpm, pale conjunctivae and poor dentition associated with bleeding gums. What is the most likely underlying diagnosis?
Thyrotoxicosis Vitamin B12 deficiency Vitamin C deficiency Diabetes mellitus Sarcoidosis
Bleeding gums and poor healing are suggestive of vitamin C deficiency.
Which of the following is not a typical feature of neuropraxia?
Transient delay in neuronal transmission Axonal degeneration distal to the site of injury Absence of neuroma formation Preservation of autonomic function Absence of axonal degeneration proximal to the site of injury
Axonal degeneration distal to the site of injury
Full recovery may occur 6-8 weeks after nerve injury in neuropraxia.
Wallerian degeneration does not usually occur in simple neuropraxia.
Autonomic function is usually preserved.
A 44 year old lady presents with a pathological fracture of the left femur. She has previously undergone a renal transplant for end stage renal failure. Her blood test results are as follows:
Serum Ca2+ 2.80
PTH 88pg/ml
Phosphate 0.30
A surgeon decides to perform a parathyroidectomy on the basis of these results. When the glands are assessed histologically, which of the appearances is most likely to be identified?
Metaplasia the gland Hypertrophy of the gland Hyperplasia of the gland Parathyroid carcinoma Necrosis of the parathyroid gland
This is likely to be a case of tertiary hyperparathyroidism (high Calcium, high PTH, low phosphate). Therefore the glands will be hyperplastic. Hypertrophy is not correct as this implies an increase in size without an increase in cellularity. This mistake has cost many candidates marks in the MRCS exams over the years!
A 78 year old man is referred to the clinic by his general practitioner. For many years he noticed a smooth swelling approximately 2cm anterior to the tragus of his right ear. Apart from being a heavy smoker he has no co-morbidities. What is the most likely diagnosis?
Pleomorphic adenoma Liposarcoma Warthins tumour Adenocarcinoma None of the above
Warthins tumours are most common in elderly smokers. They have a relatively benign and indolent course
A 56 year old man presents with lethargy, haematuria and haemoptysis. On examination he is hypertensive and has a right loin mass. A CT scan shows a lesion affecting the upper pole of the right kidney, it has a small cystic centre. Which of the options below is the most likely diagnosis?
Squamous cell carcinoma of the kidney Nephroblastoma Renal adenocarcinoma Transitional cell carcinoma of the kidney Polycystic kidney disease
Renal adenocarcinoma are the most common renal tumours. These will typically affect the renal parenchyma. Transitional cell carcinoma will usually affect urothelial surfaces. Nephroblastoma would be very rare in this age group. Renal adenocarcinoma may produce cannon ball metastasis in the lung which cause haemoptysis, this is not a feature of PKD.
A 25 year old junior doctor has a chest x-ray performed as part of a routine insurance medical examination. The x-ray shows evidence of rib notching. Auscultation of his chest reveals a systolic murmur which is loudest at the posterior aspect of the fourth intercostal space. What is the most likely diagnosis?
Patent ductus arteriosus Aortic coarctation Aortic dissection Cervical rib Subclavian steal syndrome
Coarctation of the aorta may occur due to the remnant of the ductus arteriosus acting as a fibrous constrictive band of the aorta. Weak arm pulses may be seen, radiofemoral delay is the classical physical finding. Collateral flow through the intercostal vessels may produce notching of the ribs, if the disease is long standing.
A 34-year-old man is taken immediately to theatre with aortic dissection. You note he is tall with pectus excavatum and arachnodactyly. His condition is primarily due to a defect in which one of the following proteins?
Polycystin-1 Fibrillin Type IV collagen Type I collagen Elastin
Although fibrillin is the primary protein affected (due to a defect in the fibrillin-1 gene) it should be noted that fibrillin is used as a substrate of elastin.
Which of the following are not typical of Lynch syndrome?
It is inherited in an autosomal recessive manner Affected patients are more likely to develop right colon mucinous tumours than the general population Affected individuals have an 80% lifetime risk of colon cancer Endometrial cancer is seen in 80% of women Gastric cancers are more common
Lynch syndrome is inherited in an autosomal dominant fashion. It is characterised by microsatellite instability in the DNA mismatch repair genes. Colonic tumours in patients with Lynch syndrome are more likely to be right sided tumours and to be poorly differentiated.
A 23 year old man suffers a thermal injury to his left hand. It becomes red and painful. Which of the following mediators are not involved in this process?
Histamine Free radicals Prostaglandins Leukotrienes Serotonin
Acute inflammation is not mediated by free radicals
A 32 year old man is admitted with a distended tense abdomen. He previously underwent a difficult appendicectomy 1 year previously and was discharged. At laparotomy the abdomen is filled with a gelatinous substance. What is the most likely diagnosis?
Appendiceal sarcoma Pseudomyxoma peritoneii Appendiceal adenocarcinoma Appendiceal carcinoid Caecal adenocarcinoma
Pseudomyxoma is classically associated with mucin production and the appendix is the commonest source
An enthusiastic medical student approaches you with a list of questions about blood transfusion reactions. Which of her following points is incorrect?
Graft versus host disease involves neutrophil proliferation Thrombocytopaenia may occur in women with a prior pregnancy IgA antibodies may cause blood pressure compromise during transfusion Hypocalcaemia can occur Iron overload can be avoided by chelation therapy
GVHD results from lymphocytic proliferation. The patient’s own lymphocytes are similar to the donor’s lymphocytes, therefore don’t perceive them as being foreign. The donor lymphocytes, however, sees the recipient lymphocytes as being foreign. Therefore they proliferate causing severe complications.
Thrombocytopaenia occurs a few days after transfusion and may resolve spontaneously.
Patients with IGA antibodies need IgA deficient blood transfusions.
An 82 year old lady presents with a carcinoma of the caecum. Approximately what proportion of patients presenting with this diagnosis will have synchronous lesions?
<1% 60% 50% 20% 5%
Synchronous lesions may occur in up to 5% of patients with colorectal cancer. A full and complete lumenal study with either colonoscopy, CT cologram or barium enema is mandatory in all patients being considered for surgery.
A 75 year old lady presents with weight loss, pain and a swelling over her left knee. She has been treated for Pagets disease of the bone for some time. What is the most likely diagnosis?
Ewings sarcoma Osteosarcoma Myeloma Septic arthritis Osteoclastoma
Osteosarcoma may complicate Pagets disease of bone in up to 10% cases. Radiological appearances include bone destruction coupled with new bone formation, periosteal elevation may also occur. Surgical resection is the main treatment.
A 28 year old man presents with hypertension and haematuria. Haematological investigations show polycythaemia but otherwise no abnormality. CT scanning shows a left renal mass. What is the most likely cause?
Wilms tumour Renal adenocarcinoma Renal transitional cell carcinoma Staghorn calculus Renal cyst
Renal adenocarcinoma is the most common variant and is associated with polycythaemia.
A 22 year old man undergoes a splenectomy for an iatrogenic splenic injury. On the second post operative day a full blood count is performed. Which of the following components of the full blood count is the first to be affected ?
Erythrocyte count Reticulocyte count Eosinophil count Monocyte count Lymphocyte count
The granulocyte (the eosinophil component is seldom raised) and platelet count are the first to be affected following splenectomy. Then reticulocytes increase. Although a lymphocytosis and monocytosis are reported, these take several weeks to develop.
A 28 year old lady presents with benign cyclical mastalgia. Which of the following is not a recognised treatment for the condition?
Evening primrose oil Bromocriptine Methotrexate Danazol Tamoxifen
Methotrexate is used for the treatment of breast cancer. Whilst the use of tamoxifen is of benefit other agents such as flaxseed oil or evening primrose oil should be tried first. Danazol is effective, but many women dislike the side effects.
A 3 year old boy is brought to the clinic by his mother who has noticed a mass in his neck. On examination; he has a smooth mass located on the lateral aspect of his anterior triangle, near to the angle of the mandible. On ultrasound; it has a fluid filled, anechoic, appearance. What is the most likely cause?
Cystic hygroma Dermoid cyst Thyroglossal cyst Branchial cyst Lymphoma
Branchial cysts are usually located laterally and derived from the second branchial cleft. Unless infection has occurred they will usually have an anechoic appearance on ultrasound.
A 39 year old lady has undergone surgery for breast cancer. As part of the histopathology report the pathologist provides the surgeon with a Nottingham Prognostic Index score of 6.4. He also states that the tumour size is 2cm. Which of the following inferences can be made in relation to this statement?
The tumour is likely to be grade 1 Vascular invasion is present Lymph node metastasis are definitely present The tumour is oestrogen receptor positive None of the above
A score of this value is unlikely to be reached with a grade 1 tumour and a size of 2cm. Therefore lymph node metastasis are definitely present. In addition since the maximal score for lymph node metastasis is 3 the tumour is likely be of a higher grade (see below). The Nottingham Prognostic Index provides no information about oestrogen receptor status or the presence or absence of vascular invasion.
In patients with multiple endocrine neoplasia type IIb which of the following clinical appearances is the patient most likely to display?
Acromegalic facies Turners type features Profound kyphoscoliosis Multiple bony exostoses Marfanoid features
Patients with MEN IIb may display Marfanoid features. It is unclear at the present time whether they have discrete changes in the microfibrils of elastic fibres that are present in Marfans.
A 22 year old is found to have bilateral acoustic neuromas. Which of the disorders listed below is most likely to be present?
Neurofibromatosis Type I Neurofibromatosis Type II MEN I MEN II Gardner's syndrome
In NF2 bilateral acoustic neuromas are characteristic with a family history of Neurofibroma.
A 56 year old man presents with jaundice. He has a long history of alcohol misuse. On examination he is jaundiced and ultrasound shows multiple echo dense lesions in both lobes of the liver. His alpha feto protein is elevated 6 times the normal range. What is the most likely diagnosis?
Gallstones Hepatocellular carcinoma Metastatic pancreatic adenocarcinoma Mirizzi syndrome Benign bile duct stricture
HCC may complicate cirrhosis. AFP is often raised in HCC.
A 32 year old man undergoes an appendicectomy. A large carcinoid tumour is identified and a completion right hemicolectomy is performed. He is well for several months and then develops symptoms of palpitations and facial flushing. Which of the following diagnostic markers should be requested?
Alpha feto protein Urinary 5-Hydroxyindoleacetic acid measurements Urinary catecholamines Urinary VMA measurements None of the above
5 HIAA is the most commonly used diagnostic marker for carcinoid syndrome, it is measured in a 24 hour urine collection.
A 20 year old male is referred to the clinic. He has undergone genetic testing because his father died from colorectal cancer at the age of 21. His testing revealed a mutation of the APC gene. A colonoscopy is proposed. What is the most likely finding?
Multiple colonic hamartomas Carpet villous adenoma of the rectum Caecal carcinoma Multiple colonic adenomas Multiple colonic hyperplastic polyps
APC mutations are found in familial adenomatous polyposis coli. These have multiple colonic adenomas.
A 50 year old female presents with bilateral parotid gland swelling and symptoms of a dry mouth. On examination, she has bilateral facial nerve palsies. This improved following steroid treatment. What is the likely underlying diagnosis?
Pleomorphic adenoma Sarcoid Warthins tumour Sialolithiasis Adenoid cystic carcinoma
Sarcoid occurs bilaterally in 70% of cases and facial nerve involvement is recognised. Treatment is conservative in most cases although individuals with facial nerve palsy will usually receive steroids with good effect.
Which of the following breast tumours is most commonly associated with a risk of metastasis to the contralateral breast?
Invasive ductal carcinoma Invasive lobular carcinoma Phyllodes tumour Pagets disease of the breast Atypical ductal hyperplasia
Risk of metastasis to the contralateral breast is a classical feature of invasive lobular carcinoma.
Which is the characteristic finding on a blood film post splenectomy?
Stipple cell Tear drop cell Reticulocytes Howell-Jolly bodies Schistocyte
Blood film in hyposplenism:
Howell-Jolly bodies Pappenheimer bodies Poikilocytes (Target cells) Erythrocyte containing siderotic granules Heinz bodies
