QBANK AUDIT (MLA II) (CANCER, BREAST, HAEM, PALLIATIVE, PERI-OP & ANAESTH., MSK, EM, ENT, PAEDS, REPRO, PSYCH, SEXUAL HEALTH, POP HEALTH, ETHICS & LAW)

Question 1

A 26-year-old is scheduled to undergo a proctocolectomy for ulcerative colitis. They currently take long-term daily prednisolone 10mg/day to help manage their ulcerative colitis. They take no other regular medications.

What, if any, alterations need to be made to their medications before surgery?

Answer 1

Hydrocortisone supplementation is required prior to surgery for patients taking prednisolone

Question 2

You are reviewing a 62-year-old woman in primary care.

Last week you saw her with left-sided leg swelling and you started her on rivaroxaban for a suspected deep vein thrombosis (DVT). She was seen in secondary care following this and as she had a raised D-Dimer, but her ultrasound scan came back as normal. She was discharged and advised to see her GP for follow-up.

According to current NICE guidance, what is the most appropriate management for this patient?

Answer 2

DVT investigation: if the scan is negative, but the D-dimer is positive → stop anticoagulation and repeat scan in 1 week

Question 3

DVT Guidelines Pathway

Answer 3

Wells Likely
* USS
* if -ve then D-Dimer
> apix. or rivarox

interim DOAC should be started regardless

if the scan is negative but the D-dimer is positive:
stop interim therapeutic anticoagulation
offer a repeat proximal leg vein ultrasound scan 6 to 8 days later

Wells Unlikely
* D-Dimer
* if +ve USS

Question 4

Significance of Tamoxifen and SFX

Answer 4

Tamoxifen therapy increases the risk of VTE. Tamoxifen is a selective estrogen receptor modulator used in the treatment of hormone receptor-positive breast cancer. It is known to increase the risk of venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, due to its estrogenic effects on the blood vessels. This risk is particularly significant in patients with other predisposing factors for VTE.

Question 5

An 82-year-old woman is being reviewed on the ward following a total hip replacement. She fell from a standing height while vacuuming her living room and was brought via ambulance with a shortened, externally rotated left leg. Her hip x-ray confirmed a neck of femur fracture, and she was promptly operated on. There is a past medical history of mild knee osteoarthritis and type II diabetes mellitus.

She has been in the hospital for 3-days, is weight-bearing, and is fit for discharge. Calcium and vitamin D supplementation has been initiated.

What is the next best step in this patient’s management?

Answer 5

Following a fragility fracture in women ≥ 75 years, a DEXA scan is not necessary to diagnose osteoporosis and hence commence a bisphosphonate

> Alendronate

Question 6

A 34-year-old woman who is 32 weeks pregnant presents to her local antenatal unit for a midwife check-up. Her pregnancy has also been complicated by intrahepatic cholestasis of pregnancy, which has been treated with ursodeoxycholic acid. This is her first pregnancy, and she has had no previous miscarriages. She is epileptic, and is being treated with lamotrigine.

She tells her midwife that her step-sister has just had another term stillbirth, after already having 2 prior. This has made her worried about her own pregnancy.

Which part of her medical history puts her most at risk for this outcome?

Answer 6

Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation

Question 7

A 17-year-old girl presents to her GP as she has not started menstruating. On examination, you note her short stature and webbed neck.

What would you expect to hear on auscultation of her heart?

Answer 7

Turner’s syndrome is associated with an ejection systolic murmur due to bicuspid aortic valve

Question 8

A 32-year-old professional dancer presents with acute lower back pain radiating down her left leg. She made an error during a performance yesterday and landed awkwardly. She reports sensory loss over the anterior aspect of the left knee and medial malleolus, as well as difficulty extending her left knee and adducting her left hip.

On examination, her left knee reflex is diminished. Her past medical history is not significant and she is otherwise healthy.

What is the most likely compressed spinal nerve root?

Answer 8

L4 nerve root compression: sensory loss anterior aspect of knee and medial malleolus, weak knee extension and hip adduction, reduced knee reflex

Question 9

A 74-year-old man has had a recent change to his epilepsy medication since having an increased seizure frequency following a stroke. He has a mechanical heart valve for which he takes warfarin. An INR taken 3 days after commencing treatment comes back at 2.3.

What anti-epileptic medication has likely been started for this patient?

Answer 9

Carbamazepine is a P450 enzyme inductor

Question 10

A 83-year-old lady comes to see you with her daughter, who’s wondering if her mum needs to be on something to protect her bones. Her past medical history includes a fracture neck of femur ten months ago, chronic kidney disease stage IV, hypertension and ischaemic heart disease.

After her fractured neck of femur, she was discharged from hospital on alendronic acid. This was stopped by a colleague six months ago due to distressing reflux, which resolved once the tablet was stopped. She was also unable to tolerate risedronate for the same reason. Her DEXA scan after her fractured neck of femur showed a T score of -4.2.

What is the most appropriate action?

Answer 10

> Denosumab trial referral

Question 11

A 65-year-old woman presents to the post-menopausal bleeding clinic. She reports that her last menstrual period was 9 years ago, but within the last 2 months she has been experiencing vaginal bleeding, with some clots. She reports no weight loss, abdominal or pelvic pain.

On further questioning, she reports that she has been pregnant once when she was 25, after which she took the combined oral contraceptive pill until reaching menopause. Since then, she has not been on any hormonal replacement therapy.

On further questioning, the patient reports that she underwent a total mastectomy at aged 34 for breast cancer, following which she completed a course of tamoxifen.

She has a 23 pack-year smoking history and drinks approximately one glass of wine a week.

The patient reports that she has done some online research and is worried about the risk of endometrial cancer.

Which of the following factors in this patient’s history puts her at an increased risk of that diagnosis?

Answer 11

Tamoxifen may cause increased risk of endometrial cancer

Question 12

A 35-year-old woman with Crohn’s disease is on azathioprine to maintain remission. She presents to her GP with a 3-day history of fever, lethargy, and coryzal symptoms. Due to her medication history the GP is concerned and ordered some investigations.

What investigation is the most important in this situation?

Answer 12

FBC dt Azathioprine may cause myelosuppression - consider a full blood count if infection/bleeding occurs

Question 13

A 34-year woman attends the emergency room complaining of a severe headache and some visual changes. She is 36 weeks pregnant. This is her third pregnancy and there have been no complications so far. She has a past medical history of asthma which is well-managed with inhalers.

On examination, her blood pressure is 147/101 mmHg and she has some mild peripheral oedema.

What is the most appropriate medication to start this patient on?

Answer 13

Nifedipine is the first line anti-hypertensive for pre-eclampsia in women with severe asthma

Labetalol is not the correct answer as it is contraindicated in asthma. It would normally be the first line for pregnancy-induced hypertension if the patient did not have asthma.

Question 14

A 71-year-old male presents to the GP because he is worried about memory loss. Over the last three weeks, he has been very forgetful and absent minded. He does not remember conversations that have happened earlier that day, and has been forgetting to lock the front door. He has also been very tired and has not been wanting to go out for bingo as he usually does. He is concerned about the memory loss as he lives alone, and is worried that he may put himself at risk. Initially he appears to be cheerful, but starts crying during the consultation when talking about his symptoms.

The following blood result is obtained:

TSH 2 mU/L

What is the most likely cause of this presentation?

Answer 14

Depression can be differentiated from dementia due to short history and rapid onset

Factors suggesting diagnosis of depression over dementia
short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)

Question 15

A 43-year-old man, currently an inpatient on a surgical ward for acute pancreatitis, develops episodic epistaxis. Blood tests are taken which demonstrate the following:

Platelets 52 * 109/L (150 - 400)
Prothrombin time (PT) 23 secs (10-14 secs)
Activated partial thromboplastin time (APTT) 46 secs (25-35 secs)
Fibrinogen 0.8 g/L (2 - 4)
D-Dimer 1203 ng/mL (< 400)

Given the likely diagnosis, what would be expected on blood film?

Answer 15

SHISTOCYTES

DIC is associated with schistocytes due to microangiopathic haemolytic anaemia

It can be triggered by a number of factors - in this instance, an acutely unwell patient. The blood tests show a depletion of platelets and coagulation factors, characteristic of DIC. The condition is associated with schistocytes due to microangiopathic haemolytic anaemia.

Question 16

A group of 30 patients with chronic knee osteoarthritis are enrolled in a study to evaluate the effectiveness of a new physiotherapy regimen. Each patient’s pain level is assessed using a standardised pain scale (0-10, with 10 indicating severe pain) before starting the regimen and again after 3 months of treatment. The study aims to determine if there is a statistically significant change in pain scores following the intervention.

What statistical test is most appropriate?

Answer 16

Wilcoxon signed-rank test - compares two sets of observations on a single sample, e.g. a ‘before’ and ‘after’ test on the same population following an intervention

Question 17

A 34-year-old woman attends her GP complaining fatigue over the last month. She is fit and well and takes no medications except for the combined oral contraceptive pill.

On examination, her chest is clear with no added heart sounds. There is a mild yellow discolouration of her sclera. Observations are normal.

Blood tests:

Hb 86 g/L Male: (135-180)
Female: (115 - 160)
Mean Cell Volume (MCV) 95 fl (82-100)
Reticulocytes 8 % (0.5 - 1.5)
Lactate dehydrogenase (LDH) 365 U/L (125 - 220)
Direct antiglobulin (Coombs’) positive

Given the likely diagnosis, what is the most appropriate first-line treatment?

Answer 17

Steroids (+/- rituximab) are generally used first-line in the management of patients with warm autoimmune haemolytic anaemia

This patient has normocytic anaemia, jaundice, raised reticulocytes and raised LDH which point towards haemolytic anaemia. A positive Coombs’ test indicates that this is autoimmune haemolytic anaemia.

Steroids are generally used first-line in the management of patients with warm autoimmune haemolytic anaemia. Steroids are effective because they dampen the autoimmune response, thus halting antibody production against red blood cells and haemolysis.

Question 18

Autoimmune haemolytic anaemia

Answer 18

WARM VS COLD

Idiopathic or secondary to lymhoprolifer., infection, drugs

Warm is the most common type of AIHA. In warm AIHA the antibody (usually IgG) causes haemolysis best at body temperature and haemolysis tends to occur in extravascular sites, for example the spleen.

Causes of warm AIHA
idiopathic
autoimmune disease: e.g. systemic lupus erythematosus*
neoplasia
lymphoma
chronic lymphocytic leukaemia
drugs: e.g. methyldopa

The antibody in cold AIHA is usually IgM and causes haemolysis best at 4 deg C. Haemolysis is mediated by complement and is more commonly intravascular. Features may include symptoms of Raynaud’s and acrocynaosis. Patients respond less well to steroids

Causes of cold AIHA
neoplasia: e.g. lymphoma
infections: e.g. mycoplasma, EBV

Question 19

Systemic lupus erythematosus (SLE) is an inflammatory multisystem disorder. The pathogenesis involves immune system dysregulation.

What type of hypersensitivity is this defined as?

Answer 19

Type 3

Type 3 is characterised by antigen-antibody complexes. The pathogenesis of SLE involves cellular remnants containing nuclear material being transferred to lymphatic tissues. They are then presented to T cells which in turn stimulate B cells to produce autoantibodies. IgG autoantibodies are primed to attack DNA and other nuclear material which results in antigen-antibody complexes causing damage in various areas.

Question 20

Drug agents causing secondary visual changes such as blue tinge

Answer 20

Visual changes secondary to drugs
blue vision: Viagra (‘the blue pill’)
yellow-green vision: digoxin

Question 21

A 23-year-old female presents to the GP with concerns about her mood during her period. She has been suffering from symptoms for the past 6 months despite making lifestyle changes. The week before her period she has noticed a significant change in her mood. She feels incredibly low and anxious, with poor concentration. Her irritability is starting to have an impact on her job as a primary school teacher. There are no other physical symptoms, and she feels her normal self for the rest of the month. Her medical history includes migraine with aura.

Given the likely diagnosis, what is the most appropriate treatment for this patient?

Answer 21

> SSRIs, either continuously or during the luteal phase, may help premenstrual syndrome

The combined oral contraceptive pill is used to treat PMS, particularly in women with moderate symptoms. However, in this case, it would be contraindicated (UKMEC 4) due to her history of migraine with aura.

Question 22

A 35-year-old woman has an unplanned and unwanted pregnancy. Her obstetric history includes a miscarriage 5 years ago, an ectopic pregnancy 7 years ago, and she currently has 2 children who are healthy and well. She has no other medical history.

An ultrasound scan is performed and shows an intrauterine pregnancy and her estimated gestation is 8 weeks. She has been counselled on her options and she would like a medical termination of pregnancy.

What treatment is she most likely to be offered?

Answer 22

oral mifepristone and vaginal misoprostol

Medical abortions are undertaken using mifepristone followed by prostaglandins

Question 23

A 60-year-old woman presents to the emergency department after suffering a fall. She hit her face against the footpath and reported extensive nose-bleeding for the first 10 minutes. She denies loss of consciousness or vomiting. There is no past medical history of note and she takes no regular medications.

On examination, there is bruising over the bridge of her nose that is tender to touch. There is crusted blood around the nostrils. On examination of the internal nasal cavity, there are bilateral purple swellings outpouching from the nasal septum.

What is the next step in the management of this patient?

Answer 23

Bilateral purple swelling of the nasal septum suggests septal haematoma

This patient has clinical features of a septal haematoma, given the bilateral purple swellings that are seen to be outpouching from the nasal septum. A septal haematoma is a complication of a nasal bone injury and is an ENT emergency due to the risk of pressure necrosis and septal perforation. Treatment includes incision and drainage of the septal haematoma along with antibiotic administration to prevent infection.

Question 24

An 85-year-old gentleman with a past medical history of atrial fibrillation has been commenced on amiodarone. As his GP, which of the following tests should be performed?

Answer 24

TFTs LFTs every 6mos

Current recommendations include liver and thyroid function tests on a 6 monthly basis. Chest x-rays should be performed prior to starting amiodarone treatment, however they do not need to be performed routinely post treatment unless patients develop respiratory signs or symptoms.

Question 25

A 55-year-old man presents to his general practitioner complaining of generalized bone pain, muscle weakness, and fatigue. He reports discomfort and aching in his hips, thighs, and lower back, which has progressively worsened over the past several months. He mentions that he has difficulty performing routine activities, such as walking or climbing stairs. On examination, there is tenderness in the long bones.

His blood tests show the following:

Calcium 1.9 mmol/L (2.1-2.6)
Phosphate 0.6 mmol/L (0.8-1.4)
ALP 176 u/L (30 - 100)
PTH 10.2 pmol/L (1.6 - 6.9)

What is the most likely diagnosis?

• Osteomalacia
• Osteopor
• Paget’s Disease
• 1º Hyperparathy
• 3º Hyperparathy

Answer 25

Low serum calcium, low serum phosphate, raised ALP and raised PTH - osteomalacia

The correct answer is osteomalacia. This patient is presenting with bone pain and tenderness, and proximal myopathy impeding him from walking up and down the stairs. These are characteristic features of osteomalacia, softening of the bones secondary to low vitamin D levels that in turn lead to decreased bone mineral content. This causes increased ALP, decreased calcium, decreased phosphate, and increased PTH. PTH is raised in an attempt to increase calcium stores for bone mineralisation, leading to increased ALP, but the calcium and phosphate remain low due to impaired absorption.

Question 26

A young woman who is planning to get pregnant is currently taking paroxetine and wants to know if it will have any adverse effects during pregnancy. What should you advise her?

Answer 26

Paroxetine use in pregnancy - can lead to increased risk of congenital malformations

Question 27

A 61-year-old man is referred to the haematology clinic with tiredness, significant weight loss and easy bruising over the past 18 months. His blood results are shown below:

Hb 88 g/L Male: (135-180)
Female: (115 - 160)
Platelets 89 * 109/L (150 - 400)
WBC 72.2 * 109/L (4.0 - 11.0)
Neuts 62.4 * 109/L (2.0 - 7.0)
Lymphs 1.1 * 109/L (1.0 - 3.5)
Mono 3.1 * 109/L (0.2 - 0.8)
Eosin 2.8 * 109/L (0.0 - 0.4)

Blood film Obvious leucocytosis with eosinophilia and basophilia visible. Large numbers of immature granulocytes but no blast cells visible.

Which of the following is the most appropriate first-line treatment?

• conservative
• fludarabine and cyclophosphamide
• imatinib
• prednisolone
• rituximab

Answer 27

> Chronic myeloid leukaemia - imatinib = tyrosine kinase inhibitor

The history and blood results are in keeping with chronic myeloid leukaemia (CML), indicated by the high white cell count which is due to high numbers of myeloid cells and the chronic nature of the presentation. The absence of blast cells indicates this is not acute leukaemia. The presence of anaemia and thrombocytopenia is due to bone marrow dysfunction, usually caused by myelofibrosis, indicating a need to start treatment. The first-line treatment for CML is the tyrosine kinase inhibitor imatinib. It is taken as a daily tablet and has excellent results in CML.

Question 28

A two-year-old child is brought to the hospital. His parents are concerned as he has had a temperature of 39ºC for the last five days. They have also noted that his eyes are red, his neck is swollen and he has a new rash.

On examination, there is a generalised maculopapular rash and the child has bilateral conjunctivitis. There is unilateral cervical lymphadenopathy. The lips are cracked and erythematous and a strawberry tongue is present.

What treatment should this child receive initially?

Answer 28

High dose aspirin is indicated in Kawasaki disease, despite it usually being contraindicated in children

This child has Kawasaki disease. Kawasaki disease is a systemic vasculitis that generally presents in the under 5s. Typical findings, as seen in this case, include an acute febrile illness lasting over 5 days, bilateral non-purulent conjunctivitis, unilateral cervical lymphadenopathy, a polymorphic rash, and mucosal erythema with a strawberry tongue. Swelling of the hands and feet can occur in the acute stage with desquamation in the second week. Coronary aneurysms can develop in up to one-quarter of untreated patients. The main goal of treatment is to reduce the risk of cardiac complications. The standard treatment in the UK is intravenous immunoglobulin and high dose aspirin (despite the fact that it is usually contraindicated in children) due to the additional anti-inflammatory effects this provides. S

Question 29

A 34-year-old woman presents to her GP with painful, heavy periods that have been worsening over the past few months. She is soaking several pads per day and is worried about going out in public in case of a leak. Her pain is not well controlled on regular paracetamol. Usually, her periods are regular and last for 6 days.

Observations are normal. On examination, she has a diffusely and symmetrically enlarged uterus which feels boggy. It is mildly tender to palpate and is approximately the size of a 10-week gestation pregnancy. There is no adnexal or cervical motion tenderness.

What is the most likely diagnosis?

Answer 29

Woman aged > 30 years with dysmenorrhoea, menorrhagia, enlarged, boggy uterus → ?adenomyosis

Adenomyosis is when endometrial tissue becomes embedded within the myometrium. Usually occurring in women over the age of 30, it results in painful, heavy menses which can be quite debilitating. A definitive diagnosis of adenomyosis cannot be made until histological examination after a hysterectomy, but a presumptive diagnosis can be made on the basis of history, examination and imaging. The first-line imaging modality for adenomyosis is transvaginal ultrasound.

Question 30

A 35-week neonate is admitted to the neonatal intensive care unit. They were born via emergency Caesarean section to a 16-year-old mother in preterm labour. The mother was a late booker to antenatal health services and her antenatal history including significant tobacco and alcohol use. On examination, the baby has intestinal loops protruding through a hole in the abdomen to the left of the umbilicus. What is the most likely diagnosis?

Answer 30

Gastroschisis is associated with socioeconomic deprivation (maternal age <20, maternal alcohol/tobacco use)

Vs

Gastroschisis and omphalocele present similarly, but gastroschisis refers to a defect lateral to the umbilicus whereas omphalocele refers to a defect in the umbilicus itself.

Question 31

Paget’s Disease of the Nipple

Answer 31

! suggestive of cancer

Paget’s disease is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.

Paget’s disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).

Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.

Treatment will depend on the underlying lesion.

Question 32

A 22-year-old Afro-Caribbean man presents to his general practitioner with a 4-day history of increased urinary frequency and dysuria. He denies recent unprotected sexual intercourse or penile discharge. He has a past medical history of gallstones and reports that he was hospitalised last year for a severe blood reaction that the doctors told him was after eating a meal rich in broad beans.

On examination, he has suprapubic tenderness but no evidence of renal angle tenderness. His observations are all within normal limits.

What is the most important antibiotic to avoid prescribing for this patient?

Answer 32

Ciprofloxacin is contraindicated in G6PD deficiency

This patient has a likely underlying diagnosis of G6PD deficiency. G6PD deficiency is an X-linked recessive disorder that causes a defect in the red cell enzyme glucose-6-phosphate dehydrogenase. As ciprofloxacin is mentioned in the list of drugs that precipitate haemolysis in patients with G6PD deficiency, it should be avoided in this patient.

The deficiency in the G6PD enzyme leads to intravascular haemolysis which can be triggered by the ingestion of certain drugs and foods (including fava (broad) beans). Drugs that can precipitate haemolysis in G6PD deficiency include antimalarials, ciprofloxacin, sulphonamides (including co-trimoxazole), sulphonylureas and sulphasalazine. All the other antibiotics in this question, however, are safe to prescribe in G6PD deficiency.

Question 33

Meig’s Syndrome

Answer 33

Meig’s syndrome involves a triad of:

Ovarian fibroma (a type of benign ovarian tumour)
Pleural effusion
Ascites
Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.

TOM TIP: It is worth remembering Meig’s syndrome for your MCQ exams. Look out for the woman presenting with a pleural effusion and an ovarian mass.