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Atherosclerosis defined as

atheromatous deposits in and fibrosis of the inner layer of the arteries.
intimal lesions - atheroma (atheromatous plaques) - that protrude into vessel lumen


Stages of atherosclerosis

1. Smooth endothelium damage.
2. Platelets adhere to damaged tissue
3. Proliferastion of endothelium
4. Fibrous cap forms
5. Deposition of cholesterol and enlargement of plaque with fatty core.


Atheromatous plaque definition

Raised legion, soft lipid core, white fibrous cap.


Pathogenesis of atherosclerosis

Endothelial injury
LDL accumulation
Monocyte adhesion and migration to intima forming macrophages and foam cells.
Platelet adhesion.


Fatty streak

Earliest lesion. lipid filled foamy macrophages, no flow disturbance, in all children >10y
Relationship to plaque unknow but in same sites.


Atherosclerotic Plaque

Patchy, localised flow disturbance, only involve a portion of the wall (rarely circumferential)
Composed of cells, lipid and matrix.


Critical stenosis occurs at

70% occlusion or diameter


Acute plaque changes (3)

Rupture - exposes prothrombotic plaque contents.
Erosion - exposes prothrombotic basement membrane
Haemorrhage into plaque increases size.


Reasons for a vulnerable plaque

Lots of foam cells of lipid
Thin cap
Few smooth muscle cells
Clusters inflammatory cells


Vasoconstriction effect on plaque

Reduces lumen size and increases mechanical pressure on plaque.
Due to adrenergic agonists


IHD main cause

90% due to reduced blood from from atherosclerosis.
IHD is leading cause of mortality for men and women. Due to lack of o2 to cardiac muscle less well tolerated that true hypoxia due to impaired waste clearance as well.


% stenosis of coronary arteries required to cause angina on exercise?
% stenosis to cause angina at rest?

90% stenosis for pain at rest


MI pathogenesis
Loss of contractility in?
Irreversible after?

Myocardial blood supply compromised.
Loss of contractililty in 60s (so failure can precede myocyte death)
Irreversible after 20-30mins


Locations for MI

LAD 50%
RCA 40%
LCx 20%


% of asymptomatic MI

10-15% usually in elderly or DM.


Reperfusion injury cause

due to oxidative stress, Ca overload and inflammation. Arrhythmias are common


Complications of MI (6)
Mortality of MI is 30% in one year

Contractile dysfunction
Myocardial rupture
RV infarction
Deslers syndrome (pericarditis 2-3w post MI)
Papillary muscle rupture


Chronic IHD definition

Progressive heart failure due to ischaemic myocaridal damage. May not be a prior infarction. Hypertrophies heart with dilated LV


Sudden Cardiac Death

Unexpected death in individuals without symptomatic heart disease or


Causes of sudden cardiac death

Acute MI is usually the trigger Marked atherosclerosis (>90%)
10% non atherosclerotic (long QT, HOCM)


Types of cardiomyopathy (3)

Dilated - progressive loss of myocytes


Causes of dilated cardiomyopathy

Toxic - alcohol, chemo
Hormonal - hyper/hypothyroid, DM, peripartum
Genetic - haemochromatosis


Causes of hypertrophic cardiomyopath

Familial 50%


Causes of Restrictive Cardiomyopathy

Idiopathic or secondary to myocardial disease like amyloid or scarcoidosis.


Causes of Aortic Regurgitation

Rheumatic, degenerative rigidity
Dissecting aneurysm
Syphilitc aortitis
Ankylosing spondylitis


Congenital Lung Pathology (3)

Lung agenesis or hypoplasia
Tracheical or bronchial stenosis
Congenital cysts


Causes of pulmonary oedema (4)

Left heart failure
Alveolar injury
High altitude


Diffuse alveolar damage is caused by:

In adults acute respiratory distress syndrome (from infection, aspiration, trauma, DIC...)
In neonates by hyaline membrane disease.


Definition of chronic bronchitis

Chronic cough production of sputum for most days for at least 3m over at least 2 consecutive years


Complications of COPD

Repeated infections
Chronic hypoxia which results in pulmonary HTN and R heart failure.
Increased risk of lung Ca (independent of smoking)


Definition of emphysema

Permanent loss of alveolar parenchyma distal to terminal bronchiole. Usually due to smoking or aplha1 antitrypsin. Rarely IVDU or CTD


Parthenogenesis of emphysema

Chronic inflammation from cigarette etc cause neutrophil and macrophage activation. This least to the activation of proteases and tissue damage.


Complication of emphysema?

Bullae and pneumothorax
Respiratory failure
Pulmonary HTN and cor pulmonale.


Causes of Bronchiectasis

Post infections (esp in CF)
Cillary dyskineasia (Kartageners)
Post-inflammatory (aspiration)



Usually in elderly from low virulence organisms.
Patchy bronchial and peribronchial distribution, often lower lobes. Acute inflammation surrounding airways and in alveoli


Complications of infection of lung (5)

Pleuritis and pleural effusion
Fibrous scarring


Causes of granulomatous lung infections

Fungal (aspergillus, cryptococcus)


Non-infectious granulomatous conditions?

Foreign body aspiration or IVDU
Occupational lung disease


Sarcoidosis defintion

Idiopathic granulomatous disease of lung, skin, LNs and eyes. Due to abnormal immune response to common antigens.


Pathological changes in Lung sarcoid

Discrete epithelioid and giant cell granulomas usually in upper lobes. Usually perilymph or peribronchial. Elevated ACE


Causes of pulmonary hypertension (pressure >25mmHg)

Chronic hypoxia, congenital heart defects, chronic liver disease, parasites (schistosomal), emboli, pulmonary fibrosis, left sided heart disease


Complications of pulmonary HTN

Right heart failure
Venous congestion of organs (nutmeg liver)
Peripheral oedema
Pleural effusion or ascites



Permanent alteration of lung structure due to inhaled inorganic dust and tissue reaction (excluding bronchitis and emphysema).
Often upper lobe, usually fibrosis.
Silicosis, asbestosis, berylliosis, coal workers lung.


Commonest type of lung Ca

Are epithelial tumours
Non-Small Cell
Squamous 35%
Adenocarcinoma 27%
Large cell carcinoma 10%

Small Cell 20%


Lung cancer types most strongly associated with smoking

Small cell and squamous


Angiosquamous dysplasia

Seen in high risk smokers and Squamous cell ca.
Basement membrane thickening and vascular budding.


Squamous Cell Ca of Lung

35% of pulmonary Cas
Closely assoicated with smoking
Traditionall arisised from bronchial but can be peripheral.
Locally spreads and metastasises late.
Histologically - keratinisation, intercellular prickles


Adenocarcinoma of lung

27% of pulmonary ca
smoking is a risk
Usually peripheral and multicentric
Metastasises early
Histology shows evidence of glandular differentiation.


Large cell ca of lung

10% of lung Ca
Peripheral or central tumours
Poorly differentiated, no histological evidence of glandular or squamous differentiation.
Poor prognosis.


Small Cell Ca

20% lung Ca
Closely associated with Smoking
Often central
80% present with advanced disease, is chemo sensitive but poor prognosis (survival 2-4m untreated, 10-20m treated).
p53 and RB1 mutations are common
Assoicated with paraneoplastic syndrome.


A predictive marker in Non-small cell lung Ca

ERCC1 (associated with poorer response to cisplatin)


Target for Non-small cell Lung Ca

EGFR with a tyrosine kinase inhibitor. If young, female, non-smoker. Contraindicated in Kras mutation.


Mutation in Lung Ca associated with poor prognosis



Paraneoplastic syndromes associated with Small Cell Lung Ca

Cushing's syndrome


Paraneoplastic syndrom associated with squamous cell lung Ca



Frequency, aetiology, prognosis


A 20-year-old student gives an 8 hour history of very frequent vomiting and epigastric cramping. O/E she is pale and shivering. Her serum WBC is normal.

Gastroenteritis (Staphylococcus aureus)
Staphylococcus aureus is a leading cause of gastroenteritis resulting from the consumption of contaminated food.
Staphylococcal food poisoning is due to the absorption of staphylococcal enterotoxins preformed in the food.
The onset of symptoms is rapid (from 30 min to 8 h) and usually spontaneous remission is observed after 24 h.
As the presentation is so acute, the WCC often have not had a chance to increase (lag-time).
The symptoms of staphylococcal food poisoning are abdominal cramps, nausea, vomiting, sometimes followed by diarrhea
(never diarrhea alone).


How does HPV transform cells?

It posses two proteins E6 and E7 which bind and inactivate p53 and Rb (tumour suppressors).


A 63 year old obese, diabetic male presents to A and E with tight chest pain at rest, which radiated to the left arm and lasted for less than 20 minutes. The CK was not raised.

Acute coronary syndrome (unstable angina) is defined as recurrent episodes of angina on minimal effort or at rest and persists for longer than stable angina.


A 65 year old man is in hospital after suffering an acute myocardial infarction. The house officer hears a pansystolic murmur on auscultation.

Myomalacia cordis
Softening of the dead muscle leading rupture.


A 46 year old women presents to AandE out of breath and with severe chest pain. On examination a mid systolic click late systolic murmur is revealed.

Myxomatous mitral valve.
Myxomatous degeneration is pathological weakening of soft tissue. Can lead to prolapse of mitral valve.


A 40 year old man presents with a sharp chest pain. He has a pericardial friction rub, diminished heart sounds and a raised JVP.



A 39 year old Nepalese man presents with severe watery diarrhoea. He is found to have hypokalaemia and, surprisingly, a metabolic acidosis. A RUQ mass is detected by contrast-enhanced spiral CT scanning. Stool bicarb is high and urine anion gap is negative.

VIPoma (Werner Morrision Syndrome)
Endocrine tumour of the non-betal islet cells of the pancrease that produce vasoactive intestial peptide (VIP) assocated with MEN1
Causes diarrhoea, dehydration, hypokalaemia.


A 59 year old widow complains of persistent back pain, loss of appetite and that she has dropped from dress size 18 to a size 14 in just 2 months. She was recently diagnosed with diabetes. A large central mass is palpable as well hepatosplenomegaly.

Carcinoma of the tail of the pancreas. No jaundice suggests tail as opposed to head.


65 year old female with a large, cystic mass on tail of pancreas imaged using computed tomography. Further cytology reported the presence of epithelium

Cystademona - benign, epithelial wall containing fluid.


ERCP finding due to incomplete fusing of pancreatic buds.

Pancreas divisum


Around 10 % of people with this disease eventually get primary lymphoma (less often, carcinoma) of the gut if not properly treated. HLA B8 is linked with this.



A 30 year old female complaining of diarhorrea and weight loss. Biopsy of duodenum shows increased intraepithelial cytotoxic T cells.



A 26 year old man presents with watery diarrhoea, abdominal cramps, nausea, vomiting and a low grade fever. It started 3 days after eating some undercooked meat at a barbecue.

Cryptosporidiosis - from undercooked meat.
Incubation 2-10d and lasts 7d.


A 66 year old man complaining of epigastric pain undergoes an endoscopy. The mucosa appears reddened in the antrum of the stomach. 13C is detected on a urea breath test.

H. pylori


A 58 year old female presents with malnutrition. She complains of abdominal pain, weight loss and arthritis. She has steatorrhoea. A jejunal biopsy showed periodic acid-Schiff (PAS)-positive macrophages

Whipples Disease - systemic infectious disease caused by tropheryma whipplei. Usually diarrhoea, abdo pain, weight loss and arthralgia.


A 30-year-old woman presents with haematemesis and diarrhoea. She has recurrent peptic ulceration and is taking omeprazole. Despite this, she has persistently high serum gastrin levels. Endoscopy shows a large 3cm actively bleeding ulcer in the duodenum.

Zollinger-Ellison Syndrome - Gastrin secreting stumopur.


A 40 year old man with previous hepatitis B infection presents with weight loss, muscle aches and abdominal pain. On examination he has high BP and urine dipstick reveals blood + and protein +

Polyarteritis nodosa


A 60 year old man, currently undergoing treatment for long-standing chronic renal failure, complaining of tingling in his wrist & hand when he wakes in the morning.

Haemodialysis associated amyloidosis.
Beta -2-microglobulin amyloidosis is associated with haemodialysis. This is a secondary amyloidosis due to impaired clearance of b2m across dialysis membranes that causes carpal tunnel syndrome.


A 64 year old woman with a history of chronic rheumatological disease presents to her GP complaining of abdominal discomfort – which is found to be due to hepatosplenomegaly. An ensuing liver biopsy stains positive with Congo Red stain.

Reactive Amyloidosis
Secondary or reactive amyloidosis (AA) is secondary to inflammatory conditions including rheumatoid arthritis, crohn's disease etc.


A 63 year old lady presents to A and E with acute abdominal pain. She has been vomiting. On examination her abdomen is distended and you hear tinkling bowel sounds. Abdominal X-ray shows an inverted U loop of bowel.

Sigmoid volvulus


A 70 year old gentlemen presents to his GP with left sided colicky abdominal pain which is relieved by defecation. He admits to passing constipated stools.

Diverticular disease


A 26 year old gentleman presents to A and E with acute abdominal pain. He has lost 5 kg of weight in the last 2 weeks, and has been passing bloody diarrhoea with mucus. He is pyrexial and on examination is noted to have angular stomatitis.

Chrons - stomatitis and mucus


A 25-year-old woman complains of right iliac fossa pain, diarrhoea and weight loss worsening over several weeks. Laparotomy reveals an oedematous, reddened terminal ileum and a biopsy uncovers transmural inflammation with the presence of granulomas



A 35-year-old woman presents with diarrhoea and lower abdominal pain. Examination of her stools reveals blood and mucus. A biopsy reveals a continuous superficial ulceration of the colon.



A 77 year old man was referred by his G.P. after reporting the passing of large volumes of mucus. Endoscopy revealed a 6cm sessile cauliflower-like mass covered by dysplastic columnar epithelium in the rectum. His serum potassium is 3.3 mmol/l.

Villous adenoma - not the potassium and mucus due to protein and K secretion.


Your consultant is urgently called away from out-patients and asks you to break bad news to a patient. He is distracted and has little time to inform you about the case but mentions that the original presentation was for rectal bleeding and the patient has a 40% chance of surviving 5 years. What Dukes stage?

Adenocarcinoma Dukes stage C1


A 62 year old housewife returns to your outpatient clinic following another incidence of the passing of blood. Previous sigmoidoscopy, DRE and barium enema’s have failed to identify any lesion and she denies weight loss and diarrhoea. However, blood tests show a microcytic anaemia.

Angiodysplasia - Colonic angiodysplasia is a common cause of acute or chronic rectal bleeding and iron deficiency anaemia. Angiodysplasias are tiny - 1-5 mm in diameter - hamartomatous capillary lesions in the colonic wall which produce bleeding out of proportion to their size. They are believed to be acquired, possibly as a result of tension on the veins where they pass through the muscularis. Diagnosis: subtraction mesenteric arteriography may demonstrate bleeding if rapid colonscopy: may visualise lesion Treatment: electrical coagulation via the colonoscope resection of segment of colon if the above is unsuccessful


A 73 year old woman attends complaining of recent onset of tiredness. She is pale and has hepatosplenomegaly and generalised lymphadenopathy in the neck, axillae and groins.



A 42 year old woman presents to the doctor complaining of severe itching and recent onset of jaundice. The patient had been experiencing milder pruritis and bouts of fatigue for the last year. Hepatomegaly and pigmented xantholasma are demonstrated upon examination. Serum IgM is high and apart from a high serum Alk Phosphate, other liver biochemistry is normal. Upon ELISA screen, mitochondrial antibodies are seen. (in titre of 1:200

Primary Billary Cirrhosis


A 30 year old female patient presents with abdominal pain, nausea and vomiting. Upon examination the patient has a tender hepatomegaly and ascites (with a high protein content) Abdominal CT demonstrated hepatic vein occlusion with diffuse abnormal parenchyma on contrast enhancement.

The Budd-Chiari syndrome describes hepatic vein thrombosis. The majority of patients with the Budd-Chiari syndrome present with evidence of rapidly developing abdominal pain, hepatomegaly, and ascites with distension. The pain is presumably caused by distension of the liver capsule or abdominal distension.


A 30 year old woman presents with lower abdominal pain accompanied by fever. She has been using an intra uterine contraceptive device since her wedding three years ago.



A 40 year old woman has always known cramping pain associated with her periods – which have usually been heavy. Recently this pain has become constant throughout the month, and her periods have become more frequent. She claims never to have used oral contraception and has no children. She is abstaining from sexual intercourse as it is too painful.

Endometriosis - responding to the hormonal influence
of menstruation, the history is very variable and may be progressively worse to even continuous pelvic pain.
Constant pain is often due to adhesions (which this patient may have now developed)


Differentiation of this is regulated via the RANK gene product.



Covers cortical surface of bone and delivers blood supply.



This type of bone is 80-90% calcified and its function is mainly mechanical and protective.



This type of bone is immature and usually pathological.



A 45-year-old Asian female presents with generalised bone pain. Histological findings are of increased osteoid volume with widened osteoid seams and reduced mineralization. Her diet is vegan



A 15-year-old male presents with a 2-month history of increasing pain in his right upper arm. Bone biopsy reveals sheets of cells with small, primitive nuclei and scanty cytoplasm. A positive immunoreactivity is seen with the MIC2 (CD99) antibody.

Ewings Sarcoma


Mottled rarefaction and lifting of the periosteum are seen on X-ray of the femur. Bone biopsy reveals an intense neutrophilic inflammatory infiltrate.



A 20-year-old male complains of a progressively enlarging painful mass on his right upper arm. Radiology demonstrates a lytic lesion of the proximal humerus with an accompanying Codman triangle. Microscopically, pleomorphic mesenchymal cells producing dark-staining osteoid are seen.

Primary Osteosarcoma


A 92 year-old man has asymptomatic elevation of alkaline phosphatase. Skull X-ray reveals osteoporosis circumscripta. On examination he has bowed tibia and skull changes. He also complains of a recent onset of deafness



A 24 year old police woman attends the clinic as her GP suspects she may have a parathyroid tumour. She has raised PTH and serum calcium. After a 24hr urinary collection it is noted the patient has a low urine calcium output

Familial hypocalciuric hypercalcaemia (FHH) is a dominantly inherited condition caused by a mutation of the calcium sensing receptor. The result is that the kidney reabsorbes calcium very
avidly as a primary problem. This results in hypocalciuria and
hypercalcaemia. Because the parathyroid gland calcium receptor also does not work, the parathyroids continue to secrete excess PTH despite the high calcium, so it looks just like primary hyperparathyroidism.
In true primary hyperparathyroidism however, the calcium that is filtered hugely exceeds the tubular maximum for calcium,
so there is no chance of reabsorption, so the urinary calcium is high, with resulting renal stones (which NEVER happens in FHH).


You see a new patient for the first time at the surgery, a 14 year old boy, complaining of pain in his right leg for 9 months and contracture of the right knee which has developed over this period. The child looks stunted and you can see bowing of the lower extremities in ambulators. His notes have not arrived yet from his previous doctor but his mother tells you ‘he was born 3 weeks premature with two small kidneys and three failed transplants means he has dialysis four times a day’. His blood results later show a raised PTH and phostate, low calcium and 1,25(OH)vitamin D. He is also acidotic.

Secondary hyperparathyroidism with chronic renal osteodystrophy


An 18 year old student presents to his GP with focal pain in his left fore-arm which is tender to touch and worsens at night. The pain is relieved with aspirin. An X-ray shows a 1cm are of radio-lucency in the tibia surrounded by dense bone.

Osteoid osteoma - beingn bone tumour originating from osteoblasts.


A 14 year old boy complains to you of a painless lump on his left thigh, just above the knee which is slowly growing. His past medical history reveals that he fractured his femur in the same location several years before.

Osteochondroma - commonest bony tumour, painless, slow-growing and related to previous trauma.


A 15 year old girl shows you a small lump on her upper arm on routine examination. She says the lump has been present for a couple of years and has slowly moved down, away from her shoulder.

Simple Bone cyst - lytic and well defined.


An 8 year old boy is brought to his GP by his parents with pain in his hips and a fever. Blood results demonstrate a raised ESR and biopsy histology shows droplets of glycogen in the cytoplasm of small round cells in the pelvic bones.

Ewings sarcoma


70 year old man presents to his GP with a four day history of haemoptysis. He has noticed he has been loosing weight over the last 4 months and has felt tired and unwell. On examination he has bilateral ptosis and proximal weakness in the limbs which improves on repeated testing

Small cell lung Ca can cause Lambert Eaton in 3%. In contrast to myasthenia gravis fatigue improves on repeated testing.


A 35 year old woman presents with weight loss and tiredness. Her GP examines her and finds that she also has a fine tremor and is sweaty. Investigations: TSH

Subacute thyroiditis - no pain or fever. If pain or fever think DeQuervains.
Subacute more common refers to autoimmune whereas DQ is viral.


Benign hemispherical neoplasms projecting from the endometrial mucosa into the uterine cavity. They can cause uterine bleeding and infertility and are commonest at the time of menopause

Endometiral polyps


Neoplasms found in young women as ovarian masses, usually unilateral and most often on the right. They are usually filled with sebaceous secretion and matted hair and may have a nodular projection from which teeth protrude.

Mature teratoma


The most common cancerous neoplasm of the female genital tract. It appears most frequently between the ages of 55 and 65, with obesity, diabetes, hypertension and infertility being the major risk factors.

Endometiral adenocarcinoma


Neoplasms found in women aged between 30 and 40 as ovarian masses, usually unilateral. They are usually benign (90%) and are often the largest ovarian neoplasm.

Mucinous tumour
Mucinous ovarian neoplasms account for 10-15% of all ovarian tumours and are rarely malignant (~10-15%). They are rarely bilateral, but can be very large. In contrast, whilst serous tumours are also usually benign (30% malignant) and common - accounting for 30% of all ovarian tumours - they have a strong tendency to be bilateral.


Ovarian biopsy - Squamous epithelium mixed with intestinal epithelium

mature cystic teratoma


Ovarian biopsy - Fibrous tissue containing spindle cells and lipid



Ovarian biopsy - Malignant cells surrounded by serous fluid and Psammoma bodies

Serous cystadenocarcinoma


Ovarian biopsy - Malignant signet ring cells containing mucin

Krukenberg tumour - are characterised by the appearance of mucin-secreting signet cells in the tissue of the ovary.


Ovarian biopsy - Germ cells mixed with lymphocytes



Germ cell tumour originating in testis that is radiosensitive and classically presents in the 4th decade.

Seminoma - no AFP secretion, 15% secrete HCG.


Very aggressive tumour producing HCG and AFP; neoplastic cells are anaplastic

Embryonal carcinoma


Very aggressive HCG-producing tumour composed of cytotrophoblast and syncytiotrophoblast cells that metastasizes early.



Nonseminomatous germ cell tumour that has elements derived from all 3 germ cell layers



Commonest malignant cause of testicular mass in those aged under 5.



Commonest malignant cause of testicular mass in those aged 60

Diffuse B cell lymphoma


A 29-year-old lady presented with painful ulceration of the vulval skin. Histologically, there were intraepithelial blisters, intranuclear viral inclusions and eosinophilic cytoplasmic swelling.



A young lady is found to have chronic irritation and inflammation of the vulva. A pap smear and use of a silver stain reveals fungi within the keratin layer and superficial epithelium.



A 22-year-old lady presented with a vaginal discharge. Gram staining revealed “Clue cells” surrounded by rods, that were “Gram variable”

Gardnerella vaginalis


A pap smear taken from a chronic granulomatous ulcer shows a necrotic centre, periarteritis and endarteritis obliterans and an intense peripheral cellular infiltrate consisting mainly of mononuclear cells and giant cells.

Trep pallidum (syphilis)


Peak incidence of cervical Ca



Metaplasia in transformation zone is?

Glandular to squamous


Single most useful first-line cytological investigation of an impalpable breast lump seen on a mammogram.

Stereotactic radiographic cytological sampling method


Single most useful first-line cytological investigation for the confirmation of the benign status of an ovarian cyst.



Single most useful first-line cytological investigation for the detection of pneumocystis carinii in an immunosuppressed patient.

Fluid cytology of alveolar washings


Single most useful first-line cytological investigation of a palpable breast lump in a clinic setting.

FNA - Has a 100% positive predictive value for malignant cytopathological diagnosis


An 86 year old man is admitted to AandE having collapsed at his home. He is unconscious and a couple of days later he is still deeply unconscious. His pupils are pin-point and their reaction to light is difficult to see clearly.

Brain stem infarct


A 20 year old man was taken to AandE after a pub brawl where he was stamped on whilst trying to break up a fight. He remained lucid for approximately 3 hours after the incident and then slipped in and out of consciousness with hemiparesis afterwards. He had a deep laceration on the side of his head. A CT scan showed high attenuation adjacent to the skull and a midline shift.

Extradural haemorrhage - can impinge C3 giving a fixed and dilated pupil on the side of the lesion.


Occlusion of this cerebral vessel can cause weakness and numbness in the contralateral lower limb and similar but milder symptoms in the contralateral upper limb.

Anterior cerebral artery - affects lower limbs more than upper due to homunculus.Also get apraxia, anosmia.


A 35-year old patient presented to AandE complaining of severe headache and vomiting. On examination, there is neck stiffness; fundoscopy reveals preretinal (subhyaloid) haemorrhages; CSF is spun down and shows xanthochromia. You notice the patient has palpable kidneys bilaterally.



This group of ischaemic brain lesions typically affect the basal ganglia, internal capsule, thalamus and pons and are smaller than 1cm.

lacunar infarct - 5x types.
Pure motor (most common) - hemiparesis/hemiplegi +/- dysarthria and dysphagia.
Ataxic - cerebrellar and motor symptoms.
Dysarthirc - dysarthria and clumsiness
Pure sensory
Mixed sensory - hemiparesis/hemiplegia with ipsilater sensory impairment.


Transtentorial herniations can potentially compromise the sufficiency this particular part of the cerebral circulation and cause occipital lobe infarction.

Posterior cerebral artery


An elderly diabetic lady with an acute headache and associated blurred vision and vomiting. Pain is localised to the upper anterior region of her head.



A 55 year old lady presents with a palpable lump in the left breast that is central with nipple discharge which is sometimes blood stained. FNA result shows that the lump has branching fibrovascular cores covered by cytologically bland epithelium

Ductal papilloma


A 60 year old lady presents with a hard palpable mass in the right breast. The mammography shows that the lump is calcified. FNA results show that the cells in the lump have pleomorphic nuclei and that the lump has a necrotic centre



A 23 year old lady comes to the breast clinic because she is worried of having breast cancer as her mother and grandmother both have had the disease. The mammogram finds no abnormality but you think you feel a number of multifocal lumps

Lobular carcinoma in situ


A 45 years old woman presents with multiple bilateral masses, each less than 10mm. FNA revealed serous, turbid fluid.

Breast cyst


Cystic dilatation of duct during lactation caused by obstruction



Which feature, after histological confirmation of a breast carcinoma, would suggest a worse prognosis?

Axillary lymph node metastases


A 32 year-old woman presents to her GP with a lump on her left breast which she noticed 8 months ago. The lump is mobile and she noticed it grew more rapidly while she was pregnant with her fourth child.

Fibroadenoma - The epithelium of a fibroadenoma is hormone responsive and an increases in size is due to lactational changes during pregnancy.


Bone Ca - raised ALP, adolescent men, codmans triangle and sunburst appearance.

Osteosarcoma, most common due to malignant mesenchymal cells


Bone Ca - 40+, axial skeleton, lytic lesions with fluffy calcification.

Chondrosarcoma due to malignant chondrocytes.


Bone Ca -

Ewings. ALP negative


Bone Ca - Large multinucleated cells with spindle and ovoid cells. Lytic lesions near articular surface on XR.

Giant Cell Tumour (locally aggressive).


Bone forming lesion associated with night pain and releived by NSAID. XR- radiolucent nidus with sclerotic rim.

Osteoid osteoma - in legs. Large lesion is osteoblastoma.


Bony outgrowth usually on head or neck.



Gardeners Syndrome?

Multiple osteomas with GI polyps and epidermoid cysts (Grow things as a gardener)



In hands. Cartilage tumour. XR lytic lesion with cotton wool calcification and O ring sign.


Olliers Syndrome

Multiple Enchondroms


Maffucis Syndrome

Multiple enchondromas with hemangiomas.


Cartilage capped bony outgrowth usually in long bones. Occurs in adolescences.



30 Femal, Bone replaced by fibrous tissue in metaphysis. XR- soap bubble appearance and shepards crook deformity.

Fibrous dysplasia. Histology shows irregular trabeculae