last weeks

Question 1

52-year-old woman presents to her GP with a thyroid lump. Which of the following additional clinical features would trigger an urgent referral for this patient (2-week rule)?

Answer 1

supraclavicular lymphadenopathy

Question 2

Skin feels itchy and has turned ‘yellow’, light-coloured stools recently, with dark urine and has lost 5 kg in weight.

PMH primary sclerosing cholangitis (PSC) and ulcerative colitis.

Jaundiced and has excoriations over her skin.

What is the most likely underlying diagnosis?

Answer 2

Cholangiocarcinoma
This patient has three of the key risk factors for cholangiocarcinoma (a tumour arising from the bile duct epithelium): age >50, ulcerative colitis and PSC. She also has painless jaundice, weight loss and itching, all of which are commonly seen in cholangiocarcinoma.

Question 3

liver cancer screening

Answer 3

AFP and hepatocellular USS

Question 4

MHS2 mutation

Answer 4

endometrial and ovarian in women, colorectal (HNPCC)

Question 5

laryngeal cancer referral criteria

Answer 5

45 + with unexplained persistent hoarseness or lump

Question 6

what is done before biopsy in thyroid cancer

Answer 6

calcitonin levels - for medullary thyroid cancer

Question 7

Abdo pain, rectal bleeding and weight loss. FH of colorectal cancer young.

Colonoscopy report states that there were over 100 polyps present in the colon and a colorectal cancer is diagnosed.

Given the likely diagnosis, which of the following genes is affected?

Answer 7

APC - FAP

Question 8

BRCA2 cancers in men

Answer 8

prostate and breast

Question 9

A 25 year old man presents to the GP with episodes of flushing, diarrhoea and sweats. Palpitations.

Mass is noted in the right upper quadrant of abdomen.

What is the single most likely diagnosis?

Answer 9

carcinoid syndrome
The carcinoid tumour metastasises to the liver, leading to systemic symptoms as the hormones produced do not undergo metabolism in the portal circulation

Question 10

A previously well 60-year-old man presents to A&E with a two month history of increasing jaundice, abdominal pain and weight loss.

On examination he has marked right upper quadrant tenderness and the liver edge can be palpated 4 cm below the costal margin.

A computed tomography scan of the chest, abdomen and pelvis reveals multiple round hypoechoic lesions within the liver mass.

Which of the following additional investigations is the most important to perform in the diagnostic workup of this patient?

Answer 10

Colonoscopy
This patient has presented with intrahepatic jaundice secondary to multiple liver metastases. The primary tumour is currently unknown, as the computed tomography (CT) scan has failed to detect the primary tumour in the rest of the body. Cancers most likely to metastasise to the liver include colorectal (via the portal circulation which drains the gut), breast and lung. The latter would have been detected on a staging CT scan to find the primary tumour. Small colorectal tumours are often occult on CT scans, and therefore a colonoscopy would be the best investigation to identify a missed colorectal tumour

Question 11

A 65-year-old woman has been referred to the gynaecology department under the 2-week-wait pathway with suspected ovarian cancer.
Which investigations will be used to calculate the Risk of Malignancy Index (RMI)?

Answer 11

Ultrasound findings, menopausal status and cancer antigen 125 (CA 125)
The RMI combines these three presurgical features. The ultrasound result is scored 1 point for each of the following: multilocular cysts, solid areas, ascites, bilateral lesions and metastases. The menopausal status is scored as 1 for premenopausal and 3 for postmenopausal. This is then combined with the serum CA 125 (measured in IU/mL). NICE advise that anyone with an RMI score >250 should be discussed at a specialist MDT.

Question 12

Episode of rectal bleeding.

Colonoscopy reveals evidence of over a 200 adenomatous polyps throughout the large bowel, some of which are actively bleeding.

FH colorectal cancer.

Given the diagnosis of familial adenomatous polyposis (FAP), what would be the most appropriate treatment to reduce his risk of developing colorectal carcinoma?

Answer 12

Total proctocolectomy
Prophylactic removal of the large bowel is the best treatment available for familial adenomatous polyposis, which carries nearly a 100% risk of colorectal cancer by the age of 40 in untreated patients.

Question 13

A 30-year-old female patient presents with a strong family history of breast and ovarian cancers. Her mother and maternal aunt were diagnosed with breast cancer before the age of 45.
Which genetic cancer syndrome is most likely associated with this patient’s family history?

Answer 13

Hereditary breast and ovarian cancer (HBOC) syndrome
Hereditary breast and ovarian cancer (HBOC) syndrome is an inherited genetic condition that increases the risk of developing breast, ovarian, and other types of cancer. It is most commonly associated with mutations in the BRCA1 and BRCA2 genes. This patient’s strong family history of early-onset breast and ovarian cancers is highly suggestive of HBOC syndrome.

Question 14

lynch syndrome female cancer

Answer 14

endometrial

Question 15

MEN1 syndrome

Answer 15

parathyroid, pituitary and pancreatic tumours

Question 16

phaechromocytoma seen in which men

Answer 16

men2

Question 17

A 37-year-old builder presents to the emergency department with severe lower back pain sustained whilst bending over to pick up some paving stones. The pain radiates down the back of his leg to his foot. He has no urinary incontinence or saddle anaesthesia and is systemically well.
Examination is difficult given the degree of pain he is in, but you elicit that he has sensory loss to the lateral aspect of his left foot only. Ankle plantar flexion is weakened. Straight leg raise exacerbates the pain. PR examination is normal.
Which nerve root has been affected?

Answer 17

S1
This patient has presented with acute onset back pain likely caused by a spinal disc herniation. Typically there are unilateral symptoms such as pain, numbness and tingling. Most disc herniations occur in the lumbar spine - in this case, between L5 and S1. In the majority of cases, spinal disc herniation can be managed conservatively.

Question 18

LDH in sample of pleural fluid most consistent with cancer

Answer 18

Ratio of pleural to serum LDH greater than 0.6

Correct. According to Light’s criteria, a pleural effusion is considered exudative if the pleural fluid LDH is greater than 0.6 times the upper limit of normal serum LDH. Given the suspicion of a malignant pleural effusion secondary to breast cancer, this ratio aligns with an exudative process.

Question 19

A 45-year-old woman with a history of advanced cervical cancer presents to the emergency department with chest pain and increasing shortness of breath over the past few days. She develops severe chest pain on deep inspiration. A chest X-ray appears clear, and an ECG reveals sinus tachycardia.
What is the most appropriate immediate management?

Answer 19

Oral rivaroxaban
This is the correct answer. Given the patient’s history of advanced cervical cancer and classical symptoms of pulmonary embolism (PE) (pleuritic chest pain, shortness of breath, sinus tachycardia), she is at high risk for venous thromboembolism. Rivaroxaban is a direct oral anticoagulant (DOAC) used as first-line treatment for PE in haemodynamically stable patients. Immediate anticoagulation is recommended, and rivaroxaban is effective and can be administered without the need for bridging therapy.

Question 20

lung cancer patient who smokes with central mass other features

Answer 20

slurred speech and dysphagia

This patient most likely has small cell lung cancer (SCLC) given the central location of the mass, and his significant smoking history. SCLC is associated with Lamber-Eaton myasthenic syndrome, which can present with signs of pharyngeal muscle weakness including slurred speech and dysphagia.

Question 21

A 78 year old female is being managed palliatively for small bowel obstruction secondary to metastatic bowel cancer. She is currently being treated with subcutaneous morphine, but is complaining of crampy abdominal pain, nausea and increased secretions.
What is the most appropriate pharmacological agent to treat her symptoms?

Answer 21

hycosine butyl bromide

Question 22

The palliative care team reviews a 55-year-old man for symptom control. He was diagnosed two years ago with a squamous cell carcinoma of his left cheek, which has progressed to involve his jaw and facial structures. The tumour site is leaking a large amount of serous fluid, causing him significant distress. The leakage is affecting his work as a computer engineer. Which of the following medications can be tried to help manage the fluid leakage?

Answer 22

Glycopyrronium

Question 23

A 72-year-old man with prostate cancer presents with significant pain in numerous ribs and a hip. He is known to have several bone metastases in these areas. The pain persists, despite his current morphine regime. Examination findings confirm significant tenderness over 5 distinct ribs and in the left hip.
What is the most appropriate next step in management?

Answer 23

IV zolendronate

radiotherapy not appropriate as not localised

Question 24

Hypercalcaemia secondary to multiple myeloma treatment after fluid resus

Answer 24

The patient’s symptoms and elevated calcium level are consistent with hypercalcaemia, likely secondary to multiple myeloma. After initial IV fluid resuscitation to correct dehydration and improve renal calcium excretion, the next step is IV bisphosphonate therapy with pamidronate, which works by inhibiting osteoclast-mediated bone resorption, effectively lowering calcium levels.

Question 25

methotrexate side effect

Answer 25

thrombocytopenia

Question 26

agitation in palliative care treatment

Answer 26

Haloperidol is recommended first line for management of agitation in palliative care.

Question 27

SOB and anaemia Hb of 50 treatment

Answer 27

The patient has symptomatic normocytic anaemia. This is a common complication of cancers. The CXR is normal. The patient meets the transfusion threshold, typically Hb < 80g/L if there are no features of ACS, therefore a blood transfusion is the correct management for this patient. Only EPO if evidence of renal dysfunction

Question 28

N+V associated with intracranial disease treatment

Answer 28

For nausea and vomiting associated with intracranial disease, cyclizine is the recommended first line anti-emetic. If there is mass effect and raised intracranial pressure high dose dexamethasone will also improve symptoms.

Question 29

Horners and brachial neuropathy cause

Answer 29

Squamous cell lung carcinoma This woman has Horner's syndrome and a brachial neuropathy - which would be explained by a Pancoast Tumour from squamous cell lung cancer. The weight loss also suggests a malignant process

Question 30

mild hypercalcaemia (below 3) and asymptomatic Mx

Answer 30

Hold bendroflumethiazide and encourage oral fluid intake This is the correct option since this patient has a mild hypercalcaemia (less than 3.0 mmol/L) and is currently asymptomatic. Hypercalcaemia of malignancy is an important complication to be aware of, and in milder situations such as this one, NICE advise a conservative approach with holding/stopping any medications which could be contributing to hypercalcaemia and monitoring their calcium levels. Medications that can increase calcium levels include thiazide diuretics, lithium, and medications containing calcium and/or vitamin D. This patient could be switched to a different anti-hypertensive medication which is not known to increase calcium levels, such as spironolactone.

Question 31

A 24 year old male with ongoing headaches and newly diagnosed seizures undergoes a T1 weighted MRI head scan, which reveals a single hypotense, supratentorial tumour with evidence of surrounding oedema. He has a biopsy which reveals calcified psammoma bodies. What is the most likely diagnosis?

Answer 31

Meningioma Meningiomas are typically slow-growing, extra-axial (arising outside the brain parenchyma) tumours often found supratentorially. They may exhibit calcified psammoma bodies on biopsy and are commonly hypointense on T1 MRI scans. The surrounding oedema may also occur as the tumour grows and compresses adjacent brain tissue, aligning with the presentation of headaches and seizures in this patient.

Question 32

A 70-year-old man with metastatic lung cancer is admitted to the oncology ward. Given his worsening pain, a decision is made to commence regular opioid pain control. He has never received opiates in the past and has no other medical conditions. He has normal renal function. Which of the following options represents the most effective initial dosing regimen of opioid analgesia for this patient?

Answer 32

Morphine sulphate 5 mg immediate release preparation, to be given four-hourly This is the correct answer. This regimen represents a total daily oral Morphine dose of 30mg. The National Institute for Healthcare and Excellence (NICE) recommends that a dose of 20-30 mg oral Morphine is safe and effective for opiate naïve patients initially commenced on opioid analgesia. Though dependent on patient choice, immediate release oral morphine solution given four-hourly (also known as Oramorph) is the recommended formulation used to initially determine a patient's pain control requirements. The total daily oral Morphine dose can later be converted to twice daily modified release Morphine sulphate tablets, also known as MST Continus tablets.

Question 33

when to not use metaclopramide

Answer 33

Metoclopramide is a prokinetic antiemetic and should not be used in bowel colic.

Question 34

end of life anti emetic for N+V in obstructive bowel

Answer 34

cyclizine

Question 35

mechanical back pain medication order

Answer 35

According to the WHO pain ladder and NICE, analgesia for mild-to-moderate pain should be added in a step-wise fashion. If paracetamol (step 1) is not relieving the pain, it should be substituted with ibuprofen (as long as nonsteroidal anti-inflammatory drugs (NSAIDs) are not contraindicated). If this does not help, paracetamol and ibuprofen can be given together. If this does not work or pt cannot have NSAIDS (ibrup) then give codeine

Question 36

haemorrhagic cystitis chemo cause

Answer 36

cyclophosphamide

Question 37

radiation lung side effect Investigation and examination

Answer 37

chest x-ray demonstrates pulmonary fibrosis, most likely secondary to radiation-induced injury within the upper lobe. This would result in inspiratory crackles.

Question 38

peripheral neuropathy chemo drugs

Answer 38

Vincristine, cisplatin

Question 39

A 43 year old man with a background of cancer of unknown primary is reviewed on the oncology ward. He was admitted electively for biopsy of a large hepatic mass that was recently found incidentally. He has had a lot of pain which was managed with oral morphine in the first instance. He is improving and feels he can now tolerate de-escalating his analgesia. His liver function tests are back to normal and his renal function is normal. He has been taking 2.5mg of oral morphine 3 or 4 times a day. What analgesia prescription should be started for him?

Answer 39

Codeine phosphate 30mg as required up to four times a day This is the right answer. Codeine phosphate is 1/10 the potency of morphine. 10mg of morphine is 100mg of codeine phosphate. Codeine phosphate tablets are available in 15mg, 30mg and 60mg tablets. In this case 30mg codeine phosphate up to four times a day is sufficient.

Question 40

A 56 year old woman with a background of metastatic ovarian cancer is reviewed in the GP surgery. She has chronic pain from her omental deposits and has been started on a 25mcg/hr fentanyl patch by the palliative care team during a recent admission. This is generally working well for her, but she is getting occasional breakthrough pain that she is not managing to control. You note she was discharged home with oral immediate-release morphine 5mg as required up to 4 hourly. She reports that she is sometimes taking extra doses of the immediate-release morphine at home. After discussion with the patient you decide to increase her analgesia. Which of the following would be an appropriate prescription?

Answer 40

Continue 25mcg/hr fentanyl patch and increase the breakthrough immediate-release morphine to 10mg as required This is the right answer. 25mcg/hr of fentanyl is equivalent to 60mg/24 hours of oral morphine. The dose of morphine for breakthrough pain would be 1/6 of the total daily dose converted to the morphine equivalent. That would be 10mg of immediate-release morphine. Her main issue is with the breakthrough pain for which she is under-dosed. There is no need to increase the dose of her regular fentanyl patch at this time.

Question 41

cisplatin monitoring

Answer 41

Urea & electrolytes Cisplatin can cause nephrotoxicity and ototoxicity, it is important to monitor kidney function.

Question 42

A 64-year old male presents to his GP with back pain. No red flag symptoms are present. His past medical history includes stage 4 chronic kidney disease. He is taking 1g of paracetamol four times a day. His pain is not controlled. What is the best treatment for his pain?

Answer 42

Add buprenorphine patches The WHO pain ladder recommends to add a weak opioid in step 2. Although Buprenorphine is advised at step 3, it does not accumulate in renal impairment when used transdermally and so is the best option here.

Question 43

drug to stop to improve dry mouth

Answer 43

Hyoscine hydrobromide This is the right answer. Hyoscine hydrobromide is an antiemetic that works through antimuscarinic action. Antimuscarinic side effects include dry mouth, constipation and urinary retention.

Question 44

anti epileptic last days of life

Answer 44

midazolam

Question 45

He was admitted due to increasing confusion and drowsiness. He is assessed with a full confusion screen which shows that his renal function has deteriorated further since he was last seen. He has been taking oral morphine sustained-release 20mg twice daily and has 5mg immediate-release oral morphine as required prescribed. It is thought he is accumulating morphine due to his declining renal function. What opiate prescription could he be converted to that would be appropriate for his poor renal function?

Answer 45

10mg of sustained-release oxycodone twice a day with 2.5mg of immediate-release oxycodone as required for breakthrough pain This is the right answer. Oral oxycodone is twice as potent as oral morphine so half the dose should be prescribed. Oxycodone is less likely to accumulate in moderate renal impairment, but expert advice might be required in more severe renal failure.

Question 46

first line pain relief with stage 4/5 kidney disease

Answer 46

Alfentanil This drug is first line in those with stage 4 or 5 chronic kidney disease. This is due to limited renal excretion of parent drug or metabolites.

Question 47

SOB in lung cancer with upper lobe mass

Answer 47

Upper lobe collapse This is correct, it is likely to due growth in his lung tumour causing collapse of the upper lobe.

Question 48

A 48-year-old patient with a history of pancreatic cancer presents with severe vomiting, abdominal discomfort, and weight loss. Which of the following is the most likely cause of vomiting in this patient?

Answer 48

Gastric outlet obstruction In the context of cancer, gastric outlet obstruction is a common cause of vomiting, especially in patients with pancreatic cancer, as the tumour may invade or compress the area where the stomach empties into the duodenum. Symptoms include severe vomiting, abdominal discomfort, and weight loss, which are consistent with this patient's presentation.

Question 49

pain and SOB treatment EOLC lung cancer

Answer 49

Morphine and a benzodiazepine

Question 50

A 57-year-old patient with a history of non-small cell lung cancer presents with progressive shortness of breath, cough, and fatigue. On examination, there is reduced air entry in the right lung base. Which of the following is the most likely cause of shortness of breath in this patient?

Answer 50

pleural effusion - symptoms, and reduced air entry in base unilaterally is consistent

Question 51

A 62-year-old woman underwent radiotherapy for breast cancer and now presents with progressive difficulty swallowing, hoarseness and coughing. She remarks that the coughing is terrible, becoming tearful that people look at her during the day and she keeps her wife awake in the night. What is the most likely diagnosis?

Answer 51

Radiation-induced laryngeal oedema Radiation therapy can cause damage to the normal tissues that surround the area being treated. One potential adverse effect of radiation therapy is laryngeal oedema, which can cause difficulty swallowing, hoarseness and coughing. fibrosis would not cause hoarseness

Question 52

mucositis causes

Answer 52

chemo OR RADIOTHERAPY