Pathology Binder

13/07/2015
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Question 1 of 343
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A 40 year old women presented with a mass on her forehead. On examination, she had a
fluctuant pulsatile mass on her head. Examination of her neck revealed a mass inferior to the
hyoid with a positive Berry's sign. What is the most likely underlying diagnosis?
Question stats
End and review
Score: 0%
39.3%
17.5%
16.6%
16.2%
10.5%
A. Follicular thyroid cancer

39.3% of users answered this
question correctly
B. Medullary thyroid cancer

C. Papillary thyroid cancer
D. Anaplastic thyroid cancer
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E. Parathyroid gland cancer
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Berrys sign= Absence of carotid pulse due to malignant thyromegaly.
Theme from April 2013 Exam

Papillary thyroid cancers will tend to spread via lymphatics and present with disease that is
nearly always confined to the neck. Follicular carcinomas may metastasise haematogenously
and the skull may be the presenting site of disease in between 2 and 8% of patients.
Thyroid malignancy
Papillary carcinoma
Commonest sub-type
Accurately diagnosed on fine needle aspiration cytology
Histologically, they may demonstrate psammoma bodies (areas of calcification) and so
called 'orphan Annie' nuclei
They typically metastasise via the lymphatics and thus laterally located apparently
ectopic thyroid tissue is usually a metastasis from a well differentiated papillary
carcinoma
Follicular carcinoma
Are less common than papillary lesions
Like papillary tumours, they may present as a discrete nodule. Although they appear
to be well encapsulated macroscopically there is invasion on microscopic evaluation
Lymph node metastases are uncommon and these tumours tend to spread
haematogenously. This translates into a higher mortality rate
Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology
and thus all follicular FNA's (THY 3) will require at least a hemi thyroidectomy
Anaplastic carcinoma
Less common and tend to occur in elderly females
Disease is usually advanced at presentation and often only palliative decompression
and radiotherapy can be offered.
Medullary carcinoma
These are tumours of the parafollicular cells ( C Cells) and are of neural crest origin.
The serum calcitonin may be elevated which is of use when monitoring for recurrence.
They may be familial and occur as part of the MEN -2A disease spectrum.
Spread may be either lymphatic or haematogenous and as these tumours are not
derived primarily from thyroid cells they are not responsive to radioiodine.
Lymphoma
These respond well to radiotherapy
Radical surgery is unnecessary once the disease has been diagnosed on biopsy
material. Such biopsy material is not generated by an FNA and thus a core biopsy has
to be obtained (with care!).
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Question 2 of 343
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What is the most common cause of mesenteric infarction?
Question stats
Score: 0%
18.9%
49.8%
17.7%
A. Mesenteric vein thrombosis
5.9%
B. Acute embolism affecting the superior mesenteric artery
7.8%
C. Acute on chronic thrombus of the superior mesenteric artery

question correctly
D. Sub intimal dissection of the superior mesenteric artery
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E. Proximal migration of abdominal aortic aneurysm

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Theme from January 2013 Exam

Acute embolic events account for up to 50% of cases of mesenteric infarcts. These may
occur as a result of long standing atrial fibrillation, ventricular anuerysms and post
myocardial infarction.
Mesenteric vessel disease
Mesenteric ischaemia accounts for 1 in 1000 acute surgical admissions. It is primarily caused
by arterial embolism resulting in infarction of the colon. It is more likely to occur in areas such
as the splenic flexure that are located at the borders of the territory supplied by the superior
and inferior mesenteric arteries.
Types
Acute
mesenteric
embolus
(commonest
50%)
Acute on
chronic
mesenteric
ischaemia
Mesenteric
vein
thrombosis
Low flow
mesenteric
infarction
Sudden onset abdominal pain followed by profuse diarrhoea.

May be associated with vomiting.
Rapid clinical deterioration.
Serological tests: WCC, lactate, amylase may all be abnormal
particularly in established disease. These can be normal in the early
phases.
Usually longer prodromal history.

Post prandial abdominal discomfort and weight loss are dominant
features. Patients will usually present with an acute on chronic event,
but otherwise will tend not to present until mesenteric flow is reduced by
greater than 80%.
When acute thrombosis occurs presentation may be as above. In the
chronic setting the symptoms will often be those of ischaemic colitis
(mucosa is the most sensitive area to this insult).
Usually a history over weeks.

Overt abdominal signs and symptoms will not occur until venous
thrombosis has reached a stage to compromise arterial inflow.
Thrombophilia accounts for 60% of cases.
This occurs in patients with multiple co morbidities in whom mesenteric

perfusion is significantly compromised by overuse of inotropes or
background cardiovascular compromise.
The end result is that the bowel is not adequately perfused and infarcts
occur from the mucosa outwards.
Diagnosis
Serological tests: WCC, lactate, CRP, amylase (can be normal in early disease).
Cornerstone for diagnosis of arterial AND venous mesenteric disease is CT
angiography scanning in the arterial phase with thin slices (<5mm). Venous phase
contrast is not helpful.
SMA duplex USS is useful in the evaluation of proximal SMA disease in patients with
chronic mesenteric ischaemia.
MRI is of limited use due to gut peristalsis and movement artefact.
Management
Overt signs of peritonism: Laparotomy
Mesenteric vein thrombosis: If no peritonism: Medical management with IV heparin
At operation limited resection of frankly necrotic bowel with view to relook laparotomy
at 24-48h. In the interim urgent bowel revascularisation via endovascular (preferred)
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or surgery.
Prognosis
Overall poor. Best outlook is from an acute ischaemia from an embolic event where surgery
occurs within 12h. Survival may be 50%. This falls to 30% with treatment delay. The other
conditions carry worse survival figures.
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Question 3 of 343
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A 38 year old lady presents with a recent episode of renal colic. As part of her investigations
the following results are obtained:
Question stats
Score: 33.3%
8%
18.6%
2
3
56.5%
10.2%
PTH
6.7%
88pg/ml (increased)
Corrected Calcium 3.84 mmol/l
Her serum urea and electrolytes are normal.

What is the most likely diagnosis?
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A. Carcinoma of the bronchus

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B. Secondary hyperparathyroidism
C. Primary hyperparathyroidism
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D. Tertiary hyperparathyroidism
E. Carcinoma of the breast
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Theme from September 2012 exam

In this situation the most likely diagnosis is primary hyperparathyroidism. The question
mentions that serum urea and electrolytes are normal, which makes tertiary
hyperparathyroidism unlikely.
Primary hyperparathyroidism
In exams primary hyperparathyroidism is stereotypically seen in elderly females with an
unquenchable thirst and an inappropriately normal or raised parathyroid hormone level. It is
most commonly due to a solitary adenoma
Causes of primary hyperparathyroidism
80%: solitary adenoma
15%: hyperplasia
4%: multiple adenoma
1%: carcinoma
Features - 'bones, stones, abdominal groans and psychic moans'

Polydipsia, polyuria
Peptic ulceration/constipation/pancreatitis
Bone pain/fracture
Renal stones
Depression
Hypertension
Associations
Hypertension
Multiple endocrine neoplasia: MEN I and II
Investigations
Raised calcium, low phosphate
PTH may be raised or normal
Technetium-MIBI subtraction scan
Treatment
Parathyroidectomy, if imaging suggests target gland then a focused approach may be
used
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Question 4-6 of 343
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Question stats
End and review
Score: 16.7%
Average score for registered users:
1
2
Theme: Head and neck lumps

A. Branchial cyst
42%
76.2%
38.3%
3
4-6 0 / 3
B. Cystic hygroma
C. Carotid body tumour
D. Lymphadenopathy
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E. Adenolymphoma of the parotid
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F. Pleomorphic adenoma of the parotid

G. Submandibular tumour
H. Thyroglossal cyst
I. Thoracic outlet syndrome
J. Submandibular gland calculus
Please select the most likely lesion to account for the clinical scenario given. Each option
may be used once, more than once or not at all.
4.
A 60 year old Tibetan immigrant is referred to the surgical clinic with a painless
neck swelling. On examination, it is located on the left side immediately posterior
to the sternocleidomastoid muscle. There are no other abnormalities to find.
You answered Branchial cyst
The correct answer is Carotid body tumour
Carotid body tumours typically present as painless masses. They may compress
the vagus or hypoglossal nerves with symptoms attributable to these structures.
Over 90% occur spontaneously and are more common in people living at high
altitude. In familial cases up to 30% may be bilateral. Treatment is with excision.
5.
A 40 year old women presents as an emergency with a painful mass underneath

her right mandible. The mass has appeared over the previous week with the
pain worsening as the lump has increased in size. On examination, there is a
4cm mass underneath her mandible, there is no associated lymphadenopathy.
You answered Carotid body tumour
The correct answer is Submandibular gland calculus
The sub mandibular gland is the most common site for salivary calculi. Patients
will usually complain of pain, which is worse on eating. When the lesion is
located distally the duct may be laid open and the stone excised. Otherwise the
gland will require removal.
6.
A 73 year old male smoker is referred to the clinic by his GP. On examination he
has a 3cm soft mass immediately anterior to his ear. It has been present for the
past five years and is otherwise associated with no symptoms.
You answered Pleomorphic adenoma of the parotid
The correct answer is Adenolymphoma of the parotid
Warthins tumours (a.k.a. adenolymphoma) are commoner in older men
(especially smokers). They are the second commonest benign tumour of the
parotid gland, they may be bilateral. They are soft and slow growing and
relatively easy to excise. Pleomorphic adenomas typically present in females
aged between 40 - 60 years.
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Neck lumps
The table below gives characteristic exam question features for conditions causing neck
lumps:
Reactive
lymphadenopathy
By far the most common cause of neck swellings. There may be a history
of local infection or a generalised viral illness
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13/07/2015
Lymphoma
Rubbery, painless lymphadenopathy

The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly
Thyroid swelling
May be hypo-, eu- or hyperthyroid symptomatically

Moves upwards on swallowing
Thyroglossal cyst
More common in patients < 20 years old

Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected
Pharyngeal
pouch
More common in older men

Represents a posteromedial herniation between thyropharyngeus and
cricopharyngeus muscles
Usually not seen, but if large then a midline lump in the neck that gurgles
on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic
cough
Cystic hygroma
A congenital lymphatic lesion (lymphangioma) typically found in the neck,

classically on the left side
Most are evident at birth, around 90% present before 2 years of age
Branchial cyst
An oval, mobile cystic mass that develops between the

sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in
embryonic development
Usually present in early adulthood
Cervical rib
More common in adult females

Around 10% develop thoracic outlet syndrome
Carotid aneurysm
Pulsatile lateral neck mass which doesn't move on swallowing
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Question 7 of 343
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A 12 year old child is admitted with a 12 hour history of colicky right upper quadrant pain. On
examination the child is afebrile and is jaundiced. The abdomen is soft and non tender at the
time of examination. What is the most likely cause?
Question stats
End and review
Score: 14.3%
13.4%
12.8%
9.5%
38.7%
25.6%
1
2
3
4-6 0 / 3
7
A. Infectious hepatitis
question correctly
B. Acute cholecystitis
C. Cholangitis
D. Hereditary spherocytosis
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E. Gilberts syndrome
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Theme from September 2012 Exam

The child is most likely to have hereditary spherocytosis. In these individuals there may be
disease flares precipitated by acute illness. They form small pigment stones. These may
cause biliary colic and some may require cholecystectomy.
Gilbert's syndrome is an inherited condition causing unconjugated hyperbilirubinaemia.
Patients may have jaundice or be asymptomatic. The other LFTs are normal and Gilbert's
may be confirmed with a fasting test or Nicotinic acid test. There is no need for treatment as
it is a benign condition.
Hereditary Spherocytosis
Most common disorder of the red cell membrane, it has an incidence of 1 in 5000. The
abnormally shaped erythrocytes are prone to splenic sequestration and destruction. This
can result in hyperbilirubinaemia, jaundice and splenomegaly. In older patients an
intercurrent illness may increase the rate of red cell destruction resulting in more acute
symptoms.
Severe cases may benefit from splenectomy.
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Question 8 of 343
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A 28 year old man has a carcinoid tumour identified in his appendix. Blood testing for which
of the substances listed below is likely to be helpful during follow up?
A. CA19-9
B. Alkaline phosphatase
Question stats
Score: 25%
20.3%
9.3%
10.4%
19.7%
40.3%

question correctly
C. AFP
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8
D. CEA
E. Chromogranin A
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It is important to distinguish between blood and urine tests for carcinoid syndrome. Blood
tests usually measure chromogranin A,neuron-specific enolase (NSE), substance P, and
gastrin. Urine tests usually measure 5 HIAA, which is a metabolite of serotonin. Sometimes
blood tests for 5 hydroxytryptamine (serotonin) are also performed.
Carcinoid syndrome
Carcinoid tumours secrete serotonin

Originate in neuroendocrine cells mainly in the intestine (midgut-distal ileum/appendix)
Can occur in the rectum, bronchi
Hormonal symptoms mainly occur when disease spreads outside the bowel
Clinical features
Onset: years
Flushing face
Palpitations
Pulmonary valve stenosis and tricuspid regurgitation causing dyspnoea
Asthma
Severe diarrhoea (secretory, persists despite fasting)
Investigation
5-HIAA in a 24-hour urine collection
Somatostatin receptor scintigraphy
CT scan
Blood testing for chromogranin A
Treatment
Octreotide
Surgical removal
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Question 9 of 343
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A 40 year old man presents with obstructive jaundice and dysphagia. Twenty years
previously he underwent a right hemicolectomy for a mucinous right sided colonic carcinoma.
He was subsequently diagnosed as having Lynch syndrome. A recent colonoscopy was
normal. What is the most likely cause of his jaundice?
Question stats
Score: 33.3%
11.9%
21.2%
20.2%
19.2%
27.4%

question correctly
A. Hepatocellular carcinoma
End and review
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2
3
4-6 0 / 3
7
8
9
B. Liver metastasis from colonic cancer

C. Pancreatic carcinoma
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D. Duodenal carcinoma
E. Gastric carcinoma
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Theme from April 2013

Lynch syndrome usually results in colonic cancer which is right sided and mucinous. The
next most common site to be affected is the uterus. The stomach is at particular risk and this
risk is up to 10 times greater in HNPCC (Lynch) patients than the general population.
Duodenal adenomas (and rarely carcinoma) are usually seen in association with FAP. Whilst
pancreatic carcinoma is associated with HNPCC it is far less likely to occur than gastric
cancer.
Genetics of colorectal cancer
The lifetime risk of colorectal cancer in the UK population is 5%. Up to 5% of newly
diagnosed bowel cancers will be in those individuals who have a high genetically acquired
risk of bowel cancer. Cancers arising in the low-moderate genetic risk group comprise
approximately 30% of newly diagnosed bowel cancer.
Genetics of inherited colorectal cancer syndromes
Syndrome
Features
Genes
implicated
FAP
More than 100 adenomatous polyps affecting the colon and

rectum. Duodenal and fundic glandular polyps
APC (over 90%)
Gardner
syndrome
As FAP but with desmoid tumours and mandibular

osteomas
APC
Turcots
syndrome
Polyposis and colonic tumours and CNS tumours
APC +MLH1
and PMS2
HNPCC
Colorectal cancer without extensive polyposis. Endometrial

cancer, renal and CNS
MSH2, MLH1,
PMS2 and
GTBP
PeutzJeghers
syndrome
Hamartomatous polyps in GI tract and increased risk of GI

malignancy
LKB1
andSTK11 (in
up to 70%)
Cowden
disease
Multiple hamartomas (see below)
PTEN (85%)
MYH
associated
polyposis
Autosomal recessive, multiple adenomatous polyps in GI

tract, those in colon having somatic KRAS mutations
MYH
FAP
Autosomal dominant condition, affects 1 in 12,000. Accounts for 0.5% of all CRCs. Lifetime
incidence of colorectal cancer in untreated FAP =100%. Up to 25% cases are caused by denovo germ line mutations and show no prior family history. The APC tumour suppressor gene
is affected in most cases.
APC in non inherited colorectal cancer
Up to 80% of sporadic colorectal cancers will have somatic mutations that inactivate APC[1].
Both alleles are usually affected. Although the APC protein more than likely has multiple
critical cellular functions, the best-established role for APC in the cancer process is as a
major binding partner and regulator of the - catenin protein in the so-called canonical or catenin dependent Wnt signaling pathway.
HNPCC
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HNPCC cancers differ from conventional tumours in a number of respects. In the colon the
tumours are more likely to be right sided, histologically they are more likely to be mucinous
and have dense lymphocytic infiltrates. To be diagnosed as having HNPCC individuals must
show typically HNPCC tumours in at least three individuals, (one of whom must be a first
degree relative to the other two). In at least two successive generations. At least one cancer
must be diagnosed under the age of 50. FAP must be excluded and tumours should be
verified by pathological identification (Amsterdam criteria). The genetic changes in HNPCC
stem primarily from microsatellite instability affecting DNA mismatch repair genes. In HNPCC
the mismatch repair genes most commonly implicated include; MSH2 and MLH1 and these
occur in up to 70% of people with HNPCC. The finding of microsatellite instability is unusual
in sporadic colorectal cancers. Approximately 60% of individuals who fulfill the Amsterdam
criteria will not be found to have evidence of mismatch repair gene defects on genetic
testing. The risk of developing colorectal cancer in those who have not demonstrated
mutation of the mis match repair genes is increased if they fulfill the Amsterdam criteria, but
not
the extent that it is increased in those who fulfill the criteria AND have evidence of mis match
repair gene defects.
KRAS Mutations
The RAS family of small G proteins act as molecular switches downstream of growth factor
receptors. KRAS and the other two members of the family; HRAS and NRAS, are the site of
mutation in approximately 40% of colorectal cancers. When adenomas are examined the
proportion of adenomas less than 1cm showing KRAS mutations was only 10% which
contrasts with 50% in those lesions greater than 1cm.
p53 mutations
The p53 protein functions as a key transcriptional regulator of genes that encode proteins
with functions in cell-cycle checkpoints at the G1/S and G2/M boundaries, in promoting
apoptosis, and in restricting angiogenesis . As such, selection for p53 defects at the
adenoma-carcinoma transition may reflect the fact that stresses on tumor cells activate cellcycle arrest, apoptotic, and antiangiogenic pathways in cells with wild-type p53 function.
Many colonic tumours will demonstrate changes in the p53 gene that may facilitate tumour
progression through from adenoma to carcinoma.
Cowden syndrome
Also known as multiple hamartoma syndrome. Rare autosomal dominant condition with
incidence of 1 in 200,000.. It is characterised by multiple mucocutaneous lesions,
trichilemmomas, oral papillomas and acral keratosis. Most often diagnosed in third decade of
life. Breast carcinoma may occur in up to 50% of patients and conditions such as fibrocystic
disease of the breast may occur in 75% of women. Thyroid disease occurs in 75% and may
include malignancy. Endoscopic screening will identify disease in up to 85% although the
small bowel is rarely involved. There is a 15-20% risk of developing colorectal cancer and
regular colonoscopic screening from age 45 is recommended.
Terminology
Oncogene
Oncogenes are genes which have the potential to induce cellular proliferation and
avoid apoptosis. Oncogene mutations are general gain of function and are
therefore dominant. Increased expression of oncogenes are found in most tumours
Tumour
suppressor
gene
These genes generally inhibit cellular proliferation or induce apoptosis. Mutations

in tumour suppressor genes are generally loss of function mutations, and are
therefore recessive. Mutations in both tumour suppressor gene alleles allow cells
to proliferate without restraint
References
1. Fearon, E.R. and B. Vogelstein, A genetic model for colorectal tumorigenesis. Cell, 1990.
61(5): p. 759-67.
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Question 10-12 of 343
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End and review
Score: 50%
1
2
Theme: Breast disease

A. Tuberculosis
10
82.5%
11
62.8%
12
68.6%
3
4-6 0 / 3
B. Actinomycosis
C. Duct ectasia
D. Fibroadenoma
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E. Fat necrosis
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10-12 3 / 3
F. Intraductal papilloma
G. Breast abscess
H. Breast cancer
What is the most likely diagnosis for each scenario given? Each diagnosis may be used
once, more than once or not at all.
10.
A 32 year old woman presents with a tender breast lump. She has a 2 month
old child. Clinically there is a tender, fluctuant mass of the breast.
Breast abscess
This lady is likely to be breast feeding and is at risk of mastitis. This may lead
to an abscess if not treated. Staphylococcus aureus is usually the causative
organism.
11.
A 53 year old lady presents with a creamy nipple discharge. On examination

she has discharge originating from multiple ducts and associated nipple
inversion.
Duct ectasia
Duct ectasia is common during the period of breast involution that occurs
during the menopausal period. As the ducts shorten they may contain
insipiated material. The discharge will often discharge from several ducts.
12.
A 52 year old lady presents with an episode of nipple discharge. It is usually

clear in nature. On examination the discharge is seen to originate from a single
duct and although it appears clear, when the discharge is tested with a labstix it
is shown to contain blood. Imaging and examination shows no obvious mass
lesion.
Intraductal papilloma
Intraductal papilloma usually cause single duct discharge. The fluid is often
clear, although it may be blood stained. If the fluid is tested with a labstix (little
point in routine practice) then it will usually contain small amounts of blood. A
microdocechtomy may be performed.
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Non malignant breast disease
Duct ectasia
Mammary duct ectasia may be seen in up to 25% of normal female breasts
Patients usually present with nipple discharge, which may be from single or multiple
ducts (usually present age >50 years)
The discharge is often thick and green
Duct ectasia is a normal variant of breast involution and is not the same condition as
periductal mastitis
Periductal mastitis
Present at younger age than duct ectasia
May present with features of inflammation, abscess or mammary duct fistula
Strongly associated with smoking
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Usually treated with antibiotics, abscess will require drainage
Intraductal papilloma
Growth of papilloma in a single duct
Usually presents with clear or blood stained discharge originating from a single duct
No increase in risk of malignancy
Breast abscess
Lactational mastitis is common
Infection is usually with Staphylococcus aureus
On examination there is usually a tender fluctuant mass
Treatment is with antibiotics and ultrasound guided aspiration
Overlying skin necrosis is an indication for surgical debridement, which may be
complicated by the development of a subsequent mammary duct fistula.
Tuberculosis
Rare in western countries, usually secondary TB
Affects women later in child bearing period
Chronic breast or axillary sinus is present in up to 50% cases
Diagnosis is by biopsy culture and histology
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Question 13 of 343
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A 34 year old women who has previously undergone a colectomy for familial adenomatous
polyposis coli presents with a firm lesion at the inferior aspect of her rectus abdominis
muscle. Which cell type is most typically associated with such tumours?
Question stats
Score: 53.8%
13.7%
16.6%
9.1%
11.4%
49.3%
A. Myocytes
question correctly
B. Proliferation of apocrine glands
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C. Chondrocytes
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D. Lipoblasts
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E. Myofibroblasts
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Desmoid tumours would be the most likely differential here and consist of a clonal
proliferation of myofibroblasts.
Desmoid tumours
Desmoid tumours are fibrous neoplasms arising from musculoaponeurotic structures.

They are typically contain clonal proliferations of myofibroblasts.
They are usually firm overgrowths of tissue with a propensity to local infiltration.
They occur in up to 15% of patients with familial adenomatous polyposis coli.
Desmoid tumours usually show bi allelic APC mutations
They occur most commonly in women after childbirth in the rectus abdominis muscle.
They are usually treated (regardless of site) by radical surgical resection, in some
patients radiotherapy and chemotherapy may be considered. The results of non
surgical therapy is inferior to surgical resection. In selected cases of abdominal
desmoids a period of observation may be preferred as some may spontaneously
regress.
Desmoids have a high tendency to local recurrence.
Desmoids consist of sheets of differentiated fibroblasts
Image sourced from Wikipedia
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Question 20 of 343
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A 38 year old man has been suffering from mechanical back pain for several years. One
morning he awakes from sleep and feels a sudden onset of pain in his back radiating down
his left leg. Which of the following events is most likely to account for his symptoms?
Question stats
Score: 50%
10.5%
16.3%
53.7%
10.3%
9.3%
A. Prolapse of inner annulus fibrosus

question correctly
B. Prolapse of outer annulus fibrosus
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C. Prolapse of nucleus pulposus
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10-12 3 / 3
D. Rupture of the ligamentum flavum
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E. None of the above
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18
19
Theme from 2009 Exam

The symptoms would be most likely the result of intervertebral disk prolapse. In disk prolapse
the nucleus pulposus is the structure which usually herniates.
20
Intervertebral discs
Consist of an outer annulus fibrosus and an inner nucleus pulposus.

The anulus fibrosus consists of several layers of fibrocartilage.
The nucleus pulposus contains loose fibres suspended in a mucoprotein gel with the
consistency of jelly. The nucleus of the disc acts as a shock absorber.
Pressure on the disc causes posterior protrusion of the nucleus pulposus. Most
commonly in the lumbrosacral and lower cervical areas.
The discs are separated by hyaline cartilage.
There is one disc between each pair of vertebrae, except for C1/2 and the
sacrococcygeal vertebrae.
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Question stats
End and review
Score: 47.8%
1
2
Theme: Paediatric neck masses

A. Cystic hygroma
21
42.8%
22
70.1%
23
60%
3
4-6 0 / 3
B. Thyroglossal cyst
C. Rhabdomyosarcoma
D. Branchial cyst
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E. Dermoid cyst
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10-12 3 / 3
13
Please select the most likely underlying diagnosis for the situation that is described. Each
option may be used once, more than once, or not at all.
14
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18
21.
A 2 year old boy is brought to the clinic by his mother who has noticed that he
has developed a small mass. On examination; a small smooth cyst is identified
which is located above the hyoid bone. On ultrasound the lesion appears to be
a heterogenous and multiloculated mass.
19
20
21-23 1 / 3
You answered Cystic hygroma

The correct answer is Dermoid cyst
Dermoid cysts are usually multiloculated and heterogeneous. Most are located
above the hyoid, and their appearances on imaging differentiate them from
thyroglossal cysts.
22.
A 22 month old baby is brought to the clinic by her mother who is concerned
that she has developed a swelling in her neck. On examination; she has a soft
lesion located in the posterior triangle that transilluminates.
You answered Rhabdomyosarcoma
The correct answer is Cystic hygroma
Cystic hygromas are soft and transilluminate. Most are located in the posterior
triangle.
23.
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.
Branchial cyst
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.
Next question
Neck Masses in Children
Thyroglossal cyst
Branchial cyst
Located in the anterior triangle, usually in the midline and below

the hyoid (65% cases)
Derived from remnants of the thyroglossal duct
Thin walled and anechoic on USS (echogenicity suggests infection
of cyst)
Six branchial arches separated by branchial clefts

Incomplete obliteration of the branchial apparatus may result in
cysts, sinuses or fistulae
75% of branchial cysts originate from the second branchial cleft
Usually located anterior to the sternocleidomastoid near the angle
of the mandible
Unless infected the fluid of the cyst has a similar consistency to
water and is anechoic on USS
Dermoids
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Dermoids
Thyroid gland
Lymphatic
malformations
Infantile
haemangioma
Lymphadenopathy
Derived from pleuripotent stem cells and are located in the midline
Most commonly in a suprahyoid location
They have heterogeneous appearances on imaging and contain
variable amounts of calcium and fat
True thyroid lesions are rare in children and usually represent

thyroglossal cysts or tumours like lymphoma
Usually located posterior to the sternocleidomastoid

Cystic hygroma result from occlusion of lymphatic channels
The painless, fluid filled, lesions usually present prior to the age of
2
They are often closely linked to surrounding structures and
surgical removal is difficult
They are typically hypoechoic on USS
May present in either triangle of the neck

Grow rapidly initially and then will often spontaneously regress
Plain x-rays will show a mass lesion, usually containing calcified
phleboliths
As involution occurs the fat content of the lesions increases
Located in either triangle of the neck

May be reactive or neoplastic
Generalised lymphadenopathy usually secondary to infection in
children (very common)
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Question 24 of 343
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A 34 year old man presents to the surgical clinic 8 months following a laparotomy for a
ruptured spleen. He complains of a nodule in the centre of his laparotomy wound. This is
explored surgically and a stitch granuloma is found and excised. From which of the following
cell types do granulomata arise?
Question stats
Score: 45.8%
13.2%
10.2%
9%
8.1%
59.5%

question correctly
A. Polymorpho nucleocytes
End and review
B. Plasma cells
1
2
3
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8
9
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C. Reed- Sternberg cells
13
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D. Platelets
14
E. Macrophages
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19
20
Granulomas are organised collections of macrophages
21-23 1 / 3
24

Macrophages give origin to granulomas.
Chronic inflammation
Overview
Chronic inflammation may occur secondary to acute inflammation.In most cases chronic
inflammation occurs as a primary process. These may be broadly viewed as being one of
three main processes:
Persisting infection with certain organisms such as Mycobacterium tuberculosis which
results in delayed type hypersensitivity reactions and inflammation.
Prolonged exposure to non-biodegradable substances such as silica or suture
materials which may induce an inflammatory response.
Autoimmune conditions involving antibodies formed against host antigens.
Acute vs. Chronic inflammation

Acute inflammation
Changes to existing vascular structure and increased

permeability of endothelial cells
Angiogenesis predominates
Infiltration of neutrophils
Macrophages, plasma cells and

lymphocytes predominate
Process may resolve with:
Healing by fibrosis is the main result
Suppuration
Complete resolution
Abscess formation
Progression to chronic inflammation
Healing by fibrosis
Granulomatous inflammation
A granuloma consists of a microscopic aggregation of macrophages (with epithelial type
arrangement =epitheliod). Large giant cells may be found at the periphery of granulomas.
Mediators
Growth factors released by activated macrophages include agents such as interferon and
fibroblast growth factor (plus many more). Some of these such as interferons may have
systemic features resulting in systemic symptoms and signs, which may be present in
individuals with long standing chronic inflammation.
The finding of granulomas is pathognomonic of chronic inflammation, as illustrated in this
biopsy from a patient with colonic Crohns disease
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Question 31 of 343
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As a busy surgical trainee on the colorectal unit you are given the unenviable task of
reviewing the unit's histopathology results for colonic polyps. Which of the polyp types
described below has the greatest risk of malignant transformation?
Question stats
Score: 45.2%
19.3%
12.5%
46.8%
12.5%
8.9%
A. Hyperplastic polyp
question correctly
B. Tubular adenoma
End and review
C. Villous adenoma
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D. Hamartomatous polyp
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E. Serrated polyp
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19
Villous adenomas carry the highest risk of malignant transformation. Hyperplastic polyps
carry little in the way of increased risk. Although, patients with hamartomatous polyp
syndromes may have a high risk of malignancy, the polyps themselves have little malignant
potential.
20
21-23 1 / 3
24
25
Colonic polyps
26
27
Colonic Polyps
May occur in isolation, or greater numbers as part of the polyposis syndromes. In FAP
greater than 100 polyps are typically present. The risk of malignancy in association with
adenomas is related to size, and is the order of 10% in a 1cm adenoma. Isolated adenomas
seldom give risk of symptoms (unless large and distal). Distally sited villous lesions may
produce mucous and if very large, electrolyte disturbances may occur.
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31
Follow up of colonic polyps

Group
Features
Action
Low risk
1 or 2 adenomas less than 1cm
No follow up or recolonoscopy at 5 years
Moderate
risk
3 or 4 small adenomas or 1 adenoma greater than

1cm
Re-scope at 3 years
High risk
More than 5 small adenomas or more than 3 with 1

of them greater than 1cm
Re scope at 1 year
From Atkins and Saunders Gut 2002 51 (suppl V:V6-V9). It is important to stratify patients
appropriately and ensure that a complete colonoscopy with good views was performed.
Segmental resection or complete colectomy should be considered when:
1. Incomplete excision of malignant polyp
2. Malignant sessile polyp
3. Malignant pedunculated polyp with submucosal invasion
4. Polyps with poorly differentiated carcinoma
5. Familial polyposis coli
-Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy
-Panproctocolectomy and Ileostomy or Restorative Panproctocolectomy.
Rectal polypoidal lesions may be amenable to trans anal endoscopic microsurgery.
References
Cairns S et al. Guidelines for colorectal cancer screening and surveillance in moderate and
high risk groups (update from 2002). Gut 2010;59:666-690.
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Question 32 of 343
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A 23 year old man presents to the surgical clinic with an inguinal hernia. On examination he
has a small direct hernia. However, you also notice that he has pigmented spots around his
mouth, on his palms and soles. In his history he underwent a reduction of an intussusception
aged 12 years. Which of the following lesions is most likely to be identified if a colonoscopy
were performed?
Question stats
Score: 43.8%
51.7%
12.7%
8.2%
13.8%
13.6%

question correctly
A. Hamartomas
End and review
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2
3
4-6 0 / 3
7
8
9
10-12 3 / 3
B. Tubulovillous adenoma
13
C. Colorectal cancer
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14
D. Crohns disease
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19
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20
21-23 1 / 3

He is most likely to have Peutz-Jeghers syndrome which is associated with Hamartomas.
24
25
Peutz-Jeghers syndrome
26
27
Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous

benign hamartomatous polyps in the gastrointestinal tract. It is also associated with
pigmented freckles on the lips, face, palms and soles. Around 50% of patients will have died
from a gastrointestinal tract cancer by the age of 60 years.
28
29
30
Genetics
31
32
Autosomal dominant
Responsible gene encodes serine threonine kinase LKB1 or STK11
Features
Hamartomatous polyps in GI tract (mainly small bowel)
Pigmented lesions on lips, oral mucosa, face, palms and soles
Intestinal obstruction e.g. intussusception (which may lead to diagnosis)
Gastrointestinal bleeding
Management
Conservative unless complications develop
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Question 33 of 343
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A 56 year old surgeon has been successfully operating for many years. Over the past few
weeks she has begun to notice that her hands are becoming blistering and weepy. A latex
allergy is diagnosed. Which of the following pathological processes accounts for this
scenario?
Question stats
Score: 45.5%
18.2%
12.7%
48.9%
13.2%
7%

question correctly
A. Type 1 hypersensitivity reaction
End and review
B. Type 2 hypersensitivity reaction
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2
3
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9
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C. Type 4 hypersensitivity reaction
13
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D. Type 3 hypersensitivity reaction
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20
Hypersensitivity reactions: ACID
21-23 1 / 3
24
type 1 --Anaphylactic
type 2 --Cytotoxic
type 3 --Immune complex
type 4 --Delayed hypersensitivity
25
26
27
28

Contact dermatitis of a chronic nature is an example of a type 4 hypersensitivity reaction.
Type 4 hypersensitivity reactions are cell mediated rather than antibody mediated.
29
30
31
Hypersensitivity reactions
32
33
The Gell and Coombs classification divides hypersensitivity reactions into 4 types
Type I
Type II
Type III
Type IV
Description
Anaphylactic
Cytotoxic
Immune
complex
Delayed type
Mediator
IgE
IgG, IgM
IgG, Ig A,
IgM
T-cells
Antigen
Exogenous
Cell surface
Soluble
Tissues
Response
time
Minutes
Hours
Hours
2-3 days
Examples
Asthma
Hay fever
Autoimmune haemolytic
anaemia
Pemphigus
Goodpasture's
Serum
sickness
SLE
Aspergillosis
Graft versus host

disease
Contact dermatitis
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Question 36 of 343
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A 43 year old man presents with haemoptysis and is diagnosed as having tuberculosis.
Which of the cell types listed below will usually internalise the tubercule bacullis?
A. Fibroblast
B. Neutrophil
Question stats
Score: 50%
7.6%
10.3%
7.6%
63.9%
10.6%

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C. Erythrocyte
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8
9
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D. Macrophage
13
E. Eosinophil
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18

M. Tuberculosis will reside in macrophages where it will often survive
19
20
21-23 1 / 3
Tuberculosis pathology
24
25
Is a form of primary chronic inflammation, caused by the inability of macrophages to kill

the Mycobacterium tuberculosis.
The macrophages often migrate to regional lymph nodes, the lung lesion plus affected
lymph nodes is referred to as a Ghon complex.
This leads to the formation of a granuloma which is a collection of epithelioid
histiocytes.
There is the presence of caseous necrosis in the centre.
The inflammatory response is mediated by a type 4 hypersensitivity reaction.
In healthy individuals the disease may be contained, in the immunocompromised
disseminated (miliary TB) may occur.
26
27
28
29
30
31
32
33
34
Diagnosis
35
Waxy membrane of mycobacteria prevents binding with normal stains. Ziehl - Neelsen
staining is typically used.
Culture based methods take far longer.
36
Image showing acid- alcohol fast mycobacteria stained using the Ziehl- Neelsen method
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Question 38 of 343
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A 39 year old man has suffered from terminal ileal Crohns disease for the past 20 years.
Which condition is he least likely to develop?
A. Gallstones
B. Malabsorption
Question stats
Score: 50%
17.3%
13.6%
12.3%
17.6%
39.3%

question correctly
C. Pyoderma gangrenosum
End and review
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2
3
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8
9
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D. Amyloidosis
13
E. Feltys syndrome
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18
19
Felteys syndrome:
20
Rheumatoid disease
Splenomegaly
Neutropenia
21-23 1 / 3
24
25
26
Feltys syndrome is associated with rheumatoid disease. Individuals with long standing
Crohns disease are at risk of gallstones because of impairment of the enterohepatic
recycling of bile salts. Formation of entero-enteric fistulation may produce malabsorption.
Amyloidosis may complicate chronic inflammatory states.
27
28
29
30
Crohns disease
31
Crohns disease is a chronic transmural inflammation of a segment(s) of the gastrointestinal

tract and may be associated with extra intestinal manifestations. Frequent disease patterns
observed include ileal, ileocolic and colonic disease. Peri-anal disease may occur in
association with any of these. The disease is often discontinuous in its distribution.
Inflammation may cause ulceration, fissures, fistulas and fibrosis with stricturing. Histology
reveals a chronic inflammatory infiltrate that is usually patchy and transmural.
32
33
34
35
36
37
Ulcerative colitis Vs Crohns

38
Crohn's disease
Ulcerative colitis
Distribution
Mouth to anus
Rectum and colon
Macroscopic
changes
Cobblestone appearance, apthoid ulceration
Contact bleeding
Depth of
disease
Transmural inflammation
Superficial inflammation
Distribution
pattern
Patchy
Continuous
Histological
features
Granulomas (non caseating epithelioid cell

aggregates with Langerhans' giant cells)
Crypt abscesses, Inflammatory

cells in the lamina propria
Extraintestinal manifestations of Crohns

Related to disease extent
Unrelated to disease extent
Aphthous ulcers (10%)
Sacroiliiitis (10-15%)
Erythema nodosum (5-10%)
Ankylosing spondylitis (1-2%)
Pyoderma gangrenosum (0.5%)
Primary sclerosing cholangitis (Rare)
Acute arthropathy (6-12%)
Gallstones (up to 30%)
Ocular complications (up to 10%)
Renal calculi (up to 10%)
Diarrhoea in Crohns
Diarrhoea in Crohns may be multifactorial since actual inflammation of the colon is not
common. Causes therefore include the following:
Bile salt diarrhoea secondary to terminal ileal disease
Entero-colic fistula
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Short bowel due to multiple resections

Bacterial overgrowth
Surgical interventions in Crohns disease

The commonest disease pattern in Crohns is stricturing terminal ileal disease and this often
culminates in an ileocaecal resection. Other procedures performed include segmental small
bowel resections and stricturoplasty. Colonic involvement in patients with Crohns is not
common and, where found, distribution is often segmental. However, despite this distribution
segmental resections of the colon in patients with Crohns disease are generally not
advocated because the recurrence rate in the remaining colon is extremely high, as a result
the standard options of colonic surgery in Crohns patients are generally; sub total colectomy,
panproctocolectomy and staged sub total colectomy and proctectomy. Restorative
procedures such as ileoanal pouch have no role in therapy.
Crohns disease is notorious for the developmental of intestinal fistulae; these may form
between the rectum and skin (peri anal) or the small bowel and skin. Fistulation between
loops of bowel may also occur and result in bacterial overgrowth and malabsorption.
Management of enterocutaneous fistulae involves controlling sepsis, optimising nutrition,
imaging the disease and planning definitive surgical management.
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Theme: Renal stones

A. Calcium oxalate
69%
46.2%
67.4%
End and review
Score: 100%
1-3 3 / 3
B. Uric acid
C. Cystine
D. Struvite
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E. Calcium phosphate
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Please select the most likely stone type for each of the following urinary tract stone
scenarios. Each option may be used once, more than once or not at all.
1.
A 73 year old lady is undergoing chemotherapy for treatment of acute

leukaemia. She develops symptoms of renal colic. Her urine tests positive for
blood. A KUB x-ray shows no evidence of stones.
Uric acid
Chemotherapy and cell death can increase uric acid levels. In this acute setting
the uric acid stones are unlikely to be coated with calcium and will therefore be
radiolucent.
2.
A 16 year old boy presents with renal colic. His parents both have a similar
history of the condition. His urine tests positive for blood. A KUB style x-ray
shows a relatively radiodense stone in the region of the mid ureter.
Cystine
Cystine stones are associated with an inherited metabolic disorder.
3.
A 43 year old lady with episodes of recurrent urinary tract sepsis presents with a
staghorn calculus of the left kidney. Her urinary pH is 7.3. A KUB x-ray shows a
faint outline of the calculus.
Struvite
Chronic infection with urease producing enzymes can produce an alkaline urine
with formation of struvite stone.
Next question
Renal stones
Type of
stones
Features
Percentage
of all
calculi
Calcium
oxalate
Hypercalciuria is a major risk factor (various causes)

Hyperoxaluria may also increase risk
Hypocitraturia increases risk because citrate forms complexes with
calcium making it more soluble
Stones are radio-opaque (though less than calcium phosphate
stones)
Hyperuricosuria may cause uric acid stones to which calcium
oxalate binds
85%
Cystine
Inherited recessive disorder of transmembrane cystine transport

leading to decreased absorption of cystine from intestine and renal
tubule
Multiple stones may form
Relatively radiodense because they contain sulphur
1%
Uric acid
Uric acid is a product of purine metabolism

May precipitate when urinary pH low
May be caused by diseases with extensive tissue breakdown e.g.
malignancy
More common in children with inborn errors of metabolism
Radiolucent
5-10%
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Calcium
phosphate
May occur in renal tubular acidosis, high urinary pH increases

supersaturation of urine with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase risk of stone
formation (types 2 and 4 do not)
Radio-opaque stones (composition similar to bone)
10%
Struvite
Stones formed from magnesium, ammonium and phosphate

Occur as a result of urease producing bacteria (and are thus
associated with chronic infections)
Under the alkaline conditions produced, the crystals can
precipitate
Slightly radio-opaque
2-20%
Effect of urinary pH on stone formation

Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls as purine
metabolism will produce uric acid. Then the urine becomes more alkaline (alkaline tide).
When the stone is not available for analysis the pH of urine may help to determine which
stone was present.
Stone type
Urine acidity
Mean urine pH
Calcium phosphate
Normal- alkaline
>5.5
Calcium oxalate
Variable
Uric acid
Acid
5.5
Struvate
Alkaline
>7.2
Cystine
Normal
6.5
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Question 4 of 304
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A pathologist is examining a histological section and identifies Hassall's corpuscles. With

what are they most commonly associated?
A. Follicular carcinoma of the thyroid

B. Medulla of the thymus
Question stats
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Score: 75%
1-3 3 / 3
17.2%
40%
21.9%
12.3%
8.6%
40% of users answered this

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C. Medulla of the spleen

D. Medulla of the kidney
E. Fundus of the stomach
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Hassall's corpuscles are the concentric ring of epithelial cells seen in the medulla of the
thymus.
Thymus
The thymus develops from the third and fourth pharyngeal pouches. It descends to lie in the
anterior superior mediastinum. It is encapsulated and is subdivided into lobules, these
consist of a cortex and a medulla. The cortex is composed of tightly packed lymphocytes, the
medulla consists largely of epithelial cells. The medullary epithelial cells are concentrically
arranged and may surround a keratinised centre, known as Hassall's corpuscles.
The inferior parathyroid glands also develop from the third pharyngeal pouch and may also
be located with the thymus gland.
Its arterial supply is from the internal mammary artery or pericardiophrenic arteries. Venous
drainage is to the left brachiocephalic vein.
Hassall's corpuscles stained with H+E
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Question 5 of 304
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A 64 year old man presents to the clinic with right upper quadrant discomfort. He has never
attended the hospital previously and is usually well. He has just retired from full time
employment as a machinist in a PVC factory. CT scanning shows a large irregular tumour in
the right lobe of his liver. Which of the following lesions is the most likely?
Question stats
End and review
Score: 80%
1-3 3 / 3
13.5%
45.8%
16.5%
12.7%
11.4%
4
5

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A. Liposarcoma
B. Angiosarcoma
C. Hamartoma
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D. Hyatid liver disease

E. Benign angioma
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Angiosarcoma of the liver is a rare tumour. However, it is linked to working with vinyl chloride,
as in this case. Although modern factories minimise the exposure to this agent, this has not
always been the case.
Occupational cancers
Occupational cancers accounted for 5.3% cancer deaths in 2005.
In men the main cancers include:
Mesothelioma
Bladder cancer
Non melanoma skin cancer
Lung cancer
Sino nasal cancer
Occupations with high levels of occupational tumours include:

Construction industry
Working with coal tar and pitch
Mining
Metalworkers
Working with asbestos (accounts for 98% of all mesotheliomas)
Working in rubber industry
Shift work has been linked to breast cancer in women (Health and safety executive report
RR595).
The latency between exposure and disease is typically 15 years for solid tumours and 20 for
leukaemia.
Many occupational cancers are otherwise rare. For example sino nasal cancer is an
uncommon tumour, 50% will be SCC. They are linked to conditions such as wood dust
exposure and unlike lung cancer is not strongly linked to cigarette smoking. Another typical
occupational tumour is angiosarcoma of the liver which is linked to working with vinyl chloride.
Again in the non occupational context this is an extremely rare sporadic tumour.
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Question 6 of 304
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A 32 year old man is involved in a house fire and sustains extensive partial thickness burns
to his torso and thigh. Two weeks post operatively he develops oedema of both lower legs.
The most likely cause of this is:
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Score: 83.3%
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10.5%
20.1%
53.4%
8.1%
7.9%
4
5
6
A. Iliofemoral deep vein thrombosis

question correctly
B. Venous obstruction due to scarring

C. Hypoalbuminaemia
D. Excessive administration of intravenous fluids
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Loss of plasma proteins is the most common cause of oedema developing in this time frame.
Burns pathology
Extensive burns
Haemolysis due to damage of erythrocytes by heat and microangiopathy
Loss of capillary membrane integrity causing plasma leakage into interstitial space
Extravasation of fluids from the burn site causing hypovolaemic shock (up to 48h after
injury)- decreased blood volume and increased haematocrit
Protein loss
Secondary infection e.g. Staphylococcus aureus
ARDS
Risk of Curlings ulcer (acute peptic stress ulcers)
Danger of full thickness circumferential burns in an extremity as these may develop
compartment syndrome
Healing
Superficial burns: keratinocytes migrate to form a new layer over the burn site
Full thickness burns: dermal scarring. Usually need keratinocytes from skin grafts to
provide optimal coverage.
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A 42 year old man from Southern India presents with chronic swelling of both lower legs, they
are brawny and indurated with marked skin trophic changes. Which of the following
organisms is the most likely origin of this disease process?
Question stats
End and review
Score: 85.7%
1-3 3 / 3
11.9%
48.9%
18.7%
12.9%
7.6%
4
5
A. Loa loa
question correctly
B. Wuchereria bancrofti
C. Trypanosoma cruzi
D. Trypanosoma gambiense
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W. Bancrofti is the commonest cause of filariasis leading to lymphatic obstruction. Infection

with Loa loa typically occurs in the African sub continent and usually results in generalised
sub cutaneous infections without lymphatic obstruction. Trypanosomal infections would not
produce this clinical picture.
Wuchereria bancrofti
Parasitic filarial nematode

Accounts for 90% of cases of filariasis
Usually diagnosed by blood smears
Usually transmitted by mosquitos
Treatment is with diethylcarbamazine
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A 45 year old lady has recently undergone a thyroidectomy for treatment of medullary thyroid
cancer. Which of the following tumour markers is used clinically to screen for recurrence?
A. Free T3
B. Thyroglobulin
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10.9%
17.7%
53.1%
9.1%
9.2%

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C. Calcitonin
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4
5
D. Free T4
E. Thyroid stimulating hormone
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Calcitonin is clinically utilised to screen for medullary thyroid cancer recurrence. Thyroid
function testing does not form part of either diagnosis or follow up from a malignancy
perspective. However, routine assessment of TSH may be needed in patients on thyroxine.
Thyroid malignancy
Papillary carcinoma
Commonest sub-type
carcinoma
Medullary carcinoma
Lymphoma
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Question 9 of 304
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A 22 year old man is kicked in the head during a rugby match. He is temporarily concussed,
but then regains consciousness. Half an hour later he develops slurred speech, ataxia and
loses consciousnesses. On arrival in hospital he is intubated and ventilated. A CT Scan is
performed which shows an extradural haematoma. What is the most likely cause?
Question stats
Score: 88.9%
1-3 3 / 3
9.2%
64.6%
8.5%
7.9%
9.8%

question correctly
A. Basilar artery laceration
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B. Middle meningeal artery laceration

C. Laceration of the sigmoid sinus
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D. Laceration of the anterior cerebral artery

E. Laceration of the middle cerebral artery
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The most likely vessel from those in the list to cause an acute extra dural haemorrhage is the
middle meningeal artery. The anterior and middle cerebral arteries may cause acute sub
dural haemorrhage. Acute sub dural haemorrhages usually take slightly longer to evolve
than acute extra dural haemorrhages.
Middle meningeal artery
Middle meningeal artery is typically the third branch of the first part of the maxillary
artery, one of the two terminal branches of the external carotid artery. After branching
off the maxillary artery in the infratemporal fossa, it runs through the foramen
spinosum to supply the dura mater (the outermost meninges) .
The middle meningeal artery is the largest of the three (paired) arteries which supply
the meninges, the others being the anterior meningeal artery and the posterior
meningeal artery.
The middle meningeal artery runs beneath the pterion. It is vulnerable to injury at this
point, where the skull is thin. Rupture of the artery may give rise to an extra dural
hematoma.
In the dry cranium, the middle meningeal, which runs within the dura mater
surrounding the brain, makes a deep indention in the calvarium.
The middle meningeal artery is intimately associated with the auriculotemporal nerve
which wraps around the artery making the two easily identifiable in the dissection of
human cadavers and also easily damaged in surgery.
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Question 10 of 304
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Score: 80%
1-3 3 / 3
15.8%
13.3%
20.7%
A. Altered macrophages
9.5%
B. Fused macrophages
40.8%
C. Epithelioid cells

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Which of the following is not characteristic of a granuloma?
D. Mixture of chronic inflammatory cells
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5
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9
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E. Polymorphnuclear leucocytes, cellular debris and fibrin

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These are typical components of an abscess cavity. Polymorphonuclear leucocytes may be

found in a granuloma if there is a focus of suppuration.
Overview

Acute inflammation


Suppuration
Complete resolution
Abscess formation
Healing by fibrosis
Mediators
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Question 11 of 304
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A 42 year old man presents with a painless lump in the left testicle that he noticed on self
examination. Clinically there is a firm nodule in the left testicle, ultrasound appearances show
an irregular mass lesion. His serum AFP and HCG levels are both within normal limits. What
is the most likely diagnosis?
Question stats
Score: 72.7%
1-3 3 / 3
11.5%
45.6%
17.8%
7.8%
17.3%

question correctly
A. Yolk sack tumour
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B. Seminoma
10
C. Testicular teratoma
11
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D. Epididymo-orchitis
E. Adenomatoid tumour
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Seminomas typically have normal AFP and HCG. These are usually raised in teratomas
and yolk sac tumours
This man's age, presenting symptoms and normal tumour markers make a seminoma the
most likely diagnosis. Epididymo-orchitis does not produce irregular mass lesions which are
painless.
Testicular disorders
Testicular cancer
Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of
cases of testicular cancer are germ-cell tumours. Germ cell tumours may essentially be
divided into:
Tumour type
Seminoma
Non seminomatous
germ cell tumours
(42%)
Teratoma
Yolk sac tumour
Choriocarcinoma
Mixed germ cell
tumours (10%)
Key features
Commonest
subtype
(50%)
Average
age at
diagnosis =
40
Even
advanced
disease
associated
with 5 year
survival of
73%
Younger age at
presentation =2030 years
Advanced
disease carries
worse prognosis
(48% at 5 years)
Retroperitoneal
lymph node
dissection may be
needed for residual
disease after
chemotherapy
Tumour
markers
Pathology
AFP usually
normal
HCG elevated
in 10%
seminomas
Lactate
dehydrogenase;
elevated in 1020%
seminomas (but
also in many
other
conditions)
Sheet like lobular patterns

of cells with substantial
fibrous component. Fibrous
septa contain lymphocytic
inclusions and granulomas
may be seen.
AFP elevated
in up to 70% of
cases
HCG elevated
in up to 40% of
cases
Other
markers rarely
helpful
Heterogenous texture with

occasional ectopic tissue
such as hair
Image demonstrating a classical seminoma, these tumours are typically more uniform than
teratomas
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Risk factors for testicular cancer

Cryptorchidism
Infertility
Family history
Klinefelter's syndrome
Mumps orchitis
Features
A painless lump is the most common presenting symptom
Pain may also be present in a minority of men
Other possible features include hydrocele, gynaecomastia
Diagnosis
Ultrasound is first-line
CT scanning of the chest/ abdomen and pelvis is used for staging
Tumour markers (see above) should be measured
Management
Orchidectomy (Inguinal approach)
Chemotherapy and radiotherapy may be given depending on staging
Abdominal lesions >1cm following chemotherapy may require retroperitoneal lymph
node dissection.
Prognosis is generally excellent

5 year survival for seminomas is around 95% if Stage I
5 year survival for teratomas is around 85% if Stage I
Benign disease
Epididymo-orchitis
Acute epididymitis is an acute inflammation of the epididymis, often involving the testis and
usually caused by bacterial infection.
Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea or
chlamydia are the usual infections.
Amiodarone is a recognised non infective cause of epididymitis, which resolves on
stopping the drug.
Tenderness is usually confined to the epididymis, which may facilitate differentiating it
from torsion where pain usually affects the entire testis.
Testicular torsion
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Twist of the spermatic cord resulting in testicular ischaemia and necrosis.

Most common in males aged between 10 and 30 (peak incidence 13-15 years)
Pain is usually severe and of sudden onset.
Cremasteric reflex is lost and elevation of the testis does not ease the pain.
Treatment is with surgical exploration. If a torted testis is identified then both testis
should be fixed as the condition of bell clapper testis is often bilateral.
Hydrocele
Presents as a mass that transilluminates, usually possible to "get above" it on
examination.
In younger men it should be investigated with USS to exclude tumour.
In children it may occur as a result of a patent processus vaginalis.
Treatment in adults is with a Lords or Jabouley procedure.
Treatment in children is with trans inguinal ligation of PPV.
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Question 12 of 304
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A baby is born by normal vaginal delivery at 39 weeks gestation. Initially all appears well and
then the clinical staff become concerned because the baby develops recurrent episodes of
cyanosis. These are worse during feeding and improve dramatically when the baby cries.
The most likely underlying diagnosis is:
Question stats
Score: 75%
1-3 3 / 3
32.8%
8.5%
25.5%
20.6%
12.6%

question correctly
A. Choanal atresia
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B. Oesophageal reflux
10
C. Tetralogy of Fallot
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D. Oesophageal atresia
12
E. Congenital diaphragmatic hernia
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Theme from 2011 exam

In Choanal atresia the episodes of cyanosis are usually worst during feeding. Improvement
may be seen when the baby cries as the oropharyngeal airway is used.
Choanal atresia
Congenital disorder with an incidence of 1 in 7000 births.

Posterior nasal airway occluded by soft tissue or bone.
Associated with other congenital malformations e.g. coloboma
Babies with unilateral disease may go unnoticed.
Babies with bilateral disease will present early in life as they are obligate mouth
breathers.
Treatment is with fenestration procedures designed to restore patency.
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Question 13 of 304
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A 28 year old lady presents with a pigmented lesion on her calf. Excisional biopsy confirms a
diagnosis of melanoma measuring 1cm in diameter with a Breslow thickness of 0.1mm. The
lesion is less than 1 mm at all resection margins. Which of the following surgical resection
margins is acceptable for this lesion?
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Score: 71.4%
1-3 3 / 3
9.7%
41.8%
18.2%
18.9%
11.3%

question correctly
A. 5 cm
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B. 1 cm
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C. 0.5 cm
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D. 2 cm
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E. 3 cm
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Malignant melanoma
The main diagnostic features (major criteria):
Secondary features (minor criteria)
Change in size
Change in shape
Change in colour
Diameter >6mm
Inflammation
Oozing or bleeding
Altered sensation
Treatment
Suspicious lesions should undergo excision biopsy. The lesion should be removed in
completely as incision biopsy can make subsequent histopathological assessment
difficult.
Once the diagnosis is confirmed the pathology report should be reviewed to determine
whether further re-excision of margins is required (see below):
Margins of excision-Related to Breslow thickness

Lesions 0-1mm thick
1cm
Lesions 1-2mm thick
1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick
2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick
3cm
Marsden J et al Revised UK guidelines for management of Melanoma. Br J Dermatol 2010

163:238-256.
Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block
dissection of regional lymph node groups should be selectively applied.
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Question 1 of 291
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A 20 year old man is involved in a road traffic accident. Following the incident he is unable to
extend his wrist. However, this improves over the following weeks. Which type of injury is he
most likely to have sustained?
Question stats
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Score: 100%
12.7%
65%
6.6%
8.2%
7.6%
A. Radial nerve neurotmesis

question correctly
B. Radial nerve neuropraxia

C. Axillary nerve axonotmesis
D. Ulnar nerve neuropraxia
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E. Ulnar nerve axonotmesis
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Transient loss of function makes neuropraxia the most likely injury. The wrist extensors are
innervated by the radial nerve making this the most likely site of injury.
Neuropraxia
Nerve intact but electrical conduction is affected

Myelin sheath integrity is preserved
Full recovery
Autonomic function preserved
Wallerian degeneration does not occur
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Question 2 of 291
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A 53 year old lady has undergone a bilateral breast augmentation procedure many years
previously. The implants are tense and uncomfortable and are removed. During their
removal the surgeon encounters a dense membrane surrounding the implants, it has a
coarse granular appearance. The tissue is sent for histology and it demonstrates fibrosis
with the presence of calcification. The underlying process responsible for these changes is:
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Score: 100%
11.2%
10.7%
10.8%
58.2%
9.1%
1
2

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A. Hyperplasia
B. Dysplasia
C. Metastatic calcification
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D. Dystrophic calcification
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E. Necrosis
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Breast implants often become surrounded by a pseudocapsule and this may secondarily
then be subjected to a process of dystrophic calcification.
Pathological calcification
Dystrophic
calcification
Deposition of calcium deposits in tissues that have undergone degeneration,

damage or disease in the presence of normal serum calcium levels
Metastatic
calcification
Deposition of calcium deposits in tissues that are otherwise normal in the

presence of increased serum calcium levels
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Question 3 of 291
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A 4 year old girl presents with symptoms of right sided loin pain, lethargy and haematuria. On
examination she is pyrexial and has a large mass in the right upper quadrant. The most likely
underlying diagnosis is:
Question stats
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Score: 66.7%
1
23.6%
54.1%
5.9%
9.7%
6.7%
A. Perinephric abscess
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B. Nephroblastoma
C. Renal cortical adenoma
D. Grawitz tumour
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E. Squamous cell carcinoma of the kidney
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In a child of this age, with the symptoms described a nephroblastoma is the most likely
diagnosis. A perinephric abscess is most unlikely. If an abscess were to occur it would be
confined to Gerotas fascia in the first instance, and hence anterior extension would be
unlikely.
Nephroblastoma
Nephroblastoma (Wilms tumours)
Usually present in first 4 years of life
May often present as a mass associated with haematuria (pyrexia may occur in 50%)
Often metastasise early (usually to lung)
Treated by nephrectomy
Younger children have better prognosis (<1 year of age =80% overall 5 year survival)
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Question 4-6 of 291
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Score: 44.4%
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2
Theme: Thyroid neoplasms

A. Follicular carcinoma
84.5%
42.8%
52.7%
3
4-6 1 / 3
B. Anaplastic carcinoma
C. Medullary carcinoma
D. Papillary carcinoma
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E. Lymphoma
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F. Hashimotos thyroiditis
G. Graves disease
For the following histological descriptions please select the most likely underlying thyroid
neoplasm. Each option may be used once, more than once or not at all.
4.
A 22 year old female undergoes a thyroidectomy. The resected specimen shows

a non encapsulated tumour with papillary projections and pale empty nuclei.
Papillary carcinoma
The presence of papillary structures together with the cytoplasmic features
described is strongly suggestive of papillary carcinoma. They are seldom
encapsulated.
5.
A thyroidectomy specimen from a 43 year old lady shows a mass with prominent
oxyphil cells and scanty thyroid colloid.
You answered Medullary carcinoma
The correct answer is Follicular carcinoma
Hurthle cell tumours are a variant of follicular neoplasms in which oxyphil cells
predominate. They have a poorer prognosis than conventional follicular
neoplasms
6.
A 32 year old lady undergoes a thyroidectomy for a mild goitre. The resected
specimen shows an intense lymphocytic infiltrate with acinar destruction and
fibrosis.
You answered Anaplastic carcinoma
The correct answer is Hashimotos thyroiditis
Lymphocytic infiltrates and fibrosis are typically seen in Hashimotos thyroiditis. In
Lymphoma only dense lymphatic type tissue is usually present.
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Thyroid neoplasms
Lesion
Follicular
adenoma
Papillary
carcinoma
Follicular
carcinoma
Common features
Usually present as a solitary thyroid nodule
Malignancy can only be excluded on formal histological assessment
Usually contain a mixture of papillary and colloidal filled follicles

Histologically tumour has papillary projections and pale empty nuclei
Seldom encapsulated
Lymph node metastasis predominate
Haematogenous metastasis rare
Account for 60% of thyroid cancers
May appear macroscopically encapsulated, microscopically capsular

invasion is seen. Without this finding the lesion is a follicular adenoma.
Vascular invasion predominates
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Multifocal disease rare

Account for 20% of all thyroid cancers
Anaplastic
carcinoma
Medullary
carcinoma
Most common in elderly females

Local invasion is a common feature
Treatment is by resection where possible, palliation may be achieved
through isthmusectomy and radiotherapy. Chemotherapy is ineffective.
Tumours of the parafollicular cells (C Cells)

C cells derived from neural crest and not thyroid tissue
Serum calcitonin levels often raised
Familial genetic disease accounts for up to 20% cases
Both lymphatic and haematogenous metastasis are recognised, nodal
disease is associated with a very poor prognosis.
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Question 7 of 291
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Score: 50%
13.4%
10.8%
11.1%
A. Neutrophils
52.9%
B. Myofibroblasts
11.8%
C. Fibroblasts

question correctly
From which of the following cell types do giant cells most commonly originate?
D. Macrophages
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2
3
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7
E. Goblet cells
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Theme from September 2011 and 2009 Exam

Although many cell types may give rise to giant cells, macrophages remain the most
common.
Giant cells
A giant cell is a mass formed by the union of several distinct types of cells
They are most commonly comprised of macrophages
They are different to granulomas although causative agents may overlap
Section stained using haematoxylin and eosin showing giant cell reaction to suture material
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Question 1 of 284
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A 43 year old lady with hypertension is suspected of having a phaeochromocytoma. Which of

the following investigations is most likely to be beneficial in this situation?
A. Dexamethasone suppression test

B. Urinary 5-Hydroxyindoleacetic Acid (5-HIAA)
Question stats
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Score: 100%
11.7%
24.5%
6.3%
7.8%
49.7%

question correctly
C. Histamine provocation test

D. Tyramine provocation test
E. Urinary vanillymandelic acid measurements
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Urinary VMA measurements are not completely specific but constitute first line assessment.
Stimulation tests of any sort are not justified in first line assessments.
Phaeochromocytoma and adrenal lesions
Phaeochromocytoma
Neuroendocrine tumour of the chromaffin cells of the adrenal medulla. Hypertension and
hyperglycaemia are often found.
10% of cases are bilateral.
10% occur in children.
11% are malignant (higher when tumour is located outside the adrenal).
10% will not be hypertensive.
Familial cases are usually linked to the Multiple endocrine neoplasia syndromes (considered
under its own heading).
Most tumours are unilateral (often right sided) and smaller than 10cm.
Diagnosis
Urine analysis of vanillymandelic acid (VMA) is often used (false positives may occur e.g. in
patients eating vanilla ice cream!)
Blood testing for plasma metanephrine levels.
CT and MRI scanning are both used to localise the lesion.
Treatment
Patients require medical therapy first. An irreversible alpha adrenoreceptor blocker should
be given, although minority may prefer reversible blockade(1). Labetolol may be coadministered for cardiac chronotropic control. Isolated beta blockade should not be
considered as it will lead to unopposed alpha activity.
These patients are often volume depleted and will often require moderate volumes of intra
venous normal saline perioperatively.
Once medically optimised the phaeochromocytoma should be removed. Most
adrenalectomies can now be performed using a laparoscopic approach(2). The adrenals are
highly vascular structures and removal can be complicated by catastrophic haemorrhage in
the hands of the inexperienced. This is particularly true of right sided resections where the
IVC is perilously close. Should the IVC be damaged a laparotomy will be necessary and the
defect enclosed within a Satinsky style vascular clamp and the defect closed with prolene
sutures. Attempting to interfere with the IVC using any instruments other than vascular
clamps will result in vessel trauma and make a bad situation much worse.
Incidental adrenal lesions
Adrenal lesions may be identified on CT scanning performed for other reasons(3). Factors
suggesting benign disease on CT include(4):
Size less than 3cm
Homogeneous texture
Lipid rich tissue
Thin wall to lesion
All patients with incidental lesions should be managed jointly with an endocrinologist and full
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work up as described above. Patients with functioning lesions or those with adverse
radiological features (Particularly size >3cm) should proceed to surgery.
References
1. Weingarten TN, Cata JP, O'Hara JF, Prybilla DJ, Pike TL, Thompson GB, et al.
Comparison of two preoperative medical management strategies for laparoscopic resection
of pheochromocytoma. Urology. 2010 Aug;76(2):508 e6-11.
2. Nguyen PH, Keller JE, Novitsky YW, Heniford BT, Kercher KW. Laparoscopic approach to
adrenalectomy: review of perioperative outcomes in a single center. Am Surg. 2011
May;77(5):592-6.
3. Ng VW, Ma RC, So WY, Choi KC, Kong AP, Cockram CS, et al. Evaluation of functional
and malignant adrenal incidentalomas. Arch Intern Med. 2010 Dec 13;170(22):2017-20.
4. Muth A, Hammarstedt L, Hellstrom M, Sigurjonsdottir HA, Almqvist E, Wangberg B. Cohort
study of patients with adrenal lesions discovered incidentally. Br J Surg. 2011 May 27.
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Question 2 of 284
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A 46 year old lady presents with symptoms of diarrhoea, weight loss of 10 Kg and a skin rash
of erythematous blisters involving the abdomen and buttocks. The blisters have an irregular
border and both intact and ruptured vesicles. What is the most likely diagnosis?
Question stats
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11.6%
15.6%
27.3%
32.1%
13.4%
1
2
A. Colonic adenocarcinoma
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B. Pancreatic adenocarcinoma
C. Tropical sprue
D. Glucagonoma
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E. Insulinoma
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Glucagonoma is strongly associated with necrolytic migratory erythema.
Glucagonoma
Rare pancreatic tumours arising from the alpha cells of the pancreas.
Glucagon levels markedly elevated.
Symptoms include diarrhoea, weight loss and necrolytic migratory erythema.
A serum level of glucagon >1000pg/ml usually suggests the diagnosis, imaging with
CT scanning is also required.
Treatment is with surgical resection. However, careful staging is required for these
tumours are usually malignant and non resectable.
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A 56 year old man presents with symptoms of neuropathic facial pain and some weakness of
the muscles of facial expression on the right side. On examination he has a hard mass
approximately 6cm anterior to the right external auditory meatus. What is the most likely
diagnosis?
Question stats
End and review
Score: 66.7%
1
26.5%
20.5%
13.5%
33.1%
6.5%

question correctly
A. Pleomorphic adenoma
B. Adenocarcinoma
C. Mucoepidermoid carcinoma
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D. Adenoid cystic carcinoma

E. Lymphoma
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The patient is most likely to have a malignant lesion within the parotid. Of the malignancies
listed; adenoid cystic carcinoma has the greatest tendency to perineural invasion.
Parotid gland malignancy
Most parotid neoplasms (80%) are benign lesions

Most commonly present with painless mass around the mandible
Up to 30% may present with pain, when this is associated with a discrete mass lesion
in the parotid it usually indicates perineural invasion.
Perineural invasion is very unlikely to occur in association with benign lesions
80% of patients with facial nerve weakness caused by parotid malignancies will have
nodal metastasis and a 5 year survival of 25%
Types of malignancy
Mucoepidermoid
carcinoma
30% of all parotid malignancies

Usually low potential for local invasiveness and metastasis (depends
mainly on grade)
Adenoid cystic
carcinoma
Unpredictable growth pattern

Tendency for perineural spread
Nerve growth may display skip lesions resulting in incomplete excision
Distant metastasis more common (visceral rather than nodal spread)
5 year survival 35%
Mixed tumours
Often a malignancy occurring in a previously benign parotid lesion
Acinic cell
carcinoma
Intermediate grade malignancy

May show perineural invasion
Low potential for distant metastasis
5 year survival 80%
Adenocarcinoma
Develops from secretory portion of gland

Risk of regional nodal and distant metastasis
5 year survival depends upon stage at presentation, may be up to 75% with
small lesions with no nodal involvement
Lymphoma
Large rubbery lesion, may occur in association with Warthins tumours

Diagnosis should be based on regional nodal biopsy rather than parotid
resection Treatment is with chemotherapy (and radiotherapy)
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Question 4 of 284
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A 20 year old African lady undergoes an open appendicectomy. She is reviewed for an
unrelated problem 8 months later. On abdominal inspection the wound site is covered by
shiny dark protuberant scar tissue that projects beyond the limits of the skin incision. Which
of the following is the most likely underlying process?
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Score: 50%
1
11.1%
67.8%
7.6%
7.3%
6.2%

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A. Hypertrophic scar
B. Keloid scar
C. Marjolins ulcer
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D. Repeated episodes of wound sepsis

E. Mycosis fungoides
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Keloid scars extend beyond the limits of the incision. Mycosis fungoides is a cutaneous T cell
lymphoma.
Wound healing
Surgical wounds are either incisional or excisional and either clean, clean contaminated or
dirty. Although the stages of wound healing are broadly similar their contributions will vary
according to the wound type.
The main stages of wound healing include:
Haemostasis
Minutes to hours following injury
Vasospasm in adjacent vessels, platelet plug formation and generation of fibrin rich
clot.
Inflammation
Typically days 1-5
Neutrophils migrate into wound (function impaired in diabetes).
Growth factors released, including basic fibroblast growth factor and vascular
endothelial growth factor.
Fibroblasts replicate within the adjacent matrix and migrate into wound.
Macrophages and fibroblasts couple matrix regeneration and clot substitution.
Regeneration
Typically days 7 to 56
Platelet derived growth factor and transformation growth factors stimulate fibroblasts
and epithelial cells.
Fibroblasts produce a collagen network.
Angiogenesis occurs and wound resembles granulation tissue.
Remodeling
From 6 weeks to 1 year
Longest phase of the healing process and may last up to one year (or longer).
During this phase fibroblasts become differentiated (myofibroblasts) and these
facilitate wound contraction.
Collagen fibres are remodeled.
Microvessels regress leaving a pale scar.
The above description represents an idealised scenario. A number of diseases may distort
this process. Neovascularisation is an important early process. Endothelial cells may
proliferate in the wound bed and recanalise to form a vessel. Vascular disease, shock and
sepsis can all compromise microvascular flow and impair healing.
Conditions such as jaundice will impair fibroblast synthetic function and immunity with a
detrimental effect in most parts of the healing process.
Problems with scars:
Hypertrophic scars
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Excessive amounts of collagen within a scar. Nodules may be present histologically

containing randomly arranged fibrils within and parallel fibres on the surface. The tissue itself
is confined to the extent of the wound itself and is usually the result of a full thickness dermal
injury. They may go on to develop contractures.
Image of hypertrophic scarring. Note that it remains confined to the boundaries of the original
wound:
Keloid scars
Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond the
boundaries of the original injury. They do not contain nodules and may occur following even
trivial injury. They do not regress over time and may recur following removal.
Image of a keloid scar. Note the extension beyond the boundaries of the original incision:
Drugs which impair wound healing:

Non steroidal anti inflammatory drugs
Steroids
Immunosupressive agents
Anti neoplastic drugs
Closure
Delayed primary closure is the anatomically precise closure that is delayed for a few days but
before granulation tissue becomes macroscopically evident.
Secondary closure refers to either spontaneous closure or to surgical closure after
granulation tissue has formed.
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Question 5 of 284
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End and review
Score: 60%
1
26.7%
12.8%
42.6%
A. Necrosis caused by expanding granulomas
9%
B. Ability to multiply within fibroblasts
8.9%
C. Delayed hypersensitivity reaction against bacteria

question correctly
The pathogenicity of the tubercle bacillus is due to which of the following?
D. Effect of antibody response

E. Direct toxic effect on host cells
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Mycobacteria stimulate a specific T cell response of cell mediated immunity. This is effective
in reducing the infection, the delayed hypersensitivity also damages tissues. Necrosis occurs
in TB but is usually within the granuloma.

histiocytes.
Diagnosis
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Question 6 of 284
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A 45 year old women with a thyroid carcinoma undergoes a total thyroidectomy. The post
operative histology report shows a final diagnosis of medullary type thyroid cancer. Which of
the tests below is most likely to be of clinical use in screening for disease recurrence?
Question stats
Score: 57.1%
1
7.7%
10%
7.5%
68.8%
6%

question correctly
A. Serum CA 19-9 Levels

B. Serum thyroglobulin levels
End and review
C. Serum PTH levels

D. Serum calcitonin levels
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E. Serum TSH levels
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Medullary thyroid cancers often secrete calcitonin and monitoring the serum levels of this
hormone is useful in detecting sub clinical recurrence.
Thyroid neoplasms
Lesion
Common features
Follicular
adenoma
Papillary
carcinoma
Follicular
carcinoma
Anaplastic
carcinoma
Medullary
carcinoma


Seldom encapsulated



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Question 7 of 284
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A 15 year old boy undergoes an emergency splenectomy for trauma. He makes a full
recovery and is discharged home. Eight weeks post operatively the general practitioner
performs a full blood count with a blood film. Which of the following is most likely to be
present?
Question stats
Score: 62.5%
1
8.8%
63.7%
10.4%
10.1%
7.1%

question correctly
A. Myofibroblasts
End and review
B. Howell-Jolly bodies
6
7
C. Multinucleate giant cells

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D. Reed Sternberg Cells

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Post splenectomy blood film features:

Howell- Jolly bodies
Pappenheimer bodies
Target cells
Irregular contracted erythrocytes
As the filtration function is the spleen is no longer present Howell-Jolly bodies are found.
Post splenectomy blood film changes
The loss of splenic tissue results in the inability to readily remove immature or abnormal red
blood cells from the circulation. The red cell count does not alter significantly. However,
cytoplasmic inclusions may be seen e.g. Howell-Jolly bodies.
In the first few days after splenectomy target cells, siderocytes and reticulocytes will appear
in the circulation. Immediately following splenectomy a granulocytosis (mainly composed of
neutrophils) is seen, this is replaced by a lymphocytosis and monocytosis over the following
weeks.
The platelet count is usually increased and this may be persistent, oral antiplatelet agents
may be needed in some patients.
Image showing Howell Jolly bodies (arrowed)
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Question 8 of 284
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A 43 year old women is identified as being a carrier of a BRCA 1 mutation. Apart from breast
cancer, which of the following malignancies is she at greatest risk of developing?
A. Colonic cancer
B. Ovarian cancer
C. Follicular carcinoma of the thyroid
Question stats
End and review
Score: 66.7%
1
13%
65.1%
8.2%
7.6%
6%

question correctly
D. Pituitary adenoma
7
8
E. Phaeochromocytoma
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BRCA 1 mutation patients are 55% more likely to get ovarian cancer. Those with BRCA 2 are
25% more likely. The risk of developing other malignancies is slightly increased but not to the
same extent, and not enough to justify screening.
Genetics and surgical disease
Some of the more commonly occurring genetic conditions occurring in surgical patients are
presented here.
Li-Fraumeni Syndrome
Autosomal dominant
Consists of germline mutations to p53 tumour suppressor gene
High incidence of malignancies particularly sarcomas and leukaemias
Diagnosed when:
*Individual develops sarcoma under 45 years

*First degree relative diagnosed with any cancer below age 45 years and another family
member develops malignancy under 45 years or sarcoma at any age
BRCA 1 and 2
Carried on chromosome 17 (BRCA 1) and Chromosome 13 (BRCA 2)
Linked to developing breast cancer (60%) risk.
Associated risk of developing ovarian cancer (55% with BRCA 1 and 25% with BRCA
2).
Lynch Syndrome
Autosomal dominant
Develop colonic cancer and endometrial cancer at young age
80% of affected individuals will get colonic and/ or endometrial cancer
High risk individuals may be identified using the Amsterdam criteria
Amsterdam criteria
Three or more family members with a confirmed diagnosis of colorectal cancer, one of whom
is a first degree (parent, child, sibling) relative of the other two.
Two successive affected generations.
One or more colon cancers diagnosed under age 50 years.
Familial adenomatous polyposis (FAP) has been excluded.
Gardners syndrome
Autosomal dominant familial colorectal polyposis
Multiple colonic polyps
Extra colonic diseases include: skull osteoma, thyroid cancer and epidermoid cysts
Desmoid tumours are seen in 15%
Mutation of APC gene located on chromosome 5
Due to colonic polyps most patients will undergo colectomy to reduce risk of colorectal
cancer
Now considered a variant of familial adenomatous polyposis coli
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Question 9 of 284
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A 53 year old man is due to undergo a splenectomy as a treatment for refractory haemolytic
anaemia. The underlying pathological basis for haemolytic anaemia is thought to be a Type
2 hypersensitivity response. Which of the following mechanisms best describes this process
Question stats
Score: 72.7%
1
13.1%
29.1%
10.1%
42.5%
5.2%
A. Deposition of immune complexes

question correctly
B. Cell mediated immune response
End and review
6
7
C. IgE mediated response

8
D. Formation of autoantibodies against cell surface antigens

9
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Mnemonic for the reactions and the mediators involved

ACID EGG-T
Type 1 Anaphylactic
Type 2 Cytotoxic
Type 3 Immune complex
Type 4 Delayed type
EGG T (mediators)
IgE
IgG
IgG
T cells
Type 2 hypersensitivity reactions (which includes haemolytic anaemia) are associated with
formation of antibody against cell surface antigens.
Type I
Type II
Type III
Type IV
Description
Anaphylactic
Cytotoxic
Immune
complex
Delayed type
Mediator
IgE
IgG, IgM
IgG, Ig A,
IgM
T-cells
Antigen
Exogenous
Cell surface
Soluble
Tissues
Response
time
Minutes
Hours
Hours
2-3 days
Examples
Asthma
Hay fever
anaemia
Pemphigus
Goodpasture's
Serum
sickness
SLE
Aspergillosis
Graft versus host

disease
Contact dermatitis
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Question 10 of 284
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End and review
Score: 75%
1
10.7%
12%
20.3%
A. ras
39.8%
B. myc
17.2%
C. sis

question correctly
Which of the following is not an oncogene?
D. Ki 67
E. erb-B
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Ki 67 is a nuclear proliferation marker (used in immunohistochemistry). Although, Ki67

positivity is a marker of malignancy, it is not itself, an oncogene.
Oncogenes
Oncogenes are cancer promoting genes that are derived from normal genes (protooncogenes). Proto-oncogenes play an important physiological role in cellular growth. They
are implicated in the development of up to 20% of human cancers.
Proto-oncogenes may become oncogenes via the following processes:
Mutation (point mutation)
Chromosomal translocation
Increased protein expression
Only one mutated copy of the gene is needed for cancer to occur - a dominant effect
Classification of oncogenes
Growth factors e.g. Sis
Transcription factors e.g. Myc
Receptor tyrosine kinase e.g. RET
Cytoplasmic tyrosine kinase e.g. Src
Regulatory GTPases e.g. Ras
Tumour supressor genes

Tumour supressor genes restrict or repress cellular proliferation in normal cells. Their
inactivation through mutation or germ line incorporation is implicated in renal, colonic, breast,
bladder and many other cancers. One of the best known tumour supressor genes is p53.
p53 gene offers protection by causing apoptosis of damaged cells. Other well known genes
include BRCA 1 and 2.
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Question 11 of 284
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A 25 year old man is injured in a road traffic accident. His right tibia is fractured and is
managed by fasciotomies and application of an external fixator. Over the next 48 hours his
serum creatinine rises and urine is sent for microscopy, muddy brown casts are identified.
What is the most likely underlying diagnosis?
Question stats
Score: 71.4%
1
11.3%
63.6%
9.1%
8.3%
7.8%

question correctly
A. Acute interstitial nephritis
End and review
B. Acute tubular necrosis
6
7
8
C. Glomerulonephritis
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D. IgA Nephropathy
E. Thin basement membrane disease
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This patient is likely to have had compartment syndrome (tibial fracture + fasciotomies) which
may produce myoglobinuria. The presence of worsening renal function, together with muddy
brown casts is strongly suggestive of acute tubular necrosis. Acute interstitial nephritis
usually arises from drug toxicity and does not usually produce urinary muddy brown casts.
Thin basement membrane disease is an autosomal dominant condition that causes
persistent microscopic haematuria, but not worsening renal function.
Acute Renal Failure
Final pathway is tubular cell death.

Renal medulla is a relatively hypoxic environment making it susceptible to renal tubular
hypoxia.
Renovascular autoregulation maintains renal blood flow across a range of arterial
pressures.
Estimates of GFR are best indices of level of renal function. Useful clinical estimates
can be obtained by considering serum creatinine, age, race, gender and body size.
eGFR calculations such as the Cockcroft and Gault equation are less reliable in
populations with high GFR's.
Nephrotoxic stimuli such as aminoglycosides and radiological contrast media induce
apoptosis. Myoglobinuria and haemolysis result in necrosis. Overlap exists and
proinflammatory cytokines play and important role in potentiating ongoing damage.
Post-operative renal failure is more likely to occur in patients who are elderly, have
peripheral vascular disease, high BMI, have COPD, receive vasopressors, are on
nephrotoxic medication or undergo emergency surgery.
Avoiding hypotension will reduce risk of renal tubular damage.
There is no evidence that administration of ACE inhibitors or dopamine reduces the
incidence of post-operative renal failure.
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Question 12 of 284
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A 56 year old man has undergone a radical nephrectomy. The pathologist bisects the kidney
and identifies a pink fleshy tumour in the renal pelvis. What is the most likely disease?
A. Renal cell carcinoma

B. Transitional cell carcinoma
Question stats
Score: 68.8%
1
25.7%
35.8%
21.3%
8%
9.2%

question correctly
C. Angiomyolipoma
End and review
D. Phaeochromocytoma
6
7
8
E. Renal adenoma
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Most renal tumours are yellow or brown in colour. TCC's are one of the few tumours to
appear pink.

The finding of a TCC in the renal pelvis mandates a nephroureterectomy.
Renal lesions
Lesion
Renal cell
carcinoma
Nephroblastoma
Neuroblastoma
Transitional cell
carcinoma
Angiomyolipoma
Disease specific features

Most present with haematuria
(50%)
Common renal tumour (85%
cases)
Paraneoplastic features include
hypertension and polycythaemia
Most commonly has
haematogenous mestastasis
Rare childhood tumour

It accounts for 80% of all
genitourinary malignancies in
those under the age of 15 years
Up to 90% will have a mass
50% will be hypertensive
Diagnostic work up includes
ultrasound and CT scanning
Most common extracranial

tumour of childhood
80% occur in those under 4
years of age
Tumour of neural crest origin (up
to 50% occur in the adrenal
gland)
The tumour is usually calcified
and may be diagnosed using
MIBG scanning
Staging is with CT
Accounts for 90% of lower urinary

tract tumour, but only 10% of
renal tumours
Males affected 3x more than
females
Occupational exposure to
industrial dyes and rubber
chemicals may increase risk
Up to 80% present with painless
haematuria
Diagnosis and staging is with CT
IVU
80% of these hamartoma type

lesions occur sporadically, the
remainder are seen in those with
tuberous sclerosis
Treatment
Usually radical or partial
nephrectomy
Surgical resection combined with

chemotherapy (usually
vincristine, actinomycin D and
doxorubicin)
Surgical resection, radiotherapy

and chemotherapy
Radical nephroureterectomy
50% of patients with lesions

>4cm will have symptoms and
will require surgical resection
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Tumour is composed of blood

vessels, smooth muscle and fat
Massive bleeding may occur in
10% of cases
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Question 13 of 284
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A 65 year old lady presents with a lesion affecting her right breast. On examination she has a
weeping, crusting lesion overlying the right nipple, the areolar region is not involved. There is
no palpable mass lesion in the breast, there is a palpable axillary lymph node. The patient's
general practitioner has tried treating the lesion with 1% hydrocortisone cream, with no
success. What is the most likely diagnosis?
Question stats
Score: 66.7%
1
11.5%
59.3%
11%
9.3%
8.8%

question correctly
A. Infection with Staphylococcus aureus
End and review
6
7
8
B. Pagets disease of the nipple

C. Phyllodes tumour
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D. Nipple eczema
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E. Basal cell carcinoma
10
11
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A weeping, crusty lesion such as this is most likely to represent Pagets disease of the nipple
(especially since the areolar region is spared). Although no mass lesion is palpable, a
proportion of patients will still have an underlying invasive malignancy (hence the
lymphadenopathy).
Pagets disease of the nipple
Pagets 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.
Pagets 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.
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Question 14 of 284
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A 73 year old man presents with haemoptysis and is suspected of suffering from lung cancer.
On examination he has an enlarged supraclavicular lymph node. Which of the following
features is most likely to be present on histological examination?
Question stats
Score: 68.4%
1
56.2%
10.1%
11.2%
13.3%
9.3%
A. Increased mitoses
question correctly
B. Apoptosis
End and review
6
7
C. Barr Bodies
8
D. Multinucleate giant cells

9
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E. Granuloma
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13
14
Increased mitoses are commonly seen in association with malignant transformation of cells.
Apoptosis is not a common feature of metastatic cancer. Barr Bodies are formed during X
chromosome inactivation in female somatic cells.
Histopathology of malignancy
Abnormal tissue architecture

Coarse chromatin
Invasion of basement membrane*
Abnormal mitoses
Angiogenesis
De-differentiation
Areas of necrosis
Nuclear pleomorphism
*= Those features that distinguish invasive malignancy from in situ disease

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Question 15 of 284
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Which of the following pathological explanations best describes the initial pathological
processes occurring in an abdominal aortic aneurysm in an otherwise well 65 year old,
hypertensive male?
Question stats
Score: 70%
1
16.1%
13.4%
21.1%
38.1%
11.3%
A. Loss of elastic fibres from the adventitia

question correctly
B. Loss of collagen from the adventitia
End and review
6
7
C. Loss of collagen from the media

8
D. Loss of elastic fibres from the media

9
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E. Decreased matrix metalloproteinases in the adventitia
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In established aneurysmal disease there is dilation of all layers of the arterial wall and loss of
both elastin and collagen. The primary event is loss of elastic fibres with subsequent
degradation of collagen fibres.
13
14
15
Pathology of abdominal aortic aneurysm

Abdominal aortic aneurysms occur primarily as a result of the failure of elastic proteins within
the extracellular matrix. Aneurysms typically represent dilation of all layers of the arterial wall.
Most aneurysms are caused by degenerative disease. After the age of 50 years the normal
diameter of the infrarenal aorta is 1.5cm in females and 1.7cm in males. Diameters of 3cm
and greater, are considered aneurysmal. The pathophysiology involved in the development
of aneurysms is complex and the primary event is loss of the intima with loss of elastic fibres
from the media. This process is associated with, and potentiated by, increased proteolytic
activity and lymphocytic infiltration.
Major risk factors for the development of aneurysms include smoking and hypertension. Rare
but important causes include syphilis and connective tissues diseases such as Ehlers Danlos
type 1 and Marfans syndrome.
Layers of arterial wall
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Question 17 of 284
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A 34 year old lady undergoes an elective cholecystectomy for attacks of recurrent

cholecystitis due to gallstones. Microscopic assessment of the gallbladder is most likely to
show which of the following?
Question stats
Score: 72.7%
1
14.5%
10.9%
41.2%
20.8%
12.6%
A. Dysplasia of the fundus

question correctly
B. Widespread necrosis
End and review
6
7
C. Ashoff-Rokitansky sinuses
8
D. Metaplasia of the fundus

9
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Aschoff-Rokitansky sinuses are the result of hyperplasia and herniation of epithelial cells
through the fibromuscular layer of the gallbladder wall. They may be macroscopic or
microscopic. Ashoff-Rokitansky sinuses may be identified in cases of chronic cholecystitis
and gallstones. Although gallstones may predispose to the development of gallbladder
cancer the actual incidence of dysplasia and metaplastic change is rare. In the elective
setting described above necrosis would be rare.
13
14
15
16
17
Gallbladder
Fibromuscular sac with capacity of 50ml

Columnar epithelium
Relations of the gallbladder

Anterior
Liver
Posterior
Covered by peritoneum
Transverse colon
1st part of the duodenum
Laterally
Right lobe of liver
Medially
Quadrate lobe of liver
Arterial supply
Cystic artery (branch of Right hepatic artery)
Venous drainage
Directly to the liver
Nerve supply
Sympathetic- mid thoracic spinal cord, Parasympathetic- anterior vagal trunk
Common bile duct
Origin
Confluence of cystic and common hepatic ducts
Relations at
origin
Medially - Hepatic artery

Posteriorly- Portal vein
Relations distally
Arterial supply
Duodenum - anteriorly
Pancreas - medially and laterally
Right renal vein - posteriorly
Branches of hepatic artery and retroduodenal branches of gastroduodenal
artery
Hepatobiliary triangle
Medially
Common hepatic duct
Inferiorly
Cystic duct
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Superiorly
Inferior edge of liver
Contents
Cystic artery
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Question 18 of 284
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End and review
Score: 69.6%
1
11.3%
14.3%
17.3%
A. It consists of mutations to the p53 tumour suppressor gene
41.7%
B. Is likely to be present in a teenager presenting with a liposarcoma
15.5%
C. It has an autosomal dominant inheritance pattern

question correctly
Which of the following are not true of Li-Fraumeni syndrome?
D. Affected individuals are unlikely to develop acute myeloid leukaemia

E. Adrenal malignancies are more common than in normal population
6
7
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They are at high risk of developing leukaemia.
12
13
14
presented here.
15
16
17
18
Autosomal dominant
Diagnosed when:

BRCA 1 and 2
2).
Lynch Syndrome
Autosomal dominant
Amsterdam criteria
Gardners syndrome
cancer
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Question 19 of 284
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A 35 year old type 1 diabetic presents with difficulty mobilising and back pain radiating to the
thigh. He has a temperature of 39 oC and has pain on extension of the hip. He is diagnosed
with an iliopsoas abscess. Which of the following statements is false in relation to his
diagnosis?
Question stats
Score: 64%
1
20.2%
26.5%
12.2%
24.2%
16.9%

question correctly
A. Staphylococcus aureus is the most likely primary cause
End and review
B. Recurrence occurs in 60% cases
6
7
8
C. More common in males
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D. Crohn's is the most likely secondary cause
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E. CT guided drainage is preferable first line management
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12
13
Classical features include: a limp, back pain and fever. Recurrence rates are about 15-20%.
Staphylococcus is the commonest primary cause, others include Streptococcus and E.coli.
Management is ideally by CT guided drainage.
14
15
16
Iliopsoas abscess
17
18
Collection of pus in iliopsoas compartment (iliopsoas and iliacus)

Causes:
19
Primary
Haematogenous spread of bacteria

Staphylococcus aureus: most common
Secondary
Crohn's (commonest cause in this category)

Diverticulitis, Colorectal cancer
UTI, GU cancers
Vertebral osteomyelitis
Femoral catheter, lithotripsy
Endocarditis
Note the mortality rate can be up to 19-20% in secondary iliopsoas abscesses compared with
2.4% in primary abscesses.
Clinical features
Fever
Back/flank pain
Limp
Weight loss
Clinical examination
Patient in the supine position with the knee flexed and the hip mildly externally rotated
Specific tests to diagnose iliopsoas inflammation:
Place hand proximal to the patient's ipsilateral knee and ask patient to lift thigh against your
hand. This will cause pain due to contraction of the psoas muscle.
Lie the patient on the normal side and hyperextend the affected hip. In inflammation this
should elicit pain as the psoas muscle is stretched.
Investigation
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CT is gold standard
Management
Antibiotics
Percutaneous drainage
Surgery is indicated if:
1. Failure of percutaneous drainage

2. Presence of an another intra-abdominal pathology which requires surgery
Surgical approach
The authors technique for draining these collections is given here.
Review the CT scans and plan surgical approach. An extraperitoneal approach is important.
The collection usually extends inferiorly and can be accessed from an incision at a level of
L4 on the affected side.
GA
Transverse laterally placed incision.
Incise external oblique.
Split the subsequent muscle layers.
As you approach the peritoneum use blunt dissection to pass laterally around it.
Remember the ureter and gonadal veins lie posterior at this level.
Eventually you will enter the abscess cavity, a large amount of pus is usually released at this
point. Drain the area with suction and washout with saline.
Place a corrugated drain well into the abscess cavity.
If you have made a small skin incision it is reasonable to bring the drain up through the skin
wound. Otherwise place a lateral exit site and close the skin and external oblique. If you do
this ensure that you use interrupted sutures.
Anchor the drain with strong securely tied silk sutures (it is extremely tiresome if it falls out!)
Reference
Iliopsoas abscesses
I H Mallick, M H Thoufeeq, T P Rajendran
Postgrad Med J 2004;80:459-462
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Question 20 of 284
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End and review
Score: 61.5%
1
29.1%
12.4%
23.4%
A. 15% of cases are due to parathyroid carcinoma
16.4%
B. 80% of cases are due to parathyroid adenomas
18.7%
C. Parathyroid adenomas are often encapsulated

question correctly
Which of the following statements relating to parathyroid neoplasms is incorrect?
D. 10% of parathyroid adenomas develop in ectopically located glands

E. 85% of cases of primary hyperparathyroidism are due to solitary
adenomas
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Parathyroid carcinomas account for up to 5% of tumours. Adenomas are often encapsulated.

Lesions that are fibrotic and densely adherent to the gland may be a carcinoma. 85% cases
of primary hyperparathyroidism are due to a single adenoma and this is the reason some
surgeons favour a focused parathyroidectomy.
12
13
14
15
Parathyroid glands and disorders of calcium metabolism
16
17
Hyperparathyroidism
18
Disease type
Hormone profile
Clinical
features
Cause
May be
asymptomatic if
mild
Recurrent
abdominal pain
(pancreatitis,
renal colic)
Changes to
emotional or
cognitive state
Most cases due to solitary

adenoma (80%), multifocal
disease occurs in 10-15%
and parathyroid carcinoma in
1% or less
May have few

symptoms
Eventually
may develop
bone disease,
osteitis fibrosa
cystica and soft
tissue
calcifications
Parathyroid gland hyperplasia

occurs as a result of low
calcium, almost always in a
setting of chronic renal failure
Metastatic
calcification
Bone pain
and / or fracture
Occurs as a result of ongoing

hyperplasia of the parathyroid
glands after correction of
underlying renal disorder,
hyperplasia of all 4 glands is
usually the cause
19
20
Primary
hyperparathyroidism
Secondary
hyperparathyroidism
Tertiary
hyperparathyroidism
PTH
(Elevated)
Ca2+
(Elevated)
Phosphate
(Low)
Urine
calcium :
creatinine
clearance
ratio > 0.01
PTH
(Elevated)
Ca2+ (Low or
normal)
Phosphate
(Elevated)
Vitamin D
levels (Low)
Ca2+
(Normal or
high)
PTH
(Elevated)
Phosphate
levels
(Decreased
or Normal)
Vitamin D
(Normal or
decreased)
Alkaline
phosphatase
(Elevated)
Nephrolithiasis
Pancreatitis
Differential diagnoses
It is important to consider the rare but relatively benign condition of benign familial
hypocalciuric hypercalcaemia, caused by an autosomal dominant genetic disorder. Diagnosis
is usually made by genetic testing and concordant biochemistry (urine calcium : creatinine
clearance ratio <0.01-distinguished from primary hyperparathyroidism).
Treatment
Indications for surgery
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Elevated serum Calcium > 1mg/dL above normal

Hypercalciuria > 400mg/day
Creatinine clearance < 30% compared with normal
Episode of life threatening hypercalcaemia
Nephrolithiasis
Age < 50 years
Neuromuscular symptoms
Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of
more than 2.5 standard deviations below peak bone mass (T score lower than -2.5)
Secondary hyperparathyroidism
Usually managed with medical therapy.
Indications for surgery in secondary (renal) hyperparathyroidism:
Bone pain
Persistent pruritus
Soft tissue calcifications
Tertiary hyperparathyroidism
Allow 12 months to elapse following transplant as many cases will resolve
The presence of an autonomously functioning parathyroid gland may require surgery. If the
culprit gland can be identified then it should be excised. Otherwise total parathyroidectomy
and re-implantation of part of the gland may be required.
References
1. Pitt S et al. Secondary and Tertiary Hyperparathyroidism, State of the Art Surgical
Management. Surg Clin North Am 2009 Oct;89(5):1227-39.
2. MacKenzie-Feder J et al. Primary Hyperparathyroidism: An Overview. Int J Endocrinol
2011; 2011: 251410.
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Question 21 of 284
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A 20 year old girl presents with a thyroid cancer, she is otherwise well with no significant
family history. On examination she has a nodule in the left lobe of the thyroid with a small
discrete mass separate from the gland itself. Which of the following is the most likely cause?
Question stats
Score: 59.3%
1
20.5%
7.1%
11.2%
48.7%
12.4%
question correctly
B. Anaplastic carcinoma
End and review
6
7
C. Medullary carcinoma
8
D. Papillary carcinoma
9
Search
E. B Cell Lymphoma
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10
11
12
13
Papillary carcinoma is the most common subtype and may cause lymph node metastasis
(mass separate from the gland itself) that is rare with follicular tumours. Anaplastic carcinoma
would cause more local symptoms and would be rare in this age group.
14
15
16
17
Thyroid malignancy
18
19
Papillary carcinoma
Commonest sub-type
carcinoma
20
21
Medullary carcinoma
Lymphoma
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Question 22 of 284
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A 28 year old lady is breast feeding her first child. She presents with discomfort of the right
breast. Clinical examination demonstrates erythema and an area that is fluctuant. Aspiration
and culture of the fluid is most likely to demonstrate infection with which of the following
organisms?
Question stats
Score: 60.7%
1
7.2%
64.1%
7.9%
13.1%
7.7%

question correctly
A. Clostridium perfringens
End and review
B. Staphylococcus aureus
6
7
8
C. Streptococcus pyogenes
Search
D. Staphylococcus epidermidis
E. Actinomycosis
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11
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12
13
14
15
Staphylococcus aureus is the commonest cause. The infants mouth is usually the source as
it damages the nipple areolar complex allowing entry of bacteria.
16
17
Breast abscess
18
19
In lactational women Staphylococcus aureus is the most common cause

Typical presentation is with a tender, fluctuant mass in a lactating women
Diagnosis and treatment is performed using USS and associated drainage of the
abscess cavity. Antibiotics should also be administered
Where there is necrotic skin overlying the abscess, the patient should undergo
surgery
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Question 23 of 284
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A 20 year old male presents with a tense, swollen knee joint. There is no history of
antecedent trauma. On examination the joint is tense and swollen but there is no sign of
injury. Plain x-rays show no fracture or arthritis. What is the most likely explanation?
Question stats
Score: 62.1%
1
9.9%
7.5%
7.4%
60.6%
14.6%
A. Rupture of the anterior cruciate ligament

question correctly
B. Rupture of the medial collateral ligament
End and review
6
7
C. Tibial plateau fracture

8
D. Haemophilia A
9
Search
E. von Willebrands disease
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10
11
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12
13
Haemarthrosis without trauma is typically a feature of haemophilia A and B
14
15

Without a history of trauma, ligamentous rupture or tibial plateau fractures would be unusual.
16
17
Abnormal coagulation
18
19
Cause
Factors affected
20
Heparin
Prevents activation factors 2,9,10,11
21
Warfarin
Affects synthesis of factors 2,7,9,10
DIC
Factors 1,2,5,8,11
Liver disease
Factors 1,2,5,7,9,10,11
22
23
Interpretation blood clotting test results

Disorder
APTT
PT
Bleeding time
Haemophilia
Increased
Normal
Normal
von Willebrand's disease
Increased
Normal
Increased
Vitamin K deficiency
Increased
Increased
Normal
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Question 24 of 284
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An 18 year old rock climber falls onto his left arm and sustains a large haematoma of the left
upper arm. Unfortunately the wound associated with the injury is neglected and it becomes
infected. Which of these changes is least likely to occur?
Question stats
Score: 63.3%
1
13%
61%
7.9%
8.4%
9.7%
A. Axillary lymphadenopathy
question correctly
B. Leucopenia
End and review
6
7
C. Tenderness
8
D. Mild pyrexia
9
Search
E. Local formation of yellow pus
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10
11
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12
Leucopenia would be unusual and should prompt a search for another cause.
13
14
Acute inflammation
15
16
Inflammation is the reaction of the tissue elements to injury. Vascular changes occur,
resulting in the generation of a protein rich exudate. So long as the injury does not totally
destroy the existing tissue architecture, the episode may resolve with restoration of original
tissue architecture.
17
18
19
Vascular changes
20
21
Vasodilation occurs and persists throughout the inflammatory phase.

Inflammatory cells exit the circulation at the site of injury.
The equilibrium that balances Starlings forces within capillary beds is disrupted and a
protein rich exudate will form as the vessel walls also become more permeable to
proteins.
The high fibrinogen content of the fluid may form a fibrin clot. This has several
important immunomodulatory functions.
22
23
24
Sequelae
Resolution
Organisation
Suppuration
Progression to chronic
inflammation
Typically occurs with minimal initial injury

Stimulus removed and normal tissue architecture results
Delayed removal of exudate

Tissues undergo organisation and usually fibrosis
Typically formation of an abscess or an empyema

Sequestration of large quantities of dead neutrophils
Coupled inflammatory and reparative activities

Usually occurs when initial infection or suppuration has
been inadequately managed
Causes
Infections e.g. Viruses, exotoxins or endotoxins released by bacteria
Chemical agents
Physical agents e.g. Trauma
Tissue necrosis
Presence of neutrophil polymorphs is a histological diagnostic feature of acute

inflammation
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Question stats
End and review
Score: 63.6%
1
2
Theme: Tumour markers

A. Invasive ductal carcinoma of the breast
25
59.6%
26
64.1%
27
78.4%
B. Prostate cancer
3
4
5
C. Gastric cancer
D. Ovarian cancer
Search
E. Colorectal cancer
7
Go
F. Pancreatic adenocarcinoma
8
9
G. Seminoma testicular cancer

10
H. Non-seminomatous testicular cancer

11
I. Hepatocellular carcinoma
12
For each tumour marker please select the most likely underlying malignancy. Each option
13
14
15
25.
Raised beta-human chorionic gonadotropin with a raised alpha-feto protein

level
16
17
18
You answered Prostate cancer
19
20
The correct answer is Non-seminomatous testicular cancer
21

A raised alpha-feto protein level excludes a seminoma
22
23
26.
Elevated CA 19-9
24
25-27 2 / 3
Pancreatic adenocarcinoma
27.
Raised alpha-feto protein level in a 54-year-old woman

Hepatocellular carcinoma
Next question
Tumour markers
Theme from January 2013 exam

Tumour markers may be divided into:
monoclonal antibodies against carbohydrate or glycoprotein tumour antigens
tumour antigens
enzymes (alkaline phosphatase, neurone specific enolase)
hormones (e.g. calcitonin, ADH)
It should be noted that tumour markers usually have a low specificity

Monoclonal antibodies
Tumour marker
Association
CA 125
Ovarian cancer
CA 19-9
Pancreatic cancer
CA 15-3
Breast cancer
NB: The breast cancer tumour marker is not specific or sensitive enough to be used
routinely.
Tumour antigens
Tumour marker
Association
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Prostate specific antigen (PSA)
Prostatic carcinoma
Alpha-feto protein (AFP)
Hepatocellular carcinoma, teratoma
Carcinoembryonic antigen (CEA)
Colorectal cancer
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Question 31 of 284
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A 17 year old man is identified as having a Meckels diverticulum. From which of the following
embryological structures is it derived?
A. Foregut
B. Hindgut
Question stats
Score: 56.8%
1
12.1%
10.8%
10.8%
9.5%
56.8%

question correctly
C. Urachus
End and review
D. Cloaca
6
7
8
E. Vitello-intestinal duct
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10
11
12
Rule of 2's
13
14
2% of population
2 inches (5cm) long
2 feet (60 cm) from the ileocaecal valve
2 x's more common in men
2 tissue types involved
15
16
17
18
19
The Meckels diverticulum is a persistence of the vitello-intestinal duct.
20
Meckel's diverticulum
21
22
Congenital abnormality resulting in incomplete obliteration of the vitello-intestinal duct

Normally, in the foetus, there is an attachment between the vitello-intestinal duct and
the yolk sac.This disappears at 6 weeks gestation.
The tip is free in majority of cases.
Associated with enterocystomas, umbilical sinuses, and omphaloileal fistulas.
Arterial supply: omphalomesenteric artery.
2% of population, 2 inches long, 2 feet from the ileocaecal valve.
Typically lined by ileal mucosa but ectopic gastric mucosa can occur, with the risk of
peptic ulceration. Pancreatic and jejunal mucosa can also occur.
23
24
25-27 2 / 3
28-30 0 / 3
31
Clinical
Normally asymptomatic and an incidental finding.
Complications are the result of obstruction, ectopic tissue, or inflammation.
Removal if narrow neck or symptomatic. Options are between wedge excision or formal
small bowel resection and anastomosis.
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End and review
Score: 52.5%
1
2
Theme: Rectal bleeding

A. Solitary rectal ulcer syndrome
32
85.5%
33
77.7%
34
45.6%
B. Haemorrhoidal disease
3
4
5
C. Fissure in ano
D. Fistula in ano
Search
E. Anal cancer
7
Go
F. Ulcerative colitis
8
9
Please select the most likely diagnosis for the scenario given. Each option may be used
10
11
12
13
32.
A 22 year old man presents with a 6 day history of passage of bloody

diarrhoea with passage of mucous and slime. He is passing an average of 8 to
9 bowel movements per day. On digital rectal examination there is no discrete
abnormality to feel, but there is some blood stained mucous on the glove.
14
15
16
17
You answered Solitary rectal ulcer syndrome
18
The correct answer is Ulcerative colitis

19
33.
The passage of bloody diarrhoea together with mucous and a short history
makes this a likely first presentation of inflammatory bowel disease.
20
A 17 year old man presents with a 2 week history of significant pain on

defecation accompanied by the presence of a small amount of blood which is
noticed on toilet paper.
22
21
23
24
25-27 2 / 3
28-30 0 / 3
You answered Haemorrhoidal disease

The correct answer is Fissure in ano
31
Young patients with painful rectal bleeding may have a fissure. Treatment is
with stool softeners and either GTN or Diltiazem initially.
34.
32-34 0 / 3
A 24 year old woman presents with a long history of obstructed defecation and
chronic constipation. She often strains to open her bowels for long periods and
occasionally notices that she has passed a small amount of blood. On
examination she has an indurated area located anteriorly approximately 3cm
proximal to the anal verge.
You answered Fissure in ano
The correct answer is Solitary rectal ulcer syndrome
Solitary rectal ulcers are associated with chronic constipation and straining. It
will need to be biopsied to exclude malignancy (the histological appearances
are characteristic). Diagnostic work up should include endoscopy and probably
defecating proctogram and ano-rectal manometry studies.
Next question
Rectal bleeding
Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the
clinical history it is useful to try and localise the anatomical source of the blood. Bright red
blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a
proximally sited bleeding source. Blood which has entered the GI tract from a gastroduodenal source will typically resemble malaena due to the effects of the digestive enzymes
on the blood itself.
In the table below we give some typical bleeding scenarios together with physical examination
findings and causation.
Cause
Type of
bleeding
Features in history
Examination findings
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Fissure in
ano
Bright red
rectal
bleeding
Painful bleeding that occurs

post defecation in small
volumes. Usually antecedent
features of constipation
Muco-epithelial defect usually in

the midline posteriorly (anterior
fissures more likely to be due to
underlying disease)
Haemorroids
Bright red
rectal
bleeding
Post defecation bleeding noted

both on toilet paper and drips
into pan. May be alteration of
bowel habit and history of
straining. No blood mixed with
stool. No local pain.
Normal colon and rectum.

Proctoscopy may show internal
haemorrhoids. Internal
haemorrhoids are usually
impalpable.
Crohns
disease
Bright red
or mixed
blood
Bleeding that is accompanied

by other symptoms such as
altered bowel habit, malaise,
history of fissures (especially
anterior) and abscesses.
Perineal inspection may show

fissures or fistulae. Proctoscopy
may demonstrate indurated
mucosa and possibly strictures.
Skip lesions may be noted at
colonoscopy.
Ulcerative
colitis
Bright red
bleeding
often
mixed
with stool
Diarrhoea, weight loss,

nocturnal incontinence,
passage of mucous PR.
Proctitis is the most marked

finding. Peri anal disease is
usually absent. Colonoscopy
will show continuous mucosal
lesion.
Rectal
cancer
Bright red
blood
mixed
volumes
Alteration of bowel habit.

Tenesmus may be present.
Symptoms of metastatic
disease.
Usually obvious mucosal

abnormality. Lesion may be
fixed or mobile depending upon
disease extent. Surrounding
mucosa often normal, although
polyps may be present.
Image showing a fissure in ano. Typically these are located posteriorly and in the midline.
Fissures at other sites may be associated with underlying disease.
Colonoscopic image of internal haemorroids. Note these may often be impalpable.
Investigation
All patients presenting with rectal bleeding require digital rectal examination and
procto-sigmoidoscopy as a minimal baseline.
Remember that haemorrhoids are typically impalpable and to attribute bleeding to
these in the absence of accurate internal inspection is unsatisfactory.
In young patients with no other concerning features in the history a carefully
performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be
sufficient. If clear views cannot be obtained then patients require bowel preparation
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with an enema and a flexible sigmoidscopy performed.

In those presenting with features of altered bowel habit or suspicion of inflammatory
bowel disease a colonoscopy is the best test.
Patients with excessive pain who are suspected of having a fissure may require an
examination under general or local anaesthesia.
In young patients with external stigmata of fissure and a compatible history it is
acceptable to treat medically and defer internal examination until the fissure is healed.
If the fissure fails to heal then internal examination becomes necessary along the lines
suggested above to exclude internal disease.
Special tests
In patients with a malignancy of the rectum the staging investigations comprise an MRI
of the rectum to identify circumferential resection margin compromise and to identify
mesorectal nodal disease. In addition to this CT scanning of the chest abdomen and
pelvis is necessary to stage for more distant disease. Some centres will still stage the
mesorectum with endo rectal ultrasound but this is becoming far less common.
Patients with fissure in ano who are being considered for surgical sphincterotomy and
are females who have an obstetric history should probably have ano rectal manometry
testing performed together with endo anal ultrasound. As this service is not universally
available it is not mandatory but in the absence of such information there are
continence issues that may arise following sphincterotomy.
Management
Disease
Management
Fissure in
ano
GTN ointment 0.2% or diltiazem cream applied topically is the usual first line
treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy
for those who fail with botox, can be considered earlier in males.
Haemorroids
Lifestyle advice, for small internal haemorrhoids can consider injection

sclerotherapy or rubber band ligation. For external haemorrhoids consider
haemorrhoidectomy. Modern options include HALO procedure and stapled
haemorrhoidectomy.
Inflammatory
bowel
disease
Medical management- although surgery may be needed for fistulating Crohns

(setons).
Rectal
cancer
Anterior resection or abdomino-perineal excision of the colon and rectum. Total

mesorectal excision is now standard of care. Most resections below the
peritoneal reflection will require defunctioning ileostomy. Most patients will
require preoperative radiotherapy.
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Question 35 of 284
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End and review
Score: 50%
1
21.7%
29.2%
31.1%
A. Glioblastoma multiforme
7.4%
B. Astrocytoma
10.6%
C. Medulloblastoma

question correctly
Which of the following is the most common childhood brain tumour?
D. Ependymoma
E. Meningioma
6
7
8
9
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10
11
Glioblastoma multiforme is rare in childhood. In contrast, astrocytoma is the commonest brain

tumour in children. Medulloblastoma is no longer the commonest CNS tumour in children
(Cancer research UK)
12
13
14
CNS tumours
15
16
60% = Glioma and metastatic disease

20% = Meningioma
10% = Pituitary lesions
17
18
19
In paediatric practice medulloblastomas (neuroectodermal tumours) were the commonest

lesions, astrocytomas now account for the majority.
Tumours arising in right temporal and frontal lobe may reach considerable size before
becoming symptomatic. Whereas tumours in the speech and visual areas will typically
produce early symptoms.
20
21
22
23
Diagnosis
MRI Scanning provides the best resolution.
24
25-27 2 / 3
28-30 0 / 3
Treatment
Usually surgery, even if tumour cannot be completely resected conditions such as rising ICP
can be addressed with tumour debulking and survival and quality of life prolonged.
Curative surgery can usually be undertaken with lesions such as meningiomas. Gliomas
have a marked propensity to invade normal brain and resection of these lesions is nearly
always incomplete.
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Question 36 of 284
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A keen surgical trainee is about to embark on her first hemi arthroplasty for a fractured neck
of femur. In the anaesthetic room the patient is given 1.2g intravenous co-amoxiclav. There
is a possible history of penicillin allergy but the patient is demented and the history is not
checked. The patient then develops severe respiratory compromise and haemodynamic
collapse. Which pathological process accounts for this event?
Question stats
Score: 48.8%
1
13.2%
62.8%
8.5%
9.3%
6.2%

question correctly
A. Binding of the drug to circulating IgG class antibodies
End and review
6
7
8
B. Recognition of the drug by IgE receptors on mast cells

C. Drug initiated formation of hapten-protein complexes
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D. Binding of the drug to circulating IgM class antibodies
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10
11
12
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13
14
Anaphylactic shock:
Antigen recognised by IgE molecules on the surface of mast cells resulting in rapid
degranulation with release of histamine and other inflammatory cytokines.
15
16
17
18
This is a case of anaphylactic shock. In anaphylaxis the mast cells degranulate.
19
20
Anaphylactic shock
21
22
Suspect if there has been exposure to an allergen
23
24
Management
- Remove allergen
- ABCD
- Drugs:
25-27 2 / 3
28-30 0 / 3
31
32-34 0 / 3
Adrenaline 1:1000 0.5ml INTRAMUSCULARLY (not IV). Repeat after 5 mins if no response.
Then Chlorpheniramine 10mg IV
Then Hydrocortisone 100-200mg IV
35
36
Reference
Emergency treatment of anaphylactic reactions. Guidelines for healthcare providers.
Working Group of the Resuscitation Council (UK).2008
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Question 37 of 284
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Which of the following hepatobiliary disorders are most classically associated with ulcerative
colitis?
A. Gallstones
B. Primary sclerosing cholangitis
Question stats
Score: 47.7%
1
13.9%
62.4%
8.3%
8.4%
7.1%

question correctly
C. Bile duct stones
End and review
D. Liver hamartomas
6
7
8
E. Hepatocellular carcinoma
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10
11
Primary sclerosing cholangitis is an idiopathic inflammation of the bile ducts. It may result in
episodes of cholestasis and cholangitis and ultimately result in the need for liver
transplantation. It carries a 10% risk of malignant transformation. Crohns disease is
associated with gallstones due to impaired entero-hepatic circulation. Apart from PSC,
ulcerative colitis does not increase the risk of other liver lesions.
12
13
14
15
16
Ulcerative colitis
17
Ulcerative colitis is a form of inflammatory bowel disease. Inflammation always starts at

rectum, does not spread beyond ileocaecal valve (although backwash ileitis may occur) and
is continuous. The peak incidence of ulcerative colitis is in people aged 15-25 years and in
those aged 55-65 years. It is less common in smokers.
The initial presentation is usually following insidious and intermittent symptoms. Features
include:
bloody diarrhoea
urgency
tenesmus
abdominal pain, particularly in the left lower quadrant
extra-intestinal features (see below)
18
19
20
21
22
23
24
25-27 2 / 3
28-30 0 / 3
31
32-34 0 / 3
35
Questions regarding the 'extra-intestinal' features of inflammatory bowel disease are

common. Extra-intestinal features include sclerosing cholangitis, iritis and ankylosing
spondylitis.
Common to both Crohn's disease
(CD) and Ulcerative colitis (UC)
Notes
Related to
disease
activity
Arthritis: pauciarticular, asymmetric

Erythema nodosum
Episcleritis
Osteoporosis
Arthritis is the most common extraintestinal feature in both CD and UC

Episcleritis is more common in
Crohns disease
Unrelated to
disease
activity
Arthritis: polyarticular, symmetric

Uveitis
Pyoderma gangrenosum
Clubbing
Primary sclerosing cholangitis
Primary sclerosing cholangitis is

much more common in UC
Uveitis is more common in UC
36
37
Pathology
Red, raw mucosa, bleeds easily
No inflammation beyond submucosa (unless fulminant disease)
Widespread superficial ulceration with preservation of adjacent mucosa which has the
appearance of polyps ('pseudopolyps')
Inflammatory cell infiltrate in lamina propria
Neutrophils migrate through the walls of glands to form crypt abscesses
Depletion of goblet cells and mucin from gland epithelium
Granulomas are infrequent
Barium enema
Loss of haustrations
Superficial ulceration, 'pseudopolyps'
Long standing disease: colon is narrow and short -'drainpipe colon'
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Endoscopy
Superficial inflammation of the colonic and rectal mucosa
Continuous disease from rectum proximally
Superficial ulceration, mucosal islands, loss of vascular definition and continuous
ulceration pattern.
Management
Patients with long term disease are at increased risk of development of malignancy
Acute exacerbations are generally managed with steroids, in chronic patients agents
such as azathioprine and infliximab may be used
Individuals with medically unresponsive disease usually require surgery- in the acute
phase a sub total colectomy and end ileostomy. In the longer term a proctectomy will
be required. An ileoanal pouch is an option for selected patients
References
Ford A et al. Ulcerative colitis. BMJ 2013 (346):29-34.
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End and review
Score: 48.9%
1
7.3%
14.4%
7%
A. Endothelial cell damage
61.3%
B. Use of tourniquets in surgery
10.1%
C. Formation of platelet aggregates

question correctly
Which of the following is least associated with thrombosis?
D. Thrombocytopenia
E. Carcinoma of the stomach
6
7
8
9
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10
11
All the other options either act directly to promote thrombosis e.g. endothelial cell damage or
via changes in consistency or flow of blood.
12
13
Abnormal coagulation
14
15
Cause
Factors affected
Heparin
Prevents activation factors 2,9,10,11
Warfarin
Affects synthesis of factors 2,7,9,10
DIC
Factors 1,2,5,8,11
20
Liver disease
Factors 1,2,5,7,9,10,11
21
16
17
18
19
22
23
Interpretation blood clotting test results

Disorder
APTT
PT
24
Bleeding time
Haemophilia
Increased
Normal
Normal
von Willebrand's disease
Increased
Normal
Increased
25-27 2 / 3
28-30 0 / 3
31
32-34 0 / 3
Vitamin K deficiency
Increased
Increased
35
Normal
36
37
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Question 40 of 284
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Infection with which of the following micro-organisms may result in a clinical picture
resembling achalasia of the oesphagus?
A. Epstein Barr virus

B. Wuchereria Bancrofti
Question stats
Score: 46.8%
1
11%
13%
19.9%
40%
16.1%

question correctly
C. Candida Spp
End and review
D. Trypanosoma Cruzi
6
7
8
E. Helicobacter Pylori
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11
12
Infection with Trypanosoma Cruzi may result in destruction of the ganglion cells of the
myenteric plexus, resulting in a clinical picture similar to achalasia.
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14
Trypanosoma Cruzi
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Protozoan
Causes Chagas disease
Carried by bugs which infect the skin whilst feeding
Penetrate through open wounds and mucous membranes
Intracellular proliferation
Major infective sites include CNS, intestinal myenteric plexus, spleen, lymph nodes and
cardiac muscle
Chronic disease is irreversible, nifurtimox is used to treat acute infection
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24
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Question 41 of 284
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A 45-year-old man presents to surgical outpatients with a long history of recurrent abdominal
pain and vomiting. He is noted to have a peripheral motor neuropathy on examination. What
is the most likely diagnosis?
Question stats
Score: 45.8%
1
14.1%
10.8%
46.5%
14.5%
14.2%
A. Huntington's disease
question correctly
B. Myeloma
End and review
6
7
C. Acute intermittent porphyria

8
D. Lawrence-Moon-Biedl syndrome
9
Search
E. Friedreich's ataxia
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11
Next question
12
Neurological signs combined with abdominal pain is acute intermittent porphyria or lead
poisoning until proven otherwise.
13
Acute intermittent porphyria
15
14
16
Acute intermittent porphyria (AIP) is a rare autosomal dominant condition caused by a defect
in porphobilinogen deaminase, an enzyme involved in the biosynthesis of haem. The results
in the toxic accumulation of delta aminolaevulinic acid and porphobilinogen. It
characteristically presents with abdominal and neuropsychiatric symptoms in 20-40 year
olds. AIP is more common in females (5:1)
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Features
22
abdominal: abdominal pain, vomiting

neurological: motor neuropathy
psychiatric: e.g. depression
hypertension and tachycardia common
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24
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Diagnosis
32-34 0 / 3
classically urine turns deep red on standing

raised urinary porphobilinogen (elevated between attacks and to a greater extent
during acute attacks)
assay of red cells for porphobilinogen deaminase
raised serum levels of delta aminolaevulinic acid and porphobilinogen
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Question 42 of 284
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A 56 year old man presents with episodic facial pain and discomfort whilst eating. He has
suffered from halitosis recently and he frequently complains of a dry mouth. He has a smooth
swelling underneath his right mandible. What is the most likely underlying diagnosis?
Question stats
Score: 46.9%
1
46.2%
22.5%
11.2%
12%
8.2%
A. Stone impacted in Whartons duct

question correctly
B. Stone impacted in Stensens duct
End and review
6
7
C. Benign adenoma of the submandibular gland

8
D. Adenocarcinoma of the submandibular gland

9
Search
E. Squamous cell carcinoma of the submandibular gland
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10
11
Next question
12
The symptoms are typical for sialolithiasis. The stones most commonly form in the
submandibular gland and therefore may occlude Whartons duct. Stensens duct drains the
parotid gland.
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Submandibular glands- disease
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Physiology
The submandibular glands secrete approximately 800- 1000ml saliva per day. They typically
produce mixed seromucinous secretions. When parasympathetic activity is dominant; the
secretions will be more serous. The parasympathetic fibres are derived from the chorda
tympani nerves and the submandibular ganglion. Sensory fibres are conveyed by the lingual
branch of the mandibular nerve.
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Sialolithiasis
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80% of all salivary gland calculi occur in the submandibular gland

70% of the these calculi are radio-opaque
Stones are usually composed of calcium phosphate or calcium carbonate
Patients typically develop colicky pain and post prandial swelling of the gland
Investigation involves sialography to demonstrate the site of obstruction and
associated other stones
Stones impacted in the distal aspect of Whartons duct may be removed orally, other
stones and chronic inflammation will usually require gland excision
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Sialadenitis
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Usually occurs as a result of Staphylococcus aureus infection

Pus may be seen leaking from the duct, erythema may also be noted
Development of a sub mandibular abscess is a serious complication as it may spread
through the other deep fascial spaces and occlude the airway
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Submandibular tumours
Only 8% of salivary gland tumours affect the sub mandibular gland
Of these 50% are malignant (usually adenoid cystic carcinoma)
Diagnosis usually involves fine needle aspiration cytology
Imaging is with CT and MRI
In view of the high prevalence of malignancy, all masses of the submandibular glands
should generally be excised.
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Question 43 of 284
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Question stats
End and review
Score: 46%
1
62.4%
7.2%
8.5%
A. Reed Sternberg Cells
12.1%
B. T lymphocytes
9.8%
C. Macrophages

question correctly
Which of the following cellular types or features is not seen in sarcoidosis?
D. Asteroid bodies
E. B lymphocytes
6
7
8
9
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Reed Sternberg cells are seen in Hodgkins disease. All of the other cell types are seen in
sarcoid.
10
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13
14
Overview
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Acute inflammation

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Suppuration
Complete resolution
Abscess formation
Healing by fibrosis
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Mediators
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End and review
Score: 44.2%
1
15%
9.5%
9.6%
A. Polya gastrectomy for antral ulcer
8.4%
B. Atrophic gastritis
57.5%
C. Intestinal metaplasia of columnar type at the gastric cardia

question correctly
Which of the following diseases is not considered a risk factor for gastric cancer?
D. Patient with polyp showing medium grade dysplasia

E. Long term therapy with H2 blockers
6
7
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9
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10
11
Although some acid lowering procedures increase the risk of gastric cancer the use of H2
blockers does not, at the present time, seem to increase the risk.
12
13
Gastric cancer
14
15
Overview
There are 700,000 new cases of gastric cancer worldwide each year. It is most common in
Japan and less common in western countries. It is more common in men and incidence rises
with increasing age. The exact cause of many sporadic cancer is not known, however,
familial cases do occur in HNPCC families. In addition, smoking and smoked or preserved
foods increase the risk. Japanese migrants retain their increased risk (decreased in
subsequent generations). The distribution of the disease in western countries is changing
towards a more proximal location (perhaps due to rising obesity).
Pathology
There is some evidence of support a stepwise progression of the disease through intestinal
metaplasia progressing to atrophic gastritis and subsequent dysplasia, through to cancer.
The favoured staging system is TNM. The risk of lymph node involvement is related to size
and depth of invasion; early cancers confined to submucosa have a 20% incidence of lymph
node metastasis. Tumours of the gastro-oesophageal junction are classified as below:
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Type
1
True oesophageal cancers and may be associated with Barrett's oesophagus.
Type
2
Carcinoma of the cardia, arising from cardiac type epithelium

or short segments with intestinal metaplasia at the oesophagogastric junction.
Type
3
Sub cardial cancers that spread across the junction. Involve similar nodal stations to
gastric cancer.
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41
Groups for close endoscopic monitoring

Intestinal metaplasia of columnar type
Atrophic gastritis
Low to medium grade dysplasia
Patients who have previously undergone resections for benign peptic ulcer disease
(except highly selective vagotomy).
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43
44
Referral to endoscopy
Patients of any age with
dyspepsia and any of the
following
Patients without
dyspepsia
Worsening dyspepsia
Chronic gastrointestinal bleeding
Dysphagia
Barretts oesophagus
Dysphagia
Unexplained
abdominal pain or
weight loss
Intestinal metaplasia
Weight loss
Vomiting
Dysplasia
Iron deficiency anaemia
Upper abdominal
mass
Atrophic gastritis
Upper abdominal mass
Jaundice
Patient aged over 55 years with

unexplained or persistent
dyspepsia
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Upper GI endoscopy performed for dyspepsia. The addition of dye spraying (as shown in the
bottom right) may facilitate identification of smaller tumours
Staging
CT scanning of the chest abdomen and pelvis is the routine first line staging
investigation in most centres.
Laparoscopy to identify occult peritoneal disease
PET CT (particularly for junctional tumours)
Treatment
Proximally sited disease greater than 5-10cm from the OG junction may be treated by
sub total gastrectomy
Total gastrectomy if tumour is <5cm from OG junction
For type 2 junctional tumours (extending into oesophagus) oesophagogastrectomy is
usual
Endoscopic sub mucosal resection may play a role in early gastric cancer confined to
the mucosa and perhaps the sub mucosa (this is debated)
Lymphadenectomy should be performed. A D2 lymphadenectomy is widely advocated
by the Japanese, the survival advantages of extended lymphadenectomy have been
debated. However, the overall recommendation is that a D2 nodal dissection be
undertaken.
Most patients will receive chemotherapy either pre or post operatively.
Prognosis
UK Data
Disease extent
Percentage 5 year survival
All RO resections
54%
Early gastric cancer
91%
Stage 1
87%
Stage 2
65%
Stage 3
18%
Operative procedure
Total Gastrectomy , lymphadenectomy and Roux en Y anastomosis
General anaesthesia
Prophylactic intravenous antibiotics
Incision: Rooftop.
Perform a thorough laparotomy to identify any occult disease.
Mobilise the left lobe of the liver off the diaphragm and place a large pack over it. Insert a
large self retaining retractor e.g. omnitract or Balfour (take time with this, the set up should
be perfect). Pack the small bowel away.
Begin by mobilising the omentum off the transverse colon.
Proceed to detach the short gastric vessels.
Mobilise the pylorus and divide it at least 2cm distally using a linear cutter stapling device.
Continue the dissection into the lesser sac taking the lesser omentum and left gastric artery
flush at its origin.
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The lymph nodes should be removed en bloc with the specimen where possible.
Place 2 stay sutures either side of the distal oesophagus. Ask the anaesthetist to pull back
on the nasogastric tube. Divide the distal oesophagus and remove the stomach.
The oesphago jejunal anastomosis should be constructed. Identify the DJ flexure and bring a
loop of jejunum up to the oesophagus (to check it will reach). Divide the jejunum at this point.
Bring the divided jejunum either retrocolic or antecolic to the oesophagus. Anastamose the
oesophagus to the jejunum, using either interrupted 3/0 vicryl or a stapling device. Then
create the remainder of the Roux en Y reconstruction distally.
Place a jejunostomy feeding tube.
Wash out the abdomen and insert drains (usually the anastomosis and duodenal stump).
Help the anaesthetist insert the nasogastric tube (carefully!)
Close the abdomen and skin.
Enteral feeding may commence on the first post-operative day. However, most surgeons will
leave patients on free NG drainage for several days and keep them nil by mouth.
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Question 45 of 284
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A 56 year old man is diagnosed as having a glioma. From which of the following cell types do
these tumours usually originate?
A. Astrocytes
B. Oligodendrocytes
Question stats
Score: 43.4%
1
24.5%
19%
10%
5.9%
40.6%

question correctly
C. Ependymal cells
End and review
D. Squamous cells
6
7
8
E. Neuroglial cells
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11
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Gliomas originate from glial (otherwise known as neuroglial) cells. These serve a structural
function in the CNS. The tumours produced may resemble a number of CNS cell types.
Tumours are therefore named according to the cells they resemble rather than the origin.
Where this is not possible they are termed gliomas.
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Glioma
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Glioma is a tumour that is typically found in the CNS. These tumours arise from glial cells.
They are sub categorised according to the cell type they most closely resemble.
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Glioma sub types
21
Ependymomas- Ependymal cells

Astocytomas- Astrocytes (including glioblastoma)
Oligodendrogliomas- Oligodendrocytes
Mixed- e.g. oligoastrocytomas
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Gliomas are categorised as being either high or low grade lesions (the former has the worse
prognosis). They may be either supra or infra tentorial. Their symptoms will typically reflect
their site of origin. Glioblastoma multiforme has the worst prognosis and few patients will
survive beyond 12 months.
31
32-34 0 / 3
35
36
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Question 46 of 284
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A 78 year old man presents with unilateral deafness which has been present for the past 3
months. On examination, Webers test localises to the contralateral side and a CT scan of his
head shows a thickened calvarium with areas of sclerosis and radiolucency. His blood tests
show an elevated alkaline phosphatase, normal serum calcium and normal PTH levels.
Which of the following is the most likely underlying diagnosis?
Question stats
Score: 42.6%
1
21.6%
7.8%
46%
8.1%
16.4%

question correctly
A. Multiple myeloma with skull involvement
End and review
6
7
8
B. Osteoporosis
C. Pagets disease with skull involvement
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D. Lung cancer with skull metastasis
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E. Osteopetrosis with skull involvement
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13
14
Of the conditions listed Pagets disease is the most likely diagnosis (skull vault expansion and
sensorineural hearing loss). Multiple myeloma would typically result in multiple areas of
radiolucency and usually raised calcium in this setting. Osteopetrosis is a recognised cause
of the features described. However, it is a rare inherited disorder and usually presents in
children in young adults. Presentation at this stage with no prior symptoms would be
extremely rare and therefore this is not the most likely diagnosis.
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Pagets disease
20
21
Paget's disease is a disease of increased but uncontrolled bone turnover and is

characterised by architecturally abnormal bones. It is thought to be primarily a disorder of
osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity
causing areas of sclerosis and deformity. Paget's disease is common (UK prevalence 5%)
but symptomatic in only 1 in 20 patients
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Predisposing factors
31
increasing age
male sex
northern latitude
family history
32-34 0 / 3
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Clinical features
38
39
bone pain (e.g. pelvis, lumbar spine, femur)

classical, untreated features: bowing of tibia, bossing of skull
raised alkaline phosphatase (ALP) - calcium* and phosphate are typically normal
skull x-ray: thickened vault, osteoporosis circumscripta
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43
Indications for treatment include bone pain, skull or long bone deformity, fracture,
periarticular Paget's
44
45
bisphosphonate (either oral risedronate or IV zoledronate)

calcitonin is less commonly used now
46
Complications
deafness (cranial nerve entrapment)
bone sarcoma (1% if affected for > 10 years)
fractures
skull thickening
high-output cardiac failure
*usually normal in this condition but hypercalcaemia may occur with prolonged immobilisation
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Question stats
End and review
Score: 43.9%
1
2
Theme: Genetic causes of cancer

A. Multiple endocrine neoplasia type I
47
75.6%
48
65.2%
49
73.3%
B. Multiple endocrine neoplasia type II
3
4
5
C. Gardner's syndrome
D. Lynch Syndrome
Search
E. Kartagener's syndrome
7
Go
F. Von Recklinghausen's disease
8
9
Please select the most likely condition for the disease process described. Each option may
be used once, more than once or not at all
10
11
12
13
47.
A 5 year old boy presents with recurrent episodes of sinusitis. The casualty
staff are surprised to find his liver lying in the left upper quadrant of the
abdomen
14
15
16
Kartagener's syndrome
17
This is a case of Kartagener's syndrome. The primary problem is of immotile

cilia syndrome. When associated with situs inversus Kartagener's syndrome is
diagnosed.
18
19
20
48.
A 22 year old man presents with carcinoma of the caecum. His brother died
from colorectal cancer aged 25 and his mother died from endometrial cancer
aged 38.
21
22
23
Lynch Syndrome
24
This is a case of Lynch syndrome HNPCC. It is transmitted in an autosomal

dominant fashion. Cancer of the uterine body is more common in HNPCC than
Gardners syndrome
49.
A tall 32 year old lady presents with a diffuse neck swelling a carcinoma of the
thyroid medullary type is diagnosed.
25-27 2 / 3
28-30 0 / 3
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32-34 0 / 3
35
36
You answered Multiple endocrine neoplasia type I
37
38
The correct answer is Multiple endocrine neoplasia type II

This is a case MEN type IIb. It is associated with phaeochromocytomas and is
transmitted in an autosomal dominant pattern if inherited. All MEN II tend to
have medullary carcinoma of the thyroid as a presenting feature
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42
Next question
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44
45
46
47-49 2 / 3
presented here.
Autosomal dominant
Diagnosed when:

BRCA 1 and 2
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2).
Lynch Syndrome
Autosomal dominant
Amsterdam criteria
Gardners syndrome
cancer
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Question 50 of 284
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A 45 year old man presents with symptoms of urinary colic. In the history he has suffered
from recurrent episodes of frank haematuria over the past week or so. On examination he
has a left loin mass and a varicocele. The most likely diagnosis is:
Question stats
Score: 43.1%
1
54.4%
9.2%
18%
8.8%
9.5%
A. Renal adenocarcinoma
question correctly
B. Renal cortical adenoma
End and review
6
7
C. Squamous cell carcinoma of the renal pelvis

8
D. Retroperitoneal fibrosis
9
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E. Nephroblastoma
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10
11
12
Renal adenocarcinoma are the most common renal malignancy and account for 75%
cases.
Patients may develop frank haematuria and have episodes of clot colic.
A Grawitz tumour is an eponymous name for Renal Adenocarcinoma.
May metastasise to bone.
13
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15
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17
18
Renal tumours
19
20
Renal cell carcinoma

Renal cell carcinoma is an adenocarcinoma of the renal cortex and is believed to arise from
the proximal convoluted tubule. They are usually solid lesions, up to 20% may be multifocal,
20% may be calcified and 20% may have either a cystic component or be wholly cystic. They
are often circumscribed by a pseudocapsule of compressed normal renal tissue. Spread may
occur either by direct extension into the adrenal gland, renal vein or surrounding fascia.
More distant disease usually occurs via the haematogenous route to lung, bone or brain.
Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are more
commonly affected than females and sporadic tumours typically affect patients in their sixth
decade.
Patients may present with a variety of symptoms including; haematuria (50%), loin pain
(40%), mass (30%) and up to 25% may have symptoms of metastasis.Less than 10% have
the classic triad of haematuria, pain and mass.
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37
Investigation
Many cases will present as haematuria and be discovered during diagnostic work up. Benign
renal tumours are rare, so renal masses should be investigated with multislice CT scanning.
Some units will add and arterial and venous phase to the scan to demonstrate vascularity
and evidence of caval ingrowth.
CT scanning of the chest and abdomen to detect distant disease should also be undertaken.
38
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40
41
42
43
Routine bone scanning is not indicated in the absence of symptoms.

Biopsy should not be performed when a nephrectomy is planned but is mandatory before
any ablative therapies are undertaken.
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46
47-49 2 / 3
Assessment of the functioning of the contra lateral kidney.
50
Management
T1 lesions may be managed by partial nephrectomy and this gives equivalent oncological
results to total radical nephrectomy. Partial nephrectomy may also be performed when there
is inadequate reserve in the remaining kidney.
For T2 lesions and above a radical nephrectomy is standard practice and this may be
performed via a laparoscopic or open approach. Preoperative embolisation is not indicated
nor is resection of uninvolved adrenal glands. During surgery early venous control is
mandatory to avoid shedding of tumour cells into the circulation.
Patients with completely resected disease do not benefit from adjuvant therapy with
either chemotherapy or biological agents. These should not be administered outside the
setting of clinical trials.
Patients with transitional cell cancer will require a nephroureterectomy with disconnection of
the ureter at the bladder.
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References
Lungberg B et al. EAU guidelines on renal cell carcinoma: The 2010 update. European
Urology 2010 (58): 398-406.
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Question 51 of 284
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A 63 year old man finds that he has to stop walking after 100 yards due to bilateral calf pain.
He finds that bending forwards and walking up hill helps. He is able to ride a bike without any
pain. What is the most likely underlying cause?
Question stats
Score: 44.1%
1
59.7%
7.2%
11.6%
12.9%
8.5%
A. Lumbar canal stenosis

question correctly
B. Diabetic neuropathy
End and review
6
7
C. Aorto-iliac occlusion
8
D. Occlusion of the superficial femoral artery

9
Search
E. Pelvic rheumatoid arthritis
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11
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12

The positional nature of the pain and the fact that improves with walking uphill makes an
underlying vascular aetiology far less likely.
13
14
15
16
Lumbar spinal stenosis
17
18
Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk
prolapse or other similar degenerative changes.
Patients may present with a combination of back pain, neuropathic pain and symptoms
mimicking claudication. One of the main features that may help to differentiate it from true
claudication in the history is the positional element to the pain. Sitting is better than standing
and patients may find it easier to walk uphill rather than downhill. The neurogenic
claudication type history makes lumbar spinal stenosis a likely underlying diagnosis, the
absence of such symptoms makes it far less likely.
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21
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Pathology
Degenerative disease is the commonest underlying cause. Degeneration is believed to begin
in the intervertebral disk where biochemical changes such as cell death and loss of
proteoglycan and water content lead to progressive disk bulging and collapse. This process
leads to an increased stress transfer to the posterior facet joints, which accelerates
cartilaginous degeneration, hypertrophy, and osteophyte formation; this is associated with
thickening and distortion of the ligamentum flavum. The combination of the ventral disk
bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hyptertrophy
combine to circumferentially narrow the spinal canal and the space available for the neural
elements. The compression of the nerve roots of the cauda equina leads to the
characteristic clinical signs and symptoms of lumbar spinal stenosis.
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35
36
37
38
39
40
Diagnosis
MRI scanning is the best modality for demonstrating the canal narrowing. Historically a
bicycle test was used as true vascular claudicants could not complete the test.
41
42
43
Treatment
Laminectomy
44
45
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51
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Question 52 of 284
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A 73 year old lady is admitted for a laparoscopic cholecystectomy. During her pre-operative
assessment it is noted that she is receiving furosemide for the treatment of hypertension.
Approximately what proportion of the sodium that is filtered at the glomerulus will be
subsequently excreted?
Question stats
Score: 43.3%
1
40.2%
17.1%
20.3%
12.1%
10.2%

question correctly
A. Up to 25%
End and review
B. Upt to 75%
6
7
8
C. Between 3 and 5%
Search
D. <2%
E. Between 1 and 2%
Go
10
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12
13

The loop diuretics can lead to marked increases in the amount of sodium excreted. They act
in the medullary and cortical aspects of the thick ascending limb of the loop of Henle. This
results in a decreased medullary osmolal gradient and increases free water excretion (as well
as loss of sodium). Because loop diuretics result in the loss of both sodium and water they
are less frequently associated with hyponatraemia than thiazide diuretics (these latter agents
act in the cortex and do not affect urine concentrating ability).
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17
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19
Diuretic agents
20
21
The diuretic drugs are divided into three major classes, which are distinguished according to
the site at which they impair sodium reabsorption: loop diuretics in the thick ascending loop
of Henle, thiazide type diuretics in the distal tubule and connecting segment; and potassium
sparing diuretics in the aldosterone - sensitive principal cells in the cortical collecting tubule.
22
23
24
In the kidney, sodium is reabsorbed through Na+/ K+ ATPase pumps located on the
basolateral membrane. These pumps return reabsorbed sodium to the circulation and
maintain low intracellular sodium levels. This latter effect ensures a constant concentration
gradient.
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Physiological effects of commonly used diuretics

Site of action
Diuretic
35
Carrier or
channel
inhibited
Percentage of filtered
sodium excreted
36
37
38
Ascending limb of loop of

Henle
Frusemide
Na+/K+ 2Cl carrier
Upt to 25%
Distal tubule and

connecting segment
Thiazides
Na+Cl- carrier
Between 3 and 5%
Cortical collecting tubule
Spironolactone
Na+/K+ ATP ase

pump
Between 1 and 2%
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A 59 year old man presents with recurrent episodes of urinary sepsis. In his history he
mentions that he has suffered from recurrent attacks of left iliac fossa pain over the past few
months. He has also notices bubbles in his urine. He undergoes a CT scan which shows a
large inflammatory mass in the left iliac fossa. No other abnormality is detected. The most
likely diagnosis is:
Question stats
Score: 44.3%
1
11.3%
18.5%
6.5%
54.1%
9.7%

question correctly
A. Ulcerative colitis
End and review
6
7
8
B. Crohns disease
C. Mesenteric ischaemia
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D. Diverticular disease
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E. Rectal cancer
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11
12
Next question
13
14
Diverticular disease is one of the commonest causes of colovesical fistula
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16
Theme from 2009 and 2011 Exam

Recurrent attacks of diverticulitis may cause the development of local abscesses which may
erode into the bladder resulting in urinary sepsis and pneumaturia. This would be an unusual
presentation from Crohns disease and rectal cancer would be more distally sited and
generally evidence of extra colonic disease would be present if the case were malignant and
this advanced.
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Diverticular disease
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24
Diverticular disease is a common surgical problem. It consists of herniation of colonic mucosa

through the muscular wall of the colon. The usual site is between the taenia coli where
vessels pierce the muscle to supply the mucosa. For this reason, the rectum, which lacks
taenia, is often spared.
25-27 2 / 3
28-30 0 / 3
31
32-34 0 / 3
Symptoms
Altered bowel habit
Bleeding
Abdominal pain
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39
Complications
Diverticulitis
Haemorrhage
Development of fistula
Perforation and faecal peritonitis
Perforation and development of abscess
Development of diverticular phlegmon
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45
46
Diagnosis
Patients presenting in clinic will typically undergo either a colonoscopy, CT cologram or
barium enema as part of their diagnostic work up. All tests can identify diverticular disease. It
can be far more difficult to confidently exclude cancer, particularly in diverticular strictures.
47-49 2 / 3
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52
Acutely unwell surgical patients should be investigated in a systematic way. Plain abdominal
films and an erect chest x-ray will identify perforation. An abdominal CT scan (not a CT
cologram) with oral and intravenous contrast will help to identify whether acute inflammation
is present but also the presence of local complications such as abscess formation.
53
Severity Classification- Hinchey

I
Para-colonic abscess
II
Pelvic abscess
III
Purulent peritonitis
IV
Faecal peritonitis
Treatment
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Increase dietary fibre intake.

Mild attacks of diverticulitis may be managed conservatively with antibiotics.
Peri colonic abscesses should be drained either surgically or radiologically.
Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative
indication for a segmental resection.
Hinchey IV perforations (generalised faecal peritonitis) will require a resection and
usually a stoma. This group have a very high risk of post operative complications and
usually require HDU admission. Less severe perforations may be managed by
laparoscopic washout and drain insertion.
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Question 54 of 284
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Question stats
End and review
Score: 45.2%
1
9.6%
10%
10.4%
A. Gastric ulcers
34.7%
B. Gastric cancer
35.4%
C. Anaemia

question correctly
Which of the following is least likely to occur in association with severe atrophic gastritis?
D. Duodenal ulcers
E. Gastric polyps
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7
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9
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10
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Achlorhydria would make the formation of duodenal ulcers unlikely. Note the question
states "least likely".
12
13
14
Due to the loss of gastric acid a duodenal ulcer is unlikely. Note that gastric polyps may form
(see below).
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Gastritis
18
Type of
gastritis
Features
Type A
Autoimmune
Circulating antibodies to parietal cells, causes reduction in cell mass and
hypochlorhydria
Loss of parietal cells = loss of intrinsic factor = B12 malabsorption
Absence of antral involvement
Hypochlorhydria causes elevated gastrin levels- stimulating enterochromaffin
cells and adenomas may form
Type B
Reflux
gastritis
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22
23
24
25-27 2 / 3
28-30 0 / 3
Antral gastritis
Associated with infection with helicobacter pylori infection
Intestinal metaplasia may occur in stomach and require surveillance endoscopy
Peptic ulceration may occur
31
32-34 0 / 3
35
36
Bile refluxes into stomach, either post surgical or due to failure of pyloric
function
Histologically, evidence of chronic inflammation, and foveolar hyperplasia
May respond to therapy with prokinetics
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38
39
Erosive
gastritis
Stress
ulceration
Agents disrupt the gastric mucosal barrier

Most commonly due to NSAIDs and alcohol
With NSAIDs the effects occur secondary to COX 1 inhibition
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42
This occurs as a result of mucosal ischaemia during hypotension or

hypovolaemia
The stomach is the most sensitive organ in the GI tract to ischaemia following
hypovolaemia
Diffuse ulceration may occur
Prophylaxis with acid lowering therapy and sucralfate may minimise
complications
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47-49 2 / 3
Menetriers
disease
Gross hypertrophy of the gastric mucosal folds, excessive mucous production

and hypochlorhydria
Pre malignant condition
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References
Whiting J et al. The long term results of endoscopic surveillance of premalignant gastric
lesions. Gut 2002; 50 :378381.
53
54
Dixon M et al. Reflux gastritis: distinct histopathological entity?J Clin Pathol 1986; 39 : 524530.
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End and review
Score: 44.6%
1
2
Theme: Lung cancer

A. Adenocarcinoma
55
56.3%
56
56.5%
57
41.8%
B. Small cell lung cancer
3
4
5
C. Large cell lung cancer
D. Squamous cell carcinoma
Search
Please select the most likely lung cancer variant for the scenario described. Each option may
be used once, more than once or not at all.
7
Go
8
9
10
11
55.
A 73 year old heavy smoker presents with haemoptysis. On examination he is

cachectic and shows evidence of clubbing. Imaging shows a main bronchial
tumour with massive mediastinal lymphadenopathy together with widespread
visceral metastases.
12
13
14
15
Small cell lung cancer
16

Small cell carcinoma is associated with disseminated disease at presentation in
the majority of cases. Most cases occur in the main airways and paraneoplastic
features are common.
56.
A 68 year old female who has never smoked presents with a mass at the
periphery of her right lung.
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18
19
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22
You answered Large cell lung cancer
23
The correct answer is Adenocarcinoma
24
Adenocarcinomas are the most common tumour type present in never

smokers. They are usually located at the periphery.
25-27 2 / 3
28-30 0 / 3
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57.
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.
32-34 0 / 3
35
36
37
38
You answered Small cell lung cancer
39
The correct answer is Squamous cell carcinoma

40
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.
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Next question
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46
47-49 2 / 3
Lung cancer
50
51
Lung cancers may be classified according to histological subtypes. The main distinction is
between small cell and non small cell lung cancer. Non small cell lung cancer is the most
common variant and accounts for 80% of all lung cancers.
Non small cell lung cancer
These share common features of prognosis and management. They comprise the following
tumours:
52
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54
55-57 1 / 3
Squamous cell carcinoma (25% cases)

Adenocarcinoma (40% cases)
Large cell carcinoma (10% cases)
Paraneoplastic features and early disease dissemination are less likely than with small cell
lung carcinoma. Adenocarcinoma is the most common lung cancer type encountered in
never smokers.
Small cell lung carcinoma
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Small cell lung carcinomas are comprised of cells with a neuro endocrine differentiation. The
neuroendocrine hormones may be released from these cells with a wide range of
paraneoplastic associations. These tumours are strongly associated with smoking and will
typically arise in the larger airways. They disseminate early in the course of the disease and
although they are usually chemosensitive this seldom results in long lasting remissions.
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Question 58 of 284
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Question stats
End and review
Score: 46.3%
1
14.7%
38%
16.3%
A. Pappenheimer bodies
15.8%
B. Stipple cells
15.1%
C. Erythrocyte containing siderotic granules

question correctly
Which of the following is not found on a blood film post splenectomy?
D. Howell-Jolly bodies
E. Target cells
6
7
8
9
Search
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10
11
Stipple cells are found in lead poisoning/haemoglobinopathies.
12
Blood film in hyposplenism:
13
14
Howell-Jolly bodies
Pappenheimer bodies
Poikilocytes (Target cells)
Erythrocyte containing siderotic granules
Heinz bodies
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16
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18
19
20
weeks.
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24
25-27 2 / 3
28-30 0 / 3
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32-34 0 / 3
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44
45
46
47-49 2 / 3
50
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55-57 1 / 3
58
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A 45 year old man with long standing ulcerative colitis and rectal dysplasia presents with a
DALM lesion in the rectum. What is the most appropriate management option?
A. Snare polypectomy
B. Repeat endoscopy in 2 years
Question stats
Score: 45.6%
1
22.6%
11.3%
7.3%
19.8%
39%

question correctly
C. Discharge
End and review
D. Anterior resection
6
7
8
E. Panproctocolectomy
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10
11
12
DALM lesions complicating ulcerative colitis should be managed with panproctocolectomy. An

anterior resection is inadequate since it will only remove the rectum and ulcerative colitis
affects the entire colon. Since many will be associated with invasion a snare polypectomy is
not sufficient either.
13
14
15
Colonic lesions - DALM
16
17
18
The term DALM lesion refers to a Dysplasia Associated Lesion or Mass.

They may complicate dysplasia occurring in patients with longstanding ulcerative
colitis.
They have a high incidence of invasive foci.
When they complicate longstanding ulcerative colitis, they should be treated by
panproctocolectomy.
19
20
21
22
23
24
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25-27 2 / 3
28-30 0 / 3
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31
32-34 0 / 3
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44
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47-49 2 / 3
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Question 60 of 284
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Which of the metastatic bone tumours described below is at the greatest risk of pathological
fracture ?
A. Proximal humeral lesion from a prostate cancer

B. Vertebral body lesions from a prostate cancer
Question stats
Score: 44.3%
1
7.4%
25.7%
36%
13.8%
17.1%

question correctly
C. Peritrochanteric lesion from a carcinoma of the breast
End and review
D. Proximal humeral lesion from a carcinoma of the breast
6
7
8
E. Peritrochanteric lesion from a prostate cancer
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10
11
Peritrochanteric lesions have the greatest risks of fracture (due to loading). The lesions from
breast cancer are usually lytic and therefore at higher risk rather than the sclerotic lesions
from prostate cancer.
12
Metastatic bone disease- risk of fracture
15
13
14
16
Metastatic bone tumours may be described as blastic, lytic or mixed. Osteoblastic metastatic
disease has the lowest risk of spontaneous fracture when compared to osteolytic lesions of a
similar size.
Lesions affecting the peritrochanteric region are most prone to spontaneous fracture
(because of loading forces at that site).
The factors are incorporated into the Mirel Scoring system to stratify the risk of spontaneous
fracture for bone metastasis of varying types.
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Mirel Scoring system
23
24
Score
points
Site
Radiographic
appearance
Width of bone
involved
Pain
Upper
extremity
Blastic
Less than 1/3
Mild
Lower
extremity
Mixed
Peritrochanteric
Lytic
25-27 2 / 3
28-30 0 / 3
31
32-34 0 / 3
1/3 to 2/3
35
Moderate
36
More than 2/3
37
Aggravated by
function
38
39
Depending upon the score the treatment should be as follows:
40
41
Score
Risk of fracture
Treatment
42
9 or greater
Impending (33%)
Prophylactic fixation
43
Borderline
Consider fixation
7 or less
Not impending (4%)
Non operative management
44
45
46
47-49 2 / 3
50
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55-57 1 / 3
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Question 61 of 284
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A 63 year old male presents with several episodes of haematuria. He suffers from COPD
secondary to long term smoking. What is the most likely underlying cause?
A. Renal cortical adenoma

B. Renal adenocarcinoma
Question stats
Score: 43.1%
1
6.3%
17.5%
7.1%
57.4%
11.7%

question correctly
C. Nephroblastoma
End and review
D. Transitional cell carcinoma of the bladder
6
7
8
E. Adenocarcinoma of the bladder
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10
11

TCC is the most common subtype and is strongly linked to smoking. The important point to
note in this question is the term most likely as renal adenocarcinoma may produce similar
symptoms but is less likely.
12
13
14
15
Bladder cancer
16
17
Bladder cancer is the second most common urological cancer. It most commonly affects
males aged between 50 and 80 years of age. Those who are current, or previous (within 20
years), smokers have a 2-5 fold increased risk of the disease. Exposure to hydrocarbons
such as 2-Naphthylamine increases the risk. Although rare in the UK, chronic bladder
inflammation arising from Schistosomiasis infection remains a common cause of squamous
cell carcinomas, in those countries where the disease is endemic.
18
19
20
21
22
Benign tumours
Benign tumours of the bladder including inverted urothelial papilloma and nephrogenic
adenoma are uncommon.
Bladder malignancies
23
24
25-27 2 / 3
28-30 0 / 3
31
Transitional cell carcinoma (>90% of cases)

Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis)
Adenocarcinoma (2%)
32-34 0 / 3
35
36
Transitional cell carcinomas may arise as solitary lesions, or may be multifocal, owing to the
effect of "field change" within the urothelium. Up to 70% of TCC's will have a papillary growth
pattern. These tumours are usually superficial in location and accordingly have a better
prognosis. The remaining tumours show either mixed papillary and solid growth or pure solid
growths. These tumours are typically more prone to local invasion and may be of higher
grade, the prognosis is therefore worse. Those with T3 disease or worse have a 30% (or
higher) risk of regional or distant lymph node metastasis.
37
TNM Staging
43
38
39
40
41
42
44
Stage
Description
T0
No evidence of tumour
Ta
Non invasive papillary carcinoma
T1
Tumour invades sub epithelial connective tissue
T2a
Tumor invades superficial muscularis propria (inner half)
T2b
Tumor invades deep muscularis propria (outer half)
T3
Tumour extends to perivesical fat
T4
Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina
T4a
Invasion of uterus, prostate or bowel
60
T4b
Invasion of pelvic sidewall or abdominal wall
61
N0
No nodal disease
N1
Single regional lymph node metastasis in the true pelvis (hypogastric, obturator,
external iliac, or presacral lymph node)
N2
Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator,
45
46
47-49 2 / 3
50
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55-57 1 / 3
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external iliac, or presacral lymph node metastasis)

N3
Lymph node metastasis to the common iliac lymph nodes
M0
No distant metastasis
M1
Distant disease
Presentation
Most patients (85%) will present with painless, macroscopic haematuria. In those patients
with incidental microscopic haematuria, up to 10% of females aged over 50 will be found to
have a malignancy (once infection excluded).
Staging
Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis
and information relating to depth of invasion. Locoregional spread is best determined using
pelvic MRI and distant disease CT scanning. Nodes of uncertain significance may be
investigated using PET CT.
Treatment
Those with superficial lesions may be managed using TURBT in isolation. Those with
recurrences or higher grade/ risk on histology may be offered intravesical chemotherapy.
Those with T2 disease are usually offered either surgery (radical cystectomy and ileal
conduit) or radical radiotherapy.
Prognosis
T1
90%
T2
60%
T3
35%
T4a
10-25%
Any T, N1-N2
30%
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Question stats
End and review
Score: 41.3%
1
2
Theme: Neck lumps

A. Cystic hygroma
62
79.4%
63
70.5%
64
88.3%
B. Bartonella infection
3
4
5
C. Mycobacterium tuberculosis infection
D. Branchial cyst
Search
E. Thyroglossal cyst
7
Go
F. Pharyngeal pouch
8
9
G. Follicular thyroid cyst

10
H. Parathyroid adenoma
11
I. None of the above
12
Please select the most likely underlying disease process for the scenario given. Each option
13
14
15
62.
A 25 year old cat lover presents with symptoms of abdominal pain, lethargy and
sweats. These have been present for the past two weeks. On examination she
has lymphadenopathy in the posterior triangle.
16
17
18
19
You answered Branchial cyst
20
The correct answer is Bartonella infection
21

Bartonella infection may occur following a cat scratch. The organism is
intracellular. Generalised systemic symptoms may occur for a week or so prior
to clinical presentation.
63.
A 25 year old lady presents with an swelling located at the anterior border of
the sternocleidomastoid muscle. The swelling is intermittent and on examination
it is soft and fluctuant.
22
23
24
25-27 2 / 3
28-30 0 / 3
31
32-34 0 / 3
35
You answered Follicular thyroid cyst
36
The correct answer is Branchial cyst

37
Branchial cysts are remnants of the branchial cleft. They may become infected.
64.
A 38 year old lady presents with a mass in the midline of the neck immediately
below the hyoid bone. It moves upwards on tongue protrusion.
38
39
40
41
You answered Cystic hygroma
42
The correct answer is Thyroglossal cyst
43
Thyroglossal cysts are usually located in the midline and are linked to the
foramen caecum and will thus move upwards on tongue protrusion.
44
45
46
47-49 2 / 3
Next question
50
51
52
Neck lumps
53
The table below gives characteristic exam question features for conditions causing neck
lumps:
54
55-57 1 / 3
58
Reactive
lymphadenopathy
By far the most common cause of neck swellings. There may be a history
of local infection or a generalised viral illness
Lymphoma
Rubbery, painless lymphadenopathy

The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly
Thyroid swelling
May be hypo-, eu- or hyperthyroid symptomatically

Moves upwards on swallowing
Thyroglossal cyst
More common in patients < 20 years old
59
60
61
62-64 0 / 3
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Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected
Pharyngeal
pouch
More common in older men

Represents a posteromedial herniation between thyropharyngeus and
cricopharyngeus muscles
Usually not seen, but if large then a midline lump in the neck that gurgles
on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic
cough
Cystic hygroma
A congenital lymphatic lesion (lymphangioma) typically found in the neck,

classically on the left side
Most are evident at birth, around 90% present before 2 years of age
Branchial cyst
An oval, mobile cystic mass that develops between the

sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in
embryonic development
Usually present in early adulthood
Cervical rib
More common in adult females

Around 10% develop thoracic outlet syndrome
Carotid aneurysm
Pulsatile lateral neck mass which doesn't move on swallowing
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A 22 year old man presents with a discharging area on his lower back. On examination there
is an epithelial defect located 6cm proximal to the tip of his coccyx and located in the midline.
There are two further defects located about 2cm superiorly in the same position. He is
extremely hirsute. What is the most likely diagnosis?
Question stats
Score: 42.1%
1
7%
10.1%
56.5%
7.7%
18.7%

question correctly
A. Pre sacral tumour
End and review
B. Sacrococcygeal teratoma
6
7
8
C. Pilonidal sinus
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D. Fistula in ano
E. Occult spina bifida
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10
11
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12
13
Pilonidal sinuses are extremely common in hirsute individuals and typically present as midline
sinuses in the natal cleft.
14
15
Pilonidal sinus
16
17
18
Occur as a result of hair debris creating sinuses in the skin (Bascom theory).
Usually in the natal cleft of male patients after puberty.
It is more common in Caucasians related to their hair type and growth patterns.
The opening of the sinus is lined by squamous epithelium, but most of its wall consists
of granulation tissue. Up to 50 cases of squamous cell carcinoma have been
described in patients with chronic pilonidal sinus disease.
Hairs become trapped within the sinus.
Clinically the sinus presents when acute inflammation occurs, leading to an abscess.
Patients may describe cycles of being asymptomatic and periods of pain and
discharge from the sinus.
Treatment is difficult and opinions differ. Definitive treatment should never be
undertaken when acute infection or abscess is present as this will result in failure.
Definitive treatments include the Bascom procedure with excision of the pits and
obliteration of the underlying cavity. The Karydakis procedure involves wide excision of
the natal cleft such that the surface is recontoured once the wound is closed. This
avoids the shearing forces that break off the hairs and has reasonable results.
19
20
21
22
23
24
25-27 2 / 3
28-30 0 / 3
31
32-34 0 / 3
35
36
37
Pilonidal sinuses are most commonly located in the midline of the natal cleft, as illustrated
below
38
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45
46
47-49 2 / 3
50
51
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54
55-57 1 / 3
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65
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A 43 year old man from Greece presents with colicky right upper quadrant pain, jaundice and
an urticarial rash. He is initially treated with ciprofloxacin, but does not improve. What is the
most likely diagnosis?
Question stats
Score: 41.6%
1
17.5%
37.7%
10.3%
8.5%
26.1%
A. Infection with Wucheria bancrofti

question correctly
B. Infection with Echinococcus granulosus
End and review
6
7
C. Type III hypersensitivity reaction

8
D. Allergy to ciprofloxacin
9
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E. Common bile duct stones
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10
11
Next question
12
Infection with Echinococcus granulosus will typically produce a type I hypersensitivity reaction
which is characterised by a urticarial rash. With biliary rupture a classical triad of biliary colic,
jaundice and urticaria occurs. Whilst jaundice and biliary colic may be a feature of CBD
stones they do not produce an urticarial rash. Antibiotic sensitivity with ciprofloxacin may
produce jaundice and a rash, however it was not present at the outset and does not cause
biliary colic.
13
Hydatid cysts
18
14
15
16
17
19
Hydatid cysts are endemic in Mediterranean and Middle Eastern countries. They are caused
by the tapeworm parasite Echinococcus granulosus. An outer fibrous capsule is formed
containing multiple small daughter cysts. These cysts are allergens which precipitate a type
1 hypersensitivity reaction.
20
21
22
23
Clinical features are as follows:
24
Up to 90% cysts occur in the liver and lungs

Can be asymtomatic, or symptomatic if cysts > 5cm in diameter
Morbidity caused by cyst bursting, infection and organ dysfunction (biliary, bronchial,
renal and cerebrospinal fluid outflow obstruction)
In biliary ruputure there may be the classical triad of; biliary colic, jaundice, and
urticaria
25-27 2 / 3
28-30 0 / 3
31
32-34 0 / 3
35
36
37
CT is the best investigation to differentiate hydatid cysts from amoebic and pyogenic cysts.
Surgery is the mainstay of treatment (the cyst walls must not be ruptured during removal and
the contents sterilised first).
38
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40
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41
42
43
44
45
46
47-49 2 / 3
50
51
52
53
54
55-57 1 / 3
58
59
60
61
62-64 0 / 3
65
66
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Question 67 of 284
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A 22 year old lady presents with an episode of renal colic and following investigation is
suspected of suffering from MEN IIa. Which of the following abnormalities of the parathyroid
glands are most often found in this condition?
Question stats
Score: 42.3%
1
8.2%
33.7%
30.4%
18.4%
9.4%
A. Hypertrophy
question correctly
B. Hyperplasia
End and review
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7
C. Adenoma
8
D. Carcinoma
9
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E. Metaplasia
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11
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13
MEN IIa
14
Medullary thyroid cancer

Hyperparathyroidism (usually hyperplasia)
Phaeochromocytoma
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17
18
In MEN IIa the commonest lesion is medullary thyroid cancer, with regards to the parathyroid
glands the most common lesion is hyperplasia. In MEN I a parathyroid adenoma is the most
common lesion.
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21
Multiple Endocrine Neoplasia
22
Multiple endocrine neoplasia (MEN) is inherited as an autosomal dominant disorder.
23
24
The table below summarises the three main types of MEN:

MEN type I
MEN type IIa
25-27 2 / 3
28-30 0 / 3
MEN type IIb
31
32-34 0 / 3
Mnemonic 'three P's':

Parathyroid (95%): Parathyroid adenoma
Pituitary (70%): Prolactinoma/ACTH/Growth
Hormone secreting adenoma
Pancreas (50%): Islet cell tumours/Zollinger
Ellison syndrome
Phaeochromocytoma
Medullary thyroid
cancer (70%)
Hyperparathyroidism
(60%)
Same as MEN IIa

with addition of:
Marfanoid body
habitus
Mucosal neuromas
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also: Adrenal (adenoma) and thyroid (adenoma)

MENIN gene (chromosome 11)
35
40
RET oncogene
(chromosome 10)
RET oncogene
(chromosome 10)
Most common presentation = hypercalcaemia
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45
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46
47-49 2 / 3
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Question 68 of 284
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A male infant is born prematurely at 34 weeks gestation by emergency cesarean section. He

initially appears to be stable. However, over the ensuing 24 hours he develops worsening
neurological function. Which of the following processes is most likely to have occurred?
Question stats
Score: 41.8%
1
11.6%
10.9%
9.3%
54.1%
14.1%
A. Extra dural haemorrhage

question correctly
B. Sub dural haemorrhage
End and review
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7
C. Sub arachnoid haemorrhage

8
D. Intraventricular haemorrhage
9
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E. Arteriovenous malformation
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11
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13
14
15
Intraventricular haemorrhage
16
Intraventricular haemorrhage is a haemorrhage that occurs into the ventricular system of the
brain. It is relatively rare in adult surgical practice and when it does occur, it is typically
associated with severe head injuries. In premature neonates it may occur spontaneously.
The blood may clot and occlude CSF flow, hydrocephalus may result.
In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the
aetiology is not well understood and it is suggested to occur as a result of birth trauma
combined with cellular hypoxia, together the with the delicate neonatal CNS.
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Treatment
Is largely supportive, therapies such as intraventricular thrombolysis and prophylactic CSF
drainage have been trialled and not demonstrated to show benefit. Hydrocephalus and rising
ICP is an indication for shunting.
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25-27 2 / 3
28-30 0 / 3
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Question 69 of 284
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A 22 year old man is admitted to hospital with a lower respiratory chest infection. He had a
splenectomy after being involved in a car accident. What is the most likely infective
organism?
Question stats
Score: 41.3%
1
67.9%
10.2%
6.4%
8.1%
7.3%
A. Haemophilus influenzae
question correctly
B. Staphylococcus aureus
End and review
6
7
C. Rhinovirus
8
D. Mycobacterium tuberculosis
9
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E. Moraxella catarrhalis
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10
11
12
Organisms causing post splenectomy sepsis:

Streptococcus pneumoniae
Haemophilus influenzae
Meningococci
13
14
15
16
17
Encapsulated organisms carry the greatest pathogenic risk following splenectomy. The
effects of sepsis following splenectomy are variable. This may be the result of small isolated
fragments of splenic tissue that retain some function following splenectomy. These may
implant spontaneously following splenic rupture (in trauma) or be surgically implanted at the
time of splenectomy.
Post splenectomy sepsis
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Hyposplenism may complicate certain medical conditions where splenic atrophy occurs or
may be the result of medical intervention such as splenic artery embolization and
splenectomy for trauma. Diagnosis of hyposplenism is difficult and whilst there may be
peripheral markers of the splenectomised state (e.g. Howell Jolly bodies) these are neither
100% sensitive or specific. The most sensitive test is a radionucleotide labeled red cell scan.
Hyposplenism, by whatever mechanism it occurs dramatically increases the risk of post
splenectomy sepsis, particularly with encapsulated organisms. Since these organisms may
be opsonised, but this then goes undetected at an immunological level due to loss of the
spleen. For this reason individuals are recommended to be vaccinated and have antibiotic
prophylaxis.
24
25-27 2 / 3
28-30 0 / 3
31
32-34 0 / 3
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Key recommendations
All those with hyposplenism or may become so (such as prior to an elective
splenectomy) should receive pneumococcal, haemophilus type b and meningococcal
type C vaccines. These should be administered 2 weeks prior to splenectomy or two
weeks following splenectomy. The vaccine schedule for meningococcal disease
essentially consists of a dose of Men C and Hib at 2 weeks and then a dose of the
MenACWY vaccine one month later. Those aged under 2 may require a booster at 2
years. A dose of pneumococcal polyvalent polysaccharide vaccine (PPV) is given at
two weeks. A conjugated vaccine (PCV) is offered to young children. The PCV is more
immunogenic but covers fewer serotypes. Boosting PPV is either guided by serological
measurements (where available) or by routine boosting doses at 5 yearly intervals.
Annual influenza vaccination is recommended in all cases
Antibiotic prophylaxis is offered to all. The risk of post splenectomy sepsis is greatest
immediately following splenectomy and in those aged less than 16 years or greater
than 50 years. Individuals with a poor response to pneumococcal vaccination are
another high risk group. High risk individuals should be counselled to take penicillin or
macrolide prophylaxis. Those at low risk may choose to discontinue therapy. All
patients should be advised about taking antibiotics early in the case of intercurrent
infections.
Asplenic individuals traveling to malaria endemic areas are at high risk and should
have both pharmacological and mechanical protection.
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47-49 2 / 3
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54
55-57 1 / 3
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59
60
Dosing
Penicillin V 500mg BD or amoxicillin 250mg BD
References
Davies J et al. Review of guidelines for the prevention and treatment of infection in patients
with an absent or dysfunctional spleen: Prepared on behalf of the British Committee for
Standards in Haematology by a Working Party of the Haemato-Oncology Task Force. British
Journal of Haematology 2011 (155): 308317.
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62-64 0 / 3
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Question 70 of 284
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A 24 year old man presents with symptoms of malaise, weight loss and lymphadenopathy. A
lymph node biopsy is performed and the subsequent histology report states that there is
evidence of granuloma formation and central necrosis. What is the most likely underlying
cause?
Question stats
Score: 40.7%
1
12.1%
7.8%
9.5%
7.2%
63.4%

question correctly
A. Non Hodgkins lymphoma
End and review
B. Churg Strauss syndrome
6
7
8
C. Epstein Barr Virus infection
Search
D. Rheumatoid nodule
E. Infection with Mycobacterium tuberculosis
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10
11
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12
13
These histological features are typically seen in TB. Necrosis occurring in granulomas is
usually indicative of an underlying infective cause. Churg Strauss syndrome is a form of
vasculitis, which is the usual histological finding. Granulomas are reported in the condition,
but it is rare for them to demonstrate necrosis.
14
15
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18
19

histiocytes.
20
21
22
23
24
25-27 2 / 3
28-30 0 / 3
31
32-34 0 / 3
Diagnosis
35
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45
46
47-49 2 / 3
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54
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55-57 1 / 3
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60
61
62-64 0 / 3
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Question 71 of 284
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A 20 year old man develops acute appendicitis, his appendix is removed and he makes a full
recovery. Which of the following pathological processes is least likely to be present in the
acutely inflamed tissues?
Question stats
Score: 39.8%
1
16.4%
10.6%
8.3%
55.6%
9.1%
A. Altered Starlings forces.

question correctly
B. Seqestration of neurophils
End and review
6
7
C. Formation of fluid exudate

8
D. Formation of granulomas
9
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10
11
12
Neutrophil polymorphs=Acute inflammation.

Granuloma = Chronic inflammation.
13
14
15
Acute inflammation:
3 phases
1. Changes in blood vessel and flow: flush, flare, wheal
2. Fluid exudates (rich in protein i.e. Ig, coagulation factors) produced via increased vascular
permeability
3. Cellular exudates mainly containing neutrophil polymorphs pass into extravascular space.
Neutrophils are then transported to tissues via:
16
17
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20
21
22
a. Margination of neutrophils to the peripheral plasmatic of the vessel rather than the
central axial stream
b. Pavementing: Adhesion of neutrophils to endothelial cells in venules at site of acute
inflammation
c. Emigration: neutrophils pass between endothelial cells into the tissue
25-27 2 / 3
28-30 0 / 3
Acute inflammation
32-34 0 / 3
23
24
31
35
36
37
38
39
Vascular changes
40

proteins.
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46
47-49 2 / 3
Sequelae
50
Resolution

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Organisation

54
55-57 1 / 3
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Suppuration

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inflammation

62-64 0 / 3
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Causes
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Chemical agents
Tissue necrosis
69
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71

inflammation
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Question stats
End and review
Score: 39.5%
1
2
Theme: Liver lesions

A. Haemangioma
72
90.8%
73
70.1%
74
46.8%
B. Hepatocellular carcinoma
3
4
5
C. Hepatic metastasis
D. Polycystic liver disease
Search
E. Simple liver cyst
7
Go
F. Hyatid cyst
8
9
G. Amoebic abscess
10
H. Mesenchymal hamartoma
11
Please select the most likely liver lesion for the scenario given. Each option may be used
12
13
14
15
72.
A 42 year old lady has suffered from hepatitis C for many years and has also
developed cirrhosis. On routine follow up, an ultrasound has demonstrated a
2.5cm lesion in the right lobe of the liver.
16
17
18
19
In patients with cirrhosis the presence of a lesion >2cm is highly suggestive of

malignancy. The diagnosis is virtually confirmed if the AFP is >400ng/mL.
20
21
73.
A 25 year old man from the far east presents with a fever and right upper
quadrant pain. As part of his investigations a CT scan shows an ill defined
lesion in the right lobe of the liver.
22
23
24
You answered Polycystic liver disease
25-27 2 / 3
28-30 0 / 3
The correct answer is Amoebic abscess
31
Amoebic abscesses will tend to present in a similar fashion to other pyogenic

liver abscesses. They should be considered in any individual presenting from a
region where Entamoeba histiolytica is endemic. Treatment with metronidazole
usually produces a marked clinical response.
32-34 0 / 3
35
36
37
74.
A 42 year old lady presents with right upper quadrant pain and a sensation of
abdominal fullness. An ultrasound scan demonstrates a 6.5 cm hyperechoic
lesion in the right lobe of the liver. Serum AFP is normal.
38
39
40
You answered Hepatic metastasis
41
The correct answer is Haemangioma
42
A large hyperechoic lesion in the presence of normal AFP is likely to be a

haemangioma. An HCC of equivalent size will almost always result in rise in
AFP.
43
44
45
46
Next question
47-49 2 / 3
50
51
Benign liver lesions
52
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54
Benign liver lesions

Haemangioma
55-57 1 / 3
Most common benign tumours of mesenchymal origin

Incidence in autopsy series is 8%
Cavernous haemangiomas may be enormous
Clinically they are reddish purple hypervascular lesions
Lesions are normally separated from normal liver by ring of fibrous tissue
On ultrasound they are typically hyperechoic
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62-64 0 / 3
Liver cell
adenoma
65
90% develop in women in their third to fifth decade

Linked to use of oral contraceptive pill
Lesions are usually solitary
They are usually sharply demarcated from normal liver although they
usually lack a fibrous capsule
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On ultrasound the appearances are of mixed echoity and heterogeneous

texture. On CT most lesions are hypodense when imaged prior to
administration of IV contrast agents
In patients with haemorrhage or symptoms removal of the adenoma may
be required
69
70
71
72-74 1 / 3
Mesenchymal
hamartomas
Liver abscess
Amoebic
abscess
Hyatid cysts
Polycystic
liver disease
Cystadenoma
Congential and benign, usually present in infants. May compress normal liver
Biliary sepsis is a major predisposing factor

Structures drained by the portal venous system form the second largest
source
Common symptoms include fever, right upper quadrant pain. Jaundice
may be seen in 50%
Ultrasound will usually show a fluid filled cavity, hyperechoic walls may
be seen in chronic abscesses
Liver abscess is the most common extra intestinal manifestation of

amoebiasis
Between 75 and 90% lesions occur in the right lobe
Presenting complaints typically include fever and right upper quadrant
pain
Ultrasonography will usually show a fluid filled structure with poorly
defined boundaries
Aspiration yield sterile odourless fluid which has an anchovy paste
consistency
Treatment is with metronidazole
Seen in cases of Echinococcus infection

Typically an intense fibrotic reaction occurs around sites of infection
The cyst has no epithelial lining
Cysts are commonly unilocular and may grow to 20cm in size. The cyst
wall is thick and has an external laminated hilar membrane and an
internal enucleated germinal layer
Typically presents with malaise and right upper quadrant pain.
Secondary bacterial infection occurs in 10%.
Liver function tests are usually abnormal and eosinophilia is present in
33% cases
Ultrasound may show septa and hyatid sand or daughter cysts.
Percutaneous aspiration is contra indicated
Treatment is by sterilisation of the cyst with mebendazole and may be
followed by surgical resection. Hypertonic swabs are packed around the
cysts during surgery
Usually occurs in association with polycystic kidney disease

Autosomal dominant disorder
Symptoms may occur as a result of capsular stretch
Rare lesions with malignant potential

Usually solitary multiloculated lesions
Liver function tests usually normal
Ultrasonography typically shows a large anechoic, fluid filled area with
irregular margins. Internal echos may result from septa
Surgical resection is indicated in all cases
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Question 75 of 284
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Question stats
End and review
Score: 40.2%
1
22.4%
31%
8%
A. Acute lymphoblastic leukaemia
7.3%
B. Acute myeloblastic leukaemia
31.4%
C. Acute myelomonocytic leukaemia

question correctly
Which of the following disorders is associated with massive splenomegaly?
D. Acute monoblastic leukaemia

E. Chronic granulocytic leukaemia
6
7
8
9
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Chronic leukaemia is more likely to be associated with splenomegaly than acute leukaemia.
10
11
12
Spleen
13
14
The spleen is located in the left upper quadrant of the abdomen and its size can vary
depending upon the amount of blood it contains. The typical adult spleen is 12.5cm long and
7.5cm wide. The usual weight of the adult spleen is 150g.
The exact position of the spleen can vary with respiratory activity, posture and the state of
surrounding viscera. It usually lies obliquely with its long axis aligned to the 9th, 10th and
11th ribs. It is separated from these ribs by both diaphragm and pleural cavity. The normal
spleen is not palpable.
15
16
17
18
19
20
The shape of the spleen is influenced by the state of the colon and stomach. Gastric
distension will cause the spleen to resemble the shape of an orange segment. Colonic
distension will cause it to become more tetrahedral.
21
22
23
The spleen is almost entirely covered by peritoneum, which adheres firmly to its capsule.
Recesses of the greater sac separate it from the stomach and kidney. It develops from the
upper dorsal mesogastrium, remaining connected to the posterior abdominal wall and
stomach by two folds of peritoneum; the lienorenal ligament and gastrosplenic ligament. The
lienorenal ligament is derived from peritoneum where the wall of the general peritoneum
meets the omental bursa between the left kidney and spleen; the splenic vessels lie in its
layers. The gastrosplenic ligament also has two layers, formed by the meeting of the walls of
the greater sac and omental bursa between spleen and stomach, the short gastric and left
gastroepiploic branches of the splenic artery pass in its layers. Laterally, the spleen is in
contact with the phrenicocolic ligament.
24
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39
Relations
Superiorly
Diaphragm
40
Anteriorly
Gastric impression
41
Posteriorly Kidney
42
Inferiorly
Colon
43
Hilum
Tail of pancreas and splenic vessels (splenic artery divides here, branches
pass to the w hite pulp transporting plasma)
44
45
Contents
White
pulp
Immune function. Contains central trabecular artery. The germinal centres are
supplied by arterioles called penicilliary radicles.
Red
pulp
Filters abnormal red blood cells.
46
47-49 2 / 3
50
51
52
Function
Filtration of abnormal blood cells and foreign bodies such as bacteria.
Immunity: IgM. Production of properdin, and tuftsin which help target fungi and bacteria
for phagocytosis.
Haematopoiesis: up to 5th month gestation or in haematological disorders.
Pooling: storage of 40% platelets.
Iron reutilisation
Storage monocytes
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55-57 1 / 3
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Disorders of the spleen

Massive splenomegaly
Myelofibrosis
Chronic myeloid leukaemia
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Visceral leishmaniasis (kala-azar)

Malaria
Gaucher's syndrome
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72-74 1 / 3
Other causes (as above plus)
75
Portal hypertension e.g. secondary to cirrhosis

Lymphoproliferative disease e.g. CLL, Hodgkin's
Haemolytic anaemia
Infection: hepatitis, glandular fever
Infective endocarditis
Sickle-cell*, thalassaemia
Rheumatoid arthritis (Felty's syndrome)
*the majority of adult patients with sickle-cell will have an atrophied spleen due to repeated
infarction
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Question 76 of 284
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Question stats
End and review
Score: 39.8%
1
10.9%
10.9%
10.4%
A. Sarcoidosis
37.3%
B. Tuberculosis
30.6%
C. Ulcerative colitis

question correctly
Causes of primary chronic inflammation do not include which of the following?
D. Hip prostheses
E. Chronic cholecystitis
6
7
8
9
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Chronic cholecystitis is caused by recurrent episodes of acute inflammation.

Prosthetic implants may be the site of primary chronic inflammation. A common example
clinically is breast implants which may become encapsulated. The subsequent fibrosis then
results in distortion and may be painful.
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16
Overview
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25-27 2 / 3
28-30 0 / 3

Acute inflammation


31
32-34 0 / 3
35
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38

39
Suppuration
Complete resolution
Abscess formation
Healing by fibrosis
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Mediators
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Question stats
End and review
Score: 37.6%
1
2
Theme: Adrenal gland disorders

A. Nelsons syndrome
78
73.6%
79
77.8%
80
81%
B. Conns syndrome
3
4
5
C. Cushings syndrome
D. Benign incidental adenoma
Search
E. Malignant adrenal adenoma
7
Go
F. Waterhouse- Friderichsen syndrome
8
9
G. Metastatic lesion
10
H. Walker - Warburg syndrome

11
I. Phaeochromocytoma
12
Please select the most appropriate adrenal disorder for the scenario given. Each disorder
may be selected once, more than once or not at all.
13
14
15
78.
A 19 year old lady is admitted to ITU with severe meningococcal sepsis. She is
on maximal inotropic support and a CT scan of her chest and abdomen is
performed. The adrenal glands show evidence of diffuse haemorrhage.
16
17
18
19
You answered Metastatic lesion
20
The correct answer is Waterhouse- Friderichsen syndrome
21
WaterhouseFriderichsen syndrome is defined as adrenal gland failure due to

bleeding into the adrenal glands. It is caused by severe bacterial infection
(most commonly the meningococcus Neisseria meningitidis).
22
23
24
The bacterial infection leads to massive hemorrhage into one or (usually) both
adrenal glands. It is characterised by overwhelming bacterial infection
meningococcemia leading to massive blood invasion, organ failure, coma,
haemodynamic shock, disseminated intravascular coagulation with widespread
purpura, rapidly developing adrenocortical insufficiency and death.
25-27 2 / 3
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79.
A 34 year old lady is admitted with recurrent episodes of non-specific

abdominal pain. On each admission all blood investigations are normal, as are
her observations. On this admission a CT scan was performed. This
demonstrates a 1.5cm nodule in the right adrenal gland. This is associated with
a lipid rich core. Urinary VMA is within normal limits. Other hormonal studies are
normal.
36
37
38
39
40
You answered Cushings syndrome
41
The correct answer is Benign incidental adenoma
42
This is typical for a benign adenoma. Benign adenomas often have a lipid rich
core that is readily identifiable on CT scanning. In addition the nodules are
often well circumscribed.
80.
A 38 year old man is noted to have a blood pressure of 175/110 on routine

screening. On examination there are no physical abnormalities of note. CT
scanning shows a left sided adrenal mass. Plasma metanephrines are
elevated.
43
44
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46
47-49 2 / 3
50
51
You answered Conns syndrome
52
53
The correct answer is Phaeochromocytoma
54
Hypertension in a young patient without any obvious cause should be

investigated. Urinary VMA and plasma metanephrines are typically elevated.
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Phaeochromocytoma
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Diagnosis
Treatment
Size less than 3cm
Homogeneous texture
Lipid rich tissue
Thin wall to lesion
References
May;77(5):592-6.
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Question 81 of 284
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A 43 year old man presents with dyspepsia and undergoes an upper GI endoscopy. During
the procedure diffuse gastric and duodenal ulcers are identified. A Clo test confirms the
presence of Helicobacter pylori infection. What is the most likely explanation for the ulcers?
Question stats
Score: 37.2%
1
7.7%
33%
16%
8.4%
34.9%
A. Decreased gastric motility

question correctly
B. Increased urease activity
End and review
6
7
C. Decreased release of mucous and bicarbonate

8
D. Decreased gastrin levels

9
Search
E. Increased acid production
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10
11
12

H-Pylori has a number of pathological effects. In this question the main issue is by what
mechanism the organism is able to induce both gastric and duodenal ulceration. Without
modestly elevated acid levels, the duodenum would not undergo gastric metaplasia. H-Pylori
cannot colonise duodenal mucosa and therefore the development of ulcers at this site can
only occur in those who have undergone metaplastic transformation (mediated by increased
acidity).
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18
Helicobacter Pylori
19
20
Infection with Helicobacter Pylori is implicated in many cases of duodenal ulceration and up
to 60% of patients with gastric ulceration.
21
22
It is a gram negative, helical shaped rod with microaerophillic requirements. It has the ability
to produce a urease enzyme that will hydrolyse urea resulting in the production of ammonia.
The effect of ammonia on antral G cells is to cause release of gastrin via a negative
feedback loop.
Once infection is established the organism releases enzymes that disrupt the gastric mucous
layer. Certain subtypes release cytotoxins cag A and vac A gene products. The organism
incites a classical chronic inflammatory process of the gastric epithelium. This accounts for
the development of gastric ulcers. The mildly increased acidity may induce a process of
duodenal gastric metaplasia. Whilst duodenal mucosa cannot be colonised by H-Pylori,
mucosa that has undergone metaplastic change to the gastric epithelial type may be
colonised by H- Pylori with subsequent inflammation and development of duodenitis and
ulcers.
In patients who are colonised there is a 10-20% risk of peptic ulcer, 1-2% risk gastric cancer
and <1% risk MALT lymphoma.
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Question 82 of 284
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A 15 year old boy is admitted with colicky abdominal pain of 6 hours duration. On
examination he has a soft abdomen, on systemic examination he has brownish spots around
his mouth, feet and hands. His mother underwent surgery for intussusception, aged 12, and
has similar lesions. What is the most likely underlying diagnosis?
Question stats
Score: 36.8%
1
10.3%
66%
8.5%
8.8%
6.4%

question correctly
A. Li Fraumeni syndrome
End and review
B. Peutz-Jeghers syndrome
6
7
8
C. Addisons disease
Search
D. McCune -Albright syndrome

E. Appendicitis
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10
11
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12
13
This is most likely to be Peutz-Jeghers syndrome. Addisons and McCune Albright syndrome
may produce similar skin changes but the intussusception resulting from polyps combined
with the autosomal inheritance pattern makes this the most likely diagnosis.
14
15
16
Peutz-Jeghers syndrome
17
Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous

benign hamartomatous polyps in the gastrointestinal tract. It is also associated with
pigmented freckles on the lips, face, palms and soles. Around 50% of patients will have died
from a gastrointestinal tract cancer by the age of 60 years.
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19
20
21
22
Genetics
23
Autosomal dominant
Responsible gene encodes serine threonine kinase LKB1 or STK11
24
25-27 2 / 3
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Features
31
Hamartomatous polyps in GI tract (mainly small bowel)

Pigmented lesions on lips, oral mucosa, face, palms and soles
Intestinal obstruction e.g. intussusception (which may lead to diagnosis)
Gastrointestinal bleeding
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Management
39
Conservative unless complications develop
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Question 83 of 284
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What is the most likely electrolyte abnormality in a patient with diarrhoea and a soft mass felt
on digital rectal examination?
A. Hyperkalaemia
B. Hypokalaemia
Question stats
Score: 37.5%
1
9.9%
61.3%
13.8%
7.3%
7.6%

question correctly
C. Hyponatraemia
End and review
D. Hypernatraemia
6
7
8
E. Hypocalcaemia
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10
11
Large villous adenomas of the rectum may have marked secretory activity and result in the
development of hypokalaemia as rectal secretions are rich in potassium.
12
13
14
Hypokalaemia
15
Potassium and hydrogen can be thought of as competitors. Hyperkalaemia tends to be

associated with acidosis because as potassium levels rise fewer hydrogen ions can enter the
cells
16
Hypokalaemia with alkalosis
19
17
18
20
Vomiting
Diuretics
Cushing's syndrome
Conn's syndrome (primary hyperaldosteronism)
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Hypokalaemia with acidosis
25-27 2 / 3
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Diarrhoea
Renal tubular acidosis
Acetazolamide
Partially treated diabetic ketoacidosis
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Question 84 of 284
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Question stats
End and review
Score: 38.1%
1
10.4%
19.4%
10%
A. Phaeochromocytoma
45.1%
B. Visceral ganglioneuromas
15.2%
C. Thyroid medullary carcinoma

question correctly
Which of the following is not included in Multiple Endocrine Neoplasia Type 2b?
D. Zollinger Ellison syndrome

E. Marfanoid features
6
7
8
9
Search
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10
11
MEN IIB
12
Medullary thyroid cancer

Phaeochromocytoma
Mucosal neuroma
Marfanoid appearance
13
14
15
16
17
18
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20
21
22
MEN type I
MEN type IIa
MEN type IIb
Phaeochromocytoma
Medullary thyroid
cancer (70%)
Hyperparathyroidism
(60%)
Same as MEN IIa

with addition of:
Marfanoid body
habitus
Mucosal neuromas

Ellison syndrome
24
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28-30 0 / 3
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32-34 0 / 3
35

23
36
RET oncogene
(chromosome 10)
RET oncogene
(chromosome 10)
37
38

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Question 85 of 284
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A 25 year old male pedestrian is involved in a road traffic accident. He sustains multiple
injuries and is admitted to the intensive care unit, intubated and ventilated. Over the next
week he develops adult respiratory distress syndrome. What is the main reason for
hypoxaemia in this condition?
Question stats
Score: 37.8%
1
17.1%
43%
19.1%
10.6%
10.2%

question correctly
A. Increased lung compliance
End and review
B. Reduced diffusion
6
7
8
C. Reduced surfactant
Search
D. Reduced elastase
E. Left to right shunt
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10
11
Next question
12
13

The diffuse lung injury, which is associated with loss of surfactant and increased elastase
release from neutrophils, results in fluid accumulation. This leads to reduced diffusion, which
is the main reason for hypoxaemia.
14
15
16
17
Adult respiratory distress syndrome
18
Defined as an acute condition characterized by bilateral pulmonary infiltrates and severe

hypoxemia (PaO2/FiO2 ratio < 200) in the absence of evidence for cardiogenic pulmonary
oedema (clinically or pulmonary capillary wedge pressure of less than 18 mm Hg).
In is subdivided into two stages. Early stages consist of an exudative phase of injury with
associated oedema. The later stage is one of repair and consists of fibroproliferative
changes. Subsequent scarring may result in poor lung function.
19
20
21
22
23
24
Causes
Sepsis
Direct lung injury
Trauma
Acute pancreatitis
Long bone fracture or multiple fractures (through fat embolism)
Head injury (causes sympathetic nervous stimulation which leads to acute pulmonary
hypertension)
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Clinical features
39
40
Acute dyspnoea and hypoxaemia hours/days after event

Multi organ failure
Rising ventilatory pressures
41
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43
Management
44
Treat the underlying cause

Antibiotics (if signs of sepsis)
Negative fluid balance i.e. Diuretics
Recruitment manoeuvres such as prone ventilation, use of positive end expiratory
pressure
Mechanical ventilation strategy using low tidal volumes, as conventional tidal volumes
may cause lung injury (only treatment found to improve survival rates)
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Question 86 of 284
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A 24 year old male was admitted with bloody diarrhea, cramping abdominal pain and weight
loss. Colonoscopy revealed a friable, diffusely red mucosa involving the rectum and sigmoid
colon. The mucosa was normal proximal to this. The disease progressed with time to involve
most of the entire colon, but not the ileum. Many years later, a colonic biopsy shows high
grade epithelial dysplasia. What is the most likely initial diagnosis?
Question stats
Score: 37.4%
1
6.5%
7.6%
67.4%
12.1%
6.6%

question correctly
A. Colonic tuberculosis
End and review
6
7
8
B. Collagenous colitis
C. Ulcerative colitis
Search
D. Crohns disease
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E. Ischaemic colitis
10
11
12
Next question

Ulcerative colitis spreads in a progressive distal to proximal manner. Over time a dysplastic
transformation is recognised. Such endoscopic findings mandate a minimum of close
endoscopic surveillance and if they occur in association with a colonic mass then usually a
pancproctocolectomy.
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14
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17
18
Ulcerative colitis
19
20

include:
bloody diarrhoea
urgency
tenesmus
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37

spondylitis.
38
39
40

Notes
Related to
disease
activity

Erythema nodosum
Episcleritis
Osteoporosis

Crohns disease
Unrelated to
disease
activity

Uveitis
Clubbing

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Endoscopy
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ulceration pattern.
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Management
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86
References
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Question 87 of 284
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Question stats
End and review
Score: 37%
1
38.3%
14.1%
21.5%
A. Human herpes virus 8
16.3%
B. Human papillomavirus 16
9.7%
C. Human T-lymphotropic virus 1

question correctly
Which virus is associated with Kaposi's sarcoma?
D. Epstein-Barr virus
E. Human papillomavirus 18
6
7
8
9
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10
11
12
Oncoviruses
13
14
15
Viruses which cause cancer

These may be detected on blood test and prevented by vaccine
16
17
These are the main types of oncoviruses and their diseases:
18
19
Oncovirus
Cancer
Epstein-Barr virus
Burkitt's lymphoma
Hodgkin's lymphoma
Post transplant lymphoma
Nasopharyngeal carcinoma
Human papillomavirus 16/18
20
21
22
23
24
Cervical cancer
Anal cancer
Penile cancer
Vulval cancer
Oropharyneal cancer
25-27 2 / 3
28-30 0 / 3
31
32-34 0 / 3
Human herpes virus 8
Kaposi's sarcoma
Hepatitis B virus
Hepatitis C virus
38
Human T-lymphotropic virus 1
Tropical spastic paraparesis

Adult T cell leukaemia
39
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Question 88 of 284
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Question stats
End and review
Score: 36.6%
1
10.6%
20.1%
39.9%
A. May result from an axonotmesis
13.8%
B. May occur in either the central or peripheral nervous systems
15.6%
C. The axon remains excitable throughout the whole process

question correctly
Which of the following is not a feature of Wallerian Degeneration?
D. The distal neuronal stump is affected

E. Is a component of the healing process following neuronal injury
6
7
8
9
Search
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10
11
The axon loses its excitability once the process is established.
12
Wallerian degeneration
13
14
- Is the process that occurs when a nerve is cut or crushed.

- It occurs when the part of the axon separated from the neuron's cell nucleus degenerates.
- It usually begins 24 hours following neuronal injury and the distal axon remains excitable up
until this time.
- The degeneration of the axon is following by breakdown of the myelin sheath, a process
that occurs by infiltration of the site with macrophages.
- Eventually regeneration of the nerve may occur although recovery will depend on the
extent and manner of injury
15
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21
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Question 1 of 196
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A 45 year old woman complains of painful tingling in her fingers. The pain is relieved by
hanging the arm over the side of the bed. She has a positive Tinel's sign at the wrist. Which
of the following is most likely to contribute to her diagnosis?
Question stats
End and review
Score: 0%
11.3%
7.8%
21.6%
7.6%
51.7%
A. Methotrexate use
question correctly
B. Crohn's disease
C. Hyperthyroidism
D. Tuberculosis
Search
E. Rheumatoid arthritis
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Next question
This woman has a diagnosis of carpal tunnel syndrome. Rheumatological disorders are a
common cause. Clinical examination should focus on identifying stigmata of rheumatoid
arthritis, such as rheumatoid nodules, vasculitic lesions and metacarpophalangeal joint
arthritis.
Carpal tunnel syndome
Carpal tunnel syndrome is caused by compression of median nerve in the carpal tunnel
History
pain/pins and needles in thumb, index, middle finger e.g. at night
patient flicks hand to obtain relief
Examination
weakness of thumb abduction
wasting of thenar eminence (NOT hypothenar)
Tinel's sign: tapping causes paraesthesia
Phalen's sign: flexion of wrist causes symptoms
Causes of carpal tunnel syndrome

MEDIAN TRAP Mnemonic
Myxoedema
Edema premenstrually
Diabetes
Idiopathic
Acromegaly
Neoplasm
Trauma
Rheumatoid arthritis
Amyloidosis
Pregnancy
Management
Non surgical
treatment
Surgery
May resolve
spontaneously
Avoid precipitants
and reassurance
Night-time splints
Local steroid
injections
Complete division of the flexor retinaculum and decompression of the

tunnel (successful in approximately 80% of patients)
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Question 2 of 196
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A 30 year old male presents with a painless swelling of the testis. Histologically the stroma
has a lymphocytic infiltrate. The most likely diagnosis is :
A. Differentiated teratoma
B. Malignant undifferentiated teratoma
Question stats
End and review
Score: 0%
15.2%
12.5%
44%
15.4%
13%
1
2

question correctly
C. Classical seminoma
D. Spermatocytic seminoma
E. Anaplastic seminoma
Search
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Seminoma is the commonest type of testicular tumour and is more common in males aged
between 30-40 years. Classical seminoma is the commonest subtype and histology shows
lymphocytic stromal infiltrate. Other subtypes include:
1. Spermatocytic: tumour cells resemble spermatocytes. Excellent prognosis.
2. Anaplastic
3. Syncytiotrophoblast giant cells: HCG present in cells
A teratoma is more common in males aged 20-30 years.
Testicular cancer
divided into:
Tumour type
Seminoma
Non seminomatous
germ cell tumours
(42%)
Teratoma
Yolk sac tumour
Choriocarcinoma
Mixed germ cell
tumours (10%)
Key features
Commonest
subtype
(50%)
Average
age at
diagnosis =
40
Even
advanced
disease
associated
with 5 year
survival of
73%
Younger age at
Advanced
disease carries
worse prognosis
(48% at 5 years)
Retroperitoneal
lymph node
dissection may be
needed for residual
disease after
chemotherapy
Tumour
markers
Pathology
AFP usually
normal
HCG elevated
in 10%
seminomas
Lactate
dehydrogenase;
elevated in 1020%
seminomas (but
also in many
other
conditions)

may be seen.
AFP elevated
in up to 70% of
cases
HCG elevated
in up to 40% of
cases
Other
markers rarely
helpful

such as hair
teratomas
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Cryptorchidism
Infertility
Family history
Mumps orchitis
Features
Diagnosis
Management
node dissection.

Benign disease
Epididymo-orchitis
stopping the drug.
Testicular torsion
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Hydrocele
examination.
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Question 3 of 196
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Next
A 48 year old women presents with recurrent loin pain and fevers. Investigation reveals a
staghorn calculus of the left kidney. Infection with which of the following organisms is most
likely?
Question stats
End and review
Score: 0%
1
8.4%
52.2%
9.9%
21.5%
8.1%
4 5-7 -
A. Staphylococcus saprophyticus
question correctly
B. Proteus mirabilis
C. Klebsiella
D. E-Coli
Search
E. Staphylococcus epidermidis
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Next question

Infection with Proteus mirabilis accounts for 90% of all proteus infections. It has a urease
producing enzyme. This will tend to favor urinary alkalinisation which is a relative perrequisite for the formation of staghorn calculi.
Renal stones
Type of
stones
Features
Percentage
of all
calculi
Calcium
oxalate
Hypercalciuria is a major risk factor (various causes)

Hyperoxaluria may also increase risk
Hypocitraturia increases risk because citrate forms complexes with
calcium making it more soluble
Stones are radio-opaque (though less than calcium phosphate
stones)
Hyperuricosuria may cause uric acid stones to which calcium
oxalate binds
85%
Cystine
Inherited recessive disorder of transmembrane cystine transport

leading to decreased absorption of cystine from intestine and renal
tubule
Multiple stones may form
Relatively radiodense because they contain sulphur
1%
Uric acid
Uric acid is a product of purine metabolism

May precipitate when urinary pH low
May be caused by diseases with extensive tissue breakdown e.g.
malignancy
More common in children with inborn errors of metabolism
Radiolucent
5-10%
Calcium
phosphate
May occur in renal tubular acidosis, high urinary pH increases

supersaturation of urine with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase risk of stone
formation (types 2 and 4 do not)
Radio-opaque stones (composition similar to bone)
10%
Struvite
Stones formed from magnesium, ammonium and phosphate

Occur as a result of urease producing bacteria (and are thus
associated with chronic infections)
Under the alkaline conditions produced, the crystals can
precipitate
Slightly radio-opaque
2-20%
Effect of urinary pH on stone formation

Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls as purine
metabolism will produce uric acid. Then the urine becomes more alkaline (alkaline tide).
When the stone is not available for analysis the pH of urine may help to determine which
stone was present.
Stone type
Urine acidity
Mean urine pH
Calcium phosphate
Normal- alkaline
>5.5
Calcium oxalate
Variable
Uric acid
Acid
5.5
Struvate
Alkaline
>7.2
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Struvate
Alkaline
>7.2
Cystine
Normal
6.5
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Question 4 of 196
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Question stats
End and review
Score: 0%
1
33%
30.1%
14.7%
A. Amiodarone
13.5%
B. Allopurinol
8.7%
C. Sulphonamides

question correctly
Causes of granulomatous disease do not include:
D. Beryllium
4
5-7 -
E. Wegener's granulomatosis
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Allopurinol and sulphonamides cause hepatic granulomas.

Overview

Acute inflammation


Suppuration
Complete resolution
Abscess formation
Healing by fibrosis
Mediators
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Question 5-7 of 196
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Question stats
End and review
Score: 14.3%
1
2
Theme: Facial nerve palsy

A. Adenoid cystic carcinoma
57.8%
87.4%
91.7%
B. Cerebrovascular accident
3
4
5-7 1 / 3
C. Petrous temporal fracture

D. Warthins tumour
Search
E. Sarcoidosis
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F. Pleomorphic adenoma
G. Cholesteatoma
Please select the most likely cause of facial nerve palsy for the scenario given. Each option
5.
A 22 year old man presents with symptoms of lethargy and bilateral facial nerve
palsy. On examination he has bilateral parotid gland enlargement.
You answered Cerebrovascular accident
The correct answer is Sarcoidosis
Facial nerve palsy is the commonest neurological manifestation of sarcoid. It
usually resolves. The absence of ear discharge or discrete lesion on palpation is
against the other causes.
6.
A 21 year old man presents with a unilateral facial nerve palsy after being hit in
the head. On examination he has a right sided facial nerve palsy and a watery
discharge from his nose.
Petrous temporal fracture
Nasal discharge of clear fluid and recent head injury makes a basal skull
fracture the most likely underlying diagnosis.
7.
A 43 year old lady presents with symptoms of chronic ear discharge and a right
sided facial nerve palsy. On examination she has foul smelling fluid draining from
her right ear and a complete right sided facial nerve palsy.
You answered Sarcoidosis
The correct answer is Cholesteatoma
Foul smelling ear discharge and facial nerve weakness is likely to be due to
cholesteatoma. The presence of a neurological deficit is a sinister feature.
Next question
Facial nerve palsy
Sarcoid
Facial nerve palsy is the most frequent neurological manifestation of sarcoid

Affects right and left side with equal frequency, may be bilateral
Typically resolves in up to 80% of cases
Cholesteatoma
Destructive and expanding growth of keratinised squamous epithelium

Patients often complain of chronic ear discharge
Infection with Pseudomonas may occur resulting in foul smell to discharge
Aquired lesions usually arise from the Pars flaccida region of the tympanic
membrane
Surgical removal and mastoidectomy may be needed
Recurrence rates of 20% may be seen following surgery
Basal skull
fracture
History of head injury

Presence of features such as Battles sign on examination
Clinical presence of CSF leak strongly supports diagnosis
Assessment is by CT and MRI scan
Prophylactic antibiotics should be given in cases of CSF leak
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Question 8 of 196
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A 59 year old lady is referred from the NHS breast screening program. A recent mammogram
is reported as showing linear, branching microcalcification with coarse granules. Which
disease process is the most likely underlying cause of these appearances?
Question stats
Score: 12.5%
1
16.9%
16.1%
23.5%
31.5%
12.1%
A. Invasive lobular cancer

question correctly
B. Lobular carcinoma in situ
End and review
4
5-7 1 / 3
8
C. Cribriform type ductal carcinoma in situ

D. Comedo type ductal carcinoma in situ
Search
E. Fibroadenosis
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Next question
Comedo type DCIS is usually associated with microcalcifications. Cribriform lesions are
usually multifocal but less likely to form microcalcifications. Lobular cancers and in situ
lesions rarely form microcalcifications and are difficult to detect using mammography.
Breast cancer - In situ disease
Breast cancer that has yet to invade the basement membrane is referred to as in situ
disease. Both ductal and lobular in situ variants are recognised.
Ductal carcinoma in situ
Sub types include; comedo, cribriform, micropapillary and solid
Comdeo DCIS is most likely to form microcalcifications
Cribriform and micropapillary are most likely to be multifocal
Most lesions are mixed (composed of multiple subtypes)
High nuclear grade DCIS is associated with more malignant characteristics (loss of
p53, increased erbB2 expression)
Local excision of low nuclear grade DCIS will usually produce satisfactory outcomes.
Multifocal lesions, large and high nuclear grade lesions will usually require mastectomy
Whole breast irradiation improves locoregional control when breast conserving
surgery is performed
Lobular carcinoma in situ

Much rarer than DCIS
Does not form microcalcifications
Usually single growth pattern
When an invasive component is found it is less likely to be associated with axillary
nodal metastasis than with DCIS
Low grade LCIS is usually treated by monitoring rather than excision
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Question 9 of 196
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End and review
Score: 11.1%
1
10.4%
57.4%
8.8%
A. The first part of the duodenum
11%
B. The second part of the duodenum
12.4%
C. The fourth part of the duodenum

question correctly
In patients with an annular pancreas where is the most likely site of obstruction?
D. The third part of the duodenum
4
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8
9
E. The duodeno-jejunal flexure

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The pancreas develops from two foregut outgrowths (ventral and dorsal). During rotation the
ventral bud and adjacent gallbladder and bile duct lie together and fuse. When the pancreas
fails to rotate normally it can compress the duodenum with development of obstruction.
Usually occurring as a result of associated duodenal malformation. The second part of the
duodenum is the commonest site.
Pancreas
The pancreas is a retroperitoneal organ and lies posterior to the stomach. It may be
accessed surgically by dividing the peritoneal reflection that connects the greater omentum
to the transverse colon. The pancreatic head sits in the curvature of the duodenum. Its tail
lies close to the hilum of the spleen, a site of potential injury during splenectomy.
Relations
Posterior to the pancreas
Pancreatic head
Inferior vena cava

Common bile duct
Right and left renal veins
Superior mesenteric vein and artery
Pancreatic neck
Superior mesenteric vein, portal vein
Pancreatic body-
Left renal vein

Crus of diaphragm
Psoas muscle
Adrenal gland
Kidney
Aorta
Pancreatic tail
Left kidney
Anterior to the pancreas

Pancreatic head
1st part of the duodenum

Pylorus
Gastroduodenal artery
SMA and SMV(uncinate process)
Pancreatic body
Stomach
Duodenojejunal flexure
Pancreatic tail
Splenic hilum
Superior to the pancreas

Coeliac trunk and its branches common hepatic artery and splenic artery
Grooves of the head of the pancreas
2nd and 3rd part of the duodenum
Arterial supply
Head: pancreaticoduodenal artery
Rest: splenic artery
Venous drainage
Head: superior mesenteric vein
Body and tail: splenic vein
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Ampulla of Vater
Merge of pancreatic duct and common bile duct
Is an important landmark, halfway along the second part of the duodenum, that marks
the anatomical transition from foregut to midgut (also the site of transition between
regions supplied by coeliac trunk and SMA).
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End and review
Score: 25%
1
2
Theme: Chest pain

A. Achalasia
10
86.1%
11
69%
12
84.2%
B. Pulmonary embolus
3
4
5-7 1 / 3
C. Dissection of thoracic aorta
D. Boerhaaves syndrome
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E. Gastro-oesophageal reflux
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10-12 2 / 3
F. Carcinoma of the oesophagus

G. Oesophageal candidiasis
Please select the most likely cause for chest pain for the scenario given. Each option may be
used once, more than once or not at all.
10.
A 43 year old man who has a long term history of alcohol misuse is admitted
with a history of an attack of vomiting after an episode of binge drinking. After
vomiting he developed sudden onset left sided chest pain, which is pleuritic in
nature. On examination he is profoundly septic and drowsy with severe
epigastric tenderness and left sided chest pain.
Boerhaaves syndrome
In patients with Boerhaaves the rupture is often on the left side. The story here
is typical. All patients should have a contrast study to confirm the diagnosis and
the affected site prior to thoracotomy.
11.
A 22 year old man is admitted with severe retrosternal chest pain and recurrent
episodes of dysphagia. These occur sporadically and often resolve
spontaneously. On examination there are no physical abnormalities and the
patient seems well.
Achalasia
Achalasia may produce severe chest pain and many older patients may
undergo cardiac investigations prior to endoscopy.
Endoscopic injection with botulinum toxin is a popular treatment (although the
benefit is not long lasting). Cardiomyotomy together with an antireflux
procedure is a more durable alternative.
12.
An obese 53 year old man presents with symptoms of recurrent retrosternal

discomfort and dyspepsia. This is typically worse at night after eating a large
meal. On examination there is no physical abnormality to find.
You answered Oesophageal candidiasis
The correct answer is Gastro-oesophageal reflux
Patients with GORD often have symptoms that are worse at night. In this age
group an Upper GI endoscopy should probably be performed.
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Surgical chest pain
Dissection of
thoracic
aorta
Diffuse
oesophageal
spasm
Gastrooesphageal
reflux
Tearing interscapular pain

Discrepancy in arterial blood pressures taken in both arms
May show mediastinal widening on chest x-ray
Spectrum of oesophageal motility disorders

Caused by uncoordinated contractions of oesphageal muscles
May show "nutcracker oesophagus" on barium swallow
Symptoms include dysphagia, retrosternal discomfort and dyspepsia
Common cause of retrosternal discomfort

Usually associated with symptoms of regurgitation, odynophagia and
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reflux
Boerhaaves
syndrome
Achalasia
dyspepsia
Symptoms usually well controlled with PPI therapy
Risk factors include obesity, smoking and excess alcohol consumption
Spontaneous rupture of the oesophagus

Caused by episodes of repeated vomiting often in association with
alcohol excess
Typically there is an episode of repetitive vomiting followed by severe
chest and epigastric pain
Diagnosis is by CT and contrast studies
Treatment is surgical; during first 12 hours primary repair, beyond this
usually creation of controlled fistula with a T Tube, delay beyond 24
hours is associated with fulminent mediastinitis and is usually fatal.
Difficulty swallowing, dysphagia to both liquids and solids and

sometimes chest pain
Usually caused by failure of distal oesphageal inhibitory neurones
Diagnosis is by pH and manometry studies together with contrast
swallow and endoscopy
Treatment is with either botulinum toxin, pneumatic dilatation or
cardiomyotomy
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Question 13 of 196
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A 32 year old woman presents with an episode of haemoptysis and is found to have
metastatic tumour present within the parenchyma of the lungs. This is biopsied and
subsequent histology shows clear cells. What is the most likely primary site?
Question stats
Score: 31.3%
1
44.1%
23.5%
7.3%
12.4%
12.6%
A. Kidney
question correctly
B. Breast
End and review
C. Liver
4
5-7 1 / 3
8
9
10-12 2 / 3
D. Adrenal
13
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E. Bone
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Clear cell tumours are a sub type of renal cell cancer it is associated with specific genetic
changes localised to chromosome 3.
Renal lesions
Lesion
Renal cell
carcinoma
Nephroblastoma
Neuroblastoma
Transitional cell
carcinoma
Angiomyolipoma

(50%)
cases)
Most commonly has


tumour of childhood
years of age
gland)
MIBG scanning
Staging is with CT

renal tumours
females
haematuria
IVU

tuberous sclerosis
10% of cases
Treatment
nephrectomy

doxorubicin)

and chemotherapy

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Question 14 of 196
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A laceration of the wrist produces a median nerve transection. The wound is clean and seen
immediately after injury. Collateral soft tissue damage is absent. The patient asks what the
prognosis is. You indicate that the nerve should regrow at approximately:
Question stats
Score: 35.3%
1
31.6%
44.4%
6.4%
7.2%
10.4%
A. 0.1 mm per day

question correctly
B. 1 mm per day
End and review
C. 5 mm per day
4
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8
9
10-12 2 / 3
D. 1 cm per day
13
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Transaction of a peripheral nerve results in hemorrhage and in retraction of the several

nerve ends. Almost immediately, degeneration of the axon distal to the injury begins.
Degeneration also occurs in the proximal fragment back to the first node of Ranvier.
Phagocytosis of the degenerated axonal fragments leaves neurilemmal sheath with empty
cylindrical spaces where the axons were. Several days following the injury, axons from the
proximal fragment begin to regrow. If they make contact with the distal neurilemmal sheath,
regrowth occurs at about the rate of 1 mm/day. However, if associated trauma, fracture,
infection, or separation of neurilemmal sheath ends precludes contact between axons,
growth is haphazard and a traumatic neuroma is formed. When neural transaction is
associated with widespread soft tissue damage and hemorrhage (with increased probability
of infection), many surgeons choose to delay reapproximation of the severed nerve end for 3
to 4 weeks.
Nerve injury
There are 3 types of nerve injury:
Neuropraxia
Axonotmesis
Neurotmesis

Full recovery
Axon is damaged and the myelin sheath is preserved. The connective

tissue framework is not affected.
Wallerian degeneration occurs.
Disruption of the axon, myelin sheath and surrounding connective tissue.

Wallerian Degeneration
Axonal degeneration distal to the site of injury.
Typically begins 24-36 hours following injury.
Axons are excitable prior to degeneration occurring.
Myelin sheath degenerates and is phagocytosed by tissue macrophages.
Nerve repair
Neuronal repair may only occur physiologically where nerves are in direct contact.
Where a large defect is present, the process of nerve regeneration is hampered. It
may not occur at all or result in the formation of a neuroma. Where nerve regrowth
occurs it is typically at a rate of 1mm per day.
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End and review
Score: 33.3%
1
10.3%
15%
44.8%
A. It is associated with chronic helicobacter pylori infection
9%
B. 5% of gastric malignancies are due to lymphoma
20.9%
C. In the Lauren classification the diffuse type of adenocarcinoma typically

presents as a large exophytic growth in the antrum

question correctly
Which of the following statements relating to gastric cancer is untrue?
D. Smoking is a risk factor
4
5-7 1 / 3
8
9
10-12 2 / 3
13
E. It is associated with acanthosis nigricans

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15
Barium meal appearances of linitis plastica:

Due to the increased rigidity of the wall, the stomach cannot be adequately distended,
with only a narrow lumen identified. The normal mucosal fold pattern is absent, either
distorted, thickened or nodular.
The Lauren classification describes a diffuse type of adenocarcinoma (Linitis plastica type
lesion) and an intestinal type. The diffuse type is often deeply infiltrative and may be difficult
to detect on endoscopy. Barium meal appearances can be characteristic.
Gastric cancer
Overview
Pathology
Type
1
Type
2

Type
3
gastric cancer.

Atrophic gastritis
following
Patients without
dyspepsia
Worsening dyspepsia
Dysphagia
Barretts oesophagus
Dysphagia
Unexplained
abdominal pain or
weight loss
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Weight loss
Vomiting
Dysplasia
Upper abdominal
mass
Atrophic gastritis
Jaundice

dyspepsia
Staging
Treatment
usual
undertaken.
Prognosis
UK Data
Disease extent
All RO resections
54%
91%
Stage 1
87%
Stage 2
65%
Stage 3
18%
Operative procedure
General anaesthesia
Incision: Rooftop.
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Question 16 of 196
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Which of the following statements relating to Gardners syndrome variant of familial

adenomatous polyposis coli is false?
A. It is an autosomal dominant condition

B. Patients may develop retroperitoneal desmoid tumours
Question stats
Score: 36.8%
1
8.6%
8.9%
56.6%
14.6%
11.4%

question correctly
C. The vast majority of the polyps are benign and thus the risk of
colorectal cancer is small
End and review
4
5-7 1 / 3
8
9
10-12 2 / 3
D. Patients are at increased risk of thyroid cancer
13
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E. It is characterised by a mutation in the APC gene
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The multiple polyps increase the risk of malignancy and most patients should undergo a
colectomy.
presented here.
Autosomal dominant
Diagnosed when:

BRCA 1 and 2
2).
Lynch Syndrome
Autosomal dominant
Amsterdam criteria
Gardners syndrome
cancer
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A 60-year-old man presents with lower urinary tract symptoms and is offered a PSA test.
Which one of the following could interfere with the PSA level?
A. Vigorous exercise in the past 48 hours

B. Poorly controlled diabetes mellitus
Question stats
Score: 35%
1
52.4%
10.3%
15.9%
11.4%
10%

question correctly
C. Drinking more than 4 units of alcohol in the past 48 hours
End and review
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8
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10-12 2 / 3
D. Smoking
13
E. Recent cholecystectomy
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16
17
PSA testing
Prostate specific antigen (PSA) is a serine protease enzyme produced by normal and
malignant prostate epithelial cells. It has become an important tumour marker but much
controversy still exists regarding its usefulness as a screening tool.
The NHS Prostate Cancer Risk Management Programme (PCRMP) has published updated
guidelines in 2009 on how to handle requests for PSA testing in asymptomatic men. A recent
European trial (ERSPC) showed a statistically significant reduction in the rate of death
prostate cancer by 20% in men aged 55 to 69 years but this was associated with a high risk
of over-diagnosis and over-treatment. Having reviewed this and other data the National
Screening Committee have decided not to introduce a prostate cancer screening programme
yet but rather allow men to make an informed choice.
Age-adjusted upper limits for PSA were recommended by the PCRMP*:
{Age}
{PSA level (ng/ml)}
50-59 years
3.0
60-69 years
4.0
> 70 years
5.0
PSA levels may also be raised by**:

benign prostatic hyperplasia (BPH)
prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at
least 1 month after treatment)
ejaculation (ideally not in the previous 48 hours)
vigorous exercise (ideally not in the previous 48 hours)
urinary retention
instrumentation of the urinary tract
Poor specificity and sensitivity

around 33% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer.
With a PSA of 10-20 ng/ml this rises to 60% of men
around 20% with prostate cancer have a normal PSA
various methods are used to try and add greater meaning to a PSA level including
age-adjusted upper limits and monitoring change in PSA level with time (PSA velocity
or PSA doubling time)
*aide memoire for upper PSA limit: (age - 20) / 10

**whether digital rectal examination actually causes a rise in PSA levels is a matter of debate
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End and review
Score: 33.3%
1
9.4%
37.5%
26.6%
A. Painless jaundice
7.8%
B. Hyperamylasaemia
18.8%
C. Hyperglycaemia

question correctly
Which of the symptoms below is least typical of pancreatic cancer?
D. Weight loss
4
5-7 1 / 3
8
9
10-12 2 / 3
E. Classical Courvoisier syndrome
13
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Raised serum amylase is relatively uncommon. The typical Courvoisier syndrome typically
occurs in 20% and hyperglycaemia occurs in 15-20%.
15
16
17
18
Pancreatic cancer
Adenocarcinoma
Risk factors: Smoking, diabetes, Adenoma, Familial adenomatous polyposis
Mainly occur in the head of the pancreas (70%)
Spread locally and metastasizes to the liver
Carcinoma of the pancreas should be differentiated from other periampullary tumours
with better prognosis
Clinical features
Weight loss
Painless jaundice
Epigastric discomfort (pain usually due to invasion of the coeliac plexus is a late
feature)
Pancreatitis
Trousseau's sign: migratory superficial thrombophlebitis
Investigations
USS: May miss small lesions
CT Scanning (pancreatic protocol). If unresectable on CT then no further staging
needed
PET/CT for those with operable disease on CT alone
ERCP/ MRI for bile duct assessment
Staging laparoscopy to exclude peritoneal disease
Management
Head of pancreas: Whipple's resection (SE dumping and ulcers). Newer techniques
include pylorus preservation and SMA/ SMV resection
Carcinoma body and tail: poor prognosis, distal pancreatectomy, if operable
Usually adjuvent chemotherapy for resectable disease
ERCP and stent for jaundice and palliation
Surgical bypass may be needed for duodenal obstruction
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Question 19 of 196
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A 53 year old man presents with dyspepsia. An upper GI endoscopy is performed and
Helicobacter pylori is identified. A duodenal ulcer is present in the first part of the duodenum.
Duodenal biopsies are taken and demonstrate epithelium that resembles cells of the gastric
antrum. Which of the following is the most likely explanation for this process?
Question stats
Score: 30.4%
1
9.7%
58.5%
16%
7%
8.7%

question correctly
A. Hyperplasia of the crypts of Lieberkhun
End and review
B. Duodenal metaplasia
4
5-7 1 / 3
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9
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C. Duodenal dysplasia
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D. Duodenal carcinoma
14
E. Hyptertrophy of Brunners glands
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18
Metaplasia = cell type conversion
19
Theme in January 2012 exam

The process involved is metaplasia. During metaplasia there is no direct carcinogenesis,
however the persistent presence of precipitants of metaplasia will lead to malignant changes
in cells.
Metaplastic changes in the duodenal cap are frequently seen in association with H-Pylori
induced ulcers. It typically resolves after ulcer healing and eradication therapy.
Metaplasia
Definition: reversible change of differentiated cells to another cell type.

May represent an adaptive substitution of cells that are sensitive to stress by cell types
better able to withstand the adverse environment.
Can be a normal physiological response (ossification of cartilage to form bone)
Most common epithelial metaplasia occurs with transformation of columnar cells to
squamous cells (smoking causes ciliated columnar cells to be replaced by squamous
epithelial cells; Schistosomiasis).
Metaplasia from squamous to columnar cells occurs in Barrett oesophagus.
If the metaplastic stimulus is removed, the cells will return to their original pattern of
differentiation. However, if the stimulus is not removed then progression to dysplasia
may occur.
Not considered directly carcinogenic, however the factors which predispose to
metaplasia, if persistent may induce malignant transformation.
The pathogenesis involves a reprogramming of stem cells that are known to exist in
normal tissues, or of undifferentiated mesenchymal cells present in connective tissue.
In a metaplastic change, these precursor cells differentiate along a new pathway.
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Question 20 of 196
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A 22 year old lady presents with symptoms and signs of hyperthyroidism. Her diagnostic work
up results in a diagnosis of Graves disease. Which of the following best describes the
pathophysiology of the condition?
Question stats
Score: 33.3%
1
57.4%
8.6%
16.7%
9.8%
7.5%
A. Formation of IgG antibodies to the TSH receptors on the thyroid gland

question correctly
B. Formation of IgG antibodies to the TRH receptors on the anterior

pituitary
End and review
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5-7 1 / 3
8
9
10-12 2 / 3
C. Formation of IgM antibodies to the TSH receptors on the thyroid gland
13
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D. Formation of IgA antibodies to the TSH receptors on the thyroid gland
14
E. Formation of IgM antibodies to the TRH receptors on the anterior

pituitary
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18
Usually IgG antibodies are formed against the TSH receptors on the thyroid gland. Which is
why the TSH level is often very low in Graves disease.
19
20
Thyroid hormones
Hormones of the thyroid gland
Triiodothyronine T3
Major hormone active in target cells
Thyroxine T4
Most prevalent form in plasma, less biologically active than T3
Calcitonin
Lowers plasma calcium
Synthesis and secretion of thyroid hormones

Thyroid actively concentrates iodide to twenty five times the plasma concentration.
Iodide is oxidised by peroxidase in the follicular cells to atomic iodine which then
iodinates tyrosine residues contained in thyroglobulin.
Iodinated tyrosine residues in thyroglobulin undergo coupling to either T3 or T4.
Process is stimulated by TSH, which stimulates secretion of thyroid hormones.
The normal thyroid has approximately 3 month reserves of thyroid hormones.
LATS and Graves disease

In Graves disease patients develop IgG antibodies to the TSH receptors on the thyroid
gland. This results in chronic and long term stimulation of the gland with release of thyroid
hormones. The typically situation is raised thyroid hormones and low TSH. Thyroid receptor
autoantibodies should be checked in individuals presenting with hyperthyroidism as they are
present in up to 85% cases.
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End and review
Score: 32%
1
25.1%
35.2%
22.9%
A. Thiazide use
9.2%
B. Metastatic malignancy
7.6%
C. Primary hyperparathyroidism

question correctly
What is the most common cause of hypercalcaemia in the UK in hospitalised patients?
D. Osteogenic sarcoma
4
5-7 1 / 3
8
9
10-12 2 / 3
E. Sarcoidosis
13
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Metastatic cancer accounts for most cases of hypercalcaemia in hospitalised patients. In the
community primary hyperparathyroidism is the commonest cause.
15
16
17
18
Hypercalcaemia
19
Main causes
20
Malignancy (most common cause in hospital in-patients)

Primary hyperparathyroidism (commonest cause in non hospitalised patients)
21
Less common
Sarcoidosis (extrarenal synthesis of calcitriol )
Thiazides, lithium
Immobilisation
Pagets disease
Vitamin A/D toxicity
Thyrotoxicosis
MEN
Milk alkali syndrome
Clinical features
Stones, bones, abdominal groans, and psychic moans
High serum calcium levels result in decreased neuronal excitability. Therefore sluggish
reflexes, muscle weakness and constipation may occur.
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End and review
Score: 32.3%
1
2
Theme: Diseases affecting the great vessels

A. Aortic coarctation
22
58.3%
23
66.8%
24
56.1%
B. Cervical rib
3
4
5-7 1 / 3
C. Takayasu's arteritis
D. Subclavian steal syndrome
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E. Patent ductus arteriosus
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F. Aortic dissection
10-12 2 / 3
13
14
Please select the most likely underlying cause for the symptoms described. Each option may
15
16
17
22.
A 24 year old lady from Western India presents with symptoms of lethargy and
dizziness, worse on turning her head. On examination her systolic blood
pressure is 176/128. Her pulses are impalpable at all peripheral sites.
Auscultation of her chest reveals a systolic heart murmur.
18
19
20
21
Takayasu's arteritis
22-24 1 / 3
Takayasu's arteritis most commonly affects young Asian females. Pulseless

peripheries are a classical finding. The CNS symptoms may be variable.
23.
A 48 year old man notices that he is becoming increasingly dizzy when he plays
squash, in addition he has also developed cramping pain in his left arm. One
day he is inflating his car tyre with a hand held pump, he collapses and is
brought to hospital.
You answered Aortic dissection
The correct answer is Subclavian steal syndrome
Subclavian steal syndrome is associated with a stenosis or occlusion of the
subclavian artery, proximal to the origin of the vertebral artery. As a result the
increased metabolic needs of the arm then cause retrograde flow and
symptoms of CNS vascular insufficiency.
24.
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.
You answered Patent ductus arteriosus
The correct answer is Aortic coarctation
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.
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Vascular disease
Aortic
dissection
Cervical rib
Chest pain (anterior chest pain- ascending aorta, back pain descending aorta)
Widening of aorta on chest x-ray
Diagnosis made by CT scanning
Treatment is either medical (Type B disease) or surgical (Type A
disease)
Supernumery fibrous band arising from seventh cervical vertebra

Incidence of 1 in 500
May cause thoracic outlet syndrome
Treatment involves surgical division of rib
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Subclavian
steal
syndrome
Takayasu's
arteritis
Patent ductus
arteriosus
Coarctation of
the aorta
Due to proximal stenotic lesion of the subclavian artery

Results in retrograte flow through vertebral or internal thoracic arteries
The result is that decrease in cerebral blood flow may occur and
produce syncopal symptoms
A duplex scan and/ or angiogram will delineate the lesion and allow
treatment to be planned
Large vessel granulomatous vasculitis

Results in intimal narrowing
Most commonly affects young asian females
Patients present with features of mild systemic illness, followed by
pulseless phase with symptoms of vascular insufficiency
Treatment is with systemic steroids
Ductus arteriosus is a normal foetal vessel that closes spontaneously

after birth
Results in high pressure, oxygenated blood entering the pulmonary
circuit
Untreated patients develop symptoms of congestive cardiac failure
Aortic stenosis at the site of the ductus arteriosus insertion

Most common in boys and girls with Turners syndrome
Patients may present with symptoms of arterial insufficiency, such as
syncope and claudication
Blood pressure mismatch may be seen, as may mismatch of pulse
pressure in the upper and lower limbs
Treatment is either with angioplasty or surgical resection (the former is
the most common)
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Question 25 of 196
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A 25 year old man is found to have carcinoid syndrome. Which of the following hormones is
released by carcinoids?
A. Serotonin
B. Dopamine
Question stats
Score: 34.4%
1
62.9%
9%
9.6%
8.6%
9.9%

question correctly
C. Nor adrenaline
End and review
4
5-7 1 / 3
8
9
10-12 2 / 3
D. Adrenaline
13
E. Aldosterone
Search
14
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15
16
17
Rule of thirds:
18
1/3 multiple
1/3 small bowel
1/3 metastasize
1/3 second tumour
19
20
21
22-24 1 / 3
25
Carcinoids secrete serotonin. Carcinoid syndrome will only occur in the presence of liver
metastasis as the hormone released from primary lesions will typically be metabolised by the
liver.
Carcinoid syndrome

Clinical features
Onset: years
Flushing face
Palpitations
Asthma
Investigation
CT scan
Treatment
Octreotide
Surgical removal
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Question 26 of 196
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End and review
Score: 36.4%
1
9.8%
62.5%
10%
A. sis
9.6%
B. p53
8.1%
C. ras

question correctly
Which one of the following genes protects against neoplasms?
D. myc
4
5-7 1 / 3
8
9
10-12 2 / 3
E. src
13
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14
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p53 is a tumour supressor gene and located on chromosome 17. It plays an important role in
causing cells that are undergoing neoplastic changes to enter an apoptotic pathway.
15
16
17
18
Oncogenes
19
20
21
22-24 1 / 3
25
26


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Question 27 of 196
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A 55 year old man with a long history of achalasia is successfully treated by a Hellers
Cardiomyotomy. Several years later he develops an oesophageal malignancy. Which of the
following lesions is most likely to be present?
Question stats
Score: 35.3%
1
34.9%
9.6%
10.4%
7.8%
37.3%
A. Adenocarcinoma
question correctly
B. Gastrointestinal stromal tumour
End and review
C. Leiomyosarcoma
4
5-7 1 / 3
8
9
10-12 2 / 3
D. Rhabdomyosarcoma
13
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E. Squamous cell carcinoma
14
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15
16
17
Achalasia is a rare condition. However, even once treated there is an increased risk of
malignancy. When it does occur it is most likely to be of squamous cell type.
18
19
Oesophageal cancer
20
21
Incidence is increasing
In most cases in the Western world this increase is accounted for by a rise in the
number of cases of adenocarcinoma. In the UK adenocarcinomas account for 65% of
cases.
Barretts oesophagus is a major risk factor for most cases of oesophageal
adenocarcinoma.
In other regions of the world squamous cancer is more common and is linked to
smoking, alcohol intake, diets rich in nitrosamines and achalasia.
Surveillance of Barretts is important, as it imparts a 30 fold increase in cancer risk and
if invasive malignancy is diagnosed early then survival may approach 85% at 5 years.
22-24 1 / 3
25
26
27
Diagnosis
Upper GI endoscopy is the first line test
Contrast swallow may be of benefit in classifying benign motility disorders but has no
place in the assessment of tumours
Staging is initially undertaken with CT scanning of the chest, abdomen and pelvis. If
overt metastatic disease is identified using this modality then further complex imaging
is unnecessary
If CT does not show metastatic disease, then local stage may be more accurately
assessed by use of endoscopic ultrasound.
Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is
performed in those with negative laparoscopy. Thoracoscopy is not routinely
performed.
Treatment
Operable disease is best managed by surgical resection. The most standard procedure is an
Ivor- Lewis type oesophagectomy. This procedure involves the mobilisation of the stomach
and division of the oesophageal hiatus. The abdomen is closed and a right sided
thoracotomy performed. The stomach is brought into the chest and the oesophagus
mobilised further. An intrathoracic oesophagogastric anastomosis is constructed. Alternative
surgical strategies include a transhiatal resection (for distal lesions), a left thoraco-abdominal
resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with
a cervical oesophagogastric anastomosis.
The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis
this will result in mediastinitis. With high mortality. The McKeown technique has an
intrinsically lower systemic insult in the event of anastomotic leakage.
In addition to surgical resection many patients will be treated with adjuvant chemotherapy.
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Question 29 of 196
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A 63 year old lady is suspected as having sarcoidosis. She is sent to the general surgeons
and a lymph node biopsy is performed. Which histological feature is most likely to be
identified in a lymph node if sarcoid is present?
Question stats
Score: 38.9%
1
18.6%
10.9%
21.6%
36.4%
12.6%
A. Psammoma bodies
question correctly
B. Extensive necrosis
End and review
C. Dense eosinophillic infiltrates
4
5-7 1 / 3
8
9
10-12 2 / 3
D. Asteroid bodies
13
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14
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15
16
Asteroid bodies are often found in the granulomas of individuals with sarcoid. Unlike the
granulomata associated with tuberculosis the granulomas of sarcoid are rarely associated
with extensive necrosis.
17
An Asteroid body in an individual with sarcoid
20
18
19
21
22-24 1 / 3
25
26
27
28
29
Overview

Acute inflammation


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Suppuration
Complete resolution
Abscess formation
Healing by fibrosis
Mediators
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Question 30 of 196
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Question stats
End and review
Score: 36.8%
1
10.1%
7.4%
47.9%
A. Hyperthyroidism
13.2%
B. Hypothyroidism
21.3%
C. Hyperparathyroidism

question correctly
Brown tumours of bone are associated with which of the following?
D. Hypoparathyroidism
4
5-7 1 / 3
8
9
10-12 2 / 3
E. Osteopetrosis
13
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14
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Brown tumors are tumors of bone that arise in settings of excess osteoclast activity, such as
hyperparathyroidism, and consist of fibrous tissue, woven bone and supporting vasculature,
but no matrix. They are radiolucent on x-ray. The osteoclasts consume the trabecular bone
that osteoblasts lay down and this front of reparative bone deposition followed by additional
resorption can expand beyond the usual shape of the bone, involving the periosteum thus
causing bone pain. They appear brown because haemosiderin is deposited at the site.
15
16
17
18
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20
21
22-24 1 / 3
In exams primary hyperparathyroidism is stereotypically seen in elderly females with an

unquenchable thirst and an inappropriately normal or raised parathyroid hormone level. It is
most commonly due to a solitary adenoma
25
26
27
Causes of primary hyperparathyroidism
28
29
80%: solitary adenoma

15%: hyperplasia
4%: multiple adenoma
1%: carcinoma
30
Features - 'bones, stones, abdominal groans and psychic moans'

Polydipsia, polyuria
Peptic ulceration/constipation/pancreatitis
Bone pain/fracture
Renal stones
Depression
Hypertension
Associations
Hypertension
Multiple endocrine neoplasia: MEN I and II
Investigations
Raised calcium, low phosphate
PTH may be raised or normal
Technetium-MIBI subtraction scan
Treatment
Parathyroidectomy, if imaging suggests target gland then a focused approach may be
used
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Question 31 of 196
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A 73 year old man is recovering following an emergency Hartmans procedure performed for
an obstructing sigmoid cancer. The pathology report shows a moderately differentiated
adenocarcinoma that invades the muscularis propria, 3 of 15 lymph nodes are involved with
metastatic disease. What is the correct stage for this?
Question stats
Score: 35.9%
1
8%
5.7%
14.6%
46.9%
24.8%

question correctly
A. Astler Coller Stage B2
End and review
B. Dukes stage A
4
5-7 1 / 3
8
9
10-12 2 / 3
C. Dukes stage B
13
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D. Dukes stage C
14
E. Dukes stage D
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15
16
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17
18
Remember that the term metastasis simply refers to spread and can include the lymph
nodes. In an examination setting marks can be lost by incorrectly selecting Dukes D
(which would be consistent with liver metastasis) rather than nodal metastasis (Dukes C).
19
20
21
22-24 1 / 3
25
The involvement of lymph nodes makes this Dukes C. In the Astler Coller system the B and C
subsets are split to B1 and B2 and C1 and C2. Where C2 denotes involvement of the nodes
in conjunction with penetration of the muscularis propria.
26
27
28
Dukes classification
29
30
Gives the extent of spread of colorectal cancer

31
Dukes A
Tumour confined to the mucosa (90%)
Dukes B
Tumour invading bowel wall (70%)
Dukes C
Lymph node metastases (45%)
Dukes D
Distant metastases (6%)(20% if resectable)
5 year survival in brackets

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Question 32 of 196
End and review
Next
A 55 year old man presents with a soft, fluctuant lesion overlying his right scapula. The
surgeon suspects the lesion may be a lipoma. Which of the following, if present, may be
indicative of an alternative diagnosis?
A. Located in superficial tissues

B. Size greater than 5cm
C. Presence of multiple similar lesions at other anatomical sites
D. Increased mobility of the lesion
E. Lobulated appearance during surgical excision
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Question 33 of 196
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A 55 year old man with dyspepsia undergoes an upper GI endoscopy. An irregular

erythematous area is seen to protrude proximally from the gastro-oesophageal junction.
Apart from specialised intestinal metaplasia, which of the following cell types should also be
present for a diagnosis of Barretts oesophagus to be made?
Question stats
Score: 37.5%
1
54.2%
7.9%
9.7%
15.2%
13%

question correctly
A. Goblet cell
End and review
B. Neutrophil
4
5-7 1 / 3
8
9
10-12 2 / 3
C. Lymphocytes
13
Search
D. Epithelial cells
14
E. Macrophages
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15
16
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17
18
Goblet cells need to be present for a diagnosis of Barrett's oesophagus to be made.
19
Barrett's oesophagus
20
21
Barretts oesophagus is a condition characterised by the metaplastic transformation of

squamous oesophageal epithelium to columnar gastric type epithelium. Three types of this
metaplastic process are recognised; intestinal (high risk), cardiac and fundic. The latter two
categories may cause difficulties in diagnosis. The most concrete diagnosis can be made
when endoscopic features of Barretts oesophagus are present together with a deep biopsy
that demonstrates not just goblet cell metaplasia but also oesophageal glands.
22-24 1 / 3
25
26
27
28
Barrett's can be sub divided into short (<3cm) and long (>3cm). The length of the affected
segment correlates strongly with the chances of identifying metaplasia. The overall
prevalence of Barrett's oesophagus is difficult to determine but may be in the region of 1 in
20 and is identified in up to 12% of those undergoing endoscopy for reflux.
29
30
31
32
A proportion of patients with metaplasia will progress to dysplasia and for this reason
individuals identified as having Barrett's should undergo endoscopic surveillance (every 2-5
years). Biopsies should be quadrantic and taken at 1-2cm intervals. Biopsies need to be
adequate. Where mass lesions are present consideration should be given to endoscopic sub
mucosal resection. Up to 40% of patients will be upstaged from high grade dysplasia to
invasive malignancy with such techniques.
33
Treatment
Long term proton pump inhibitor
Consider pH and manometry studies in younger patients who may prefer to consider
an anti reflux procedure
Regular endoscopic monitoring (more frequently if moderate dysplasia). With
quadrantic biopsies every 2-3 cm
If severe dysplasia be very wary of small foci of cancer
References
A consensus statement of the British approach is provided by:
Bennett C et al Consensus Statements for Management of Barrett's Dysplasia and EarlyStage Esophageal Adenocarcinoma, Based on a Delphi Process. Gastroenterology Volume
143, Issue 2 , Pages 336-346, August 2012.
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Question 34 of 196
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Question stats
End and review
Score: 39%
1
19%
9.6%
36.2%
A. Alanine
21%
B. Aspartime
14.2%
C. Glycine

question correctly
Which of the following amino acids is present in all types of collagen?
D. Tyrosine
4
5-7 1 / 3
8
9
10-12 2 / 3
E. Cysteine
13
Search
14
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Collagen has a generic structure of Glycine- X- Y, where X and Y are variable sub units. The
relatively small size of the glycine molecule enables collagen to form a tight helical structure.
15
16
17
18
Collagen
19
Collagen is one of the most important structural proteins within the extracellular matrix,
collagen together with components such as elastin and glycosaminoglycans determine the
properties of all tissues.
20
21
22-24 1 / 3
Composed of 3 polypeptide strands that are woven into a helix, usually a combination
of glycine with either proline or hydroxyproline plus another amino acid
Numerous hydrogen bonds exist within molecule to provide additional strength
Many sub types but commonest sub type is I (90% of bodily collagen), tissues with
increased levels of flexibility have increased levels of type III collagen
Vitamin c is important in establishing cross links
Synthesised by fibroblasts
25
26
27
28
29
30
31
Collagen Diseases
Disorders of collagen range from relatively common, acquired defects (typically aging),
through to rarer congenital disorders. The latter are exemplified by conditions such as
osteogenesis imperfecta and Ehlers Danlos syndromes.
32
33
34
Osteogenesis imperfecta:
-8 Subtypes
-Defect of type I collagen
-In type I the collagen is normal quality but insufficient quantity
-Type II- poor quantity and quality
-Type III- Collagen poorly formed, normal quantity
-Type IV- Sufficient quantity but poor quality
Patients have bones which fracture easily, loose joint and multiple other defects depending
upon which sub type they suffer from.
Ehlers Danlos:
-Multiple sub types
-Abnormality of types 1 and 3 collagen
-Patients have features of hypermobility.
-Individuals are prone to joint dislocations and pelvic organ prolapse. In addition to many
other diseases related to connective tissue defects.
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Question 35 of 196
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An 8 year old boy presented with a painless swelling on the superotemporal aspect of his
orbit. It was smooth on examination, produced no visual disturbances. Following excision it
was found to be lined by squamous epithelium and hair follicles. Which of the following
lesions most closely matches these findings?
Question stats
Score: 38.1%
1
57.2%
13.1%
6.9%
15.8%
7%

question correctly
A. Dermoid cyst
End and review
B. Desmoid tumour
4
5-7 1 / 3
8
9
10-12 2 / 3
C. Lipoma
13
Search
D. Sebaceous cyst
14
E. Schwannoma
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15
16
17
Dermoid cysts are embryological remnants and may be lined by hair and squamous
epithelium (like teratomas). They are often located in the midline and may be linked to
deeper structures resulting in a dumbbell shape to the lesion. Complete excision is required
as they have a propensity to local recurrence if not excised.
Desmoid tumours are a different entity, they most commonly develop in ligaments and
tendons. They are also referred to as aggressive fibromatosis and consist of fibroblast
dense lesions (resembling scar tissue). They should be managed in a similar manner to soft
tissue sarcomas.
18
19
20
21
22-24 1 / 3
25
26
27
Skin Diseases
28
Skin lesions may be referred for surgical assessment, but more commonly will come via a
dermatologist for definitive surgical management.
29
30
Skin malignancies include basal cell carcinoma, squamous cell carcinoma and malignant
melanoma.
31
32
33
Basal Cell Carcinoma
34
Most common form of skin cancer.

Commonly occur on sun exposed sites apart from the ear.
Sub types include nodular, morphoeic, superficial and pigmented.
Typically slow growing with low metastatic potential.
Standard surgical excision, topical chemotherapy and radiotherapy are all successful.
As a minimum a diagnostic punch biopsy should be taken if treatment other than
standard surgical excision is planned.
35
Squamous Cell Carcinoma

Again related to sun exposure.
May arise in pre - existing solar keratoses.
May metastasize if left.
Immunosupression (e.g. following transplant), increases risk.
Wide local excision is the treatment of choice and where a diagnostic excision biopsy
has demonstrated SCC, repeat surgery to gain adequate margins may be required.
Malignant Melanoma
Change in size
Change in shape
Change in colour
Diameter >6mm
Inflammation
Oozing or bleeding
Altered sensation
Treatment
difficult.

Lesions 0-1mm thick
1cm
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Lesions 1-2mm thick
Lesions 2-4mm thick
Lesions >4 mm thick
3cm
Marsden J et al. Revised UK guidelines for management of Melanoma. Br J Dermatol 2010

163:238-256.
Kaposi Sarcoma
Tumour of vascular and lymphatic endothelium.
Purple cutaneous nodules.
Associated with immuno supression.
Classical form affects elderly males and is slow growing.
Immunosupression form is much more aggressive and tends to affect those with HIV
related disease.
Non malignant skin disease

Dermatitis Herpetiformis
Chronic itchy clusters of blisters.
Linked to underlying gluten enteropathy (coeliac disease).
Dermatofibroma
Benign lesion.
Firm elevated nodules.
Usually history of trauma.
Lesion consists of histiocytes, blood vessels and fibrotic changes.
Pyogenic granuloma
Overgrowth of blood vessels.
Red nodules.
Usually follow trauma.
May mimic amelanotic melanoma.
Acanthosis nigricans
Brown to black, poorly defined, velvety hyperpigmentation of the skin.
Usually found in body folds such as the posterior and lateral folds of the neck, the
axilla, groin, umbilicus, forehead, and other areas.
The most common cause of acanthosis nigricans is insulin resistance, which leads to
increased circulating insulin levels. Insulin spillover into the skin results in its abnormal
increase in growth (hyperplasia of the skin).
In the context of a malignant disease, acanthosis nigricans is a paraneoplastic
syndrome and is then commonly referred to as acanthosis nigricans maligna.
Involvement of mucous membranes is rare and suggests a coexisting malignant
condition.
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Question 36 of 196
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A 55 year old man from Hong Kong presents with left sided otalgia and recurrent episodes of
epistaxis. On examination his pharynx appears normal. Examination of his neck reveals left
sided cervical lymphadenopathy. What is the most likely underlying diagnosis?
Question stats
Score: 39.5%
1
8.1%
61.1%
10.2%
9.9%
10.6%
A. Antrochoanal polyp
question correctly
B. Nasopharyngeal carcinoma
End and review
C. Adenocarcinoma of the tonsil
4
5-7 1 / 3
8
9
10-12 2 / 3
D. Angiofibroma
13
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E. Globus syndrome
14
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15
16
17
Given this mans ethnic origin and presenting features a nasopharyngeal carcinoma is the
most likely underlying diagnosis.
18
19
Nasopharyngeal carcinoma
20
21
Squamous cell carcinoma of the nasopharynx

Rare in most parts of the world, apart from individuals from Southern China
Associated with Epstein Barr virus infection
22-24 1 / 3
25
26
27
Presenting features
28
Systemic
Local
Cervical lymphadenopathy
Otalgia
29
30
31
Unilateral serous otitis media
32
Nasal obstruction, discharge and/ or epistaxis
33
34
Cranial nerve palsies e.g. III-VI
35
36
Imaging
Combined CT and MRI.
Treatment
Radiotherapy is first line therapy.
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Question 37 of 196
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A women is diagnosed as having pernicious anaemia. What is the most likely underlying
explanation for this?
A. Autoimmune antibodies to parietal cells

B. Autoimmune antibodies to chief cells
Question stats
Score: 42.2%
1
57%
17.1%
9.2%
8.8%
7.9%

question correctly
C. Autoimmune antibodies to goblet cells
End and review
4
5-7 1 / 3
8
9
10-12 2 / 3
D. Autoimmune antibodies to Brunners glands
13
E. Autimmune antibodies to fundic cells
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14
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15
16
Parietal cell destruction is a major cause of pernicious anaemia and is usually autoimmune
mediated. Other conditions such as bacterial overgrowth may produce mixed patterns and
require more complex diagnostic evaluation.
17
18
19
Pernicious anaemia
20
21
Pernicious anaemia is a chronic illness caused by impaired absorption of vitamin B-12

because of a lack of intrinsic factor (IF) in gastric secretions. It occurs as a relatively
common adult form of anaemia that is associated with gastric atrophy and a loss of IF
production and as a rare congenital autosomal recessive form in which IF production is
lacking without gastric atrophy.
Classic pernicious anaemia is caused by the failure of gastric parietal cells to produce
sufficient IF (a gastric protein secreted by parietal cells) to permit the absorption of
adequate quantities of dietary vitamin B-12. Other disorders that interfere with the
absorption and metabolism of vitamin B-12 can produce cobalamin deficiency, with the
development of a macrocytic anaemia and neurologic complications. In many cases
the underlying cause is autoimmune destruction of the parietal cell mass of the gastric
antrum.
Diagnostic evaluation may include investigations to delineate the precise cause and
this may include Schilling test, trials of B12 and in some cases bone marrow sampling.
Treatment of the disorder is with 3 monthly treatment of vitamin B12 injections. Folic
acid supplementation may also be required.
22-24 1 / 3
25
26
27
28
29
30
31
32
33
34
35
36
37
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Question 38 of 196
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End and review
Score: 44.7%
1
9.3%
11.3%
23.7%
42.9%
A. Temporal artery biopsy is only diagnostic if there is visual loss
12.9%
B. Biopsy is typically taken from the non-symptomatic side to avoid the risk
of blindness

question correctly
Patients with suspected temporal arteritis are often sent for temporal artery biopsy. Which
statement is true?
C. Pre-operative localisation with duplex is mandatory
4
5-7 1 / 3
8
9
10-12 2 / 3
D. Biopsies may be non diagnostic in over 50% of cases
13
Search
E. Biopsies are usually performed under general anaesthesia
14
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15
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16
17
Temporal artery biopsies are frequently non diagnostic. They should be taken from the
symptomatic side and though not mandatory a duplex ultrasound is a helpful investigation,
particularly if they mark the artery. It is usually performed under local anaesthetic.
18
19
20
Temporal artery biopsy
21
22-24 1 / 3
Superficial temporal artery is a terminal branch of the external carotid artery
25
26
Main indication
27
Temporal arteritis
28
29
American College of Rheumatology guidelines recommend a temporal artery biopsy if:
30
31
Age of onset older than 50 years

New-onset headache or localized head pain
Temporal artery tenderness to palpation or reduced pulsation
ESR > 50 mm/h
32
33
34
35
36
Histopathology
37
Vessel wall granulomatous arteritis with mononuclear cell infiltrates and giant cell
formation
38
Procedure
Position: supine, head 45 degrees
USS doppler to locate the superficial temporal artery or palpate
Local anaesthetic
Artery within temporoparietal fascia
Clamp and ligate the vessel
Cut 3-5cm
Ligate the remaining ends with absorbable suture
Close the skin
Contraindication
Glucocorticoid therapy > 30 days
Risks
Injury to facial or auriculotemporal nerve
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Question 39 of 196
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Which of the following best describes the processes underpinning type IV hypersensitivity
reactions?
A. Deposition of immune complexes of IgG and antigen at the site of

inflammation
Question stats
Score: 46.9%
1
12.9%
7.5%
10.6%
11.7%
57.3%

question correctly
B. Deposition of IgA complexes at the site of inflammation
End and review
C. Deposition of IgM and IgG complexes at the site of inflammation
4
5-7 1 / 3
8
9
10-12 2 / 3
D. Degranulation of mast cells at the site of inflammation
13
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E. T cell mediated response at the site of inflammation
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15
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16
17
Hypersensitivity reactions: ACID
18
19
type 1 --Anaphylactic
type 2 --Cytotoxic
type 3 --Immune complex
type 4 --Delayed hypersensitivity
20
21
22-24 1 / 3
25
T Cells are the mediators of type 4 hypersensitivity reactions which are characterised by the
absence of immune complex deposition.
26
27
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29
30
31
Description
Mediator
Type I
Type II
Type III
Type IV
Anaphylactic
Cytotoxic
Immune
complex
Delayed type
IgG, Ig A,
IgM
T-cells
IgE
IgG, IgM
32
33
34
35
36
37
Antigen
Exogenous
Cell surface
Soluble
Tissues
Response
time
Minutes
Hours
Hours
2-3 days
Examples
Asthma
Hay fever
anaemia
Pemphigus
Goodpasture's
Serum
sickness
SLE
Aspergillosis
Graft versus host

disease
Contact dermatitis
38
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Question stats
End and review
Score: 48.1%
1
2
Theme: Bone tumours

A. Osteosarcoma
40
54.3%
41
59%
42
32.7%
B. Fibrosarcoma
3
4
5-7 1 / 3
C. Osteoclastoma
D. Ewings sarcoma
Search
E. Leiomyosarcoma
Go
10-12 2 / 3
F. Chondrosarcoma
13
G. Rhabdomyosarcoma
14
H. Osteoid osteoma
15
I. Malignant fibrous histiocytoma
16
17
Please select the most appropriate lesion for the clinical scenario given. Each option may be
18
19
20
40.
A 16 year-old boy presents to his GP with loss of weight, pain and fever. On
examination, a soft tissue mass is palpable over the mid-thigh region
21
22-24 1 / 3
25
You answered Fibrosarcoma
26
The correct answer is Ewings sarcoma
27
Ewing's sarcoma is a malignant round cell tumour occurring in the diaphysis of

the long bones in the children. These are not confined to the ends of long
bones. x Rays often show a large soft-tissue mass with concentric layers of new
bone formation ( 'onion-peel' sign). The ESR may be elevated, thus suggesting
an inflammatory or an infective cause such as osteomyelitis; although
osteomyelitis usually affects the metaphyseal region in children. Treatment is
with chemotherapy and surgical excision, an endoprothesis may be used to
conserve the limb.
28
29
30
31
32
33
34
41.
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.
35
36
Osteosarcoma
37
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.
42.
38
39
40-42 2 / 3
A 17-year-old girl presents with weight loss, fever and a swelling over her right
knee. Movements of her knee are restricted. A plain x-ray of the affected site
shows multiple lytic and lucent lesions with clearly defined borders.
Osteoclastoma
Osteoclastoma has a characteristic appearance on x-ray with multple lytic and
lucent areas (Soap bubble) appearances. Pathological fractures may occur.
The disease is usually indolent.
Next question
Sarcomas
Malignant tumours of mesenchymal origin
Types
May be either bone or soft tissue in origin.
Bone sarcoma include:
Osteosarcoma
Ewings sarcoma (although non bony sites recognised)
Chondrosarcoma - originate from Chondrocytes
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Soft tissue sarcoma are a far more heterogeneous group and include:
Liposarcoma-adipocytes
Rhabdomyosarcoma-striated muscle
Leiomyosarcoma-smooth muscle
Synovial sarcomas- close to joints (cell of origin not known but not synovium)
Malignant fibrous histiocytoma is a sarcoma that may arise in both soft tissue and bone.
Features
Certain features of a mass or swelling should raise suspicion for a sarcoma these include:
Large >5cm soft tissue mass
Deep tissue location or intra muscular location
Rapid growth
Painful lump
Assessment
Imaging of suspicious masses should utilise a combination of MRI, CT and USS. Blind biopsy
should not be performed prior to imaging and where required should be done in such a way
that the biopsy tract can be subsequently included in any resection.
Ewings sarcoma
Commoner in males
Incidence of 0.3 / 1, 000, 000
Onset typically between 10 and 20 years of age
Location by femoral diaphysis is commonest site
Histologically it is a small round tumour
Blood borne metastasis is common and chemotherapy is often combined with surgery
Osteosarcoma
Mesenchymal cells with osteoblastic differentiation
20% of all primary bone tumours
Incidence of 5 per 1,000,000
Peak age 15-30, commoner in males
Limb preserving surgery may be possible and many patients will receive chemotherapy
Liposarcoma
Malignancy of adipocytes
Rare, approximately 2.5 per 1,000,000. They are the second most common soft tissue
sarcoma
Typically located in deep locations such as retroperitoneum
Affect older age group usually >40 years of age
May be well differentiated and thus slow growing although may undergo dedifferentiation and disease progression
Many tumours will have a pseudocapsule that can misleadingly allow surgeons to feel
that they can 'shell out' these lesions. In reality, tumour may invade at the edge of the
pseudocapsule and result in local recurrence if this strategy is adopted
Usually resistant to radiotherapy, although this is often used in a palliative setting
Malignant Fibrous Histiocytoma

Tumour with large number of histiocytes
Most common sarcoma in adults
Also described as undifferentiated pleomorphic sarcoma NOS (i.e. Cell of origin is not
known)
Four major subtypes are recognised: storiform-pleomorphic (70% cases), myxoid (less
aggressive), giant cell and inflammatory
Treatment is usually with surgical resection and adjuvant radiotherapy as this reduces
the likelihood of local recurrence
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Question 1 of 154
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A 56 year old man is diagnosed with an abdominal aortic aneurysm and undergoes a CT
scan to asses the size of the aorta. During the course of his investigations a lesion of the
adrenal gland is identified. It measures 1.5 cm in diameter and the gland is otherwise normal.
What is the most likely diagnosis?
Question stats
End and review
Score: 0%
5.1%
12.1%
23.2%
15.6%
44%

question correctly
A. Adrenal gland metastasis

B. Adrenal gland arterio-venous malformation
C. Adrenal cyst
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D. Phaeochromocytoma
E. Adrenal cortical adenoma
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25% of all adrenal lesions >4cm in diameter are malignant

Incidentalomas of the adrenal gland are common and represent the most likely lesion in this
scenario. Clearly the other lesions are all possibilities but are unlikely.
Adrenal lesions- Incidental
Incidentaloma of the adrenal glands have become increasingly common as CT scanning of
the abdomen is widely undertaken. Prevalences range from 1.5-9% in autopsy studies.
Overall, 75% will be non functioning adenomas. However, a thorough diagnostic work up is
required to exclude a more significant lesion.
Investigation
Morning and midnight plasma cortisol measurements
Dexamethasone suppression test
24 hour urinary cortisol excretion
24 hour urinary excretion of catecholamines
Serum potassium, aldosterone and renin levels
Management
The risk of malignancy is related to the size of the lesion and 25% of all masses greater than
4cm will be malignant. Such lesions should usually be excised. Where a lesion is a suspected
metastatic deposit a biopsy may be considered. Smaller, innocent lesions are usually
followed up by serial CT scans at 6, 12 and 24 months.
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A 22 year old man is undergoing an abdominal ultrasound scan as part of a series of

investigations for abdominal pain. The radiologist notes that there is evidence of splenic
atrophy. What is the most likely cause?
Question stats
End and review
Score: 50%
17.9%
32.1%
12%
23.1%
14.9%
1
2
A. Letterer-Siwe disease
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B. Coeliac disease
C. Malaria
D. Niemann-Pick disease
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E. Sarcoidosis
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Splenic atrophy may occur in coeliac disease together with the appearance of Howell-Jolly
bodies in erythrocytes. Letterer - Siwe disease is a form of Histiocytosis X in which
macrophages proliferate.
Spleen
The spleen is located in the left upper quadrant of the abdomen and its size can vary
depending upon the amount of blood it contains. The typical adult spleen is 12.5cm long and
7.5cm wide. The usual weight of the adult spleen is 150g.
The exact position of the spleen can vary with respiratory activity, posture and the state of
surrounding viscera. It usually lies obliquely with its long axis aligned to the 9th, 10th and
11th ribs. It is separated from these ribs by both diaphragm and pleural cavity. The normal
spleen is not palpable.
The shape of the spleen is influenced by the state of the colon and stomach. Gastric
distension will cause the spleen to resemble the shape of an orange segment. Colonic
distension will cause it to become more tetrahedral.
The spleen is almost entirely covered by peritoneum, which adheres firmly to its capsule.
Recesses of the greater sac separate it from the stomach and kidney. It develops from the
upper dorsal mesogastrium, remaining connected to the posterior abdominal wall and
stomach by two folds of peritoneum; the lienorenal ligament and gastrosplenic ligament. The
lienorenal ligament is derived from peritoneum where the wall of the general peritoneum
meets the omental bursa between the left kidney and spleen; the splenic vessels lie in its
layers. The gastrosplenic ligament also has two layers, formed by the meeting of the walls of
the greater sac and omental bursa between spleen and stomach, the short gastric and left
gastroepiploic branches of the splenic artery pass in its layers. Laterally, the spleen is in
contact with the phrenicocolic ligament.
Relations
Superiorly
Diaphragm
Anteriorly
Gastric impression
Posteriorly Kidney
Inferiorly
Colon
Hilum
Tail of pancreas and splenic vessels (splenic artery divides here, branches
pass to the w hite pulp transporting plasma)
Contents
White
pulp
Immune function. Contains central trabecular artery. The germinal centres are
supplied by arterioles called penicilliary radicles.
Red
pulp
Filters abnormal red blood cells.
Function
Filtration of abnormal blood cells and foreign bodies such as bacteria.
Immunity: IgM. Production of properdin, and tuftsin which help target fungi and bacteria
for phagocytosis.
Haematopoiesis: up to 5th month gestation or in haematological disorders.
Pooling: storage of 40% platelets.
Iron reutilisation
Storage monocytes
Disorders of the spleen
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Massive splenomegaly
Myelofibrosis
Chronic myeloid leukaemia
Visceral leishmaniasis (kala-azar)
Malaria
Gaucher's syndrome
Other causes (as above plus)

Portal hypertension e.g. secondary to cirrhosis
Lymphoproliferative disease e.g. CLL, Hodgkin's
Haemolytic anaemia
Infection: hepatitis, glandular fever
Infective endocarditis
Sickle-cell*, thalassaemia
Rheumatoid arthritis (Felty's syndrome)
*the majority of adult patients with sickle-cell will have an atrophied spleen due to repeated
infarction
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Score: 66.7%
1
11.7%
10.1%
22.2%
A. They are tumours of chromaffin cells in the adrenal medulla.
8.4%
B. They are bilateral in 10% of cases.
47.6%
C. When located in an extra adrenal location have a higher incidence of

malignancy.

question correctly
Which statement relating to phaeochromocytoma is untrue?
D. May be associated with an elevated urinary VMA.

E. Up to 40% may have a blood pressure within the normal range.
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Normotension is seen in around 10% cases. The remainder show a degree of hypertension.
Phaeochromocytoma
Diagnosis
Treatment
Size less than 3cm
Homogeneous texture
Lipid rich tissue
Thin wall to lesion
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References
May;77(5):592-6.
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A 69 year old man presents with a purple lesion on his forearm. It is excised and an a 3 cm
Merkel cell tumour is diagnosed. Which of the following statements relating to this diagnosis
is false?
Question stats
End and review
Score: 50%
1
16.6%
12.9%
13.5%
32.1%
25%
A. He should undergo a sentinel lymph node biopsy.

question correctly
B. Lymphovascular invasion is typically seen histologically

C. They are more common in immunosupressed patients
D. Histologically they may resemble pyogenic granuloma
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E. They are associated with visceral metastasis
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Merkel cell tumours are rare cutaneous tumours. Histologically they consist of sheets and
nodules of hyperchromatic epithelial cells, with high rates of mitosis and apoptosis. As such
they are relatively easy to distinguish from pyogenic granuloma which has no features of
malignancy and would not show lymphovascular invasion.
Merkel cell tumours of the skin
Rare but aggressive tumour.

Develops from intra epidermal Merkel cells.
Usually presents on elderly, sun damaged skin. The periorbital area is the commonest
site.
Histologically these tumours appear within the dermis and subcutis. The lesions
consist of sheets and nodules of small hyperchromatic epithelial cells with high rates of
mitosis and apoptosis. Lymphovascular invasion is commonly seen.
Pre-existing infection with Merkel Cell Polyomavirus is seen in 80% cases.
Treatment
Surgical excision is first line. Margins of 1cm are required. Lesions >10mm in diameter should
undergo sentinel lymph node biopsy. Adjuvant radiotherapy is often given to reduce the risk
of local recurrence.
Prognosis
With lymph node metastasis 5 year survival is 50% or less.
Small lesions without nodal spread are usually associated with a 5 year survival of
80%.
Skin biopsy demonstrating a Merkel Cell cancer. Note the hyperchromatic epithelial cells and
high mitotic rate
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A 58 year old lady undergoes a screening mammogram and appearances are suspicious for
ductal carcinoma in situ. A stereotactic core biopsy is performed. If ductal carcinoma in situ is
to be diagnosed, which of the following pathological features must not be present?
Question stats
End and review
Score: 40%
1
9.2%
10.6%
10.3%
13.2%
56.7%
A. Nuclear pleomorphism
question correctly
B. Coarse chromatin
C. Abnormal mitoses
D. Angiogenesis
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E. Dysplastic cells infiltrating the suspensory ligaments of the breast
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The presence of invasion is a hallmark of invasive disease and thus would not be a feature
of DCIS. Angiogenesis may occur in association with high grade DCIS.
Histopathology of malignancy
Abnormal tissue architecture

Coarse chromatin
Invasion of basement membrane*
Abnormal mitoses
Angiogenesis
De-differentiation
Areas of necrosis
Nuclear pleomorphism
*= Those features that distinguish invasive malignancy from in situ disease

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Score: 33.3%
1
7.3%
37.3%
10%
A. Plasma leakage into interstitial space
13.5%
B. Absolute polycythaemia
31.9%
C. Increased haematocrit

question correctly
Which of the following does not occur as a pathological response to extensive burns?
D. Keratinocyte migration during healing
E. Cardiac output reduction by 50% in first 30 minutes

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Haemolysis is the main pathological response.

Burns pathology
Extensive burns
Haemolysis due to damage of erythrocytes by heat and microangiopathy
Loss of capillary membrane integrity causing plasma leakage into interstitial space
Extravasation of fluids from the burn site causing hypovolaemic shock (up to 48h after
injury)- decreased blood volume and increased haematocrit
Protein loss
Secondary infection e.g. Staphylococcus aureus
ARDS
Risk of Curlings ulcer (acute peptic stress ulcers)
Danger of full thickness circumferential burns in an extremity as these may develop
compartment syndrome
Healing
Superficial burns: keratinocytes migrate to form a new layer over the burn site
Full thickness burns: dermal scarring. Usually need keratinocytes from skin grafts to
provide optimal coverage.
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End and review
Score: 33.3%
1
2
Theme: Chest pain

A. Pulmonary embolism
53.5%
46.6%
82.2%
B. Acute exacerbation asthma
3
4
5
C. Physiological
D. Mitral valve stenosis
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E. Aortic dissection
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F. Mitral regurgitation
G. Bronchopneumonia
H. Tuberculosis
I. None of the above
What is the most likely diagnosis for the scenario given? Each option may be used once,
more than once or not at all.
7.
A 28 year old Indian woman, who is 18 weeks pregnant, presents with increasing
shortness of breath, chest pain and coughing clear sputum. She is apyrexial,
blood pressure is 140/80 mmHg, heart rate 130 bpm and saturations 94% on
15L oxygen. On examination there is a mid diastolic murmur, there are bibasal
crepitations and mild pedal oedema. She suddenly deteriorates and has a
respiratory arrest. Her chest x-ray shows a whiteout of both of her lungs.
Mitral valve stenosis
Mitral stenosis is the commonest cause of cardiac abnormality occurring in
pregnant women. Mitral stenosis is becoming less common in the UK population,
however should be considered in women from countries where there is a higher
incidence of rheumatic heart disease. Mitral stenosis causes a mid diastolic
murmur which may be difficult to auscultate unless the patient is placed into the
left lateral position. These patients are at risk of atrial fibrillation (up to 40%),
which can also contribute to rapid decompensation. Physiological changes in
pregnancy may cause an otherwise asymptomatic patient to suddenly
deteriorate. Balloon valvuloplasty is the treatment of choice.
8.
A 28 year old woman, who is 30 weeks pregnant, presents with sudden onset
chest pain associated with loss of consciousness. Her blood pressure is 170/90
mmHg, saturations on 15L oxygen 93%, heart rate 120 bpm and she is
apyrexial. On examination there is an early diastolic murmur, occasional bibasal
creptitations and mild peal oedema. An ECG shows ST elevation in leads II, III
and aVF.
You answered Mitral regurgitation
The correct answer is Aortic dissection
Aortic dissection is associated with the 3rd trimester of pregnancy, connective
tissue disorders (Marfan's, Ehlers- Danlos) and bicuspid valve. Patients may
complain of a tearing chest pain or syncope. Clinically they may be
hypertensive. The right coronary artery may become involved in the dissection,
causing myocardial infarct in up to 2% cases (hence ST elevation in the inferior
leads). An aortic regurgitant murmur may be auscultated.
9.
A 28 year old woman, who is 18 weeks pregnant, presents with sudden chest
pain. Her blood pressure is 150/70 mmHg, saturations are 92% on 15L oxygen
and her heart rate is 130 bpm. There are no murmurs and her chest is clear.
There is signs of thrombophlebitis in the left leg.
You answered Tuberculosis
The correct answer is Pulmonary embolism
Chest pain, hypoxia and clear chest on auscultation in pregnancy should lead to
a high suspicion of pulmonary embolism.
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Theme question in September 2011 exam

Pregnant women can decompensate rapidly from cardiac compromise.
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Chest pain in pregnancy
Aortic dissection
Predisposing factors in pregnancy are hypertension, congenital heart disease and
Marfan's syndrome
Mainly Stanford type A dissections
Sudden tearing chest pain, transient syncope
Patient may be cold and clammy, hypertensive and have an aortic regurgitation
murmur
Involvement of the right coronary artery may cause inferior myocardial infarction
Surgical management
Gestational
timeframe
Management
< 28/40
Aortic repair with the fetus kept in utero
28-32/40
Dependent on fetal condition
> 32/40
Primary Cesarean section followed by aortic repair at the same

operation
Mitral stenosis
Most cases associated with rheumatic heart disease
Becoming less common in British women; suspect in Immigrant women
Commonest cardiac condition in pregnancy
Commonly associated with mortality
Valve surgery; balloon valvuloplasty preferable
Pulmonary embolism
Leading cause of mortality in pregnancy
Half dose scintigraphy; CT chest if underlying lung disease, should aid diagnosis
Treatment with low molecular weight heparin throughout pregnancy and 4-6 weeks
after childbirth
Warfarin is contra indicated in pregnancy
References
1. Bates S.M. and Ginsberg J.S. How we manage venous thromboembolism during
pregnancy. Blood 2002 (100): 3470-3478.
2. Scarsbrook A.Fand Gleeson V. Investigating suspected pulmonary embolism in
pregnancy. BMJ 2007 (326) : 1135 doi: 10.1136/bmj.7399.1135.
3. Morley C. A. and Lim B. A. Lesson of the Week: The risks of delay in diagnosis of
breathlessness in pregnancy. BMJ 1995 (311) : 1083.
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A 67 year old man is investigated for biliary colic and a 4.8 cm abdominal aortic aneurysm is
identified. Which of the following statements relating to this condition is untrue?
A. The wall will be composed of dense fibrous tissue only

B. The majority are located inferior to the renal arteries
Question stats
Score: 40%
54.1%
12.7%
9%
12.2%
12%
D. He should initially be managed by a process of active surveillance

E. Aortoduodenal fistula is a recognised complication following repair.
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question correctly
C. They occur most often in current or former smokers
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They are true aneurysms and have all 3 layers of arterial wall.
Abdominal aorta aneurysm
Abdominal aortic aneurysms are a common problem in vascular surgery.

They may occur as either true or false aneurysm. With the former all 3 layers of the
arterial wall are involved, in the latter only a single layer of fibrous tissue forms the
aneurysm wall.
True abdominal aortic aneurysms have an approximate incidence of 0.06 per 1000
people. They are commonest in elderly men and for this reason the UK is now
introducing the aneurysm screening program with the aim of performing an abdominal
aortic ultrasound measurement in all men aged 65 years.
Causes
Several different groups of patients suffer from aneurysmal disease.
The commonest group is those who suffer from standard arterial disease, i.e. Those
who are hypertensive, have diabetes and have been or are smokers.
Other patients such as those suffering from connective tissue diseases such as
Marfan's may also develop aneurysms. In patients with abdominal aortic aneurysms
the extracellular matrix becomes disrupted with a change in the balance of collagen
and elastic fibres.
Management
Most abdominal aortic aneurysms are an incidental finding.
Symptoms most often relate to rupture or impending rupture.
20% rupture anteriorly into the peritoneal cavity. Very poor prognosis.
80% rupture posteriorly into the retroperitoneal space
The risk of rupture is related to aneurysm size, only 2% of aneurysms measuring less
than 4cm in diameter will rupture over a 5 year period. This contrasts with 75% of
aneurysms measuring over 7cm in diameter.
This is well explained by Laplaces' law which relates size to transmural pressure.
For this reason most vascular surgeons will subject patients with an aneurysm size of
5cm or greater to CT scanning of the chest, abdomen and pelvis with the aim of
delineating anatomy and planning treatment. Depending upon co-morbidities, surgery
is generally offered once the aneurysm is between 5.5cm and 6cm.
A CT reconstruction showing an infrarenal abdominal aortic aneurysm. The walls of the sac
are calcified which may facilitate identification on plain x-rays
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Symptomatic aneurysms (80% annual mortality if untreated)
Increasing size above 5.5cm if asymptomatic
Rupture (100% mortality without surgery)
Surgical procedures
Abdominal aortic aneurysm repair
Procedure:
GA
Invasive monitoring (A-line, CVP, catheter)
Incision: Midline or transverse
Bowel and distal duodenum mobilised to access aorta.
Aneurysm neck and base dissected out and prepared for cross clamp
Systemic heparinisation
Cross clamp (proximal first)
Longitudinal aortotomy
Atherectomy
Deal with back bleeding from lumbar vessels and inferior mesenteric artery
Insert graft either tube or bifurcated depending upon anatomy
Suture using Prolene (3/0 for proximal , distal anastomosis suture varies according to site)
Clamps off: End tidal CO2 will rise owing to effects of reperfusion, at this point major risk of
myocardial events.
Haemostasis
Closure of aneurysm sac to minimise risk of aorto-enteric fistula
Closure: Loop 1 PDS or Prolene to abdominal wall
Skin- surgeons preference
Post operatively:
ITU (Almost all)
Greatest risk of complications following emergency repair
Complications: Embolic- gut and foot infarcts
Cardiac - owing to premorbid states, re-perfusion injury and effects of cross clamp
Wound problems
Later risks related to graft- infection and aorto-enteric fistula
Special groups
Supra renal AAA
These patients will require a supra renal clamp and this carries a far higher risk of
complications and risk of renal failure.
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Ruptured AAA
Pre-operatively the management depends upon haemodynamic instability. In patients with
symptoms of rupture (typical pain, haemodynamic compromise and risk factors) then ideally
prompt laparotomy. In those with vague symptoms and haemodynamic stability the ideal test
is CT scan to determine whether rupture has occurred or not. Most common rupture site is
retroperitoneal 80%. These patients will tend to develop retroperitoneal haematoma. This
can be disrupted if Bp is allowed to rise too high so aim for Bp 100mmHg.
Operative details are similar to elective repair although surgery should be swift, blind rushing
often makes the situation worse. Plunging vascular clamps blindly into a pool of blood at the
aneurysm neck carries the risk of injury the vena cava that these patients do not withstand.
Occasionally a supracoeliac clamp is needed to effect temporary control, although leaving
this applied for more than 20 minutes tends to carry a dismal outcome.
EVAR
Increasingly patients are now being offered endovascular aortic aneurysm repair. This is
undertaken by surgeons and radiologists working jointly. The morphology of the aneurysm is
important and not all are suitable. Here is a typical list of those features favoring a suitable
aneurysm:
Long neck
Straight iliac vessels
Healthy groin vessels
Clearly few AAA patients possess the above and compromise has to be made. The use of
fenestrated grafts can allow supra renal AAA to be treated.
Procedure:
GA
Radiology or theatre
Bilateral groin incisions
Common femoral artery dissected out
Heparinisation
Arteriotomy and insertion of guide wire
Dilation of arteriotomy
Insertion of EVAR Device
Once in satisfactory position it is released
Arteriotomy closed once check angiogram shows good position and no endoleak
Complications:
Endoleaks depending upon site are either Type I or 2. These may necessitate reintervention and all EVAR patients require follow up . Details are not needed for MRCS.
References
A reasonable review is provided by:
Sakalihasan N, Limet R, Defawe O. Abdominal aortic aneurysm. Lancet 2005 (365):15771589
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Score: 45.5%
1
33.4%
12.1%
27.1%
A. It may induce necrosis of cells with non repairable DNA damage
10.3%
B. It is affected in Li Fraumeni syndrome
17.1%
C. It can induce DNA repair

question correctly
Which of the following statements in relation to the p53 tumour suppressor protein is false?
D. It can halt the cell cycle
6
7-9 1 / 3
10
E. It may inhibit angiogenesis
11
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When DNA cannot be repaired it will induce cellular apoptosis (not necrosis)
presented here.
Autosomal dominant
Diagnosed when:

BRCA 1 and 2
2).
Lynch Syndrome
Autosomal dominant
Amsterdam criteria
Gardners syndrome
cancer
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Score: 41.7%
1
50.2%
12.5%
18.8%
A. Squamous cells
10%
B. Goblet cells
8.5%
C. Columnar cells

question correctly
Which of the following cell types is most likely to be identified in the wall of a fistula in ano?
D. Ciliated columnar cells
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11
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A fistula is an abnormal connection between two epithelial lined surfaces, in the case of a
fistula in ano it will be lined by squamous cells.
Fistulas
A fistula is defined as an abnormal connection between two epithelial surfaces.

There are many types ranging from Branchial fistulae in the neck to entero-cutaneous
fistulae abdominally.
In general surgical practice the abdominal cavity generates the majority and most of
these arise from diverticular disease and Crohn's.
As a general rule all fistulae will resolve spontaneously as long as there is no distal
obstruction. This is particularly true of intestinal fistulae.
The four types of fistulae are:

Enterocutaneous
These link the intestine to the skin. They may be high (>500ml) or low output (<250ml)
depending upon source. Duodenal /jejunal fistulae will tend to produce high volume,
electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-cutaneous
fistulae will tend to leak faeculent material. Both fistulae may result from the spontaneous
rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or
may occur as a result of iatrogenic input. In some cases it may even be surgically desirable
e.g. mucous fistula following sub total colectomy for colitis.
Suspect if there is excess fluid in the drain.
Enteroenteric or Enterocolic
This is a fistula that involves the large or small intestine. They may originate in a similar
manner to enterocutaneous fistulae. A particular problem with this fistula type is that bacterial
overgrowth may precipitate malabsorption syndromes. This may be particularly serious in
inflammatory bowel disease.
Enterovaginal
Aetiology as above.
Enterovesicular
This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract
infections, or the passage of gas from the urethra during urination.
Management
Some rules relating to fistula management:
They will heal provided there is no underlying inflammatory bowel disease and no
distal obstruction, so conservative measures may be the best option
Where there is skin involvement, protect the overlying skin, often using a well fitted
stoma bag- skin damage is difficult to treat
A high output fistula may be rendered more easily managed by the use of octreotide,
this will tend to reduce the volume of pancreatic secretions.
Nutritional complications are common especially with high fistula (e.g. high jejunal or
duodenal) these may necessitate the use of TPN to provide nutritional support
together with the concomitant use of octreotide to reduce volume and protect skin.
When managing perianal fistulae surgeons should avoid probing the fistula where
acute inflammation is present, this almost always worsens outcomes.
When perianal fistulae occur secondary to Crohn's disease the best management
option is often to drain acute sepsis and maintain that drainage through the judicious
use of setons whilst medical management is implemented.
Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have
an intra abdominal source the use of barium and CT studies should show a track. For
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perianal fistulae surgeons should recall Goodsall's rule in relation to internal and
external openings.
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Question 13 of 154
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A 22 year old man is referred to the surgical clinic. He has been complaining of varicose
veins for many years. On examination he has extensive varicosities of the right leg, there are
areas of marked port wine staining. The saphenofemoral junction is competent on doppler
assessment. The most likely underlying diagnosis is:
Question stats
Score: 46.2%
1
8.5%
46.3%
11.9%
25.7%
7.6%

question correctly
A. Deep vein thrombosis
End and review
B. Klippel-Trenaunay syndrome
6
7-9 1 / 3
10
C. Varicose veins due to sapheno-popliteal junction incompetence

11
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D. Sturge - Weber syndrome
12
E. Angiosarcoma
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13
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Sturge - Weber syndrome is a an arteriovenous malformation affecting the face and CNS,
the peripheral vessels are not affected. Simple varicose veins should not typically be
associated with port wine staining, nor should a DVT or angiosarcoma.
Klippel-Trenaunay syndrome
Klippel-Trenaunay-Weber syndrome generally affects a single extremity, although cases of
multiple affected limbs have been reported. The leg is the most common site followed by the
arms, the trunk, and rarely the head and the neck
Signs and symptoms
The birth defect is diagnosed by the presence of a combination of these symptoms:
One or more distinctive port-wine stains with sharp borders
Varicose veins
Hypertrophy of bony and soft tissues, that may lead to local gigantism or shrinking.
An improperly developed lymphatic system
In some cases, port-wine stains (capillary port wine type) may be absent. Such cases are
very rare and may be classified as "atypical Klippel-Trenaunay syndrome".
KTS can either affect blood vessels, lymph vessels, or both. The condition most commonly
presents with a mixture of the two. Those with venous involvement experience increased pain
and complications.
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Question 14 of 154
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A 68 year old man presents with an ulcerated lesion on his right cheek. It is excised and on
histological assessment a squamous cell carcinoma is diagnosed. It measures 25mm in
diameter and is 4mm deep. Which of the following statements relating to this condition is
false?
Question stats
Score: 42.9%
1
25.2%
15.5%
27%
13.8%
18.5%

question correctly
A. In this particular case margins of at least 6mm are required
End and review
B. Use of cryosurgery to treat this patients lesion would have been unsafe
6
7-9 1 / 3
10
C. Use of radiotherapy to treat this lesion would have been unsafe

11
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D. This patients local recurrence rate may approach 15%
12
E. The disease usually spreads via lymphatics
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13
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14
Poor prognostic factors in SCC:

Size >20mm (local recurrence rate of up to 15%)
Depth greater than 4mm (risk of metastasis up to 30%)
This man has an SCC with significant risk of metastasis. Although cryotherapy may be used
to treat SCC it would be most unsafe in this setting as the lesion extends deeply. However,
radiotherapy is a safe treatment modality for SCC and may be used in selected cases. It is
unwise to use radiotherapy in areas prone to radionecrosis e.g. the nose.
Squamous cell carcinoma of the skin
Second most common skin malignancy

Derived from epidermal keratinocytes
Commonest in fair skinned individuals in sun exposed sites
May occur in perianal and genital skin especially in association with Human Papilloma
Virus 16 and 18 infections.
Groups at high risk

Renal transplant and on immunosuppression
Individuals with HIV
Those who have received psoralen UVA therapy
Chronic wounds (Marjolins ulcer)
Xeroderma pigmentosum
Oculocutaneous albinism
Prognosis
Good Prognosis
Poor prognosis
Well differentiated tumours
Poorly differentiated tumours
<20mm diameter
>20mm in diameter
<2mm deep
>4mm deep
No associated diseases
Immunosupression for whatever reason
Treatment
Surgical excision with 4mm margins if lesion <20mm in diameter. If tumour >20mm then
margins should be 6mm.
Squamous cell carcinomas of the skin typically arise in areas of sun exposure as shown here
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References
The British Association of Dermatology provides guidelines for the diagnosis and treatment
of SCC.
http://www. bad.org.uk
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Question 15 of 154
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A 23 year old man presents with weight loss fatigue and lymphadenopathy. He is diagnosed
with tuberculosis. Which of the following processes most closely matches the underlying
pathological process?
Question stats
Score: 46.7%
1
6.9%
10.4%
13.7%
59.6%
9.4%
A. Type 1 hypersensitivity reaction

question correctly
B. Type 2 hypersensitivity reaction
End and review
C. Type 3 hypersensitivity reaction
6
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10
D. Type 4 hypersensitivity reaction
11
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12
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13
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14
15
Granulomas (which occur in tuberculosis) are a feature of Type 4 hypersensitivity reactions.

Type I
Type II
Type III
Type IV
Description
Anaphylactic
Cytotoxic
Immune
complex
Delayed type
Mediator
IgE
IgG, IgM
IgG, Ig A,
IgM
T-cells
Antigen
Exogenous
Cell surface
Soluble
Tissues
Response
time
Minutes
Hours
Hours
2-3 days
Examples
Asthma
Hay fever
anaemia
Pemphigus
Goodpasture's
Serum
sickness
SLE
Aspergillosis
Graft versus host

disease
Contact dermatitis
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Question 16 of 154
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A 73 year old man undergoes an emergency amputation for severe lower limb sepsis and
gangrene. Post operatively he develops disseminated intravascular coagulation. Which of
the following clotting factors will be most rapidly consumed in this process?
Question stats
Score: 43.8%
1
53.1%
10.3%
9.1%
15.3%
12.1%
A. Factor V and VIII

question correctly
B. Factor I
End and review
C. Factor I and III
6
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10
D. Factor III and VII
11
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E. Factor VI and VIII
12
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14
15
D-I-S-S-E-M-I-N-A-T-E-D
16
D-Dx: D dimer
I-Immune complexes
S-Snakebite, shock, heatstroke
S-SLE
E-Eclampsia, HELLP syndrome
M-Massive tissue damage
I-Infections: viral and bacterial
N-Neoplasms
A-Acute promyelocytic leukemia
T-Tumor products: Tissue Factor (TF) and TF-like factors released by carcinomas of
pancreas, prostate, lung,
colon, stomach
E-Endotoxins (bacterial)
D-Dead fetus (retained)
DIC Will tend to consume factors five and eight intially (and platelets).
Disseminated intravascular coagulation
Simultaneous coagulation and haemorrhage caused by initially formation of thrombi which
consume clotting factors (factors 5,8) and platelets, ultimately leading to bleeding
Causes include:
Infection
Malignancy
Trauma e.g. major surgery, burns, shock, dissecting aortic aneurysm
Liver disease
Obstetric complications
Key points
Clinically bleeding is usually a dominant feature, bruising, ischaemia and organ failure
Blood tests: prolonged clotting times, thrombocytopenia, decreased fibrinogen,
increased fibrinogen degradation products
Treat the underlying cause and supportive management
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Question 17 of 154
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A pregnant women suddenly develops bilateral leg swelling. Her mother and aunt were
troubled by the same problem. What is the most likely underlying abnormality?
A. Anti endomysial antibodies

B. Anti nuclear antibodies
Question stats
Score: 47.1%
1
14.8%
16.1%
44%
10.2%
15%

question correctly
C. Anti cardiolipin antibodies
End and review
D. Anti thyroid antibodies
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10
E. Anti mitochondrial antibodies
11
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13
14
Anti phospholipid syndrome= following antibodies

Lupus anticoagulant
Anti-cardiolipin
Anti-2-glycoprotein
15
16
17

Antiphospholipid syndrome, is an autoimmune, hypercoagulable state caused by
antiphospholipid antibodies. APS provokes blood clots (thrombosis) in both arteries and
veins as well as pregnancy-related complications such as miscarriage, stillbirth, preterm
delivery, or severe preeclampsia.
The diagnostic criteria requires one clinical event, i.e. thrombosis or pregnancy complication,
and two positive blood tests spaced at least 3 months apart. These antibodies are: lupus
anticoagulant, anti-cardiolipin and anti-2-glycoprotein.
Antiphospholipid syndrome can be primary or secondary. Primary antiphospholipid syndrome
occurs in the absence of any other related disease. Secondary antiphospholipid syndrome
occurs with other autoimmune diseases, such as systemic lupus erythematosus (SLE). In
rare cases, APS leads to rapid organ failure due to generalised thrombosis; this is termed
"catastrophic antiphospholipid syndrome" (CAPS) and is associated with a high risk of death.
Antiphospholipid syndrome often requires treatment with anticoagulant medication such as
heparin to reduce the risk of further episodes of thrombosis and improve the prognosis of
pregnancy. Warfarin is not used during pregnancy because it can cross the placenta, unlike
heparin, and is teratogenic.
Hypercoagulability
Type of
thrombophilia
Features
Antithrombin deficiency
Antithrombin inactivates thrombin and factor XII a, XIa, IXa and Xa

Rare defect, inherited in autosomal dominant fashion
10x increase in risk of thrombotic events
Heparin may be ineffective because it works via antithrombin
Protein C and S
deficiency
These are natural anticoagulants (vitamin K dependent synthesis)

Protein C produced by liver
Protein S produced by liver, megakaryocytes, Leydig cells and
endothelial cells
Protein C and S bind to form activated complex which binds to factor
V
Deficiency accounts for up to 5% of thrombotic episodes
Factor V Leiden
Resistance to anticoagulant effect of activated protein C

May account for up to 20% or more of thrombotic episodes
Prevalence of 7% in Europe
Most common genetic defect accounting for DVT
Antiphospholipid
syndrome
Multi organ disease

Pregnancy involvement common
Arterial and venous thromboses
Either Lupus anticoagulant or Anti cardiolipin antibodies
APTT usually prolonged
Antibodies may be elevated following surgery, drugs or malignancy
Need anticoagulation with INR between 3 and 4
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Question 18 of 154
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Next
A 63 year old Japanese man presents with epigastric discomfort and iron deficiency
anaemia. He undergoes an upper GI endoscopy, where the following appearances are
found:
Question stats
End and review
Score: 44.4%
1
30.7%
36.2%
10.1%
14.7%
8.3%

question correctly
6
7-9 1 / 3
10
11
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12
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13
14
15
16
17
18
The most likely diagnosis is:
A. Squamous cell carcinoma

B. Linitis plastica
C. Leiomyosarcoma
D. Gastric varices
Next question
During upper GI endoscopy, a linitis plastica lesion may prevent gastric distension.
Linitis plastica produces a diffuse infiltrating lesion, the stomach is fibrotic and rigid and will
not typically distend. This may be described as a 'leather bottle stomach'. Diagnosis is made
with a combination of pathology examination with endoscopy, radiological or surgical
assessment. Pathologically signet-ring cell proliferation occurs.
At the present time clinical images do not form part of the MRCS Part A exam
Gastric cancer
Overview
Pathology
Type
1
Type
2

Type
3
gastric cancer.
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Atrophic gastritis
following
Patients without
dyspepsia
Worsening dyspepsia
Dysphagia
Barretts oesophagus
Dysphagia
Unexplained
abdominal pain or
weight loss
Weight loss
Vomiting
Dysplasia
Upper abdominal
mass
Atrophic gastritis
Jaundice

dyspepsia
Staging
Treatment
usual
undertaken.
Prognosis
UK Data
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Disease extent
All RO resections
54%
91%
Stage 1
87%
Stage 2
65%
Stage 3
18%
Operative procedure
General anaesthesia
Incision: Rooftop.
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Question stats
End and review
Score: 42.9%
1
2
Theme: Genetics and cancer

A. Multiple endocrine neoplasia type I
19
61.8%
20
32.3%
21
56.3%
B. Multiple endocrine neoplasia type II
3
4
5
C. Gardner's syndrome
D. Lynch Syndrome
Search
E. Kartagener's syndrome
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10
F. Neurofibromatosis Type I
11
G. Neurofibromatosis Type II
12
Please select the most likely condition for the disease process described. Each option may
13
14
15
16
19.
A 40 year old male is found to have multiple colonic polyps during a

colonoscopy. He mentions that he has extra teeth.
17
18
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Gardner's syndrome
Gardner's syndrome is an AD disorder, characterised by: Colonic polyps,
supernumerary teeth, jaw osteomas, congenital hypertrophy of retinal pigment.
osteomas of the skull, thyroid cancer, epidermoid cysts, fibromas and
sebaceous cysts.
20.
A 10 year old boy who has learning difficulties, reports a difference in size
between his two legs.
You answered Neurofibromatosis Type II
The correct answer is Neurofibromatosis Type I
Neurofibromatosis type I. A hallmark finding is a plexiform neurofibroma, which
is a sheet of neurofibromatosis tissue which encases major nerves. In children
this attracts extra blood circulation, which can accelerate growth of the affected
limb.
Other features include:
Schwannoma, > 6
Cafe au lait spots, axillary freckling, Lisch nodules, Optic glioma. Meningiomas,
Glioma, or Schwannoma.
21.
A 22 year old is found to have bilateral acoustic neuromas.

You answered Neurofibromatosis Type I
The correct answer is Neurofibromatosis Type II
In NF2 bilateral acoustic neuromas are characteristic with a family history of
Neurofibroma,
Next question
presented here.
Autosomal dominant
Diagnosed when:

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BRCA 1 and 2
2).
Lynch Syndrome
Autosomal dominant
Amsterdam criteria
Gardners syndrome
cancer
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Question 22 of 154
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A 52 year old lady is referred to the breast clinic with symptoms of nipple discharge. The
discharge is usually thick and green. Which of the following statements relating to the most
likely underlying diagnosis is untrue?
Question stats
Score: 40.9%
1
11.9%
40.4%
26.8%
10%
11%
A. The majority of patients will be smokers

question correctly
B. Typically produces blood stained nipple discharge
End and review
C. It is not associated with increased risk of breast cancer
6
7-9 1 / 3
10
D. May result in development of mammary duct fistula

E. May require total duct excision (Hadfields operation) if it fails to resolve
11
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13
14
15
Blood stained nipple discharge should always be investigated.

Nipple fluid cytology is generally unhelpful.
16
17
Discharge of this type of material is most likely to be due to duct ectasia. Green or brown
discharge is most common. Blood stained discharge should raise concern of intraductal
papilloma or cancer.
18
19-21 1 / 3
22
Nipple discharge
Causes of nipple discharge
Physiological
During breast feeding
Galactorrhoea
Commonest cause may be response to emotional events, drugs such

as histamine receptor antagonists are also implicated
Hyperprolactinaemia
Mammary duct
ectasia
Carcinoma
Intraductal
papilloma
Commonest type of pituitary tumour

Microadenomas <1cm in diameter
Macroadenomas >1cm in diameter
Pressure on optic chiasm may cause bitemporal hemianopia
Dilatation breast ducts.

Most common in menopausal women
Discharge typically thick and green in colour
Most common in smokers
Often blood stained

May be underlying mass or axillary lymphadenopathy
Commoner in younger patients

May cause blood stained discharge
There is usually no palpable lump
Assessment of patients
Examine breast and determine whether there is mass lesion present
All mass lesions should undergo Triple assessment.
Reporting of investigations
Where a mass lesion is suspected or investigations are requested these are prefixed using a
system that denotes the investigation type e.g. M for mammography, followed by a numerical
code as shown below:
1
No abnormality
Abnormality with benign features
Indeterminate probably benign
Indeterminate probably malignant
Malignant
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Management of non malignant nipple discharge

Exclude endocrine disease
Nipple cytology unhelpful
Smoking cessation advice for duct ectasia
For duct ectasia with severe symptoms, total duct excision may be warranted.
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Question 23 of 154
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End and review
Score: 39.1%
1
7.7%
16%
59.9%
A. There is necrosis with putrefaction
9.2%
B. The causative pathogens may be detected on normal perineal skin
7.1%
C. Treatment with low dose penicillin is indicated

question correctly
Which of the following statements relating to gas gangrene is untrue?
D. Hyperbaric oxygen may be beneficial
6
7-9 1 / 3
10
E. Clostridium perfringens is a recognised cause
11
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12
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13
Rapid surgery and high dose antibiotics are indicated in the treatment of gas gangrene.
Meleney's Gangrene and Necrotising Fasciitis
14
15
16
Necrotising fasciitis
Advancing soft tissue infection associated with fascial necrosis
Uncommon, but can be fatal
In many cases there is underlying background immunosuppression e.g. Diabetes
Caused by polymicrobial flora (aerobic and anaerobic) and MRSA is seen increasingly
in cases of necrotising fasciitis
Streptococcus is the commonest organism in isolated pathogen infection (15%)
17
18
19-21 1 / 3
22
23
Meleneys gangrene
Meleneys is a similar principle but the infection is more superficially sited than
necrotising fasciitis and often confined to the trunk
Fournier gangrene
Necrotising fasciitis affecting the perineum
Polymicrobial with E-coli and Bacteroides acting in synergy
Clinical features
Fever
Pain
Cellulitis
Oedema
Induration
Numbness
Late findings
Purple/black skin discolouration
Blistering
Haemorrhagic bullae
Crepitus
Dirty Dishwater fluid discharge
Septic shock
A typical case of gas gangrene presenting late demonstrating some of the features
described above
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Image sourced from gangrene" target="_blank" style = "font-
size:11px; color:#777;" >Wikipedia

Diagnosis is mainly clinical
Management
Radical surgical debridement forms the cornerstone of management
Sterile dressing is used to dress the wound
Reconstructive surgery is considered once the infection is completely treated
Reference
Hasham S, Matteucci P, Stanley PR, Hart NB. Necrotising fasciitis. BMJ 2005;330:830-833.
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Question 24 of 154
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A 30 year old man presents with abdominal distension, a laparotomy is performed, at

operation the abdomen is filled with a large amount of gelatinous fluid. What is the most likely
underlying diagnosis?
Question stats
Score: 37.5%
1
9.2%
53.6%
7.7%
23.8%
5.7%
A. Infection with entamoeba histolytica

question correctly
B. Pseudomxyoma peritonei
End and review
C. Metastatic colonic cancer
6
7-9 1 / 3
10
D. Chylous ascites
11
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14
15
Pseudomyxoma is associated with the deposition of large amounts of gelatinous material.

The appendix is the commonest organ or origin.
16
17
Pseudomyxoma Peritonei
18
19-21 1 / 3
Rare mucinous tumour

Most commonly arising from the appendix (other abdominal viscera are also
recognised as primary sites)
Incidence of 1-2/1,000,000 per year
The disease is characterised by the accumulation of large amounts of mucinous
material in the abdominal cavity
22
23
24
Treatment
Is usually surgical and consists of cytoreductive surgery (and often peritonectomy c.f
Sugarbaker procedure) combined with intra peritoneal chemotherapy with mitomycin C.
Survival is related to the quality of primary treatment and in Sugarbakers own centre 5 year
survival rates of 75% have been quoted. Patients with disseminated intraperitoneal
malignancy from another source fare far worse.
In selected patients a second look laparotomy is advocated and some practice this routinely.
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Question 25 of 154
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A 30 year old man is suspected of having appendicitis. At operation an inflamed Meckels

diverticulum is found. Which of the following vessels is responsible for the blood supply to a
Meckels diverticulum?
Question stats
Score: 36%
1
20.8%
53.7%
11.9%
8%
5.6%
A. Right colic artery

question correctly
B. Vitelline artery
End and review
C. Appendicular artery
6
7-9 1 / 3
10
D. Internal iliac artery
11
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E. External iliac artery
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14
15
The vitelline arteries supply a Meckels these are usually derived from the ileal arcades.
16
17
18

19-21 1 / 3
22
23
24
25
Clinical
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Question 26 of 154
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End and review
Score: 34.6%
1
9.7%
14.6%
49.5%
A. Afro-Caribbean skin and keloid scarring
11%
B. Extensive third degree burns and wound contraction
15.2%
C. Chemotherapy and dehisence of healed wounds

question correctly
Which of the following associations are incorrect?
D. Poor healing at the site of previous radiotherapy
6
7-9 1 / 3
10
E. Zinc deficiency and delayed healing
11
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13
14
Wound healing
15
16
17
18
19-21 1 / 3
22
23
Haemostasis
24

clot.
25
26
Inflammation
Typically days 1-5
Regeneration
Remodeling
Hypertrophic scars
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wound:
Keloid scars

Steroids
Closure
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Question 27 of 154
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A 45 year old women is identified as having a gastric gastro-intestinal stromal tumour. What
is the usual cell of origin of these lesions?
A. Brunners glands
B. Interstitial cells of Cajal
Question stats
Score: 33.3%
1
16.8%
29.8%
29.8%
6.1%
17.6%

question correctly
C. Primitive stem cells of the gut wall
End and review
D. Fundic glands
6
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10
E. Antral goblet cells
11
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13
14
GIST's are derived from the interstitial pacemaker cells of Cajal. This means that they are
often located extramucosally and macroscopically, demonstrate little mucosal disruption.
15
16
Gastrointestinal stromal tumour
17
18
GIST's are not common tumours (10 per million) and originate primarily from the interstitial
pacemaker cells (of Cajal). Up to 70% occur in the stomach, the remainder occurring in the
small intestine (20%) and the colon and rectum (5%). Up to 95% are solitary lesions and
most are sporadic. The vast majority express CD117 which is a transmembrane tyrosine
kinase receptor and in these there is a mutation of the c-KIT gene.
19-21 1 / 3
22
23
24
The goal of surgery is resection of the tumour with a 1-2cm margin of normal tissue. As a
result extensive resections are not required. Unfortunately there is a high local recurrence
rate, the risk of which is related to site, incomplete resections and high mitotic count. Salvage
surgery for recurrent disease is associated with a median survival of 15 months.
25
26
27
The prognosis in high risk patients is greatly improved through the use of imatinib, which in
the ACOSOG trial (imatinib vs placebo) improved relapse rates from 17% to 2%.
In the UK it is advocated by NICE for use in patients with metastatic disease or locally
unresectable disease.
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Question 28 of 154
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A 23 year old man fractures his right tibia in a sporting accident. At which point in the healing
process is fracture callus most likely to be visible radiologically?
A. 1 day
B. 7 days
Question stats
Score: 35.7%
1
6.7%
22.8%
9.6%
21.1%
39.8%

question correctly
C. 8 weeks
End and review
D. 6 weeks
6
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10
E. 3 weeks
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14
Fracture callus is composed of fibroblasts and chondroblasts and the synthesis of

fibrocartilage. It is typically visible on radiographs approximately 3 weeks following injury. If
delayed then there may be risk of non union.
15
16
17
Fracture healing
18
19-21 1 / 3
Bone fracture
- Bleeding vessels in the bone and periosteum
- Clot and haematoma formation
- The clot organises over a week (improved structure and collagen)
- The periosteum contains osteoblasts which produce new bone
- Mesenchymal cells produce cartilage (fibrocartilage and hyaline cartilage) in the soft tissue
around the fracture
- Connective tissue + hyaline cartilage = callus
- As the new bone approaches the new cartilage, endochondral ossification occurs to bridge
the gap
- Trabecular bone forms
- Trabecular bone is resorbed by osteoclasts and replaced with compact bone
22
23
24
25
26
27
28
Factors affecting fracture healing

Age
Malnutrition
Bone disorders: osteoporosis
Systemic disorders: diabetes, Marfan's syndrome and Ehlers-Danlos syndrome cause
abnormal musculoskeletal healing.
Drugs: steroids, non steroidal anti inflammatory agents.
Type of bone: Cancellous (spongy) bone fractures are usually more stable, involve
greater surface areas, and have a better blood supply than cortical (compact) bone
fractures.
Degree of Trauma: The more extensive the injury to bone and surrounding soft tissue,
the poorer the outcome.
Vascular Injury: Especially the femoral head, talus, and scaphoid bones.
Degree of Immobilization
Intra-articular Fractures: These fractures communicate with synovial fluid, which
contains collagenases that retard bone healing.
Separation of Bone Ends: Normal apposition of fracture fragments is needed for union
to occur. Inadequate reduction, excessive traction, or interposition of soft tissue will
prevent healing.
Infection
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Question 29 of 154
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End and review
Score: 34.5%
1
10.6%
11.1%
17.6%
A. Kawasaki disease
21%
B. Systemic Lupus Erthematosus
39.6%
C. Phenytoin

question correctly
Of the options below, which does not cause lymphadenopathy?
D. Hydrallazine
6
7-9 1 / 3
10
E. Amiodarone
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12
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13
14
15
Lymphadenopathy
16
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Lymphadenopathy in the neck, axillae, groins and abdomen

Need to note: solitary/multiple, defined/indistinct, hard/rubbery/soft, tender/painless
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19-21 1 / 3
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Causes of lymphadenopathy
23
Mnemonic: Hodgkins disease
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H aematological: Hodgkins lymphoma, NHL, Leukaemia

O ncological: metastases
D ermatopathic lympadenitis
G aucher's disease
K awasaki disease
I nfections: TB, glandular fever, Syphilis
N iemann Pick disease
S erum sickness
D rug reaction (phenytoin)
I mmunological (SLE)
S arcoidosis
E ndocrinological (Hyperthyroidism)
A ngioimmunoplastic lymphadenopathy
S LE
E osinophilic granulomatosis
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Question 30 of 154
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A 23 year old man is reviewed on the ward 10 days following a laparotomy. The wound is
inspected and is healing well. Which of the following processes is least likely to be occurring
in the wound at this stage?
Question stats
Score: 36.7%
1
13.4%
12.3%
45.8%
12.1%
16.3%
A. Angiogenesis
question correctly
B. Synthesis of collagen
End and review
C. Necrosis of fibroblasts
6
7-9 1 / 3
10
D. Secretion of matrix metalloproteinases by fibroblasts
11
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E. Proliferation of fibroblasts
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13
14
15
Vasculogenesis vs Angiogenesis
Vascu is new. Angi is pre
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Vasculogenesis is new vessels developing in situ from existing mesenchyme.

Angiogenesis is vessels develop from sprouting off pre-existing arteries.
19-21 1 / 3
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23
Fibroblasts are an important cell type in healing wounds. They typically proliferate in the
early phases of wound healing. They release matrix metalloproteinases and these facilitate in
the remodelling of the matrix within the healing wound. Necrosis in a healing wound would be
unusual as wounds will tend to show clinical evidence of angiognesis by this time.
Wound healing
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Haemostasis
clot.
Inflammation
Typically days 1-5
Regeneration
Remodeling
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Hypertrophic scars
wound:
Keloid scars

Steroids
Closure
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Question 31 of 154
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A 25 year old women presents with a slowly enlarging mass on the side of the face. Clinical
examination demonstrates that the mass is located in the tail of the parotid gland. There is
no evidence of facial nerve involvement. What is the most likely cause?
Question stats
Score: 35.5%
1
14.3%
7.9%
16.7%
7.4%
53.7%
A. Sialolithiasis
question correctly
B. Adenocarcinoma
End and review
C. Warthins tumour
6
7-9 1 / 3
10
D. Oncocytoma
11
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E. Pleomorphic adenoma
12
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13
14
Pleomorphic adenomas are the commonest tumours of the parotid gland and are often slow
growing, smooth and mobile. Warthins tumours are typically found in elderly males and are
composed of multiple cysts and solid components consisting of lymphoid tissue. Warthins
tumours are most often found in the tail of the parotid gland, but not in 25 year old females,
where a pleomorphic adenoma remains the most likely lesion.
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Parotid gland clinical
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Benign neoplasms
Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these
are benign. There is no consistent correlation between the rate of growth and the malignant
potential of the lesion. However, benign tumours should not invade structures such as the
facial nerve.
With the exception of Warthins tumours, they are commoner in women than men. The
median age of developing a lesion is in the 5th decade of life.
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Benign tumour types

30
Tumour type
Features
Benign pleomorphic
adenoma or benign mixed
tumor
Most common parotid neoplasm (80%)

Proliferation of epithelial and myoepithelial cells of the ducts and an
increase in stromal components
Slow growing, lobular, and not well encapsulated
Recurrence rate of 1-5% with appropriate excision (parotidectomy)
Recurrence possibly secondary to capsular disruption during
surgery
Malignant degeneration occurring in 2-10% of adenomas observed
for long periods, with carcinoma ex-pleomorphic adenoma occurring
most frequently as adenocarcinoma
Warthin tumor (papillary

cystadenoma lymphoma
or adenolymphoma)
Second most common benign parotid tumor (5%)

Most common bilateral benign neoplasm of the parotid
Marked male as compared to female predominance
Occurs later in life (sixth and seventh decades)
Presents as a lymphocytic infiltrate and cystic epithelial
proliferation
May represent heterotopic salivary gland epithelial tissue trapped
within intraparotid lymph nodes
Incidence of bilaterality and multicentricity of 10%
Malignant transformation rare (almost unheard of)
Monomorphic adenoma
Account for less than 5% of tumours

Slow growing
Consist of only one morphological cell type (hence term mono)
Include; basal cell adenoma, canalicular adenoma, oncocytoma,
myoepitheliomas
Haemangioma
Should be considered in the differential of a parotid mass in a child

Accounts for 90% of parotid tumours in children less than 1 year of
age
Hypervascular on imaging
Spontaneous regression may occur and malignant transformation is
almost unheard of
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Malignant salivary gland tumours

Types of malignancy
Mucoepidermoid
carcinoma

mainly on grade)
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Adenoid cystic
carcinoma

5 year survival 35%
Mixed tumours
Acinic cell
carcinoma

5 year survival 80%
Adenocarcinoma

5 year survival depends upon stage at presentation, may be up to 75%
with small lesions with no nodal involvement
Lymphoma

resection
Treatment is with chemotherapy (and radiotherapy)
Diagnostic evaluation
Plain x-rays may be used to exclude calculi
Sialography may be used to delineate ductal anatomy
FNAC is used in most cases
Superficial parotidectomy may be either diagnostic of therapeutic depending upon the
nature of the lesion
Where malignancy is suspected the primary approach should be definitive resection
rather than excisional biopsy
CT/ MRI may be used in cases of malignancy for staging primary disease
Treatment
For nearly all lesions this consists of surgical resection, for benign disease this will usually
consist of a superficial parotidectomy. For malignant disease a radical or extended radical
parotidectomy is performed. The facial nerve is included in the resection if involved. The
need for neck dissection is determined by the potential for nodal involvement.
Other parotid disorders
HIV infection
Lymphoepithelial cysts associated with HIV occur almost exclusively in the parotid
Typically presents as bilateral, multicystic, symmetrical swelling
Risk of malignant transformation is low and management usually conservative
Sjogren syndrome
Autoimmune disorder characterised by parotid enlargement, xerostomia and
keratoconjunctivitis sicca
90% of cases occur in females
Second most common connective tissue disorder
Bilateral, non tender enlargement of the gland is usual
Histologically, the usual findings are of a lymphocytic infiltrate in acinar units and
epimyoepithelial islands surrounded by lymphoid stroma
Treatment is supportive
There is an increased risk of subsequent lymphoma
Sarcoid
Parotid involvement occurs in 6% of patients with sarcoid
Bilateral in most cases
Gland is not tender
Xerostomia may occur
Management of isolated parotid disease is usually conservative
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End and review
Score: 37.5%
1
10.8%
7%
60.5%
A. Lung cancer
9.8%
B. Bowel cancer
11.9%
C. Bladder cancer

question correctly
Beta-naphthalamine is associated with which of the following malignancies?
D. Liver cancer
6
7-9 1 / 3
10
E. Renal cancer
11
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13
Beta-naphthalamine is used in the rubber industry.
14
15
The following factors are associated with the development of bladder cancer:
16
smoking
occupational: aniline dyes used in printing and textile industry, rubber manufacture
schistosomiasis
drugs: cyclophosphamide
17
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19-21 1 / 3
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23
24
25

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Mesothelioma
Bladder cancer
Lung cancer
Sino nasal cancer
28
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32

Mining
Metalworkers
RR595).
leukaemia.
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A 56 year old man with Wilsons disease presents with right upper quadrant discomfort. An
ultrasound scan is performed and this demonstrates a mass lesion in the right lobe of the
liver. What is the most appropriate method of establishing the underlying diagnosis?
Question stats
Score: 36.4%
1
7.8%
23.5%
30.6%
21.4%
16.7%
A. PET CT scan
question correctly
B. Ultrasound guided biopsy
End and review
C. Measurement of serum alpha feto protein
6
7-9 1 / 3
10
D. MRI scan of the liver
11
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E. CT scan of the liver
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13
14
15
High AFP + chronic liver inflammation = Hepatocellular carcinoma.
16
17
This is likely to be a hepatocellulcar carcinoma. Diagnosis is usually made by AFP

measurement (with further imaging depending on the result). Biopsy should not be
performed as it may seed the tumour. Chronic liver diseases such as Wilsons disease
(Hepato-lenticular degeneration) increase the risk.
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19-21 1 / 3
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23
Liver tumours
Primary liver tumours
The most common primary tumours are cholangiocarcinoma and hepatocellular carcinoma.
Overall metastatic disease accounts for 95% of all liver malignancies making the primary liver
tumours comparatively rare.
Primary liver tumours include:
Cholangiocarcinoma
Hepatoblastoma
Sarcomas (Rare)
Lymphomas
Carcinoids (most often secondary although primary may occur)
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These account for the bulk of primary liver tumours (75% cases). Its worldwide incidence
reflects its propensity to occur on a background of chronic inflammatory activity. Most cases
arise in cirrhotic livers or those with chronic hepatitis B infection, especially where viral
replication is actively occurring. In the UK it accounts for less than 5% of all cancers,
although in parts of Asia its incidence is 100 per 100,000.
The majority of patients (80%) present with existing liver cirrhosis, with a mass discovered on
screening ultrasound.
Diagnosis
CT/ MRI (usually both) are the imaging modalities of choice
a-fetoprotein is elevated in almost all cases
Biopsy should be avoided as it seeds tumours cells through a resection plane.
In cases of diagnostic doubt serial CT and FP measurements are the preferred
strategy.
Treatment
Patients should be staged with liver MRI and chest, abdomen and pelvic CT scan.
The testis should be examined in males (testicular tumours may cause raised AFP).
PET CT may be used to identify occult nodal disease.
Surgical resection is the mainstay of treatment in operable cases. In patients with a
small primary tumour in a cirrhotic liver whose primary disease process is controlled,
consideration may be given to primary whole liver resection and transplantation.
Liver resections are an option but since most cases occur in an already diseased liver
the operative risks and post-operative hepatic dysfunction are far greater than is seen
following metastectomy.
These tumours are not particularly chemo or radiosensitive however, both may be
used in a palliative setting. Tumour ablation is a more popular strategy.
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Survival
Poor, overall survival is 15% at 5 years.
Cholangiocarcinoma
This is the second most common type of primary liver malignancy. As its name suggests
these tumours arise in the bile ducts. Up to 80% of tumours arise in the extra hepatic biliary
tree. Most patients present with jaundice and by this stage the majority will have disease that
is not resectable.
Primary sclerosing cholangitis is the main risk factor. In deprived countries typhoid and liver
flukes are also major risk factors.
Diagnosis
Patients will typically have an obstructive picture on liver function tests.
CA 19-9, CEA and CA 125 are often elevated
CT/ MRI and MRCP are the imaging methods of choice.
Treatment
Surgical resection offers the best chance of cure. Local invasion of peri hilar tumours
is a particular problem and this coupled with lobar atrophy will often contra indicate
surgical resection.
Palliation of jaundice is important, although metallic stents should be avoided in those
considered for resection.
Survival
Is poor, approximately 5-10% 5 year survival.
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Question 34 of 154
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A 55 year old man has suffered from reflux oesophagitis for many years. During a recent
endoscopy a biopsy is taken from the distal oesophagus. The histopathology report indicates
that cells are identified with features of coarse chromatin and abnormal mitoses. The cells
are confined to the superficial epithelial layer only. Which of the following accounts for this
process?
Question stats
Score: 38.2%
1
31.2%
4.9%
6.4%
50.5%
6.9%

question correctly
A. Metaplasia
End and review
6
7-9 1 / 3
10
B. Apoptosis
C. Autoimmune oesophagitis
11
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12
D. Dysplasia
Go
13
E. Infection with Helicobacter pylori
14
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15
16
17
Dysplasia = pre cancerous
18
19-21 1 / 3
Dysplasia tends to develop as a result of prolonged stimulation by precipitants. Removal of

these precipitants may possibly reverse these changes. Replacement of differentiated cells
with another cell type describes metaplasia rather than dysplasia. The absence of invasion
distinguishes this from malignancy.
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23
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25
Dysplasia
26
27
Premalignant condition
Disordered growth and differentiation of calls
Alteration in size, shape, and organization of cells
Features increased abnormal cell growth (increased number of mitoses/abnormal
mitoses and cellular differentiation)
Underlying connective tissue is not invaded
Causes include smoking, Helicobacter pylori, Human papilloma virus
Main differences to metaplasia is that dysplasia is considered to be part of
carcinogenesis (pre cancerous) and is associated with a delay in maturation of cells
rather than differentiated cells replacing one another
The absence of invasion differentiates dysplasia from invasive malignancy
Severe dysplasia with foci of invasion are well recognised
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End and review
Score: 40%
1
36.5%
18.2%
13.2%
A. Obesity
15.1%
B. Long term unfractionated heparin therapy
16.9%
C. Gastrectomy

question correctly
Which one of the following confers the least risk of developing osteoporosis?
D. Osteogenesis imperfecta
6
7-9 1 / 3
10
E. Diabetes
11
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13
Low body weight is a risk factor for osteoporosis.
14
15
Osteoporosis
16
Risk factors
17
18
Family history
Female sex
Increasing age
Deficient diet
Sedentary lifestyle
Smoking
Premature menopause
Low body weight
Caucasians and Asians
19-21 1 / 3
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Diseases which predispose
29
Endocrine: glucocorticoid excess (e.g. Cushing's, steroid therapy), hyperthyroidism,

hypogonadism (e.g. Turner's, testosterone deficiency), growth hormone deficiency,
hyperparathyroidism, diabetes mellitus
Multiple myeloma, lymphoma
Gastrointestinal problems: inflammatory bowel disease, malabsorption (e.g. Coeliacs),
gastrectomy, liver disease
Rheumatoid arthritis
Long term heparin therapy
Chronic renal failure
Osteogenesis imperfecta, homocystinuria
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A 63 year old man has a history of claudication that has been present for many years. He is
recently evaluated in the clinic and a duplex scan shows that he has an 85% stenosis of the
superficial femoral artery. Two weeks later he presents with a 1 hour history of severe pain in
his leg. On examination he has absent pulses in the affected limb and it is much cooler than
the contra-lateral limb. Which process best accounts for this presentation?
Question stats
Score: 37.8%
1
41.3%
30.3%
12.8%
9.6%
6.1%

question correctly
A. Thrombosis
End and review
6
7-9 1 / 3
10
B. Embolus
C. Atheroma growth
11
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12
D. Sub intimal dissection
Go
13
E. Anaemia
14
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15
16

In an existing lesion a complication such as thrombosis is more likely than embolus. These
patients should receive heparin and imaging with duplex scanning. Whilst an early surgical
bypass or intra-arterial thrombolysis may be indicated, an embolectomy should not generally
be performed as the lesion is not an embolus and the operation therefore ineffective.
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19-21 1 / 3
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Claudication
24
Claudication is a condition in which patients develop pain in a limb during periods of exercise.
The underlying disorder is usually that of arterial insufficiency. Atheroma develops in the
arterial wall and once this occludes >50-75% of the lumenal diameter the supply to
metabolising tissues distally may become compromised. The typical claudicant complains of
calf pain that is worse on exercise and relieved by rest. This typical description assumes that
the SFA is the site of disease, more proximal disease may present with other symptoms such
as buttock claudication and impotence.
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30
The history is usually a progressive one, patients presenting as an emergency with severe
pain, diminished sensation, pallor and absent pulses have critical limb ischaemia. This may
complicate claudication and usually indicates a plaque related complication, such as
thrombosis.
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34
Risk factors
Risk factors for claudication include smoking, diabetes and hyperlipidaemia.
35
36
Diagnosis
Diagnostic work -up includes measurement of ankle- brachial pressure indices, duplex
scanning and formal angiography.
Treatment
Those with long claudication distances, no ulceration or gangrene may be managed
conservatively. Patients with rest pain, ulceration or gangrene will almost always require
intervention. All patients should receive an antiplatelet agent and a statin unless there are
compelling contra-indications.
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The following are true of carcinoid tumours except:
A. When present in the appendix tip and measure less than 2 cm have an
excellent prognosis
B. Even when metastatic disease is present it tends to follow a protracted
course
Question stats
End and review
Score: 39.5%
1
10%
20.9%
44.8%
15.5%
8.7%

question correctly
C. When present in the appendix body tend to present with carcinoid

syndrome even when liver metastases are not present
6
7-9 1 / 3
10
D. May be imaged using 5 HIAA radionucleotide scanning
11
Search
12
E. Advanced appendiceal carcinoids may require right hemicolectomy
Go
13
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14
15
16
Rule of thirds:
17
1/3 multiple
1/3 small bowel
1/3 metastasize
1/3 second tumour
18
19-21 1 / 3
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24
Liver metastases are necessary for the presence of carcinoid syndrome.
25
Carcinoid syndrome
26
27

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32
Clinical features
33
Onset: years
Flushing face
Palpitations
Asthma
34
35
36
37
Investigation
CT scan
Treatment
Octreotide
Surgical removal
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Question 38 of 154
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During a difficult femoro-popliteal bypass operation the surgeon inadvertently places a clamp
across the femoral nerve. It remains there for most of the procedure. At the end of the
operation the nerve is inspected, it is in continuity but has evidence of being crushed. Which
of the following is most likely to occur over the following months?
Question stats
Score: 41%
1
44%
15.8%
23.1%
10%
7.1%

question correctly
A. Wallerian degeneration
End and review
B. Rapid restoration of neuronal function because the axon itself is intact
6
7-9 1 / 3
10
C. Normal but delayed neuronal transmission due to disruption of the

myelin
11
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12
D. Absence of neuroma formation
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13
14
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15
16
A neuronal injury such as this will result in Wallerian degeneration even though the nerve
remains in continuity. Neuromas may well form.
17
18
Nerve injury
19-21 1 / 3
22

Neuropraxia
23
24

Full recovery
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Axonotmesis
28

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Neurotmesis

32
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36

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38
Nerve repair
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A 38 year old lady who smokes heavily presents with recurrent episodes of infection in the
right breast. On examination she has an indurated area at the lateral aspect of the nipple
areaolar complex. Imaging shows no mass lesions. What is the most likely diagnosis?
Question stats
Score: 40%
1
25.5%
37.7%
17.6%
13%
6.2%
A. Duct ectasia
question correctly
B. Periductal mastitis
End and review
C. Pagets disease of the nipple
6
7-9 1 / 3
10
D. Mondors disease of the breast
11
Search
E. Radial scar
12
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13
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14
15
Periductal mastitis is common in smokers and may present with recurrent infections.
Treatment is with co-amoxyclav. Mondors disease of the breast is a localised
thrombophlebitis of a breast vein.
16
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18
Duct ectasia
19-21 1 / 3
Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the
nipple. It is common and the incidence increases with age. It typically presents with nipple
retraction and occasionally creamy nipple discharge. It may be confused with periductal
mastitis, which presents in younger women, the vast majority of which are smokers.
Periductal mastitis typically presents with periareolar or sub areolar infections and may be
recurrent.
Patients with troublesome nipple discharge may be treated by microdochectomy (if young) or
total duct excision (if older).
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Question stats
End and review
Score: 39%
1
14.9%
30.1%
32.4%
A. Mutations in oncogenes lead to cell survival
11.3%
B. Cells with oncogene mutations are always resistant to cell necrosis
11.3%
C. Oncogene mutations must typically involve two allelic mutations for

biological effects to become manifest

question correctly
With respect to oncogenes which statement is false?
D. May prevent cellular apoptosis
6
7-9 1 / 3
10
E. Include MYC mutations in the development of Burkitts Lymphoma
11
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12
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13
14
Tumour suppressor gene mutations tend to be recessive and thus twin allelic mutations are
required as exemplified in the Knudson two hit hypothesis in the development of
retinoblastoma. Necrosis will occur at the centre of tumours that outgrow their blood supply
and induction of angiogenesis is a key feature of tumour progression.
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Oncogenes
19-21 1 / 3
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31

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36

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End and review
Score: 38.1%
1
28.1%
11.2%
10.6%
A. Chronic inflammation is mainly secondary to acute inflammation
9.7%
B. Neutrophils are the predominant cells involved
40.4%
C. Growth factors are not involved in the process

question correctly
Which of the following statements relating to chronic inflammation is true?
D. Appendicitis is mainly a form of chronic inflammation
6
7-9 1 / 3
10
E. Fibrosis is a macroscopic feature
11
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12
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13
Macroscopic features include:
14
Ulcers
Fibrosis
Granulomatous process
15
16
17
It most commonly occurs as a primary event rather than as a result of acute inflammation.
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Overview
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Acute inflammation


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Suppuration
Complete resolution
Abscess formation
Healing by fibrosis
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Mediators
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End and review
Score: 35.6%
1
2
Theme: Paediatric ano-rectal disorders

A. Ulcerative colitis
42
78%
43
45.8%
44
76.5%
B. Juvenile polyps
3
4
5
C. Haemorroids
D. Intussceception
Search
E. Rectal cancer
7-9 1 / 3
Go
10
F. Anal fissure
11
G. Arteriovenous malformation
12
Please select the most likely cause for the condition described. Each option may be used
13
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42.
A 4 year old boy is brought to the clinic. He gives a history of difficult, painful
defecation with bright red rectal bleeding.
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19-21 1 / 3
You answered Juvenile polyps
22
The correct answer is Anal fissure
23

Painful rectal bleeding in this age group is typically due to a fissure. Treatment
should include stool softeners and lifestyle advice.
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43.
A 2 year old has a history of rectal bleeding. The parents notice that post
defecation, a cherry red lesion is present at the anal verge.
27
28
You answered Haemorroids
29
30
The correct answer is Juvenile polyps
31

These lesions are usually hamartomas and this accounts for the colour of the
lesions. Although the lesions are not themselves malignant they serve as a
marker of an underlying polyposis disorder.
44.
A 12 year old is brought to the colorectal clinic with a history of rectal bleeding,
altered bowel habit, weight loss and malaise. Abdominal examination is normal.
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37
You answered Anal fissure
38
The correct answer is Ulcerative colitis
39
The systemic features in the history are strongly suggestive of inflammatory

bowel disease rather than the other causes.
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Paediatric proctology
Children may present with altered bowel habit and/ or rectal bleeding. Classical haemorroidal
disease is relatively rare in children. Painful bright red rectal bleeding is much more common
since constipation is a relatively common childhood disorder. The hard stool causes a tear of
the ano-rectal mucosa with subsequent fissure. The pain from the fissure must be addressed
promptly or the child will delay defecation and this fissure will worsen.
Inflammatory bowel disease may present in a similar pattern in paediatric practice with
altered bowel habit (usually diarrhoea) and bleeding. Systemic features may be present and
investigation with an endoscopy may be required.
Children with intussceception usually present at a relatively young age and the history is
usually one of colicky abdominal pain, together with a mass on clinical examination.The often
cited red current jelly type stool is a rare but classical feature.
Juvenile polyps may occur as part of the familial polyposis coli syndromes. The lesions, which
are hamartomas, are often cherry red if they protrude externally.
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Question 45 of 154
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You review a 42-year-old woman 8 months following a renal transplant for focal segmental
glomerulosclerosis. She is on a combination of tacrolimus, mycophenolate, and
prednisolone. She has now presented with a five day history of feeling generally unwell with
jaundice, fatigue and arthralgia. On examination she has jaundice, widespread
lymphadenopathy and hepatomegaly. What is the most likely diagnosis?
Question stats
End and review
Score: 34.8%
1
8.8%
28.4%
8%
8.4%
46.5%

question correctly
6
7-9 1 / 3
10
A. Hepatitis C
B. Epstein-Barr virus
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C. HIV
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D. Hepatitis B
13
E. Cytomegalovirus
14
15
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16
17
Post transplant complications
18
19-21 1 / 3
CMV: 4 weeks to 6 months post transplant

EBV: post transplant lymphoproliferative disease. > 6 months post transplant
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23
Post transplant lymphoproliferative disorder is most commonly associated with Epstein-Barr

virus. It typically occurs 6 months post transplant and is associated with high dose
immunosupressant therapy. Remember cytomegalovirus presents within the first 4 weeks to
6 months post transplant.
Renal transplant:HLA typing and graft failure
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25
26
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28
29
The human leucocyte antigen (HLA) system is the name given to the major histocompatibility
complex (MHC) in humans. It is coded for on chromosome 6.
30
Some basic points on the HLA system
32
Class 1 antigens include A, B and C. Class 2 antigens include DP,DQ and DR

When HLA matching for a renal transplant the relative importance of the HLA antigens
are as follows DR > B > A
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36
Graft survival
1 year = 90%, 10 years = 60% for cadaveric transplants
1 year = 95%, 10 years = 70% for living-donor transplants
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Post-op problems
ATN of graft
Vascular thrombosis
Urine leakage
UTI
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45
Hyperacute acute rejection

Due to antibodies against donor HLA type 1 antigens
Rarely seen due to HLA matching
Acute graft failure (< 6 months)

Usually due to mismatched HLA
Other causes include cytomegalovirus infection
Management: give steroids, if resistant use monoclonal antibodies
Causes of chronic graft failure (> 6 months)

Chronic allograft nephropathy
Ureteric obstruction
Recurrence of original renal disease (MCGN > IgA > FSGS)
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Question 46 of 154
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End and review
Score: 36.2%
1
10.9%
63.7%
10.2%
A. Apoptosis
6.6%
B. Opsonisation
8.6%
C. Proteolysis

question correctly
Which of the following processes facilitates phagocytosis?
D. Angiogenesis
6
7-9 1 / 3
10
E. Necrosis
11
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12
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13

Opsonisation will facilitate phagocytosis. The micro-organism becomes coated with antibody,
C3b and certain acute phase proteins. The macrophages and neutrophils have up regulation
of phagocytic cell surface receptors in these circumstances, a process mediated by proinflammatory cytokines. These cells then engulf the micro organism.
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Phagocytosis
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22
Ingestion of pathogens or foreign materials by cells

First step is opsonisation whereby the organism is coated by antibody
Second step is adhesion to cell surface
Third step is pseudopodial extension to form a phagocytic vacuole
Lysosomes fuse with vacuole and degrade contents
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Question 47 of 154
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Features which are evaluated for the grading of breast cancer include all the following,
except:
A. Tubule formation
B. Mitoses
Question stats
Score: 35.4%
1
31.8%
10.2%
8.5%
35.4%
14.1%

question correctly
C. Nuclear pleomorphism
End and review
D. Tumour necrosis
6
7-9 1 / 3
10
E. Coarse chromatin
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14
The necrosis of a tumour may be suggestive of a high grade tumour which has out grown its
blood supply. However, the grading of breast cancer which classically follows the Bloom Richardson grading model will tend to favor nuclear appearances (which include mitoses,
coarse chromatin and pleomorphism). Tubule formation is an important marker of the degree
of differentiation with formation of tubular structures being associated with well differentiated
tumours.
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Tumour grading
22
23
Tumours may be graded according to their degree of differentiation, mitotic activity and other
features. Grade 1 tumours are the most differentiated and grade 3 or 4 the least. The
assessment is subjective, in most cases high grade equates to poor prognosis, or at least
rapid growth.
Tumours of glandular epithelium will tend to arrange themselves into acinar type structures
containing a central lumen. Well differentiated tumours may show excellent acinar formation
and poorly differentiated tumours simply clumps of cells around a desmoplastic stroma.
Sometimes tumours demonstrate mucous production without evidence of acinar formation.
Since mucous production is evidence of a glandular function such tumours are often termed
mucinous adenocarcinoma.
Squamous cell tumours will typically produce structures resembling epithelial cell
components. Well differentiated tumours may also produce keratin (depending upon tissue
of origin).
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Question 48 of 154
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A 34 year old man is diagnosed with an aggressive caecal adenocarcinoma. His sister died
from the same disease at 38 years of age. His mother died from endometrial cancer at the
age of 41. What is the most likely underlying abnormality?
Question stats
Score: 34.7%
1
23%
26.3%
26.9%
9.1%
14.6%
A. Familial adenopolypomatosis coli

question correctly
B. Gardeners syndrome
End and review
C. Mutation of mismatch repair genes
6
7-9 1 / 3
10
D. Deletion of chromosome 6
11
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E. MYH gene mutation
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13
14
Lynch syndrome which is characterised by aggressive right sided colonic malignancy and
endometrial cancer is caused by microsatellite instability of DNA repair genes.
15
16
17
Genetics of colorectal cancer
18
The lifetime risk of colorectal cancer in the UK population is 5%. Up to 5% of newly

diagnosed bowel cancers will be in those individuals who have a high genetically acquired
risk of bowel cancer. Cancers arising in the low-moderate genetic risk group comprise
approximately 30% of newly diagnosed bowel cancer.
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24
Genetics of inherited colorectal cancer syndromes

Syndrome
Features
25
Genes
implicated
26
28
27
FAP
More than 100 adenomatous polyps affecting the colon and

rectum. Duodenal and fundic glandular polyps
APC (over 90%)
Gardner
syndrome
As FAP but with desmoid tumours and mandibular

osteomas
APC
Turcots
syndrome
Polyposis and colonic tumours and CNS tumours
APC +MLH1
and PMS2
32
HNPCC
Colorectal cancer without extensive polyposis. Endometrial

cancer, renal and CNS
MSH2, MLH1,
PMS2 and
GTBP
34
PeutzJeghers
syndrome
Hamartomatous polyps in GI tract and increased risk of GI

malignancy
LKB1
andSTK11 (in
up to 70%)
Cowden
disease
Multiple hamartomas (see below)
PTEN (85%)
MYH
associated
polyposis
Autosomal recessive, multiple adenomatous polyps in GI

tract, those in colon having somatic KRAS mutations
MYH
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FAP
Autosomal dominant condition, affects 1 in 12,000. Accounts for 0.5% of all CRCs. Lifetime
incidence of colorectal cancer in untreated FAP =100%. Up to 25% cases are caused by denovo germ line mutations and show no prior family history. The APC tumour suppressor gene
is affected in most cases.
47
48
APC in non inherited colorectal cancer

Up to 80% of sporadic colorectal cancers will have somatic mutations that inactivate APC[1].
Both alleles are usually affected. Although the APC protein more than likely has multiple
critical cellular functions, the best-established role for APC in the cancer process is as a
major binding partner and regulator of the - catenin protein in the so-called canonical or catenin dependent Wnt signaling pathway.
HNPCC
HNPCC cancers differ from conventional tumours in a number of respects. In the colon the
tumours are more likely to be right sided, histologically they are more likely to be mucinous
and have dense lymphocytic infiltrates. To be diagnosed as having HNPCC individuals must
show typically HNPCC tumours in at least three individuals, (one of whom must be a first
degree relative to the other two). In at least two successive generations. At least one cancer
must be diagnosed under the age of 50. FAP must be excluded and tumours should be
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verified by pathological identification (Amsterdam criteria). The genetic changes in HNPCC

stem primarily from microsatellite instability affecting DNA mismatch repair genes. In HNPCC
the mismatch repair genes most commonly implicated include; MSH2 and MLH1 and these
occur in up to 70% of people with HNPCC. The finding of microsatellite instability is unusual
in sporadic colorectal cancers. Approximately 60% of individuals who fulfill the Amsterdam
criteria will not be found to have evidence of mismatch repair gene defects on genetic
testing. The risk of developing colorectal cancer in those who have not demonstrated
mutation of the mis match repair genes is increased if they fulfill the Amsterdam criteria, but
not
the extent that it is increased in those who fulfill the criteria AND have evidence of mis match
repair gene defects.
KRAS Mutations
The RAS family of small G proteins act as molecular switches downstream of growth factor
receptors. KRAS and the other two members of the family; HRAS and NRAS, are the site of
mutation in approximately 40% of colorectal cancers. When adenomas are examined the
proportion of adenomas less than 1cm showing KRAS mutations was only 10% which
contrasts with 50% in those lesions greater than 1cm.
p53 mutations
The p53 protein functions as a key transcriptional regulator of genes that encode proteins
with functions in cell-cycle checkpoints at the G1/S and G2/M boundaries, in promoting
apoptosis, and in restricting angiogenesis . As such, selection for p53 defects at the
adenoma-carcinoma transition may reflect the fact that stresses on tumor cells activate cellcycle arrest, apoptotic, and antiangiogenic pathways in cells with wild-type p53 function.
Many colonic tumours will demonstrate changes in the p53 gene that may facilitate tumour
progression through from adenoma to carcinoma.
Cowden syndrome
Also known as multiple hamartoma syndrome. Rare autosomal dominant condition with
incidence of 1 in 200,000.. It is characterised by multiple mucocutaneous lesions,
trichilemmomas, oral papillomas and acral keratosis. Most often diagnosed in third decade of
life. Breast carcinoma may occur in up to 50% of patients and conditions such as fibrocystic
disease of the breast may occur in 75% of women. Thyroid disease occurs in 75% and may
include malignancy. Endoscopic screening will identify disease in up to 85% although the
small bowel is rarely involved. There is a 15-20% risk of developing colorectal cancer and
regular colonoscopic screening from age 45 is recommended.
Terminology
Oncogene
Oncogenes are genes which have the potential to induce cellular proliferation and
avoid apoptosis. Oncogene mutations are general gain of function and are
therefore dominant. Increased expression of oncogenes are found in most tumours
Tumour
suppressor
gene
These genes generally inhibit cellular proliferation or induce apoptosis. Mutations

in tumour suppressor genes are generally loss of function mutations, and are
therefore recessive. Mutations in both tumour suppressor gene alleles allow cells
to proliferate without restraint
References
1. Fearon, E.R. and B. Vogelstein, A genetic model for colorectal tumorigenesis. Cell, 1990.
61(5): p. 759-67.
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End and review
Score: 36%
1
57.9%
13%
8.3%
A. Jaundice
8.2%
B. Patients taking carbamazepine
12.6%
C. General anaesthesia using thiopentone

question correctly
Which of the following is associated with poor wound healing?
D. General anaesthesia using ketamine
6
7-9 1 / 3
10
E. Multiple sclerosis
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13
Mnemonic to remember factors affecting wound healing: DID NOT HEAL
14
15
D iabetes
I nfection, irradiation
D rugs eg steroids, chemotherapy
16
17
18
N utritional deficiencies (vitamin A, C & zinc, manganese), Neoplasia

O bject (foreign material)
T issue necrosis
19-21 1 / 3
22
23
H ypoxia
E xcess tension on wound
A nother wound
L ow temperature, Liver jaundice
24
25
26
27
Multiple sclerosis is associated with pressure sores, however the cellular healing process is
not affected.
Wound healing
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Haemostasis
clot.
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Inflammation
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Typically days 1-5

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Regeneration
Remodeling
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Hypertrophic scars
wound:
Keloid scars

Steroids
Closure
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Question 50 of 154
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A 55 year old man undergoes a colonoscopy and a colonic polyp is identified. It has a lobular
appearance and is located on a stalk in the sigmoid colon. Which of the processes below
best accounts for this disease?
Question stats
Score: 37.3%
1
6.6%
25.6%
52.4%
6.9%
8.5%
A. Apoptosis
question correctly
B. Metaplasia
End and review
C. Dysplasia
6
7-9 1 / 3
10
D. Calcification
11
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E. Degeneration
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14
15

Most colonic polyps described above are adenomas. These may have associated dysplasia.
The more high grade the dysplasia the greater the level of clinical concern.
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Colonic polyps
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Colonic Polyps
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27
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Group
Features
Action
Low risk
Moderate
risk

1cm
Re-scope at 3 years
High risk

Re scope at 1 year
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39

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Question 51 of 154
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A 56 year old lady has just undergone a colonoscopy and a 1.5cm lesion was identified in
the caecum. The histology report states that biopsies have been taken from a sessile
serrated polyp with traditional features. What is the best management option?
Question stats
Score: 36.5%
1
24.7%
31.2%
8.3%
17.8%
18%
A. Perform a right hemicolectomy

question correctly
B. List the patient for colonoscopic polypectomy
End and review
C. Discharge the patient
6
7-9 1 / 3
10
D. Re scope the patient in 6 months
11
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E. Re scope the patient at 3 years
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14
15
These polyps represent an alternative pathway to progression to carcinoma and may be

diagnostically confused with hyperplastic polyps. Hyperplastic polyps are more common in
the left colon and confer no increased risk. SSA's are more common in the right colon and
are usually larger. Those with "traditional features" on histology have dysplasia with
increased risk of malignant transformation.
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Colonic polyps
22
23
Colonic Polyps
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29
Group
Features
Action
30
Low risk
31
33
Moderate
risk

1cm
Re-scope at 3 years
High risk

Re scope at 1 year
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40

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49
50
References
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A 30 year old male presents with gynaecomastia. Clinically, he is noted to have a nodule in
the left testis. What is the most likely diagnosis?
A. Oestrogen abuse
B. Seminoma with syncytiotrophoblast giant cells
Question stats
Score: 35.8%
1
7.4%
28.2%
21.3%
12.3%
30.9%

question correctly
C. Teratoma
End and review
D. Choriocarcinoma
6
7-9 1 / 3
10
E. Leydig cell tumour
11
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Leydig cell tumours are rare testicular sex cord stromal tumours (which also include sertoli
cell tumours) which are associated with hormonal activity.
Patients with Leydig cell tumours may present with gynaecomastia before they notice
testicular enlargement.
Majority are benign
Histology: eosinophilic cells in columns
Go
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24
Testicular cancer
divided into:
25
26
27
28
Tumour type
Seminoma
Key features
Commonest
subtype
(50%)
Average
age at
diagnosis =
40
Even
advanced
disease
associated
with 5 year
survival of
73%
Tumour
markers
Pathology
AFP usually
normal
HCG elevated
in 10%
seminomas
Lactate
dehydrogenase;
elevated in 1020%
seminomas (but
also in many
other
conditions)

may be seen.
29
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35
36
37
38
39
40
41
Non seminomatous
germ cell tumours
(42%)
Teratoma
Yolk sac tumour
Choriocarcinoma
Mixed germ cell
tumours (10%)
Younger age at
Advanced
disease carries
worse prognosis
(48% at 5 years)
Retroperitoneal
lymph node
dissection may be
needed for residual
disease after
chemotherapy
AFP elevated
in up to 70% of
cases
HCG elevated
in up to 40% of
cases
Other
markers rarely
helpful

such as hair
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teratomas
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Cryptorchidism
Infertility
Family history
Mumps orchitis
Features
Diagnosis
Management
node dissection.

Benign disease
Epididymo-orchitis
stopping the drug.
Testicular torsion
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Hydrocele
examination.
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End and review
Score: 38.2%
1
17%
24.7%
16.3%
A. Osteosarcoma
9%
B. Neuroblastoma
33%
C. Leukaemia

question correctly
What is the most common cause of osteolytic bone metastasis in children?
D. Rhabdomyosarcoma
6
7-9 1 / 3
10
E. Nephroblastoma
11
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13
Neuroblastomas are a relatively common childhood tumour and have a strong tendency to
developing widespread lytic metastasis.
14
15
Secondary malignant tumours of bone
16
17
Metastatic lesions affecting bone are more common than primary bone tumours.
18
19-21 1 / 3
The typical tumours that spread to bone include:
22
Breast
Bronchus
Renal
Thyroid
Prostate
23
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25
26
27
75% cases will affect those over the age of 50

28
The commonest bone sites affected are:
29
Vertebrae (usually thoracic)

Proximal femur
Ribs
Sternum
Pelvis
Skull
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32
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35
Pathological fracture
Osteolytic lesions are the greatest risk for pathological fracture
The risk and load required to produce fracture varies according to bone site. Bones with
lesions that occupy 50% or less will be prone to fracture under loading (Harrington). When
75% of the bone is affected the process of torsion about a bony fulcrum may produce a
fracture.
The Mirel scoring[1] system may be used to help determine the risk of fracture and is more
systematic than the Harrington system described above.
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Mirel Scoring system
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Score
points
Site
Radiographic
appearance
Width of bone
involved
Pain
Upper
extremity
Blastic
Less than 1/3
Mild
Lower
extremity
Mixed
1/3 to 2/3
Moderate
Peritrochanteric
Lytic
More than 2/3
Aggravated by
function
48
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50
51
52
53
Depending upon the score the treatment should be as follows:

Score
Risk of fracture
Treatment
9 or greater
Impending (33%)
Prophylactic fixation
Borderline
Consider fixation
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7 or less
Not impending (4%)
Non operative management
Where the lesion is an isolated metastatic deposit consideration should be given to excision
and reconstruction as the outcome is better [2].
Non operative treatments
Hypercalcaemia- Treat with re hydration and bisphosphonates.
Pain- Opiate analgesics and radiotherapy.
Some tumours such as breast and prostate will benefit from chemotherapy and or hormonal
agents.
References
1. Mirels, H. Metastatic disease in long bones. A proposed scoring system for diagnosing
impending pathologic fractures. Clin Orthop Relat Res, 1989(249): p. 256-64.
2. Mavrogenis, A.F. et al. Survival analysis of patients with femoral metastases. J Surg
Oncol, 2011.
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End and review
Score: 40.4%
1
8.7%
8.6%
10.1%
A. Complex fistula in ano
21.4%
B. Small bowel strictures
51.3%
C. Skip lesions

question correctly
Which of the following features are not typical of Crohns disease?
D. 'Rose thorn ulcers' on barium studies
6
7-9 1 / 3
10
E. Pseudopolyps on colonoscopy
11
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13
Pseudopolyps are a feature of ulcerative colitis and occur when there is severe mucosal
ulceration. The remaining islands of mucosa may then appear to be isolated and almost
polypoidal.
14
15
16
Crohns disease
17

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19-21 1 / 3
22
23
24
25
26
Crohn's disease
Ulcerative colitis
27
Distribution
Mouth to anus
Rectum and colon
28
Macroscopic
changes
Contact bleeding
Depth of
disease
Distribution
pattern
Patchy
Continuous
Histological
features


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Diarrhoea in Crohns
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54

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End and review
Score: 41.4%
1
25.4%
10%
11.2%
A. Caecum
9.4%
B. Ascending colon
44%
C. Transverse colon

question correctly
At which of the following sites is the development of diverticulosis least likely?
D. Sigmoid colon
6
7-9 1 / 3
10
E. Rectum
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13
Rectal involvement with diverticular disease almost never occurs.
14
15
Because the rectum has a circular muscle coat (blending of of the tenia marks the rectosigmoid junction), diverticular disease almost never occurs here. Right sided colonic
diverticular disease is well recognised (though less common than left sided).
Diverticular disease
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22
Diverticular disease is a common surgical problem. It consists of herniation of colonic mucosa

through the muscular wall of the colon. The usual site is between the taenia coli where
vessels pierce the muscle to supply the mucosa. For this reason, the rectum, which lacks
taenia, is often spared.
23
24
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26
Symptoms
Altered bowel habit
Bleeding
Abdominal pain
27
28
29
30
31
Complications
Diverticulitis
Haemorrhage
Development of fistula
Perforation and faecal peritonitis
Perforation and development of abscess
Development of diverticular phlegmon
32
33
34
35
36
37
38
Diagnosis
Patients presenting in clinic will typically undergo either a colonoscopy, CT cologram or
barium enema as part of their diagnostic work up. All tests can identify diverticular disease. It
can be far more difficult to confidently exclude cancer, particularly in diverticular strictures.
Acutely unwell surgical patients should be investigated in a systematic way. Plain abdominal
films and an erect chest x-ray will identify perforation. An abdominal CT scan (not a CT
cologram) with oral and intravenous contrast will help to identify whether acute inflammation
is present but also the presence of local complications such as abscess formation.
Severity Classification- Hinchey
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Para-colonic abscess
II
Pelvic abscess
51
III
Purulent peritonitis
52
IV
Faecal peritonitis
50
53
Treatment
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55
Increase dietary fibre intake.

Mild attacks of diverticulitis may be managed conservatively with antibiotics.
Peri colonic abscesses should be drained either surgically or radiologically.
Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative
indication for a segmental resection.
Hinchey IV perforations (generalised faecal peritonitis) will require a resection and
usually a stoma. This group have a very high risk of post operative complications and
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laparoscopic washout and drain insertion.
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Question 56 of 154
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A 32 year old lady presents with a 1.5cm pigmented lesion on her back. The surgeon is
concerned that this may be a melanoma. What is the most appropriate course of action?
A. 2mm punch biopsy from the centre of the lesion

B. 4mm punch biopsy from the centre of the lesion
Question stats
Score: 42.4%
1
8%
8.3%
19.7%
32.1%
31.9%

question correctly
C. Wide excision of the lesion with 3cm margins
End and review
D. Excisional biopsy of the lesion
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7-9 1 / 3
10
E. Wide excision of the lesion with 1cm margins
11
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12
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13
14
Suspicious naevi should NOT be partially sampled as histological interpretation is

severely compromised. Complete excision is mandatory where lesions fulfil diagnostic
criteria. However, wide excision for margins may be deferred until definitive histology is
available.
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Lesions that are suspicious for melanoma should be excised with complete margins. Radical
excision is not routinely undertaken for diagnostic purposes and therefore if subsequent
histopathological assessment determines that the lesion is a melanoma a re-exicision of
margins may be required. Incisional punch biopsies of potential melanomas makes
histological interpretation difficult and is best avoided.
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Malignant melanoma
26
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Change in size
Change in shape
Change in colour
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Diameter >6mm
Inflammation
Oozing or bleeding
Altered sensation
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Treatment
34
difficult.
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Lesions 0-1mm thick
1cm
Lesions 1-2mm thick
Lesions 2-4mm thick
Lesions >4 mm thick
3cm
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48
Marsden J et al Revised UK guidelines for management of Melanoma. Br J Dermatol 2010

163:238-256.
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Question 57 of 154
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A 70 year old male presents with painless frank haematuria. Clinical examination is
unremarkable. Routine blood tests reveal a haemoglobin of 18g/dl but are otherwise normal.
Question stats
Score: 41.7%
1
14.3%
8.6%
47.8%
9.3%
20%
A. Squamous cell carcinoma of the bladder

question correctly
B. Adenocarcinoma of the prostate
End and review
C. Adenocarcinoma of the kidney
6
7-9 1 / 3
10
D. Wilms tumour
11
Search
E. Transitional cell carcinoma of the renal pelvis
12
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13
14

Polycythaemia is a recognised feature of renal cell carcinoma. Wilms tumours most
commonly occur in children.
15
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17
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Haematuria
19-21 1 / 3
Causes of haematuria
22
23
Trauma
Injury to renal tract

Renal trauma commonly due to blunt injury (others penetrating
injuries)
Ureter trauma rare: iatrogenic
Bladder trauma: due to RTA or pelvic fractures
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Infection
Remember TB
29
30
Malignancy
Renal cell carcinoma (remember paraneoplastic syndromes):

painful or painless
Urothelial malignancies: 90% are transitional cell carcinoma, can
occur anywhere along the urinary tract. Painless haematuria.
Squamous cell carcinoma and adenocarcinoma: rare bladder
tumours
Prostate cancer
Penile cancers: SCC
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37
Renal disease
Glomerulonephritis
38
39
Stones
Microscopic haematuria common
40
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Structural
abnormalities
42-44 0 / 3
Benign prostatic hyperplasia (BPH) causes haematuria due to

hypervascularity of the prostate gland
Cystic renal lesions e.g. polycystic kidney disease
Vascular malformations
Renal vein thrombosis due to renal cell carcinoma
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48
Coagulopathy
Drugs
49
Causes bleeding of underlying lesions
50
51
Cause tubular necrosis or interstitial nephritis: aminoglycosides,

chemotherapy
Interstitial nephritis: penicillin, sulphonamides, and NSAIDs
Anticoagulants
52
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55
Benign
Exercise
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57
Gynaecological
Iatrogenic
Endometriosis: flank pain, dysuria, and haematuria that is cyclical
Catheterisation
Radiotherapy; cystitis, severe haemorrhage, bladder necrosis
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Pseudohaematuria
For example following consumption of beetroot
References
Http://bestpractice.bmj.com/best-practice/monograph/316/overview/aetiology.html
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Question stats
End and review
Score: 40.9%
1
2
Theme: Thyroid neoplasms

58
78.1%
59
52.8%
60
64%
B. Follicular adenoma
3
4
5
C. Papillary carcinoma
D. Papillary adenoma
Search
E. Anaplastic carcinoma
7-9 1 / 3
Go
F. Medullary carcinoma
10
11
Please select the most likely underlying diagnosis for the thyroid masses described. Each
option may be used once, more than once or not at all.
12
13
14
15
58.
A 78 year old lady presents to the surgical clinic with symptoms of both
dysphagia and dyspnoea. On examination there is a large mass in the neck
that moves on swallowing. CT scanning of the neck shows a locally infiltrative
lesion arising from the thyroid and invading the strap muscles.
16
17
18
19-21 1 / 3
You answered Follicular carcinoma
22
The correct answer is Anaplastic carcinoma
23
Marked local invasion is a feature of anaplastic carcinoma. These tumours are

more common in elderly females.
59.
A 25 year old female presents with a lump in her neck. On examination she has
a discrete nodule in the right lobe of the thyroid. A fine needle aspirate shows
papillary cells. An adjacent nodule is also sampled which shows similar well
differentiated papillary cells.
24
25
26
27
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29
30
Papillary carcinoma
Multifocal disease is a recognised feature of papillary lesions. Papillary
adenomas are not really recognised and most well differentiated lesions are
papillary carcinomas.
60.
A 45 year old man presents with a fracture of his right humerus. On

examination there is a lytic lesion of the proximal humerus and a mass in the
neck, this moves on swallowing.
31
32
33
34
35
36
37
You answered Medullary carcinoma
38
The correct answer is Follicular carcinoma

39
Follicular carcinomas are a recognised source of bone metastasis. Up to 60%

will show vascular invasion histologically.
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41
42-44 0 / 3
Next question
45
46
47
Thyroid neoplasms
48
49
Lesion
Common features
50
51
Follicular
adenoma

52
53
54
Papillary
carcinoma
Follicular
carcinoma

Seldom encapsulated
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58-60 1 / 3

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Anaplastic
carcinoma
Medullary
carcinoma


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Question 61 of 154
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Question stats
End and review
Score: 41.8%
1
21.3%
7.1%
5.7%
7%
B. Gastro intestinal stromal tumours
58.8%
C. Carcinoid tumours

question correctly
Which of these lesions is most closely associated with Barretts oesophagus?
D. Leiomyosarcoma
6
7-9 1 / 3
10
E. Adenocarcinoma
11
Search
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12
Go
13

Barretts oesophagus is most closely associated with adenocarcinoma, and it confers a 30
fold increased risk of developing the condition.
14
15
16
Oesophageal cancer
17
18
cases.
adenocarcinoma.
19-21 1 / 3
22
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29
Diagnosis
30

is unnecessary
performed.
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40
Treatment
41
42-44 0 / 3
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Question 62 of 154
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A 56 year old man presents with epigastric discomfort and episodes of migratory
thrombophlebitis. On examination he is mildly jaundiced. A CT scan shows peri hilar
lymphadenopathy and a mass in the pancreatic head. Which of the following is the most
likely underlying diagnosis?
Question stats
Score: 40.6%
1
9.3%
55.1%
8.8%
16%
10.8%

question correctly
A. Squamous cell carcinoma of the pancreas
End and review
B. Adenocarcinoma of the pancreas
6
7-9 1 / 3
10
C. Insulinoma
11
Search
D. Glucagonoma
12
E. Gastrinoma
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13
14
Next question
15
Adenocarcinoma of the pancreas is the most likely diagnosis and migratory thrombophlebitis
is associated with the condition. Squamous cells carcinoma is extremely uncommon in the
pancreas. Gastrinoma are extremely rare and thus not the most likely diagnosis.
16
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18
19-21 1 / 3
Pancreatic cancer
22
23
Adenocarcinoma
Risk factors: Smoking, diabetes, Adenoma, Familial adenomatous polyposis
Mainly occur in the head of the pancreas (70%)
Spread locally and metastasizes to the liver
Carcinoma of the pancreas should be differentiated from other periampullary tumours
with better prognosis
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27
28
Clinical features
29
30
Weight loss
Painless jaundice
Epigastric discomfort (pain usually due to invasion of the coeliac plexus is a late
feature)
Pancreatitis
Trousseau's sign: migratory superficial thrombophlebitis
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32
33
34
35
Investigations
36
37
USS: May miss small lesions

CT Scanning (pancreatic protocol). If unresectable on CT then no further staging
needed
PET/CT for those with operable disease on CT alone
ERCP/ MRI for bile duct assessment
Staging laparoscopy to exclude peritoneal disease
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42-44 0 / 3
45
Management
46
Head of pancreas: Whipple's resection (SE dumping and ulcers). Newer techniques
include pylorus preservation and SMA/ SMV resection
Carcinoma body and tail: poor prognosis, distal pancreatectomy, if operable
Usually adjuvent chemotherapy for resectable disease
ERCP and stent for jaundice and palliation
Surgical bypass may be needed for duodenal obstruction
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Question 63 of 154
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Question stats
End and review
Score: 41.4%
1
9.1%
7.6%
13%
A. B-HCG
54.1%
B. Histamine
16.2%
C. Chromogranin A

question correctly
What is the urinary diagnostic marker for carcinoid syndrome?
D. 5-Hydroxyindoleacetic acid
6
7-9 1 / 3
10
E. 5-Hydroxytryptamine
11
Search
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12
Go
13
Urinary measurement of 5- HIAA is an important part of clinical follow up.
14
15
Carcinoid syndrome
16

17
18
19-21 1 / 3
22
23
Clinical features
24
Onset: years
Flushing face
Palpitations
Asthma
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27
28
29
30
Investigation
31

CT scan
32
33
34
35
36
Treatment
37
Octreotide
Surgical removal
38
39
40
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41
42-44 0 / 3
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Question 64 of 154
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A 22 year old man presents with symptoms of headache, lethargy and confusion. On
examination he is febrile and has a right sided weakness. A CT scan shows a ring enhancing
lesion affecting the left motor cortex. Which of the following is the most likely diagnosis?
Question stats
Score: 42.3%
1
8.5%
58.2%
12.9%
6.8%
13.6%
A. Arteriovenous malformation
question correctly
B. Cerebral abscess
End and review
C. Herpes simplex encephalitis
6
7-9 1 / 3
10
D. Metastatic renal adenocarcinoma
11
Search
E. Glioblastoma multiforme
12
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13
14
The combination of rapidly progressive neurology, fever and headache is highly suggestive
of cerebral abscess. CT scanning will show a ring enhancing lesion because the intravenous
contrast cannot penetrate the centre of the abscess cavity. HSV encephalitis does not
produce ring enhancing lesions.
15
16
17
18
19-21 1 / 3
Brain abscess
22
CNS abscesses may result from a number of causes including, extension of sepsis
from middle ear or sinuses, trauma or surgery to the scalp, penetrating head injuries
and embolic events from endocarditis.
The presenting symptoms will depend upon the site of the abscess (those in critical
areas e.g.motor cortex) will present earlier. Abscesses have a considerable mass
effect in the brain and raised intra cranial pressure is common.
Although fever, headache and focal neurology are highly suggestive of a brain
abscess the absence of one or more of these does not exclude the diagnosis, fever
may be absent and even if present, is usually not the swinging pyrexia seen with
abscesses at other sites.
Assessment of the patient includes imaging with CT scanning.
Treatment is usually surgical, a craniotomy is performed and the abscess cavity
debrided. The abscess may reform because the head is closed following abscess
drainage.
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Question 65 of 154
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A 56 year old man from Egypt has suffered from recurrent attacks of haematuria for many
years. He presents with suprapubic discomfort and at cystoscopy is found to have a mass
lesion within the bladder. What is the most likely diagnosis?
Question stats
Score: 41.7%
1
53.7%
23.4%
7.7%
8.4%
6.8%

question correctly
B. Transitional cell papilloma
End and review
C. Adenocarcinoma
6
7-9 1 / 3
10
D. Leiomyosarcoma
11
Search
E. Rhabdomyosarcoma
12
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13
14
In Egypt, Schistosomiasis is more common than in the UK and may cause recurrent episodes
of haematuria. In those affected with the condition who develop a bladder neoplasm, an SCC
is the most common type.
Bladder cancer
15
16
17
18
19-21 1 / 3
Bladder cancer is the second most common urological cancer. It most commonly affects
males aged between 50 and 80 years of age. Those who are current, or previous (within 20
years), smokers have a 2-5 fold increased risk of the disease. Exposure to hydrocarbons
such as 2-Naphthylamine increases the risk. Although rare in the UK, chronic bladder
inflammation arising from Schistosomiasis infection remains a common cause of squamous
cell carcinomas, in those countries where the disease is endemic.
22
Benign tumours
Benign tumours of the bladder including inverted urothelial papilloma and nephrogenic
adenoma are uncommon.
27
Bladder malignancies
30
23
24
25
26
28
29
31
Transitional cell carcinoma (>90% of cases)

Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis)
Adenocarcinoma (2%)
32
33
34
Transitional cell carcinomas may arise as solitary lesions, or may be multifocal, owing to the
effect of "field change" within the urothelium. Up to 70% of TCC's will have a papillary growth
pattern. These tumours are usually superficial in location and accordingly have a better
prognosis. The remaining tumours show either mixed papillary and solid growth or pure solid
growths. These tumours are typically more prone to local invasion and may be of higher
grade, the prognosis is therefore worse. Those with T3 disease or worse have a 30% (or
higher) risk of regional or distant lymph node metastasis.
35
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38
39
40
TNM Staging
41
42-44 0 / 3
Stage
Description
T0
No evidence of tumour
Ta
Non invasive papillary carcinoma
T1
Tumour invades sub epithelial connective tissue
T2a
Tumor invades superficial muscularis propria (inner half)
50
T2b
Tumor invades deep muscularis propria (outer half)
51
T3
Tumour extends to perivesical fat
T4
Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina
T4a
Invasion of uterus, prostate or bowel
T4b
Invasion of pelvic sidewall or abdominal wall
45
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52
53
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55
56
N0
No nodal disease
N1
Single regional lymph node metastasis in the true pelvis (hypogastric, obturator,
external iliac, or presacral lymph node)
N2
Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator,
57
58-60 1 / 3
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external iliac, or presacral lymph node metastasis)

65
N3
Lymph node metastasis to the common iliac lymph nodes
M0
No distant metastasis
M1
Distant disease
Presentation
Most patients (85%) will present with painless, macroscopic haematuria. In those patients
with incidental microscopic haematuria, up to 10% of females aged over 50 will be found to
have a malignancy (once infection excluded).
Staging
Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis
and information relating to depth of invasion. Locoregional spread is best determined using
pelvic MRI and distant disease CT scanning. Nodes of uncertain significance may be
investigated using PET CT.
Treatment
Those with superficial lesions may be managed using TURBT in isolation. Those with
recurrences or higher grade/ risk on histology may be offered intravesical chemotherapy.
Those with T2 disease are usually offered either surgery (radical cystectomy and ileal
conduit) or radical radiotherapy.
Prognosis
T1
90%
T2
60%
T3
35%
T4a
10-25%
Any T, N1-N2
30%
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Question 66 of 154
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A newborn infant is noted to have a unilateral cleft lip only. What is the most likely
explanation for this process?
A. Incomplete fusion of the second branchial arch

B. Incomplete fusion of the nasolabial muscle rings
Question stats
Score: 42.5%
1
19%
42%
12.7%
10%
16.3%

question correctly
C. Incomplete fusion of the first branchial arch
End and review
D. Incomplete fusion of the third branchial arch
6
7-9 1 / 3
10
E. Incomplete fusion of the secondary palate
11
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12
Next question

Unilateral isolated cleft lip represents a failure of nasolabial ring fusion. It is not related to
branchial arch fusion. Arch disorders have a far more profound phenotype and malformation
sequences.
Go
13
14
15
16
17
18
Cleft lip and palate
19-21 1 / 3
Cleft lip and palate are the most common congenital deformity affecting the orofacial
structures. Whilst they may be an isolated developmental malformation they are also a
recognised component of more than 200 birth defects. The incidence is as high as 1 in 600
live births. The commonest variants are:
22
23
24
25
Isolated cleft lip (15%)

Isolated cleft palate (40%)
Combined cleft lip and palate (45%)
26
27
The aetiology of the disorder is multifactorial; both genetic (affected first degree relative
increases risk) and environmental factors play a role.
28
29
30
Cleft lip
Cleft lip occurs as a result of disruption of the muscles of the upper lip and nasolabial region.
These muscles comprise a chain of muscles viz; nasolabial, bilabial and labiomental. Defects
may be unilateral or bilateral.
Cleft palate
The primary palate consists of all anatomical structures anterior to the incisive foramen. The
secondary palate lies more posteriorly and is sub divided into the hard and soft palate. Cleft
palate occurs as a result of non fusion of the two palatine shelves. Both hard and soft palate
may be involved. Complete cases are associated with complete separation of the nasal
septum and vomer from the palatine processes.
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38
39
Treatment
Surgical reconstruction is the mainstay of management. The procedures are planned
according to the extent of malformation and child age. Simple defects are managed as a
single procedure. Complex malformations are usually corrected in stages. Affected
individuals have a higher incidence of hearing and speech problems.
40
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42-44 0 / 3
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46
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Question stats
End and review
Score: 44.2%
1
2
Theme: Pharyngitis
A. Infectious mononucleosis
68
56%
69
80.9%
70
70.5%
B. Acute bacterial tonsillitis
3
4
5
C. Quinsy
D. Lymphoma
Search
E. Diptheria
7-9 1 / 3
Go
Please select the most likely underlying cause for the following patients presenting with
pharyngitis. Each option may be used once, more than once or not at all.
10
11
12
13
14
68.
An 8 year old child presents with enlarged tonsils that meet in the midline and
are covered with a white film that bleeds when you attempt to remove it. He is
pyrexial but otherwise well.
15
16
17
Acute bacterial tonsillitis
18

In acute tonsillitis the tonsils will often meet in the midline and may be covered
with a membrane. Individuals who are systemically well are unlikely to have
diptheria.
19-21 1 / 3
22
23
24
69.
A 10 year old child presents with enlarged tonsils that meet in the midline.
Oropharyngeal examination confirms this finding and you also notice peticheal
haemorrhages affecting the oropharynx. On systemic examination he is noted
to have splenomegaly.
25
26
27
28
Infectious mononucleosis
29
A combination of pharyngitis and tonsillitis is often seen in glandular fever.

Antibiotics containing penicillin may produce a rash when given in this situation,
leading to a mistaken label of allergy.
30
31
32
70.
A 19 year old man has had a sore throat for the past 5 days. Over the past 24
hours he has notices increasing and severe throbbing pain in the region of his
right tonsil. He is pyrexial and on examination he is noted to have a swelling of
this area.
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34
35
36
Quinsy
37
Unilateral swelling and fever is usually indicative of quinsy. Surgical drainage

usually produces prompt resolution of symptoms.
38
39
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Acute tonsillitis
45
46
47
Characterised by pharyngitis, fever, malaise and lymphadenopathy.

Over half of all cases are bacterial with Streptococcus pyogenes the most common
organism
The tonsils are typically oedematous and yellow or white pustules may be present
Infectious mononucleosis may mimic the condition.
Treatment with penicillin type antibiotics is indicated for bacterial tonsillitis.
Bacterial tonsillitis may result in local abscess formation (quinsy)
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Acute streptococcal tonsillitis
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68-70 3 / 3
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Question 71 of 154
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A 4 year old boy is brought to the clinic by his mother who has noticed a small lesion at the
external angle of his eye. On examination there is a small cystic structure which has
obviously been recently infected. On removal of the scab, there is hair visible within the
lesion. What is the most likely diagnosis?
Question stats
Score: 44.9%
1
57.5%
11.4%
12.5%
10.2%
8.4%

question correctly
A. Dermoid cyst
End and review
B. Desmoid cyst
6
7-9 1 / 3
10
C. Sebaceous cyst
11
Search
D. Epidermoid cyst
12
E. Keratoacanthoma
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13
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14
15
Dermoid cysts occur at sites of embryonic fusion and may contain multiple cell types.
They occur most often in children.
16
17
18
The lesion is unlikely to be a desmoid cyst as these are seldom located either at this site or
in this age group. In addition they do not contain hair. Sebaceous cysts will usually have a
punctum and contain a cheesy material. Epidermoid cysts contain keratin plugs.
19-21 1 / 3
22
23
24
Dermoid cysts
25
A cutaneous dermoid cyst may develop at sites of embryonic developmental fusion. They are
most common in the midline of the neck, external angle of the eye and posterior to the pinna
of the ear. They typically have multiple inclusions such as hair follicles that bud out from its
walls. They may develop at other sites such as the ovary and in these sites are synonymous
with teratomas.
26
27
28
29
30
A desmoid tumour is a completely different entity and may be classified either as low grade
fibrosarcomas or non aggressive fibrous tumours. They commonly present as large
infiltrative masses. They may be divided into abdominal, extra abdominal and intra
abdominal. All types share the same biological features. Extra abdominal desmoids have an
equal sex distribution and primarily arise in the musculature of the shoulder, chest wall, back
and thigh. Abdominal desmoids usually arise in the musculoaponeurotic structures of the
abdominal wall. Intra abdominal desmoids tend to occur in the mesentery or pelvic side walls
and occur most frequently in patients with familial adenomatous polyposis coli syndrome.
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Question 72 of 154
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Which of the following tumours are most likely to give rise to para-aortic nodal metastasis
early?
A. Ovarian
B. Bladder
Question stats
Score: 43.8%
1
53.2%
10.5%
13.1%
10.1%
13.2%

question correctly
C. Rectal
End and review
D. Caecal
6
7-9 1 / 3
10
E. Cervical
11
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12
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13
14
15
Ovarian tumours are supplied by the ovarian vessels, these branch directly from the aorta.
The cervix drains to the internal and external iliac nodes.
16
17
18
Para-aortic lymphadenopathy
19-21 1 / 3
Organ sites that may metastasise (early) to the para-aortic lymph nodes:
22
23
Testis
Ovary
Uterine fundus
24
25
Many other organs may result in para-aortic nodal disease. However, these deposits will
represent a much later stage of the disease, since other nodal stations are involved earlier.
26
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Question 73 of 154
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End and review
Score: 43.2%
1
16.3%
6.4%
49.1%
A. It may be treated by extrapleural pneumonectomy.
12%
B. It is linked to asbestos exposure.
16.2%
C. It is linked to cigarette smoking independent of asbestos exposure.

question correctly
Which of the following statements relating to malignant mesothelioma is false?
D. It may occur intra abdominally.
6
7-9 1 / 3
10
E. It is relatively resistant to radiotherapy
11
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12
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13
It is not linked to cigarette smoking. When identified at an early stage a radical resection is
the favored option. Radiotherapy is often given perioperatively. However, it is not a
particularly radiosensitive tumour. Combination chemotherapy gives some of the best results
and most regimes are cisplatin based.
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Mesothelioma
Bladder cancer
Lung cancer
Sino nasal cancer
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Mining
Metalworkers
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RR595).
35
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leukaemia.
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Question stats
End and review
Score: 41.7%
1
2
Theme: Thyroid disorders

A. Sick euthyroid
74
73.3%
75
84.6%
76
25.8%
B. Hyperthyroidism
3
4
5
C. Hypothyroidism
D. Normal euthyroid
Search
E. Anxiety state
7-9 1 / 3
Go
F. Factitious hyperthyroidism
10
11
For each of the scenarios please match the scenario with the most likely underlying
diagnosis. Each answer may be used once, more than once or not at all.
12
13
14
15
74.
A 33 year old man is recovering following a protracted stay on the intensive

care unit recovering from an anastomotic leak following a difficult trans hiatal
oesophagectomy. His progress is slow, and the intensive care doctors receive
the following thyroid function test results:
TSH
1.0 u/L
16
17
18
19-21 1 / 3
Free T4 8
22
T3
23
1.0 (1.2-3.1 normal)
24
25
You answered Hypothyroidism
26
The correct answer is Sick euthyroid
27

Sick euthyroid syndrome is caused by systemic illness. With this, the patient
may have an apparently low total and free T4 and T3, with a normal or low
TSH. Note that the levels are only mildly below normal.
75.
A 28 year old female presents to the general practitioner with symptoms of

fever and diarrhoea. As part of her diagnostic evaluation the following thyroid
function tests are obtained:
TSH
< 0.01
29
30
31
32
33
34
Free T4 30
T3
28
35
4.0
36
37
You answered Sick euthyroid
38
39
The correct answer is Hyperthyroidism
40
The symptoms are suggestive of hyperthyroidism. This is supported by the

abnormal blood results; suppressed TSH with an elevated T3 and T4.
41
42-44 0 / 3
76.
A 19 year old lady presents with palpitations. The medical officer takes a blood
sample for thyroid function tests. The following results are obtained:
TSH
45
46
> 6.0
47
Free T4 20
48
T3
2.0
49
50
You answered Hyperthyroidism
51
52
The correct answer is Hypothyroidism
53
An elevated TSH with normal T4 indicates partial thyroid failure. This is caused
by Hashimotos, drugs (lithium, antithyroids) and dyshormogenesis.
54
55
56
Next question
57
58-60 1 / 3
Hyperthyroidism
61
62
63
Causes of hyperthyroidism include:
64
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Diffuse toxic goitre (Graves Disease)

Toxic nodular goitre
Toxic nodule
Rare causes
65
66
67
68-70 3 / 3
71
Graves disease
Graves disease is characterised by a diffuse vascular goitre that appears at the same time
as the clinical manifestations of hyperthyroidism. It is commonest in younger females and
may be associated with eye signs. Thyrotoxic symptoms will predominate. Up to 50% of
patients will have a familial history of autoimmune disorders. The glandular hypertrophy and
hyperplasia occur as a result of the thyroid stimulating effects of the TSH receptor
antibodies.
72
73
74-76 0 / 3

In this disorder the goitre is present for a long period of time prior to the development of
clinical symptoms. In most goitres the nodules are inactive and in some cases it is the
internodular tissue that is responsible for the goitre.
Toxic nodule
Overactive, autonomously functioning nodule. It may occur as part of generalised nodularity
or be a true toxic adenoma. The TSH levels are usually low as the autonomously functioning
thyroid tissue will exert a negative feedback effect.
Signs and symptoms
Symptoms
Signs
Lethargy
Tachycardia
Emotionally labile
Agitation
Heat intolerance
Hot, moist palms
Weight loss
Exopthalmos
Excessive appetite
Thyroid goitre and bruit
Palpitations
Lid lag/retraction
Diagnosis
The most sensitive test for diagnosing hyperthyroidism is plasma T3 (which is raised). Note in
hypothyroidism the plasma T4 and TSH are the most sensitive tests. A TSH level of <0.5U/L
suggests hyperthyroidism. TSH receptor antibodies may be tested for in the diagnosis of
Graves.
Treatment
First line treatment for Graves disease is usually medical and the block and replace regime is
the favored option. Carbimazole is administered at higher doses and thyroxine is
administered orally. Patient are maintained on this regime for between 6 and 12 months.
Attempts are then made to wean off medication. Where relapse then occurs the options are
between ongoing medical therapy, radioiodine or surgery.
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Question stats
End and review
Score: 41.7%
1
2
Theme: Thyroid disorders

A. Sick euthyroid
74
73.3%
75
84.6%
76
25.8%
B. Hyperthyroidism
3
4
5
C. Hypothyroidism
D. Normal euthyroid
Search
E. Anxiety state
7-9 1 / 3
Go
F. Factitious hyperthyroidism
10
11
For each of the scenarios please match the scenario with the most likely underlying
diagnosis. Each answer may be used once, more than once or not at all.
12
13
14
15
74.
A 33 year old man is recovering following a protracted stay on the intensive

care unit recovering from an anastomotic leak following a difficult trans hiatal
oesophagectomy. His progress is slow, and the intensive care doctors receive
the following thyroid function test results:
TSH
1.0 u/L
16
17
18
19-21 1 / 3
Free T4 8
22
T3
23
1.0 (1.2-3.1 normal)
24
25
You answered Hypothyroidism
26
The correct answer is Sick euthyroid
27

Sick euthyroid syndrome is caused by systemic illness. With this, the patient
may have an apparently low total and free T4 and T3, with a normal or low
TSH. Note that the levels are only mildly below normal.
75.
A 28 year old female presents to the general practitioner with symptoms of

fever and diarrhoea. As part of her diagnostic evaluation the following thyroid
function tests are obtained:
TSH
< 0.01
29
30
31
32
33
34
Free T4 30
T3
28
35
4.0
36
37
You answered Sick euthyroid
38
39
The correct answer is Hyperthyroidism
40
The symptoms are suggestive of hyperthyroidism. This is supported by the

abnormal blood results; suppressed TSH with an elevated T3 and T4.
41
42-44 0 / 3
76.
A 19 year old lady presents with palpitations. The medical officer takes a blood
sample for thyroid function tests. The following results are obtained:
TSH
45
46
> 6.0
47
Free T4 20
48
T3
2.0
49
50
You answered Hyperthyroidism
51
52
The correct answer is Hypothyroidism
53
An elevated TSH with normal T4 indicates partial thyroid failure. This is caused
by Hashimotos, drugs (lithium, antithyroids) and dyshormogenesis.
54
55
56
Next question
57
58-60 1 / 3
Hyperthyroidism
61
62
63
Causes of hyperthyroidism include:
64
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Diffuse toxic goitre (Graves Disease)

Toxic nodule
Rare causes
65
66
67
68-70 3 / 3
71
Graves disease
Graves disease is characterised by a diffuse vascular goitre that appears at the same time
as the clinical manifestations of hyperthyroidism. It is commonest in younger females and
may be associated with eye signs. Thyrotoxic symptoms will predominate. Up to 50% of
patients will have a familial history of autoimmune disorders. The glandular hypertrophy and
hyperplasia occur as a result of the thyroid stimulating effects of the TSH receptor
antibodies.
72
73
74-76 0 / 3

In this disorder the goitre is present for a long period of time prior to the development of
clinical symptoms. In most goitres the nodules are inactive and in some cases it is the
internodular tissue that is responsible for the goitre.
Toxic nodule
Overactive, autonomously functioning nodule. It may occur as part of generalised nodularity
or be a true toxic adenoma. The TSH levels are usually low as the autonomously functioning
thyroid tissue will exert a negative feedback effect.
Signs and symptoms
Symptoms
Signs
Lethargy
Tachycardia
Emotionally labile
Agitation
Heat intolerance
Hot, moist palms
Weight loss
Exopthalmos
Excessive appetite
Thyroid goitre and bruit
Palpitations
Lid lag/retraction
Diagnosis
The most sensitive test for diagnosing hyperthyroidism is plasma T3 (which is raised). Note in
hypothyroidism the plasma T4 and TSH are the most sensitive tests. A TSH level of <0.5U/L
suggests hyperthyroidism. TSH receptor antibodies may be tested for in the diagnosis of
Graves.
Treatment
First line treatment for Graves disease is usually medical and the block and replace regime is
the favored option. Carbimazole is administered at higher doses and thyroxine is
administered orally. Patient are maintained on this regime for between 6 and 12 months.
Attempts are then made to wean off medication. Where relapse then occurs the options are
between ongoing medical therapy, radioiodine or surgery.
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Question 1 of 78
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Question stats
Score: 100%
22.1%
23.3%
14.4%
A. Vitiligo
14.2%
B. Molluscum contagiosum
26%
C. Lichen planus

question correctly
Which of the following conditions is least likely to exhibit the Koebner phenomenon?
D. Psoriasis
End and review
E. Lupus vulgaris
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Lupus vulgaris is not associated with the Koebner phenomenon.

Koebner phenomenon
The Koebner phenomenon describes skin lesions which appear at the site of injury. It is seen
in:
Psoriasis
Vitiligo
Warts
Lichen planus
Lichen sclerosus
Molluscum contagiosum
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Question 3 of 78
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A 20 year old man is suspected of having an inflamed Meckels diverticulum. At which of the
following locations is it most likely to be found?
A. Approximately 60 cm distal to the ileo-caecal valve

B. Approximately 60 cm proximal to the ileocaecal valve
Question stats
End and review
Score: 66.7%
1
16.9%
52.4%
10%
12%
8.7%

question correctly
C. Approximately 200cm distal to the ileocaecal valve

D. Approximately 200cm proximal to the ileocaecal valve
E. 50cm distal to the DJ flexure
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Rule of 2's
2% of population
2 inches (5cm) long
2 feet (60 cm) from the ileocaecal valve
2 x's more common in men
2 tissue types involved
They are typically found 2 feet proximal to the ileocaecal valve (or approximately 60cm).

Clinical
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Next
A 43 year old lady presents with severe chest pain. Investigations demonstrate a dissecting
aneurysm of the ascending aorta which originates at the aortic valve. What is the optimal
long term treatment?
Question stats
End and review
Score: 50%
1
15.3%
11.2%
8.8%
14.9%
49.7%
A. Endovascular stent
question correctly
B. Medical therapy with beta blockers

C. Medical therapy with ACE inhibitors
D. Sutured aortic repair
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E. Aortic root replacement
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Proximal aortic dissections are generally managed with surgical aortic root replacement. The
proximal origin of the dissection together with chest pain (which may occur in all types of
aortic dissection) raises concerns about the possibility of coronary ostial involvement (which
precludes stenting). There is no role for attempted suture repair in this situation.
Aortic dissection
More common than rupture of the abdominal aorta

33% of patients die within the first 24 hours, and 50% die within 48 hours if no
treatment received
Associated with hypertension
Features of aortic dissection: tear in the intimal layer, followed by formation and
propagation of a subintimal hematoma. Cystic medial necrosis (Marfan's)
Most common site of dissection: 90% occurring within 10 centimetres of the aortic
valve
Stanford Classification
Type
Location
Treatment
Ascending aorta/ aortic root
Surgery- aortic root replacement
Descending aorta
Medical therapy with antihypertensives
DeBakey classification
Type
Site affected
Ascending aorta, aortic arch, descending aorta
II
Ascending aorta only
III
Descending aorta distal to left subclavian artery
Clinical features
Tearing, sudden onset chest pain (painless 10%)
Hypertension or Hypotension
A blood pressure difference greater than 20 mm Hg
Neurologic deficits (20%)
Investigations
CXR: widened mediastinum, abnormal aortic knob, ring sign, deviation of the
trachea/oesophagus
CT angiography of the thoracic aorta
MRI angiography
Conventional angiography (now rarely used diagnostically)
Management
Beta-blockers: aim HR 60-80 bpm and systolic BP 100-120 mm Hg
For type A dissections the standard of care is aortic root replacement
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Question 5 of 78
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A 45 year old lady presents with a pathological fracture of her femoral shaft. She is a poor
historian, but it transpires that she underwent a thyroidectomy 1 year previously. She has no
other illness or co-morbidities. What is the most likely underlying diagnosis?
Question stats
End and review
Score: 40%
1
9.9%
8.5%
14%
58.6%
9%
A. Hyperparathyroidism
question correctly
B. Metastatic papillary carcinoma of the thyroid

C. Metastatic medullary carcinoma of the thyroid
D. Metastatic follicular carcinoma of the thyroid
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Next question
Follicular carcinomas are a recognised cause of bone metastasis. Papillary lesions typically
spread via the lymphatics.
Thyroid malignancy
Papillary carcinoma
Commonest sub-type
carcinoma
Medullary carcinoma
Lymphoma
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Question 6-8 of 78
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Question stats
End and review
Score: 50%
1
2
Theme: Cardiac murmurs

A. Pulmonary stenosis
74.9%
59.6%
55.6%
B. Mitral regurgitation
3
4
5
C. Tricuspid regurgitation
6-8 2 / 3
D. Aortic stenosis
Search
E. Mitral stenosis
Go
F. Aortic sclerosis
What is the most likely cause of the cardiac murmur in the following patients? Each option
6.
A 35 year old Singaporean female attends a varicose vein pre operative clinic.
On auscultation a mid diastolic murmur is noted at the apex. The murmur is
enhanced when the patient lies in the left lateral position.
Mitral stenosis
A mid diastolic murmur at the apex is a classical description of a mitral stenosis
murmur. The most common cause is rheumatic heart disease. Complications of
mitral stenosis include atrial fibrillation, stroke, myocardial infarction and infective
endocarditis.
7.
A 22 year old intravenous drug user is found to have a femoral abscess. The
nursing staff contact the on call doctor as the patient has a temperature of
39oC. He is found to have a pan systolic murmur loudest at the left sternal edge
at the 4th intercostal space.
Tricuspid regurgitation
Intravenous drug users are at high risk of right sided cardiac valvular
endocarditis. The character of the murmur fits with a diagnosis of tricuspid valve
endocarditis.
8.
An 83 year old woman is admitted with a left intertrochanteric neck of femur

fracture. On examination the patient is found to have an ejection systolic murmur
loudest in the aortic region. There is no radiation of the murmur to the carotid
arteries. Her ECG is normal.
You answered Aortic stenosis
The correct answer is Aortic sclerosis
The most likely diagnosis is aortic sclerosis. The main differential diagnosis is of
aortic stenosis, however as there is no radiation of the murmur to the carotids
and the ECG is normal, this is less likely.
Next question
Cardiac murmurs
Type of Murmur
Conditions
Ejection systolic
Aortic stenosis
Pulmonary stenosis, HOCM
ASD, Fallot's
Pan-systolic
Mitral regurgitation
Tricuspid regurgitation
VSD
Late systolic
Mitral valve prolapse

Coarctation of aorta
Early diastolic
Aortic regurgitation
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Graham-Steel murmur (pulmonary regurgitation)

Mid diastolic
Mitral stenosis
Austin-Flint murmur (severe aortic regurgitation)
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Question 9 of 78
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A 55 year old lady presents with discomfort in the right breast. On clinical examination a small
lesion is identified and clinical appearances suggest fibroadenoma. Imaging confirms the
presence of a fibroadenoma alone. A core biopsy is taken, this confirms the presence of the
fibroadenoma. However, the pathologist notices that a small area of lobular carcinoma in situ
is also present in the biopsy. What is the best management?
Question stats
Score: 55.6%
1
6.6%
12.4%
13.5%
43.3%
24.2%

question correctly
A. Whole breast irradiation
End and review
5
6-8 2 / 3
9
B. Simple mastectomy
C. Mastectomy and sentinal lymph node biopsy
Search
D. Wide local excision and sentinel lymph node biopsy
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E. Breast MRI scan

Next question
Lobular carcinoma in situ has a low association with invasive malignancy. It is seldom
associated with microcalcification and therefore MRI is the best tool for determining disease
extent. Resection of in situ disease is not generally recommended and most surgeons would
simply pursue a policy of close clinical and radiological follow up.
Lobular carcinoma of the breast
Lobular breast cancers are less common than their ductal counterparts. They typically
present differently, the mass is usually more diffuse and less obvious on the usual imaging
modalities of ultrasound and mammography. This is significant since the disease may be
understaged resulting in inadequate treatment when wide local excision is undertaken.
In women with invasive lobular carcinoma it is usually safest to perform an MRI scan of the
breast, if breast conserving surgery is planned.
Lobular carcinomas are also more likely to be multifocal and metastasise to the contralateral
breast.
Lobular carcinoma in situ is occasionally diagnosed incidentally on core biopsies. Unlike
DCIS, lobular carcinoma in situ is far less strongly associated with foci of invasion and is
usually managed by close monitoring.
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Question 10 of 78
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Which one of the following may be associated with an increased risk of venous
thromboembolism?
A. Diabetes
B. Cannula
Question stats
Score: 50%
1
16.9%
17.2%
9.5%
45.8%
10.6%

question correctly
C. Hyperthyroidism
End and review
D. Tamoxifen
5
6-8 2 / 3
9
10
E. Amiodarone
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Consider thromboembolism in breast cancer patients on tamoxifen!

Venous thromboembolism: risk factors
Common predisposing factors include malignancy, pregnancy and the period following an
operation. The comprehensive list below is partly based on the 2010 SIGN venous
thromboembolism (VTE) guidelines:
General
increased risk with advancing age
obesity
family history of VTE
pregnancy (especially puerperium)
immobility
hospitalisation
anaesthesia
central venous catheter: femoral >> subclavian
Underlying conditions
malignancy
thrombophilia: e.g. Activated protein C resistance, protein C and S deficiency
heart failure
antiphospholipid syndrome
Behcet's
polycythaemia
nephrotic syndrome
sickle cell disease
paroxysmal nocturnal haemoglobinuria
hyperviscosity syndrome
homocystinuria
Medication
combined oral contraceptive pill: 3rd generation more than 2nd generation
hormone replacement therapy
raloxifene and tamoxifen
antipsychotics (especially olanzapine) have recently been shown to be a risk factor
SIGN also state that the following are risk factors for recurrent VTE:
previous unprovoked VTE
male sex
obesity
thrombophilias
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Question 11 of 78
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A 42 year old lady is investigated for symptoms of irritability and altered bowel habit. On
examination she is noted to have a smooth enlargement of the thyroid gland. As part of her
investigations thyroid function tests are requested, these are as follows:
Question stats
End and review
Score: 45.5%
1
10.5%
9.1%
65.5%
7.5%
7.4%
TSH
0.1 mug/l
Free T4
35 pmol/l

question correctly
The most likely underlying diagnosis is:
5
6-8 2 / 3
9
10
11
Search
A. Multinodular goitre
B. Follicular carcinoma of the thyroid gland
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C. Graves disease
D. Pregnancy
Next question
TSH receptor antibodies will cause stimulation of the thyroid to synthesise T4. However, this
will have a negative feedback effect on the pituitary causing decrease in TSH levels.
Where hyperthyroidism occurs secondary to pregnancy the TSH is typically elevated.
Thyroid disease
Patients may present with a number of different manifestations of thyroid disease. They can
be broadly sub classified according to whether they are euthyroid or have clinical signs of
thyroid dysfunction. In addition it needs to be established whether they have a mass or not.
Assessment
History
Examination including USS
If a nodule is identified then it should be sampled ideally via an image guided fine
needle aspiration
Radionucleotide scanning is of limited use
Thyroid Tumours
Papillary carcinoma
Medullary carcinoma
Lymphoma's
Multinodular goitre
One of the most common reasons for presentation
Provided the patient is euthyroid and asymptomatic and no discrete nodules are seen,
they can be reassured.
In those with compressive symptoms surgery is required and the best operation is a
total thyroidectomy.
Sub total resections were practised in the past and simply result in recurrent disease
that requires a difficult revisional resection.
Endocrine dysfunction
In general these patients are managed by physicians initially.
Surgery may be offered alongside radio iodine for patients with Graves disease that
fails with medical management or in patients who would prefer not to be irradiated (e.g.
pregnant women).
Patients with hypothyroidism do not generally get offered a thyroidectomy. Sometimes
people inadvertently get offered resections during the early phase of Hashimotos
thyroiditis, however, with time the toxic phase passes and patients can simply be
managed with thyroxine.
Complications following surgery

Anatomical such as recurrent laryngeal nerve damage.
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Bleeding. Owing to the confined space haematoma's may rapidly lead to respiratory
compromise owing to laryngeal oedema.
Damage to the parathyroid glands resulting in hypocalcaemia.
Further sources of information

1. http://www.acb.org.uk/docs/TFTguidelinefinal.pdf- Association of Clinical Biochemistry
guidelines for thyroid function tests.
2. British association of endocrine surgeons website- http://www.baets.org.uk
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Question 12 of 78
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End and review
Score: 50%
1
26.5%
7.4%
9.8%
A. Gastrectomy
7.3%
B. Solid organ transplantation with immunosupression
48.9%
C. Intravenous drug use

question correctly
Which of the following is not a risk factor for developing tuberculosis?
D. Haematological malignancy
5
6-8 2 / 3
9
10
E. Amiodarone
11
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12
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Risk factors for developing active tuberculosis include:

silicosis
chronic renal failure
HIV positive
solid organ transplantation with immunosuppression
intravenous drug use
haematological malignancy
anti-TNF treatment
previous gastrectomy
Tuberculosis
Tuberculosis (TB) is an infection caused by Mycobacterium tuberculosis that most commonly
affects the lungs. Understanding the pathophysiology of TB can be difficult - the key is to
differentiate between primary and secondary disease.
Primary tuberculosis
A non-immune host who is exposed to M. tuberculosis may develop primary infection of the
lungs. A small lung lesion known as a Ghon focus develops. The Ghon focus is composed of
tubercle-laden macrophages. The combination of a Ghon focus and hilar lymph nodes is
known as a Ghon complex
In immunocompetent people the initial lesion usually heals by fibrosis. Those who are
immunocompromised may develop disseminated disease (miliary tuberculosis).
Secondary (post-primary) tuberculosis
If the host becomes immunocompromised the initial infection may become reactivated.
Reactivation generally occurs in the apex of the lungs and may spread locally or to more
distant sites. Possible causes of immunocomprise include:
immunosuppressive drugs including steroids
HIV
malnutrition
The lungs remain the most common site for secondary tuberculosis. Extra-pulmonary
infection may occur in the following areas:
central nervous system (tuberculous meningitis - the most serious complication)
vertebral bodies (Pott's disease)
cervical lymph nodes (scrofuloderma)
renal
gastrointestinal tract
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Score: 46.2%
1
14.3%
6.9%
53.4%
A. There is an association with blood group A
10%
B. Adenocarcinoma is the most common subtype
15.3%
C. Individuals with histological evidence of signet ring cells have a lower

incidence of lymph node metastasis

question correctly
Which of the following is not true of gastric cancer?
D. Lymphomas account for 5% cases
5
6-8 2 / 3
9
10
E. In Western Countries a more proximal disease distribution has been

noted
11
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12
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13
Signet ring cells are features of poorly differentiated gastric cancer associated with a
increased risk of metastatic disease.
Gastric cancer
Overview
Pathology
Type
1
Type
2

Type
3
gastric cancer.

Atrophic gastritis
following
Patients without
dyspepsia
Worsening dyspepsia
Dysphagia
Barretts oesophagus
Dysphagia
Unexplained
abdominal pain or
weight loss
Weight loss
Vomiting
Dysplasia
Upper abdominal
mass
Atrophic gastritis
Jaundice

dyspepsia
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Staging
Treatment
usual
undertaken.
Prognosis
UK Data
Disease extent
All RO resections
54%
91%
Stage 1
87%
Stage 2
65%
Stage 3
18%
Operative procedure
General anaesthesia
Incision: Rooftop.
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Question 14 of 78
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End and review
Score: 42.9%
1
5.1%
9.1%
14.9%
A. Parapharyngeal mass
26.7%
B. Mass at anterior border of masseter
44.2%
C. Mass inferior to the angle of the mandible

question correctly
What is the most common presentation of a parotid gland tumour?
D. Mass behind the angle of the mandible
5
6-8 2 / 3
9
10
E. Mass anterior to the ear
11
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12
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13
Parotid tumours may present at any region in the gland. However, most lesions will be
located behind the angle of the mandible, inferior to the ear lobe. Tumours of the deep lobe
of the parotid may present as a parapharyngeal mass and large lesions may displace the
tonsil.
14
Parotid gland malignancy
Most parotid neoplasms (80%) are benign lesions

Most commonly present with painless mass around the mandible
Up to 30% may present with pain, when this is associated with a discrete mass lesion
in the parotid it usually indicates perineural invasion.
Perineural invasion is very unlikely to occur in association with benign lesions
80% of patients with facial nerve weakness caused by parotid malignancies will have
nodal metastasis and a 5 year survival of 25%
Types of malignancy
Mucoepidermoid
carcinoma

mainly on grade)
Adenoid cystic
carcinoma

5 year survival 35%
Mixed tumours
Acinic cell
carcinoma

5 year survival 80%
Adenocarcinoma

5 year survival depends upon stage at presentation, may be up to 75% with
small lesions with no nodal involvement
Lymphoma

resection Treatment is with chemotherapy (and radiotherapy)
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Question 15 of 78
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A 52 year old male is referred to urology clinic with impotence. He is known to have
hypertension. He does not have any morning erections. On further questioning the patient
reports pain in his buttocks, this worsens on mobilising. On examination there is some muscle
atrophy. The penis and scrotum are normal. What is the most likely diagnosis?
Question stats
Score: 40%
1
48%
19.2%
15.1%
7.1%
10.6%

question correctly
A. Leriche syndrome
End and review
5
6-8 2 / 3
9
B. S3-S4 cord lesion

10
C. Pudendal nerve lesion

11
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D. Psychological impotence
12
E. Beta blocker induced impotence
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13
14
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15
Leriche syndrome
Classically, it is described in male patients as a triad of symptoms:
1. Claudication of the buttocks and thighs
2. Atrophy of the musculature of the legs
3. Impotence (due to paralysis of the L1 nerve)
Leriche syndrome, is atherosclerotic occlusive disease involving the abdominal aorta and/or
both of the iliac arteries. Management involves correcting underlying risk factors such as
hypercholesterolaemia and stopping smoking. Investigation is usually with angiography.
Leriche syndrome
Atheromatous disease involving the iliac vessels. Blood flow to the pelvic viscera is
compromised. Patients may present with buttock claudication and impotence (in this
particular syndrome). Diagnostic work up will include angiography, where feasible, iliac
occlusions are usually treated with endovascular angioplasty and stent insertion.
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Question 16 of 78
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A 23 year old man presents with diarrhoea and passage of mucous. He is suspected of
having ulcerative colitis. Which of the following is least likely to be associated with this
condition?
Question stats
Score: 37.5%
1
9.8%
8.5%
40.7%
10.9%
30%
A. Superficial mucosal inflammation in the colon

question correctly
B. Significant risk of dysplasia in long standing disease
End and review
C. Epsiodes of large bowel obstruction during acute attacks
5
6-8 2 / 3
9
10
D. Haemorrhage
11
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E. Disease sparing the anal canal
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13
14
Large bowel obstruction is not a feature of UC, patients may develop megacolon. However,
this is a different entity both diagnostically and clinically. Ulcerative colitis does not affect the
anal canal and the anal transitional zone. Inflammation is superficial. Dysplasia can occur in
2% overall, but increases significantly if disease has been present over 20 years duration.
Granulomas are features of crohn's disease.
15
16
Other features:
Disease maximal in the rectum and may spread proximally
Contact bleeding
Longstanding UC crypt atrophy and metaplasia/dysplasia
Ulcerative colitis
include:
bloody diarrhoea
urgency
tenesmus

spondylitis.
Notes
Related to
disease
activity

Erythema nodosum
Episcleritis
Osteoporosis

Crohns disease
Unrelated to
disease
activity

Uveitis
Clubbing

Pathology
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Barium enema
Endoscopy
ulceration pattern.
Management
References
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Question 17 of 78
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A 23 year old lady undergoes a total thyroidectomy as treatment for a papillary carcinoma of
the thyroid. The pathologist examines histological sections of the thyroid gland and identifies
a psammoma body. What are these primarily composed of?
Question stats
Score: 41.2%
1
46.3%
10.3%
16.8%
17.4%
9.2%
A. Clusters of calcification
question correctly
B. Aggregations of neutrophils
End and review
C. Aggregations of macrophages
5
6-8 2 / 3
9
10
D. Giant cells surrounding the tumour
11
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E. Clusters of oxalate crystals
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14
15
Psammoma bodies consist of clusters of microcalcification. They are most commonly seen in
papillary carcinomas.
16
17
Thyroid malignancy
Papillary carcinoma
Commonest sub-type
carcinoma
Medullary carcinoma
Lymphoma
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Question 18 of 78
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A 52 year old woman attends clinic for investigation of abdominal pain and constipation. On
examination you note blue lines on the gum margin. She mentions that her legs have
become weak in the past few days. What is the most likely diagnosis?
Question stats
Score: 44.4%
1
24.2%
53.6%
5.7%
9.8%
6.6%
A. Acute intermittent porphyria

question correctly
B. Lead poisoning
End and review
C. Constipation
5
6-8 2 / 3
9
10
D. Guillan Barre syndrome
11
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E. Rectal carcinoma
12
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13
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14
15
This would be an impressive diagnosis to make in the surgical out patient department! The
combination of abdominal pain and a motor periperal neuropathy, should indicate this
diagnosis. The blue line along the gum margin can occur in up to 20% patients with lead
poisoning.
16
17
18
Lead poisoning
Along with acute intermittent porphyria, lead poisoning should be considered in questions
giving a combination of abdominal pain and neurological signs
Features
abdominal pain
peripheral neuropathy (mainly motor)
fatigue
constipation
blue lines on gum margin (only 20% of adult patients, very rare in children)
Investigations
The blood lead level is usually used for diagnosis. Levels greater than 10 mcg/dl are
considered significant
Full blood count: microcytic anaemia. Blood film shows red cell abnormalities including
basophilic stippling and clover-leaf morphology
Raised serum and urine levels of delta aminolaevulinic acid may be seen making it
sometimes difficult to differentiate from acute intermittent porphyria
Urinary coproporphyrin is also increased (urinary porphobilinogen and uroporphyrin
levels are normal to slightly increased)
Management - various chelating agents are currently used:

Dimercaptosuccinic acid (DMSA)
D-penicillamine
EDTA
Dimercaprol
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End and review
Score: 52.4%
1
2
Theme: Vasculitis
A. Wegeners granulomatosis
19
74.6%
20
82.5%
21
77.7%
B. Polyarteritis nodosa
3
4
5
C. Giant cell arteritis
6-8 2 / 3
D. Takayasu's arteritis
Search
E. Buergers disease
Go
For each of the scenarios provided please select the most likely underlying diagnosis from
the list below. Each option may be used once, more than once or not at all.
10
11
12
13
14
19.
A 20 year old lady is referred to the vascular clinic. She has been feeling
generally unwell for the past six weeks. She works as a typist and has noticed
increasing pain in her forearms whilst working. On examination she has absent
upper limb pulses. Her ESR is measured and mildly elevated.
15
16
17
18
19-21 3 / 3
Takayasus arteritis may be divided into acute systemic phases and the chronic
pulseless phase. In the latter part of the disease process the patient may
complain of symptoms such as upper limb claudication. In the later stages of
the condition the vessels will typically show changes of intimal proliferation,
together with band fibrosis of the intima and media.
20.
A 32 year old man presents to the vascular clinic with symptoms of foot pain
during exertion. He is a heavy smoker and has recently tried to stop smoking.
On examination he has normal pulses to the level of the popliteal. However,
foot pulses are absent. A diagnostic angiogram is performed which shows an
abrupt cut off at the level of the anterior tibial artery, together with the
formation of corkscrew shaped collateral vessels distally.
Buergers disease
Buergers disease is most common in young male smokers. This demographic
is changing in those areas where young female smokers are more common. In
the acute lesion the internal elastic lamina of the vessels is usually intact. As
the disease progresses the changes progress to hypercellular occlusive
thrombus. Tortuous corkscrew collaterals may reconstitute patent segments of
the distal tibial or pedal vessels.
21.
A 78 year old man presents with symptoms of headaches and deteriorating

vision. He notices that there is marked pain on the right hand side of his face
when he combs his hair.
Giant cell arteritis
Temporal arteritis may present acutely with symptoms of headache and visual
loss, or with a less acute clinical picture. Sight may be threatened and
treatment with immunosupressants should be started promptly. The often
requested temporal artery biopsy (which can be the bane of many surgeons) is
often non diagnostic and unhelpful.
Next question
Vasculitis
The vasculitides are a group of conditions characterised by inflammation of the blood vessel
walls. This may, in turn, compromise vessel integrity. Constitutional symptoms may be
present. Whilst certain disease subtypes are reported to affect specific vessels, there is
often a degree of overlap clinically.
Vessel diameter and vasculitis classification
Aorta and branches
Buergers disease
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Large and medium sized arteries
Medium sized muscular arteries
Small muscular arteries
Buergers disease
Polyarteritis nodosa
Polyarteritis nodosa
Wegeners granulomatosis
Wegeners granulomatosis
Rheumatoid vasculitis
Specific conditions
Takyasu's arteritis
Buergers disease
Polyarteritis
nodosa
Wegeners
granulomatosis
Inflammatory, obliterative arteritis affecting aorta and branches

Females> Males
Symptoms may include upper limb claudication
Clinical findings include diminished or absent pulses
ESR often affected during the acute phase
Segmental thrombotic occlusions of the small and medium sized

lower limb vessels
Commonest in young male smokers
Proximal pulses usually present, but pedal pulses are lost
An acuter hypercellular occlusive thrombus is often present
Tortuous corkscrew shaped collateral vessels may be seen on
angiography
Systemic granulomatous arteritis that usually affects large and

medium sized vessels
Females > Males
Temporal arteritis is commonest type
Granulomatous lesions may be seen on biopsy (although up to
50% are normal)
Systemic necrotising vasculitis affecting small and medium sized

muscular arteries
Most common in populations with high prevalence of hepatitis B
Renal disease is seen in 70% cases
Angiography may show saccular or fusiform aneurysms and
arterial stenoses
Predominantly affects small and medium sized arteries

Systemic necrotising granulomatous vasculitis
Cutaneous vascular lesions may be seen (ulceration, nodules
and purpura)
Sinus imaging may show mucosal thickening and air fluid levels
Treatment
Conditions such as Buergers disease are markedly helped by smoking cessation.
Immunosupression is the main treatment for vasculitides.
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Question 22 of 78
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End and review
Score: 50%
1
53.6%
8.7%
13.1%
11.7%
A. First line treatment is with pentavalent antimony.
12.9%
B. Peritoneal contamination with active daughter cysts may complicate

surgery.

question correctly
A 28 year old man presents with right upper quadrant pain and hydatid disease is suspected.
Which of the following statements relating to the disease is untrue?
C. CT scanning of the liver may show a floating membrane.
5
6-8 2 / 3
9
10
D. Biliary communication with the cysts may occur.
11
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E. It is caused by Echinococcus granulosus.
12
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13
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Drug treatment is with albendazole or mebendazole. Praziquantzel may be used in the pre
operative stages.
15
16
17
Hydatid cysts
18
19-21 3 / 3
Hydatid cysts are endemic in Mediterranean and Middle Eastern countries. They are caused
by the tapeworm parasite Echinococcus granulosus. An outer fibrous capsule is formed
containing multiple small daughter cysts. These cysts are allergens which precipitate a type
1 hypersensitivity reaction.
22
Clinical features are as follows:

Up to 90% cysts occur in the liver and lungs
Can be asymtomatic, or symptomatic if cysts > 5cm in diameter
Morbidity caused by cyst bursting, infection and organ dysfunction (biliary, bronchial,
renal and cerebrospinal fluid outflow obstruction)
In biliary ruputure there may be the classical triad of; biliary colic, jaundice, and
urticaria
CT is the best investigation to differentiate hydatid cysts from amoebic and pyogenic cysts.
Surgery is the mainstay of treatment (the cyst walls must not be ruptured during removal and
the contents sterilised first).
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Question 23 of 78
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End and review
Score: 47.8%
1
19.4%
19.7%
14.6%
A. Produce nitrogen peroxide as a microbicidal agent
29.6%
B. Not involved in opsonisation
16.7%
C. Deficiency leads to AIDS

question correctly
Which of the following statements relating to neutrophil polymorphs is true?
D. Neutrophil disorders cause chronic granulomatous diseases
5
6-8 2 / 3
9
10
E. Have a lifespan of 9 hours
11
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12
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13
Neutrophils are the main cells of acute inflammation, important action against gram -ve
and +ve bacteria
Appearance of segmented nucleus and granulated cytoplasm
Have a lifespan of 1-3 days (shorter when consumed during septic process, though 9
hours is unusual)
Actions include: movement, opsonise microorganisms, phagocytosis & intracellular
killing of microorganisms via aerobic (produce HYDROGEN PEROXIDE) & anaerobic
mechanisms.
Neutrophil disorders include chronic granulomatous diseases: rare
AIDS associated with T cell deficiency
14
15
16
17
18
19-21 3 / 3
22
23
Acute inflammation
Vascular changes
proteins.
Sequelae
Resolution
Organisation
Suppuration
inflammation




Causes
Chemical agents
Tissue necrosis
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inflammation
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Question 24 of 78
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A 33 year old man is involved in a road traffic accident. He is initially stable and transferred
to the accident and emergency department. On arrival he is catheterised. One minute later
he becomes hypotensive, with evidence of angioedema surrounding his penis. What is the
most likely explanation for this event?
Question stats
Score: 50%
1
8%
12.8%
7.5%
63.4%
8.3%

question correctly
A. Type V latex hypersensitivity reaction
End and review
5
6-8 2 / 3
9
B. Type IV latex hypersensitivity reaction

10
C. Type III latex hypersensitivity reaction

11
Search
D. Type I latex hypersensitivity reaction
12
E. Type II latex hypersensitivity reaction
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13
14
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15
Theme from January 2013 exam

Sudden collapse and angioedema following exposure to latex (of which most urinary
catheters are manufactured) suggests a type I hypersensitivity reaction.
16
17
18
19-21 3 / 3
22
23
24
Type I
Type II
Type III
Type IV
Description
Anaphylactic
Cytotoxic
Immune
complex
Delayed type
Mediator
IgE
IgG, IgM
IgG, Ig A,
IgM
T-cells
Antigen
Exogenous
Cell surface
Soluble
Tissues
Response
time
Minutes
Hours
Hours
2-3 days
Examples
Asthma
Hay fever
anaemia
Pemphigus
Goodpasture's
Serum
sickness
SLE
Aspergillosis
Graft versus host

disease
Contact dermatitis
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Question 25 of 78
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A 43 year old female develops severe chest wall cellulitis following a mastectomy. On
examination the skin is markedly erythematous. Which of the acute inflammatory mediators
listed below is least likely to produce vasodilation?
Question stats
Score: 48%
1
17.9%
21.2%
14.3%
31.4%
15.3%
A. Complement component C5a

question correctly
B. Lysosomal compounds
End and review
C. Histamine
5
6-8 2 / 3
9
10
D. Serotonin
11
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E. Prostaglandins
12
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13
14
Erythema is a classical feature of acute inflammation. Potent mediators of vascular dilatation

include; histamine, prostaglandins, nitric oxide, platelet activating factor, complement C5a
(and C3a) and lysosomal compounds. Although serotonin is associated with acute
inflammation it is a vasoconstrictor. The effects of serotonin are dependent upon the state of
the vessels in the tissues. Intact and healthy tissues and vessels will respond to a serotonin
infusion with vasodilation (hence the flushing seen in carcinoid syndrome). In contrast it
worsens cardiac ischaemia in myocardial infarcts when released from damaged platelets.
15
16
17
18
19-21 3 / 3
22
23
Acute inflammation
24
25
Vascular changes
proteins.
Sequelae
Resolution
Organisation
Suppuration
inflammation




Causes
Chemical agents
Tissue necrosis

inflammation
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Question 26 of 78
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A 43 year old man presents with a 3 week history of malaise, sore throat, odynophagia and
dysphagia. On examination he is found to have patchy white spots in his oropharynx. An
upper GI endoscopy is performed and similar lesions are identified in the oesophagus. Which
investigation is most likely to identify the underlying pathology in this case?
Question stats
Score: 50%
1
6.8%
22.4%
15.8%
11.9%
43.1%

question correctly
A. Serum urea and electrolytes
End and review
5
6-8 2 / 3
9
B. Oesophageal biopsy for culture

10
C. Oesophageal biopsy for histology

11
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D. Glucose tolerance testing
12
E. Viral serology
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13
14
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15
Oesophageal candidiasis is associated with immunosupression; mainly in patients on

chemotherapy, with haematological malignancy, HIV or inhaled steroids. In patients with HIV,
oesophageal candidiasis is part of the spectrum of AIDS defining illnesses and usually
occurs when the CD4 count is less than 200. Others include PCP pneumonia and CMV
infections.
16
17
18
19-21 3 / 3
22
Oesophageal candidiasis
23
24
Characterised by white spots in the oropharynx with extension into the oesophagus.
Associated with broad spectrum antibiotic usage, immunosupression and immunological
disorders.
Patients may present with oropharyngeal symptoms, odynophagia and dysphagia.
Treatment is directed both at the underlying cause (which should be investigated for) and
with oral antifungal agents.
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Question stats
End and review
Score: 48.3%
1
2
Theme: Colonic obstruction

A. Malignant obstruction
27
77.4%
28
82.4%
29
63.4%
B. Ogilvies syndrome
3
4
5
C. Volvulus
6-8 2 / 3
D. Diverticular stricture
Search
E. Ischaemic stricture
Go
Please select the most likely cause of obstruction for the situation described. Each option
10
11
12
13
14
27.
A 78 year old man has undergone a hemi-arthroplasty for a intracapsular hip

fracture. Post operatively he develops electrolyte derangement and receives
intravenous fluids. Over the previous 24 hours he develops marked abdominal
distension. On examination he has a tense, tympanic abdomen which is not
painful. A contrast enema shows flow of contrast through to the caecum and
through the ileocaecal valve.
15
16
17
18
19-21 3 / 3
You answered Volvulus
22
23
The correct answer is Ogilvies syndrome
24
Patients with electrolyte disturbance and previous surgery may develop colonic
pseudo-obstruction (Ogilvies syndrome). The diagnosis is made using a
contrast enema and treatment is usually directed at the underlying cause with
colonic decompression if indicated.
28.
25
26
27-29 1 / 3
A 67 year old man has had multiple episodes with fever and left iliac fossa pain.
These have usually resolved with courses of intravenous antibiotics. He is
admitted with a history of increasing constipation and abdominal distension. A
contrast x-ray is performed which shows flow of contrast to the sigmoid colon,
here the contrast flows through a long narrow segment of colon into dilated
proximal bowel.
Diverticular stricture
The long history of left iliac fossa pain and development of bowel obstruction
suggests a diverticular stricture. These may contain a malignancy and most will
require resection.
29.
A 78 year old lady from a nursing home is admitted with a 24 hour history of
absolute constipation and abdominal pain. On examination she has a
distended abdomen with a soft mass in her left iliac fossa. An x-ray is
performed which shows a large dilated loop of bowel in the left iliac fossa which
contains a fluid level.
You answered Ogilvies syndrome
The correct answer is Volvulus
Sigmoid volvulus may present with an asymmetrical mass in an elderly patient.
It may contain a fluid level, visible on plain films.
Next question
Colonic obstruction
Cause
Cancer
Features
Usually insidious onset
History of progressive constipation
Systemic features (e.g. anaemia)
Abdominal distension
Absence of bowel gas distal to site of
obstruction
Diverticular
Treatment
Establish diagnosis (e.g.
contrast enema/
endoscopy)
Laparotomy and resection,
stenting, defunctioning
colostomy or bypass
Once diagnosis
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Diverticular
stricture
Volvulus
Acute
colonic
pseudoobstruction
Usually history of previous acute

diverticulitis
Long history of altered bowel habit
Evidence of diverticulosis on imaging or
endoscopy
Twisting of bowel around its mesentery

Sigmoid colon affected in 76% cases
Patients usually present with abdominal
pain, bloating and constipation
Examination usually shows asymmetrical
distension
Plain X-rays usually show massively dilated
sigmoid colon, loss of haustra and "U"
shape are typical, the loop may contain fluid
levels
Symptoms and signs of large bowel

obstruction with no lesion
Usually associated with metabolic disorders
Usually a cut off in the left colon (82%
cases)
Although abdomen tense and distended, it
is usually not painful
All patients should undergo contrast enema
(may be therapeutic!)
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Once diagnosis
established, usually
surgical resection
Colonic stenting should not
be performed for benign
disease
Initial treatment is to
untwist the loop, a flexible
sigmoidoscopy may be
needed
Those with clinical evidence
of ischaemia should
undergo surgery
Patient with recurrent
volvulus should undergo
resection
Colonoscopic
decompression
Correct metabolic disorders
IV neostigmine
Surgery
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Question 30 of 78
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A 52 year old man with dyspepsia is found to have a duodenal ulcer. A CLO test is taken and
is positive. Which statement relating to the likely causative organism is false?
A. It is a gram negative organism

B. It preferentially colonises gastric type mucosa
Question stats
Score: 46.7%
1
15.9%
22.6%
12.4%
37.7%
11.3%

question correctly
C. It may occupy areas of ectopic gastric metaplasia
End and review
D. In patients who are colonised there is commonly evidence of fundal

gastritis on endoscopy
5
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11
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E. It produces a powerful urease that forms the basis of the Clo test
12
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13
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14
15
Helicobacter pylori accounts for >75% cases of duodenal ulceration. It may be diagnosed
with either serology, microbiology, histology or CLO testing.
16
17
18

Helicobacter pylori rarely produces any typical features on endoscopy. Where infection is
suspected the easiest course of action is to take an antral biopsy for Clo testing in the
endoscopy suite.
19-21 3 / 3
22
23
24
Helicobacter Pylori
25
Infection with Helicobacter Pylori is implicated in many cases of duodenal ulceration and up
to 60% of patients with gastric ulceration.
26
27-29 1 / 3
30
It is a gram negative, helical shaped rod with microaerophillic requirements. It has the ability
to produce a urease enzyme that will hydrolyse urea resulting in the production of ammonia.
The effect of ammonia on antral G cells is to cause release of gastrin via a negative
feedback loop.
Once infection is established the organism releases enzymes that disrupt the gastric mucous
layer. Certain subtypes release cytotoxins cag A and vac A gene products. The organism
incites a classical chronic inflammatory process of the gastric epithelium. This accounts for
the development of gastric ulcers. The mildly increased acidity may induce a process of
duodenal gastric metaplasia. Whilst duodenal mucosa cannot be colonised by H-Pylori,
mucosa that has undergone metaplastic change to the gastric epithelial type may be
colonised by H- Pylori with subsequent inflammation and development of duodenitis and
ulcers.
In patients who are colonised there is a 10-20% risk of peptic ulcer, 1-2% risk gastric cancer
and <1% risk MALT lymphoma.
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Question 31 of 78
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A 34 year old male presents with painful rectal bleeding and a fissure in ano is suspected.
On examination he has an epithelial defect at the mucocutaenous junction that is located
anteriorly. Approximately what proportion of patients with fissure in ano will present with this
pattern of disease?
Question stats
Score: 45.2%
1
22.3%
39.2%
11.8%
18.8%
7.9%

question correctly
A. 90%
End and review
5
6-8 2 / 3
9
B. 10%
10
C. 50%
11
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D. 25%
12
E. 100%
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13
14
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15
Only a minority of patients with fissure in ano will have an anteriorly sited fissure. They are
particularly rare in males and an anterior fissure in a man should prompt a search for an
underlying cause.
16
17
18
19-21 3 / 3
Anal fissure
22
Anal fissures are a common cause of painful, bright red, rectal bleeding.
Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior
midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly
if they are multiparous. Multiple fissures and those which are located at other sites are more
likely to be due to an underlying cause.
Diseases associated with fissure in ano include:
23
24
25
26
27-29 1 / 3
Crohns disease
Tuberculosis
Internal rectal prolapse
30
31
Diagnosis
In most cases the defect can be visualised as a posterior midline epithelial defect. Where
symptoms are highly suggestive of the condition and examination findings are unclear an
examination under anaesthesia may be helpful. Atypical disease presentation should be
investigated with colonoscopy and EUA with biopsies of the area.
Treatment
Stool softeners are important as the hard stools may tear the epithelium and result in
recurrent symptoms. The most effective first line agents are topically applied GTN (0.2%) or
Diltiazem (2%) paste. Side effects of diltiazem are better tolerated.
Resistant cases may benefit from injection of botulinum toxin or lateral internal
sphincterotomy (beware in females). Advancement flaps may be used to treat resistant
cases.
Sphincterotomy produces the best healing rates. It is associated with incontinence to flatus in
up to 10% of patients in the long term.
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Question 32 of 78
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Question stats
End and review
Score: 46.9%
1
44%
8.5%
29%
A. Osteoclast function
9.4%
B. PTH receptors
9.1%
C. Osteoblast function

question correctly
The pathogenesis of osteopetrosis is best explained by a defect in which of the following?
D. Calcium resorption in proximal tubule
5
6-8 2 / 3
9
10
E. Calcium absorption
11
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12
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13
14
15
Osteopetrosis
16
Overview
17
18
Also known as marble bone disease

Rare disorder of defective osteoclast function resulting in failure of normal bone
resorption
Stem cell transplant and interferon-gamma have been used for treatment
19-21 3 / 3
22
23
24
25
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27-29 1 / 3
30
31
32
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Question 33 of 78
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A 13 month old boy is brought to the surgical clinic by his mother because his left testicle is
not located in the scrotum. At which of the following sites would the testicle be located if it
were an ectopic testis?
Question stats
Score: 45.5%
1
17.4%
25%
15.3%
32.1%
10.1%
A. Canalicular
question correctly
B. Inguinal
End and review
C. External inguinal ring
5
6-8 2 / 3
9
10
D. Superficial inguinal pouch
11
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E. High scrotal
12
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13
14

September 2013
Ectopic testes are those that come to lie outside the normal range of embryological descent
(i.e. in the superficial inguinal pouch). Other sites of ectopic testes include; base of penis,
femoral and perineal.
15
16
17
18
19-21 3 / 3
22
Testicular disorders-paediatric
23
Testicular disorders are some of the commonest conditions present in paediatric urological
practice.
24
25
26
27-29 1 / 3
Cryptorchidism
30
The embryological descent of the testicle from within the abdominal cavity may be
subject to a number of variations. Distinctions need to be made clinically from a non
descended testis and a testis that is retractile.
Testis that lie outside the normal path of embryological descent are termed ectopic
testis. Undescended testis occurs in 1% of male infants. Where the testis does not lie
in an intra scrotal location, its location should be ascertained. Where both testes are
absent, the infant may be intersex.
MRI scanning may reveal intra-abdominal testes; however a GA is often needed to
perform this investigation in this age group.
Testes that are undescended should be placed in the scrotum after 1 year of age, as
the testosterone surge that may facilitate descent occurs at 6 months of age.
Where the testes lie distally e.g. Superficial inguinal pouch an open orchidopexy is the
procedure of choice.
With abdominal testes a laparoscopy should be performed. The risk of seminoma is
increased in individuals with a non descended testes and this risk is not reduced by
orchidopexy.
31
32
33
Testicular torsion
Typically the patient has severe sudden onset of scrotal pain. The difficulty in
paediatric practice is the lack of clear history.
On examination the testis is tender and enlarged.
Management is by surgical exploration.
Delay beyond 6 hours is associated with low salvage rates.
A torted hyatid produces pain that is far more localised and the testis itself should feel
normal. However, diagnostic doubt often exists and in such cases surgical exploration
is warranted.
Hydrocele
Occur secondary to patent processus vaginalis
Present as fluid filling in scrotum or as cyst of the spermatic cord
Communicating hydroceles are treated by a trans inguinal ligation of the PPV
Cystic hydroceles in older children may be treated with scrotal exploration
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Question 34 of 78
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Which of the following is seen more commonly with Crohns disease rather than ulcerative
colitis?
A. Mucosal islands at endoscopy

B. Goblet cell depletion on biopsy
Question stats
Score: 47.1%
1
21.7%
12.6%
36.4%
19.2%
10.1%

question correctly
C. Fat wrapping of the terminal ileum
End and review
D. Attenuated symptoms in smokers
5
6-8 2 / 3
9
10
E. Toxic megacolon
11
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12
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13
14
Crohns disease is worse in smokers and smoking is an independent risk factor for
disease recurrence following resection.
15
16
17
Fat wrapping of the terminal ileum is commonly seen in patients with ileal disease (the
commonest disease site). The mesenteric fat in patients with IBD is often dense, hard and
prone to considerable haemorrhage during surgery. At endoscopy, the mucosa in patients
with Crohns disease is said to resemble cobblestones, mucosal islands (pseudopolyps) are
seen in ulcerative colitis.
18
19-21 3 / 3
22
23
24
Crohns disease
25

26
27-29 1 / 3
30
31
32
33

34
Crohn's disease
Ulcerative colitis
Distribution
Mouth to anus
Rectum and colon
Macroscopic
changes
Contact bleeding
Depth of
disease
Distribution
pattern
Patchy
Continuous
Histological
features



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Question 35 of 78
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Question stats
End and review
Score: 45.7%
1
7.2%
25.6%
7.7%
A. Pneumococcus
48.5%
B. Klebsiella
11%
C. Haemophilus influenzae

question correctly
A splenectomy increases the risk of infection from all the following organisms except?
D. Staphylococcus aureus
5
6-8 2 / 3
9
10
E. Neisseria meningitidis
11
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13
14
15
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.
16
17
18
19-21 3 / 3
Hyposplenism may complicate certain medical conditions where splenic atrophy occurs or
may be the result of medical intervention such as splenic artery embolization and
splenectomy for trauma. Diagnosis of hyposplenism is difficult and whilst there may be
peripheral markers of the splenectomised state (e.g. Howell Jolly bodies) these are neither
100% sensitive or specific. The most sensitive test is a radionucleotide labeled red cell scan.
Hyposplenism, by whatever mechanism it occurs dramatically increases the risk of post
splenectomy sepsis, particularly with encapsulated organisms. Since these organisms may
be opsonised, but this then goes undetected at an immunological level due to loss of the
spleen. For this reason individuals are recommended to be vaccinated and have antibiotic
prophylaxis.
22
23
24
25
26
27-29 1 / 3
30
31
32
Key recommendations
33
All those with hyposplenism or may become so (such as prior to an elective

splenectomy) should receive pneumococcal, haemophilus type b and meningococcal
type C vaccines. These should be administered 2 weeks prior to splenectomy or two
weeks following splenectomy. The vaccine schedule for meningococcal disease
essentially consists of a dose of Men C and Hib at 2 weeks and then a dose of the
MenACWY vaccine one month later. Those aged under 2 may require a booster at 2
years. A dose of pneumococcal polyvalent polysaccharide vaccine (PPV) is given at
two weeks. A conjugated vaccine (PCV) is offered to young children. The PCV is more
immunogenic but covers fewer serotypes. Boosting PPV is either guided by serological
measurements (where available) or by routine boosting doses at 5 yearly intervals.
Annual influenza vaccination is recommended in all cases
Antibiotic prophylaxis is offered to all. The risk of post splenectomy sepsis is greatest
immediately following splenectomy and in those aged less than 16 years or greater
than 50 years. Individuals with a poor response to pneumococcal vaccination are
another high risk group. High risk individuals should be counselled to take penicillin or
macrolide prophylaxis. Those at low risk may choose to discontinue therapy. All
patients should be advised about taking antibiotics early in the case of intercurrent
infections.
Asplenic individuals traveling to malaria endemic areas are at high risk and should
have both pharmacological and mechanical protection.
34
35
Dosing
Penicillin V 500mg BD or amoxicillin 250mg BD
References
Davies J et al. Review of guidelines for the prevention and treatment of infection in patients
with an absent or dysfunctional spleen: Prepared on behalf of the British Committee for
Standards in Haematology by a Working Party of the Haemato-Oncology Task Force. British
Journal of Haematology 2011 (155): 308317.
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Question 36 of 78
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Question stats
End and review
Score: 47.2%
1
14.2%
21%
10.2%
A. Iritis
42.2%
B. Clubbing
12.4%
C. Aphthous ulcers

question correctly
Which of the following is not an extraintestinal feature Crohns disease?
D. Erythema multiforme
5
6-8 2 / 3
9
10
E. Pyoderma gangrenosum
11
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12
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13
Extraintestinal manifestation of inflammatory bowel disease: A PIE SAC
14
15
Aphthous ulcers
Iritis
Erythema nodosum
Sclerosing cholangitis
Arthritis
Clubbing
16
17
18
19-21 3 / 3
22
23
24
25
Crohns disease
26
27-29 1 / 3

30
31
32
33
34
35

Crohn's disease
Ulcerative colitis
Distribution
Mouth to anus
Rectum and colon
Macroscopic
changes
Contact bleeding
Depth of
disease
Distribution
pattern
Patchy
Continuous
Histological
features


36

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Question 37 of 78
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Which of the following is not considered a risk factor for the development of oesophageal
malignancy?
A. Oesophageal metaplasia
B. Smoking
Question stats
Score: 48.6%
1
9.1%
7.8%
7.3%
14.1%
61.8%

question correctly
C. Excessive intake of alcoholic spirits
End and review
D. Achalasia
5
6-8 2 / 3
9
10
E. Blood group O
11
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13
14
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.
15
16
Oesophageal cancer
17
18
cases.
adenocarcinoma.
19-21 3 / 3
22
23
24
25
26
27-29 1 / 3
30
31
Diagnosis
32
33

is unnecessary
performed.
34
35
36
37
Treatment
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Question stats
End and review
Score: 50%
1
2
Theme: Thyroid blood testing

A. Measurement of antibodies to TSH receptor
38
87%
39
64.3%
40
61%
B. Thyroid peroxidase antibodies
3
4
5
C. Thyroglobulin antibodies
6-8 2 / 3
D. Serum calcitonin
Search
Please select the blood test most commonly performed for the diagnosis or assessment of
the thyroid disorder described. Each answer may be used once, more than once or not at all.
Go
10
11
12
13
38.
A 32 year old lady is diagnosed with Medullary carcinoma of the thyroid and
has undergone resection of the tumour.
14
15
16
Serum calcitonin
Measurement of basal or stimulated calcitonin concentrations is used to assess
the completeness of surgical resection, and is of use in detecting diseases
recurrences during follow up.
17
18
19-21 3 / 3
22
39.
A 20 year old lady has undergone a total thyroidectomy for a well differentiated
papillary carcinoma. She attends clinic and is well and the surgeon wishes to
screen for disease recurrence.
23
24
25
You answered Thyroid peroxidase antibodies
26
The correct answer is Thyroglobulin antibodies
27-29 1 / 3
Antibodies to thyroglobulin, the major constituent of colloid and precursor of

thyroid hormones may be elevated in those with metastatic or recurrent thyroid
cancer. Results may be erronoeous in those with other thyroid disorders.
40.
A 33 year old lady presents with a recently diagnosed goitre and a diagnosis of
Hashimotos thyroiditis is suspected.
30
31
32
33
34
35
Thyroid peroxidase antibodies
36
Antibodies to thyroid peroxidase are found in most patients with Graves

disease or Hashimotos thyroiditis.
37
38-40 2 / 3
Next question
Blood testing in thyroid disease
Assay
Usage
Thyroid peroxidase
(microsomal)
antibodies
Found in autoimmune disease affecting the thyroid (Hashimotos

100%) and Graves (70%)
Antibodies to TSH
receptor
Individuals with Graves disease (95%)
Thyroglobulin
antibodies
Calcitonin
Not useful for clinically distinguishing between different types of

thyroid disease, may be used as part of thyroid cancer follow up
Released from the parafollicular cells

Usually found in patients with medullary carcinoma of the thyroid
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Question 41 of 78
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Question stats
End and review
Score: 48.8%
1
10%
22.8%
10.7%
A. Right heart failure
18.9%
B. Aortic regurgitation
37.7%
C. Eisenmenger's complex

question correctly
Which one of the following complications is least associated with ventricular septal defects?
D. Infective endocarditis
5
6-8 2 / 3
9
10
E. Atrial fibrillation
11
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12
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13
Atrial fibrillation is associated more with atrial septal defects
14
15
Ventricular septal defect
16
Ventricular septal defects are the most common cause of congenital heart disease. They
close spontaneously in around 50% of cases. Non-congenital causes include post
myocardial infarction
17
18
19-21 3 / 3
Features
22
23
classically a pan-systolic murmur which is louder in smaller defects
24
25
Complications
26
aortic regurgitation*
infective endocarditis
Eisenmenger's complex
right heart failure
27-29 1 / 3
30
31
32
*aortic regurgitation is due to a poorly supported right coronary cusp resulting in cusp
prolapse
33
34
35
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37
38-40 2 / 3
41
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Question 42 of 78
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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?
Question stats
Score: 50%
1
8%
72.3%
5.7%
7.4%
6.6%

question correctly
A. Gram stain
End and review
5
6-8 2 / 3
9
B. Ziehl-Neelsen stain
10
C. Von Kossa stain

11
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D. Van Gieson stain
12
E. Masson Trichrome stain
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13
14
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15
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.
16
17
18
19-21 3 / 3
22
23

histiocytes.
24
25
26
27-29 1 / 3
30
31
32
33
34
Diagnosis
35
36
37
38-40 2 / 3
41
42
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Question 43 of 78
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Question stats
End and review
Score: 48.8%
1
39.7%
14%
8.8%
A. Resemblance to ductal epithelial cells
26%
B. Angiogenesis
11.5%
C. Nuclear pleomorphism

question correctly
Which of the following is not a pathological feature of breast cancer?
D. Metastatic calcification
5
6-8 2 / 3
9
10
E. Vascular invasion
11
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12
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13
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.
14
15
16
17
18
Breast cancer pathology
19-21 3 / 3
The histological features of breast cancer depend upon the underlying diagnosis. The
invasive component is usually comprised of ductal cells (unless it is an invasive lobular
cancer). In situ lesions may co-exist (such as DCIS).
22
23
24
Typical changes seen in conjunction with invasive breast cancer include:

1. Nuclear pleomorphism
2. Coarse chromatin
3. Angiogenesis
4. Invasion of the basement membrane
5. Dystrophic calcification (may be seen on mammography)
6. Abnormal mitoses
7. Vascular invasion
8. Lymph node metastasis
25
26
27-29 1 / 3
30
31
32
33
34
The primary tumour is graded on a scale of 1-3 where 1 is the most benign lesion and 3 the
most poorly differentiated.
35
36
Immunohistochemistry for oestrogen receptor and herceptin status is routinely performed.
37
38-40 2 / 3
The grade, lymph node stage and size are combined to provide the Nottingham prognostic
index.
41
42
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Question stats
End and review
Score: 42.9%
1
2
Theme: Renal lesions

A. Renal cell carcinoma
44
73.4%
45
73.8%
46
48%
B. Renal transitional cell carcinoma
3
4
5
C. Nephroblastoma
6-8 2 / 3
D. Neuroblastoma
Search
E. Angiomyolipoma
Go
10
F. Renal squamous cell carcinoma
11
G. Retroperitoneal fibrosis
12
For each scenario please select the most likely underlying diagnosis. Each option may be
13
14
15
16
44.
A 69 year old male presents with haematuria. He worked in the textile industry.
He has a left flank mass. A CT IVU shows a lesion of the left renal pelvis.
17
18
19-21 3 / 3
You answered Renal cell carcinoma
22
The correct answer is Renal transitional cell carcinoma
23
TCC is a rare form of renal cancer, accounting for approximately 7% of all renal
tumours. Risk factors include exposure to chemicals in the textile, plastic and
rubber industry.
24
25
26
45.
A 2 year old boy presents with a right renal mass. On examination he has an
irregular mass arising from the right flank and is hypertensive. A CT scan
shows a non calcified irregular lesion affecting the apex of the right kidney and
the right adrenal gland.
27-29 1 / 3
30
31
32
You answered Neuroblastoma
46.
33
The correct answer is Nephroblastoma
34
Wilm's tumour of the kidney is the most common renal tumour in children. Both
nephroblastoma and neuroblastoma may occupy the adrenal and apex of the
kidney. In the case of neuroblastoma the lesion will have arisen from the
adrenal, in the case of nephroblastoma the lesion will have arisen from the
kidney. Hypertension is more commonly associated with nephroblastoma.
Neuroblastomas are usually calcified, whereas nephroblastomas are not and
this may be of diagnostic usefulness pre operatively.
35
A 35 year old male presents with haematuria. He is found to have bilateral

masses in the flanks. He has a history of epilepsy and learning disability.
36
37
38-40 2 / 3
41
42
43
44-46 0 / 3
You answered Retroperitoneal fibrosis

The correct answer is Angiomyolipoma
This patient has tuberous sclerosis. This is associated with angiomyolipoma,
which is present in 60-80% patients. It is a benign lesion.
Next question
Renal lesions
Lesion
Renal cell
carcinoma

(50%)
cases)
Most commonly has
Treatment
nephrectomy
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Nephroblastoma
Neuroblastoma
Transitional cell
carcinoma
Angiomyolipoma


tumour of childhood
years of age
gland)
MIBG scanning
Staging is with CT

renal tumours
females
haematuria
IVU

tuberous sclerosis
10% of cases
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doxorubicin)

and chemotherapy

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Question 47 of 78
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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. What is the most likely underlying diagnosis?
Question stats
Score: 42%
1
55.4%
10.2%
6.2%
21.2%
7%
A. Urethral valves
question correctly
B. Meatal stenosis
End and review
C. Hydronephrosis
5
6-8 2 / 3
9
10
D. Pelvico-ureteric junction obstruction
11
Search
E. Benign prostatic hyperplasia
12
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13
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14
15

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.
16
17
18
19-21 3 / 3
Urethral valves
22
Posterior urethral valves are the commonest cause of infravesical outflow obstruction in
males. They may be diagnosed on ante natal ultrasonography. Because the bladder has to
develop high emptying pressures in utero, the child may develop renal parenchymal
damage. This translates to renal impairment noted in 70% of boys at presentation.
Treatment is with bladder catheterisation. Endoscopic valvotomy is the definitive treatment of
choice with cystoscopic and renal follow up.
23
24
25
26
27-29 1 / 3
30
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31
32
33
34
35
36
37
38-40 2 / 3
41
42
43
44-46 0 / 3
47
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At which of the following anatomical sites does dormant tuberculosis most frequently
reactivate?
A. Apex of the lung

B. Base of the lung
Question stats
Score: 43.1%
1
64.8%
10.3%
7.1%
8.4%
9.4%

question correctly
C. Brain
End and review
D. Terminal ileum
5
6-8 2 / 3
9
10
E. Lumbar spine
11
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12
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13
14
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.
15
16
17
18
19-21 3 / 3

histiocytes.
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Diagnosis
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Question 49 of 78
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Question stats
End and review
Score: 44.2%
1
9.1%
70.7%
7.3%
7.1%
B. Adenocarcinoma
5.8%
C. Lymphoma

question correctly
What is the commonest tumour type encountered in the colon?
D. Anaplastic carcinoma
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6-8 2 / 3
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E. Sarcoma
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12
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13
Adenocarcinoma are the most common and typically arise as a result of the adenoma carcinoma sequence.
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Colorectal cancer
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Annually about 150,000 new cases are diagnosed and 50,000 deaths from the
disease
About 75% will have sporadic disease and 25% will have a family history
Colorectal tumours comprise a spectrum of disease ranging from adenomas through
to polyp cancers and frank malignancy.
Polyps may be categorised into: neoplastic polyps, adenomatous polyps and non
neoplastic polyps.
The majority of adenomas are polypoidal lesions, although flat lesions do occur and
may prove to be dysplastic.
Non-neoplastic polyps include hyperplastic, juvenile, hamartomatous, inflammatory,
and lymphoid polyps, which have not generally been thought of as precursors of
cancer.
Three characteristics of adenomas that correlate with malignant potential have been
characterised. These include increased size, villous architecture and dysplasia. For
this reason most polyps identified at colonoscopy should be removed.
The transformation from polyp to cancer is described by the adenoma - carcinoma
sequence and its principles should be appreciated. Essentially genetic changes
accompany the transition from adenoma to carcinoma; key changes include APC, cmyc, K RAS mutations and p53 deletions.
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Question 50 of 78
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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?
A. Transmural aortitis
B. Cystic medial necrosis
Question stats
Score: 45.3%
1
21.5%
35.3%
14.4%
17.4%
11.4%

question correctly
C. Foamy macrophages
End and review
D. Dense dystrophic calcification
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12
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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.
Go
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Aortic dissection
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More common than rupture of the abdominal aorta

33% of patients die within the first 24 hours, and 50% die within 48 hours if no
treatment received
Associated with hypertension
Features of aortic dissection: tear in the intimal layer, followed by formation and
propagation of a subintimal hematoma. Cystic medial necrosis (Marfan's)
Most common site of dissection: 90% occurring within 10 centimetres of the aortic
valve
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Stanford Classification
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Type
Location
Treatment
Ascending aorta/ aortic root
Surgery- aortic root replacement
Descending aorta
Medical therapy with antihypertensives
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DeBakey classification
Type
Site affected
Ascending aorta, aortic arch, descending aorta
II
Ascending aorta only
III
Descending aorta distal to left subclavian artery
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Clinical features
50
Tearing, sudden onset chest pain (painless 10%)

Hypertension or Hypotension
A blood pressure difference greater than 20 mm Hg
Neurologic deficits (20%)
Investigations
CXR: widened mediastinum, abnormal aortic knob, ring sign, deviation of the
trachea/oesophagus
CT angiography of the thoracic aorta
MRI angiography
Conventional angiography (now rarely used diagnostically)
Management
Beta-blockers: aim HR 60-80 bpm and systolic BP 100-120 mm Hg
For type A dissections the standard of care is aortic root replacement
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Question 51 of 78
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A 58 year old man undergoes an upper GI endoscopy for the investigation of odynophagia.
At endoscopy a reddish area is seen to protrude up into the oesophagus from the
gastrooesophageal junction. Which of the following pathological events is most likely to
explain this process?
Question stats
Score: 44.4%
1
47.9%
7.2%
25.5%
6.4%
13%

question correctly
A. Metaplasia
End and review
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6-8 2 / 3
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B. Anaplasia
10
C. Dysplasia
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D. Hypoplasia
12
E. Hyperplasia
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Next question
15
This is most likely to represent Barretts oesphagus and is thus metaplasia. Dysplasia is less
likely in this setting although biopsies are mandatory.
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Barrett's oesophagus
19-21 3 / 3
Barretts oesophagus is a condition characterised by the metaplastic transformation of

squamous oesophageal epithelium to columnar gastric type epithelium. Three types of this
metaplastic process are recognised; intestinal (high risk), cardiac and fundic. The latter two
categories may cause difficulties in diagnosis. The most concrete diagnosis can be made
when endoscopic features of Barretts oesophagus are present together with a deep biopsy
that demonstrates not just goblet cell metaplasia but also oesophageal glands.
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Barrett's can be sub divided into short (<3cm) and long (>3cm). The length of the affected
segment correlates strongly with the chances of identifying metaplasia. The overall
prevalence of Barrett's oesophagus is difficult to determine but may be in the region of 1 in
20 and is identified in up to 12% of those undergoing endoscopy for reflux.
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33
A proportion of patients with metaplasia will progress to dysplasia and for this reason
individuals identified as having Barrett's should undergo endoscopic surveillance (every 2-5
years). Biopsies should be quadrantic and taken at 1-2cm intervals. Biopsies need to be
adequate. Where mass lesions are present consideration should be given to endoscopic sub
mucosal resection. Up to 40% of patients will be upstaged from high grade dysplasia to
invasive malignancy with such techniques.
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Treatment
41
Long term proton pump inhibitor

Consider pH and manometry studies in younger patients who may prefer to consider
an anti reflux procedure
Regular endoscopic monitoring (more frequently if moderate dysplasia). With
quadrantic biopsies every 2-3 cm
If severe dysplasia be very wary of small foci of cancer
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49
References
A consensus statement of the British approach is provided by:
Bennett C et al Consensus Statements for Management of Barrett's Dysplasia and EarlyStage Esophageal Adenocarcinoma, Based on a Delphi Process. Gastroenterology Volume
143, Issue 2 , Pages 336-346, August 2012.
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Question 52 of 78
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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?
Question stats
Score: 45.5%
1
13.6%
11.5%
45.8%
14.6%
14.6%
A. Intestinal malrotation
question correctly
B. Hiatus hernia
End and review
C. Foramen of Bochdalek hernia
5
6-8 2 / 3
9
10
D. Foramen of Morgagni hernia
11
Search
E. Tracheo-oesphageal fistula
12
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13
14
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.
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Embryology of the diaphragm and diaphragmatic hernia
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Embryology
The diaphragm is formed between the 5th and 7th weeks of gestation through the
progressive fusion of the septum transversum, pleuroperitoneal folds and via lateral
muscular ingrowth. The muscular origins of the diaphragm are somites located in cervical
segments 3 to 5, which accounts for the long path taken by the phrenic nerve. The
components contribute to the following diaphragmatic segments:
Septum transversum - Central tendon
Pleuroperitoneal membranes - Parietal membranes surrounding viscera
Cervical somites C5 to C7 - Muscular component of the diaphragm
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Diaphragmatic hernia
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Type of hernia
Features
Morgagni
Anteriorly located
Minimal compromise on lung development
Minimal signs on antenatal ultrasound
Usually present later
Usually good prognosis
Bochdalek hernia
Posteriorly located
Larger defect
Often diagnosed antenatally
Associated with pulmonary hypoplasia
Poor prognosis
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48
The posterior hernias of Bochdalek are the most common type and if not diagnosed
antenatally will typically present soon after birth with respiratory distress. The classical
finding is that of a scaphoid abdomen on clinical examination because of herniation of the
abdominal contents into the chest. Bochdalek hernias are associated with a number of
chromosomal abnormalities such as Trisomy 21 and 18. Infants have considerable
respiratory distress due to hypoplasia of the developing lung. Historically this was considered
to be due to direct compression of the lung by herniated viscera. This view over simplifies the
situation and the pulmonary hypoplasia occurs concomitantly with the hernial development,
rather than as a direct result of it. The pulmonary hypoplasia is associated with pulmonary
hypertension and abnormalities of pulmonary vasculature. The pulmonary hypertension
renders infants at risk of right to left shunting (resulting in progressive and worsening
hypoxia).
Diagnostic work up of these infants includes chest x-rays/ abdominal ultrasound scans and
cardiac echo.
Surgery forms the mainstay of treatment and both thoracic and abdominal approaches may
be utilised. Following reduction of the hernial contents a careful search needs to be made for
a hernial sac as failure to recognise and correct this will result in a high recurrence rate.
Smaller defects may be primarily closed, larger defects may require a patch to close the
defect. Malrotation of the viscera is a recognised association and may require surgical
correct at the same procedure (favoring an abdominal approach).
The mortality rate is 50-75% and is related to the degree of lung compromise and age at
presentation (considerably better in infants >24 hours old).
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Question 53 of 78
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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?
Question stats
Score: 44.6%
1
14.7%
33.8%
11.8%
13.9%
25.8%

question correctly
A. Non union of the fracture
End and review
5
6-8 2 / 3
9
B. Angiogenesis at the fracture site

10
C. Increased numbers of fibroblasts at the fracture site

11
Search
D. Osteochondritis dissecans
12
E. Apoptosis of osteoblasts
Go
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Next question
15
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.
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Avascular necrosis
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23
Cellular death of bone components due to interruption of the blood supply, causing
bone destruction
Main joints affected are hip, scaphoid, lunate and the talus.
It is not the same as non union. The fracture has usually united.
Radiological evidence is slow to appear.
Vascular ingrowth into the affected bone may occur. However, many joints will develop
secondary osteoarthritis.
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31
Causes
P ancreatitis
L upus
A lcohol
S teroids
T rauma
I diopathic, infection
C aisson disease, collagen vascular disease
R adiation, rheumatoid arthritis
A myloid
G aucher disease
S ickle cell disease
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Presentation
Usually pain. Often despite apparent fracture union.
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Investigation
MRI scanning will show changes earlier than plain films.
49
50
Treatment
In fractures at high risk sites anticipation is key. Early prompt and accurate reduction is
essential.
51
52
53
Non weight bearing may help to facilitate vascular regeneration.

Joint replacement may be necessary, or even the preferred option (e.g. Hip in the elderly).
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Question 54 of 78
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Which one of the following is least associated with the development of colorectal cancer in
patients with ulcerative colitis?
A. Unremitting disease
B. Disease duration > 10 years
Question stats
Score: 45.6%
1
14.8%
9.2%
13.3%
12.2%
50.5%

question correctly
C. Onset before 15 years old
End and review
D. Poor compliance to treatment
5
6-8 2 / 3
9
10
E. Disease confined to the rectum
11
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13
14
15
Ulcerative colitis and colorectal cancer
16
17
Overview
18
risk of colorectal cancer is 10-20 times that of general population

the increased risk is mainly related to chronic inflammation
worse prognosis than patients without ulcerative colitis (partly due to delayed
diagnosis)
lesions may be multifocal
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25
Factors increasing risk of cancer
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disease duration > 10 years

patients with pancolitis
onset before 15 years old
unremitting disease
poor compliance to treatment
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Question stats
End and review
Score: 45%
1
2
Theme: Causes of chest pain

A. Pulmonary embolism
55
51.3%
56
76.3%
57
77%
B. Anterior myocardial infarction
3
4
5
C. Inferior myocardial infarction
6-8 2 / 3
D. Proximal aortic dissection
Search
E. Distal aortic dissection
Go
10
F. Boerhaave Syndrome
11
G. Mallory weiss tear
12
H. Perforated gastric ulcer
13
Please select the most likely cause of chest pain for the scenario given. Each option may be
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55.
A 52 year old male presents with tearing central chest pain. On examination he
has an aortic regurgitation murmur. An ECG shows ST elevation in leads II, III
and aVF.
18
19-21 3 / 3
22
You answered Inferior myocardial infarction
23
24
The correct answer is Proximal aortic dissection
25

An inferior myocardial infarction and AR murmur should raise suspicions of an
ascending aorta dissection rather than an inferior myocardial infarction alone.
Also the history is more suggestive of a dissection. Other features may include
pericardial effusion, carotid dissection and absent subclavian pulse.
26
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56.
A 52 year old male presents with central chest pain and vomiting. He has drunk
a bottle of vodka. On examination there is some mild crepitus in the epigastric
region.
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33
34
Boerhaave Syndrome
35
The Mackler triad for Boerhaave syndrome: vomiting, thoracic pain,

subcutaneous emphysema. It commonly presents in middle aged men with a
background of alcohol abuse.
57.
A 52 year old male presents with central chest pain. On examination he has an
mitral regurgitation murmur. An ECG shows ST elevation in leads V1 to V6.
There is no ST elevation in leads II, III and aVF.
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You answered Pulmonary embolism
47
The correct answer is Anterior myocardial infarction
48
The most likely diagnosis is an anterior MI. As there are no ST changes in the
inferior leads, aortic dissection is less likely.
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51
Next question
52
53
54
Chest pain
55-57 1 / 3
Aortic dissection
This occurs when there is a flap or filling defect within the aortic intima. Blood tracks
into the medial layer and splits the tissues with the subsequent creation of a false
lumen. It most commonly occurs in the ascending aorta or just distal to the left
subclavian artery (less common). It is most common in Afro-carribean males aged 5070 years.
Patients usually present with a tearing intrascapular pain, which may be similar to the
pain of a myocardial infarct.
The dissection may spread either proximally or distally with subsequent disruption to
the arterial branches that are encountered.
In the Stanford classification system the disease is classified into lesions with a
proximal origin (Type A) and those that commence distal to the left subclavian (Type
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B).
Diagnosis may be suggested by a chest x-ray showing a widened mediastinum.
Confirmation of the diagnosis is usually made by use of CT angiography
Proximal (Type A) lesions are usually treated surgically, type B lesions are usually
managed non operatively.
Pulmonary embolism
Typically sudden onset of chest pain, haemoptysis, hypoxia and small pleural effusions
may be present.
Most patients will have an underlying deep vein thrombosis
Diagnosis may be suggested by various ECG findings including S waves in lead I, Q
waves in lead III and inverted T waves in lead III. Confirmation of the diagnosis is
usually made through use of CT pulmonary angiography.
Treatment is with anticoagulation, in those patients who develop a cardiac arrest or
severe compromise from their PE, consideration may be given to thrombolysis.
Myocardial infarction
Traditionally described as sudden onset of central, crushing chest pain. It may radiate
into the neck and down the left arm. Signs of autonomic dysfunction may be present.
The presenting features may be atypical in the elderly and those with diabetes.
Diagnosis is made through identification of new and usually dynamic ECG changes
(and cardiac enzyme changes). Inferior and anterior infarcts may be distinguished by
the presence of specific ECG changes (usually II, III and aVF for inferior, leads V1-V5
for anterior).
Treatment is with oral antiplatelet agents, primary coronary angioplasty and/ or
thrombolysis.
Perforated peptic ulcer

Patients usually develop sudden onset of epigastric abdominal pain, it may be soon
followed by generalised abdominal pain.
There may be features of antecendant abdominal discomfort, the pain of gastric ulcer
is typically worse immediately after eating.
Diagnosis may be made by erect chest x-ray which may show a small amount of free
intra-abdominal air (very large amounts of air are more typically associated with
colonic perforation).
Treatment is usually with a laparotomy, small defects may be excised and overlaid with
an omental patch, larger defects are best managed with a partial gastrectomy.
Boerhaaves syndrome
Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes
of vomiting.
The rupture is usually distally sited and on the left side.
Patients usually give a history of sudden onset of severe chest pain that may
complicate severe vomiting.
Severe sepsis occurs secondary to mediastinitis.
Diagnosis is CT contrast swallow.
Treatment is with thoracotomy and lavage, if less than 12 hours after onset then
primary repair is usually feasible, surgery delayed beyond 12 hours is best managed
by insertion of a T tube to create a controlled fistula between oesophagus and skin.
Delays beyond 24 hours are associated with a very high mortality rate.
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Question 58 of 78
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Next
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.
Question stats
Score: 44.3%
1
5.9%
63.6%
10%
12.6%
8%
A. Thrombophlebitis of the great saphenous vein

question correctly
B. Femoral hernia
End and review
C. Thrombophlebitis of saphena varix
5
6-8 2 / 3
9
10
D. Inguinal hernia
11
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E. Obturator hernia
12
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Next question
13
14

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.
Femoral canal
15
16
17
18
19-21 3 / 3
The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a
fascial tunnel containing both the femoral artery laterally and femoral vein medially. The
canal lies medial to the vein.
22
23
24
Borders of the femoral canal

Laterally
Femoral vein
25
26
27-29 1 / 3
Medially
Lacunar ligament
Anteriorly
Inguinal ligament
Posteriorly
Pectineal ligament
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33
Image showing dissection of femoral canal
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Contents
Lymphatic vessels
Cloquet's lymph node
Physiological significance
Allows the femoral vein to expand to allow for increased venous return to the lower limbs.
Pathological significance
As a potential space, it is the site of femoral hernias. The relatively tight neck places these at
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high risk of strangulation.

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Question 59 of 78
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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?
A. On the distal ventral surface of the penis

B. On the proximal ventral surface of the penis
Question stats
Score: 45.2%
1
48.1%
16.1%
19.5%
10.1%
6.3%

question correctly
C. On the distal dorsal surface of the penis
End and review
D. On the proximal dorsal surface of the penis
5
6-8 2 / 3
9
10
E. At the base of the scrotum
11
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12
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13
14
The defect is located ventrally and most often distally. Proximally located urethral openings
are well recognised. Circumcision may compromise reconstruction.
15
16
Hypospadias
17
18
The urethral meatus opens on the ventral surface of the penis. There is also a ventral
deficiency of the foreskin. The urethral meatus may open more proximally in the more severe
variants. However, 75% of the openings are distally located. The incidence is 1 in 300 male
births.
19-21 3 / 3
22
23
24
Features include:
25
26
Absent frenular artery

Ventrally opened glans
Skin tethering to hypoplastic urethra
Splayed columns of spongiosum tissue distal to the meatus
Deficiency of the foreskin ventrally
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33
Management:
34
35
No routine cultural circumcisions

Urethroplasty
Penile reconstruction
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41
The foreskin is often utilised in the reconstructive process. In boys with very distal disease no
treatment may be needed.
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Question 60 of 78
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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?
Question stats
Score: 44.4%
1
29.2%
6.8%
43.9%
13.8%
6.3%

question correctly
A. Asbestosis
End and review
5
6-8 2 / 3
9
B. Pneumonia
10
C. Mesothelioma
11
Search
D. Silicosis
12
E. Left ventricular failure
Go
13
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Next question
15
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.
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19-21 3 / 3
Mesothelioma
22
Features
23
Dyspnoea, weight loss, chest wall pain

Clubbing
30% present as painless pleural effusion
Only 20% have pre-existing asbestosis
History of asbestos exposure in 85-90%, latent period of 30-40 years
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Basics
32
Malignancy of mesothelial cells of pleura

Metastases to contralateral lung and peritoneum
Right lung affected more often than left
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35
Management
36
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Investigation: pleural biopsy, CT Scanning, (PET Scanning if surgery considered)

Symptomatic
Industrial compensation
Chemotherapy, Surgery if operable
Prognosis poor, median survival 12 months
38-40 2 / 3
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Question 61 of 78
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A 64-year-old woman who 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?
Question stats
Score: 45.3%
1
7.1%
14.8%
62.5%
8.4%
7.3%

question correctly
A. Thyrotoxicosis
End and review
5
6-8 2 / 3
9
B. Vitamin B12 deficiency

10
C. Vitamin C deficiency
11
Search
D. Diabetes mellitus
12
E. Sarcoidosis
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Next question
15
Bleeding gums and poor healing are suggestive of vitamin C deficiency.
16
17
Vitamin C deficiency
18
19-21 3 / 3
Vitamin C deficiency (scurvy) leads to defective synthesis of collagen resulting in capillary

fragility (bleeding tendency) and poor wound healing
22
23
Features
24
gingivitis, loose teeth

poor wound healing
bleeding from gums, haematuria, epistaxis
general malaise
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Question 62 of 78
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Question stats
End and review
Score: 44.6%
1
8.6%
46.1%
13.7%
A. Transient delay in neuronal transmission
14.1%
B. Axonal degeneration distal to the site of injury
17.5%
C. Absence of neuroma formation

question correctly
Which of the following is not a typical feature of neuropraxia?
D. Preservation of autonomic function
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6-8 2 / 3
9
10
E. Absence of axonal degeneration proximal to the site of injury
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13
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.
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Nerve injury
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19-21 3 / 3
Neuropraxia
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Full recovery
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Axonotmesis
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Neurotmesis

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Nerve repair
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50
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Question 63 of 78
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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+
PTH
Question stats
Score: 45.5%
1
8.1%
18.3%
55.3%
11.6%
6.6%
2.80
question correctly
88pg/ml
End and review
5
6-8 2 / 3
9
10
Phosphate
0.30
11
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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?
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A. Metaplasia the gland
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B. Hypertrophy of the gland
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C. Hyperplasia of the gland
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D. Parathyroid carcinoma
19-21 3 / 3
E. Necrosis of the parathyroid gland
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24
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!
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Parathyroid glands and disorders of calcium metabolism
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Hyperparathyroidism
Disease type
Hormone profile
Clinical
features
Cause
May be
asymptomatic if
mild
Recurrent
abdominal pain
(pancreatitis,
renal colic)
Changes to
emotional or
cognitive state
Most cases due to solitary

adenoma (80%), multifocal
disease occurs in 10-15%
and parathyroid carcinoma in
1% or less
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Primary
hyperparathyroidism
PTH
(Elevated)
Ca2+
(Elevated)
Phosphate
(Low)
Urine
calcium :
creatinine
clearance
ratio > 0.01
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Secondary
hyperparathyroidism
PTH
(Elevated)
Ca2+ (Low or
normal)
Phosphate
(Elevated)
Vitamin D
levels (Low)
May have few

symptoms
Eventually
may develop
bone disease,
osteitis fibrosa
cystica and soft
tissue
calcifications
Parathyroid gland hyperplasia

occurs as a result of low
calcium, almost always in a
setting of chronic renal failure
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55-57 1 / 3
Tertiary
hyperparathyroidism
Ca2+
(Normal or
high)
PTH
(Elevated)
Phosphate
levels
(Decreased
or Normal)
Vitamin D
(Normal or
decreased)
Alkaline
phosphatase
(Elevated)
Metastatic
calcification
Bone pain
and / or fracture
Nephrolithiasis
Pancreatitis
Occurs as a result of ongoing

hyperplasia of the parathyroid
glands after correction of
underlying renal disorder,
hyperplasia of all 4 glands is
usually the cause
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Differential diagnoses
It is important to consider the rare but relatively benign condition of benign familial
hypocalciuric hypercalcaemia, caused by an autosomal dominant genetic disorder. Diagnosis
is usually made by genetic testing and concordant biochemistry (urine calcium : creatinine
clearance ratio <0.01-distinguished from primary hyperparathyroidism).
Treatment
Elevated serum Calcium > 1mg/dL above normal
Hypercalciuria > 400mg/day
Creatinine clearance < 30% compared with normal
Episode of life threatening hypercalcaemia
Nephrolithiasis
Age < 50 years
Neuromuscular symptoms
Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of
more than 2.5 standard deviations below peak bone mass (T score lower than -2.5)
Secondary hyperparathyroidism
Usually managed with medical therapy.
Indications for surgery in secondary (renal) hyperparathyroidism:
Bone pain
Persistent pruritus
Soft tissue calcifications
Tertiary hyperparathyroidism
Allow 12 months to elapse following transplant as many cases will resolve
The presence of an autonomously functioning parathyroid gland may require surgery. If the
culprit gland can be identified then it should be excised. Otherwise total parathyroidectomy
and re-implantation of part of the gland may be required.
References
1. Pitt S et al. Secondary and Tertiary Hyperparathyroidism, State of the Art Surgical
Management. Surg Clin North Am 2009 Oct;89(5):1227-39.
2. MacKenzie-Feder J et al. Primary Hyperparathyroidism: An Overview. Int J Endocrinol
2011; 2011: 251410.
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Question 64 of 78
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A 78 year old man is referred to the clinic by his general practitioner. For many years he
noticed a smooth swelling approximately 5cm 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?
Question stats
Score: 46.3%
1
33.5%
8.1%
38.4%
12.1%
7.9%
A. Pleomorphic adenoma
question correctly
B. Liposarcoma
End and review
C. Warthins tumour
5
6-8 2 / 3
9
10
D. Adenocarcinoma
11
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14
Warthins tumours are most common in elderly smokers. They have a relatively benign and
indolent course. They are usually well circumscribed as illustrated below:
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Parotid gland clinical
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Benign neoplasms
Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these
are benign. There is no consistent correlation between the rate of growth and the malignant
potential of the lesion. However, benign tumours should not invade structures such as the
facial nerve.
With the exception of Warthins tumours, they are commoner in women than men. The
median age of developing a lesion is in the 5th decade of life.
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44-46 0 / 3
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50
Benign tumour types

Tumour type
Features
Benign pleomorphic
adenoma or benign mixed
tumor
Most common parotid neoplasm (80%)

Proliferation of epithelial and myoepithelial cells of the ducts and an
increase in stromal components
Slow growing, lobular, and not well encapsulated
Recurrence rate of 1-5% with appropriate excision (parotidectomy)
Recurrence possibly secondary to capsular disruption during
surgery
Malignant degeneration occurring in 2-10% of adenomas observed
for long periods, with carcinoma ex-pleomorphic adenoma occurring
most frequently as adenocarcinoma
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52
Warthin tumor (papillary

cystadenoma lymphoma
or adenolymphoma)
Second most common benign parotid tumor (5%)

Most common bilateral benign neoplasm of the parotid
Marked male as compared to female predominance
Occurs later in life (sixth and seventh decades)
Presents as a lymphocytic infiltrate and cystic epithelial
proliferation
May represent heterotopic salivary gland epithelial tissue trapped
within intraparotid lymph nodes
Incidence of bilaterality and multicentricity of 10%
Malignant transformation rare (almost unheard of)
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Monomorphic adenoma
Account for less than 5% of tumours

Slow growing
Consist of only one morphological cell type (hence term mono)
Include; basal cell adenoma, canalicular adenoma, oncocytoma,
myoepitheliomas
Haemangioma
Should be considered in the differential of a parotid mass in a child

Accounts for 90% of parotid tumours in children less than 1 year of
age
Hypervascular on imaging
Spontaneous regression may occur and malignant transformation is
almost unheard of
Malignant salivary gland tumours

Types of malignancy
Mucoepidermoid
carcinoma

mainly on grade)
Adenoid cystic
carcinoma

5 year survival 35%
Mixed tumours
Acinic cell
carcinoma

5 year survival 80%
Adenocarcinoma

5 year survival depends upon stage at presentation, may be up to 75%
with small lesions with no nodal involvement
Lymphoma

resection
Treatment is with chemotherapy (and radiotherapy)
Diagnostic evaluation
Plain x-rays may be used to exclude calculi
Sialography may be used to delineate ductal anatomy
FNAC is used in most cases
Superficial parotidectomy may be either diagnostic of therapeutic depending upon the
nature of the lesion
Where malignancy is suspected the primary approach should be definitive resection
rather than excisional biopsy
CT/ MRI may be used in cases of malignancy for staging primary disease
Treatment
For nearly all lesions this consists of surgical resection, for benign disease this will usually
consist of a superficial parotidectomy. For malignant disease a radical or extended radical
parotidectomy is performed. The facial nerve is included in the resection if involved. The
need for neck dissection is determined by the potential for nodal involvement.
Other parotid disorders
HIV infection
Lymphoepithelial cysts associated with HIV occur almost exclusively in the parotid
Typically presents as bilateral, multicystic, symmetrical swelling
Risk of malignant transformation is low and management usually conservative
Sjogren syndrome
Autoimmune disorder characterised by parotid enlargement, xerostomia and
keratoconjunctivitis sicca
90% of cases occur in females
Second most common connective tissue disorder
Bilateral, non tender enlargement of the gland is usual
Histologically, the usual findings are of a lymphocytic infiltrate in acinar units and
epimyoepithelial islands surrounded by lymphoid stroma
Treatment is supportive
There is an increased risk of subsequent lymphoma
Sarcoid
Parotid involvement occurs in 6% of patients with sarcoid
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Bilateral in most cases

Gland is not tender
Xerostomia may occur
Management of isolated parotid disease is usually conservative
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Question 65 of 78
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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?
Question stats
Score: 45.6%
1
10.7%
10%
51.6%
9.2%
18.6%

question correctly
A. Squamous cell carcinoma of the kidney
End and review
5
6-8 2 / 3
9
B. Nephroblastoma
10
C. Renal adenocarcinoma
11
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D. Transitional cell carcinoma of the kidney
12
E. Polycystic kidney disease
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13
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14
15
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.
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19-21 3 / 3
Renal tumours
22
23
Renal cell carcinoma

Renal cell carcinoma is an adenocarcinoma of the renal cortex and is believed to arise from
the proximal convoluted tubule. They are usually solid lesions, up to 20% may be multifocal,
20% may be calcified and 20% may have either a cystic component or be wholly cystic. They
are often circumscribed by a pseudocapsule of compressed normal renal tissue. Spread may
occur either by direct extension into the adrenal gland, renal vein or surrounding fascia.
More distant disease usually occurs via the haematogenous route to lung, bone or brain.
Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are more
commonly affected than females and sporadic tumours typically affect patients in their sixth
decade.
Patients may present with a variety of symptoms including; haematuria (50%), loin pain
(40%), mass (30%) and up to 25% may have symptoms of metastasis.Less than 10% have
the classic triad of haematuria, pain and mass.
Investigation
Many cases will present as haematuria and be discovered during diagnostic work up. Benign
renal tumours are rare, so renal masses should be investigated with multislice CT scanning.
Some units will add and arterial and venous phase to the scan to demonstrate vascularity
and evidence of caval ingrowth.
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CT scanning of the chest and abdomen to detect distant disease should also be undertaken.
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44-46 0 / 3
Routine bone scanning is not indicated in the absence of symptoms.

Biopsy should not be performed when a nephrectomy is planned but is mandatory before
any ablative therapies are undertaken.
Assessment of the functioning of the contra lateral kidney.
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50
51
Management
T1 lesions may be managed by partial nephrectomy and this gives equivalent oncological
results to total radical nephrectomy. Partial nephrectomy may also be performed when there
is inadequate reserve in the remaining kidney.
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55-57 1 / 3
For T2 lesions and above a radical nephrectomy is standard practice and this may be
performed via a laparoscopic or open approach. Preoperative embolisation is not indicated
nor is resection of uninvolved adrenal glands. During surgery early venous control is
mandatory to avoid shedding of tumour cells into the circulation.
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Patients with completely resected disease do not benefit from adjuvant therapy with
either chemotherapy or biological agents. These should not be administered outside the
setting of clinical trials.
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Patients with transitional cell cancer will require a nephroureterectomy with disconnection of
the ureter at the bladder.
65
References
Lungberg B et al. EAU guidelines on renal cell carcinoma: The 2010 update. European
Urology 2010 (58): 398-406.
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Question 66 of 78
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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?
Question stats
Score: 44.9%
1
7.5%
27.8%
23.5%
21.2%
20%
A. Polycystin-1
question correctly
B. Fibrillin
End and review
C. Type IV collagen
5
6-8 2 / 3
9
10
D. Type I collagen
11
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E. Elastin
12
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13
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14
15
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.
16
17
Marfan's syndrome
18
19-21 3 / 3
Marfan's syndrome is an autosomal dominant connective tissue disorder. It is caused by a

defect in the fibrillin-1 gene on chromosome 15 and affects around 1 in 3,000 people.
22
23
Features
24
tall stature with arm span to height ratio > 1.05

high-arched palate
arachnodactyly
pectus excavatum
pes planus
scoliosis of > 20 degrees
heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm,
aortic dissection, aortic regurgitation, mitral valve prolapse (75%),
lungs: repeated pneumothoraces
eyes: upwards lens dislocation (superotemporal ectopia lentis), blue sclera, myopia
dural ectasia (ballooning of the dural sac at the lumbosacral level)
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27-29 1 / 3
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31
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35
36
The life expectancy of patients used to be around 40-50 years. With the advent of regular
echocardiography monitoring and beta-blocker/ACE-inhibitor therapy this has improved
significantly over recent years. Aortic dissection and other cardiovascular problems remain
the leading cause of death however.
37
38-40 2 / 3
41
42
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44-46 0 / 3
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Question 67 of 78
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Question stats
End and review
Score: 44.3%
1
50%
9.5%
8%
A. It is inherited in an autosomal recessive manner
15.5%
B. Affected patients are more likely to develop right colon mucinous

tumours than the general population
17%
Which of the following are not typical of Lynch syndrome?
C. Affected individuals have an 80% lifetime risk of colon cancer

question correctly
D. Endometrial cancer is seen in 80% of women
5
6-8 2 / 3
9
10
E. Gastric cancers are more common
11
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12
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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.
Go
13
14
15
16
17
18
presented here.
19-21 3 / 3
22
23
24
Autosomal dominant
Diagnosed when:
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27-29 1 / 3
30

31
BRCA 1 and 2
34

2).
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Lynch Syndrome
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Autosomal dominant
44-46 0 / 3
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Amsterdam criteria
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Gardners syndrome
55-57 1 / 3

cancer
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Question 68 of 78
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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?
A. Histamine
B. Free radicals
Question stats
Score: 43.7%
1
11.5%
29.9%
8%
9.1%
41.4%

question correctly
C. Prostaglandins
End and review
D. Leukotrienes
5
6-8 2 / 3
9
10
E. Serotonin
11
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12
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13
14
Acute inflammation is not mediated by free radicals
15
16
Chemical mediators facilitate the spread of inflammation into normal tissue

Chemical mediators include:
Lysosomal compounds
Chemokines such as serotinin and histamine (released by platelets and mast cells)
17
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19-21 3 / 3
22
23
Other enzyme cascades producing inflammatory mediators include:

Complement, kinin, coagulation system and fibrinolytic system
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30
Acute inflammation
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35
Vascular changes
36

proteins.
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Sequelae
Resolution
48

49
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Organisation

52
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Suppuration

55-57 1 / 3
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inflammation

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Causes
Chemical agents
Tissue necrosis
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inflammation
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Question 69 of 78
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An enthusiastic medical student approaches you with a list of questions about blood
transfusion reactions. Which of her following points is incorrect?
A. Graft versus host disease involves neutrophil proliferation

B. Thrombocytopaenia may occur in women with a prior pregnancy
Question stats
Score: 43.1%
1
36%
11.7%
27.3%
16.2%
8.9%

question correctly
C. IgA antibodies may cause blood pressure compromise during

transfusion
End and review
5
6-8 2 / 3
9
10
D. Hypocalcaemia can occur
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E. Iron overload can be avoided by chelation therapy
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14
15
Mnemonic for transfusion reactions:

Got a bad unit
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G raft vs. Host disease

O verload
T hrombocytopaenia
19-21 3 / 3
22
23
A lloimmunization
B lood pressure unstable
A cute haemolytic reaction
D elayed haemolytic reaction
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27-29 1 / 3
30
U rticaria
N eutrophilia
I nfection
T ransfusion associated lung injury
31
32
33
34
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.
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38-40 2 / 3
Thrombocytopaenia occurs a few days after transfusion and may resolve spontaneously.
Patients with IGA antibodies need IgA deficient blood transfusions.
41
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43
Blood transfusion reactions
44-46 0 / 3
47
Acute transfusion reactions present as adverse signs or symptoms during or within 24 hours
of a blood transfusion. The most frequent reactions are fever, chills, pruritus, or urticaria,
which typically resolve promptly without specific treatment or complications. Other signs
occurring in temporal relationship with a blood transfusion, such as severe dyspnoea,
pyrexia, or loss of consciousness may be the first indication of a more severe potentially fatal
reaction.
The causes of adverse reactions are multi-factorial. Immune mediated reactions, some of the
most feared, occur as a result of component mismatch, the commonest cause of which is
clerical error. More common, non immune mediated, complications may occur as a result of
product contamination, this may be bacterial or viral.
Transfusion related lung injury is well recognised and there are two proposed mechanisms
which underpin this. One involves the sequestration of primed neutrophils within the recipient
pulmonary capillary bed. The other proposed mechanism suggests that HLA mismatches
between donor neutrophils and recipient lung tissue is to blame.
The table below summarises the main types of transfusion reaction.
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Immune mediated
Non immune mediated
Pyrexia
Hypocalcaemia
Alloimmunization
CCF
Thrombocytopaenia
Infections
Transfusion associated lung injury
Hyperkalaemia
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Graft vs Host disease

Urticaria
Acute or delayed haemolysis
ABO incompatibility
Rhesus incompatibility
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Question 70 of 78
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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?
A. <1%
B. 60%
Question stats
Score: 42.5%
1
12.8%
10.5%
10%
27.9%
38.8%

question correctly
C. 50%
End and review
D. 20%
5
6-8 2 / 3
9
10
E. 5%
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13
14
Synchronous colonic tumours are seen in 5% cases and all patients having a flexible
sigmoidoscopy should have completion colonoscopy if tumours or polyps are found
15
16
17
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.
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19-21 3 / 3
22
Colorectal cancer
23
24
Annually about 150,000 new cases are diagnosed and 50,000 deaths from the
disease
About 75% will have sporadic disease and 25% will have a family history
Colorectal tumours comprise a spectrum of disease ranging from adenomas through
to polyp cancers and frank malignancy.
Polyps may be categorised into: neoplastic polyps, adenomatous polyps and non
neoplastic polyps.
The majority of adenomas are polypoidal lesions, although flat lesions do occur and
may prove to be dysplastic.
Non-neoplastic polyps include hyperplastic, juvenile, hamartomatous, inflammatory,
and lymphoid polyps, which have not generally been thought of as precursors of
cancer.
Three characteristics of adenomas that correlate with malignant potential have been
characterised. These include increased size, villous architecture and dysplasia. For
this reason most polyps identified at colonoscopy should be removed.
The transformation from polyp to cancer is described by the adenoma - carcinoma
sequence and its principles should be appreciated. Essentially genetic changes
accompany the transition from adenoma to carcinoma; key changes include APC, cmyc, K RAS mutations and p53 deletions.
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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 ?
Question stats
End and review
Score: 0%
18.8%
49.5%
8.7%
11.2%
11.9%
A. Erythrocyte count
question correctly
B. Reticulocyte count
C. Eosinophil count
D. Monocyte count
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E. Lymphocyte count
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The granulocyte 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.
weeks.
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A 28 year old lady presents with benign cyclical mastalgia. Which of the following is not a
recognised treatment for the condition?
A. Evening primrose oil

B. Bromocriptine
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C. Methotrexate
D. Danazol
E. Tamoxifen
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Surgical excision of tender breast tissue is inappropriate
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.
Benign cyclical mastalgia
Benign cyclical mastalgia is a common cause of breast pain in younger females. It varies in
intensity according to the phase of the menstrual cycle. It is not associated with point
tenderness of the chest wall (more likely to be Tietze's syndrome).
The underlying cause is difficult to pinpoint, examination should focus on identifying focal
lesions (such as cysts) that may be treated to provide symptomatic benefit. Women should
be advised to wear a supportive bra. Conservative treatments include flax seed oil and
evening primrose oil. There is slightly more evidence in favor of flax seed oil, though neither
has performed much better than placebo in RCT's.
Hormonal agents such as bromocriptine and danazol may be more effective. However, many
women discontinue these therapies due to adverse effects.
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Question 4 of 8
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In patients with multiple endocrine neoplasia type IIb which of the following clinical
appearances is the patient most likely to display?
A. Acromegalic facies
B. Turners type features
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C. Profound kyphoscoliosis
D. Multiple bony exostoses
E. Marfanoid features
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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.
MEN type I
MEN type IIa
MEN type IIb
Phaeochromocytoma
Medullary thyroid
cancer (70%)
Hyperparathyroidism
(60%)
Same as MEN IIa

with addition of:
Marfanoid body
habitus
Mucosal neuromas
RET oncogene
(chromosome 10)
RET oncogene
(chromosome 10)

Ellison syndrome
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Question 5 of 8
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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?
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A. Alpha feto protein

B. Urinary 5-Hydroxyindoleacetic acid measurements
C. Urinary catecholamines
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D. Urinary VMA measurements

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5 HIAA is the most commonly used diagnostic marker for carcinoid syndrome, it is measured
in a 24 hour urine collection.
Carcinoid syndrome

Clinical features
Onset: years
Flushing face
Palpitations
Asthma
Investigation
CT scan
Treatment
Octreotide
Surgical removal
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Question 6 of 8
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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?
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28.6%
A. Multiple colonic hamartomas

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B. Carpet villous adenoma of the rectum
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C. Caecal carcinoma
D. Multiple colonic adenomas
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E. Multiple colonic hyperplastic polyps
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APC mutations are found in familial adenomatous polyposis coli. These have multiple colonic
adenomas.
Polyposis syndromes
Syndrome
Genetic defect
Features
Screening and
management
Associated
disorders
Familial
adenomatous
polyposis
Mutation of APC
gene (80%)
cases, dominant
Typically over
100 colonic
adenomas
Cancer risk of
100%
20% are new
mutations
If known to be at
risk then predictive
genetic testing as
teenager
Annual flexible
sigmoidoscopy from
15 years
If no polyps found
then 5 yearly
colonoscopy started
at age 20
Polyps found =
resectional surgery
(resection and
pouch Vs sub total
colectomy and IRA)
Gastric fundal
polyps (50%).
Duodenal
polyps 90%.
If severe
duodenal
polyposis
cancer risk of
30% at 10
years.
Abdominal
desmoid
tumours.
MYH
associated
polyposis
Biallelic mutation
of mut Y human
homologue (MYH)
on chromosome
1p, recessive
Multiple colonic
polyps
Later onset right
sided cancers
more common
than in FAP
100% cancer
risk by age 60
Once identified
resection and
ileoanal pouch
reconstruction is
recommended
Attenuated
phenotype - regular
colonoscopy
Duodenal
polyposis in
30%
Associated
with increased
risk of breast
cancer (self
examination)
Peutz Jeghers
syndrome
STK11 (LKB1)
mutation on
chromosome 19 in
some (but not all)
cases, dominant
Multiple benign
intestinal
hamartomas
Episodic
obstruction and
intussceception
Increased risk
of GI cancers
(colorectal
cancer 20%,
gastric 5%)
Increased risk
of breast,
ovarian, cervical
pancreatic and
testicular
cancers
Annual examination
Pan intestinal
endoscopy every 23 years
Malignancies
at other sites
Classical
pigmentation
pattern
Cowden
disease
Mutation of PTEN
gene on
chromosome
10q22, dominant
Macrocephaly
Multiple
intestinal
hamartomas
Multiple
trichilemmomas
89% risk of
cancer at any
site
16% risk of
colorectal
cancer
Targeted
individualised
screening
Breast cancer
(81% risk)
Thyroid
cancer and
non toxic
goitre
Uterine
cancer
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HNPCC
(Lynch
syndrome)
Germline
mutations of DNA
mismatch repair
genes
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Colo rectal
cancer 30-70%
Endometrial
cancer 30-70%
Gastric cancer
5-10%
Scanty colonic
polyps may be
present
Colonic tumours
likely to be right
sided and
mucinous
Colonoscopy every
1-2 years from age
25
Consideration of
prophylactic surgery
Extra colonic
surveillance
recommended
Extra colonic
cancers
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Question 7 of 8
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Which of the following breast tumours is most commonly associated with a risk of metastasis
to the contralateral breast?
A. Invasive ductal carcinoma

B. Invasive lobular carcinoma
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C. Phyllodes tumour
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D. Pagets disease of the breast

E. Atypical ductal hyperplasia
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Risk of metastasis to the contralateral breast is a classical feature of invasive lobular

carcinoma.
Lobular carcinoma of the breast
Lobular breast cancers are less common than their ductal counterparts. They typically
present differently, the mass is usually more diffuse and less obvious on the usual imaging
modalities of ultrasound and mammography. This is significant since the disease may be
understaged resulting in inadequate treatment when wide local excision is undertaken.
In women with invasive lobular carcinoma it is usually safest to perform an MRI scan of the
breast, if breast conserving surgery is planned.
Lobular carcinomas are also more likely to be multifocal and metastasise to the contralateral
breast.
Lobular carcinoma in situ is occasionally diagnosed incidentally on core biopsies. Unlike
DCIS, lobular carcinoma in situ is far less strongly associated with foci of invasion and is
usually managed by close monitoring.
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Question 8 of 8
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A. Stipple cell
71.2%
B. Tear drop cell
5.7%
C. Reticulocytes

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Which is the characteristic finding on a blood film post splenectomy?
D. Howell-Jolly bodies
E. Schistocyte
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7
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Blood film in hyposplenism:
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Howell-Jolly bodies
Pappenheimer bodies
Poikilocytes (Target cells)
Erythrocyte containing siderotic granules
Heinz bodies
Splenectomy
Indications
Trauma: 1/4 are iatrogenic
Spontaneous rupture: EBV
Hypersplenism: hereditary spherocytosis or elliptocytosis etc
Malignancy: lymphoma or leukaemia
Splenic cysts, hydatid cysts, splenic abscesses
Splenectomy
Technique
Trauma
GA
Long midline incision
If time permits insert a self retaining retractor (e.g. Balfour/ omnitract)
Large amount of free blood is usually present. Pack all 4 quadrants of the abdomen.
Allow the anaesthetist to 'catch up'
Remove the packs and assess the viability of the spleen. Hilar injuries and extensive
parenchymal lacerations will usually require splenectomy.
Divide the short gastric vessels and ligate them.
Clamp the splenic artery and vein. Two clamps on the patient side are better and allow
for double ligation and serve as a safety net if your assistant does not release the
clamp smoothly.
Be careful not to damage the tail of the pancreas, if you do then this will need to be
formally removed and the pancreatic duct closed.
Wash out the abdomen and place a tube drain to the splenic bed.
Some surgeons implant a portion of spleen into the omentum, whether you decide to
do this is a matter of personal choice.
Post operatively the patient will require prophylactic penicillin V and pneumococcal
vaccine.
Elective
Elective splenectomy is a very different operation from that performed in the emergency
setting. The spleen is often large (sometimes massive). Most cases can be performed
laparoscopically. The spleen will often be macerated inside a specimen bag to facilitate
extraction.
Complications
Haemorrhage (may be early and either from short gastrics or splenic hilar vessels
Pancreatic fistula (from iatrogenic damage to pancreatic tail)
Thrombocytosis: prophylactic aspirin
Encapsulated bacteria infection e.g. Strep. pneumoniae, Haemophilus influenzae and
Neisseria meningitidis
Post splenectomy changes

Platelets will rise first (therefore in ITP should be given after splenic artery clamped)
Blood film will change over following weeks, Howell Jolly bodies will appear
Other blood film changes include target cells and Pappenheimer bodies
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Other blood film changes include target cells and Pappenheimer bodies
Increased risk of post splenectomy sepsis, therefore prophylactic antibiotics and
pneumococcal vaccine should be given.

Typically occurs with encapsulated organisms
Opsonisation occurs but then not recognised
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A. Follicular thyroid cancer

B. Medullary thyroid cancer

E. Parathyroid gland cancer

Berrys sign= Absence of carotid pulse due to malignant thyromegaly.

Theme from April 2013 Exam

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Terms and Conditions

What is the most common cause of mesenteric infarction?

A. Mesenteric vein thrombosis

B. Acute embolism affecting the superior mesenteric artery

C. Acute on chronic thrombus of the superior mesenteric artery

49.8% of users answered this

D. Sub intimal dissection of the superior mesenteric artery

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E. Proximal migration of abdominal aortic aneurysm

Theme from January 2013 Exam

Sudden onset abdominal pain followed by profuse diarrhoea.

Usually longer prodromal history.

Usually a history over weeks.

This occurs in patients with multiple co morbidities in whom mesenteric

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Corrected Calcium 3.84 mmol/l

Her serum urea and electrolytes are normal.

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56.5% of users answered this

A. Carcinoma of the bronchus

Theme from September 2012 exam

Features - 'bones, stones, abdominal groans and psychic moans'

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Terms and Conditions

Question 4-6 of 343

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Average score for registered users:

Theme: Head and neck lumps

E. Adenolymphoma of the parotid

F. Pleomorphic adenoma of the parotid

A 40 year old women presents as an emergency with a painful mass underneath

Rubbery, painless lymphadenopathy

May be hypo-, eu- or hyperthyroid symptomatically

More common in patients < 20 years old

More common in older men

A congenital lymphatic lesion (lymphangioma) typically found in the neck,

An oval, mobile cystic mass that develops between the

More common in adult females

Pulsatile lateral neck mass which doesn't move on swallowing

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Terms and Conditions

End and review

Theme from September 2012 Exam

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Terms and Conditions

40.3% of users answered this

End and review

Theme from September 2013 Exam

Carcinoid tumours secrete serotonin

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