G.

PATH-SBA-71-140
71. A 47-year-old barmaid presents to the Accident and Emergency department with a 12-hour history of right upper quadrant
pain and vomiting. She says that the pain is radiating to her right scapula and exacerbates on breathing. She appears pale and
mildly jaundiced. On examination, her pulse rate is 98/min, blood pressure is 126/84 mmHg and temperature is 37.6 C.
Abdominal examination reveals tenderness over the right hypochondrium but no mass is palpable. Plain radiographs of the
abdomen (supine) and chest (erect) are unremarkable. From the options below choose the ONE that you think is the most
likely diagnosis in this patient:
Perforated peptic ulcer
Acute pancreatitis
Acute biliary cholangitis
Acute cholecystitis

Correct answer

Infective hepatitis
The history, signs and symptoms in this patient are suggestive of acute cholecystitis. Acute cholecystitis is more common in
females over the age of 40 and with high BMI. Gallstones are the commonest cause for acute cholecystitis. Obstruction of the
common bile duct due to stones leads to accumulation of bile and inflammation, resulting in an acutely inflammed gall bladder.
Other risk factors for acute cholecystitis include alcohol abuse and tumours of the gall bladder. The signs and symptoms of
acute cholecystitis include severe right hypochondrial pain exacerbated by respiration, nausea and vomiting, and increase in
temperature. The rise in temperature is frequently mild to moderate; a very high temperature with or without chills and rigors
may point to a diagnosis of acute cholangitis. A tender, inflamed gall bladder may be palpable in some patients. Likewise,
jaundice may or may not be present. The differential diagnoses for acute cholecystitis include acute pancreatitis, peptic ulcer
disease or perforated peptic ulcer, appendicitis, acute infective hepatitis and pleurisy.
72. A 51-year-old lady presents to the Surgical Emergency Assessment Unit with a 12-hour history of central colicky abdominal
pain and vomiting. She has undergone a subtotal colectomy and formation of an end ileostomy for ulcerative colitis 7 years
ago. Her ileostomy has not functioned for 2 days. On examination, she is tender over the upper abdomen and the abdomen is
mildly distended. Plain abdominal radiograph reveals number of small loops in the centre of the abdomen. From the options
below choose the ONE that you think is the most likely diagnosis in this patient:
Acute colonic pseudo-obstruction
Incarcerated incisional hernia
Bacterial peritonitis
Adhesional small bowel obstruction

Correct answer

Sigmoid volvulus
Small bowel obstructions make up 80-85% of all intestinal obstructions. Of these, adhesions accounts for nearly 90% of all
small bowel obstructions. Adhesions usually develop following laparotomy and/or surgery to the bowel. It can occur as a
sequlae of minor abdominal surgeries such as appendicectomies or major surgeries such as resection of large sections of
the bowel. In females, gynaecological procedures are an important cause; in addition, pelvic inflammatory disease can also
lead to adhesions even in the absence of a surgical intervention in the abdomen. The cardinal features of small bowel
obstruction are pain, vomiting and abdominal distension; untreated, this leads to constipation with reduction in flatus which then
becomes absolute. The pain is usually colicky due to excessive peristalsis, but may become continuous if strangulation or
perforation occurs. Vomiting is early in high small bowel obstruction, late in low small bowel obstruction and delayed or absent
in large bowel obstruction. The management involves appropriate resuscitation of the patient and surgical exploration of the
abdomen to relieve the obstruction.
73. A 25-year-old footballer presents to the Accident and Emergency department with pain in his left lower leg after he was
violently kicked (in his leg) during a tackle. On examination, his pulse rate is 96/min and blood pressure is 116/74 mmHg.
There is considerable bruising over the posterior aspect of his leg, and that part of the limb is tense, swollen and tender. He
complains of altered sensation over the dorsum of his foot. Dorsiflexion of the foot and extension of the toes are painful and
limited. Although he had normal anterior tibial and dorsalis pedis pulsations when he was brought to the Accident and
Emergency department, they soon become weak and difficult to palpate. Plain radiograph of this limb does not reveal any
fractures.
From the options below choose the most appropriate cause for this patients signs and symptoms:

Deep venous thrombosis

Torn muscle bellies of gastrocnemius and soleus

Correct answer

Compartment syndrome
Ruptured Achilles tendon

Thrombosis of the popliteal artery

Compartment syndrome is defined as an increase in the interstitial fluid pressure within an osteofascial compartment of
sufficient magnitude to cause a compromise of the microcirculation leading to necrosis of the affected nerve(s) and muscle(s).
It is a well-recognised and important complication of lower limb injuries, most commonly seen after fractures and crush injury,
although it can occur in the absence of bony injury. The other causes for compartment syndrome include electrical injuries,
deep thermal burns, venom from snake bites, restricting tourniquets, and fluid extravasation (e.g. intravenous regional
anaesthesia). The patient may present with unremitting pain that is not relieved by high doses of opioid analgesics. Severe
pain in response to passive stretch of the ischaemic muscles is by far the most dramatic and reliable clinical sign of
compartment syndrome. Sensory loss occurs before motor loss. Early in its development, the peripheral pulses are normal, as
is the colour and temperature of the affected part, since it is the microvasculature that is initially affected. Loss of peripheral
pulses is usually a late and often sinister sign. With progression of the condition, the limb becomes tense and swollen, and if
left treated, the muscle weakness progresses to paralysis. Untreated, irreversible myoneural necrosis occurs within 6-8 hours.
The areas of muscle may also infarct causing rhabdomyolysis, hyperkalaemia, hyperphosphataemia, high uric acid levels and
metabolic acidosis.
74. A 28-year-old hair stylist presents to her General Practitioner with a three-month history of crampy lower abdominal pain,
diarrhoea (12-15 times/day), mouth ulcers and loss of appetite. She reckons that she has lost nearly a stone in weight during
this period. She smokes 20 cigarettes/day. Abdominal examination reveals a mildly tender mass over her right iliac fossa. A
few abscesses with sinus formation are noticed in the perianal region.
From the options below choose the ONE which you think is the most likely diagnosis in this patient:
.
Pelvic inflammatory disease
Pseudomembranous colitis
Ulcerative colitis
Crohns disease

Correct answer

Carcinoma of the colon

The signs and symptoms in this patient are very suggestive of Crohns disease. Crohns disease can affect the whole of the GI
tract, leading to ulcers in the mouth. Risk factors for Crohns disease include a strong positive family history, a variety of food,
smoking (increases the risk by three folds), and infective agents such as mycobacterium and cell wall deficient organisms such
as pseudomonas. The clinical presentation of this condition includes cramp-like or constant pain over the umbilical region/right
iliac fossa, low-grade fever, loss of appetite, loss of weight, anaemia and general fatigability. Diarrhoea may be troublesome,
which is usually non-bloody and intermittent. If the colon is involved, patients may present with diffuse abdominal pain
accompanied by mucus, blood and pus in the stool. Perianal fissures or fistulae (e.g., entero-colic, entero-cutaneous), intraabdominal abscesses and adhesions, and intestinal obstruction may develop with progression of the disease.
75. A 44-year-old female presents to the Surgical Emergency Assessment Unit with a 72-hour history of abdominal pain,
vomiting and being generally unwell. She has also noticed pale stools and dark urine. On examination, she is jaundiced and is
tender over the right upper quadrant. An ultrasound reveals a dilated proximal common bile duct with intra hepatic duct
dilatation. A MR cholangiopancreatogram confirms a fistula between the gallbladder and the common bile duct, and a large
calculi is found in the common bile duct just distal to the fistula.
From the options below choose the ONE that you think is the most likely diagnosis in this patient:
.
Carcinoma of the head of the pancreas
Cholangiocarcinoma
Mirizzis Syndrome

Correct answer

Hepatocellular carcinoma
Carcinoma of the ampulla of Vater
Mirizzis syndrome is caused due to impaction of gallstones either in the cystic duct or the Hartmann pouch of the gallbladder,
leading to compression of the common hepatic duct from the outside, resulting in symptoms of obstructive jaundice. Impaction

of gallstones in the Hartmann pouch or cystic duct results in the Mirizzi syndrome either by: (i) chronic and/or acute
inflammatory changes leading to contraction of the gallbladder and stenosis of the common hepatic duct, or (ii)
cholecystocholedochal fistula formation due to direct pressure necrosis of adjacent duct walls from large impacted stones.
Patients may present with pain over the right upper quadrant of the abdomen, vomiting, fever, recurrent cholangitis,
cholecystitis or pancreatitis. Pale stools and dark urine result from obstruction of the flow of bile into the intestine. Treatment of
this condition is exploration of the common bile duct by either open or laparoscopic cholecystectomy and placement of a Ttube.
76. A 56-year-old man, who drinks about 60-70 units of alcohol per week, presents to the Accident and Emergency department
with severe abdominal pain and 2-3 episodes of vomiting blood. On examination, he appears pale with a pulse rate of 110/min.
Abdominal examination reveals dilated veins in the anterior abdominal wall, mild ascites, a large spleen and a small nodular
liver. From the options below choose the ONE that you think is the most likely diagnosis in this patient:
.
Chronic pancreatitis
Hepatocellular carcinoma
Amoebic hepatitis
Portal hypertension

Correct answer

Myeloproliferative disorder
Portal hypertension is defined as an increase in the portal vein pressure of more than 10mmHg (the normal portal vein
pressure is in the range of 5-10 mmHg). Among other causes, cirrhosis of the liver is one of the important causes of portal
hypertension and currently accounts for up to 90% of cases in the UK. Collateral channels develop in portal hypertension
between the portal system and systemic circulation such as in the lower end of oesophagus (resulting in oesophageal varices),
distal rectum, and anterior abdominal wall (resulting in dilated tortuous veins in the anterior abdominal wall known as caput
medusae). Some of the signs and symptoms of portal hypertension include abdominal pain, ascites, jaundice, splenomegaly
and signs of cirrhosis (such as spider naevi, gynaecomastia, palmar erythema and testicular atrophy); signs of shock may be
present if there is bleeding from sites of porto-systemic anastamosis, particularly oesophageal varices leading to
haematemesis and/or melaena.
77. A 22-year-old female is referred by her General Practitioner to the rapid access breast clinic with a lump in her left breast.
She says that it has been present for about 8-weeks now and is painless. There is no bleeding or discharge from her nipples.
On examination, there is a 2-cm sized, firm, mobile and smooth lump in the upper outer quadrant of her left breast. There is no
palpable axillary lymphadenopathy. Her paternal aunt died from breast cancer at the age of 62.
From the options below choose the ONE that you think is the most likely diagnosis in this patient:
.
Cystosarcomma phyllodes
Fibroadenoma

Correct answer

Fibrocystic disease
Mondors disease
Pagets disease
Fibroadenoma is the most commonly diagnosed breast tumour in women under 30 years of age. They are benign tumours
originating from the breast lobule. They show proliferation of both epithelium and connective tissue elements, and is considered
as an 'Aberration of Normal Development and Involution (ANDI)'. Most fibroadenomas measure 2-3 cm in diameter.
Fibroadenoma is common between 16 and 24 yrs of age; the incidence decreases towards menopause. Fibroadenomas are
usually mobile, firm and smooth lumps (but sometimes may be lobulated). It may be multiple in approximately 10% of the
cases. The diagnosis is confirmed by triple assessment: (i) clinical examination (ii) radiological assessment (mammography or
ultrasound scan), and (iii) cytological/histological (fine needle aspiration, core biopsy). Over a 5-year period, 50% increase in
size, 25% remain stable and 25% decrease in size. Risk of malignant transformation is approximately 1 in 1,000.
78. A 54-year-old male presents to his General Practitioner with a two-week history of sweating, headache, constipation and
itchy lesions over his back. On examination, his blood pressure is 162/94 mmHg and his pulse rate is 102/min. Twenty-four
hour urinary catecholamines, metanephrines and vanillyl-mandellic acid are found to be elevated. A CT and a 131I-meta-iodobenzyl-guanidine scan confirms a phaeochromocytoma. He is subsequently found to have a medullary carcinoma of the
thyroid.
From the options below choose the ONE that you think is the most likely diagnosis in this patient:
.
Multiple Endocrine Neoplasia I

Secondary hyperparathyroidism
Multiple Endocrine Neoplasia IIB
Carcinoid tumour
Correct answer
Multiple Endocrine Neoplasia IIA
Multiple Endocrine Neoplasia II (MEN II) is an autosomal dominant disorder caused by mutations in the RET proto-oncogene.
MEN II has 3 distinct subtypes - MEN IIA, MEN IIB, and familial medullary thyroid carcinoma-only. MEN II describes the
association of medullary thyroid carcinoma, phaeochromocytomas and parathyroid tumours. MEN IIB is characterised by MEN
IIA plus Marfanoid features and mucosal neuromas. In MEN IIB, the medullary cancer is very aggressive with most patients
dying before developing either a phaeochromocytoma or hyperparathyroidism. A patient with medullary carcinoma of the
thyroid may present with diarrhoea due to elevated prostaglandin or calcitonin levels. Patients with hypercalcemia may present
with constipation, polyuria, polydipsia, depression, nephrolithiasis, glucose intolerance, gastroesophageal reflux, loss of bone
density and fatigue. Patients with pheochromocytomas may present with hypertension, tachycardia, sweating and headaches.
Cutaneous lichen amyloidosis in patients with MEN IIA manifests as multiple pruritic scaly skin lesions in the scapular area of
the back.
79. A 30-year-old woman presents with a lump in the right lobe of the thyroid. It is hard, non-tender and has rapidly increased
in size. Her lymph nodes are enlarged. She has previously had radiotherapy to her neck. Histology shows Orphan Annie nuclei
.
The most likely tumour is?

Follicular adenoma
Anaplastic carcinoma
Medullary carcinoma
Papillary carcinoma

Correct answer

Follicular carcinoma
Papillary carcinoma is the commonest malignant thyroid tumour. This is more common in younger patients, females and those
with a past history of head and neck irradiation. It often spreads to local lymph nodes. Orphan Annie nuclei are characteristic,
Psammoma bodies may also be seen.
80. The histology from a lymph node biopsy reveals Reed-Sternberg cells. The patient has?

Hodgkins lymphoma

Correct answer

Follicle centre cell lymphoma

Langerhans cell histiocytosis
Burkitts lymphoma
Non-Hodgkins lymphoma
Reed-Sternberg cells are characteristic of Hodgkins lymphoma.
B and D are examples of non-Hodgkins lymphoma along with B-cell and T-cell lymphoma. Langerhans cell histiocytosis is a
neoplastic condition of the Langerhans cells causing lymphadenopathy.
81. You receive the histology report from a specimen from a colonic resection. It reveals that the tumour extends through the
muscularis propria to the serosal surface. There are local lymph nodes involved, but not the node at the level of the ligated
vascular pedicle.
What is the Dukes stage of the tumour:

A
B
C1

Correct answer

C2
D
The Dukes classification is:
A Confined to the bowel wall, not extending through the muscularis propria
B Extends through the bowel wall into the serosa. No lymph node involvement
C1 Local lymph nodes involved, but not the apical node (at vascular pedicle)
C2 Local lymph nodes involved including the apical
D Distant metastases
82. In a patient with bladder transitional cell carcinoma, the occupation most likely to have exposed them to a carcinogen is?

Painter
Peanut farmer
Printer
Dye worker

Correct answer

Miner
Beta-naphthylamine exposure is related to transitional cell carcinoma, and this is used in the dye industry. Painting and printing
are linked to benzopyrene exposure and an increased risk of lung cancer. Mining is linked to chromium, asbestos, arsenic and
nickel exposure, and increases the risk of lung cancer. Peanut farming causes exposure to aflatoxin and increases the risk of
hepatocellular carcinoma.
83. The predominant cell in a healing wound 5 days old is?

Neutrophils
Myofibroblasts
Endothelial cells

Correct answer

Macrophages
Fibroblasts
The cells involved in wound healing appear in the following order:
Immediately Platelets for clot formation
Neutrophils for initiation of phagocytosis respectively.
Intermediate (1 2 days) Macrophages for continued phagocytosis and growth factor secretion
Fibroblasts for synthesis of extracellular matrix components
Myofibroblasts for wound contraction
Late (3 5 days) Endothelial cells for capillary formation
84. When classifying surgical procedures according to the risk of wound contamination, appendicectomy is an example of?

Clean
Clean contaminated

Correct answer

Contaminated
Dirty
Infected
Infected is not part of the classification of risk of wound contamination.
In a clean wound the viscus wall is not breached. In a clean contaminated wound the viscus wall is breached, but the contents
are contained and no spillage occurs. In a contaminated wound the viscus wall is breached and contents spilled. In a dirty
wound there is already pus or spilled bowel contents.
85. A 50-year-old man has an adrenal mass noted on CT scan. This is a metastasis. The most likely primary source is:

Kidney
Lung

Correct answer

Prostate
Pancreas
Colorectal
Tumours commonly metastasising to the adrenal glands are lung and breast cancers.
Kidney and prostate more commonly metastasize to lung and bone, pancreas to liver and colorectal to lung and liver.
86. A 70-year-old female presents with increasing pain in the right femur.
X-rays reveal a single lytic lesion consistent with bony metastasis.
Which of the following is LEAST likely to be the primary:
Single best answer question choose ONE correct option only
Colon

Correct answer

Breast
Bronchus
Kidney
Thyroid
The five tumours commonly metastasising to bone are breast, bronchus, kidney, thyroid and prostate, however prostate tend to
cause sclerotic lesions. Colorectal cancer commonly metastasises to lung and liver.
87. An 18-year-old male presents with a left testicular lump. Which of the following tumour markers would be LEAST useful?

Alpha-fetoprotein
LDH
Beta-HCG
Ca 15-3

Correct answer

GGT
Alpha-fetoprotein, beta-HCG and LDH are elevated by NSGCT. Beta-HCG can be elevated with seminoma. GGT can be
elevated by testicular tumours, but is not commonly used in clinical practice.
Ca 15-3 is a tumour marker for breast cancer.
88. An 18-month-old presents with septic arthritis of the left hip. The most likely causative organism is?

Neisseria gonorrhoeae
Haemophilus influenzae

Correct answer

Staphylococcus aureus
Haemolytic streptococcus
Salmonella
Haemophilus influenzae is the most common cause of septic arthritis in infants <5 years, Staphylococcus aureus is the second
commonest cause. Staphlococcus aureus is most common in children >5 years and adults >50 years, and second most
common in adults <50 years. In adults <50 years the commonest cause is Neisseria gonorrhoeae. Salmonella may be seen in
sickle cell patients. Haemolytic streptococcus is a more common cause of osteomyelitis in children <5 years.
89. A 60-year-old female presents with a painful knee. The pain has been gradually increasing, is worse at the end of the day,
and with exercise and is associated with a swollen joint. Her FBC, ESR and CRP are all normal. The most likely condition is?

Septic arthritis
Correct answer

Osteoarthritis
Rheumatoid arthritis
Gout

Bursitis
This is a chronic condition, septic arthritis, gout and bursitis all have a more acute presentation, and the pain of these is
unaffected by exercise.
Rheumatoid arthritis pain is relieved by exercise and worse on waking/resting, in contrast to osteoarthritis, which is worse with
exercise and at the end of the day. Rheumatoid arthritis causes anaemia of chronic disease and during flare-ups a raised ESR
and CRP. Osteoarthritis does not cause any such blood result abnormalities. The knee is very commonly affected by
osteoarthritis.
90. Which virus is most commonly associated with hepato-cellular carcinoma?

Hepatitis A
Hepatitis B

Correct answer

Hepatitis D
Hepatitis E
Epstein Barr Virus
Hepatitis B is strongly associated with hepatocellular carcinoma, and patients are often HbsAg positive.
Hepatitis A and E are self-limiting diseases, not known to cause chronic liver disease. Hepatitis D requires HbsAg co-existence.
EBV is linked to nasopharyngeal carcinoma, Burkitts lymphoma and Hodgkins lymphoma.
91. A swab result from one of your patients shows a gram positive aerobic coccus, which is coagulase negative. Which of the
following
is
the
most
likely
organism?
Single best answer question - choose ONE true option only
Staphylococcus aureus
Streptococcus viridans
Staphylococcus epidermidis

Correct answer

Streptococcus faecalis
Enterococcus faecalis
Staphylococcus and streptococcus are both aerobic gram positive cocci, enterococcus faecalis is anaerobic. The presence of
the coagulase enzyme is a test to subdivide the staph micro-organisms. Staphylococcus aureus is coagulase positive.
Haemolytic groupings are used for Streptococcus.
92. An 80-year-old patient on IV cefuroxime develops diarrhoea. The organ ism that you should test the stool sample for is:

Clostridium difficile

Correct answer

Clostridium perfringens
Clostridium tetani
Clostridium botulinum
Escherichia coli

The patient is on antibiotics which increases the risk of pseudomembranous colitis, cephalosporins are particularly linked to
this, and Clostridium difficile is the causative organism. E. coli can cause diarrhoea, but is a less likely cause in this patient.
Clostridium perfringens can cause gas gangrene, clostridium tetani causes tetanus, and clostridium botulinum causes botulism.
93. A patient presents with hyponatraemia. The chest X-ray shows a lesion. The most l ikely type of lung cancer is:

Squamous cell carcinoma

Adenocarcinoma
Giant cell carcinoma
Clear cell carcinoma
Correct answer
Small cell carcinoma
The patient has a syndrome of inappropriate ADH secretion secondary to the lung mass. Small cell (oat cell) tumours are most
commonly associated with paraneoplastic syndromes (15% of patients have them at presentation).Increased ADH secretion
and increased ACTH secretion are most common. Squamous cell tumours can cause ectopic PTH secretion.
94. A 30-year-old female who has had recurrent UTIs, presents with loin pain. The KUB shows a staghorn calculus. The most l
ikely type of calculus is:

Calcium
Struvite

Correct answer

Oxalate
Urate
Xanthine
Struvite stones are radio-opaque and associated with infections with urea splitting organisms e.g. Proteus. They are also more
commonly responsible for staghorn calculi.
The calculi associated with urate and xanthine are radiolucent. Calcium are associated with excess calcium absorption and
bone disorders. Oxalate are associated with bowel pathology.
95. A biopsy result from a colonoscopy reveals changes throughout the layers of the bowel wall including a non-caseating
epitheloid granuloma, cobblestone appearance of the mucosa and fissuring ulcers. The most l ikely diagnosis is:

Crohns

Correct answer

Ulcerative colitis
Pseudomembranous colitis
Familial adenomatous polyposis
Ischaemic colitis
The appearances are those of inflammatory bowel disease. In order to differentiate between Crohns and ulcerative colitis, UC
is limited to the mucosa, doesnt feature granulomas and only causes small, shallow ulcers.
96. A patient has anti-A and anti-B antibodies in their blood. The ir blood group genotype must be:

OO

Correct answer

AA
AO
BB
AB

Phenotypically O patients have antigen O and antibodies to A and B. Since O is recessive, genotypically the patient must be
OO, as AO would give a phenotypically A patient, and BO would give a phenotypically B patient.
97. A patient presents with a painful slowly enlarging left parotid mass and a facial nerve palsy. The most likely lesion is:
Single best answer question - choose ONE true option only
Pleomorphic adenoma
Warthins tumour
Myoepithelioma
Adenoid cystic carcinoma

Correct answer

Ductal papilloma
The facial nerve involvement points to a malignant tumour. The other tumours are all benign. Benign tumours are also more
often painless.
98. A patient has primary hyperparathyroidism, in order to confirm adenoma, the best biopsy type would be:

Fine needle aspiration cytology

CT guided biopsy
Core biopsy
US guided biopsy
Correct answer
Intra-operative frozen section
The difficulty with parathyroid biopsy is the variable location of the glands, making them inaccessible to simple biopsy
techniques, even with image guidance, so intra-operative frozen section is the only way of being certain that parathyroid tissue
has been sampled.
99. A 33-year-old woman underwent a total unilateral thyroid lobectomy for a suspicious dominant nodule. Subsequent
histology demonstrated multi-focal papillary cancer with 18mm and 4mm foci. Resection margins were clear, with no
lymphadenopathy noted at operation. Which of the following treatment options is the most appropriate next stage of treatment?

Completion total thyroidectomy and radical neck dissection

Correct answer

Completion total thyroidectomy

Local radiotherapy
Radioactive iodine (131I) imaging and ablation

Regular out-patient follow-up with thyroglobulin measurements

Micropapillary tumours (<10mm diameter) are frequently co-incidental findings and can be safely managed without total
thyroidectomy in the absence of clinically overt contralateral or metastatic disease. Larger tumours, especially when multi-focal,
should be considered for completion thyroidectomy. There is no evidence to support radical block dissection of the neck.
Excision of locally infiltrated structures may be required with extensive extrathyroidal disease, along with radiotherapy.
Radioactive iodine is a useful means of detecting metastatic disease after total thyroidectomy. Measurement of thyroglobulin is
a sensitive indicator of recurrent disease after total thyroidectomy when the patient is on full thyroxine replacement therapy.
100. A 26-year-old woman presents with right upper quadrant discomfort and elevated serum transaminases. A diagnosis of
hepatitis C is made following detection of antihepatitis C virus antibodies. Which of the following represents the most likely
subsequent event?

Complete recovery
Development of chronic hepatitis C

Correct answer

End stage liver disease

Transmission to her monogamous partner

Vertical transmission to potential children
Hepatitis C is transmitted by parenteral or permucosal exposure to infected blood or body fluids. Many patients have a history
of intravenous drug abuse or transmission of blood products before the implementation of antihepatitis C virus screening of
blood donors in 1992. 70-85% of those with acute hepatitis C will develop a chronic infection and of these 20% will develop end
stage liver failure due to progressive cirrhosis. Transmission to monogamous partners and vertical transmission is uncommon
and accounts for the minority of new cases of hepatitis C. Hepatocellular carcinoma occurs in 1-4% of those with associated
cirrhosis per year.
101. A 48-year-old woman presents with a painless slow growing mass in the left parotid gland. There is no apparent
involvement of the facial nerve. From the following list, which is the most likely finding on biopsy?

Adenoid cystic carcinoma

Adenolymphoma (Warthins tumour)
Monomorphic adenoma
Mucoepidermoid tumour
Correct answer
Pleomorphic adenoma
Pleomorphic adenoma is the most common benign salivary gland tumour accounting for approximately 80% of parotid tumours.
It contains mixed epithelial and mesenchymal elements and generally develops superficial to the facial nerve. Facial nerve
involvement is suggestive of malignant disease and adenoid cystic carcinomas in particular are unusual in their predilection for
peri-neural spread. Adenolymphomas constitute 18% of all salivary gland neoplasms occurring in the sixth and seventh
decades of life. Monomorphic adenomas are rare and although 90% of malignant mucoepidermoid tumours arise in the parotid,
they are much rarer than pleomorphic adenomas.
102. A mammogram undertaken as part of a screening programme demonstrates an area of coarse linear branching
calcification. Which of the following conditions is this calcification pattern most likely to represent?

Atypical ductal hyperplasia

Comedo type ductal carcinoma in situ

Correct answer

Lobular carcinoma in situ

Non-comedo type ductal carcinoma in situ
Sclerosing adenosis
Ductal carcinoma in situ is divided into two main sub-types according to the presence or absence of comedo necrosis. A
tumour can be designated as comedo if atypical cells, with abundant luminal necrosis, fill at least one duct. This necrotic
material frequently calcifies producing a characteristic coarse linear branching pattern. Lobular carcinoma in situ is not evident
on mammography. Sclerosing adenosis can sometimes be difficult to differentiate from invasive carcinoma on mammography
alone with heterogeneous calcification and tissue distortion. Similarly there are no pathognomonic mammographic features of
atypical ductal hyperplasia, however areas are sometimes represented by clustered microcalcifications.
103. A 42-year-old man with a past history of a parathyroid adenoma presents with a mass in the neck and enlarged cervical
lymph nodes. Fine needle aspiration cytology confirms a diagnosis of medullary carcinoma of the thyroid. Which one of the
following forms of familial endocrine disease is this most likely to represent?

Cowdens syndrome
Familial medullary carcinoma of the thyroid
Multiple endocrine neoplasia type 1
Multiple endocrine neoplasia type 2A

Correct answer

Multiple endocrine neoplasia type 2B

10

The principle features of multiple endocrine neoplasia (MEN) 1 are parathyroid hyperplasia, anterior pituitary adenoma and
neuroendocrine tumours of pancreas & duodenum . MEN 2A is characterised by a combination of medullary thyroid cancer
(MTC), phaeochromocytoma and hyperparathyroidism (hyperplasia or adenoma of the parathyroid glands). Some patients with
MEN 2A have Hirschsprungs disease. Individuals with MEN 2B have the thyroid and adrenal features of MEN 2A, no
parathyroid involvement, mucosal neuromas and a marfanoid habitus. Familial medullary carcinoma of the thyroid is a
condition in which affected individuals only develop MTC. Cowdens syndrome is associated with hamartomatous lesions of the
thyroid but not MTC.
104. A middle-aged woman presents with a moderately enlarged thyroid gland. The enlargement is symmetrical with a rubbery
texture. She is euthyroid. Anti-thyroglobulin and anti-thyroid peroxidase / anti-microsomal antibodies are raised. Which one of
the following is the most likely diagnosis?

Acute suppurative thyroiditis

Autoimmune thyroiditis (Hashimotos thyroiditis)

Correct answer

Graves disease
Riedels thyroiditis
Subacute thyroiditis (de Quervains thyroiditis)
Hashimotos thyroiditis tends to present with painless enlargement of the thyroid. It is often rubbery in texture and can mimic
multinodular disease or malignancy. Anti-thyroglobulin and anti-thyroid peroxidase / anti-microsomal antibodies are raised
(although can be raised in 8% of the normal population). Thyroid infiltration by lymphocytes and plasma cells is evident with a
small risk of developing primary lymphoma. De Quervains thyroiditis is often associated with a viral infection and painful goitre.
Graves disease is typified by a diffuse toxic gland and positive thyroid-stimulating antibodies. Riedels thyroiditis is usually iron
hard and associated with other sites of idiopathic fibrosis.
105. For gallbladder pathology, which of the following clinical conditions is most likely to be associated with identification of
Aschoff-Rokitansky sinuses?

Acute cholecystitis
Cholesterosis of the gallbladder (strawberry gallbladder)
Chronic cholecystitis

Correct answer

Mucocele of the gallbladder

Xanthogranulomatous cholecystitis
Chronic cholecystitis is associated with a fibrotic thick walled gallbladder. Within the thickened wall are Aschoff-Rokitansky
sinuses, mucosal herniations often containing inspissated bile. Acute cholecystitis is associated with increased vascular
permeability and infiltration with acute inflammatory cells. Mucocele of the gallbladder normally occurs in a thin walled noninflammed gallbladder. Cholesterol-laden macrophages in the lamina propria of the gallbladder mucosa is a feature of
cholesterosis. Xanthogranulomatous cholecystitis is a rare form of chronic cholecystitis characterised by huge numbers of lipidladen macrophages and giant cells. Xanthogranulomatous cholecystitis can easily be mistaken for carcinoma.
106. Concerning operative intervention for an incompetent sapheno-popliteal junction (SPJ), which of the following is
imperative?

Closure of popliteal fascia

Flush ligation of the SPJ
Identification of the Giacomini vein (upward continuation of the short saphenous vein)
Pre-operative marking of the SPJ with duplex imaging

Correct answer

Stripping of the short saphenous vein

Location of the SPJ is extremely variable and marking is essential to prevent misplaced incisions. Tracing the Giacomini vein
can be helpful in SPJ identification, SPJ, however is not a constant anatomical feature. Flush ligation of the SPJ is generally
thought to reduce recurrence but can be difficult to achieve, especially in the obese where possible benefit is outweighed by

11

potential nerve and vascular injury. Stripping of the short saphenous vein is associated with an unacceptable risk to the sural
nerve. Closure of the popliteal fascia prevents an unsightly bulge at the back of the knee.
107. In case of contact dermatitis from latex based gloves, which of the following is the related hypersensitivity reaction?

Gell and Coombs Type I

Gell and Coombs Type II
Gell and Coombs Type III
Gell and Coombs Type IV

Correct answer

Un-classified by Gell and Coombs

Gell and Coombs classified hypersensitivity reactions in to four categories:
Type I immediate hypersensitivity due to overproduction of IgE antibody on mast cells or basophils; Type II causes antibody to
cell-bound antigen; Type III causes immune complex reactions; Type IV is delayed hypersensitivity mediated by T-cells.
Latex, as the sensitising antigen or hapten, becomes bound to skin proteins. This complex is presented to T-lymphocytes in
association with MHC class II antigen by Langerhans cells. Induction of T-cells usually occurs after months of exposure to
small amounts of antigen with cytokine release in the epidermis. Inflammation and induration is effected at the contact site.
108. A 35-year-old man is admitted with ischaemic rest pain in both feet. There is no history of preceding intermittent
claudication. He is a heavy smoker. Femoral and popliteal pulses are palpable. From the list below select the most likely
diagnosis.

Atherosclerosis
Fibromuscular dysplasia
Polyarteritis nodosa
Takayasus arteritis
Correct answer
Thromboangiitis obliterans (Buergers disease)
Buergers disease is characterised by segmental thrombotic occlusions of the small and medium sized arteries usually of the
distal lower limb. It occurs predominantly in young male smokers, frequently associated with rest pain and tissue loss.
Intermittent claudication is not a major feature. Tobacco abstinence is essential. Takayasus arteritis has a female
preponderance manifest by an obliterative arteritis of the aorta and its branches. Polyarteritis nodosa occurs between 40-60
years and affects small and medium sized arteries. Fibromuscular dysplasia affects renal and carotid arteries. Atherosclerosis
tends to have a preceding history and very rarely manifests at such an early age.
109. A 2-year-old boy presents with a pedunculated polyp prolapsing through the childs anus. Which of the following types of
polyp is this most likely to represent?

Adenoma
Benign lymphoma
Hamartomatous polyp

Correct answer

Hyperplastic polyp
Lipoma
Hamartomatous polyps (juvenile polyps) occur predominately in infants and children. The polyp is characteristically 1-2 cm in
diameter with a smooth surface and slender stalk. Hamartomatous polyps mostly occur in the rectum and can proplapse
through the anus. Hyperplasic polyps also occur commonly in the rectum, although they are usually small plaque like lesions
occurring at all ages. Lipomas occur mainly in the right colon and caecum, often ulcerating with the appearance of an
adenocarcinoma. Benign lymphomas appear as reddish purple rounded polyps throughout the large bowel. Adenomas can
occur at any age but become progressively more common with advancing years.
110. A 56-year-old Caucasian man is diagnosed with a liver abscess . He has no recent history of foreign travel, or significant
past medical history. Which of the following micro-organisms is the most likely to be the causative agent?

12

Candida albicans
Echinococcus
Entamoeba histolytica
Escherichia coli

Correct answer

Streptococcus milleri
Pyogenic abscesses account for 75 per cent of liver abscesses in developed counties. Most pyogenic liver abscesses are
secondary to intra-abdominal infections. The most common cause is cholangitis associated with biliary stones followed by
diverticulitis. Most are polymicrobial with Gram negative aerobic and anaerobic organisms predominating. Streptococcus milleri
usually arises from bacterial endocarditis. Fungal abscesses are associated with immunosuppression. World wide, amoebic
abscesses are the commonest cause of liver abscess with 10 per cent of the worlds population infected with Entamoeba
histolytica. Hydatid disease is common in many sheep-raising countries. Echinococcus granulosus is the causative species of
Hydatid disease.
111. A 35-year-old man has a clinical diagnosis of a testicular malignancy in a previously maldescended testis. From the
following list of testicular malignancies which is the most likely histological diagnosis?

Interstitial (Leydig) cell tumour

Lymphoma
Seminoma

Correct answer

Teratoma
Yolk sac tumour
Seminomas and teratomas are of germ cell origin accounting for 85-90 per cent of testicular tumours. Peak incidence of
seminomas is 30-50 years compared to 20-30 years for teratomas. Seminomas are the commonest testicular tumours to
develop in maldescended testicles. Lymphomas of the testis are far less common with a peak incidence of 60-70 years. They
are often bilateral and can be a manifestation of more diffuse disease. Yolk sac tumours occur before the age of three years
and are the commonest testicular malignancy in children.
112. A 72-year-old man has a swelling behind his knee consistent with a popliteal artery aneurysm. Which of the following is
the strongest indication for surgical intervention?

Diameter of the aneurysm

Patients concern of the risk of rupture
Presence of all three patent run-off vessels
Presence of an associated abdominal aortic aneurysm
Correct answer
Presence of thrombus within the aneurysmal sac and a single patent run-off vessel
Rupture of a popliteal aneurysm is rare. 50% of cases present with limb threatening ischaemia. Laminated thrombus can
develop within the sac and is constantly subjected to flexion and extension movements that greatly increase the risk of
fragmentation. Microembolisation of the distal circulation occurs silently until sudden occlusion of the remaining run-off vessels.
Thus, the presence of thrombus is a strong indication for surgical intervention, especially if a single run-off vessel remains. In
the absence of laminated thrombus, it is generally accepted that aneurysms with a diameter of 2cm or greater warrant
consideration for repair.
113. Which of the following associated extra-alimentary conditions is more suggestive of ulcerative colitis than Crohns
disease?

Ankylosing spondylitis
Arthropathy
Erythema nodosum

13

Primary sclerosing cholangitis

Correct answer

Pyoderma gangrenosum
Primary sclerosing cholangitis is far more commonly seen in ulcerative colitis than Crohns disease. The condition is
characterised by a fibrous inflammatory reaction within the biliary tree leading to irregularity with multiple stenosis and biliary
obstruction. There is no apparent relationship between duration or severity of ulcerative colitis and ultimately progresses to liver
failure. Arthropathy and ankylosing spondylitis are both features of ulcerative colitis and Crohns disease. Erythema nodosum is
the commonest cutaneous manifestation of inflammatory bowel disease and occurs slightly more commonly in Crohns
disease. Conversely pyoderma gangrenosum is slightly more prevalent in ulcerative colitis.
114. A 40-year-old man is diagnosed with right sided synchronous colonic tumours, which are mucinous and poorly
differentiated. His mother had died at an early age of ovarian cancer and his maternal grandfather had died aged
approximately 40 years of advanced caecal carcinoma. From the following list of inherited syndromes which is most likely to be
prevalent in this family?

Cowdens syndrome
Familial adenomatous polyposis
Hereditary non-polyposis colorectal cancer

Correct answer

Juvenile polyposis
Peutz-Jeghers syndrome
Colonic tumours associated with hereditary non-polyposis colorectal cancer (HNPCC) tend to have certain distinguishing
pathological features. They occur on average twenty years before the peak incidence of sporadic tumours and are frequently
synchronous and metachronous with a predilection for the proximal colon. They tend to be mucinous, poorly differentiated and
signet-ring in appearance. Ovarian cancer is associated with NHPCC along with cancers of the endometrium and stomach.
115. A 75-year-old woman is admitted with small bowel obstruction and pain radiating down the medial aspect of the right
thigh to the knee. There is no palpable abnormality in the groin but the inner aspect of the groin is tender. From the following
list, which is the most likely diagnosis?

Femoral hernia
Gluteal hernia
Lumbar hernia
Obturator hernia

Correct answer

Sciatic hernia
An obturator hernia is six times more common in women and twice as common on the right side. It particularly affects elderly
women who have had recent rapid weight loss. The hernial sac protrudes through the obturator canal potentially compressing
the geniculate branch of the obturator nerve causing referred pain. Strangulated femoral hernias are generally palpable and
lumbar hernias are associated with paralysed muscles especially by poliomyelitis or spina bifida. Gluteal and sciatic hernias are
very rare and are suggested by the presence of a painful swelling in the buttock or pain in the distribution of the sciatic nerve.
116. A 16-year-old girl presents with a four month history of an aching discomfort in the distal right femur, relieved with simple
analgesia. Plain radiograph of the knee shows an area of slight sclerosis. Which is the most likely diagnosis?

Chondroma
Fibroma
Osteochondroma
Osteoclastoma
Correct answer
Osteoid osteoma
Osteoid osteomas are commonest in the femur and tibia. They are unusual as benign tumours in that they produce a constant
aching pain which is classically relieved by simple analgesia. They can be difficult to see on plain radiographs.

14

Osteochondromas often appear as a bony pedicle growing away from the epiphyseal plate, covered in a large cartilage cap.
Chondromas are made up almost entirely of cartilage and are common in the hands and feet. Fibromas are well-circumscribed
lytic lesions and osteoclastomas are commonly found lying close to the epiphyseal plate with destruction of the overlying
cortex.
117. A 56-year-old woman presents with a rapidly growing raised solitary lesion on her face. Over the course of four weeks it
has reached two centimetres in diameter. The lesion has now developed a necrotic, crusted centre. From the following list of
skin lesions which is the most likely diagnosis?

Basal cell carcinoma

Histiocytoma
Correct answer

Keratocanthoma
Pyogenic granuloma

Squamous cell carcinoma

Keratocanthomas are epidermal nodules almost indistinguishable from squamous cell carcinomas, however unlike squamous
cell carcinomas, they grow very rapidly. Having attained the size of two to three centimetres over several weeks they
spontaneously involute leaving a pitted scar. Histiocytomas appear as firm flesh coloured nodules mainly on the lower limb.
Pyogenic granulomas also grow rapidly, however they usually occur on the fingers after trivial trauma and appear as raised,
wet, pedunculated lesions. Basal cell carcinomas are slow growing.
118. A 30-year-old man presents with a painless swelling behind the anterior edge of the upper third of the right sternomastoid
muscle. Fine needle aspiration reveals opalescent fluid. From the list below which is the most likely diagnosis?

Branchial cyst

Correct answer

Branchial fistula
Chemodectoma
Pharyngeal pouch
Thyroglossal cyst
Branchial cysts originate from embryonic branchial cleft tissue remnants. Most present in the third decade with swelling behind
the anterior border of sternomastoid. These cysts often present when they become infected and contain inflamed lymphoid
tissue. Classically opalescent fluid containing cholesterol crystals can be aspirated. Branchial fistulae arising from
abnormalities of the first cleft appear as a sinus anterior or posterior to the ear and those of the second, along the anterior
boarder of sternomastoid. Pharyngeal pouches present behind sternomastoid and thyoglossal cysts, in the midline.
Chemodectomas are slow growing, often painful, pulsatile masses at the angle of the mandible.
119. In pulmonary tuberculosis, what is the most discriminating lung pathology feature?

Multinucleate giant cells

Caseating necrosis

Correct answer

Gram negative organisms

Macrophages
Colliquative necrosis
Caseating necrosis is characteristic of TB, and rarely seen in other conditions. It refers to the creamy white appearance of the
dead tissue, that resembles cheese. Multinucleate giant cells are seen in TB, but also in some viral infections and
malignancies. TB is not gram negative, but requires specialised Ziehl Neelson staining. Colliquative (Liquefaction) necrosis
occurs in the brain and spinal cord.
120. A patient develops an erythematous rash under the dressing site 24 hours post operatively. Whatis the most likely
hypersensitivity reaction type?

Type I

15

Type II
Type III
Type IV

Correct answer

Type V
There are 4 types of hypersensitivity reaction, I to IV;
Type I is the immediate IgE mediated response Type II is antibody mediated towards antigen attached to cells Type III is
antibody mediated towards antigen not attached to cells Type IV, or delayed type hypersensitivity reaction is T cell mediated,
and onset is typically between 24 and 72 hours after exposure
121. A 2-year-old boy presents with painful, swollen right knee. Apart from recurrent epistaxis, he is fit and well. His blood
results reveal the following abnormalities.
Hb 13.2 g/dl
MCV 95 fl
WCC 8.3 x109/l
Plts 250 x109/l
PT Normal
APTT Prolonged
What is the most likely diagnosis?
Single best answer question - choose ONE true option only
Septic arthritis
Haemophilia
Disseminated intravascular coagulation (DIC)
Von Willebrand Disease (VWD)

Correct answer

Factor V Leiden
The child has a bleeding disorder of the intrinsic pathway indicated by the raised APTT. The recurrent epistaxis suggests VWD
due to abnormality of platelets and factor 8. Platelets cause mucosal bleeding, factor 8 deficiency causes deep bleeding, such
as hemoarthroses in this case. Haemophilia which does not involve platelets would not explain the epistaxis.
122. A 52-year-old ladys breast biopsy histology shows poorly differentiated duct epithelial cells which do not breach the
basement membrane. Whatis the best classification of this breast pathology?

Phyllodes tumour
Ductal carcinoma in situ

Correct answer

Lobular carcinoma in situ

Fibroadenoma
Von Willebrand Disease (VWD)
The cells arise from the ductal cells as opposed to the gland or lobule cells, in lobular carcinoma in situ. The cells have not
invaded the basement membrane, so this is a carcinoma in situ as opposed to a carcinoma. Phyllodes tumour is a type of
fibroadenoma with malignant potential
123. A 56-year-old woman presents with abdominal pain and constipation. She has no past medical history. Her blood tests
show the following.
Hb
15.3 g/dl (13-18 g/dl)
MCV
95 fl (76-96 fl)
WCC
10.3 x109/l (4-11 x109/l)
Serum corrected calcium
2.95 mmol/l (2.12-2.65 mmol/l)
Serum phosphate
0.7 mmol/l (1.2-1.7 mmol/l)

16

Serum alkaline phosphatase 150 iu/l (30-35 iu/l)

What is the underlying diagnosis?
Single best answer question - choose ONE true option only
Primary hyperparathyroidism

Correct answer

Secondary hyperparathyroidism
Tertiary hyperparathyroidism
Osteoporosis
Pagets disease
The calcium is inappropriately high suggesting this is primary hyperparathyroidism. Secondary hyperparathyroidism is an
appropriately high PTH to a low calcium level. Tertiary hyperparathyroidism is an inappropriately high PTH following prolonged
stimulation for example following renal transplant for chronic renal failure. Osteoporosis and Pagets disease have no effect on
calcium unless there is prolonged immobility when it is raised. ALP is markedly raised in Pagets disease.
124. A 60-year-old man is 2 weeks post-renal transplant complaining of polyuria and polydypsia.
His blood tests show the following;
Hb
10.1 g/dl (13-18 g/dl)
MCV
80 fl (76-96 fl)
Ca
2.95 mmol/l (2.12-2.65 mmol/l)
Phosphate 0.70 mmol/l (1.2-1.7 mmol/l)
ALP
150 iu/l (30-35 iu/l)
What is the underlying problem?
Single best answer - choose ONE true option only
Primary hyperparathyroidism
Secondary hyperparathyroidism
Tertiary hyperparathyroidism

Correct answer

Osteoporosis
Pagets disease
Tertiary hyperparathyroidism is an inappropriately high PTH following prolonged stimulation, for example following renal
transplant for chronic renal failure. Osteoporosis and Pagets disease have no effect on calcium unless there is prolonged
immobility when it is raised. ALP is markedly raised in Pagets disease. Secondary hyperparathyroidism is an appropriately
high PTH to a low calcium level. Primary hyperparathyroidism is an inappropriately raised PTH, for example due to a
parathyroid adenoma, causing hypercalcaemia.
125. A 26-year-old man presents with a hard, non-tender lump in his left testicle. Both AFP and HCG are raised. Whatis the
most likely nature of the lump?

Hematoma
Abscess
Teratoma

Correct answer

Seminoma
Hydrocoele
Testicular lumps are often noticed after trauma. Seminomas do not cause a raised AFP and peak age is 30-40 years.
Teratomas are derived from multipotent germ cells so cause both AFP and bHCG to rise, peak age being 20-30 years.
126. A 21 year old man undergoes drainage of a perianal abscess. Which is the best method to manage the wound?

Primary closure

17

Delayed primary closure

Healing by secondary intention

Correct answer

Permanent fistula
Tertiary closure by skin graft
Infected wounds are best left open to heal by secondary intention. Primary closure is achieved by suturing or stapling or
steristrip. Delayed primary closure is needed for contaminated wounds that are left open day 1 and closed by suturing by day 3
to 5 before excessive granulation is started.
127. A 19-year-old girl develops lip swelling and stridor after administration of Penicillin. What is the type of hypersensitivity
reaction seen here?

Type I

Correct answer

Type II
Type III
Type IV
Type V
There are 4 types of hypersensitivity reaction, I to IV;
Type I is the immediate IgE mediated response
Type II is antibody mediated towards antigen attached to cells
Type III is antibody mediated towards antigen not attached to cells
Type IV, or delayed type hypersensitivity reaction is T cell mediated, and onset is typically between 24 and 72 hours after
exposure
128. A 76-year-old man develops a pyrexia and cough 7 days after an open cholecystectomy. What is the most likely organism
involved?

Gram negative bacteria

Correct answer

Streptococcus pneumoniae
Clostridium difficile
Staphylococcus aureus
Mycobacterium tuberculosis
This is a hospital acquired infection, mostly likely to be caused by gram negative bacteria.
129. In Barretts oesophagus, what is the pathological process that converts squamous cells to gastric type cells?

Dysplasia
Hypertrophy
Hyperplasia
Apoptosis
Correct answer
Metaplasia
Metaplasia is the replacement of one differentiated cell type with another as in this case. Hypertrophy is the increase in cell
size, hyperplasia an increase in cell number. Apoptosis is programmed cell death, while dysplasia is the abnormal development
of cells which is often a pre-malignant state.
130. A 35-year old lady develops a DVT 7 days following a panproctocolectomy for Crohn's disease. She is positive for
anticardiolipin and lupus anticoagulant antibodies. What is the underlying condition behind this DVT?

18

Factor V Leiden
Protein C deficiency
Protein S deficiency
Antiphospholipid syndrome

Correct answer

Antithrombin III deficiency

The presence of the two antibodies indicate that this patient has the hypercoagulable state of antiphospholipid syndrome.
131. What is the pathological process in benign prostate enlargement?

Hypertrophy
Hyperplasia

Correct answer

Dysplasia
Metaplasia
Neoplasia
Hyperplasia, the increase in number of cells is responsible for BPH
132. An 81-year-old man with newly diagnosed AF develops sudden onset left leg pain and pallor. What is the underlying
pathology?

Embolus

Correct answer

Thrombophilia
Atheroma
Thrombocytopenia
Thrombosis
The leg is acutely ischaemic, most probably an atrial embolus has caused a sudden blockage to the arterial supply of the leg.
133. A 45-year-old lady presents with right flank mass and haematuria. She also complains of depression, constipation and
vomiting. What is the underlying diagnosis?
Single best answer question - choose ONE true option only
Colorectal carcinoma
Renal stones
Renal carcinoma

Correct answer

Bladder carcinoma
Pyelonephritis
This collection of symptoms can all be explained by renal carcinoma with hypercalcaemia as a paraneoplastic syndrome.
Paraneoplastic syndromes are non-metastatic systemic effects caused by cancer. Hypercalcaemia causes depression,
abdominal pain, lethargy and constipation.
134. An 81-year-old man, an ex-smoker, presents with a 2 year history of left calf pain after walking 500 metres. What is the
underlying pathological process?

Embolus
Thrombophilia

19

Atheroma

Correct answer

Thrombocytopenia
Thrombosis
This is intermittent claudication due to chronic ischaemia caused by atheroma.
135. An 81-year-old ex-smoker presents with a 2-day history of worsening left calf pain even at rest. He has been getting pain
for the last 10 years but was able to walk 500 metres. What is the underlying pathological process?

Embolus
Thrombophilia
Atheroma
Thrombocytopenia
Correct answer
Thrombosis
This is acute on chronic ischaemia, caused by rupture of the atheroma and formation of a thrombus on top.
136. A 72-year-old diabetic man with chronic renal failure has the following blood results;
Hb
15.3 g/dl (13-18 g/dl)
MCV
95 fl (76-96 fl)
WCC
10.3 x109/l (4-11 x109/l)
Serum corrected calcium 1.95 mmol/l (2.12-2.65 mmol/l)
Phosphate
1.8 mmol/l (1.2-1.7 mmol/l)
ALP
150 iu/l (30-35 iu/l)
What is the underlying diagnosis?

Primary hyperparathyroidism
Secondary hyperparathyroidism

Correct answer

Tertiary hyperparathyroidism
Osteoporosis
Pagets disease
In chronic renal failure, secondary hyperparathyroidism is an appropriate response to low calcium levels that occur due to low
calcitriol levels, which is produced in the kidneys. Phosphate is high as it cannot be cleared from the kidneys.
137. Which of the following cells secretes intrinsic factor?

Goblet cells
Kupffer cells
Peptic cells
Chief cells
Correct answer
Parietal cells
Goblet cells are mucus-secreting cells widely distributed in epithelial surfaces, but especially dense in the gastrointestinal and
respiratory tracts.
Kupffer cells have phagocytic properties and are found in the liver. They participate in the removal of ageing erythrocytes and
other particulate debris.
The gastric mucosa contains many cell subtypes, including acid-secreting cells (also known as parietal or oxyntic cells), pepsin
secreting cells (also known as peptic, chief or zymogenic cells) and G-cells (gastrin-secreting cells). Peptic cells synthesise and
secrete the proteolytic enzyme, pepsin. Parietal cells actively secrete hydrochloric acid into the gastric lumen, accounting for

20

the acidic environment encountered in the stomach. However parietal cells are also involved in the secretion of the
glycoprotein, intrinsic factor.
Intrinsic factor plays a pivotal role in the absorption of vitamin B12 from the terminal ileum. Autoimmune damage to parietal
cells leads to a lack of intrinsic factor and hydrochloric acid, leading to vitamin B12 deficiency and achlorhydria. This is known
as pernicious anaemia.
138. Splenectomy increases susceptibility to which of the following organisms?

Streptococcus pyogenes
Schistosoma haematobium
Bacteroides fragilis
Neisseria meningitidis

Correct answer

Staphylococcus aureus
The spleen plays an important role in the removal of dead and dying erythrocytes and in the defence against microbes.
Removal of the spleen (splenectomy) leaves the host susceptible to a wide array of pathogens, but especially to encapsulated
organisms.
Certain bacteria have evolved ways of evading the human immune system. One way is through the production of a slimy
capsule on the outside of the bacterial cell wall. Such a capsule resists phagocytosis and ingestion by macrophages and
neutrophils. This allows them not only to escape direct destruction by phagocytes but also to avoid stimulating T-cell responses
through the presentation of bacterial peptides by macrophages. The only way that such organisms can be defeated is by
making them more palatable by coating their capsular polysaccharide surfaces in opsonising antibody.
The production of antibody against capsular polysaccharide primarily occurs through T-cell independent mechanisms. The
spleen plays a central role in both the initiation of the antibody response and the phagocytosis of opsonised encapsulated
bacteria from the bloodstream. This helps to explain why following a splenectomy the host is most susceptible to infection by
encapsulated organisms, notably Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus) and
Haemophilus influenzae.
Understanding the above, one can quickly envisage what preventative strategies must be employed post-splenectomy.
Patients are given relevant immunisations and are advised to take prophylactic penicillin, in most cases for the rest of their
lives. In addition they are advised to wear a MedicAlert bracelet to warn other health care professionals of their condition.
139. A 65-year-old man suffered a massive myocardial infarction that was complicated by shock and prolonged hypotension.
On arrival in the Emergency Department he was found to have focal neurological signs in addition to feature consistent with
low-output cardiac failure. Despite the best efforts of the medical team he died the next day.
At autopsy, the most likely change you would expect to see in a brain biopsy would be:

Acute haemorrhagic change

Coagulative necrosis
Granulomatous change
Lacunar infarct
Correct answer
Liquefactive necrosis
Liquefactive necrosis is characteristic of focal bacterial or, occasionally, fungal infections, because microbes stimulate the
accumulation of inflammatory cells. Hypoxic death of cells within the central nervous system often evokes liquefactive necrosis,
though the reasons for this are obscure. Whatever the pathogenesis, liquefaction completely digests the dead cells. The end
result is transformation of the tissue into a viscous liquid mass. If the process was initiated by acute inflammation the material is
frequently creamy yellow in colour because of the presence of dead white cells and this is called 'pus'.
140. A 42-year-old woman has complained of mild, burning, substernal or epigastric pain following meals for the past 3 years.
Upper gastrointestinal endoscopy is performed and biopsies are taken of an erythaematous area of the lower oesophageal
mucosa 3 cm above the gastro-oesophageal junction. There is no mass lesion, no ulceration and no haemorrhage is noted.
The biopsies demonstrate the presence of columnar epithelium with goblet cells.
Which of the following mucosal alterations is most likely to be represented by these findings?

Carcinoma

21

Dysplasia
Hyperplasia
Ischaemia
Correct answer
Metaplasia
Metaplasia is the substitution of one tissue type normally found at a site for another. The epithelium undergoes metaplasia in
response to ongoing inflammation from reflux of gastric contents. It is common in the lower oesophagus with gastrooesophageal reflux disease. The growth of the epithelial cells must become disordered to be dysplastic. Hyperplasia can occur
with inflammation, as the number of cells increases, but hyperplasia does not explain the presence of the columnar cells.
Carcinoma is characterised by cellular atypia with hyperchromatism and pleomorphism. Goblet cells would not be seen.
Ischaemia would be unusual at this site and would be marked by coagulative necrosis.

22