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Emrcs-Pathology-326-Mcqs.pdf
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1. A 38 year old lady presents with a recent episode of renal colic. As part of her investigations the following results areobtained: Corrected Calcium: 3.84 mmol/l; PTH: 88pg/ml (increased). Her serum urea and electrolytes are normal. What is
the most likely diagnosis?
A. Carcinoma of the bronchus
B. Secondary hyperparathyroidism
C. Primary hyperparathyroidism
D. Tertiary hyperparathyroidism
E. Carcinoma of the breast
Answer: C
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.
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
Theme: Head and neck lumps
A. Branchial cyst
B. Cystic hygroma
C. Carotid body tumour
D. Lymphadenopathy
E. Adenolymphoma of the parotid
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.
2. 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 anterior to the sternocleidomastoid muscle. There are no other abnormalities to find on
examination.
Answer: 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.
3. 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.
Answer: 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.
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,4. 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.
Answer: 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.
The table below gives characteristic exam question features for conditions causing neck lumps:
Reactive By far the most common cause of neck swellings. There may be a history of local infection or a
lymphadenopathy 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
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
5. 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?
A. Infectious hepatitis
B. Acute cholecystitis
C. Cholangitis
D. Hereditary spherocytosis
E. Gilberts syndrome
Answer: D
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.
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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,6. A 2 day old baby is noted to have voiding difficulties and on closer inspection is noted to have hypospadias. Which of the
following abnormalities is most commonly associated with the condition?
A. Cryptorchidism
B. Diaphragmatic hernia
C. Ventricular - septal defect
D. Bronchogenic cyst
E. Atrial septal defect
Answer: A
Hypospadias most commonly occurs as an isolated disorder. Associated urological abnormalities may be seen in up to 40% of
infants, of these cryptorchidism is the most frequent (10%).
Hypospadias: The urethral meatus opens on the ventral surface of the penis. There is also a ventral deficiency of the foreskin. The
uretral 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.
Features include: 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
Management: No routine cultural circumcisions; Urethroplasty; Penile reconstruction. The foreskin is often utilised in the
reconstructive process. In boys with very distal disease no treatment may be needed.
Theme: Liver lesions
A. Cystadenoma
B. Hyatid cyst
C. Amoebic abscess
D. Mesenchymal hamartoma
E. Liver cell adenoma
F. Cavernous haemangioma
Please select the most likely lesion for the scenario given. Each option may be used once, more than once or not at all.
7. A 38 year old lady presents with right upper quadrant pain and nausea. She is otherwise well and her only medical therapy
is the oral contraceptive pill which she has taken for many years with no ill effects. Her liver function tests are normal. An
ultrasound examination demonstrates a hyperechoic well defined lesion in the left lobe of the liver which measures 14 cm in
diameter.
Answer: Cavernous haemangioma
Cavernous haemangioma often presents with vague symptoms and signs. They may grow to considerable size. Liver function tests
are usually normal. The lesions are typically well defined and hyperechoic on ultrasound. A causative link between OCP use and
haemangiomata has yet to be established, but is possible.
8. A 37 year old lady presents with right upper quadrant pain and nausea. She is otherwise well and her only medical therapy
is the oral contraceptive pill which she has taken for many years with no ill effects. Her liver function tests and serum alpha
feto protein are normal. An ultrasound examination demonstrates a 4cm non encapsulated lesion in the right lobe of the
liver which has a mixed echoity and heterogeneous texture.
Answer: Liver cell adenoma
Liver cell adenomas are linked to OCP use and 90% of patients with liver cell adenomas have used the OCP. Liver function tests are
often normal. The lesions will typically have a mixed echoity and heterogeneous texture.
9. A 38 year old shepherd presents to the clinic with a 3 month history of malaise and right upper quadrant pain. On
examination he is mildly jaundiced. His liver function tests demonstrate a mild elevation in bilirubin and transaminases, his
full blood count shows an elevated eosinophil level. An abdominal x-ray is performed by the senior house officer and
demonstrates a calcified lesion in the right upper quadrant of the abdomen.
Answer: Hyatid cyst
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, Hyatid disease is more common in those who work with sheep or dogs. Liver function tests may be abnormal and an eosinophilia is
often present. Plain radiographs may reveal a calcified cyst wall.
Benign liver lesions
Haemangioma: 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
Liver cell adenoma: 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. 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
Mesenchymal hamartomas: Congential and benign, usually present in infants. May compress normal liver
Liver abscess: 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
Amoebic abscess: 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
Hyatid cysts: 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 indicate 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
Polycystic liver disease: Usually occurs in association with polycystic kidney disease. Autosomal dominant disorder. Symptoms
may occur as a result of capsular stretch
Cystadenoma: 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
10. A 72 year old man presents with symptoms and signs of benign prostatic hyperplasia. Which of the following structures is
most likely to be enlarged on digital rectal examination?
A. Posterior lobe of the prostate
B. Median lobe of the prostate
C. Right lateral lobe of the prostate
D. Left lateral lobe of the prostate
E. Anterior lobe of the prostate
Answer: B
Carcinoma of the prostate typically occurs in the posterior lobe. The median lobe is usually enlarged in BPH. The anterior lobe has
little in the way of glandular tissue and is seldom enlarged.
Benign Prostatic Hyperplasia: Prostatic enlargement occurs in many elderly men . >90% of men aged over 80 will have at least
microscopic evidence of benign prostatic hyperplasia. Pathology: As part of the hyperplastic process increase in both stromal and
glandular components are seen. The changes are most notable in the central and periurethral region of the gland. Presentation: The
vast majority of men will present with lower urinary tract symptoms. These will typically be: Poor flow. Nocturia. Hesitancy.
Incomplete and double voiding. Terminal dribbling. Urgency. Incontinence. Investigation: Digital rectal examination to assess
prostatic size and morphology. Urine dipstick for infections and haematuria. Uroflowmetry (a flow rate of >15ml/second helps to
exclude BOO). Bladder pressure studies may help identify detrusor failure and whilst may not form part of first line investigations
should be included in those with atypical symptoms and prior to redo surgery. Bladder scanning to demonstrate residual volumes.
USS if high pressure chronic retention. Management: Lifestyle changes such as stopping smoking and altering fluid intake may
help those with mild symptoms. Medical therapy includes alpha blockers and 5 alpha reductase inhibitors.
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