?Bicuspid Valve with Calcification

PHOTOS

Elderly woman dies suddenly in the community. Photo of her heart (doesn’t say specifically which bit).

?bicuspid valve with calcification

Other options included acute endocarditis, subacute endocarditis, marantic endocarditis

Young man in his 20s dies whilst exercising. Photo of ventricles. What is the cause of death.

LV looked thickened (asymmetrical) – HOCM

Other options included ischaemic heart disease and hypertensive heart disease

Photo of underside of brain with herniation. Arrow pointed to parahippocampalgyrus and asked to identify.

Man dies after a long illness. Not given any further details. Photo of lung with ?cavitating lesions ?very severe bronchiectasis. Asked for diagnosis.

Options included TB, parasitic infection, cystic fibrosis, metastatic carcinoma

Photo of breast lesion - ?lactating adenoma

Options included fibrocystic change, colloid carcinoma

Elderly man with testicular tumour. Photo looked like lymphoma.

Options included various germ cell tumours, spermatocytic seminoma

Photo of a lesion from the cheek of an elderly female. Looked like lentigomaligna.

Photo of a breast lesion. Sclerotic tissue with calcification ?sclerosedfibroadenoma. No obvious glandular tissue. Asked for management

Options included back to routine screening, excision

Photo of FNA of salivary gland tumour. Looked cellular, not obvious malignant. Options included mixed tumour, Warthins tumour, oncocytoma, acinic cell carcinoma, adenoid cystic carcinoma

Photo of gynae cytology. Looked like koilocytes. Told in question that patient tests high risk HPV positive. Asked for management. Options included colposcopy, repeat smears

Photo of lesion from hand. Looked like granuloma annulare with central necrobiotic collagen and palisading (photo wasn’t great quality). Can’t remember other options

Photo of parathyroid adenoma. Asked for biochemical profile i.e. PTH, Ca, Phosphate.

Man dies in hospital. Photo of post mortem lung history. Looked like diffuse lung injury with hyaline membranes in alveoli

Photo of FNA of lymph node. Told patient had melanoma previously. Options included metastatic melanoma, normal, various lymphomas

Photo of lymph node biopsy. Refractile material - ?silicosis. Can’t remember other options

Photo of refractile material from lung of IVDU. Options included injected foreign material, inhaled foreign material, can’t remember others

Photo of small bowel biopsy with Whipples. Asked which test is LEAST helpful in making diagnosis. Options included D-PAS, tissue PCR, blood PCR, EM, stool culture

Alcoholic dies in community. Photo of liver (looks like fatty liver). If I remember rightly they say the blood alcohol is normal. Asked which test most useful to establish cause of death – B hydroxybutyrate.

Photo of immunofluorescence in skin biopsy – liner staining at DEJ – bullous pemphigoid. Other options included dermatitis herpetiformis, pemphigus vulgaris

Man dies in community – something about neglect. Photo of stomach mucosa from post mortem. Multiple small haemorrhages / erosions. Asked for likely cause of death. Looked like Wischnewski spots from hypothermia. Other options included IHD, stroke.

Photo of prostate adenocarcinoma with well formed glands. Asked for gleason grade GROUP (not grade). Options 1-5.

Photo of bladder biopsy with malakoplakia. Arrows pointed to intracellular concretions and asked what these contain – calcium.

Photo of coronal section from brain with multiple abscesses/infective lesions. Told patients is 6 months post renal transplant and has had pneumonia before neurological symptoms.

Options included toxoplasmosis, aspergillosis

Man has sudden onset abdominal pain and dies in hospital. Photo of stomach mucosa fungating/ulcerating lesion. Asked for likely cause of pain. Options included perforation into lesser sac, invasion into aorta, invasion into pancreas, malignant transformation with perineural invasion.

Photo of BCC. Told patient has genetic predisposition syndrome. Asked for molecular alteration. ?Gorlins – PTCH gene. Other options included PTEN.

Photo of products of conception – looked like complete mole. Asked for likely karyotype. 46XX

Photo of liver biopsy with Mallory’s hyaline bodies. Asked what these are due to – accumulation of intermediate filaments. Can’t remember other options.

Photo of lobular carcinoma. Asked for likely receptor profile – ER/PR, Her2 and E-cad.

Photo of small bowel biopsy with Giardia.

30. ??

EMQs

Question about the aetiology of vascular tumours e.g. angiosarcoma occurring in lymphedema after breast surgery, pyogenic granuloma occurring on gums of pregnant woman, liver tumour after thorotrast given for imaging brain tumour in childhood, bacilliaryangiomatosis. There WASN’T Kaposi sarcoma.
Question about the likely cell of origin or location of change in various endocrine disorders e.g. Adrenocortical adenoma, parathyroid adenoma, Vitamin A toxicity.

Options included things like zonaglomerulosa, zonafasciculata, neurons, water clear cells.

Story of apical lung tumour invading various cranial nerves and sympathetic chain – had to identify which cranial nerve was responsible for tongue deviation, insensate palate, sternocleidomastoid malfunction. Had to identify which location could account for all these changes – jugular fossa / cervical spinal cord

Infectious aetiology of various conditions – 4 year old with meningitis incl petechial rash, child with bloody diarrhoea and renal failure (E.Coli), infant with respiratory infection (RSV), congenital infection with cerebral calcification (I think CMV classically causes calcification).

Aetiology of various gynae findings in cytology – actinomyces, high risk HPV subtypes as a cause of CIN, asked about what is in the cervical vaccine e.g. live virus or inactivated, trichomonas

Different nasal tumours. All present with epistaxis and nasal stuffiness. I think the descriptions matched angiofibroma in young man, embryonalrhabdomyocarcoma with description of cambium layer, olfactory neuroma, nasopharyngeal carcinoma. Can’t remember the rest.

Lymphoma stem with descriptions (all relatively similar sounding with diffuse infiltrate of medium cells etc). Need to know immuno.

Had to match descriptions of disorders to paraneoplastic syndromes. E.g. weakness from Lambert Eaton, hypercalcaemia from PTH related peptide, Cushings from ectopic ACTH

Molecular stem – had to match molecular aberration with disorder. E.g. PDGFRA in GIST, MDMT in liposarcoma, 8:14 translocation in Burkitt. There was a question about a paediatric sarcoma.

Described various disorders and asked for aetiology – e.g. keloid on ear due to trauma, ?sarcoid (hilar lymphadenopathy and shin lesions I presumed erythema nodosum) – I put autoimmune although I don’t think we really know the mechanism of sarcoid. Can’t remember others but options included things like allergic, traumatic, autoimmune.

SBAs

Young woman, primigravida, misses antenatal scans. Has early stillborn baby. Describes limb shortening ‘but straight’ with large head and large brain: liver ratio. Asked for likely cause ?pre-eclampsia (malperfusionusualy spares the head) ?skeletal dysplasia (common cause of stillbirth) can’t remember other options

Child with rash, Darrier’s sign – urticariapigmentosa. Options included mastocytosis (can’t remember others)

Question about diabetic ketoacidosis and what finding is LEAST likely to be present options included raised glucose in vitreous, raised urea and electrolytes in vitreous, raised HbA1c, aldehyde.

Given list of causes of death and asked which it is most appropriate to register without discussing with coroner – hospital acquired pneumonia. Other options included things like iatrogenic causes of death, occupational.

Question about molecular basis of microsattelite instability in Lynch. Didn’t ask for proteins mutated. Asked what was least likely to be present – options included things like somatic hypermutation.

Lump under areola with discharge. Later causes fistula. Can’t remember all options but they included duct ectasia, abscess and cancer. I went with duct ectasia as my understanding is it starts with this, get squamous metaplasia, duct blocks, gets inflamed, eventually get a fistula. Abscesses classically in lactating women and didn’t describe being unwell but many people put abscess.

Asked how to handle a fresh lymph node with risk of infection – options included handle in cupboard with extractor, wear mask and goggles, cut as normal but wash board afterwards, don’t cut fresh and fix.

Asked for molecular alteration in papillary thyroid carcinoma – BRAF

Calcium oxalate crystal in urine after man drinks fluid in gym – ethylene glycol poisoning.

See maltese cross on birefringence – starch

Patient with sickle cell anaemia has cholecystectomy – what is likely to be the primary content of the gallstones – bilirubin. Other options were cholesterol etc

Describe Cushings with high dose dexamethasone test positive. Asked for likely findings. I think this was pituitary adenoma and hence would expect bilateral adrenal hyperplasia driven by pituitary ACTH. Ectopic ACTH doesn’t respond to the high dose dex.

Describe dendritic cells in skin and asked for function – antigen presentation.

Described vulval Paget’s and gave immune profile. Had to say whether primary / secondary etc

Asked about basic liver histology – structure and function. Had to pick which was incorrect. Options included things like zone 3 most prone to hypoxia, bile cannaliculi bounded by apical membranes of hepatocytes, sinusoids stain with CD34 (I think this was the incorrect one)

Scenario where trainee writes report with features (cellular heterogeneity, hyperchromasia, architectural uniformity, necrosis) and calls it DCIS. Didn’t tell you whether low grade or high grade so I think this is a bad question. Because then asked which feature least consistent with DCIS. ?cellular heterogeneity as this sounds more like usual type hyperplasia

Young man with proximal weakness. Can’t remember the options but sounded like Duchenne muscular dystrophy

Given list of features and asked which is a feature of craniopharynioma – keratin formation.

Man with cancer and darkened axillae – acanthosisnigricans.

Patient previously diagnosed with Tetraology of Fallot –asked which is NOT a classical features – ASD.

Tall man with what sounded like Marfan’s. Dies – asked for likely cause of death – probably aortic dissection. Can’t remember other options

Asked what stain to use for neurofibrillary tangles when trying to diagnose dementia in a post mortem brain – hyperphosphorylated tau.

Question about different types of amyloid. Patient had chronic inflammatory condition – serum amyloid A protein. Other options included B2 microglobulin, B amyloid, transthyretin.

Question about some form of heart disease and what the most likely finding in the lung would be – pulmonary hypertension.

Describes a vasculitis. Asked what ANCA stands for.

Asked what pT0 means.

Asked what features inform melanoma staging – ulceration, Breslow and mitotic count.

List of different cases waiting to be reported and asked which was most important – rejection of graft will be most important. Other options included melanoma and various malignancies, sentinel node biopsy.

Described macro lung at cut up. Described all kinds of features like distance from bronchial resection margin and pleura and atelectasis of lung. Asked which feature would actually affect staging – atelectasis of whole lung. Distance from CARINA would affect but not distance from bronchial resection margin per se. The distance to pleura also wouldn’t affect but pleural invasion would.

Diabetic patient with renal disease. Asked what process causes it – I think formation of advanced glycosylation end products causing microvascular disease. Other options included side effect of diabetic medication causing glomerulonephritis. Can’t remember other options.

Described post-streptococcal disease with rheumatic fever. Asked which feature LEAST likely to be associated. I think it’s jaundice. Other options included chorea (get Sydenham’s chorea), rash, subcutaneous nodules.

What are adrenaline – amines.

Had a list of immuno e.g. p63, ER, CK5, CK14 asked which is least helpful making a diagnosis in breast cance, Her2. Can’t remember specific scenario so make sure understand their uses and what they mean.

Asked what the best reason to do CPD is. Options included things like to make indemnity insurance valid, because it’s needed for revalidation. Not a great question. Best answer was something along the lines of because you need it to maintain competence in your clinical knowledge.

Alcoholic dies in house fire. No obvious interference. Which feature would suggest he was alive at the time of the fire? High carbon monoxide.