Infection, Haematology & Oncology

A 62-year-old man has a haemoglobin of 98 g/L with an MCV of 68 fL and a low ferritin. He has no obvious source of blood loss. What is the most appropriate next step?

• ARequest a bone marrow biopsy to exclude a primary haematological cause
• BUrgent referral for upper and lower gastrointestinal investigation✓
• CReassure and give dietary advice, since dietary iron deficiency is common at this age
• DStart oral ferrous sulfate and recheck the full blood count in three months

Answer: Iron-deficiency anaemia in a man, or a woman after the menopause, is assumed to come from gastrointestinal blood loss until proven otherwise. NICE now uses a FIT test to guide suspected-cancer referral in adults with iron-deficiency anaemia (referring on the two-week pathway if FIT is 10 micrograms per gram or more, and without delay if clinical concern is strong), and the British Society of Gastroenterology recommends urgent upper and lower gastrointestinal investigation for men and post-menopausal women with confirmed iron deficiency. Iron is given alongside, not instead of, investigation.

A 55-year-old woman receiving chemotherapy has a temperature of 38.4°C. Her neutrophil count is 0.3 × 10⁹/L. What is the most appropriate immediate action?

• ATake blood cultures, a chest X-ray and a urine sample, and wait for the culture results before starting any antibiotic so that the choice is targeted to the organism
• BGive paracetamol and observe on the assessment unit for four hours, starting antibiotics only if the temperature has not settled by then
• CGive intravenous broad-spectrum antibiotics such as piperacillin-tazobactam within one hour, without waiting for culture results✓
• DGive oral co-amoxiclav to take at home, with advice to return if the temperature is still raised when she is reviewed in the clinic in the morning

Answer: Neutropenic sepsis is a medical emergency: empirical intravenous antibiotics are started within an hour of presentation, after cultures are taken but without waiting for results. Delay is associated with a marked increase in mortality.

A 48-year-old woman has a swollen, tender right calf. Her two-level Wells score for DVT is 3. What is the most appropriate next step?

• AProximal leg-vein ultrasound within four hours, with interim anticoagulation if it will be delayed✓
• BA D-dimer test, with discharge and no further imaging if the result comes back negative
• CA chest X-ray and ECG to exclude pulmonary embolism before any leg imaging is arranged
• DGraduated compression stockings and simple analgesia, with review in the clinic in a week

Answer: A Wells score of 2 or more means DVT is 'likely', so NICE recommends proximal leg-vein ultrasound within four hours, or interim anticoagulation and a scan within 24 hours if that is not possible. D-dimer is used to rule out DVT only when the score makes it 'unlikely'.

A 30-year-old man from a high-incidence country has six weeks of cough, night sweats and weight loss, and his sputum is positive for acid-fast bacilli. Which drugs form the standard initial phase of treatment?

• AAmoxicillin and clarithromycin for two weeks
• BRifampicin, isoniazid, pyrazinamide and ethambutol for two months✓
• CRifampicin and isoniazid alone for six months, with pyridoxine to prevent neuropathy
• DCiprofloxacin for three months

Answer: Standard treatment for drug-sensitive pulmonary tuberculosis is four drugs for two months (rifampicin, isoniazid, pyrazinamide and ethambutol), then rifampicin and isoniazid for a further four months. Tuberculosis is a notifiable disease and contacts are traced.

A 40-year-old man has a hot, red, tender, spreading area of skin on his lower leg with a temperature of 37.9°C. He is otherwise well and has no allergies. What is the first-line antibiotic?

• AMetronidazole
• BNitrofurantoin
• CTrimethoprim
• DFlucloxacillin✓

Answer: Cellulitis is most often caused by streptococci or Staphylococcus aureus, and NICE recommends flucloxacillin as first-line treatment (clarithromycin or doxycycline if penicillin-allergic). The other antibiotics do not cover the likely organisms.

A 58-year-old man reports painless visible blood in his urine on two occasions. Urine culture is negative. What is the most appropriate action?

• ARequest an ultrasound and review the result in routine clinic
• BUrgent two-week-wait referral to urology for suspected bladder cancer✓
• CTreat empirically for a urinary infection and review
• DReassure and repeat the urine test in six months

Answer: Unexplained visible haematuria in a person aged 45 or over meets the NICE criteria for an urgent suspected-cancer referral, because bladder cancer commonly presents this way. It should not be attributed to infection when the culture is negative.

A 24-year-old man with sickle cell disease attends with severe pain in his back and legs typical of his previous crises. What is the priority in the first 30 minutes?

• AAnti-inflammatory tablets and paracetamol only, to avoid the risk of opioid dependence in a young patient
• BBlood transfusion before any analgesia
• CIntravenous antibiotics and observation until the pain settles, since infection is the usual trigger
• DEffective analgesia, with strong opioids if needed, plus oxygen if hypoxic and fluids✓

Answer: In a sickle cell painful crisis, adequate analgesia should be given within 30 minutes of arrival, titrated to effect and including strong opioids where necessary, alongside oxygen for hypoxia, hydration and a search for precipitants. Transfusion is not routine for uncomplicated painful crises.

A 70-year-old woman on warfarin for atrial fibrillation has an INR of 9.0 with no bleeding. What is the most appropriate management?

• AGive fresh frozen plasma
• BWithhold warfarin and give oral vitamin K, then recheck the INR✓
• CContinue warfarin at a reduced dose
• DGive prothrombin complex concentrate immediately to reverse the warfarin effect

Answer: An INR above 8 without bleeding is managed by stopping warfarin and giving oral vitamin K (phytomenadione), repeating the INR the next day. Prothrombin complex concentrate is reserved for major bleeding.

A 35-year-old woman has fatigue, a sore tongue and paraesthesia in her feet. Her haemoglobin is low with an MCV of 110 fL. What is the most likely cause?

• AAnaemia of chronic disease
• BThalassaemia trait
• CVitamin B12 deficiency✓
• DIron-deficiency anaemia

Answer: Macrocytic anaemia with glossitis and peripheral neuropathy points to vitamin B12 deficiency, most often from pernicious anaemia. Iron deficiency and thalassaemia cause microcytosis.

A 45-year-old man returning from sub-Saharan Africa has fever, rigors and a headache. What is the most important investigation?

• AA chest X-ray to look for pneumonia, the commonest cause of fever
• BThick and thin blood films for malaria, repeated if negative✓
• CA throat swab for streptococcal infection
• DAn abdominal ultrasound to look for a liver abscess or an enlarged spleen

Answer: Fever in a traveller from a malaria-endemic area is malaria until proven otherwise; falciparum malaria can be fatal within days, and up to three sets of blood films (or a rapid antigen test) are needed before it is excluded.

A 60-year-old man has a painless lump in his neck, night sweats and weight loss. What is the most appropriate action?

• AReassurance, since painless lumps are usually benign
• BA course of antibiotics and review in a month
• CUrgent two-week-wait referral for suspected lymphoma✓
• DA trial of antihistamines

Answer: Unexplained lymphadenopathy with 'B symptoms' meets the criteria for urgent referral for suspected lymphoma; a biopsy is needed for diagnosis.

A 30-year-old woman has a positive urinary pregnancy test and is rhesus D negative. Why does this matter?

• AHer baby will definitely be rhesus negative, so no special precautions are needed at any stage of the pregnancy
• BShe cannot have a normal pregnancy, and will need to be delivered by planned caesarean section at 37 weeks to protect the baby
• CShe may need anti-D immunoglobulin at sensitising events and at 28 weeks to prevent haemolytic disease in a future baby✓
• DShe needs a blood transfusion of rhesus-negative blood during pregnancy to replace the antibodies she will make

Answer: Rhesus-negative women can develop antibodies against a rhesus-positive baby's cells, harming later pregnancies; anti-D given at sensitising events and routinely in the third trimester prevents this.