Case 7: A man with right upper quadrant pain
A 53-year-old man presented to his GP with a 3-week history of loss of weight, early satiety and discomfort in the right upper quadrant of the abdomen. He had a past history of a Duke’s B colorectal cancer 3 years earlier, treated with hemicolectomy and no adjuvant therapy.
On examination he had lost weight. There were no palpable lymph nodes in any nodal region, and no anaemia. He was possibly mildly icteric. There was tenderness in the right upper quadrant with liver enlargement that measured 19 cm in the mid-clavicular line. There was no other organomegaly and no free peritoneal fluid detected.
- What is the most likely diagnosis?
- What factors correlate with survival?
- What are the approaches to management?
Case 8: A woman with hip pain
A 46-year-old woman presented with a 2-week history of pain in the left hip. She had a fall while gardening and the hip has been painful ever since. She had occasional backache, but not worse recently. Pain was worse on weight bearing, flexion and abduction of the hip.
She had breast cancer 4 years ago treated with a wide local excision and radiotherapy for a 1.8 cm grade 2 invasive ductal carcinoma and she continues on tamoxifen.
On examination there was tenderness over the left hip with reduced flexion and abduction due to pain. There was some tenderness over L2/L3 spine and left lateral ribs (8, 9, 10). There was no other focal tenderness in the axial or peripheral skeleton.
- What investigations may be helpful in obtaining a diagnosis?
- What are the approaches to management?
- What are the main goals of management?
Case 9: A man with breathlessness on exertion
A 59-year-old man presented with a 3-week history of dyspnoea, particularly on exertion. He had an occasional cough over the same time period, which was dry and unproductive. He had a dull chest discomfort as tightness.
On examination there was nicotine staining of the left index and second fingers. There was no peripheral lymphadenopathy. There was no evidence of heart failure, and JVP and heart sounds were normal. On chest examination there was reduced expansion on the right, with decreased tactile vocal fremitus, dullness to percussion and diminished breath sounds. Examination of the left hemithorax was unremarkable. PEFR was 450 L/min. All other examination was unremarkable.
- What do the clinical signs suggest?
- What is the most likely underlying cause?
- What is the approach to management?
Case 10: A young woman with a neck swelling
A 39-year-old woman presented with a 1-month history of painless swelling in her left neck and 10 kg weight loss over the preceding 3 months. An ENT surgeon performed a thorough examination of the nasopharynx, oropharynx and indirect laryngoscopy and found no abnormalities. A thoracic CT scan was reported as showing no abnormalities. She had a left low anterior triangle lymph node biopsy, which demonstrated a poorly differentiated squamous cell carcinoma with keratin pearl formation.
- What is the likelihood of finding a primary site?
- What is the likely site if the same histology was found in an inguinal lymph node?
- What investigations should be considered if this was adenocarcinoma instead?
Case 11: A history of asbestos exposure
A 62-year-old man presented with a pleural effusion and had a history of asbestos exposure. A pleural biopsy demonstrated malignant mesothelioma.
- From which anatomical structures can this tumour develop?
- What is the risk of lung cancer associated with asbestos exposure?
- What is the risk of mesothelioma with smoking?
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