Breast and Endocrine Surgery

A 20-year-old woman who has undergone a total thyroidectomy for a well-differentiated papillary carcinoma returns for a follow-up appointment. She is feeling well, and the surgeon wants to screen for any potential recurrence of the disease. Which of the following blood tests would be most useful in detecting recurrence?

A 19-year-old female college student presents to the clinic with concerns about a non-tender lump in her left breast, which she first noticed a few weeks ago. The lump is mobile, smooth, and approximately 2 cm in diameter. She is otherwise healthy and has no significant family history of breast cancer. On examination, the lump is located in the upper outer quadrant of the left breast, and it is freely mobile, with no attachment to the skin or underlying tissues. The overlying skin appears normal. There is no evidence of nipple discharge or lymphadenopathy. What is the most likely cause of the lump?

A 72-year-old woman presents to her primary care physician with concerns about two breast lumps that she recently discovered. One is located in the upper outer quadrant of the left breast, and the other is in the lower inner quadrant. She has a history of breast cancer in her right breast, diagnosed 5 years ago, for which she underwent a lumpectomy and radiation therapy. She is otherwise in good health and has no new systemic symptoms. The lumps are firm and non-tender, and there is no associated nipple discharge or skin changes. What is the most likely underlying diagnosis?

A 50-year-old woman with a history of estrogen receptor-positive breast cancer is started on tamoxifen therapy to reduce the risk of recurrence. She is being monitored for side effects and long-term complications related to the medication. Tamoxifen is an estrogen receptor antagonist in breast tissue, but she is concerned about the potential effects of tamoxifen on other organs, especially after learning about the risks associated with the medication. Which malignancy is most commonly associated with tamoxifen use?

A 28-year-old woman presents to her general practitioner with a three-day history of fever, diarrhea, and fatigue. Concerned about a possible thyroid disorder, the physician orders thyroid function tests, which reveal the following results:
TSH: <0.01 Free T4: 30 T3: 9.0 Given these findings, what is the most likely interpretation of her thyroid function tests?

A 56-year-old woman undergoes a wide local excision and axillary node sampling for a breast mass. The histology confirms a 2.5 cm invasive ductal carcinoma (grade 1), which is completely excised. No axillary lymph node involvement is noted. Given the findings and the patient’s age, what is the most appropriate next step in her management?

A 44-year-old woman presents with a 1.5 cm mass in the upper outer quadrant of her right breast. Imaging, histology, and clinical examination confirm the mass is malignant, with no clinical evidence of axillary nodal involvement. What is the most appropriate treatment for this patient?

An 82-year-old woman from a nursing home is admitted to the orthopedic ward after sustaining a hip fracture. On examination, she is acutely confused, agitated, and appears dehydrated. She is unable to provide a coherent history, but family members report that she has a past history of osteoporosis, hypertension, and chronic kidney disease. Her medication includes antihypertensives and calcium supplements. Lab results reveal a calcium level of 2.95 mmol/L (elevated) and a parathyroid hormone (PTH) level of 12 pmol/L (elevated). Based on her clinical presentation and lab findings, what is the most appropriate course of action?

A 42-year-old lady presents with symptoms of irritability and altered bowel habits. On examination, she is noted to have a smooth enlargement of the thyroid gland. Thyroid function tests reveal:
TSH: 0.1 μg/L
Free T4: 35 pmol/L
What is the most likely underlying diagnosis?

A 58-year-old woman presents to the Emergency Department with a large fluctuant swelling at the site of a recent insect bite. She is anxious, tachycardic, and pyrexial. An ECG shows atrial fibrillation, and she is noted to have a goitre. The swelling at the site of the bite requires surgical drainage. Which of the following classes of drug would be most appropriate as part of her preoperative preparation for surgery?

A 45-year-old woman presents to the emergency department two hours after undergoing total thyroidectomy for a large multinodular goitre. She is now experiencing difficulty breathing and is noted to have stridor. Upon examination, her wound appears intact and clean, but there is a visible swelling at the site of the operation. Her oxygen saturation is 88% on room air, and she is mildly tachycardic. What is the most likely cause of her symptoms?

A 27-year-old woman presents to her primary care physician with a palpable breast lump. She has a history of breast augmentation with implants and reports no trauma to the area. On examination, a smooth, non-tender lump is noted, and there is no evidence of implant rupture. What is the most appropriate next step in imaging evaluation for this patient?

A 28-year-old female presents with a painless lump in the upper outer quadrant of her left breast. She is concerned about the lump, and imaging with ultrasound reveals an indeterminate result (U3). Two core needle biopsies are performed, and both show normal breast tissue (B1). Given this scenario, what is the most appropriate next step in management?

A 52-year-old woman presents with an episode of nipple discharge. The discharge is usually clear, but on examination, it is seen to originate from a single duct. When tested with a labstix, the discharge is shown to contain blood. Imaging and examination do not reveal any obvious mass lesion. Based on these findings, what is the most likely diagnosis?

A 72-year-old woman with a history of back pain and chronic renal failure presents for further evaluation. Blood tests show the following results:
Calcium (Ca2+) = 2.03 mmol/L (Reference range: 2.15-2.55 mmol/L)
Parathyroid hormone (PTH) = 10.4 pmol/L (Reference range: 1-6.5 pmol/L)
Phosphate = 0.70 mmol/L (Reference range: 0.6-1.25 mmol/L)
Given her clinical background and laboratory findings, what is the most likely diagnosis?

A 43-year-old woman with a history of hypertension is suspected of having a pheochromocytoma due to intermittent episodes of hypertension, headaches, and palpitations. Which of the following investigations is most likely to be beneficial in confirming the diagnosis?

A 20-year-old woman presents with a firm, mobile mass in the upper outer quadrant of her right breast. On examination, the lump is well-defined and moves freely. She is otherwise healthy, and there is no history of trauma. What is the most likely underlying disease process?

A 46-year-old man is admitted to the hospital after sustaining a femoral shaft fracture while walking his dog. He has no neurovascular deficit distal to the fracture site. Upon examination, a large firm nodule is noted in the left lobe of his thyroid, but there is no associated lymphadenopathy. What is the most likely underlying cause?

A 48-year-old woman presents with discomfort in her right breast. On examination, there is a discrete, soft, fluctuant area in the upper outer quadrant of her right breast. A mammogram is performed, and a halo sign is noted by the radiologist. What is the most likely explanation for this process?

A 33-year-old woman presents with a recently diagnosed goitre, and Hashimoto’s thyroiditis is suspected. Which of the blood tests listed below is most likely to be abnormal in this case?

A 74-year-old woman with a history of hypertension and osteoarthritis presents to her general practitioner with concerns about a new rash on her breast. She has noticed that a red, itchy rash appeared on her nipple a few weeks ago and has progressively spread to the surrounding areola. The rash is associated with mild tenderness and occasional itching. She reports no history of trauma, discharge, or changes in the shape of the breast. On examination, the nipple appears erythematous with scaling and crusting. The surrounding areola is also involved, but there is no palpable mass or axillary lymphadenopathy. She denies any pain or systemic symptoms like weight loss or fever. Given her age and presentation, what is the most likely diagnosis?

A 30-year-old woman presents to the clinic with a painful, swollen mass in the midline of her neck, just above the level of the thyroid cartilage. She has had this lump for several years, but it has recently become red, warm, and increasingly tender. She is concerned because the swelling is enlarging, and she is worried it may be infected. Upon examination, the mass is soft, mobile, and located at the level of the hyoid bone. It is tender to palpation, and there is evidence of mild erythema over the overlying skin. Ultrasound imaging confirms the diagnosis of a thyroglossal cyst with signs of acute infection. After discussion, she requests definitive treatment for her condition. What is the most appropriate course of action?

A 30-year-old woman presents to the clinic with a painful, swollen mass in the midline of her neck, just above the level of the thyroid cartilage. She has had this lump for several years, but it has recently become red, warm, and increasingly tender. She is concerned because the swelling is enlarging, and she is worried it may be infected. Upon examination, the mass is soft, mobile, and located at the level of the hyoid bone. It is tender to palpation, and there is evidence of mild erythema over the overlying skin. Ultrasound imaging confirms the diagnosis of a thyroglossal cyst with signs of acute infection. After discussion, she requests definitive treatment for her condition. What is the most appropriate course of action?

An 18-year-old female presents with three nodules palpated in the right lobe of her thyroid. She is clinically euthyroid and has no signs of hyperthyroidism or hypothyroidism. Upon further examination, she also has cervical lymphadenopathy. There is no significant family history of thyroid disease. Given these findings, what is the most likely cause of the thyroid nodules?

A 45-year-old male presents with episodic headaches, sweating, and palpitations. His blood pressure is elevated at 180/110 mmHg during the visit. Imaging shows a mass in the right adrenal gland, which is consistent with a phaeochromocytoma. Urinary catecholamines and metanephrines are elevated. Which of the following statements regarding phaeochromocytomas is untrue?

A 53-year-old woman presents to her healthcare provider with a complaint of a bloody nipple discharge, which she first noticed approximately 2 weeks ago. The discharge is intermittent and associated with mild discomfort. She is otherwise asymptomatic and has no history of breast pain or significant changes in the breast tissue. She has no family history of breast cancer or other significant medical conditions. On physical examination, her right breast is unremarkable except for a small, firm, and non-tender mass at the nipple-areolar complex. There is no axillary lymphadenopathy or signs of inflammation.
Mammography is performed, revealing microcalcifications within the breast tissue behind the nipple-areolar complex. The pattern of calcifications is irregular, and the radiologist notes some clustering in a ductal distribution. Given the suspicious findings on imaging, a core needle biopsy is performed. Histopathological examination reveals benign background changes in the tissue, but the biopsy also demonstrates the presence of comedo necrosis within ductal structures, with cells showing high-grade nuclear atypia. Importantly, the basement membrane remains intact, and no evidence of invasion is seen.
Considering the patient’s presentation, radiologic findings, and biopsy results, what is the most likely diagnosis?

A 45-year-old man presents to the clinic with a complaint of breast enlargement that has developed over the past few months. He is otherwise healthy and does not report any significant weight gain or changes in his diet. He is currently taking the following medications for various health conditions:
Spironolactone 50 mg daily for chronic hypertension
Cimetidine 400 mg twice daily for gastroesophageal reflux disease (GERD)
Methyldopa 250 mg twice daily for managing hypertension
He reports mild tenderness in both breasts, with the left side slightly more prominent. The enlargement is non-tender and soft, with no associated pain or nipple discharge. He denies any family history of breast cancer or endocrine disorders. Upon physical examination, there is bilateral, symmetric enlargement of the breast tissue without any palpable mass. There are no signs of systemic illness, and his general physical examination is otherwise unremarkable.
Given his current medication regimen and symptoms, what is the most likely cause of his breast enlargement?

A 34-year-old woman presents to the endocrinology clinic with a painless thyroid nodule that she noticed a few months ago. She has a strong family history of thyroid disease, with both of her sisters having undergone total thyroidectomy in their early 30s due to thyroid abnormalities. She also reports long-standing hypertension that has been difficult to control despite multiple antihypertensive medications. She denies any weight changes, dysphagia, hoarseness, or compressive symptoms.
On examination, she has a firm, non-tender, solitary nodule in the right thyroid lobe without overlying skin changes. There is no cervical lymphadenopathy. Blood pressure is elevated at 160/95 mmHg, and her resting heart rate is 92 bpm. Laboratory investigations reveal normal thyroid function tests, but serum calcitonin is markedly elevated. Genetic testing for RET proto-oncogene mutations is positive. Given her presentation, family history, and laboratory findings, what is the most likely diagnosis?

A 19-year-old male presents to the clinic with progressive bilateral gynecomastia and nipple discharge over the past six months. He also reports recent onset of headaches and worsening peripheral vision. He denies any history of steroid use, medications, or illicit drug use. There is no significant family history of endocrine disorders.
On physical examination, he has noticeable bilateral gynecomastia with milky nipple discharge. Visual field testing reveals bitemporal hemianopia. Neurological examination is otherwise unremarkable. Blood pressure and other vital signs are within normal limits. Given his symptoms, which of the following blood tests is most likely to be abnormal?

An 8-year-old boy is brought to the clinic by his parents due to a lump in his neck that they first noticed several months ago. The lump has gradually increased in size but is not painful. There is no history of fever, weight loss, or difficulty swallowing. His parents note that the lump moves when he sticks out his tongue.
On physical examination, there is a well-defined, non-tender, midline neck mass located just below the hyoid bone. The mass elevates with tongue protrusion and swallowing. There are no signs of infection or inflammation, and the rest of the examination is unremarkable.
What is the most likely diagnosis?

A 74-year-old woman presents to the breast clinic with a painless lump in her left breast that she noticed a few weeks ago. She has no history of weight loss, nipple discharge, or skin changes. There is no family history of breast cancer.
On physical examination, a soft, mobile, non-tender mass is palpated in the upper outer quadrant of the left breast. There are no signs of skin retraction or ulceration, and no axillary lymphadenopathy is detected. The remainder of her examination is unremarkable.
The lump is surgically excised and sent for histopathological evaluation. On gross examination, the mass has a gelatinous, grey appearance.
What is the most likely diagnosis?

A 52-year-old woman presents to the surgical clinic with a gradually enlarging swelling in the front of her neck over the past few months. She reports occasional difficulty swallowing but denies pain, hoarseness, or compressive symptoms. She has no significant weight changes, heat or cold intolerance, or palpitations. Her medical history includes a long-standing psychiatric disorder for which she has been taking medication for several years.
On examination, she has a diffuse, non-tender goitre without nodularity. There is no cervical lymphadenopathy, and no signs of hyperthyroidism or hypothyroidism are evident.
Which of the following medications is most likely responsible for her condition?

A 38-year-old man presents for routine health screening and is found to have a blood pressure of 175/110 mmHg. He denies headaches, palpitations, diaphoresis, or weight changes. His past medical history is unremarkable, and he is not on any medications. There is no family history of hypertension or endocrine disorders.
On examination, his heart rate is 88 beats per minute, and he has no signs of Cushing’s syndrome, thyroid dysfunction, or renal bruits. Routine blood tests, including kidney function and electrolytes, are normal. A CT scan of the abdomen reveals a 4 cm mass in the left adrenal gland. Further biochemical testing shows significantly elevated plasma metanephrines.
What is the most likely diagnosis?

A 46-year-old woman is referred to the endocrine surgery clinic for evaluation of a tender neck swelling that has been present for two weeks. She reports a recent upper respiratory tract infection and now experiences mild fever and fatigue. Blood tests reveal the following:
TSH: <0.1 mU/L T4: 188 nmol/L Hb: 14.2 g/dL Plt: 377 × 10⁹/L WBC: 6.4 × 10⁹/L ESR: 65 mm/hr A technetium thyroid scan shows globally reduced uptake. On examination, her thyroid gland is diffusely tender without lymphadenopathy. What is the most likely diagnosis?

A 52-year-old woman presents to the emergency department with an acutely ischemic right arm. She reports a sudden onset of pain and numbness. On examination, her right arm is cold, pale, and pulseless. She has a history of palpitations and has been feeling generally unwell over the past few weeks. A 12-lead ECG reveals fast atrial fibrillation. Blood tests show the following:
Free T4: 20 pmol/L
TSH: <0.01 mU/L What is the most likely diagnosis?

A 33-year-old woman presents to the clinic with a 3-month history of palpitations and irritability. She also reports feeling jittery, with a decreased tolerance to heat. On examination, she appears anxious, has a slightly increased heart rate, and a mildly elevated blood pressure. Laboratory results are as follows:
Thyroid function:
Free T4: 40 pmol/L
TSH: <0.1 mIU/L Free T3: 25 pmol/L (normal 3.5–7.7 pmol/L) PTH and calcium: PTH: 10 pg/ml (normal 10–55 pg/ml) Calcium: 2.12 mmol/L What is the most likely diagnosis?

You are a specialist trainee in an endocrinology clinic, and the medical team has referred a 55-year-old man for a parathyroidectomy. He has a corrected calcium level of 2.82 mmol/L (elevated) and a PTH level of 11 pmol/L (elevated). His past medical history includes a history of nephrolithiasis, and his recent bone mineral density scan shows a reduction of 3.2 standard deviations below peak bone mass at the lumbar spine. He is also under 50 years of age. Based on these findings, which of the following is not an indication for parathyroidectomy?

A 52-year-old woman with a known history of Hashimoto’s thyroiditis presents with a rapidly increasing neck swelling over the past 3 months. She also reports difficulty swallowing solids (dysphagia). On examination, there is an asymmetrical swelling of the thyroid gland. What is the most likely diagnosis?

A 55-year-old man is on the intensive care unit after undergoing open aortic surgery. He has been maintained on total parenteral nutrition for several months. Clinically, he is euthyroid, but thyroid function tests show a low TSH and low T4. What is the most likely diagnosis?

A 58-year-old woman presents to the endocrine clinic with a complaint of progressive neck swelling over the past six months. She reports occasional difficulty swallowing, especially with solid foods, and a sensation of tightness in her throat. She also mentions feeling increasingly fatigued, experiencing cold intolerance, and has gained 8 kg over the last three months despite no change in her diet or physical activity. Her family history is significant for autoimmune thyroid disease, as her mother was diagnosed with Hashimoto’s thyroiditis. The patient has a history of hypertension, well-controlled with medication, and no other significant comorbidities.
On examination, the patient has a firm, non-tender, enlarged thyroid gland with an asymmetrical enlargement, and a palpable nodule in the left lobe of the thyroid. There is no lymphadenopathy. Neurological examination reveals no focal deficits, but she does show some delayed reflexes. Her vitals are stable, and there are no signs of overt hyperthyroidism or hypothyroidism.
Her laboratory results are as follows:
TSH: 5.8 mU/L (normal: 0.5–4.5 mU/L)
Free T4: 12.5 pmol/L (normal: 10–22 pmol/L)
Anti-TPO antibodies: Positive (normal < 34 IU/mL) Anti-thyroglobulin antibodies: Positive (normal < 40 IU/mL) Free T3: 3.0 pmol/L (normal: 3.5–7.7 pmol/L) Calcium: 9.2 mg/dL (normal: 8.5–10.2 mg/dL) PTH: 45 pg/mL (normal: 10–65 pg/mL) Ultrasound of the thyroid: Shows a 2 cm hypoechoic nodule in the left thyroid lobe, consistent with a benign lesion, and diffuse enlargement of the thyroid. Which of the following is the most likely diagnosis?

A 42-year-old woman presents to the clinic with complaints of fatigue, weight gain, and cold intolerance over the past several months. She also reports noticing a swelling in her neck that has gradually increased in size. On examination, she has a diffusely enlarged, firm, and mildly irregular thyroid gland. Her laboratory results show a TSH of 12 mU/L (elevated) and a free T4 of 2 pmol/L (low). Further testing reveals significantly elevated anti-thyroid peroxidase (anti-TPO) antibodies.
What is the most likely cause?

A 53-year-old woman, who recently moved to the UK from the Far East, undergoes a thyroidectomy for a large multinodular goitre with retrosternal extension. The surgery is uneventful, and she is transferred to the recovery area. Shortly after, she develops sudden, profound dyspnoea and hypoxia. On examination, the surgical wound appears healthy and dry, and the drain remains empty.
What is the most likely cause?

A 52-year-old woman presents with a neck swelling. Her general practitioner reports that her TSH level is low at 0.01 mU/L. A thyroid scintigraphy scan demonstrates a hot nodule.
What is the most likely diagnosis?

A 35-year-old woman undergoes a wide local excision for breast cancer. Histology reveals invasive lobular carcinoma with involvement at three resection margins. Cavity shavings taken during the original operation are also involved. Sentinel node biopsy is negative.
What is the most appropriate course of action?

A 43-year-old woman presents to the oncology clinic for follow-up after undergoing a wide local excision and sentinel lymph node biopsy for an invasive ductal carcinoma of the left breast. Her tumor measured 2.8 cm in diameter and was noted to be estrogen receptor (ER) positive, progesterone receptor (PR) negative, and HER2 negative. Histopathology revealed a high mitotic index and a poorly differentiated tumor (grade III). The sentinel lymph node biopsy showed metastasis in two of three sampled lymph nodes. She is otherwise healthy with no known comorbidities.
Which of the following factors provides the most important prognostic information in this patient?

A 53-year-old woman presents to the breast clinic with complaints of a creamy nipple discharge that has been present for several months. She denies any pain, skin changes, or a palpable lump. On examination, she has nipple inversion along with a non-bloody discharge originating from multiple ducts. No discrete masses are noted, and there is no significant axillary lymphadenopathy. She is otherwise healthy and has no family history of breast cancer.
What is the most likely cause of her symptoms?

A 55-year-old woman presents to the breast clinic with nipple discharge and retraction. On examination, there is a slit-like retraction of the nipple with a small amount of cheese-like material at the center. No discrete mass is palpable in the underlying breast, and there is no associated skin dimpling or axillary lymphadenopathy. She has a 30-pack-year smoking history but denies alcohol use or a family history of breast cancer.
Which of the following factors is most strongly associated with the development of this condition?

A 59-year-old man is referred to the endocrine clinic with symptoms of progressive dysphagia over the past few months. On examination, he has a large, palpable goitre, and imaging reveals significant retrosternal extension and features suggestive of a multinodular goitre. Given the size of the goitre and the symptoms of compression, what is the most appropriate course of action?

A 44-year-old woman with a history of renal transplant for end-stage renal failure presents with a pathological fracture of the left femur. Her blood test results are as follows:
Serum Ca2+: 2.80 mmol/L
PTH: 88 pg/ml
Phosphate: 0.30 mmol/L
Given the abnormal lab results, the surgeon decides to perform a parathyroidectomy. When the glands are assessed histologically, which of the following appearances is most likely to be identified?

A 55-year-old woman presents with nipple discharge. On examination, there is a slit-like retraction of the nipple, and in the center of this area, a small amount of cheese-like material is observed. No discrete mass lesion is palpable in the underlying breast. What is the commonest underlying cause?

A 48-year-old woman undergoes a redo thyroidectomy for a multinodular goitre. Twenty-four hours post-operatively, she develops oculogyric crises and diffuse muscle spasm. What is the most appropriate course of action?

A 32-year-old woman presents with a tender breast lump. She has a 2-month-old child. Clinically, there is a tender, fluctuant mass of the breast. What is the most likely explanation for this process?

A 28-year-old man with a history of kidney stones, generalized musculoskeletal pain, and fatigue presents to the clinic. His x-rays reveal widespread osteopaenia with well-circumscribed lucent areas in the bones, particularly around the wrists and spine. He reports experiencing increased thirst and frequent urination over the past several months. His laboratory tests show elevated serum calcium and parathyroid hormone (PTH) levels. Given his clinical presentation and radiological findings, which of the following imaging modalities is most likely to demonstrate the cause?

A 56-year-old woman who recently underwent a mastectomy for multifocal ductal carcinoma in situ presents to the clinic with a complaint of a diffuse swelling at the surgical site. She reports that the swelling appeared two weeks after the surgery. On examination, a large, fluctuant area is noted underneath the mastectomy skin flaps. The patient is otherwise well and has no fever or signs of systemic infection. Given her clinical presentation, what is the most likely cause of the swelling?

A 35-year-old woman with a strong family history of breast cancer is found to carry both a BRCA 1 mutation and a TP53 mutation. Given her genetic profile and family history, she is at an elevated risk for breast cancer. What is the most appropriate surveillance strategy for her?

A 44-year-old woman presents with a mass lesion in the upper outer quadrant of her left breast. On clinical examination, a 2cm mass lesion is palpated. A core biopsy confirms invasive ductal carcinoma. Additionally, an FNA of a bulky axillary lymph node shows malignant cells. What is the most appropriate course of action?

A 53-year-old woman undergoes a mastectomy for the removal of a breast cancer. Microscopic analysis of the tumor reveals a pronounced lymphocytic infiltrate. Which of the following tumor types is most commonly associated with this finding?

A 38-year-old woman with a history of recurrent kidney stones presents to the emergency department complaining of severe flank pain, which she describes as radiating to her groin. This episode is similar to previous ones, and she reports having at least three such episodes in the past two years. She denies any recent infections or changes in her diet. Her medical history includes mild hypertension, but she is otherwise healthy and not taking any medications. On examination, her blood pressure is 130/85 mmHg, and she is afebrile. There is mild tenderness over the lower abdomen and costovertebral angle. Laboratory results show:
Corrected Calcium: 3.84 mmol/L
PTH: 88 pg/mL (increased)
Serum urea and electrolytes are within normal limits
Serum creatinine: 1.0 mg/dL
Urine analysis: No signs of infection
Given these results, what is the most likely diagnosis?

A 21-year-old woman presents to the clinic with a complaint of bloody nipple discharge from her left breast. She reports that the discharge has occurred intermittently over the past few weeks, and she has no associated pain or discomfort. She is otherwise well and has no significant past medical history. On examination, no discrete lumps or masses are palpated in the breast. The nipple is slightly tender, but there is no evidence of inflammation or infection. Mammography reveals dense breast tissue, but no obvious mass lesion is identified. The patient is otherwise healthy and has no family history of breast cancer. What is the most likely cause of the bloody nipple discharge?

A 32-year-old Indian woman presents to the clinic with a diffuse swelling in her left breast. She is breastfeeding her 4-month-old child and reports noticing increasing swelling and erythema of the breast over the past few days. On examination, she is found to have jaundice and marked erythema of the left breast, with the skin appearing pitted and edematous. There is no distinct lump palpated, but the entire breast is warm and tender. The patient is concerned, as this is her first episode of such symptoms, and there is no history of trauma or infection. Given her lactating status and symptoms, what is the most likely diagnosis?

A 63-year-old man is recovering from a prolonged stay in the intensive care unit following an anastomotic leak after a difficult transhiatal oesophagectomy. His progress has been slow, and recent thyroid function tests show the following results:
TSH: 1.0 mU/L
Free T4: 8 micrograms/dL (normal: 4-11)
T3: 1.0 micrograms/dL (normal: 1.2-3.1)
What is the most likely interpretation of these results and findings?

A patient presents with multiple lytic bone lesions on X-ray and is found to have elevated serum calcium levels. Further evaluation reveals excessive osteoclast activity leading to fibrous tissue deposition within the bone. These lesions appear radiolucent on imaging and have a characteristic brown appearance due to hemosiderin deposition.
Brown tumors of bone are associated with which of the following conditions?

A 34-year-old woman is admitted with recurrent episodes of non-specific abdominal pain. On each admission, all blood investigations and vital signs are normal. During this admission, a CT scan reveals a 1.5 cm nodule in the right adrenal gland with a lipid-rich core. Urinary vanillylmandelic acid (VMA) levels and other hormonal studies are within normal limits.
What is the most likely diagnosis?

A 50-year-old man presents to the hospital with a six-month history of intermittent upper abdominal pain, chronic diarrhea, and significant weight loss. He describes the pain as a burning sensation that worsens after meals and is partially relieved with proton pump inhibitors (PPIs), though symptoms persist. He also reports several episodes of nocturnal diarrhea and fatigue.
On examination, he appears pale and has mild epigastric tenderness. Laboratory tests reveal:
Hemoglobin: 10.2 g/dL (low)
Mean corpuscular volume (MCV): 72 fL (low)
Serum ferritin: 8 ng/mL (low)
Serum gastrin: 1,200 pg/mL (elevated)
Serum calcium: 11.2 mg/dL (high)
Parathyroid hormone (PTH): Elevated
An upper gastrointestinal endoscopy reveals multiple deep ulcers in the first and second portions of the duodenum, some of which show signs of healing, while others are actively inflamed. A secretin stimulation test is positive, confirming the diagnosis.
What is the most likely diagnosis?

A 48-year-old woman with a history of thyrotoxicosis presents to the endocrine clinic for further management. She was initially treated with carbimazole but had poor disease control. Due to severe proptosis, she underwent orbital radiotherapy, which improved her symptoms. However, after discontinuing carbimazole, she experienced a relapse of hyperthyroid symptoms, including weight loss, palpitations, heat intolerance, and worsening tremors. Examination reveals persistent goiter and mild residual exophthalmos.
What would be the best intervention to consider at this stage?

A 39-year-old woman presents with a palpable mass in her right breast. Clinical examination reveals a firm, irregular mass in the upper inner quadrant and a second lesion at the central aspect of the same breast. Imaging and core biopsy confirm two invasive carcinoma lesions, measuring 2.5 cm and 1.5 cm, respectively. Axillary examination reveals palpable lymphadenopathy, and fine-needle aspiration cytology of the lymph node confirms malignant cells.
What is the best course of action?

A 30-year-old woman with a recent diagnosis of Graves’ disease underwent incision and drainage of a pilonidal abscess three hours ago. Shortly after the procedure, she becomes agitated, confused, and is noted to be jaundiced and sweating profusely. Her temperature is 39°C, pulse 152 beats per minute, and blood pressure 95/60 mmHg. An ECG shows an irregular ventricular rate with absent P waves. Laboratory tests reveal elevated liver enzymes and hyperbilirubinemia.
After initial resuscitation, what is the most appropriate next step in management?

A 72-year-old woman presents with a painless breast lump that she recently noticed. On clinical examination, there is a firm, irregular, non-tender mass measuring approximately 4 cm in diameter in the upper outer quadrant of the left breast. No skin changes, nipple retraction, or axillary lymphadenopathy are noted. A mammogram reveals a spiculated mass with microcalcifications, and a core biopsy is performed.
What is the most likely diagnosis?

A 45-year-old woman presents with a 2 cm mobile breast mass. On clinical examination, the mass is felt to be smooth, mobile, and non-tender. A mammogram reveals an indeterminate result (M3), and the ultrasound shows benign changes (U2). Despite these findings, clinical examination is indeterminate (P3), meaning the lump is palpable, but its features are not entirely typical for a benign mass. The patient’s family history is non-contributory, and there are no other concerning symptoms such as skin changes or nipple discharge.
What is the next most appropriate course of action?