A 35-year-old man presents with intermittent fevers up to 39°C over 3 weeks, associated with rigors and night sweats. He has no significant past medical history but mentions he had a dental procedure 4 weeks ago. On examination, temperature is 38.2°C, pulse 96/min regular, BP 128/76 mmHg. A grade 3/6 pansystolic murmur is heard at the apex. What is the single most important immediate investigation?
Q162
A 28-year-old woman presents with a 6-week history of intermittent fevers up to 38.5°C, night sweats, and fatigue. She returned from a 3-month backpacking trip through Southeast Asia 8 weeks ago. Examination reveals no focal signs. Blood tests show: Hb 125 g/L, WCC 6.8 × 10⁹/L, platelets 285 × 10⁹/L, CRP 45 mg/L, normal liver and renal function. Malaria films are negative. Chest X-ray shows bilateral hilar lymphadenopathy. What is the most likely diagnosis?
Q163
A 72-year-old man presents with a 6-week history of progressive fatigue and 7kg unintentional weight loss. He is a lifelong smoker of 40 pack-years. Examination reveals mild pallor and a palpable left supraclavicular lymph node measuring approximately 2cm. Blood tests show Hb 102 g/L (MCV 88 fL), WCC 8.1 × 10⁹/L, platelets 385 × 10⁹/L. What is the most appropriate immediate management?
Q164
A 45-year-old woman presents with a 3-month history of persistent fatigue and a 5kg weight loss. She reports feeling generally unwell with poor appetite. Blood tests show: Hb 118 g/L, WCC 7.2 × 10⁹/L, platelets 245 × 10⁹/L, ESR 52 mm/hr, CRP 28 mg/L, normal renal and liver function, TSH 2.8 mU/L, HbA1c 38 mmol/mol. Chest X-ray is normal. What is the most appropriate next step in management?
Q165
A 68-year-old man presents with a 4-month history of unintentional weight loss of 8kg and increasing fatigue. He has a history of type 2 diabetes mellitus and hypertension. On examination, his BMI is 21 kg/m². Cardiovascular and respiratory examinations are unremarkable. Blood pressure is 138/82 mmHg, pulse 76/min regular. What is the most appropriate initial investigation?
Undifferentiated Symptoms UK Medical PG Practice Questions and MCQs
Question 161: A 35-year-old man presents with intermittent fevers up to 39°C over 3 weeks, associated with rigors and night sweats. He has no significant past medical history but mentions he had a dental procedure 4 weeks ago. On examination, temperature is 38.2°C, pulse 96/min regular, BP 128/76 mmHg. A grade 3/6 pansystolic murmur is heard at the apex. What is the single most important immediate investigation?
A. Echocardiography
B. Full blood count and inflammatory markers
C. Chest X-ray
D. Electrocardiogram
E. Three sets of blood cultures from different sites (Correct Answer)
Explanation: ***Three sets of blood cultures from different sites***
- Obtaining **blood cultures** prior to starting antibiotic therapy is the single most critical step in diagnosing **infective endocarditis** and identifying the causative pathogen.
- Following the **Duke criteria**, three sets taken from separate venepuncture sites increase the sensitivity for detecting **continuous bacteremia**, which is a hallmark of this condition.
*Echocardiography*
- While **transthoracic or transoesophageal echocardiography** is a major diagnostic tool for visualizing **vegetations**, it does not identify the specific organism required for targeted therapy.
- It should be performed urgently, but it follows blood cultures in the sequence of immediate management for suspected endocarditis.
*Full blood count and inflammatory markers*
- Elevated **WBC count**, **CRP**, and **ESR** are non-specific findings that support an underlying inflammatory or infectious process but do not confirm the diagnosis.
- These tests help monitor the response to treatment but are not the primary diagnostic investigation for **endocarditis**.
*Chest X-ray*
- A **Chest X-ray** is useful for identifying secondary complications such as **pulmonary edema** or septic emboli in right-sided endocarditis.
- It provides limited information regarding the direct cause of the patient's **fever and heart murmur**.
*Electrocardiogram*
- An **ECG** is important to check for **conduction abnormalities**, such as a prolonged PR interval, which may indicate a **root abscess**.
- Although clinically significant for monitoring complications, it is not the definitive investigation for a patient presenting with high-grade fever and a new **pansystolic murmur**.
Question 162: A 28-year-old woman presents with a 6-week history of intermittent fevers up to 38.5°C, night sweats, and fatigue. She returned from a 3-month backpacking trip through Southeast Asia 8 weeks ago. Examination reveals no focal signs. Blood tests show: Hb 125 g/L, WCC 6.8 × 10⁹/L, platelets 285 × 10⁹/L, CRP 45 mg/L, normal liver and renal function. Malaria films are negative. Chest X-ray shows bilateral hilar lymphadenopathy. What is the most likely diagnosis?
A. Tuberculosis (Correct Answer)
B. Brucellosis
C. Sarcoidosis
D. Infectious mononucleosis
E. Lymphoma
Explanation: ***Tuberculosis***- Recent travel to a **high-prevalence region** (Southeast Asia) coupled with prolonged **constitutional symptoms** (fever, night sweats, fatigue) strongly suggests active **Mycobacterium tuberculosis** infection.- The presence of **bilateral hilar lymphadenopathy (BHL)** on chest X-ray, in the context of a travel history from an endemic area and constitutional symptoms, is a recognized presentation of primary or reactivated **tuberculosis**.*Brucellosis*- This infection is primarily acquired through contact with **infected animals** or consumption of **unpasteurized dairy products**, which is not explicitly mentioned in the patient's travel.- While brucellosis can cause intermittent fever and constitutional symptoms, **bilateral hilar lymphadenopathy** is not a characteristic imaging finding for this disease.*Sarcoidosis*- While **bilateral hilar lymphadenopathy** is a hallmark of sarcoidosis, the presence of **high-grade fever (38.5°C)** and significant **night sweats** makes it less likely, as sarcoidosis often presents with milder or no systemic symptoms initially.- Given the patient's recent travel to an **endemic area**, an infectious etiology like tuberculosis must be thoroughly excluded before considering a diagnosis of sarcoidosis.*Infectious mononucleosis*- Typically presents with symptoms like **pharyngitis**, profound fatigue, and diffuse **lymphadenopathy** (especially cervical and axillary), often accompanied by splenomegaly.- **Isolated bilateral hilar lymphadenopathy** without other prominent features like pharyngitis, and a symptom duration of **6 weeks**, is an atypical presentation for infectious mononucleosis.*Lymphoma*- Lymphoma can cause **B-symptoms** (fever, night sweats, fatigue) and **lymphadenopathy**, including hilar involvement.- However, hilar lymphadenopathy in lymphoma is often more **bulky or asymmetric**, and given the strong epidemiological link to **tuberculosis** through recent travel to Southeast Asia, an infectious cause is a more immediate concern.
Question 163: A 72-year-old man presents with a 6-week history of progressive fatigue and 7kg unintentional weight loss. He is a lifelong smoker of 40 pack-years. Examination reveals mild pallor and a palpable left supraclavicular lymph node measuring approximately 2cm. Blood tests show Hb 102 g/L (MCV 88 fL), WCC 8.1 × 10⁹/L, platelets 385 × 10⁹/L. What is the most appropriate immediate management?
A. Arrange urgent CT chest and refer to respiratory medicine (Correct Answer)
B. Perform excision biopsy of the lymph node in primary care
C. Commence oral iron supplementation and review in 2 weeks
D. Arrange ultrasound-guided fine needle aspiration of the lymph node
E. Refer urgently to haematology under 2-week wait pathway
Explanation: ***Arrange urgent CT chest and refer to respiratory medicine***- The patient's presentation with a **40 pack-year smoking history**, progressive fatigue, significant **unintentional weight loss**, normocytic anemia, and a palpable **left supraclavicular lymph node** (Virchow's node) are classic **red flag features** highly suggestive of an underlying malignancy, most commonly **lung cancer** given the extensive smoking history. - Urgent **CT chest** is essential to evaluate the primary tumor and assess for metastatic disease, while referral to **respiratory medicine** ensures a prompt and specialized diagnostic and management pathway.
*Perform excision biopsy of the lymph node in primary care*- **Excision biopsy** for suspected malignancy should not be performed in primary care; it requires a sterile environment and specialized surgical and pathological expertise. - Prioritizing a localized biopsy over comprehensive imaging could significantly delay the diagnosis and staging of a potentially advanced **thoracic or abdominal primary tumor**.
*Commence oral iron supplementation and review in 2 weeks*- The patient has **normocytic anemia** (MCV 88 fL), making iron deficiency less likely as the primary cause; it is more consistent with **anemia of chronic disease** often associated with malignancy. - Simply treating the anemia symptomatically without investigating the underlying **red flag symptoms** would dangerously delay the diagnosis of a suspected high-grade malignancy.
*Arrange ultrasound-guided fine needle aspiration of the lymph node*- While **fine needle aspiration (FNA)** can be diagnostic, it often provides insufficient tissue for comprehensive histological assessment compared to core or excision biopsy and does not replace the critical need for **cross-sectional imaging** to stage the primary tumor. - Arranging only an FNA in primary care as the immediate step would delay the broader staging and multidisciplinary management required for suspected **metastatic cancer**.
*Refer urgently to haematology under 2-week wait pathway*- Although lymphadenopathy and anemia can be associated with **haematological malignancies**, the patient's profound **smoking history** and the specific finding of a **Virchow's node** (implying metastasis from a solid organ primary, frequently lung or gastrointestinal) point more strongly towards a **solid tumor**. - Referral to **respiratory medicine** is the more appropriate initial step for a lifelong smoker with these constitutional symptoms to investigate for a primary lung pathology first.
Question 164: A 45-year-old woman presents with a 3-month history of persistent fatigue and a 5kg weight loss. She reports feeling generally unwell with poor appetite. Blood tests show: Hb 118 g/L, WCC 7.2 × 10⁹/L, platelets 245 × 10⁹/L, ESR 52 mm/hr, CRP 28 mg/L, normal renal and liver function, TSH 2.8 mU/L, HbA1c 38 mmol/mol. Chest X-ray is normal. What is the most appropriate next step in management?
A. Reassure and review in 3 months
B. Refer urgently to haematology under 2-week wait pathway
C. Arrange CT chest, abdomen and pelvis (Correct Answer)
D. Prescribe oral prednisolone 30mg daily
E. Screen for depression and commence antidepressant therapy
Explanation: ***Arrange CT chest, abdomen and pelvis***
- The patient's **unexplained weight loss** (5kg over 3 months), **persistent fatigue**, and elevated **inflammatory markers** (ESR 52 mm/hr, CRP 28 mg/L) are significant red flags for an underlying serious condition, such as **malignancy** or systemic inflammatory disease.
- A normal chest X-ray does not rule out pathology in other areas; a **CT scan of the chest, abdomen, and pelvis** is the most appropriate comprehensive imaging modality to identify occult solid tumors, lymphadenopathy, or widespread inflammatory processes that could explain her symptoms.
*Reassure and review in 3 months*
- **Unexplained weight loss** and persistently **elevated inflammatory markers** strongly suggest an organic pathology that requires urgent investigation, not reassurance.
- Delaying further diagnostic workup for three months could significantly delay the diagnosis and treatment of potentially serious conditions, including **cancer**, which might worsen the prognosis.
*Refer urgently to haematology under 2-week wait pathway*
- While some haematological conditions can cause fatigue and elevated ESR, the patient's **full blood count** (Hb, WCC, platelets) is largely normal, making a primary haematological malignancy less likely as the immediate referral indication.
- A **CT scan** is a broader initial investigation that can identify solid tumors or lymphadenopathy in various locations, which may then guide the appropriate specialist referral.
*Prescribe oral prednisolone 30mg daily*
- Administering **corticosteroids** empirically without a definitive diagnosis is inappropriate and potentially harmful, as it can mask symptoms and signs of serious infections or **malignancies**.
- Steroids can also interfere with diagnostic tests, such as biopsies, and cause significant systemic side effects without addressing the **underlying cause** of the patient's symptoms.
*Screen for depression and commence antidepressant therapy*
- Although fatigue and weight loss can be symptoms of **depression**, the presence of significantly **elevated ESR and CRP** strongly points towards an underlying **organic physical illness** rather than a primary psychiatric disorder.
- It is crucial to thoroughly **exclude medical causes** with appropriate investigations before concluding that the symptoms are solely attributable to a mental health condition and initiating psychiatric treatment.
Question 165: A 68-year-old man presents with a 4-month history of unintentional weight loss of 8kg and increasing fatigue. He has a history of type 2 diabetes mellitus and hypertension. On examination, his BMI is 21 kg/m². Cardiovascular and respiratory examinations are unremarkable. Blood pressure is 138/82 mmHg, pulse 76/min regular. What is the most appropriate initial investigation?
A. Full blood count, renal function, liver function tests, thyroid function tests, HbA1c, and chest X-ray (Correct Answer)
B. CT chest, abdomen and pelvis
C. Upper gastrointestinal endoscopy
D. Colonoscopy
E. PSA and urinalysis
Explanation: ***Full blood count, renal function, liver function tests, thyroid function tests, HbA1c, and chest X-ray***
- In patients with **unintentional weight loss**, the first-line approach in primary care involves broad screening to identify common causes such as **malignancy**, **chronic disease**, or **endocrine disorders**.
- This panel covers essential differentials: FBC for **anemia or infection**, HbA1c for **uncontrolled diabetes**, TFTs for **hyperthyroidism**, and a CXR to screen for **lung malignancy**.
*CT chest, abdomen and pelvis*
- While highly sensitive for detecting occult **malignancy**, cross-sectional imaging is not considered an **initial investigation** without localizing symptoms.
- Performing a CT-CAP as the first step is not **cost-effective** and exposes the patient to unnecessary **radiation** before simpler tests are conducted.
*Upper gastrointestinal endoscopy*
- This is a targeted investigation used to evaluate specific symptoms such as **dysphagia**, persistent **dyspepsia**, or suspected **gastric cancer**.
- In the absence of specific GI symptoms (e.g., vomiting, early satiety), it is not appropriate as the **first-line screening** tool for generalized weight loss.
*Colonoscopy*
- Colonoscopy is indicated if the patient presents with a **change in bowel habit**, rectal bleeding, or unexplained **iron-deficiency anemia**.
- Without specific lower GI symptoms or a positive **fecal immunochemical test (FIT)**, it would not be the immediate next step.
*PSA and urinalysis*
- Urinalysis is useful for checking for **proteinuria** or **glycosuria**, and PSA can screen for **prostate cancer**, but these are too narrow in scope.
- Relying only on these tests would miss more common systemic causes, making them part of a wider assessment rather than a standalone **initial investigation**.
