MLA Applied Knowledge Practice Test 2

The Dix-Hallpike manoeuvre is used to evaluate for benign paroxysmal positional vertigo (BPPV), when caused by canalithiasis in the posterior semicircular canal. During the Dix-Hallpike manoeuvre, the patient is quickly moved from a seated position to a lying position with the head turned to one side, which causes displacement of free-floating calcium carbonate crystals (otoconia) in the inner ear. The manoeuvre is diagnostic if it elicits vertigo and nystagmus (involuntary eye movement) in patients with BPPV. Most cases are clinically diagnosed and imaging is not helpful.

Dual energy X-ray absorptiometry (DEXA) is the most appropriate investigation to evaluate future fracture risk in this patient. The presence of hot flushes, night sweats, and irregular menstruation suggests that the patient is likely going through menopause. The patient’s use of long-term inhaled corticosteroids for asthma increases her risk of osteoporosis. DEXA scan is a simple, non-invasive test that measures bone mineral density and is the gold standard for diagnosing osteoporosis and assessing fracture risk. A bone scintigraphy or MR scan are not first-line investigations for evaluating osteoporosis and would not provide the same level of detail as DEXA. X-rays and CT scans are not sensitive enough to diagnose osteoporosis but may be used to assess for fractures after they have occurred.

The most common cause of postmenopausal bleeding is atrophic vaginitis; however, endometrial cancer must be excluded. The initial evaluation of women with postmenopausal bleeding is an ultrasound to measure the endometrial thickness. If the thickness is >4 mm, further investigation is needed. In this case, since the endometrial thickness is 10 mm, hysteroscopy and endometrial biopsy are the most appropriate next investigations to evaluate for endometrial cancer. CA 125 is not specific for endometrial cancer and can be elevated in other conditions as well. Cervical cytology is not indicated in postmenopausal bleeding unless cervical cancer is suspected. CT and MR scans are not the initial investigations for postmenopausal bleeding.

Based on the information provided, the most likely diagnosis is depression. The patient is presenting with symptoms such as forgetfulness, loss of appetite, early morning awakening, and feelings of worthlessness. While some of these symptoms can be seen in dementia, the Mini-Mental State Examination score of 27/30 suggests that cognitive impairment may not be the primary cause of her symptoms. Age-associated memory impairment is not a recognised diagnosis, and frontotemporal dementia typically presents with more behavioural changes and personality changes rather than forgetfulness. Vascular dementia may also present with cognitive changes, but there is no indication of a history of cerebrovascular disease in this case. Therefore, depression is the most likely diagnosis.

The patient is experiencing an acute exacerbation of COPD and is in respiratory failure with a low oxygen level and high CO2 level (type II respiratory failure). The most appropriate next step in management would be to provide non-invasive ventilation (NIV) to help improve his gas exchange and reduce his work of breathing. NIV can be provided through a mask and helps to provide positive pressure to the airways, reducing the effort required by the patient to breathe. This can improve oxygenation, reduce CO2 retention, and reduce the need for invasive ventilation. Increasing the oxygen concentration alone is unlikely to improve the patient’s condition and could potentially worsen his hypercapnia. Antibiotics and diuretics may be indicated in some cases, but the priority in this scenario is to improve the patient’s respiratory status with NIV.

IV fluid bolus is the most appropriate first line of management for this patient. The patient has signs of hypovolemia, including tachycardia, hypotension, and oliguria. The 500 mL intravenous crystalloid bolus he received may not have been sufficient to address his ongoing fluid losses following the laparotomy. Therefore, another fluid bolus is indicated to improve his perfusion and restore his blood pressure. IV diuretic would not be appropriate as the patient is hypovolemic, and administering a diuretic would exacerbate his intravascular volume depletion. IV vasoconstrictor could be considered if the patient's hypotension persists despite adequate fluid resuscitation, but it is not the first-line treatment. Placing the bed head down may help with improving venous return and increasing blood pressure. Still, it would not be the first-line management in this case, especially since the patient is oliguric and, if prolonged, could risk cephalad spread of epidural solution. Stopping epidural analgesia may be considered if there is a concern for epidural-induced hypotension, but it is not the most appropriate first-line management in this situation.

α-Fetoprotein is the most appropriate serum investigation to aid diagnosis in this case. The patient has a history of liver cirrhosis and a palpable mass in the right upper quadrant, which raises suspicion of hepatocellular carcinoma (HCC). α-Fetoprotein is a tumour marker that is often elevated in patients with HCC. However, it is essential to note that not all patients with HCC have elevated α-fetoprotein, and elevated levels can also be seen in other conditions such as pregnancy and some benign liver diseases. Therefore, a definitive diagnosis of HCC usually requires confirmation by imaging studies such as ultrasound, CT scan or MRI, and/or tissue biopsy.

Chemotherapy is the most appropriate first-line treatment for classical Hodgkin lymphoma. Corticosteroids may be used in addition to chemotherapy in certain cases but are not typically used as a first-line treatment. Immunotherapy and radiotherapy may be used as part of a treatment regimen but are not typically used as a first-line treatment for classical Hodgkin lymphoma. Surgical excision of mediastinal lymph nodes is not a treatment option for Hodgkin lymphoma.

The most appropriate initial medication is nonsteroidal anti-inflammatory drugs (NSAIDs) in this age group if there are no contra-indications. Paracetamol on its own is not recommended. Amitriptyline, fentanyl and triamcinolone are not typically used for the initial treatment of mechanical back pain.

The most appropriate management decision is no action is necessary. The newborn remains clinically well, and the mother has detectable varicella antibodies, indicating potential passive immunity transfer to the newborn. The fact that the newborn is clinically well also supports a conservative approach with no specific treatment or observation required.

A finger splint is the most appropriate management option for a 30-year-old man with a flexion deformity of the finger at the distal interphalangeal joint and an inability to actively extend his finger following an injury. A finger splint can support and immobilise the finger, allowing the tendon to heal and the finger to regain its full range of motion.

Triple assessment is the most appropriate management for a pregnant woman with a breast lump. This includes clinical examination, imaging (usually ultrasound), and biopsy. Whilst the most likely diagnosis is a breast abscess, pregnancy does not preclude the possibility of breast cancer and should be excluded in this case. It is essential to thoroughly investigate breast lumps in pregnant women promptly to ensure early diagnosis and treatment if necessary.

The patient’s previous opinion should be the most important factor influencing the decision on whether to move him to a hospice. The patient desires to stay in the respiratory ward because he knows and trusts the nurses. It is important to respect the patient’s wishes and provide care in the location where the patient feels most comfortable, especially in end-of-life care situations. The son’s wishes can also be considered, but the patient’s wishes should be the primary consideration.

Capillary blood glucose is the most important immediate investigation to exclude hypoglycaemia (particularly in the context of alcohol) or hyperglycaemia. Although an arterial blood gas may be helpful, there is no evidence of respiratory compromise, and a venous blood gas may be appropriate (following a capillary blood glucose) to exclude a metabolic cause of this collapse. Blood alcohol level is likely to be high based upon the history and would not be the most important immediate investigation. Although urea and electrolytes are important investigations to consider, a capillary blood glucose would be more important to do immediately. A urinary drug screen may be helpful if the diagnosis is unclear, but this is not the most important immediate investigation.

The history and presentation is suggestive of conjugated hyperbilirubinaemia, which is indicative of pathology rather than being physiological. A split bilirubin measures the ratio of conjugated and unconjugated bilirubin levels in the baby’s blood, which is necessary to diagnose conjugated jaundice.

Intravenous noradrenaline/norepinephrine infusion is the most appropriate next step in management. The patient is presenting with signs of sepsis and is experiencing hypotension despite adequate fluid resuscitation. This suggests septic shock, and the most appropriate next step in management is to initiate vasopressor support, such as noradrenaline/norepinephrine infusion, to increase systemic vascular resistance and maintain blood pressure. Haemofiltration may be appropriate if the patient develops worsening acute kidney injury, but it is not the first-line management for septic shock. Intravenous gelatin or sodium chloride may provide additional fluid resuscitation; however, the central venous pressure of +12 mmHg suggests adequate fluid replacement and further volume expansion will not address the underlying hypotension. Intravenous furosemide may exacerbate the patient’s hypotension and should be avoided.

The weak grip, cough and shallow breathing suggest residual effects of neuromuscular blockade that has been administered to facilitate laryngoscopy and vocal chord biopsy under general anaesthetic. Doxapram acts on central and peripheral chemoreceptors to stimulate respiration but would have no effect on improving neuromuscular strength. Naloxone is an opioid antagonist and would not reverse the effects of neuromuscular blockade. Glycopyrronium is an antimuscarinic agent and would not have any effect on reversing neuromuscular blockade at the neuromuscular junction and improving strength. Neostigmine is a cholinesterase inhibitor and is the most appropriate agent to administer to reverse the effects of neuromuscular blockade. It reduces the breakdown of acetylcholine at the neuromuscular junction increasing its availability to bind to the acetylcholine receptor and therefore trigger muscular contraction and increased strength. Administration would increase grip strength, respiratory
muscular strength and may improve vocal chord movement and speech. Rocuronium is a neuromuscular blocking agent and would not be appropriate in this situation.

Based on the provided information, the most appropriate diagnostic investigation is direct antiglobulin test (coombs test). The patient has anaemia with raised bilirubin and LDH but otherwise normal liver function tests. The polychromasia on the film is due to an increase in reticulocytes and together these laboratory results are consistent with haemolytic anaemia (evidence of both increased RBC production and destruction). The recent history suggests an acquired not hereditary cause and there are spherocytes on the film in keeping with autoimmune haemolytic anaemia. The diagnosis would be confirmed by a direct antiglobulin test which tests for immunoglobulin or complement on the surface of red cells. Bone marrow causes of anaemia, B12 and folate deficiency can also cause anaemia and raised LDH but the blood film appearances, including increased red cell production, are not in keeping with this diagnosis. Therefore, bone marrow aspiration, B12 and folate are not as appropriate next investigations. Antinuclear antibody is also not a diagnostic investigation for haemolysis.

The most appropriate strategy to prevent colon cancer in this situation is panproctocolectomy, which is the removal of the entire colon, rectum, and anus. This patient has a strong family history of early-onset colorectal cancer and has already developed hundreds of colonic polyps with evidence of adenomatous change and low-grade dysplasia. These findings are consistent with a diagnosis of familial adenomatous polyposis (FAP), an inherited condition that predisposes to the development of colorectal cancer. Prophylactic surgery is recommended in patients with FAP to prevent the growth of colorectal cancer. Daily low-dose aspirin and a diet rich in fruit and vegetables have been shown to have some protective effect against colon cancer, but these measures are not sufficient for a patient with FAP. Annual FIT and colonoscopy and biopsy are not adequate for cancer prevention in a patient with FAP.

Hydrofluorocarbon propellant in the metered dose inhaler has the highest carbon footprint of the components listed. It is a greenhouse gas that contributes to climate change. Dry powder inhalers do not use propellants and are considered to have a lower carbon footprint. However, the manufacturing and disposal of all inhalers contribute to environmental impact.

Procyclidine is an antispasmodic drug and a muscarinic antagonist that crosses the blood-brain barrier and is used in the treatment of drug-induced extrapyramidal disorders and parkinsonism. Here, Co-Benedopa can treat Parkinson's disease but not EPSE. Drug-induced parkinsonism is likely the most common drug-induced movement disorder and one of the most common nondegenerative causes of parkinsonism. Any medication that interferes with dopamine transmission may cause Parkinsonism. Haloperidol is a dopamine receptor-blocking agent.

This patient is experiencing an anaphylactic reaction, which is a type of immediate hypersensitivity reaction. It is caused by the release of histamine and other mediators from mast cells and basophils in response to an allergen. The symptoms include skin rash, itching, and shortness of breath. Treatment involves immediate cessation of the offending agent, administration of epinephrine, and supportive care.

The most likely diagnosis is scarlet fever. Scarlet fever is a bacterial infection caused by Group A Streptococcus. It typically presents with a high fever, sore throat, and a characteristic sandpaper-like rash that starts on the trunk and spreads to the extremities. The cheeks may look flushed with often a pale area around the mouth. Measles can cause fever and rash, but typically presents with a cough, runny nose, and red, watery eyes. Parvovirus infection can cause a rash, but it is typically milder and not associated with a fever. Kawasaki disease can also cause a fever and rash, but it usually presents with conjunctivitis, swollen lymph nodes, and redness and peeling of the hands and feet. Rhinovirus infection can cause a runny nose, but is not typically associated with fever or rash.

Based on the patient’s symptoms and laboratory results, she may be experiencing tumour lysis syndrome, which is a potentially life-threatening complication of chemotherapy that can cause electrolyte imbalances and kidney damage. The most appropriate investigation to identify the cause of her acute deterioration would be urate, as elevated uric acid levels are a hallmark of tumour lysis syndrome. However, all of the other options may also be useful in helping to manage her condition. Blood culturesmay be taken to rule out a bacterial infection, C-reactive protein can indicate inflammation or infection, creatine kinase may be elevated in rhabdomyolysis (another potential complication of chemotherapy), and phosphate levels may also be elevated in tumour lysis syndrome.

Placement of an oesophageal stent can provide palliation of dysphagia in patients with oesophageal cancer. It is a minimally invasive procedure that can be done under sedation or general anaesthesia. It involves placement of a metal or plastic stent into the oesophagus to hold it open, allowing food and liquid to pass through. It is a safe and effective option for patients with dysphagia due to oesophageal cancer, particularly in those with advanced or metastatic disease who may not be candidates for curative treatment.

The surge in luteinising hormone is most likely to coincide with the pain experienced by the 18-year-old woman. This is because the pain is localised to the left iliac fossa, where the ovary is located. The surge in luteinising hormone occurs just before ovulation and stimulates the release of an ovum from the ovary. It is most likely that the pain was caused by the follicle rupture during ovulation with this temporal relationship.

Transient synovitis is unlikely as there is no evidence of preceding viral infection. Septic arthritis would be a concern, given the fever, but the pain is typically more severe and constant, with systemic signs of inflammation. Osgood–Schlatter disease affects the knee rather than hip. Slipped upper femoral epiphysis presents in older children and typically presents with acute onset of pain and a limp.
Perthes (Legg-Calvé-Perthes disease) is more common in boys, with peak presentation at age 4-6 years. It is characterised by insidious onset of a limp with or without pain. There is no history of trauma, and the presentation is usually unilateral.

Brainstem evoked response test would be the most appropriate additional assessment in this case. This test measures the electrical activity in the auditory pathway in response to sound and can detect hearing loss even in newborn infants. It is a reliable and objective way of assessing the function of the auditory system. It can identify hearing loss early, which is vital for early intervention and treatment.

The most likely diagnosis is Polymyalgia rheumatica. This is based on the patient’s age, symptoms of malaise and pain in the arms and legs, morning stiffness lasting for 3 hours each day, difficulty washing and dressing, inability to lift her arms above her head, and elevated CRP. Heberden’s nodes are not a feature of polymyalgia rheumatica but are seen in osteoarthritis. Rheumatoid arthritis would present with joint inflammation. Osteomalacia is a metabolic bone disease that is unlikely to cause these symptoms. Polymyositis would be associated with muscle weakness, which is absent in this case.

Intravenous morphine is most likely to reduce the breathlessness in this patient. The patient is experiencing severe dyspnea, which is a common symptom in end-stage heart failure. Morphine is an opioid analgesic with respiratory depressant effects that can reduce the sensation of dyspnea. Glyceryl trinitrate and nebulised salbutamol are more appropriate for patients with bronchospasm or heart failure due to left ventricular dysfunction. Nasal intermittent positive pressure ventilation is more suitable for patients with acute respiratory failure due to hypoventilation. Haloperidol is indicated for patients with delirium, agitation or confusion.

The most appropriate subsequent investigation for this patient is the aspiration of the left knee joint for microscopy and culture. The patient has a painful swollen left knee with fever and raised inflammatory markers, which suggests an acutely infected knee joint. Aspiration of the joint for microscopy and culture is the most appropriate investigation to identify the causative organism and guide antibiotic treatment. MR imaging may be useful in cases of chronic joint disease but is not necessary in this acute presentation. X-ray may be useful in cases of trauma or chronic joint disease, but again is not indicated acutely. Testing for anti-cyclic citrullinated peptide antibody and serum uric acid are not relevant in this scenario.

This patient has sickle cell disease and is presenting with a severe pain crisis. Treatment of an acute painful sickle cell crisis needs to be considered an acute medical emergency. Pain must be assessed immediately and treated with an acute bolus of a strong opioid such as morphine. The patient is afebrile with a normal white cell count and thus no evidence of infection; hence, antibiotics such as co-amoxiclav are not indicated at this stage. Oral prednisolone may be used to treat acute chest syndrome, but it is not the first-line treatment for a pain crisis. There is no immediate urgency for red cell transfusion in an acute pain crisis, although it can be considered at a later stage. Treatment dose dalteparin is indicated in patients with sickle cell disease who have a high risk of thromboembolism, but it is not indicated for this patient’s current presentation.

The patient is presenting with symptoms consistent with renal colic, which is typically associated with severe, colicky pain that can radiate to the groin, nausea, and vomiting. The tenderness on palpation of the left costovertebral angle and the presence of blood in the urine (indicated by 3+ on urinalysis) suggest that the patient has a kidney stone causing the obstruction and pain. The most appropriate initial analgesic agent for this patient would be a nonsteroidal anti-inflammatory drug such as diclofenac. Tramadol and oxycodone are opioid analgesics that are effective for the treatment of moderate to severe pain, including renal colic; however, they are not first line and should be used only if NSAIDs are contraindicated and following treatment with intravenous paracetamol. Aspirin is rarely used for its analgesic effects in renal colic. Paracetamol is an analgesic that can be used for mild to moderate pain but is the second line (if given in intravenous form) to NSAIDs.

It is important to ensure that blood glucose levels are well-controlled in patients with diabetes undergoing surgery. Omitting insulin doses can lead to hyperglycaemia, which increases the risk of surgical complications, while taking too much insulin can lead to hypoglycaemia, which can also be dangerous.
In this case, he should take his usual long-acting insulin the evening before but will need to adjust his short-acting insulin dose based on the anticipated timing of the surgery the following day. As he is scheduled as first on the list in the morning, and having been starved from midnight he should omit his morning short acting insulin prior to surgery and recommence this when eating and drinking. The anaesthetist should be informed of the patient's diabetes and insulin regimen, and should monitor blood glucose levels during
the perioperative period.

In this case, the most effective drug to control the patient’s pain would likely be morphine sulfate continuous subcutaneous infusion. This is because the patient is unable to take oral medication due to bowel obstruction and vomiting.
The use of an intramuscular injection would be painful to administer and only provide intermittent analgesia, whereas the patient needs continuous analgesia.
A buprenorphine transcutaneous patch and fentanyl transcutaneous patch would not be appropriate as his pain may change due to the progressive bowel obstruction and, therefore, not be stable enough for transcutaneous analgesia.

Based on the given information, the best description of his hepatitis B status would be immune due to naturally resolved infection. The negative HBsAg and positive anti-HBc IgG and anti-HBs IgG results suggest that the patient has been exposed to hepatitis B virus in the past but has cleared the infection, leading to the development of immunity against the virus. The presence of anti-HBs IgG indicates that the patient has developed protective antibodies against the virus, likely through natural infection or previous vaccination.

Acute infection would be characterised by the presence of HBsAg, which is not present in this case. Chronic infection would be characterised by the presence of HBsAg for at least six months, which is not the case here. Immunity due to previous vaccination for hepatitis B could also be a possibility. Still, the patient is unsure of his vaccination status, and the presence of anti-HBc IgG suggests that he may have had a natural infection. Not infected but susceptible to further infection would be characterised by negative results for all hepatitis B markers, which is not the case here.

Otitis externa is an inflammation or infection of the external auditory canal and is commonly associated with water exposure, as in swimmers and surfers. Pulling the pinna, or pressure on the tragus often exacerbates the pain.

Human papilloma virus (HPV) is associated with squamous cell carcinoma of the oropharynx, which includes the tonsils (typically palatine tonsils and lingual tonsils). Other risk factors for this cancer include smoking and alcohol use, but the incidence of HPV-associated oropharyngeal cancers is increasing. HPV-associated cancers also include cervical, vulval, penile and anal cancers.

This patient has back pain, fatigue, normocytic anaemia, thrombocytopenia and renal failure. The location of the back pain is low thoracic which is higher than the lumbosacral area commonly affected by mechanical back pain. Based on the patient’s clinical presentation and laboratory results, the most likely diagnosis is myeloma. The most appropriate initial investigation to confirm this diagnosis is serum-free light chains testing. This will detect the presence of Bence-Jones protein characteristic of myeloma. Other options are not relevant to the diagnosis of myeloma.

The patient is exhibiting symptoms of acute dystonia, which is a side effect of antipsychotic medication such as risperidone. It is characterised by muscle spasms and contractions, often in the neck and facial muscles. Treatment includes anticholinergic medication such as benztropine or diphenhydramine.

While randomised controlled trials provide high-quality evidence about interventions, a meta-analysis of trials includes an assessment of their risk of bias, and a pooling of results, which increases the statistical power of the findings.

Unpaired Student’s t-test would be the most appropriate statistical test to compare these groups, as it is used to compare the means of two independent groups of data with equal variances assuming normal distribution.

Based on the given information, the most likely cause of their inability to conceive is anovulatory cycles. The woman’s menstrual cycle is longer than the normal range of 21-32 days, suggesting she may not ovulate regularly. The absence of any other medical conditions or abnormalities in either partner suggests that anovulation is the most likely cause of their infertility.

The patient’s fear of public speaking, avoidance behaviour, and recognition that his fears are irrational are consistent with a diagnosis of social phobia. Social phobia is a type of anxiety disorder characterised by an excessive and persistent fear of social situations,
including public speaking. It can cause significant distress and interfere with daily activities. Treatment options may include cognitive-behavioural therapy and/or medication.

Temporal artery biopsy is the most appropriate investigation in this patient to establish the diagnosis of giant cell arteritis. The typical symptoms of headache, jaw claudication, and unintentional weight loss, along with elevated CRP levels, raise a strong suspicion of giant cell arteritis. Temporal artery biopsy is the gold standard test for diagnosis, as it shows characteristic histopathological changes of giant cell arteritis such as mononuclear cell infiltration and granulomatous inflammation. Some centres will arrange a temporal artery ultrasound to help with the diagnostic process but this is not an option in this question, so biopsy is the most appropriate.

The most appropriate investigation in this case is liver function tests. The persistent itching and scratch marks suggest obstetric cholestasis, a liver disorder that occurs in pregnancy. Liver function tests are essential to assess the degree of hepatic dysfunction, and elevated serum bile acids would confirm the diagnosis. Other investigations such as anti-mitochondrial antibody, iron studies, thyroid function tests, and urea and electrolytes would not be helpful in diagnosing obstetric cholestasis.

Based on the given information, the most likely explanation for her deterioration would be the development of a pneumothorax following admission based on the acute nature of her symptoms, reduced breath sounds on examination, and association with her history of asthma; The reduced expansion of the upper left chest and reduced breath sounds over the left apex could suggest a possible collapse of the left upper lobe of the lung however one would expect to see changes on the chest X-ray. Anaphylaxis, increasing severity of asthma, and pulmonary embolus can all cause respiratory distress, but do not explain the physical examination findings.

As the patient is currently unable to answer questions and although his wife reports that he planned to discontinue active treatment, this has not been documented and cannot be verified. The admitting team should, therefore, decide about the best clinical approach to the patient, including the appropriateness or otherwise of CPR.

The most appropriate immediate treatment for this patient would be Dexamethasone. The patient has an isolated metastasis in the brain with cerebral oedema, which can cause significant symptoms and can be life-threatening if left untreated. Dexamethasone is a corticosteroid that can help to reduce cerebral oedema and alleviate symptoms such as headaches. It is commonly used as an initial treatment for brain metastases. Anastrozole is a hormonal therapy used for the treatment of breast cancer but would not be the appropriate treatment for this patient's current symptoms. Chemotherapy may be used for the treatment of metastatic breast cancer, but it would not be the most appropriate immediate treatment for this patient's presentation. Most chemotherapy drugs do not cross the blood-brain barrier. Radiotherapy and surgical decompression are also treatment options for brain metastases, but they would not be the most appropriate immediate treatment for this patient. Radiotherapy (including stereotactic radiotherapy) and surgical intervention may be considered following complete radiological staging to define extent of metastatic disease and discussion at neuro-oncology MDM. These options are considered following control of initial symptoms with dexamethasone.

The histological description of duct-like structures lined by regular, low columnar cells separated by loose fibrous tissue, with well-defined margins is consistent with a fibroadenoma. These are the most common benign breast lumps in young women, often presenting as a solitary, painless, firm, mobile mass. They can be surgically removed if they are causing discomfort or for cosmetic reasons. Carcinoma in situ and ductal carcinoma are malignant breast cancer and would have different histological features. Intraductal papilloma presents as a small, soft, often palpable mass and can be associated with nipple discharge. Paget’s disease of the breast presents with nipple and areolar changes, such as erythema, scaling, and ulceration, and is usually associated with an underlying invasive or in situ breast carcinoma.