The purpose of these questions is to practice forming a coherent answer in the moment. They are likely to be most valuable if you read them only once you have sat down ready with a pen and started a timer. Like all exams, practicing the technique is half the work.
If possible find a friendly consultant who will mark your answer and provide some feedback. I have tried to give some suggested answers to each question but I am not an examiner and they will be multiple approaches I have not considered. Many of them better than the one I have given.
Mr Blofeld is a 62-year-old man admitted under the medical team with fever, cervical lymphadenopathy and lethargy. He gave a 6-week history of night sweats, fever and increasing tiredness. He has stopped working as a clinical trials manager due to his symptoms, but he is still able to carry out his daily activities of living and walk round to the corner shop for his groceries. A CT scan demonstrated small volume lymphadenopathy above and below the diaphragm with a spleen measuring 17cm in length. A cervical lymph node was biopsied and he was sent home pending the results.
He has returned to clinic to discuss treatment. The biopsy has shown small to medium sized atypical lymphoid cells. Immunohistochemistry shows them to be CD19+, CD20+, CD5+, Cyclin D1+ B cells, with a t(11;14) translocation identified by FISH. A bone marrow biopsy shows involvement with the same infiltrate.
Write a clinic letter addressed to the patient’s GP outlining the diagnosis, the treatment options and their risks, and a management plan going forwards. Include the patient’s performance status and Ann Arbor stage.
Mr Soze is a 58 year old gentleman who was found to have a lymphocytosis following a Well Man clinic. He gives a six week history of tiredness and a few, small lymph nodes palpable in his neck which he has noticed in the mirror. He is still able to work full time and does not report any other symptoms. He has a past medical history of hypertension, which is well controlled on monotherapy.
His lymphocyte count is 12 x10e9/l and a blood film has been reported to show a monomorphic population of small, mature lymphoid cells with condensed nuclear chromatin. His other blood counts are normal.
No further action is taken until 18 months later when the GP refers him to the haematology clinic. In the last three months he has lost one stone in weight and has had to reduce his hours at work. He tires easily and is waking at night with sweats 2-3 times per week. His full blood count is as follows: Hb 102 g/l, Platelets 95 x10e9/l, WBC 35 x10e9/l, Lymphocyte count 30 x10e9/l. A CT scan shows widespread bulky cervical, axillary and pelvic lymphadenopathy, with a 20cm spleen.
Peripheral blood immunophenotyping finds the lymphoid cells to be CD19+, CD23+, CD5+, CD200+, CD10-, FMC7-, CD79b-.
A. Discuss your management of this patient, with particular attention to: any further work-up of the disease, the treatment you would offer and your rationale for it, including any important considerations for supportive care.
B. Two years later, the patient relapses. Discuss the treatment options in this setting and your preferred choice.
Miss Scaramanga is a 25-year-old woman brought to the emergency department with confusion. She had been feeling unwell with a fever for the previous 24 hours. She has no past medical history and does not currently take any medication. On examination, she has a temperature of 39oC and a purpuric rash affecting both legs.
Laboratory tests are as follows: Haemoglobin 100 g/l, Platelets 2 x10e9/l, WBC 4.2 x10e9/l. Sodium 134 mmol/l, Potassium 5.4 mmol/l, Urea 12 mmol/l, Creatinine 230 umol/l. An urgent blood film confirms genuine thrombocytopenia with marked red cell fragmentation. A urine pregnancy test is negative.
A. State the likely diagnosis and outline your further investigation and management of this patient in the next 24 hours. Briefly explain the rationale for each treatment.
B. You are asked by your Trust to develop an apheresis service for the hospital. Discuss how you would approach this.
Mr Gruber is a 55-year-old gentleman attending the medical day unit for a two unit red cell transfusion as part of his supportive care for myelodysplasia. Fifteen minutes into the first unit he calls the nurse over as he feels unwell. He reports new back pain and feels nauseous.
Bed side observations are taken: Respiratory rate 20, Temperature 39oC, Heart Rate 100bpm, Blood Pressure 95/70.
A. Describe your investigation and management of this scenario, with reference to your diagnosis / differential diagnosis.
B. The following week you are called by the transfusion laboratory and asked to investigate a near miss incident. A group and screen sample from a patient on the surgical day unit has been typed as group A Rh positive, but the historical record on the laboratory information system is for group B Rh positive. Discuss how you would address this discrepancy.