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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.
I have dated when I wrote questions, to help you gauge if particular answers may be obsolete.
Mock Paper
Paper A - Click to Download - Dr Deepak Chandra, Consultant Haematologist at University Hospitals of North Midlands has provided this complete mock paper, along with thorough model answers (found in the Essay Answers tab). Thank you Dr Chandra!
N.B. The answer to question 4 is awaited and I will update this once available.
FRCPath Practice Questions
The FRCPath posts a few sample questions each year. Dr Bulushi has compiled these into this large practice question document.
haembase Questions
Question 1 (Written 2019)
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.
question 2 (Written 2019)
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.
question 3 (Written 2019)
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.
Question 4 (Written 2020)
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.
Question 5 (written 2020)
Mr Thanos is a 81 year old man presenting to the haematology day unit with two days of worsening breathlessness and lethargy. He is on a monthly transfusion programme for supportive management of myelodysplasia, and he had been transfused two units of red cells without incident five days previously. His pre-transfusion haemoglobin five days ago was 79g/l.
On examination he is pale, with jaundiced sclera. Repeat blood tests show haemoglobin 80g/l, platelet count 100 x10e9/l, neutrophil count 1.4 x10e9/l and bilirubin 42 umol/l.
A. With reference to the suspected diagnosis, describe your investigation and management in the first 24 hours after this patient’s presentation.
B. List the potential future clinical & laboratory consequences for a patient who develops a red cell alloantibody.
C. Using examples, discuss the transfusion policies and practices in place to reduce the risk of alloimmunisation in patients receiving red cell transfusions
Question 6 (written 2020)
Mrs Coulter is a 35 year old biomedical scientist who presents to the emergency department with epistaxis and a rash. She gives a one week history of feeling tired and lethargic. She has had three nose bleeds in the last 48 hours and tasted blood in her mouth after brushing her teeth. She has no past medical history and is not currently taking any over the counter medications.
On examination she has a petechial rash affecting both lower legs. There are blood blisters inside her mouth. The remainder of the physical examination is normal.
A full blood count shows haemoglobin 125g/l, platelet count 5x10e9/l, white cell count 5.6x10e9/l and neutrophil count 2.3x10e9/l. The blood film is reported as follows: Genuine thrombocytopenia with large platelets. Unremarkable appearances of the red and white blood cells.
A. Given the likely diagnosis, state how you would investigate this patient with reference to the relevant differential diagnoses. Explain how you would discuss the treatment options with the patient in order to agree a management plan. State your preferred treatment.
B. Following treatment, her platelet count rises to a stable count of around 80-100x10e9/l. She returns to clinic one year later and informs you that she is pregnant. Prepare a management plan for this patient’s pregnancy and the immediate postnatal period.
question 7 (written 2020)
Mr Palpatine is a 55 year old gentleman you arrange to review on the day unit after the laboratory biomedical scientist brings the patient’s blood film to your attention. Two days earlier the patient developed sudden onset blurred vision in his right eye and was found to have a retinal haemorrhage. He has no past medical history and is not currently taking any medication. Today his full blood count is as follows:
WBC 196 x10^9/l, Hb 105 g/l, Platelet 143 x10^9/l
Blood film examination reveals left-shifted leukocytosis with 50% neutrophils, 35% myelocytes, 5% promyelocytes, 2% blasts, 4% basophils, 1% eosinophils, 3% lymphocytes.
Fluorescent in situ hybridisation (FISH) performed on the peripheral blood shows that 91% of cells have the BCR-ABL1 t(9;22) rearrangement. Diagnostic PCR identifies the e14a2 BCR-ABL1 transcript.
A. Outline any further diagnostic investigations that are required and the justification for these. Discuss the treatment options and give a rationale for your preferred choice. Assume that there are no trial options.
B. State how and when you would assess response to treatment in the first year, including the expected optimal results.
C. Three years later Mr Palpatine remains on his first like treatment with a BCR-ABL1/ABL1 transcripts ratio of <0.01%. He asks you about the possibility of stopping his treatment. Write a clinic letter covering your discussion of the advantages, disadvantages and requirements for stopping therapy.
Question 8 (written 2020)
Dr Langstrom is a 49 year old acute medicine consultant presenting with a six week history of night sweats, lethargy, right flank pain and rapidly increasing lump in the right side of her neck. Although she stopped working one week ago, she is still active around the house and independent with all daily activities and house work. Examination reveals bilateral cervical lymphadenopathy and fullness in the right flank.
WBC 6.0 x10e9/l, Hb 120 g/l, platelets 300 x10e9/l, Cr 160 mmol/l, LDH 680 U/l.
PET-CT confirms presence of lymphadenopathy above and below the diaphragm. The right kidney is enlarged and shows avid FDG uptake. No other organ involvement is identified.
Core biopsy a cervical lymph node shows replacement of the normal node architecture with sheets of monomorphic large cells. Immunohistochemistry demonstrates these cells to be CD10+, CD20+, CD5- and with a high proliferation index. No MYC translocation is present.
A. Discuss the further work-up and subsequent management of this patient, with specific reference to the prognostic information available.
B. The patient has been reading about central nervous system relapse of her disease. She asks you for more information about her risk of this complication and whether any preventative steps are warranted. Write a clinic letter summarising your conversation with this medically literate patient.
Question 9 (written 2021)
Miss Trunchbull is a 28 year old woman with beta thalassaemia. She is on a chronic red cell transfusion programme, every six weeks, to maintain haemoglobin >100g/l and takes oral deferasirox as iron chelation. Her most recent ferritin was 800ng/ml. She attends her annual haemoglobinopathy clinic appointment today and informs you of her intention to start planning for pregnancy.
A. Discuss the potential complications in pregnancy for a woman with thalassaemia, and outline your pre-conception advice and management of this patient.
B. Miss Trunchbull returns to clinic nine months later and informs you that she is six weeks pregnant. List the antenatal management of this patient and write a short letter to the obstetric team with your recommendations for the delivery as regards her thalassaemia.
question 10 (written 2021)
Mrs Deville is an 80 year old lady who presented to hospital with breathlessness and worsening peripheral oedema, attributed to her known heart failure. Her admission full blood count shows haemoglobin 50g/l and two units red cells are transfused. Within 50ml remaining of the second unit she became acutely unwell with tachycardia, hypoxia and worsening tachypnoea. Respiratory examination revealed an elevated jugular venous pressure and coarse bilateral crackles on chest auscultation. Post-transfusion her haemoglobin is 155g/l and it later transpires that a venous blood gas taken on arrival to hospital recorded haemoglobin of 130g/l but this result had not been noted at the time.
A. Give a differential diagnosis for this patient’s acute deterioration and outline your immediate clinical management.
B. List the critical steps of the transfusion process and highlight those most relevant to avoidance of an incident such as this.
C. In your capacity as the haematologist responsible for your hospital’s transfusion service, describe the steps you would take following this incident.
question 11 (Written 2022)
Miss Clyde is a 54 year old taxidermist admitted electively for a cholecystectomy. She is nervous about the procedure as she is all too aware from her own profession of the damage that a scalpel can inflict.
A. Using an example, discuss the factors that need to be considered when assessing the bleeding risk associated with an invasive procedure or operation.
B. The junior doctors rotating through surgical specialties at your hospital have asked for guidance on how to assess a patient’s bleeding risk prior to surgery. Design a short checklist to aid their initial clerking.
C. Pre-operative assessment at your new hospital includes routine testing of prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen for all patients. Using examples, discuss the potential consequences of this policy.
Question 12 (written 2022)
Mr Lecter is a 76 year old presenting with a two week history of fever and lethargy. He attends the emergency department due to an uncontrolled nose bleed.
On examination he is pale with a purpuric rash on both lower legs. His temperature is 38.2 degrees.
A full blood count shows haemoglobin 72g/l, platelet count 13x10e9/l, white cell count 15x10e9/l and neutrophil count 0.9x10e9/l. The blood film is reported as follows: Genuine thrombocytopenia. Red cell anisopoikilocytosis. Population of large, mononuclear, monomorphic cells with high nuclear:cytoplasmic ratio and prominent nucleoli.
Flow cytometry is performed and the immunophenotype of the abnormal cells is as follows: CD34+, HLA-DR+, CD13+, CD33+, CD2-, CD19-.
A.State the diagnosis and outline the remaining diagnostic work-up of this patient. Include two specific examples of abnormalities found in this condition and the prognostic significance attached to them.
B. Discuss how you would assess this patient’s fitness for treatment.
C. List the available first line treatment options available in the UK for this patient, accompanied by the advantages and disadvantages of each approach.
D. Briefly state the mechanism of action of one drug of your choice that is available as a first line treatment for this condition in the UK.
question 13 (2023)
Mr Buchanon is a 54 year old receiving infusional chemotherapy (R-da-EPOCH) for Diffuse Large B Cell Lymphoma. He presents a few days prior to his third cycle of treatment with a painful, swollen right arm. He has a Peripherally Inserted Central Catheter (PICC) in situ on that side. Doppler ultrasound confirms the diagnosis of line-associated thrombosis.
A full blood count shows haemoglobin 110g/l, platelet count 125x10e9/l, white cell count 4x10e9/l and neutrophil count 1.8x10e9/l.
A. List factors known to contribute to the increased risk of venous thrombosis in patients with cancer.
B. Discuss the options for therapeutic anticoagulation in this case. State your preference and provide a rationale to justify it.
C. Would you remove the PICC? Briefly state the assessment you would make to aid this decision.
D. The patient proceeds with cycle 3 chemotherapy on schedule. Two weeks later his platelet count drops to 20x10e9/l. Discuss the options for his anticoagulation management and state your preferred strategy.