Viva questions

These may range from the simple to taxing - there will be some straightforward questions in the viva but they will also be interspersed with some more obscure questions which might be at the limits of your knowledge. Best thing to do is to test each other in a group nearer the exam, but alternatively they can be used to check your knowledge base to fill in any gaps that remain. Answers are provided on the following page.

Malignant

1. A man has been referred by his GP with an incidental finding of an IgG lambda paraprotein of 7g/L and has come to clinic for the first time. What features of the medical history would you be particularly interested in and what further tests would you consider?

He has subsequently been diagnosed with myeloma with a 20% plasma cell differential on his bone marrow trephine and reveals that he has had some problems with walking as he cannot feel the floor very well at night. Comment on the findings and what treatment would you recommend for him? How would you monitor the course of the disease?

2. A 70 year old man has come to clinic on a two week wait referral with two lymph nodes in the right side of his neck and one in his right axilla. Outline your initial plan of investigation and management.

He has been diagnosed with Stage 2 Hodgkin's disease and also has a history of angina and cigarette smoking. Outline what your treatment options would be in this gentleman.

Coagulation

1. The medical team have admitted a lady in her 70s to the ward with recurrent falls and she subsequently suffered a haematoma while being on warfarin for a history of atrial fibrillation with an elevated INR of 8.0. They are asking about starting her on one of the newer oral anticoagulants.

- what are the criteria by which you might consider starting this lady on a NOAC?

- you decide to start her on rivaroxaban. If at some later date you wanted to assess compliance to the medication as you suspect she is not taking it, what laboratory assessments could you use?

2. A pregnant lady who has type 1 von WIllebrand's disease has been attending your haematology antenatal clinic for the last several months and is now at 32 weeks' gestation. She is keen to know what her options are in terms of pain relief and delivery. Her last tested (during pregnancy) of vW antigen was 0.80IU/ml and RCo 0.75IU/ml. Outline your peridelivery plan for her that the obstetricians may be able to follow.

3. A young lady in her 20s presents with an infection and the house officer contacts you with some abnormal blood results they have noted which include a Hb80g/L, WCC 12.5 x10⁹/L, Plt 79 x10⁹/L. Outline what differentials you might consider and what investigations you may perform to establish the diagnosis.

Subsequently you diagnose her with TTP. What treatment will you offer her, and what specific further blood tests might be able to rule out atypical HUS, as well as further investigations to risk stratify her disease?

Transfusion

1. You are contacted at 6am in the morning while on call as the haematology consultant - the biomedical scientist on overnight informs you that the fridge temperature where the red cells are stored for collection is currently at 10 degrees Celsius. Unfortunately the fridge temperature was not checked regularly - the last recorded check was at 10pm last night and was 5 degrees Celsius. The alarm on the fridge failed to go off to warn about the rise in temperature. 14 units were issued overnight between the time of the last temperature check and the telephone call - 8 of which went to a massive haemorrhage and 6 to four separate patients. Outline your plan of management.

2. As part of a routine antenatal booking screen at ten weeks for a lady who is G2P1, the midwife asks you to review an abnormal result of an anti-D of 3.2U/ml. She has booked the patient into the haematology clinic for next week. What will you plan to do next and outline the plan for the pregnancy up until delivery.

3. Your department has selected you as the lead consultant to develop a service in apheresis. What operational considerations do you need to take into account for this to be safe and a clinical success?

General

1. You are contacted by the paediatricians about a nine month old baby who looks relatively well but hasn't been as active over the last couple of weeks. FBC was done which shows Hb35g/L, with a normal WCC and platelet count - this was repeated and showed the similar value. What would be your next investigations and differential diagnoses?

2. A 42 year old man is newly diagnosed with JAK2 positive essential thrombocythaemia and has come for his results today. What investigations would you perform (if any) and what factors would enable you to decide whether or not to start treatment?

Unfortunately his platelet count continued to rise and reached 1600 and started to develop nose bleeds. You started interferon-alpha and he was unable to tolerate this and the second option was hydroxycarbamide. He was stable for five years with no cytopenias and with no major changes in dosing. Subsequently he developed a mild anaemia (Hb 120g/L). How would you proceed to manage him?

3. The hospital you work in currently would like to have a point of care testing (POCT) machine in the Emergency Department because of delays in sample processing, and the workload of the department has grown because of merging departments across two sites. You decide to proceed with the request. What factors do you need to take into account with setting up a POCT service?

4. You are contacted by a GP for some telephone advice about a lady whose neutrophils have been persistently elevated for a year – a year ago it was 9x10⁹/L; now it is 15x10⁹/L. A blood film has been previously reported by a registrar as being unremarkable. Outline your discussion and what you would recommend to the GP.

5. You are contacted at night about a neonate who was born pre-term at 38 weeks to a Japanese couple requiring Ventouse delivery and was noted to have a purpuric rash. Subsequent investigations have shown that the baby has a normal haemoglobin and WCC; but the platelet count is 20 x10⁹/L. Outline your differentials and immediate management.

Please see the answers on this page.