[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

Your Role: you are the doctor on duty for the Acute Medical Unit.

You have 10-minutes with each patient. The Examiners will alert you when 6-minutes have elapsed and will stop you after 8-minutes.

In the remaining 2-minutes, one examiner will ask you to report on any abnormal physical signs elicited, your diagnosis or differential diagnoses, and your plan for management (if not already clear from your discussion with the patient).

Scenario

David Smith (70-years)

GP Letter: Please see this gentleman in whom I found a new anaemia, results attached. Hb 780 g/dl; MCV 98.2 µm3; Plt 457; bilirubin 103 mg/dl; ALP 45 IU/L and ALT 34 IU/L.

Please advise on how to investigate and manage

Physiological observations

Respiratory rate / minute: 18

Pulse rate / minute: 86

Systolic blood pressure (mmHg): 138

Diastolic blood pressure (mmHg): 84

Oxygen saturations (%): 98

Temperature: 36.4°

Your task is to:

Assess the problem by means of a brief focused clinical history and a focused relevant physical examination. You do not need to complete the history before carrying out an appropriate examination.

Advise the patient of your probable diagnosis (or differential diagnoses), and your plan for investigation and treatment where appropriate. Respond directly to any specific questions which the patient may have.

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/205184523″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” underline_digit=”no” separator=”yes” digit=”20″ title=”Minutes” text=”Station time”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” separator=”yes” digit=”10″ title=”Minutes” text=”Time for this encounter”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”8″ title=”Minutes” text=”Maximum time to examine your patient”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”2″ title=”Minutes” text=”Minimum time for discussion and questions”][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has widespread sub-mandibular, cervical and axillary palpable lymphadenopathy. In additoin, a new anaemia with a raised bilirubin. my primary diagnosis is lymphoma.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]Lymphoma can initially appear bewildering in scope. There are dozens of different types and sub-types. You will not be expected to know all of the different types, sub-types and treatment regimens, but be able to understand the general classifications and some of the more common regimes.

There can be confusen about the terminology of leukaemia versus lymphoma. Leukaemia refers to lymphocytic malignancy with widespread involvement of the bone marrow, with markers in the bloodstream. Lymphoma refers to more localised neoplasms in the specific tissues. As research has continued, these lines have blurred as numerous crossovers in histopathology and genetics have shown.

Lymphomas are malignancies of the lymphocytes, as the name suggests, with the two primary sub-divisions of Hodgkin’s Lymphoma (HL) and Non-Hodgkin’s Lymphoma (NHL). HL is the most uncommon, hence the NHL group of lymphomas is by far more prevalent.

NHL can be further sub-divided into B-cell, T-cell and NK-cell sub-types depending upon the lymphocytic origin of the malignancy.

HL

HL has a bimodal distribution, affecting those aged between 15-35 and those over 55-years of age. In low socioeconomic countries, HL has a generally lower incidence than in developed countries, except in children below 15-years, where a higher incidence is seen. There is an association with Epstein-Barr virus (EBV), but this is still controversial as the evidence is not conclusive either way.

NHL

NHL can be misleading, as it encompasses a wide, heterogeneous group of lymphoproliferative disorders. The most common type of NHL are the B-cell lymphomas, accounting for over 80% of cases. Next are the T-cell lymphomas, accounting for up to 20% and then rarely the NK-cell lymphomas accounting for less than 0.1% of cases. Lymphomas account for 4% of cancer related deaths in developing countries.

There was a dramatic increase in the incidence of NHL between 1970 and 1995, which has been attributed to the HIV epidemic and NHL becoming a AIDS-defining illness due to immunosuppression. However, HIV infections would not account for the rising incidence occurring in those aged in their 50’s and 60’s. It is thought this could be accounted for the rising living standards that has led to a higher elderly population.

Investigations

Baseline blood tests:

  • full blood count (pancytopenia)
  • liver function tests (high bilirubin and/or liver infiltration)
  • lactate dehydrogenase (high)
  • erythrocyte sedimentation rate (high)
  • blood film (detects giant platelets and nucleated red blood cells)

Biopsy of a lymph node – which ideally should be a core biopsy to allow for maximum yield.

A skin biopsy can be carried out, if there is concern for a cutaneous malignancy.

Bone marrow biopsy – if either of the above are negative, and there are still strong suspicions for a lymphoma, or there are no peripheral lymph nodes palpable for biopsy, a bone marrow biopsy maybe the only site to obtain a sample and confirm disease.

The above samples must be sent for the following investigations:

  • flow cytometry – to look for tumour surface markers
  • immunohistochemistry – looks for tumour surface markers
  • cytogenetics – PCR for tumour markers

A CT scan of the chest, abdomen and pelvis should be carried out for staging of the disease. There are a number of staging classifications that have emerged over the years, and the most recent is the Lugano classification. The Lugano classification not only uses routine CT, but also 18F-FDG PET-CT for staging and monitoring fresponse to treatment. Staging involves measuring the largest lymph nodes detected as well as the splenic measurements.

If lymphoma is confirmed, the following investigations should be carried out, or at least considered, depending upon the clinical scenario:

  • hepatitis B and C serology (if positive, increases the risk of reactivation of disease after treatment)
  • HIV (AIDS defining illness if positive)

There are a number of other, more complex investigations, but the above are key in the initial diagnosis and staging of the disease.

Management

Management can be divided into supportive and medical. There are no surgical options for treatment unless there is lymphatic obstruction. Medical treatment focuses on chemotherapy and/or radiotherapy. Given the dozens of sub-types and the focus on individualized combinations, there is no reason to even attempt to learn all of them. The examiner will not know the combinations and unless you are aiming to become a haemato-oncologist, there is no reason for you to too.

The type of therapy depends upon the sub-type, staging and patient’s health. The older a patient, the more likely they will have multiple co-morbidities which will affect their ability to manage and cope with the treatments and side effects.

Not only in station 5…

This scenario is common in Communications Skills (station 4) as a breaking bad news station. For an illustration of breaking bad news, see this video. If you want to watch the video with commentary, visit here. Remember the following principles:

  • you are not a haemato-oncologist/expert in this area, so dot try to be, be comfortable in saying that there are treatment options, but until the patient is seen by a specialist, you cannot go into them
  • offer written information
  • if the patient wants to see the consultant, do not say no, but offer to arrange it
  • offer access to a support nurse
  • advise about organisations, every cancer and chronic condition, like lymphoma, has online patient support
  • ensure you inform the patient that this is not the only consultation about this

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This gentleman has suspicion of lymphoma as evidenced by his splenomegaly, weight loss, night sweats, alcohol induced pain and anaemia with a high bilirubin. I would like to repeat his baseline bloods, including full blood count, liver, renal and clotting tests, a blood film and arrange an urgent bone marrow biopsy. I would also like to stage the patient with initially a contrast CT of the chest, abdomen and pelvis. I will urgently refer to the Haematology/Oncology team for further assessment and management”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]