Haem Practice Q Flashcards
A 24-year-old female presents to her GP with a single mass in her lower neck. It first appeared about 2 months ago. She recently moved to a new house and attributed her recent weight loss and night sweats to the stress of this. However, the lump in her neck has started to grow and she is getting worried as it now has a 3 cm diameter. On a recent girls night out, she found that it was very painful after drinking alcohol. What is the most likely diagnosis?
A. Hodgkin’s lymphoma
B. Multiple myeloma
C. Non-Hodgkin’s lymphoma
D. Polycythaemia Ruba Vera
E. Stomach Cancer
A- Hodgkin’s lymphoma
Hodgkin’s lymphoma has a bimodal presentation in the twenties and the sixties. It presents with a painless asymmetrical presentation but there is pain when drinking alcohol.
B) Multiple myeloma tends to present in those aged 70 and above. It presents with:
o Anaemia, neutropenia, thrombocytopenia due to bone marrow infiltration
o Recurrent infection due to monoclonal Igs
o Renal impairment due to the free light chains
o Bone pain, pathological fractures and vertebral collapse due to bone lesions (increases calcium and Il-6)
C) Non-Hodgkin’s lymphoma is incorrect because this tends to present in the elderly and has a symmetrical presentation.
D) Polycythaemia Ruba Vera presents with symptoms that are related to blood hyper viscosity due to an increase in cellular content. This leads to “thicker” blood and thrombosis meaning that there is poor oxygen delivery. Symptoms relate to this include headache, dizziness, visual disturbances, vertigo, tinnitus and intermittent claudication.
E) Stomach cancer can present with Virchow’s node, a supraclavicular lymph node. However, there would be more signs of GI upset such as nausea, vomiting, heartburn, indigestion
A 55-year-old male is asked to attend a haematology clinic due to his recent diagnosis of chronic myeloid leukaemia. He has some initial investigations prior to his appointment. What is most likely to be found?
A. Auer rods
B. Decrease in the number of basophils
C. Increase in haemoglobin
D. Philadelphia chromosome
E. Reed-Steinburg cells
D- Philadelphia Chromosome
CML is a proliferation of the myeloid cells which are the eosinophils, basophils and neutrophils.
A) Auer rods found in acute myeloid lymphoma
B) CML causes an increase in basophils not decrease
C) CML causes a decrease in haemoglobin and platelets due to the replacement of normal bone marrow cells with cancerous one.
E) Reed-Steinburg cells are found in Hodgkin’s lymphoma
A 76-year-old female has been diagnosed Non-Hodgkin’s lymphoma. She has nodal involvement on both sides of her diaphragm. What stage is she classified under using the Ann-Arbor Classification?
A. 1
B. 2
C. 3
D. 4
E. 4+B
C- 3
The Ann Arbor Classification is used for both Hodgkin’s and Non-Hodgkin’s Lymphoma.
- Single LN region
- > /= 2 nodal area on the same side of the diaphragm
- Nodes on both sides of the diaphragm
- Disseminate e.g. metastasised to the liver
‘B symptoms’ are constitutional symptoms such as fever, weight loss and night sweats
A 50-year-old woman is investigated for weight loss and anaemia. She has no past medical history of note. On clinical examination, the GP finds splenomegaly and pale conjunctivae. Her blood test results are below:
> Haemoglobin: 10.9g/dl (12 – 165)
> Platelets: 702109/l (150 – 450)
> White cell count: 56.6109/l (4 – 11)
> Blood film: Leucocytosis seen with all stages of granulocyte maturation seen. What is
the most likely diagnosis?
A. Acute lymphoblastic leukaemia
B. Chronic lymphocytic leukaemia
C. Chronic myeloid leukaemia
D. Myelodysplasia
E. Myeloma
C- Chronic myeloid leukaemia
Test results show the haemoglobin is slightly low, the platelets are very high and the white cell count is very high.
In CML- WCC will be very high and the haemoglobin and platelets can be higher or lower. This is because there is an increase in cell turnover of myeloblast cells which further differentiate into basophils, neutrophils and eosinophils. Leucocytosis is an increase in WBCs in the blood stream which occurs due to the abnormal proliferation of WBCs in CML.
In myeloma (E) you would expect to find monoclonal antibodies and Bence-Jones proteins.
Which of the following is not a risk factor for a deep vein thrombosis?
A. Dehydration
B. Malignancy
C. Nausea
D. Obesity
E. Varicose Veins
D- Nausea
Risk factors for DVT are based upon Virchow’s triad: stasis of blood flow, hypercoagulability and vessel wall injury. Examples include immobility e.g. hospital bed/long haul flight, dehydration, oestrogen e.g. pregnancy, genetic clotting disorders e.g. lack of protein C, obesity e.g. atherosclerosis, age (the older you are), varicose veins, surgery, previous DVT, trauma, infection and malignancy.
Note that Well’s score is used to calculate the likelihood that someone has had a DVT.
A 45-year-old man has come into hospital after recently having day surgery on his knee with a swollen calf. After taking a history the FY1 finds out that he has also recently been to America and got back 3 days ago. The most likely diagnosis is a DVT. What is the gold standard investigation?
A. CT Scan
B. D-dimer
C. Doppler ultrasound scan
D. Venography
E. XR
C- Doppler USS
Doppler US scan is the gold standard for DVT.
A) E) CT scan and XR are not used for investigating DVT.
B) D-dimer is carried out in someone with a suspected DVT however it has a high sensitivity and a low specificity which means that if negative it rules out a DVT but if positive it does not mean that the patient definitely has a DVT.
D) Venography used to be gold standard but it is now Doppler US scan.
A 15-year-old girl presents to the GP with heavy periods. The GP starts the girl on the oral combined contraceptive pill but is worried that she may have developed iron deficiency anaemia as a result of the blood loss. Which of the following findings would you least expect to find in a patient with iron deficiency anaemia?
A. Brittle hair and nails
B. Koilonychia
C. Pale conjunctivae
D. Reduced reflexes
E. Systolic flow murmur
D- Reduced reflexes
Reduced reflexes are a feature of macrocytic anaemia caused by hypothyroidism (note- reduced/absent reflexes also seen in vit B12 deficiency macrocytic anaemia).
Pale skin and conjunctivae are typical signs in anaemia as is a systolic flow murmur. Brittle or spoon shaped (koilonychia) and brittle hair are signs of iron-deficiency anaemia
A 35-year-old vegan presents to her GP with peripheral neuropathy. In her past medical history, the GP also notes that she has coeliac disease that has been troubling her over the past 2 months. She orders a blood test and finds that she has megaloblastic anaemia. What is the most likely cause?
A. Folate deficiency anaemia
B. Iron deficient anaemia
C. Fanconi anaemia
D. Sickle cell disease
E. Vitamin B12 deficient anaemia
E- Vitamin B12 deficient anaemia
Vitamin B12 anaemia is caused by a lack of vitamin B12 in the diet. Vitamin B12 is found in fish, meat, poultry, eggs and is not generally present in plant-based foods therefore a vegan diet which excludes these food products may make someone more likely to be vitamin B12 deficient. Another cause is impaired absorption.
Vitamin B12 is absorbed at the terminal ileum with the help of intrinsic factor (produced by the stomach), therefore disease of the terminal ileum is more likely to result in VitB12 Deficiency. Vitamin B12 deficiency anaemia also present with neurological symptoms such as peripheral neuropathy making it the most likely answer.
The main causes of megaloblastic anaemia are vitamin B12 deficiency or folate deficiency, but folate deficiency does not present with neurological symptoms
A patient recently started ceftriaxone for meningitis which has caused haemolysis, what would you expect to see on assessment of the patient?
A. Decreased reticulocyte count
B. Decreased serum albumin
C. Decreased serum phosphate
D. Increased Haemoglobin
E. Presence of dark urine
E- Presence of dark urine
With haemolysis there is an increase in the destruction of RBCs. As a result, the bone marrow tries to increase the production of RBCs through the process of erythropoiesis which means that an increased reticulocyte will be seen (A). Due to the increased destruction of the RBCs, haemoglobin is released which increases bilirubin levels. The bilirubin is conjugated in the liver and when the liver is having a hard time keeping up with the amount of bilirubin it means that urine will be darker because the extra bilirubin is excreted in the kidneys.
Albumin is not affected by haemolysis (B).
Which of the following is not a cause of iron deficiency anaemia?
A. Chronic kidney disease
B. GI bleed
C. NSAIDS
D. Pregnancy
E. Sickle cell disease
E- Sickle Cell Disease
Answers A-D are all causes of iron deficient anaemia. Sickle cell disease is a cause of microcytic anaemia. Iron deficient anaemia is also microcytic anaemia but sickle cell disease is not caused by iron deficiency.
How is Hodgkins lymphoma (HL) clinically different from Non-Hodgkins lymphoma (NHL)?
A. Clinical presence of B symptoms in HL and its absence in NHL
B. Disease is limited to lymph nodes in HL whilst in NHL disease can spread beyond lymph nodes
C. Presence of Reed-Sternberg cells in HL on histological observation and absence of such cells in NHL
D. Presence of Auer rods in HL on histological observation and absence of such cells in NHL
E. Physical examination reveals lymphadenopathy in HL whilst this is not the case in NHL
C- Presence of Reed-Sternberg cells in HL on histological observation and absence of such cells in NHL
Lymphomas are histologically divided into Hodgkin’s and non-Hodgkin’s types. In Hodgkin’s lymphoma, characteristic cells with mirror-image nuclei are found, called Reed-Sternberg cells.
Although systemic ‘B’ symptoms (loss of appetite, weight loss and drenching night sweats) may be less common in NHL, nevertheless they can be present in both types of lymphoma and hence do not differentiate between the 2.
The disease can spread beyond lymph nodes in both HL and NHL.
Auer rods are found on bone marrow biopsy in Acute Myeloid leukaemia and help differentiate it from the other leukaemias.
Lymphadenopathy can be seen in both HL and NHL.
Which one of the following is not a definite risk factor for DVT?
A. Pregnancy
B. Recent surgery
C. Recent leg fracture
D. Progestogen-only pill (POP)
E. Recent history of cancer
D- Progestogen-only pill (POP)
Risk factors for DVT are - Recent surgery, immobilisation/leg fracture/Plaster of Paris, Oestrogens (Oral combined contraceptive pill, hormone replacement therapy, pregnancy, etc), Malignancy, History of DVT or PE, Long haul flights/travel (rare), Inherited thrombophilia.
Therefore, we can see that the single best answer for this question is Progestogen only contraceptive pill. In fact, since the Combined hormonal contraceptives (pill, transdermal patch or vaginal ring) contain oestrogen and are hence contraindicated in someone with a history of venous-thromboembolism, NICE recommends Progestogen-only pill (POP) as one of the options for contraception in women with a history of venous thromboembolism (VTE), known thrombogenic mutations, or who is taking anticoagulants for current VTE.
A 46-year-old male comes into your GP practice and is found to have fever and fatigue. It becomes apparent when you are taking a history from him that he has recently come back from Africa. You suspect he could have malaria. What organism would you see in his blood film that would confirm that he has malaria?
A. Giardia lamblia
B. Trypanosoma brucei gambiense
C. Plasmodium falciparum
D. Toxoplasma gondii
E. Anopheles gambiae
C- Plasmodium falciparum
Malaria is a protozoal infection. It can be caused by 5 species of the same family (plasmodium). Plasmodium falciparum = can cause most severe form of malaria (complicated malaria) and has the highest mortality, it is most prevalent in Sub-Saharan Africa. Others include: plasmodium ovale, plasmodium vivax, plasmodium malariae , plasmodium knowlesi
Giardia lamblia (A) - causes giardiasis. Faeco-oral spread. Diarrhoea and other key features - Cramps, bloating, flatulence. Risk factors - recent travel and childcare. Trophozoites/cysts seen in stool. Treated with metronidazole.
Trypanosoma brucei gambiense (B) - causes African Trypanosomiasis - “Sleeping sickness”. transmitted via Tsetse fly bite (you get a chancre). Flu like symptoms. CNS involvement (sleepy, confusion, personality change). Diagnosed on blood film (you can see the protozoa in blood film) or CSF.
Toxoplasma gondii (D) - Ingestion of contaminated food and water/feline faeces. (ONLY CATS CAN PASS IT ON! So not acquirable form other ppl). If immunocompetent, then usually not a problem, but if immunocompromised devastating - can cause: - disseminated disease: - Toxoplasma Encephalitis, Chorioretinitis (Chorioretinitis is an inflammation of the choroid (thin pigmented vascular coat of the eye) and retina of the eye.) and subsequent scarring. Acute maternal infection can be devastating in pregnancy - can end in miscarriage, hydrocephalus, anencephaly, etc.
Anopheles gambiae (E) - a species of mosquito from the Anopheles family of mosquitoes. The female mosquitoes of this species are known to transmit malaria.
A patient presents to A&E with a fever and confusion. Upon further investigation, you find that she has AKI and her FBC reveals thrombocytopenia and anaemia. You recognise this as Thrombotic Thrombocytopenic Purpura and realise it is a medical emergency and you need to treat her immediately without waiting for diagnostic confirmation. What is the urgent gold standard treatment for someone with TTP?
A. Platelets
B. Hydroxycarbamide
C. Immunosuppressants
D. Plasma exchange
E. Broad spectrum antibiotic
D- Plasma exchange
The correct treatment is urgent plasma exchange (replenishes ADAMTS13 and removes antibody). TTP has 90% mortality if untreated and this drops to 10 – 20% if treatment is started promptly! TREAT ASAP WITHOUT DIAGNOSTIC CONFIRMATION. It is a medical EMERGENCY.
Do NOT give platelets –increases thrombosis!!!
Hydroxycarbamide is a bone marrow suppressive drug and is used in treatment of polycythaemia rubra vera and sometimes also in sickle cell disease [prevention of vaso- occlusive complications].
Immunosuppression (reduce antibody level) is actually used as part of treatment of TTP but it is not the urgent treatment that was being asked by the question.
Broad spectrum antibiotics in the context of TTP is not appropriate. This treatment is usually used for sepsis or when as a consequence of a chemotherapy, a patient gets febrile neutropenia (haematological emergency - infection/fever with a low white cell count) and the appropriate management there is to perform ABC, blood cultures and start broad spectrum IV antibiotics (e.g. Tazosin and Gentamicin).
*Extra knowledge nugget: TTP Signs & Symptoms - Pentad: microangiopathic haemolytic anaemia, ↓ platelets, aki, neurological symptoms (headache, palsies, seizure, confusion, coma), and fever. RBC fragments (schistocytes) on film.
You are a junior doctor on the acute medical unit and are doing your clerking. You come across a 60-year-old woman who recently had an accident due to which she suffered a fractured right leg a week ago and she has been relatively bed bound since. She tells you she is concerned her right leg is slightly swollen compared to her left leg and her GP sent her here. On further questioning you find out she is currently on hormone replacement therapy. Which risk score would be most appropriate to determine the next step in managing this patient?
A. CHA2DS2VASc
B. FRAX score
C. HAS-BLED score
D. QRISK-3
E. Well’s score
E- Well’s Score
To be more accurate, the correct answer is DVT Well’s score. Be aware that there is another Well’s score called PE Well’s score which is different from the DVT Well’s score.
CHA2DS2VASc - Calculates stroke risk for patients with Atrial Fibrillation and is used to guide anticoagulant treatment.
FRAX - gives 10 year probability of fracture
HAS-BLED Score - Estimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care.
The QRISK®3 algorithm calculates a person’s risk of developing a heart attack or stroke over the next 10 years.
A 22-year-old male is diagnosed with Hodgkin’s lymphoma. Imaging and bone marrow biopsy reveal that the lymphoma is present in his axillary lymph nodes and in his inguinal lymph nodes. He has also lost significant weight and reports having night sweats. What clinical stage is his Hodgkin’s lymphoma currently, according to the Ann Arbor staging system?
A. Stage II A
B. Stage III B
C. Stage IV A
D. Stage IV B
E. Stage III A
B- Stage IIIB
Staging influences treatment and prognosis. Done by imaging ± marrow biopsy if B symptoms, or stage iii– iv disease.
I Confined to single lymph node region.
II Involvement of two or more nodal areas on the same side of the diaphragm.
III Involvement of nodes on both sides of the diaphragm.
IV Spread beyond the lymph nodes, e.g. liver or bone marrow.
Each stage is either
‘a’—no systemic symptoms other than pruritus;
or ‘b’—presence of b symptoms: loss of appetite, weight loss and drenching night sweats.
In this scenario, patient has lymphoma in his axillary and inguinal lymph nodes (so on both sides of his diaphragm) but it has not spread beyond lymph nodes hence it is stage III. It is also mentioned that he has had weight loss and gets night sweats which are both systemic ‘B’ symptoms and therefore the clinical stage of his Hodgkin’s lymphoma is III B.
Jennifer, a 49-year-old female, was recently started on chemotherapy in preparation for a bone marrow transplant. Which of the following is the least likely complication of her chemotherapy?
A. Cytopenia (anaemia, neutropenia and thrombocytopenia)
B. Excessive hair growth
C. Infertility
D. Nausea and GI disturbances (constipation/diarrhoea)
E. Secondary malignancies
B- Excessive Hair Growth
Chemotherapy has a LOT of adverse effects. It is a very toxic treatment but usually the positives of therapy outweigh the negatives. Excessive hair growth is not a side effect whilst someone is on chemotherapy. In fact, alopecia (temporary hair loss) is a well-known side effect of chemotherapy.
This was a question simply to raise awareness of the adverse effects of chemo, some of the most devastating being infertility, cytopenia and secondary malignancies. Nausea, constipation and diarrhoea are all also side effects of chemotherapy. Chemotherapy has numerous side effects.
You are the FY1 on an orthopaedic ward. A 65-year-old man is on the ward recovering from a recent total hip replacement following a neck of femur fracture. What is an appropriate thromboprophylaxis regimen?
A. Alteplase
B. Compression stockings and aspirin
C. Dalteparin acutely and then maintenance treatment with apixaban
D. Dalteparin acutely and then maintenance treatment with aspirin
E. Aspirin acutely and then maintenance treatment with apixaban
C- Dalteparin acutely then maintenance treatment with apixaban
Taken from BNF- management of Venous ThromboEmbolsism in post-hip replacement patients states… “Patients undergoing an elective hip replacement should be given thromboprophylaxis with either a low molecular weight heparin administered for 10 days followed by low-dose aspirin for a further 28 days, or a low molecular weight heparin administered for 28 days in combination with anti-embolism stockings until discharge, or rivaroxaban. If these options are unsuitable, apixaban or dabigatran etexilate can be considered as alternatives. If pharmacological prophylaxis is contra-indicated, anti-embolism stockings can be used until discharge”.
Alteplase is a fibrinolytic drug used mainly in Acute myocardial infarction, PE and Acute ischaemic stroke.
Aspirin is usually used for secondary prevention of CVD, Management of unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI), transient ischaemic attack and acute ischaemic stroke.
What is the protein target of Rituximab?
A. CD4
B. CD8
C. CD20
D. HER2
E. TNF-alpha
C- CD20
Rituximab is a monoclonal antibody. It targets a protein called CD20 on the surface of B- cells. Rituximab sticks to all the CD20 proteins it finds. Then the cells of the immune system pick out the marked cells and kill them. CD-20 is only found on B cells and nowhere else. Rituximab is used for treatment of Non-Hodgkin’s lymphoma, Chronic lymphocytic leukaemia, etc. A main side-effect = allergic reactions (wide range).
HER2 = Trastuzumab - treatment for cancers that have large amounts of a protein called human epidermal growth factor receptor 2
TNF-alpha = Adalimumab - subcutaneously administered biological disease modifier for the treatment of rheumatoid arthritis and other chronic debilitating diseases mediated by tumour necrosis factor.
CD4 = human immunodeficiency virus infection. It is usually expressed on helper T lymphocytes and it is these CD4 cells that the HIV virus target.
CD8 = a glycoprotein expressed on cells that are generally classified to be known as killer-T cells or CD8 cytotoxic T cells.
What is the ideal first line treatment for severe/complicated malaria?
A. IV Artesunate
B. IV quinine + doxycycline
C. PO chloroquine
D. PO primaquine
E. Artemisinin combination therapy
IV artesunate is the ideal first line treatment for severe/complicated malaria.
IV quinine + doxycycline is an alternative to IV artesunate in treating severe malaria if IV Artesunate is contraindicated or not available.
Oral chloroquine can be used as treatment for uncomplicated malaria/Treatment of non- falciparum malaria.
Primaquine is used to eliminate P. ovale and P.vivax can form hypnozoites in the liver which can lie dormant in the liver for years. Screening for G6PD deficiency is essential before treatment with primaquine is started as it can cause haemolysis in G6PD deficient individuals, which can be fatal. It is contraindicated in pregnancy and breastfeeding.
Artemisinin combination therapy (ACT) is the preferred treatment for mixed infection in uncomplicated malaria.
Which of the following is not a cause of macrocytic anaemia?
A. Alcohol excess
B. Bone Marrow infiltration
C. B12/Folate deficiency
D. Chronic disease
E. Hypothyroidism
D- Chronic Disease
Chronic disease is classically associated with Normocytic or Microcytic anaemia. The rest impair meiosis and cell division, hence the cells that are produced are larger than they would ordinarily be i.e. macrocytic cells.
What is the 1st line treatment for the most common form of anaemia?
A. Blood transfusion
B. Folic acid
C. Hydroxycarbamide
D. Oral iron supplements
E. Pyridoxine
D- Oral iron supplements
The most common form of anaemia is Iron deficiency anaemia, a microcytic anaemia.
(D) Iron supplements are the initial treatment for iron deficiency anaemia.
(A) Blood transfusion is a treatment for Iron-deficiency anaemia, but it is not the 1st line treatment.
(B) Folic acid is the treatment for macrocytic anaemia to stimulate cell division.
(C)Hydroxycarbamide is generally used as prophylaxis for sickle cell crises.
(E) Pyridoxine is the treatment for Sideroblastic anaemia
A 73-year-old lady presents to you complaining of recent fatigue and unexplained weight loss. In her records you see she has visited the GP 3 times in the past month with infections and been prescribed various antibiotics. On examination you note that her arms are covered in bruises, owing to your concern you order several investigations.
The results are as follows:
> Hb – 85g/L (115-160g/L)
> MCV – 79fL (76-96fL)
> Platelets – 90x109/L (150-400x109/L)
> WCC – 25x109/L (4-11x109/L)
Bone marrow biopsy shows significant numbers of blast cells with Auer rods. What is the diagnosis?
A. Acute lymphoblastic leukaemia
B. Acute myeloid leukaemia
C. Chronic lymphocytic leukaemia
D. Chronic myeloid leukaemia
E. Hodgkin’s lymphoma
B- Acute myeloid leukaemia
The history suggests a more acute course, making the chronic leukaemia’s less likely but not impossible (C)(D). They will, however, tend to present more insidiously.
Hodgkin’s Lymphoma (E) will typically present with a painless lump and a white cell count that is not normally raised.
The difficulty is distinguishing between ALL (A) and AML (B).
ALL is typically a disease of children whereas AML is the most common leukaemia of adults which would make you lean towards AML in this case as the lady is the perfect age for AML.
The 2 diseases are differentiated by the presence of Auer rods in blast cells on bone marrow biopsy.
Which of the following is a characteristic cytogenic finding in Chronic Myeloid Leukaemia?
A. Bite cells
B. Philadelphia chromosome
C. Roth spots
D. Schistocytes
E. Xanthoma
B- Philadelphia chromosome
Philadelphia chromosomes are characteristic in cytogenics of CML (B).
Bite cells (A) are a characteristic finding in G6PD deficiency, a haemolytic disorder.
Roth spots (C) are signs found in the eyes in Infective endocarditis.
Schistocytes (D) are cell fragments found post haemolysis which is not a feature of Leukaemia’s.
Xanthoma (E) are yellowy fatty spots which develop under the skin, commonly in liver disease.
Monoclonal Gammopathy of Undetermined Significance (MGUS) is a condition which carries a risk of developing into which condition?
A. Acute Myeloid Leukaemia
B. Chronic Lymphocytic leukaemia
C. Myeloma/Multiple Myeloma
D. Burkitt’s Lymphoma
E. Sickle Cell anaemia
C- Myeloma/multiple myeloma
MGUS is a precursor condition which has a 1% chance per year of developing into myeloma. It causes no end organ damage and has no symptoms. It is characterised by overproduction of a monoclonal immunoglobulin, generally found incidentally on blood tests. It has no relation to any of the other conditions.
Thomas Jones, a 17-year-old male, presents to his GP with a large, non-tender lump on his neck. He is referred to a haematologist and diagnosed with Hodgkin’s Lymphoma. Which of the following is least likely to be found in a patient with Hodgkin’s Lymphoma?
A. Anaemia
B. Hepatosplenomegaly
C. Pruritis (itching)
D. Raised white cell count
E. Reed-Sternberg cells on blood film
D- Raised white cell count
In Hodgkin’s Lymphoma white cells are not typically raised. It is counter intuitive that the WCC is not raised and it can be easy to be caught out.
Pruritis can occasionally be the only presenting symptom in Hodgkin’s lymphoma.
Reed-Sternberg cells are diagnostic if found on a blood film.
A 70-year-old man presents with chronic back ache, constipation, renal stone and weight loss. His GP ordered some investigations and referred him to hospital.
The investigation results are as follows:
> Hb - 84g/L (130-180g/L) (Male range)
> MCV – 77fL (76-96fL)
> ESR – 150 (45) (Male and Age appropriate range)
> Creatine – 170 (70-100)
> Urea – 7.3mmol/L (2.5-6.7 mmol/L)
> Ca2+ - 2.5mmol/L (1.0-1.5mmol/L)
Urine Electrophoresis showed Bence Jones proteins. Blood films showed Rouleaux formation. What is the diagnosis?
A. Acute Lymphoblastic Leukaemia
B. Bronchial carcinoma
C. Chronic Myeloid Leukaemia
D. Follicular Lymphoma
E. Multiple Myeloma
E- Multiple myeloma
Myeloma symptoms can be remembered by the acronym CRAB – Calcium (raised due to bone resorption), Renal impairment (creatinine high), Anaemia and Bone (osteoporosis). The above history and investigations are indicative in derangement of all of these. In addition, Bence jones proteins in the urine and rouleaux formation in the blood are characteristic of Myeloma.
While advanced Bronchial Ca could have metastasised into various organs to produce the spread of symptoms and investigative results we have here, it would be very advanced and the patient would be significantly more unwell with a very severe cough likely with haemoptysis.
Acute lymphoblastic leukaemia presents typically with an anaemia/infection/bleeding picture and tends to develop more rapidly and do not typically cause renal impairment or calcium derangement until later in their disease course.
CML tends to be much slower in bone erosion, and more typically causes fatigue, sweats and potentially gout over a chronic course.
Follicular lymphoma is also a very slow developing (indolent) cancer which does not fit the presented symptoms or investigations.
An 80-year-old lady is diagnosed with polycythaemia rubra vera and is treated with hydroxycarbamide and aspirin. Which of the following is not an identified feature or complication of PCV?
A. Dizziness
B. Itching
C. Haemorrhage
D. Weight Loss
E. Thrombosis
D- Weight loss
Weight loss (D) is not a known complication or feature of PCV.
PCV is a condition in which the bone marrow over produces blood cells caused in 95% of cases by a JAK2 mutation.
Dizziness (A) occurs because the blood is overly viscous causing various CNS abnormalities.
Itching (B) occurs because the abnormal numbers of RBC’s stimulate histamine.
Haemorrhage (C) can occur due to defective platelet function.
Which of the following is not a risk factor for deep vein thrombosis?
A. Immobility
B. Malignancy
C. Surgery
D. Trauma
E. Tay-Sachs disease
E- Tay-sachs disease
You almost certainly will not know what Tay-Sachs disease is and you’re not meant to. It is a very rare neuro-degenerative disease of children. The point is that you should know that all of the other options are major risk factors for DVT – immobility, trauma and surgery because they all impair the body’s ability to move the blood from the legs back to the heart and malignancy because of cell wall damage in the blood vessels.
A 25-year-old lady presents with menorrhagia and tiredness. On investigation she is found to have Iron-deficiency anaemia. Which of the following will not be found on her blood film?
A. Abnormally shaped red blood cells (Poikilocytosis)
B. Heinz bodies
C. Pale (hypochromic) red blood cells.
D. Red blood cells of varying size (anisocytosis)
E. Small (microcytic) red blood cells.
B- Heiz Bodies
Heinz bodies are seen in G6PD deficiency not in IDA. The RBC’s will be pale due to insufficient haemoglobin and small for the same reason. They will also form in abnormal shapes as the normal structure requires a set amount of haemoglobin. The cells will vary wildly in size depending on the store of iron in the bone marrow which created them
Which of the following is not a cause of neutrophilia?
A. AIDS infection
B. Appendicitis
C. Chronic Myeloid Leukaemia
D. Myocardial Infarction
E. Strep pyogenes infection
A- AIDS infection
Neutrophilia is a high neutrophil count. This often occurs in response to infection, inflammation or trauma. In contrast, neutropenia is a low neutrophil count and is often a result of immunosuppression by particular drugs and cancers. Despite AIDS (A) being an infection, it targets the immune system and can cause life-threatening neutropenia.
In contrast, despite CML (C) being a cancer, it causes proliferation of neutrophils (as well as other cells such as basophils and eosinophils) and so is a cause of neutrophilia.
Appendicitis (B), MI (D) and Strep pyogenes (E) infections all increase neutrophil count as the body responds to the acute event.
In which of the following conditions would you find Reed Sternberg cell?
A. Acute lymphoblastic leukaemia
B. Acute myeloid leukaemia
C. Hodgkin’s lymphoma
D. Myeloma
E. Non- Hodgkin’s lymphoma
C- Hodgkin’s Lymphoma
The Reed Sternberg cell is an abnormal lymphocyte which is classic of Hodgkin’s lymphoma.
Other buzz words for haematological malignancies include the Philadelphia chromosome in CML and the Bence Jones Protein in Myeloma.
Pauline is a 58-year-old lady attending your GP clinic. She complains of becoming increasingly tired over the past few years and has lost 2 stone. Pauline initially put these symptoms down to the menopause but has come to see you after experiencing more symptoms, including mouth ulcers and pins and needles in her feet. You notice Pauline’s skin has a slight yellow tinge. Which of the following would be the most appropriate first line treatment given the likely diagnosis?
A. Blood transfusion
B. Chemotherapy
C. Ferrous sulphate
D. Venesection
E. Vitamin B12 injections
E- Vitamin B12 injections
Pauline is likely suffering from Pernicious Anaemia, an autoimmune condition that prevent the uptake of vitamin B12/folate in the bowel. It is most commonly diagnosed in women around the age of 60. As well as ‘classic’ anaemia symptoms, pernicious anaemia can also cause peripheral neuropathy (hence the pins and needles), lemon tinged skin (due to a mix of mild jaundice and pallor), mouth ulcers, depression and dementia. Vitamin B12 injections can replace that which the body cannot absorb.
Blood transfusions (A) and chemotherapy (B) are more commonly used in sickle cell anaemia
Ferrous sulphate (C) is used in iron deficiency anaemia.
Venesection is not a treatment for anaemia but for polycythaemia (D).
Which of the following is not a cause of macrocytic anaemia?
A. B12/folate deficiency
B. Bone marrow failure
C. Hypothyroidism
D. Iron deficiency
E. Liver disease
D- Iron deficiency
Iron deficiency anaemia is a hypochromic, microcytic anaemia.
The other options: B12/folate deficiency (A), bone marrow failure (B), hypothyroidism (C) and liver disease (E) all cause macrocytic anaemia.
Lucy is a 7-year-old girl with a known haematological malignancy receiving outpatient treatment. Over the weekend, her parents bring her to A&E as she is red in the face and the veins of her chest are dilated. You also notice Lucy has facial features, including a small chin, slanted eyes and drooping of the left side of her face. Which haematological malignancy is Lucy likely to have?
A. Acute Lymphoblastic Leukaemia
B. Acute Myeloid Leukaemia
C. Chronic Lymphocytic Leukaemia
D. Chronic Myeloid Leukaemia
E. Hodgkin’s Lymphoma
A- Acute Lymphoblastic Leukaemia (ALL)
ALL is more commonly found in children and is associated with Down’s syndrome (note the facies listed in the question- small chin, slanted eyes). It usually presents with anaemia, bleeding and infection alongside hepatosplenomegaly and peripheral lymphadenopathy. Lucy is suffering from two additional complications: CNS involvement causing facial nerve palsy (drooping), and Superior Vena Cava obstruction causing red face and dilated chest veins. These complications are rare but point towards a diagnosis of ALL.
Mary is a 62-year-old lady presenting to your GP clinic to discuss symptomatic relief for menopause. Lately, she has felt tired and has lost her appetite. Her bowel movements have increased in frequency. During her visit, you do a routine health check, including a full blood count which shows microcytic, hypochromic red blood cells. Which of the following is the most appropriate next step?
A. Begin Ferrous sulphate tablets and review in 3 months
B. Give dietary advice regarding iron and fibre
C. Refer to Gynaecology
D. Refer urgently for a colonoscopy
E. Refer routinely for a colonoscopy
D- Refer urgently for colonoscopy
Mary is displaying red flag symptoms for bowel cancer, a concerning cause of iron deficiency anaemia in post-menopausal women and all men. An urgent (2 week wait) colonoscopy (D) is needed to rule out malignancy.
Ferrous sulphate (A) and dietary advice (B) is appropriate management for pre-menopausal women with iron deficiency anaemia and no red flags.
A referral to gynaecology (C) is appropriate for women with anaemia and unresponsive menorrhagia or post-menopausal bleeding.
Robert is a 6-year-old boy being investigated for recurrent nosebleeds. He is found to have Haemophilia B. Which clotting factor is deficient in Haemophilia B?
A. Factor 6
B. Factor 7
C. Factor 8
D. Factor 9
E. Factor 10
D- Factor 9
Haemophilia B is an inherited condition in which Factor 9 is deficient, causing easy bruising and bleeding. It is less common that Haemophilia A, in which Factor 8 is deficient
(memory trick: A comes before B, and 8 comes before 9, so A=8 and B=9)
Bill is a 56-year-old. He is overweight and has smoked 30 cigarettes a day since the age of 14. He has a past medical history of COPD and hypertension. He presents to A&E with a swollen red calf and is diagnosed with a DVT. You notice he also has red palms and soles. Which of the following conditions is most likely to be the cause of Bill’s DVT?
A. Disseminated intravascular coagulation
B. Immune thrombocytopaenia
C. Polycythaemia rubra vera
D. Secondary polycythaemia
E. Von Willebrand disease
D- Secondary polycythaemia
Polycythaemia is an increase in RBC production. Primary polycythaemia (rubra vera) (C) is an issue with RBC overproduction, whereas secondary polycythaemia has an underlying cause, commonly chronic hypoxia as a result of lung disease, smoking, or low FiO2. In this case, we know Bill has a significant smoking history and COPD, making secondary polycythaemia more likely than primary.
DIC (A) is a condition where many small clots form throughout the body, causing bleeding as clotting factors are used up. There is usually a distinct trigger such as sepsis, major surgery or trauma, making this less likely in Bill’s situation.
Joshua is a 14-year-old with known sickle cell disease. He is brought into A&E experiencing intense pain in his legs. Which of the following is most likely to have triggered his sickle cell crisis?
A. Anti-malarial medication
B. Green beans
C. Hepatitis B vaccine
D. Influenza vaccine
E. Parvovirus B19
E- Parvovirus B19
Parvovirus B19 causes Fifth disease, a usually mild rash illness. However, in people with sickle cell, it can precipitate a painful crisis.
Anti-malarial medications (A) containing quinine and green beans (B) are known to precipitate crises in people with G6PD.
Both the Hepatitis B (C) and influencza vaccine (D) are recommended by NICE for people with sickle cell disease due to an increased risk of complications from infections and the increased likelihood of receiving a blood transfusion in their lifetime.
Robert is a 73-year-old gentleman who presents to your GP clinic with back pain. He describes an aching pain that wakes him at night and has been worsening for 3 months. His blood results show the following:
> Hb 78g/dL (130-180)
> WCC 7.6 x 109 /L (4 x 109 - 11 x 109)
> Platelets 317 x 109 (150 x 109 – 450 x 109)
> Creatinine 220umol/L (60-110)
> Sodium 141mmol/L (135-145)
> Calcium 3.1mmol/L (2.1-2.6)
Which of the following is Robert least likely to be prescribed, given the likely diagnosis?
A. Bisphosphonates
B. Calcium gluconate
C. Dexamethasone
D. Radiotherapy
E. Thalidomide
B- Calcium gluconate
Robert has multiple myeloma causing back pain, anaemia, AKI and hypercalcaemia of malignancy. The presentation of myeloma can be remembered using CRAB – calcium, renal impairment, anaemia, bone lesions. Calcium gluconate (B) is the treatment for hypocalcaemia and so is unlikely to be prescribed in this context.
Myeloma is incurable but often managed with a combination of chemotherapy, steroids (C) and thalidomide (E).
Supplementary treatments include bisphosphonates (A) and radiotherapy (D) to address bony pain.
Which of the following is not a cause of microcytic anaemia?
a) Iron deficiency
b) Beta thalassaemia
c) Sideroblastic anaemia
d) Folate deficiency
e) Anaemia of chronic disease
D) Folate deficiency
Folate deficiency is a cause of macrocytic megaloblastic anaemia.
Which of the following is the correct mechanism of absorption of vitamin B12?
a) B12 binds to CCK produced by enterochromaffin cells
b) B12 binds to intrinsic factor produced by the parietal cells of the stomach
c) B12 binds to intrinsic factor produced by the terminal ileum
d) B12 binds to pepsinogens produced by the chief cells of the stomach
e) B12 diffuses freely into the epithelial cells of the terminal ileum
B) B12 binds to intrinsic factor produced by the parietal cells of the stomach it is then absorbed in the terminal ileum
In pernicious anaemia (most common cause of vitamin B12 deficiency) the parietal cells of the stomach are attacked by the immune system, resulting in atrophic gastritis and the loss of intrinsic factor production
What is the management for hereditary spherocytosis?
a) Ferrous sulphate
b) Life-long blood transfusions
c) Fresh frozen plasma
d) Splenectomy
e) Bone marrow transplant
D) Splenectomy
Management:
* Relieves symptoms due to anaemia or splenomegaly, reverses growth failure and prevents
recurrent gallstones
* Best to postpone until after childhood due to infection risk post-op
* After operation give appropriate immunisation and life-long penicillin prophylaxis
Which of the following describes the appearance of a blood film of a patient with beta thalassaemia major?
a) Large and small irregular hypochromic RBCs
b) Sickled erythrocytes
c) Oval macrocytes (large RBCs) with hypersegmented neutrophil polymorphs with six or more lobes in the
nucleus
d) Blast cells present
e) Plasmodium falciparum present
A) Large and small irregular hypochromic RBCs
Beta thalassaemia is an example of a haemolytic anaemia. RBCs can either be normocytic or if there are many young RBCs (reticulocytes – which are larger) due to excessive destruction of old RBCs then
macrocytic.
Sickled erythrocytes (B) are seen in sickle cell anaemia, another type of haemolytic anaemia.
Oval macrocytes (C) would be seen on the blood film of a patient who has megaloblastic. anaemia i.e. B12 or folate deficiency.
Blast cells (D) are seen in acute lymphoblastic leukaemia.
Plasmodium falciparum (E) is one of the causative organisms of malaria
A 72-year-old man presents to A&E complaining of general malaise, back pain and not passing urine in a few days. Blood tests were performed with the results below:
* Hb 64g/dL (130-180)
* WCC 6.8 x 109 (4 x 109 – 11 x 109)
* Platelets 300 x 109 (150 x 109 – 450 x 109)
* Creatinine 400umol/L (60 – 110)
* Sodium 138mmol/L (135 -145)
* Calcium 3.5mmol/L (2.1-2.6)
Which of the following conditions is most likely to be the cause of his symptoms?
a) Chronic Lymphocytic Leukaemia
b) Acute Myeloid Leukaemia
c) Multiple Myeloma
d) Hodgkin’s Lymphoma
e) Non-Hodgkin’s Lymphoma
C) Multiple Myeloma
Multiple myeloma presents in adults aged over 70. The most prominent features on presentation of multiple myeloma can be remembered using CRAB. There are also non-specific presentations of tiredness/malaise or infection.
C – calcium over 2.75mmol/L
R – Renal impairment
A – Anaemia
B – Bone lesions -> pepper pot skull, cord compression, back pain
The blood results confirm this diagnosis, the low Hb shows anaemia, WCC and platelets remain normal, high creatinine suggests renal impairment and high calcium
CLL is a leukaemia affecting the B cells, it is the most common leukaemia normally affecting adults > 70-years-old. Often, those presenting with CLL are asymptomatic or have enlarged, rubbery nontender nodes – not the symptoms described in the question. As for the blood results, CLL causes a high WCC with high lymphocytes and a blood film would show small, mature lymphocytes. The blood results do not confirm this diagnosis as the WCC is not raised.
AML tends to affect those aged over 40-years. It presents with anaemia, bleeding and infection. The blood results in a patient in AML would show anaemia, thrombocytopenia and neutropenia. On a bone marrow biopsy, you would expect to see Auer Rods to confirm a diagnosis. The blood results do not confirm this diagnosis as the patient has normal platelet levels not thrombocytopenia
Hodgkin’s Lymphoma has a bimodal incidence affecting young adults and the elderly. The most common presentation of HL is fevers, sweating, enlarged rubbery non-tender nodes and systemic B symptoms (loss of appetite/night sweats). You would expect to see anaemia on the blood results however the remaining blood results do not fit with this diagnosis.
Non-Hodgkin’s Lymphoma affects adults aged over 40 years. The presentation of NHL is similar to HL except B symptoms are less common and there may be some GI and skin involvement.
Which of these findings would you expect to confirm a diagnosis of multiple myeloma in a patient?
a) Leukaemic blast cells
b) Rouleaux formation
c) Auer rods
d) Reed-Sternberg cells
e) Raised myeloid cells
B) Rouleaux formation
Rouleaux formation is seen on the blood film of patients with multiple myeloma
You would expect to find Leukaemic blast cells on the blood film of a patient with acute lymphoblastic leukaemia (ALL)
Auer Rods are seen on a bone marrow biopsy of someone with Acute Myeloid Leukaemia (AML)
The Reed-Sternberg cell is a characteristic cell of Hodgkin’s Lymphoma
Raised myeloid cells would be seen in chronic myeloid leukaemia (CML)
The most severe form of the disease malaria with the highest rate of mortality in humans is caused by which species of mosquito?
a) Plasmodium vivax
b) Plasmodium ovale
c) Plasmodium malariae
d) Plasmodium knowlesi
e) Plasmodium falciparum
E) Plasmodium falciparum – causes the most severe form of malaria and has the highest rate of mortality. This species is mainly found in Africa, it is the most common type of malarial parasite.
P. vivax can also cause severe disease and kill people; however, it contributes much less to the global burden of malaria than P. falciparum. Mainly found in Asia and South America. This species can stay in the liver for up to 3 years therefore there is the potential for relapses.
P. ovale – this is very uncommon and usually is found in West Africa. This species can remain in your liver for several years without producing symptoms
P malariae – this species is quite rare and usually only found in Africa
P. knowlesi – this species is very rare and found in parts of southeast Asia.
A 38-year-old lady presents to her GP complaining of feeling very ‘warm and cold’ for the past few days. She recently got back from visiting family in Africa and since then she has had some vomiting and diarrhoea, abdominal pain and has just been feeling unwell. Which diagnosis is most likely in this lady?
a) Uncomplicated malaria
b) Tuberculosis
c) Complicated malaria
d) Food poisoning
e) Cholera
A) Uncomplicated malaria – the key feature in this question was the feeling ‘warm and cold’ which represents the fever causing sweats and chills in an individual with malaria. Questions with fever and recent travel – THINK could it be malaria!
TB – These symptoms this lady presented with are not typical of TB. A persistent cough, weight loss, night sweats and a fever are the symptoms expected in a TB infection
Complicated malaria is characterised by vascular occlusion which can affect different organs therefore causing specific symptoms e.g., cerebral malaria leads to micro-infarcts and therefore symptoms include drowsiness, increased intracerebral pressure causing seizures and coma.
Food poisoning – this would cause similar symptoms to uncomplicated malaria however the key in this question is the recent travel!
Cholera is caused by the bacteria Vibrio cholerae and this releases a toxin which increases water release from intestinal cells resulting in severe diarrhoea. Infection occurs through ingestion of contaminated food or water.
You see a 52-year-old female who went to her GP as she noticed her lymph nodes were enlarged. She has also had a fever recently and is worried she has an infection. You run some blood tests and see a raised ESR and lactose dehydrogenase. You refer her to oncology who do a lymph node biopsy and imaging. The images show non-Hodgkin lymphoma in both her upper and lower body. There are no signs of nonlymph node involvement.
What would the staging for this woman’s lymphoma be?
a) Stage II A
b) Stage II B
c) Stage III A
d) Stage III B
e) Stage IV B
D) Stage III B
This patient’s lymphoma has spread to nodal areas on both sides of the diaphragm so it is Stage III. She also presents with a fever so has systemic symptoms, therefore her stage would include the suffix B.
Stage II describes a cancer that is one a single side of the diaphragm, and stage IV has spread beyond the lymph nodes
- Below is the coagulation cascade
a) Fill in the table below.
