Haematology Flashcards
1
Q
What is ABO blood grouping?
A
inherityed surface antigens on RBCs
A- have A antigens on RBCs, and anti-B antibodies in plasma
B- Have B antigens on RBCs, and anti-A antibodies in plasma
AB- have both A and B antigens on RBCs, neither anti-A or anti-B antibodies
O- have neither A or B antigens on RBCs, have both anti- B and anti-A antibodies
2
Q
What blood can type A receive
A
A, O
3
Q
What blood can type B receive
A
B, O
4
Q
What blood can type AB receive
A
A, B, AB, O
5
Q
What blood can type O receive
A
O
Universal donor
6
Q
What is Rhesus types
A
C, D and E antigens on RBCs
Rhesus -ve/+ve refers to the presence or absence of the D antigen
7
Q
why are rhesus types important in pregnancy/childbirth
A
Rhesus negative (dd) mothers who are exposed to rhesus positive cells (from +ve baby), will make IgG anti-D antigens which ccan cross the placenta and haemolyse baby’s blood
8
Q
What are the indications of fresh frozen plasma
A
- contains COAGULATION proteins, albumin, carrier proteins for nutrients/hormones, Ig
- lost about half of their blood volume- major haemorrhage protocol-
- actively bleeding with deranged clotting (PT, APTT, INR)
- consider prophylactically before surgery if clotting is deranged
- give units one by one and reassess coag status
9
Q
When do you give platelets
A
- major haemorrhage
- thrombocytopenia (plt<30)
- prophylaxis pre-surgery if plt <50
do not routinely offer to pt with bone marrow failure, autoimmune thrombocytopenia, herpain induced thrombocytopenia, thrombotic thrombocytopenic purpura
- give one unit and reassess unless severely haemorrhaging
10
Q
indications for cryoprecipitate
A
- significant bleeding and fibrinogen level <1.5g/L
- prophylactically for pts with fibinogen level <1g/L pre-surgery
- adult dose= 2 ‘pools’– reassess and repeat
11
Q
what is in cyroprecipitate
A
fibrinogen, fibronectin, factor VIII, vWF, factor XIII
12
Q
how do you order blood
A
- 2x group and saves from a pt taken 15 mins apart for safe blood typing
- likely need to code the reason for the request
- major haemorrhage– 2u of O- instant access
- prescribe either on fluid chart or on specific blood products chart- each unit needs to be it’s own px
13
Q
how do you give blood products
A
- wide bore cannula to prevent haemolysis
- give over 2-3 hours in non urgent cases
- give within 30mins of leaving the fridge (should be warmed before administering)
- baseline obs at 0, 15, 30mins into the transfusion
14
Q
Complications of blood transfusions
A
- acute haemolytic transfusion reaction- ABO incompatibility
- Anaphylaxis
- Transfuion related acute lung injury
- transfusion associated circulatory overload
- hypocalcaemia
- post transfusion purpura
- graft versus host disease
- transmission of blood borne diseases
15
Q
what is acute haemolytic reaction (ABO incombatibility)
A
- Anti-a/b antibodies activate complement pathway, triggering inflammatory cytokine release
- most severe is when A is given to O pt
16
Q
ix for ?acute haemolytic reaction
A
- blood film
- direct antiglobulin test
- retest both bloods (cross match and antibody screen)
17
Q
tx acute haemolytic reaction
A
- stop transfusion
- fluid replacement
- FFP/platelets to tx DIC
- *- dopamine (vasodilation in the kidneys)
18
Q
sx of acute haemolytic reaction
A
sx
- fever
- hypotension
- abdo/chest pain
- SOB
- haematuria and widespread haemorrhage (DIC)
19
Q
what is transfusion related acute lung injury , sx
A
- not related to fluid overload (that is an immune response of unknown mechanism causing pulm oedema and ARDS)
- more typically due to FFP/plts than with red packed cells
sx- onset is sudden and severe, occurs within 6hours of transfusion:
- Dyspnoea
- Hypoxaemia
- hypotension
- fever
20
Q
management of transfusion related acute lung injury
A
usually resolves within 48-96hours
- O2
- sometime ventilation
- fluids
- corticosteroids sometimes
21
Q
What is transfusion associated circulatory overload
A
- hypervolaemia as a result of a transfusion
22
Q
sx of transfusion assoc circulatory overload
A
- dyspnoea
- orthopnoea
- peripheral oedema
- rapid increase in BP
- pulmonary oedema
23
Q
RF for tranfusion assoc circulatory overload
A
CVD kidney disease lung disease hypoalbuminaemia severe anaemia age (<3years old and >60)
24
Q
Management of transfusion assoc circulatory overload
A
stop transfusion
oxygen
diretics (furosemide)
other tx for - ACEI/ARB, BB
25
why can hypocalcaemia occur after a transfusion, tx
- citrate (anticoagulant present in the bag) binds to free serum Ca in plasma, leaving the pt hypocalcaemic
- rare, only in massive transfusions
tx- calcium gluconate
26
What is post transfusion purpua, why does it occur
- immune reaction- antibodies to the new platelets' antigens are produced, causing plt destruction leading to thrombocytopenia and bleeding under the skin
27
sx of post transfusion purpura
- purple rash
| - 5-12 days after transfusion
28
tx post transfusion purpura
supportive
| igG IV
29
what is graft versus host disease
White cells in donated tissue recognise the recipient as foreign
attack of host cells
30
what are some transmission of blood-borne disease
```
HIV
Hep B, C
syphillis
malaria
chagas disease (trypanosomiasis)- parasite
```
31
Name some P2Y12 receptor antagonist antiplatelets
clopidogrel
ticagrelor
prasugrel
32
name a COX inhibitor antiplatelet
aspirin
33
Name some GPIIIaIIB inhibitor antiplatelets
abciximab
tirofiban
eptifibatide
34
name some antithrombin anticoagulants
```
fondaparinux
unfractionated heparin
enoxaparin- LMWH
dalteparin- LMWH
tinzaparin- LMWH
```
35
name some factor Xa inhibitor anticoagulants
Rivaroxiban
apixaban
DOACs
36
name a vitamins K antagonist anticoagulant
warfarin
37
name some plasminogen activator anticoagulants
alteplase
reletplase
streptokinase is also a thrombolytic but is not used widely due to high levels of anaphylaxis
38
what is the difference between antiplatelets and anticoagulants
Anticoagulants
- inhibit clotting factors and fibrin
Antiplatelets
- inhibit enzymes that cause platelets aggregation
39
how do p2y12 inhibitors work
- ADP released from damaged endothelium and activated plts
- binds to P2Y12 receptor on platelet (which is blocked by these drugs)
- activates glycoproten IIB/IIa receptors, which causes fibrinogen mediated platelet cross-linking
40
how do cox inhibitors work
- when platelet is acitvated, arachidonic acid is released into the plt
- COX-1 metabs this into prostaglandin H2
- this is metab into thromboxane A2, which is released
- stimulates more platelets and aggregation
41
how do glycoprotein 2b.3a inhibitors work
- glycoproten IIB/IIa receptors, causes fibrinogen mediated platelet cross-linking
- administered only IV
42
contraindications for aspirin
- active peptic ulceration
- bleedgng disorders/haemophilia***
- <16y/o- Reye's
- breastfeeding****
caution
- asthmatics
- HTN
43
what is reye's syndrome
- rapid encephalopathy, hepatitis
sx
- vomiting
- change in personality
- confusion
- seizures
- LoC
44
SE of aspirin
- gastric irritation/bleeding
- asthmatic attack/bronchospasm
- reye syndrome in children
45
what is dual antiplatelet therapy
aspirin+ticagrelor - secondary prevention of MI
46
when is aspirin used
MI- 300mg tx/75mg prophylactic
secondary prevention of MI/DVT
- TIA (300mg, 75mg)
- acute ischaemic stroke 300mg
47
when are p2y12 inhibitors used
ticagrelor/clopidogrel
- prophylaxis during PCI
- alternative to aspirin in stroke
- dual antiplatelet therapt- secondary prevention post MI/vascular disease
48
What classes of drug are included in the umbrella term 'antiplatelets'
COX inhibitors
P2Y12 inhibitors
Glycoprotein IIb/IIIa inhibitors
49
what class drugs are included in the umbrella term 'anticoagulants'
NOACs/DOACs- factor Xa inhibs*****
Vit k antagonists - warfarin
Plasminogen activators- alteplase
Antithrombins- LMWH, unfract. hep.
50
mechanism of warfarin
vit K antagonism
blocks vit K oxide reductase
this usually activates vit K and uses vit k to produce factors 2 (prothrombin), 7, 9, 10
long half life- full effect not seen until a few days
may become hypercoagulable at first
51
indications for warfarin
- VTE tx
- TIA
- AF
- heart valve disease- rheumatic, mechanical, mitral
- inherited, symptomatic thrombophilia
52
warfarin interaction
enzyme inducers (decrease INR)- CRAPS (cabamazepine, rifampicin, bArbituates/alcohol chronic, phenytoin, St johns wort/sulphonylureas)
vit K (leafy greens)
```
enzyme inhibitors (increase INR) Some, certain Damn Silly Compounds Annoyingly Inhibit Enzymes GRR
Sodium Val, Cipro, Dilitiazem, Sulphonamide, Cimetidine/omezop, antifungals/Amiodarone, Isoniazid, Erythro/clarithro, Grapefruit juice
```
AODEVICES- Allopurinol, omezoprazole, disulfiram, erythro, valproate, isoniazid, cipro, ehtanol (acute), sulphonamides
53
monitoring of warfarin
amount adjusted to maintain:
2-3 INR (venous embolism, AD, Mitral valve, inherited thrombophilia)
2.5-3.5- mechanical heart valves
54
how are the effects of warfarin reversed eg for emergency surgery
- witholding warfarin
- vit K (oral/IV)-- phytomenadione
- prothrombin complex concentrate- have factors 2,7,9,10
55
pt info for warfarin
- take before, during or after a meal OD
- remember to take dose
- do NOT double dose
- no piercings or tattoos
- must always stick with same brand (bioavailabilities differ)
- seek urgent medical help if theres' blood in stool/urine/black poo/severe bruising/long nosebleeds/significant blow to the head/any signs of bleeding or prologned bleeding
- always check new meds/OTC meds can be taken with warfarin
56
What does bridging anticoagulant medication mean
- pts taking vit k antagonists at high risk of thromb emb (VTE in last 3m, AF with previous stroke/TIA, mitral mechanical valve)
- warfarin stopped in perioperative period, so require unfractinated heparin or LMWH in interim
- using tx dose
- LMWH then stopped 24hours before surgery
57
How are the effects of LMWH and unfractionated herparin reversed
protamine
LMWH- partially (60%)
UFH- fully
58
what is polycythaemia
too many RBCs
59
causes of polycythaemia
- Primary- Polycythaemia rubra vera (overactive bone marrow)
Secondary
- lung disease, smoking
- living at high altitude
- pregnancy**
- malignancy
- kidney disease/RCC-- too much EPO****
- CYANOTIC heart disease
60
sx of polycythemia
- plethoric face
- thrombosis/VTE
- pruritis
- splenomegaly /abdo discomfort
- unusual bleeding (nosebleeds)
- severe headache, dizziness
- fatigue
- paraesthesia
61
ix for ?polycythemia rubra vera
- FBC
- JAK2 on genotyping
- USS abdo- kidneys, spleen
62
management of polycythemia rubra vera
- venesection
63
management of secondary polycythemia
aspirin- reduced risk of clots
- venesection
- bone marrow supression - hydroxycarbamide, interferon
64
Causes of anaemia
MCV <80
- iron deficiency
- thalassaemia
- haemoglobinopathies
- ** sideroblastic anaemia (iron cannot be incorp into RBC)***
- chronic disease (incl. kidney, less common)
- lead
MCV 81-95
- blood loss
- chronic disease (incl. kidney, more common)
- pregnancy
- haemolysis ***
- combined iron/b12/folate deficiency
MCV >96-- ABCDEF
- alcoholic/ liver disease****
- b12 deficiency
- compensatory reticucytosis
- drugs- cytotoxic
- endocrine- hypothyroid
- Folate deficiency/foetus
65
presentation of anaemia
fatigue, faintness, anorexia
dyspnoea
palpitations, angina
headache, tinnitus
Signs:
- pallor- conjunctival
- tachycardia
- jaundice if haemolytic
66
ix for anaemia
- Bloods- FBC (hb, MCV), iron studies, haematinics (B12/folate)
* *- blood film- reticulocyte count
- FIT, LFTs
* *- USS spleen, kidney
* *- direct coombs
- genetic testing
67
management of anaemia
Acute anaemia/v symptomatic
- ferinject (IV iron)
- transfusion if Hb <70 ro <80+IHD
Chronic
- iron/folate/b12 supplements and diet advice
68
how do you interpret reticulocyte count
high (megaloblastic)- producing lots of, large, immature RBCs:
- bone marrow working well to compensate for anaemia
- loss of blood (chronic)
- hypersplenism
- haemolysis
Low (non-megalobastic)
- bone marrow is working not well
- do MCV
- Mircocytic- iron, thalassaemia, sideroblastic
- normocytic- kidneys, chronic, acute bleeds
- macro- b12/folate, hypothyroid, bone marrow failure
69
causes of hypersplenic megaloblastic anaemia (and Ixs)
- congestion (LFTs, portal vein doppler, abdo imaging, d-dimer)
- infiltration (protein electrphoresis, blood film (malignancies), spleen biopsy
- poliferation- viral serologies, blood film (RBC abnomrlaities)
70
causes of megalobastic, haemolytic anaemia (and ixs)
A type of macrocytic anaemia-- Bone marrow producing large, immature RBC , due to increased rates of haemolysis
bilirubin and LFTs deranged
Extrinsic
Immune- direct coombs:
-drug induced (penicillin, quinine)
-autoimmune- SLE, infection, idiopathic
-Infection- malaria- blood film
DIC- coag profile
Thrombotic thrombocytopenic purpura- low plts due to clots
```
Intrinsic- genetic and blood film testing:
Enzyme defects
- G6PD (xlinked, broad beans)
- Pyruvate Kinase,
Membrane defects:
-spherocytosis
-ellipotcytosis
-ovalocytosis
-stomatocytosis
Haemoglobinopathoes
-sickle cell
-thalassaemia
```
71
specific sx of iron deficiency anaemia
- koilonychia (soft, scooped out/spoon nails)
- angular cheilitis
- atrophic glossitis- swollen, painful/itchy tongue
72
ix results in iron deficiency anaemia
- Hb low
- MCV <80
- reticulocyte count low
73
tx for iron deficiency anaemia
- ferrous sulphate 200mg TDS PO for at least 3 months
- urgent 2ww if >60 or women >55 with PMB
- consider coeliac screen, urine dipstick, stool sample for parasites, FIT
74
SE of ferrous sulfate
black stools
diarrhoea, constipation
nausea
75
normal hb levels
120-180 g/L
76
Specific sx for b12/folate deficiency
v. insidious
- pallor, jaundice, glossitis
- mood- irritability, depression, psychosis
NEURO:
- sensory neuropathy- paraesthesia
- upper and lower motor neuron signs (extensor plantar, absent reflexes, ataxia)
- weakness
- urinary incontinence
- optic neuropathy
77
management of b12/folate deficiency
always correct b12 Before starting folate as folate can hide sx of b12 deficiency and if untx--> spinal cord degeneration
hydroxocobalamin IM then folic acid
78
what is pernicious anaemia
- b12 deficiency due to autoimmune atrophic gastritis
- parietal cells in stomach destroyed
- reduced intrinsic factor secretion
- reduced b12 absorption in terminal ileum
79
management of pernicious anaemia
- 1mg IM hydroxocobalamin for life
| 3x a week for 2w, then every 2-3m
80
what is sideroblastic anaemia
- ineffective erythropoeisis
- leading to increased Iron absorption and iron loading in marrow (not in RBCs)
- production of erythrocytes with ferritin granules in them that cannot incorporate the iron in the Hb (sideroblasts)
- these get deposited into endocrine organs, liver and heart
81
causes of sideroblastic anaemia
- congenital
- malignancy- CML
- alcohol
Iatrogenic:
- chemo
- anti-TB drugs
- irradiation
82
sx of sideroblastic anaemia
pallor
fatigue
dizziness
hepatosplenomegaly
83
tx of sideroblastic anaemia
tx cause
blood transfusion and iron chelation
******pyridoxine (vit B6)*******
84
sx of haemolytic, megaloblastic anaemias
- anaemia sx
- jaundice
- dark urine
85
ix for ?haemolyic anaemia
- malaria testing
- Coomb's test (autoimmune causes)
- FBC, LFTS
- blood film- malaria, RBC deformities
- LDH levels- raised
- Hb electrphoresis- sickle cell, thalassaemia
- sickle solubility test
86
precipitants of glucose 6 phosphate deficiency
Broad beans
Primaquine
Sulphonamides
- Dapsone (gangrene, hermatitis, herptiformis, bascuitits)
Nitrofurantoin
Quinolones- cipro
infection
stress
87
inheritance pattern G6PD
x linked
| recessive
88
inheritance pattern membranopathies
dominant
89
inheritance pattern sickle cell
recessive
90
what is sickle cell anaemia
- Hb conatins an abnormal Hb globin chain
- single base substitution in beta chain
- creates HbS which changes the solubility of Hb and damages the cell containing it
- inflexible
91
sx sickle cell disease
Homozygous- severe sx
Heterozygous- may have mild sx
- from 3- 6 months of age as HbF replaced by HbSS (instead of Beta)
- anaemia sx
- growth restriction, delayed puberty
- recurrent infections
Sickle crises
- acute painful crisis due to vaso-occ
- sequestrian crisis
- hyperhaemolytic crisis
- acute chest syndrome- chest pain, SOB
- splenomegaly, asplenism
92
ix for sickle cell
```
FBC- anaemia
LFTS- bilirubin
Blood film
sickle solubility test
Hb electrophoresis- diagnostic
```
neonatal screening- heel prick
93
How to avoid sickle cell crises
- avoid triggers- cold temps, dehydration, exhaustion, alcohol, smoking
- prevent infections- oral penicillin, vaccination
- folic acid supplementation
94
tx of sickle cell
- blood tranfusions
- iron chelation
- hydroxycarbamide (B12) OD (increase HbF)
- stem cell/bone marrow transplant
95
management of sickle crisis
- paracetemol, ibuprofen
- opioids
- IV fluids
- O2 to avoid acute chest
- empirical broad spec abx if fever
96
what is a sequestration crisis, tx
erythrocytes trapped in spleen-- causing dangerous drop in circulating blood vol, infarction, atrophy
Acute anaemia:
- profound pallor, SOB, weakness
- Acute splenomegaly
- Shock
urgent transfusion
97
what is an aplastic crisis, sx, tx
- temporary cessation of erythropoesis
- usually due to parvovirus b19
sx
- severe anaemia- SOB, pallor, weakness
- may present as high output congestive HF- SOB, oedema
- tx- blood transfusion
98
What is thalassamia
reduced synthesis of alpha or beta chains with consequent reduction of haemoglobin
99
presentation of beta thalassaemia
MAJOR
- present at 6-12 months of age (beta chains replace gamma)
- Failure to feed
- listless, crying
- pale
- anaemia
100
types of beta thalassaemia
major- no beta chain at all, transfusion dependent
intermedia- microcytic anaemia, can survive without transfusions
Carrier/heterozygote- clinically well
101
pathophysiology of beta thalassaemia
beta chain production affected
| only become apparent when adult Hb replaces HbF (Y chains--> b chains)
102
ix ?thalassaemia
FBC- severe anaemia, low MCV- MICROCYTIC, reticuloyes low (non-megaloblastic)
blood film- large and small, irregular pale red cells
HbF >90% in foetal sample
103
A thalassaemia- pathophysiology
- production of alpha chain affected, meaning HbF is affected
- 4 alleles involved- 2 mum, 2 dad
- generally caused by deletion mutations
104
presentation of alpha thalassaemia
*depends on how many alleles are involved*
1- asymptomatic
2- asymptomatic but low MCV
3- moderate anaemia and features of haemolysis eg hepatosplenomegaly, leg ulcers
4- Bart's hydrops (foetal death)
105
What is thrombocytosis
too many platelets (>450)
106
causes of thrombocytosis
Primary (thrombocytopemia)- NOT thrombocytoPENIA
- essential thrombocytopemia
- Polycythemia rubra vera- increased RBC with also hgih WCC and plt in most cases
- haematological malignancy (CML)
- primary myelofibrosis - scarring of BM, can cause high or low plts
Secondary
- chronic inflammation
- severe systemic infection
- bleeding/healing, clotting- surgery/trauma
- malignancy
107
What is thrombocytopenia
too few platelets (<150)
108
Causes of thrombocytopenia
Decreased production
- congenital platelet abnormalities
- bone marrow suppression /infiltration
Increased destruction
- immune conditions
- hypersplenism
- consumption- DIC, ITP, HELLP
109
hx for ?thrombocytosis
- Essential
- inflammation
- Malignancy-sx of possible cancers:
- bowel-- habits, rectal bleeding
- ENT/gastric/oes- dysphagia, dyspepsia
- Resp- dyspnoea, fatigue, cough, haemoptysis
- gynae- PMB
- wt loss
Polycythaemia vera
110
ix for ?thrombocytosis
- FBC, CRP/ESR, iron studies
- blood film
- CXR if >40yo
- USS pelvis if females >55yo
- FIT
- JAK-2 testing- essential thrombocytopemia, PRV
111
Management of someone with thrombocytosis
- Urgent referral if plt >1000 or 600-1000 with clinical features
- tx the cancer
112
what causes bone marrow suppression/failure (not by infiltration)
- low b12/folate
- alcoholism
- CT, radiation
- azathioprine. methotrexate
- NSAIDs
- viral infections (parvovirus- aplastic, HIV, hepatitis)
113
what conditions infiltrate into bone marrow
- leukaemia
- mets
- lymphoma
- myeloma
- myelofibrosis
114
presentation of thrombocytopenia
- usually asymptomatic until severe/found incidentally
- bleeding/bruising
- petechiae/purpura
- infections
- Fam hx
- obstetric hx
- screen for sx of occult malignancy
115
ix for ?thrombocytopenia
- FBC, UE, clotting, haematinics (b12/folate)
- blood film
- bone marrow biopsy if ?myeloproliferative disease
- genetic screening
116
management of thrombocytopenia
pt education
- avoid contact sports
- avoids NSAIDs (impairs platelet function)
- maintain good dental hygiene (minimise risk of gingival bleeding/need to dental procedures)
- avoid deep IM injections (sc when poss)
- platelet transfusion- if severe
- TXA
- Prednisolone (ITP)
- TPO agonsists- hormone that increases plt prod.
- bone marrow transplant
Urgent referral
- plt <20
- severe bleeding
- red cell fragments or blasts on film (cancer)
- hx of b sx (fever, wt loss, sweats)
- consider discussion with haematologist if plt <100
117
What is immune thrombocytopenic purpura
- immune destruction of plts
| - IgG atnibodies to platelet and megakaryocyte surface protein
118
presentation of ITP
bruising
petechiae (esp on lower legs)
bleeding- gums, nose, menorrhagia
NO splenomegaly
119
ix ?ITP
dx of exclusion
- bloods- isolated low plt
- blood film - normal (exclude cancer- red cell blasts/fragments)
- bone marrow biopsy - normal (cancer, myelofibrosis)
- serology for hep b/c
120
management of ITP
- IV IG *******
- prednisolone/dexamtethasone PO/hydrocortisone IV if severe
- plts and TXA**** if severe bleeding
- splenectomy**** if not responding to tx
- pt education
- tx underlying cause
- if post-viral in children - may resolve without tx
121
what is thrombotic thrombocytopenic purpura
- reduction in protease enzyme (ADAMTS13) which usually breaks down VWF
- more VWF--> clotting
- leads to less plts, as theyre all used up and consumed
122
causes/triggers of thrombotic thrombocytopenic purpura
- bacterial infection
- iatrogenic- plt inhibitors, CT, anti-virals, immunosuppressants
- AI diseases- SLE
- pregnancy
123
presentation of thrombotic thrombocytopenic purpura
- large bruises
- weakness, lethargy
- SOB
- confusion
- headache, confusion, fever
- reduced kidney function
- often preceded by diarrhoeal/flu-like illness
124
ix ?thrombotic thrombocytopenic purpura
- FBC (low plts, anaemia)
| - ADAMTS13 levels (very low)
125
management of thrombotic thrombocytopenic purpura
- urgent plasma exchange- replaces ADAMTS13 levels and removes antibody
- corticosteroids, rituximab
- do NOT give blood/plts as this increases thrombosis
126
pathophysiology of DIC
```
cytokines released
activation of clotting cascade
fibrin production-- consumptive coagulopathy
thrombosis
consumption of plts
```
--> clotting plus bleeding plus multi-organ failure
127
Causes of DIC
- shock
- sepsis
- major trauma or burns
- malignancies (AML)
- snake bites
- severe immune reactions- ABO mismatch, organ transplant rejection
- severe organ dysfunction - acute hepatic failure, acute pancreatitis
- obstetric emergencies- eclampsia, HELLP, placental abruption, intrauterine death, amniotic fluid embolism
128
presentation of DIC
- precipitating event
- bleeding- from unusual sites (haematuria, rectum, bruising/petechiae, ears, nose, haemoptysis, sites of venepuncture/cannulation)
- circulatory collapse- hypotension, tachycardia, cyanosis, confusion/LoC/coma
signs of microvascular thrombosis and tissue damage
- Cerebral- new confusion or disorientation, dysphagia/dysarthria, weakness
- chest pain
- leg pain, necrosis, gangrene
129
ix ?DIC
- septic screen
- FBC- thrombocytopenia
- Prolonged PT, APPT, high INR, low fibrinogen
- high d-dimers
- ISTH scoring- uses plt count d-dimer, PT and fibrinogen
130
ddx of DIC
- decompensated liver failure (coagulopathy)
- vit K defieciency/anticoag overdose
- HELLP
- ITP- immune thrombocytopenic purpura
- TTP- thrombotic thrombocytopenic purpura
131
management of DIC
- tx cause
- urgent haematological review
- fresh platelets (try to maintain >50)
- FFP (contains clotting factors)
- Cryoprecipitate (if fibrinogen is low)
- transfusion
- therapeutic dose heparin
132
what is haemolytic uraemic syndrome
- usually due to E.coli shiga toxins (verotoxin) leading to increased thrombogenicity
- 'thrombotic microangiopathy'
- kidney microvasculatrue damaged
- increases clotting in this microvasc.
- plt consumption--> thrombocytopenia with AKI
133
the triad and presentation of haemolytic uraemic syndrome
- microangiopathic haemolytic anaemia
- thrombocytopenia (bleeding/bruising)
- AKI- HTN, oedema, olgio/anuria
- bloody diarrhoea
- abdo pain
- vomiting
- petechiae
- pallor
- often in children <5
134
ix ?haemolytic uraemic syndrome
- FBC, UE, Clotting, LFTs
- peripheral blood smear
- stool culture- SHiga toxin
- urinanalysis
135
management of haemolytic uraemic syndrome
- fluid restriction (AKI)
- avoid abx, antimotitly agents, NSAIDs (kidney strain)
- dialysis/renal transplant
136
What is HELLP syndrome
- haemolysis
- elevated liver enzymes
- low plts
- form of pre-eclammpsia
- assumed due to endothelial injury--> increased vWF --> consumption of plts--> widespread thrombotic microangiography
137
presentation and signs of HELLP syndrome
often 27-37 weeks antepartum
- new onset abdo pain (RUQ, epigastric)
- N+V
- headache
- blurry vision
may lead to seizures
pre-eclampsia--- HTN, proteinuria
138
diagnostic criteria for HELLP
- elevated transanimases (AST) twice the upper limit of normal
- low plt count <100
- haemolysis- elevated bilirubin, LDH elevation, schistocytes on peripheral blood smear, haematuria, worsening anaemia, low serum haptoglobin
139
Management of HELLP
- delivery of the baby
tx pre-eclampsia
- labetolol, nifedipine, methyldopa
- IV dexamethasone
- MgSO4- prevent seizures
140
what is thrombophilia
- umbrella term-- increased tendency to clot--- hypercoagulable
(NB: thrombocytosis is high plts specifically, thrombopemia is idiopathic high plts)
141
causes of thrombophilia
Congenital
- Factor V leiden
- prothrombin mutation
- antithrombin deficiency
- protein C and S
Acquired
- antiphospholipid synrome- lupus anticoag, anti-cardiolipin, antibeta1-glycoprotein
- autoimmune SLE, IBD
- cancer
- hyperviscosity- sickle cell, myeloproliferative, PRV, essential thrombocytosis/thrombocytopemia
- nephrotic syndrome (urinary loss of antithrombotic proteins)
- high oestrogens- pregnancy, OCP, obesity
- heparin induced thrombocytopenia (type II)- immune response causing immune complexes binding to plt--> plt destruction plus plt aggregation--> thrombocytopenia plus thrombosis/thrombophilia
142
presentation of thrombophilia
- DVT, PE
- thrombosis
- venous sinus thrombosis (headache, blurred vision, movement issues, seizure, coma)
- portal vein
thrombosis/hepatic vein thrombosis- RUQ pain, jaundice, blood in stool
- mesenteric vein and veins in arms
- obstetric - recurrent miscarriage, IUGR, stillbirth, severe pre-eclampsia, placental abruption
143
ix for thrombophilia
FBC, clotting profile
- blood film
thrombophilia screen- congen
- antithrombin - congen deficiencies
- Protein C and S- congen deficiency of anticoagulant factors
- lupus anticoagulant (antiphospholipid syndrome)
- factor V Leiden- mutation of factor V
- prothrombin gene mutation
- anti beta 2 glycoprotein-1 antibodies
- anti-cadiolipin antibodies (antiphospholipid syndrome)
144
Management of thrombophilia
- tx undelrying cause
- warfarin, LMWH
- IVC filter as prophylaxis for events
145
What is hyperviscosity syndrome
- change in cellular or protein fractions in the blood
- eg polycythemias, multiple myeloma, leukaemia, monoclonal gammopathies, sick cell anaemia, sepsis
- changes viscosity of the blood---> produces this set of sx
146
sx of hyperviscosity syndrome
- spontaneous mucosal bleeding
- visual disturbances due to papilloedema
- pulm oedema- SOB, hypoxia
- HF
- Neuro sx- headache, vertigo, reduced GCS, seizures, coma
147
ix for hyperviscosity syndrome
blood counts- high
| plasma viscosity
148
management of hyperviscosity syndrome
- IV fluids
tx cause
haematology input
plasmapheresis/venesection
149
what is antiphospholipid syndrome
Autoimmune disorder
- attacks phospholipid (fat) molecules
- causes blood to become hypercoagulable (thrombophillic)
150
presentation of antiphospholipid syndrome
- DVT, stroke, TIA, PE
- HTN, migraines, visual disurbances
- balance and mobility issues
- speech, memory problems
- paraesthesia
- fatigue
- livedo reticularis- marbeling of the skin
- thrombophlebitis
- unexplained miscarriage, PROM, severe pre-eclampsia
151
Blood autoantibodies suggesting antiphospholipid syndrome
lupus anticoagulant
| anti-apolipoprotein/anti- cariolipin antibodies
152
tx antiphosphlolipid syndrome
- lifestyle- wt loss, stop smoking, exercise, low fat diet
- anticoags/antiplatelets, lifelong
- acute- SC heparin
153
what is haemophilia
- inherited
- deficiency in clotting factors
- recessive and x-linked
154
types of haemophilias
- A- Factor VIII
- B- Factor IX
- C- Factor XI
155
presentation of haemophilia
- spontaneous/prolonged bleeding
- bruising
- bleeding- gums, epistaxis, haematuria
- joint pain (arthrosis)
156
ix haemophilia
Blood- anaemia
clotting- normal PT/fibrinogen/vWF, prolonged APTT (intrinsic pathway)
reduced factor VIII, IX, XI activity level
in haemophilia A (factor VIII), vWF also low as they;re connected
157
management if haemophilia
avoid competitive sports/excessive manual labour
LT/pre-procedure factor infusions
TXA
regular monitoring
158
what is von willebrand disease
- genetic deficiency of vWF-- lack of clotting
159
sx vWF disease
- bruising, bleeding
| - menorrhagia
160
ix vWF disease
FBC, clotting, INR
vWF levels and activity (glycoprotein Ib binding assay)
factor VIII levels- also low, as these 2 factors are connected
161
management of vWF disease
desmopressin- vassopressin, stimulates vwf release, may also increase factor VIII
TXA
vWF concentrate prior to surgery
162
What is the extrinsic pathway of clotting
- due to tissue trauma
- thromboplastin/tissue factor is released
- factor Vii--> Viia
- Viia + TF+ Ca2+ activate Factor X--> prothrombin activator (Xa)
- prothrombin (II)-- Xa---> thrombin (IIa)
- fibrinogen---IIa---> fibrin
- crosslinked fibrin clot
163
What blood test measures the extrinsic pathway
```
Prothrombin time (PT)
(Play Tennis OUTSIDE)
```
also good for common pathway
164
what is the intrinsic pathway
damaged vessel wall
- collagen fibres bind to vWF factor that are released from damaged endothelium
- vWF to vWF receptors on platelets-- adhesion
- collagen also bind to collagen receptors on platelets-- adhesion
```
Clotting cascade triggered-
(--> XII
--> XIIa + kininogen
--> XIa + Ca 2+
--> IXa + VIIIa + Ca2+
---> Xa + Ca2+ + V)
---> prothrombin (II)
---> thrombin (IIa)
--> fibrinogen (I)
--> fibrin (Ia)
```
165
what is the common pathway
- propthrombin activator (Xa) activated prothrombin (II) into thrombin (IIa)
- leading to fibrinogen (I) into firbin (Ia)
- ca+ ions and fibrin stabilising factor (XIII) stabilise fibrin into fibrin polymers
- forms mesh
- this attracts more platelets, phospholipids
- platelet adhesion-- haemostasis, stable clot
166
how does fibrinolysis occur
plasminogen produced by liver
- factors XIa and XIIa make plasminogen into plasmin
- plasmin breaks down fibrin into d-dimers
167
what tests tests the intrinsic pathway
Activated partial thromboplastin time (APTT)
| Play Table Tennis INSIDE
168
what does thrombin time mean
how fast fibrinogen (I) is converted into fibrin (Ia) by thrombin (IIa)
169
What is international normalised ratio (INR)
ratio of PT:normal
170
what types of leucocytes are there
Granulocytes
| agranulocytes
171
what types of granulocytes are there
Neutrophils (most)
Eosinophils
Basophils (least)
172
when are neutrophils raised
bacterial infections
- stress
- cancers
- trauma
- inflammation
173
when are eosinophils raised
parasitic infetions
| allergic reactions
174
when are basophils raised
allergens
175
What types of agranulocytes are there
Lymphocytes (most)
| monocytes
176
When are lymphocytes raised
viral infections
177
when are monocytes raised
bacterial infecitons
178
What 2 cell progenitors can a multipotent haematopoietic stemm cell/haemocytoplast turn into
common myeloid progenitor
| common lymphoid progenitor
179
what cells can a common myeloid progenitor turn into
- Megakaryocyte (thrombocytes/plts)
- erythrocytes
- mast cells
- myeloblasts
180
what can a myeloblast become
- basophil
- neutrophil
- eosinophil
- monocyte (--> macrophage)
181
what cells can a common lymphoid progenitor turn into
```
Natural killer cell
Small lymphocyte (--> T and B)
```
182
What cell type do plasma cells derive from
B lymphocyte
183
What 2 leucocytes are phagocytic
neutrophils, monocytes
184
function of neutrophils
- phagocytosis
| - attract monocytes
185
function of eosinophils
- produce histamine and enzymes that inactivate inflammaotry agents released by mast cells
186
histological appearance of neutrophil
- multilobed, purple nucleus
187
histological appearance of eosinophils
- bilobed, sausage shaped nucleus
188
functin of basophils
- allergen response
- contain histamine granules that cause local inflammatory response via interaction with IgE (similar function to mast cells)
189
appearance of basophils histologically
bilobed, S shaped nucleus
| - lots of blue staining granules in cytoplasm
190
funciton of different types of lymphocytes
NKC
- non specific, innate immunity
T cells
- formed in bone marrow, mature in thymus
- acquired/adaptive immune system
- once active, cytotoxic t cells attack non self/infected self
- helper t cells activate b cells and form memory t cells
B cells
- form and mature in bone marrow
- adaptive immune system
- secrete antibodies
- develop into plasma/memory cells which make antibodies
191
histological appearance of lymphocytes
- round, densely staining nuclei, takes up most of cytoplasmic space
192
what is the funciton of monocytes
- release cytokines, modulates immune response
- can diff. into dendritic cells, which assist t cell acitvation
- diff. into macrophages which then phagocytose microorgs
- can transform into osteoclasts
193
appearance of monocytes histologically
- kidney shaped nucleus
194
how many Hb molecules does one RBC have in it
~27 million
195
structure of Hb molecule
4 heme groups-- each composed of a ringlike porphyrin ring which an iron atom is attached and one O2 or CO2 molecule can bind to
2 beta chains, 2 alpha chains
196
how many O2 molecules can one Hb molecule carry
4
197
how is heme extracted from Hb
liver and spleen breakdown Hb--> bile pigments/bilirubin) exctreted in urine/faeces
198
what is the Bohr effect
as CO2 binds to RBCs, the affinity for O2 decreases
199
What is the haldane effect
reduced blood pH also causes a reduction in total binding capacity of Hb to O2
200
What adhesion receptrs are on the surface of platelets
GPIIb-IIIa fibrinogen
vWF
GPIa-IIa collagen
201
what agonist receptors are there on the surface of a platelet
- Collagen
- Thromboxane
- ADP
- Thrombin
202
how is eruthropoiesus regulated
erythropoietin-- sectreted by kidneys
-- increased RBC production
reduced partial pressure of O2 is detected in interstitial peritubular cells, causing EPO production
203
Where is Iron absorbed
Dueodenum
204
Where is folate absorbed
Jejunum
205
Where is B12 absorbe
Ileum
206
how is iron absorbed
- low pH of gastric acid in the proximal duodenum allows ferritic reductase enzyme to convert Fe3+ ferric into ferrous Fe2+
- *why PPIs reduce iron absorption*
- ferrous moves into cell
- transferred into blood stream via ferroportin- (inhibited by hepcidin)
- Fe2+ is reoxidised into Fe3+
- bound to transferrin
- transported to bone marrow for RBC production
207
why does chronic disease cause anaemia
1. inflammation causes liver to produce hepcidin
hepcidin stops ferroportin from transferring ferritin into bloodstream
2. less EPO produced from kidneys
208
how is B12 aborbed
Parietal cells in stomach make intrinsic factors
- this binds to B12
- in ileum, the complex attaches to brush order in the presence of Ca2+ and alkaline pH
209
what cann effect b12 absorption
- abnormal ileal structure
| - gastric atrophy- pernicious anaemia
210
What is acute lymphoblastic leukaemia
- hyperproliferation of immature lymphoblasts , affects T and B cells
211
What genetic feature is assoc with acute lymphoblastic leukaemia
- philidelphia chromosome
212
what is the most common paediatric leukaemia
acute lymphoblastic leukaemia
213
sx of acute lymphoblastic leukaemia
bone marrow:
- infections
- Anaemia- weak, fatigue, SOB pale
- bleeding
- fever
- wt loss
- easy bruising
- painful bones/joints
214
signs of acute lymphoblastic leukaemia
- lymphadenopathy
- hepatosplenomegaly
- SVCO- hgih JVP, facial oedema
215
Ix for ?acute lymphoblastic leukaemia
- blood film
- biopsy- marrow, node
- PCR
216
treatment of acute lymphoblastic leukaemia
- bone marrow transplant
- allopruinol
- abx antivirals, antifungals
- vincristine, prednisolone, methotrexate
217
what is Chronic lymphoblastic leukaemia
accumulation of b lymphocytes in blood, marrow, nodes
218
who does chronic lymphoblastic leukaemia occur in
elderly
219
sx and signs of chronic lymphoblastic leukaemia
```
wt loss
anorexia
sweats
infection
easy bruising (bruising easily)
anaemia- SOB, fatigue
```
hepatosplenomegaly
lymphadenopathy- large, rubbery, non-tender
220
ix for chronic lymphblastic leukaemia
FBC- often incidental
221
tx of chronic lymphoblastic leukaemia
- fludarabine with rituximab +- cyclophosphamide
- steroids
- anticlonal antibodies- anti VD20, rituximab
- bruton kinase inhibitors
- bone marrow transplant
222
what is acute myeloid leukaemia
- myeloblast hyperproliferation
| - rapid progression
223
who does acute myeloid leukaemia affect
adults
224
symptoms of acute myeloid luekaemia
- anaemia- SOB
- infection
- bleeding/bruising
- fever
- gum hypertrophy
- skin/CNS involvement
225
ix for acute myeloid leukaemia
- WCC high but poor immunity
| - bone marrow biopsy- Auer rods
226
tx acute myeloid leukaemia
fluids, plts, transfusion
infection prophylaxis
daunorubicin, cytarabine
bone marrow transplant
227
what is chronic myeloid leukaemia
uncontrolled proliferation of myeloblasts
228
who gets chronic myeloid leukaemia
adults
| philadelphia chromosome
229
sx and signs of chronic myeloid leukaemia
- anaemia, bruising, bleeding
- tried, fever, sweats, wt loss
- gout (purine breakdown)
Hepato/splenomegaly
230
ix chronic myeloid leukaemia
- FBC
- Film
- Philadelphia chromosome t(9,22)
231
tx chronic myelid leukaemia
imatinib
| bone marrow stem cell transplant
232
What is lymphoma
cancer of the lymphocytes in the lymphatic system (lymph glands, pleen, thymus, bone marrow)
233
sx of Hodgkin's lymphoma
```
Large, painless lymph nodes
painful after alcohol
B sx
severe itching
anaemia- SOB, fatigue
infections
easy bruising/bleeding
```
234
signs of Hodgkin's lymphoma
facial oedema
spleno/hepatomegaly
SVCO- high JVP, distanded neck vessels
235
ix ?Hodgkin's Lymphoma
- blood- lymphocytosis
| - lymph node biopsy- reed Sternberg
236
tx Hodgkin's lymphoma
Adriamycin
Bleomycin
Vinbastine
Dacarbazine
237
Sx of non-Hodgkin's lymphoma
Small bowel sx:
- diarrhoea
- vomiting
- wt loss
- abdo pain
```
fever, night sweats
anaemia
infection
bleeding
erythroderma- severe skin erythema/swelling
lymphadenopathy
```
238
Ix for non-Hodgkin's lymphoma
marrow, node biopsy
(no reed sternberg cells)
CT +- PET
239
tx non-Hodgkin's
nothing- watch and wait
```
RT
RCHOP
- rituximab- monoclinal antibody
- cyclophosphamide
- hydroxyduanorubicin
- oncovin
- prednisolone
```
bone marrow transplant
240
What is a myeloma
cancer of plasma cells (differentiated B cells)
241
sx and signs of myeloma
```
CRAB
HyperCalcaemia
- stones
- psychiatric moans
- thrones- constipation, polyuria
- abdo groans- N+V,
- Painful bones
- confusion, weakness, fatigue
```
Renal impairment
- haematuria, anuria/oliguria,
- pruritis, cramping,
- SOB/oedema,
- insomnia, poor appetite, N+V, lethargy, wt loss
Anaemia
Bone destruction-#, OP, spinal cord compression, pain
Bone marrow failure- bleeding, infection, anaemia
**amyloidosis- large tongue, syncope, peipheral neuropathy, GI upset, carpal tunnel
hyperviscosity- headaches, visual blurring
242
ix for myeloma
```
bone marrow aspirate
bloods
- hypercalcaemia
- high Cr
- low RBC, normal MCV, neutropenia, thrombocytopenia
- low albumin
```
- serum electrophoresis- high igG monoclonal protein
- urine electrophoresis- bence jones proteins
- blood film- rouleaux
- serum free light chain assay- high free light chains
consider whole body MRI
243
who gets myeloma
older patients
244
tx myeloma
- monitor
- stem cell transplant with thalidomide, dexamathasone, fludarabrine, terosulfan medications
give thalidomide with corticosteroid if not for stem cell transplant
```
bisphosphonates- zoledronic acid
analgesia
aspirin/LMWH
flu vaccine
pneumococcal vaccine
IVIG
acyclovir
```
245
what precursor conditions are there to myeloma
- Monoclonal gammopathy of undetermined significance (MGUS)- earliest stage, no active disease, just high Ig
- smouldering multiple myeloma- intermediate stage, higher level of monoclonal protein and abnormal plasma cells, no CRAB criteria
monitor both with MRIs, serum electrophoresis, Cr, Ca, FBC
246
What pathogens cause malaria
```
Plasmodium falciparum
Plasmodium vivax
Plasmodium ovale
Plasmodium malariae
Plasmodium knowlesi
```
247
what parasite causes malaria most commonly
Plasmodium falciparum
248
what is the pathophysiology of malaria
- mosquito bite
- sporozoites in saliva of mosquito enter blood
- to the liver
- sporozoites mature in liver and lie dormant-- hypnozoites
- mature organisms rupture and release merozoites
- merozoites invade RBCs and undergo asexual reprod.
- RBCs rupture and release gametocytes
- mosquitoes ingest these
- parasite undergoes sexual reprod.--> sporozoites
249
sx of malaria
swinging fever
malaise, fatigue, rigors, headache
myalgia, arthralgia
sore throat, cough, LRTI
GI upset
anorexia, jaundice
children- poor feeding
hx of travelling to high prevalence country (Africa, Asia, Central/south America, Middle East)
250
signs of malaria
```
fevere
splenomegaly
hepatomegaly
jaundice
+- abdo tenderness
```
251
sx/signs of severe disease (P. falciparum)
- reduced GCS, seizures
- bleeding/DIC
- SOB, hypovolaemia, shock
- hypoglycaemia
- AKI- oliguria, oedema, SOB, confusion, tiredness, nausea, nephrotic syndrome
- ARDS
252
ix malaria
- thick/thin blood smears - GOLD STANDARD
- antigen detection test
- FBC- thrombocytopenia, anaemia
- G6PD- prior to giving primaquine
- LFTs
- UEs
- hypoglycaemia if severe
if ill/unstable
- blood gas
- cultures
- clotting
- urine/stool culture
- CXR
- LP
253
tx of malaria
falciparum:
- artesunate
- artemisinin combination therapy- artemether (artemisinin derivative) with lumfantrine
non-falciparum
- chloroquine- overdose is fatal
- primaquine prevents relapses (check G6PD before)
inform PHE
warn family members about sx
254
Conditions that may cause paraproteinaemia
Cancers:
- MGUS, myeloma(Ig, plama cells)
- chronic lymphoblastic leukaemia (b lymphocytes)
- non-hodgkin's
Other:
- autoimmune- RA, scleroderma, hasimotos
- liver- hepatitis, cirrhosis
- infection- TB, endocarditis
255
what is paraproteinaemia
monoclonal immunoglobulin or light chain in blood
excess immunoglobulin M component
- produced by B cells
- there is a group of blood disorders that are characterised by an imbalance/disproportionate proliferation of immunoglobulin producing cells
256
sx of paraproteinaemia
think CRAB like syndrome:
- hypercalcaemia- stones, moans, thrones, groans
- impaired renal function- oliguria, confusion
- normochromic, normocytic anaemia +- pancytopenia- SOB, recurrent infection
- bone disease- back pain, osteopenia, lytic lesions
- malaise, fatigue
- hyperviscosity- headaches, vision
- cardiac failure- SOB, orthopnoea, PND
- ESR elevation
257
ix for ?paraproteinaemia
- serum electrophresis
- FBC, blood film, ESR- total protein, myeloma, Ca
- urine- bence jones
- bone marrow biopsy
258
what is amyloidosis
- deposition of abnormal amyloid fibrils
259
classificaiton of amyloidosis
Amyloid A protein (AA)
- acute phase reactant produced by liver
- response to cytokines
- chronic inflammatory diseases eg RA ank spond, maligancnies
- kidneys, liver , spleen
Primary (AL)
- affects every organ- mainly heart, kidney, peripheral nerves
- monoclonal bands/asymptomatic myeloma
Transthyretin
- inherited- autosomal dominant
- peripheral neuropathy, cardiomyopathy, kidney damage
260
sx of amyloidosis
fatigue, weight loss
- easy bruising (spleen)
- SOB (lungs, heart)
- peripheral oedema (heart)
- sensory changes, carpal tunnel- peripheral nerves
- postural hypotension, early satiety- autonomic
- oliguria- kidneys
261
signs amyloidosis
- renal disease- nephrotic syndrome- proteinuria
- restrictive cardiomyopathy, HF- oedema, raised JVP
- hepatomegaly without jaundice
- oeseophageal varices, portal HTN
- glove stocking neuropathy
- interstitial sounding lungs
- racoon eye sign- spont periorbital purpura
- non tender goitre
262
ix amyloidosis
Serum amyloid scintigraphy- Radiolabelled serum amyloid P component- imaging amyloid deposits, diagnostic
- organ biopsy
Organ Damage:
- urinalysis- proteinuria
- FBC- anaemia , thrombocytopenia
- blood film- howell jolly bodies (splenic dysfunction)
- LFTs- normal, clotting- abnormal
- raised ESR
- ECG, Echo
263
Management of amyloidosis
- diuretics for kidney and CHF
- erythropoetin
- tx malignancy, inflammation, chronic infections
- thalidomide in AL amyloidosis
- stem cell transplant
- liver kidney transplant
264
what drugs are contraindicated in amyloidosis
CCB, beta blockers, digoxin
risks of toxicity (kidneys)
265
differentials of pruritis and differentiating features
Liver disease
- hx alcohol
- spider naevi, bruising, palmar erythema, gynaecomastia
- decomp sx- juandise, ascites, encephalopathy
Fe deficiency
- pallor
- koilonchychia
- atrophic glossitis
- post cricoid webs
- angular stomatitis
Polycythemia
- after warm baths
- ruddy complexion
- gout (increased cell turnover)
- peptic ulcer disease
CKD
- lethargy
- pallor
- oedema, wt gain
- hypertension
Lymphoma
- night sweats
- lymph nodes
- spleno/hepatomegaly
- fatigue
- hyper/hypothyoid
- diabetes
- pregnancy
- old age
- urticaria
- eczema, scabies, psoriasis, pityriasis rosea
266
management of antiphospholipid syndrome
- low dose aspirin if no hx of VTE
| - warfarin if prev hx of clots with a 2-3 INR target
