Haematology Flashcards
Name 6 causes of bleeding disorders
coagulation disorders:
haemophilia
von Willebrand’s disease
disorders of platelets:
liver cirrhosis
medications (NSAIDs, omega‑3)
myelodysplastic syndrome
ITP
Symptoms that suggest bleeding disorder
Nose bleed 2x>10mins, or 1xblood transfusion.
Cutaneous haemorrhage and bruisability with minimal or no apparent trauma, requiring medical treatment.
Bleeding from trivial wounds >15 minutes or recurring spontaneously during the 7 days after injury
Oral cavity bleeding that requires medical attention
Spontaneous GI bleeding requiring medical attention, or anaemia, unexplained by ulceration or portal hypertension.
Heavy, prolonged, or recurrent bleeding after tooth extraction or tonsillectomy requiring medical attention.
Menorrhagia resulting in anaemia, or requiring medical treatment without fibroids
Ix for bleeding disorder
FBC, blood film, LFTs, U+E
A coagulation screen with INR, APTT, PFA-100
Von Willebrand’s factor
Refer haem if abnormal clotting or Ix abnormal platelets
Initial anaemia Ix
B12, folate, ferritin, iron level, U+E, LFT, CRP, bone profile + rpt FBC to see trend
Consider:
Myeloma screen – immunoglobulins, electrophoresis, serum free light chains.
Blood film –?bone marrow malignancy
Haemolytic anaemia- ↑LDH, ↓haptoglobin, ↑bilirubin, ↑reticulocytes
PSA
Causes of macrocytic anaemia
Pregnancy
Folate/B12 deficiency
Hypothyroidism
Alcohol/liver disease
Myeloma
AZA/MTX
Causes microcytic anaemia
Iron deficiency
Anaemia chronic disease
Sickle cell
Thalassaemia (esp if normal ferritin and FHx- haemoglobinopathy screen)
Causes normocytic anaemia
Co-existent iron, b12 + folate def
Haemorrhage.
renal failure.
thyroid disease
anaemia of chronic disease.
bone marrow malignancy
If ferritin<100 with anaemia, give a trial of oral iron
Referral criteria for anaemia
Admit haem if:
?acute leukaemia
blood film ?CML
Urgent haem ref if:
unexplained progressive symptomatic anaemia.
anaemia in association with splenomegaly, lymphadenopathy, or other cytopenias.
leucoerythroblastic anaemia on blood film
?haemolysis, positive direct antiglobulin test.
Routine haem ref if:
?myelodysplasia, myeloma, CLL
haemoglobinopathies – not if haemoglobinopathy trait.
Warfarin management if raised INR with bleeding
Major bleeding, stop warfarin, admit for IV vit K+ prothrombin complex concentrate or FFP
> 8 + minor bleeding- stop warfarin and give vit K slow IV injection. Rpt vit K after 24 hours if the INR is still too high.
Restart warfarin when INR<5
5–8 + minor bleeding- stop warfarin and give vit K slow IV injection.
Restart warfarin when INR<5
Warfarin management if raised INR no bleeding
> 8 no bleeding- stop warfarin vit K PO using the IV preparation orally Rpt dose after 24 hours if the INR is still too high.
Restart warfarin when INR<5
5–8 no bleeding- withhold 1 or 2 doses of warfarin and reduce subsequent maintenance dose.
Advice for pts taking warfarin
INR checks regularly w/yellow book
INR affected by diet, alcohol, acute illness, medications incl OTC vitamins
Small amounts alcohol, no binge drinking
Expect to bruise more easily.
Extra care when brushing teeth or shaving
Immediate medical advice if:
Spontaneous bleeding (bruising, bleeding gums, nosebleeds, prolonged bleeding from cuts, blood in the urine or stools, coughing up blood, a subconjunctival haemorrhage, PMB)
Sudden severe back pain (retroperitoneal bleeding).
SOB, chest pain (PE)
Stop warfarin treatment temporarily for certain surgical and dental treatments.
Features of B cell CLL
Unexplained fever.
Weight loss> 10% in 6 months.
Night sweats.
Fatigue.
Infection.
Lymphadenopathy
Hepatomegaly and splenomegaly
Persistent lymphocytes>7
Red flags in children for haem conditions
Admit:
shortness of breath
pruritis
weight loss
pallor
lymphadenopathy
Unexplained petechiae or hepatosplenomegaly (leukaemia)
If persistent unexplained infection/parental concern, pallor, unexplained bruising/bleeding or fatigue: FBC within 48 hrs
When to consider myeloma
Age>60 with persistent:
Back pain
Bone pain
Unexplained fracture
Offer FBC, bone profile, ESR, U+E, electrophoresis, paraprotein, immunoglobulins
Criteria for organising FBC within 48hrs in adults?
To assess for leukaemia if:
Pallor.
Persistent fatigue.
Unexplained fever.
Unexplained persistent or recurrent infection.
Generalised lymphadenopathy.
Unexplained bruising.
Unexplained bleeding.
Unexplained petechiae.
Hepatosplenomegaly.
Referral criteria for ?lymphoma in adults
USC if: unexplained lymphadenopathy or splenomegaly (non-Hodgkin’s)
unexplained lymphadenopathy (Hodgkins)
fever, night sweats, shortness of breath, pruritus, weight loss, or alcohol-induced lymph node pain. (Hodgkins)
Name 8 differentials for unilateral leg swelling
DVT
Muscle strain, tear, or injury
Oedema in a paralysed limb
Lymphatic obstruction
Ruptured Baker’s cyst
Cellulitis and soft tissue infections
Knee pathology
Haematoma
Well’s DVT criteria
Active cancer- Treatment or palliation within 6 months
Bedridden recently >3 days or major surgery within 12 weeks
Calf swelling >3 cm compared to the other leg, Measured 10 cm below tibial tuberosity
Collateral (nonvaricose) superficial veins present
Entire leg swollen
Localised tenderness along the deep venous system
Pitting oedema, confined to symptomatic leg
Paralysis, paresis, or recent plaster immobilization of the lower extremity
Previous DVT
Alternative diagnosis to DVT as likely or more likely (-2)
Management ?DVT based on Well’s score
0 or 1: DVT unlikely, consider admit gen med for d-dimer
2+: DVT clinic same day, or DOAC + DVT clinic next day, or admit gen med
No DOAC if pregnant, age<18, CrCl<30, recent surgery, low plts, bleeding
Causes of raised ferritin not associated with iron overload
Infection
Inflammation (autoimmune, inflammatory arthritis)
Alcohol use
Liver inflammation, hep B or hep C
Fatty liver disease, metabolic syndrome
Malignancy
Thyrotoxicosis
Renal disease
Ix raised ferritin
Rpt 3 months if new + could be associated with infection
Add FBC, CRP, U+E, LFT, HbA1c, lipids, TSATs, AST
TSAT<50% likely no iron overload
TSAT>50% do HFE testing + refer routine haem
If ferritin>1000 on 2 occasions, organise liver USS, liver screen bloods + routine gastro ref
If ferritin 300-1000, calculate FIB-4 ?fatty liver, routine gastro ref
Describe the 2 types of polycythaemia
Primary (polycythaemia vera), splenomegaly, ↑plt ↑WCC, myeloproliferative neoplasm, JAK2 mutation, age 50-70 , ↑ incidence of VTE + arterial thrombosis
Secondary – 2ndary to chronic hypoxia/COPD/high altitude/cyanotic heart disease/carbon monoxide exposure, or erythropoietin-secreting tumours (such as renal tumours), uterine fibroids, or long‑term excessive testosterone replacement/steroids/EPO use in sports.
Symptoms of Polycythaemia vera PCV
Venous/arterial thrombus
Bruising.
Pruritis, especially on contact with warm water.
Abdominal discomfort (relating to splenomegaly).
Insomnia.
Hot flushes, hyperhidrosis or night sweats.
Tenderness or painful burning and/or redness of fingers, palms, heels, or toes
Who should be Ix for PCV?
Hct (>0.6 in males and >0.56 in females)
↑plt ↑WCC
Splenomegaly
Not secondary causes
Thrombus
Criteria for USC referral gastroscopy/colonoscopy/CT colonography
Men and postmenopausal women who are:
<60 with iron deficiency anaemia.
>50 with iron deficiency no anaemia
<50 years with rectal bleeding (lower GI Ix only)
Oral iron advice for pts
take on an empty stomach
Avoid, for 1 hour before or 2 hours after:
dairy products.
tea, coffee, wine.
wholegrain breads and cereals, nuts, and legumes.
calcium supplements
If side effects, try alternate day dosing
What is MGUS?
Low level of monoclonal protein (less than 30 g/L) and absence of end organ damage (anaemia, hypercalcaemia, lytic bone lesions, renal failure, hyperviscosity)
Extremely common, increasingly prevalent with age, affecting 5% of people age>70
Definition of multiple myeloma
CRAB
Serum monoclonal protein (IgG or IgA more than 30 g/L+ otherwise unexplained:
Hypercalcaemia >2.75
Renal impairment
Anaemia – Hb<100
Bony lytic lesions on radiologic imaging
Causes neutropaenia
African decent lower normal range is 1.0
Infections – viral, including EBV, CMV, hepatitis A, B, C, HIV, malaria, typhoid, TB.
Autoimmune – SLE, rheumatoid arthritis, Crohn’s disease, autoimmune neutropenia.
Nutritional – B12 deficiency, folate deficiency, alcohol dependency, anorexia nervosa.
Splenomegaly.
Bone marrow pathology if other abnormalities
What drugs can cause neutropaenia
chloramphenicol, co-trimoxazole, sulfasalazine, penicillins
Phenytoin, carbamazepine
Carbimazole
Clozapine, mirtazapine, imipramine
Chemotherapy and radiation therapy
Methotrexate, gold, penicillamine
Management neutropaenia
Admit if neutropaenic sepsis/febrile
Rpt w/blood film within 72hrs + acute haem advice if<0.5
If 0.5-1 and well consider:
B12, Folate, Ferritin, LFT, ANA, ENA, dsDNA, RF, free light chains, immunoglobulins, electrophoresis
Hepatitis B, HIV, Hepatitis C
If drug induced, stop drug and use shared care agreements
What are the PERC criteria for ruling out PE? (8)
Age<50
No hormone use
No prev VTE
HR<100
Sats>95%
No haemoptysis
No unilateral leg swelling
No surgery or immobilisation last 4 weeks
Management after splenectomy
phenoxymethylpenicillin 250 mg orally twice a day
Pneumococcal vaccine 5yrly
Influenza/COVID vaccine yearly
Causes of thrombocytopaenia
Spurious, clotted sample
Pregnancy
Reduced production, post‑viral, congenital, drugs (clozapine), alcohol, low B12 or folate.
Leukaemia, myeloma, myelofibrosis, aplasia, myelodysplastic syndrome.
Increased destruction, drugs, ITP, autoimmune, DIC
Referral criteria for thrombocytopaenia
Admit if<10
If 10-80 re-test next day with film
Haem advice
Consider stopping clozapine/anticoag
Differential diagnoses of secondary thrombocythaemia
Infectious diseases
Inflammatory diseases
Neoplasms
Acute blood loss, iron deficiency anaemia
Hyposplenism
Trauma or surgery
Exercise
Steroids, adrenaline, LMWH
Pregnancy
Allergic reactions
When and how to test for thrombophilia
Antithrombin III, activated protein C resistance, and protein C and S
Unprovoked VTE or stroke, age<45
Unprovoked thrombus + FHx clots
1º relative with a confirmed, inherited thrombophilia
VTE unusual site
Recurrent miscarriage, with no alternative obstetric or cytogenetic cause
Features sickle cell crisis
Admit if:
Severe pain
Dehydration caused by severe vomiting or diarrhoea.
Severe sepsis.
Acute chest syndrome-tachypnoea, low sats, signs of lung consolidation.
New neuro symptoms
Acute enlargement of spleen or liver over 24 hours, particularly in young children.
Increase in jaundice.
Any change in vision.
Haematuria.
Fulminant priapism
Management sickle crisis
Pain relief (opiates)
Oxygen
IV fluids
Admit haem
