Haematology Flashcards
What Hb levels would be considered anaemia for
Male:
Female:
Term 1 of Pregnancy:
Terms 2 and 3 of pregnancy:
Male: <13
Female: <12
Term 1 of Pregnancy: <11
Terms 2 and 3 of pregnancy: <10.5
What is the presentation of anaemia
What exam findings?
Fatigue
SOB
Palpitations
Angina (chest pain)
Night cramps
Tachycardia
Pallor
Carotid bruits
HFpEF (High output HF)
When determining ddx for anaemia, what is the best investigation to narrow down the diagnoses? Give the normal range
What are other relevant investigations
FBC: MCV 80-120 + Reticulocyte count
Blood Film!
Ferritin
CRP/ESR
Serum B12 and folate
Serum bilirubin
Renal function
TFTs
LFTs
+/- Hb Electrophoresis
You conduct an FBC and obtain an MCV <80. What are your differentials?
Fe-deficiency
Thalassaemia
Anaemia of chronic disease
You conduct an FBC and obtain an MCV 80-120 . What are your differentials?
Acute blood loss
Sickle cell
Anaemia of chronic disease
Haemolysis
Uraemia
Marrow failure
You conduct an FBC and obtain an MCV >120. What are your differentials?
Folate/B12 deficiency
Alcohol
Liver disease
Thyroid disease
Marrow infiltration
What is another word for B12?
In what dietary products are B12 found in?
Cobalamin
Liver, kidney and dairy products
Where is the intrinsic factor for B12 formed?
Gastric parietal cells
B12 deficiency causes Macrocytic anaemia. Give 3 causes
1) Inadequate intake (vegans)
2) Malabsorption: Gastritis, H.pylori, Gastrectomy, chronic pancreatitis, Ileal resection, coeliac disease, Crohn’s
3) Drugs: Metformin, PPIs, H2 antagonists, COCP (by reducing carrier protein)
How does Macrocytic anaemia present?
Anaemia:
Fatigue
SOB
Palpitations
Angina (chest pain)
Night cramps
Tachycardia
Pallor
Carotid bruits
HFpEF (High output HF)
+
Glossitis
Mouth ulcers
Peripheral neuropathy
Ataxia
Optic atrophy
Memory loss
Degeneration of spinal cord
Psychosis (rarely)
Dementia is associated with what type of anaemia
Folate-deficiency anaemia (otherwise exactly the same sx as B12 deficiency)
What dietary products is Folate present in?
Liver, yeast, spinach, vegetables, nuts
What are the causes of Folate-deficiency anaemia
1) Reduced intake: Old age, malignancy, anorexia, excess alcohol (spirits)
2) Malabsorption: Coeliac disease, Crohn’s, gastrectomy, lymphoma, Diabetic enteropathy
3) Drugs: Anticonvulsants, Methotrexate, Trimethoprim
4) Excess use: Pregnancy, lactation, increased cell turnover (malignancy, haemolysis)
Define pernicious anaemia
What diseases (2) are associated with pernicious anaemia?
How is it managed?
Autoimmune condition characterised by with gastric atrophy and intrinsic factor/gastric parietal cell antibodies => reduced B12
Gastric and colorectal Ca
Mild B12 deficiency: Oral B12 supplements
Severe B12 deficiency: IM hydroxycobalamin 3x/week for 2 weeks then 2-3 monthly
You order bloods for a 60-year old person with suspected Fe anaemia. What results would you expect to confirm the diagnosis?
What other investigation must be ordered?
reduced serum ferritin +/- reduced transferrin saturation
In patients >60 or >50 with rectal bleeding => FIT test
What is the effect of vitamin C on Iron absorption
Increases it
What are the causes of Iron-deficiency anaemia?
1) GI blood loss: Aspirin/NSAID use, colonic Ca, Gastric Ca, Gastric ulceration, oesophagitis, Oesophageal varices
2) Non-GI blood loss: Menstruation, blood donation, haematuria, epistaxis
3) Malabsorption: Coeliac disease, H. Pylori
4) Excess use: Pregnancy, lactation, premature infants, deficient diet
What is the pathophysiology behind anaemia of chronic disease?
Inflammatory cytokines suppress bone marrow erythropoeisis => normocytic anaemia but microcytic if severe
A 70 year old male presents for a review of routine bloods. Their MCV was 130 but their Hb is 15. What is the most likely diagnosis?
What other findings would be on the blood results?
Myelodysplastic syndrome. Macrocytosis preceeds anaemia by a few years
Also would have neutropenia, thrombocytopenia => pancytopenia
What is Myelodysplastic syndrome?
What type of anaemia does it cause?
Common pre-leukaemia disorder in those >65 causing macrocytic anaemia.
What is the management of Myelodysplastic syndrome?
Refer to haematology
Supportive: Blood transfusion, erythropoeitin, Chemo/immunosuppressive therapy
Curative: Stem cell transplant can be curative for young, fit patients
A patient presents with chest pain, SOB and angina. they appear pale on exam and is tachycardic. On examination you note splenomegaly. There is no history of trauma. What is their likely MCV?
What other examination finding is common here?
What would their FBC and Blood film show?
You decide to refer to haematology. In all cases what should you offer the patient?
Normocytic anemia due to haemolysis
Jaundice (scleral icterus)
Reduced Hb, Increased reticulocytes “spherocytes” and polychromasia
Refer to haematology and stop the drug causing it if applicable. In all cases, give folate supplements.
What virus is known for its association with haemolytic anaemia?
Parvovirus
Give 5 causes of haemolytic anaemia
Congenital:
1) Membrane abnormality: Spherocytosis, elliptocytosis
2) Haemoglobin abnormality: Sickle cell, thalassaemia
3) Metabolic: G6PD Deficiency, Pyruvate kinase
Acquired:
1) Autoimmune: SLE, CLL, EBV
2) Isoimmune: Transusion
3) Drug-induced
4) Hypersplenism: Malaria, lymphoma, RA, portal HTN
5) Artificial heart valves
What is aplastic anaemia?
Bone marrow failure characterised by pancytopenia
A patient suffers from recurrent infections and anaemia. What are the 2 most likely causes?
Myelodysplastic syndrome
Aplastic anaemia
When are haemoglobinopathies screened for?
Pre-conceptual screening
Antenatal screening
Neonatal bloodspot screening
What is thalassaemia?
AR disorder of haemoglobin production
Have a review of this
And this. There will be questions
Homozygous alpha 0 thalassaemia will cause…
Bart’s hydrops causing foetal death at 38 weeks
Heterozygous alpha + and alpha 0 will cause?
what examination finding is associated with it?
Haemoglobin H
Splenomegaly
Which thalassaemia is associated with mediterranean and southeast asia?
Alpha thalassaemia
Beta thalassaemia is present in all ethnic groups except the northern europeans. Explain its pathophysiology
Reduced beta chain production leads to increased alpha chain synthesis leading to destruction of RBC in spleen and bone marrow causing:
1) Proliferation of bone marrow
2) Bony deformities: Bossing of skull, Mongoloid facies, thinning of long bones
3) Splenomegaky
Homozygous beta thalassaemia newborns will die unless they have repeated transfusions. What is the risk of that and how is that managed?
What is the curative management?
Iron overload => Chelation (removal of iron) and specialist care
Stem cell transplant is curative
A stroke has occurred in an immigrant that is <10 yo. What would be the most likely reason?
Sickle cell anaemia causing infarction
Sickle cell anaemia is most common in the mediterranean, middle east, indian, and malarial populations. There are many types. What are they?
Homozygous SS
Heterozygous AS
Heterozygous SC, SD, SE or even S+ thalassaemia
Imagine a heterozygous patient with AS. They are asymptomatic. What does this mean?
Even though there are normally asymptomatic, what might cause them to be symptomatic?
<40% are S-trait allele.
Anaesthesia , infection, or anything affecting the demand of the body or reducing breathing (anaesthesia)
What is the pathophysiology of Sickle cell anaemia?
Haemoglobin S undergoes liquid crystal formation when de-oxygenated causing sickling of affected blood cells =>
1) shortens lifespan of RBC => Haemolysis and splenomegaly
2) Aggregation of cells => Tissue infarction (stroke <10), organ sequestration (liver, spleen, lungs)
What are diagnostic findings of sickle cell anaemia?
FBC and blood film showing reduced Hb, and increased reticulocyte count with sickling on film.
Confirmed with Haemoglobin electrophoresis!!
Sickle cell patients have a mean survival of 50y. What is the most common cause of death?
Infection
What is the management of sickle cell anaemia?
Referral and management in specialist centres
Offered Hydroxycarbamide !!
Considered asplenic => immunosuppressed => Give all vaccines, avoid cold, warn about danger of anaesthetics, treat infection early, lower threshold for analgesia and admission.
What is the anticoagulation for MI?
DAPT
DOAC if A.fib also
What is the anticoagulation for HF
DAPT
DOAC if A.fib also
How will you determine if the risk of a bleed?
HASBLED
HTN
Abnormal LFTs or creatinine
Stroke hx
Bled (prior major bleed)
Labile INR
Elderly (>65)
Drugs (drugs predisposing to bleeding)
3+ = more regular reviews needed
How will you decide whether to give anti-coag in Primary stroke prevention?
CHADSVASC score
1+ oral anticoag depending on patient preference
2+ Give oral anti-coag
Weighed against:
HASBLED
How would you determine whether to give Anticoag after a stroke
After ruling our haemorrhagic stroke on non-contrast CT
In all cases, except <12 months after ACS, antiplatelet agents are stopped if initiating anti-coag. What is the mechanism of action of:
Heparin:
Warfarin:
DOAC:
Heparin: Increases anti-thrombin 3 activity
Warfarin: Vitamin K antagonist
DOAC: Inhibits Factor X except Dabigatran (inhibits thrombin)
What is the target INR for warfarin?
Target INR is 2.5 unless thromboembolism. Then it is 3.5.
Also special for prosthetic heart valves
What is the anti-coag of choice for prosthetic heart valves?
Warfarin
Patients on warfarin
