Haematology

Question 1

A CTPA was requested which showed a pulmonary embolism. She is started immediately on dalteparin. What is the most appropriate next step?

Answer 1

Stop dalteparin. Start a direct oral anticoagulant for 3 months

As this patient developed a pulmonary embolism secondary to something (in this case severe illness with associated immobility) an anticoagulation period of 3 months is generally recommended.

Question 2

A 47-year-old woman is given a red blood cell transfusion in the emergency department following a road traffic collision. After 45 minutes, they develop a fever and start to feel anxious.

The transfusion is stopped and the following observations are recorded: respiratory rate 21 breaths per minute, heart rate 74 bpm, saturations 98% (room air), blood pressure 125/85mmHg, temperature 39ºC. The patient appears comfortable at rest and chest auscultation is normal with no wheeze.

What is the most appropriate treatment for this patient’s reaction?

Answer 2

Paracetamol may be used to reduce pyrexia in cases of non-haemolytic febrile transfusion reaction

This patient is experiencing a non-haemolytic febrile transfusion reaction and paracetamol is used to reduce pyrexia in these patients. This is usually a diagnosis of exclusion in clinical practice due to the severe consequences if a more serious reaction is missed. Once other causes are excluded, the transfusion can be resumed (at a slower rate if necessary).

Question 3

A 36-year-old woman is due to undergo an operation to treat an inguinal hernia. She is currently only taking the combined oral contraceptive pill and no other medications. What should the patient be advised to do regarding this medication prior to her operation?

Answer 3

Continue taking the pill until four weeks before her operation

Use of the contraceptive pill should be ceased before an operation to prevent a pulmonary embolism

NICE guidelines recommends that patients on the pill who are undergoing operations should cease intake of the pill four weeks before their operation to reduce the risk of a pulmonary embolism. Oral contraceptives are known risk factors of thrombosis.

Question 4

The antidote for warfarin (reversal agent pairs )

Answer 4

vitamin K

Question 5

The antidote for dabigatran (reversal agent pairs )

Answer 5

idarucizumab

Question 6

The antidote for heparin (reversal agent pairs )

Answer 6

protamine sulfate

Question 7

Cancer patients with VTE

Answer 7

Direct oral anticoagulants (DOACs) for 3-6 months

Question 8

After a complicated revision of a total hip replacement, an 80-year-old lady receives two units of packed red cells. She has a history of heart failure and currently takes bisoprolol, ramipril and furosemide.

Which should be prescribed between the units?

Answer 8

Stat dose of furosemide

Although packed red cells have a higher haematocrit than blood, transfusion of two units or more can result in fluid overload. Therefore, furosemide should be prescribed to be given between every other unit, if two or more units are given. Paracetamol can be used if there is a non-haemolytic febrile reaction to the transfusion. Cetirizine and hydrocortisone are used in cases of an anaphylactic reaction to the transfusion. Platelets may be given in cases of major haemorrhage, alongside packed red cells.

Question 9

A 61-year-old woman comes for review. Around one year ago she finished a 6 month course of warfarin after being diagnosed with an unprovoked, proximal deep vein thrombosis. For the past few weeks she has been experiencing ‘heaviness’ and ‘aching’ in the the same leg. This is associated with an itch and some swelling, although this seems to go down each night. Past medical history of note includes osteoarthritis and type 2 diabetes mellitus.

On examination prominent varicose veins are seen on the affected leg with some brown discolouration of the skin above the medial malleolus. There is no difference in the circumference of the calves. Her temperature is 36.9ºC, pulse 78/min and blood pressure 108/82 mmHg. What is the most likely diagnosis?

Answer 9

Post-thrombotic syndrome
The slowly progressive symptoms of pruritus and pain accompanied by the examination findings are strongly suggestive of post-thrombotic syndrome.

Question 10

A 17-year-old man is investigated after he bled excessively following a tooth extraction. The following results are obtained:

Plt 173 * 109/l
PT 12.9 secs
APTT 84 secs

Which clotting factor is he most likely to be deficient in?

Answer 10

Factor VIII
This young man’s prolonged APTT (Activated Partial Thromboplastin Time) but normal PT (Prothrombin Time) and platelet count suggest a deficiency in the intrinsic pathway of the coagulation cascade. Factor VIII, along with factors IX, XI, XII and prekallikrein, are part of this intrinsic pathway. The most common inherited bleeding disorder is Haemophilia A which is caused by a deficiency in factor VIII. It typically presents in males with excessive bleeding following trauma or surgery, as seen in this patient.

Question 11

Patient having transfusion of packed red cells He is noted to develop ECG changes that are not consistent with ischaemia. What is the most likely cause?

Answer 11

Hyperkalaemia
The transfusion of packed red cells has been shown to increase serum potassium levels. The risk is higher with large volume transfusions and with old blood.

Question 12

medications is most likely to have increased her risk of developing a deep vein thrombosis?

Answer 12

Tamoxifen

Tamoxifen increases the risk of VTE + endometrial cancer

Question 14

A 45-year-old woman presents to the emergency department with acute right lower calf pain. She denies any recent immobilisation, or surgery, combined oral contraceptive pill use, and has no past medical history. There has been no trauma.

Her temperature is 37.1ºC, her heart rate is 95 bpm, and her blood pressure is 128/76 mmHg. There is no localised tenderness on palpation or pitting oedema. Her right calf is 2 cm larger than the left leg, however, the entire right leg is swollen. The left leg is unaffected.

DVT WELLS SCORE: 7

No delays in investigations or management are anticipated.

What is the most appropriate next step?

Answer 14

Perform D-dimer testing
This patient has an acutely swollen and painful lower calf, which should raise suspicion of deep vein thrombosis (DVT). She has no history of immobilisation, surgery, oral combined contraceptive pill use, or cancer, and on examination, there is no localised tenderness, or pitting oedema, and her calf swelling is only 2 cm larger than the rest. However, her entire leg is swollen, which scores 1 point according to the 2-level DVT Wells test. An alternative diagnosis would be less likely given that there are no signs of other causes, such as trauma or infection (as she is afebrile). This makes her Wells score 1, meaning a DVT is unlikely. When patients present with features of a DVT, but a DVT is unlikely (their Wells score is 1 or less), the most appropriate next step is a D-dimer test within 4 hours to rule it out entirely. If the D-dimer is negative, no further action is necessary. If it is positive, a lower limb ultrasound scan should be arranged.

Question 15

A 65-year-old man comes to see his GP complaining of intense itching after getting out the shower. This started about two months ago and has not got any better. His past medical history is unremarkable except for a deep vein thrombosis in his left leg three years ago and an episode of gout in his right hallux six years ago.

Which of the following conditions is most likely in this patient?

Answer 15

Polycythaemia vera

Question 16

Polycythaemia vera

Answer 16

Polycythaemia vera is a neoplasm of the bone marrow which results in the production of excessive red blood cells. The classic symptom of this condition is intense itching which usually occurs after exposure to hot water or hot and humid weather. It is believed that this is due to abnormal histamine or prostaglandin production.

Due to the excess of red cells, patients who suffer from polycythaemia vera are predisposed to blood clots which could explain the deep vein thrombosis this patient had. Also in polycythaemia vera, roughly 20% of patients will also suffer from gouty arthritis.

Question 17

A 43-year-old attends her general practitioner with recurrent infections, reduced appetite and a fullness in her abdomen. She has a history of coeliac disease.

Which of the following would likely be seen on a blood film?

Answer 17

Howell-Jolly bodies
Target cells and Howell-Jolly bodies may be seen in coeliac disease → hyposplenism

The cause of this woman’s symptoms is functional hyposplenism as a result of her coeliac disease. On a blood film this may show Howell-Jolly bodies and target cells.

Question 18

Which of the following blood products poses the greatest risk in her immunocompromised state?

Answer 18

Platelets

Platelet transfusions have the highest risk of bacterial contamination compared to other types of blood products

As this patient is actively bleeding with platelets <30 and haemoglobin of 76g/L, she needs both red blood cells and platelets.

Platelet transfusions pose the highest risk to this immunocompromised patient as they are the most likely to be contaminated by bacteria. This is because refrigeration causes irreversible glycoprotein clustering on the platelet surface, which causes the platelets to be recognised by liver macrophages and rapidly cleared by phagocytosis. Therefore, they have a shelf life of only five days from donation to reduce the risk of contamination.

Question 19

Mr Brown is a 54-year-old man a new diagnosis of anaemia. He has no relevant past medical history. His haematinics values are as follows:

Test Value Reference Range
Iron 10 g/l 10-20 g/l
Folate 2.1 3.1-20.0 ug/l
Vitamin B12 150 ng/l 200-883 ng/l

What treatment would you offer to manage his anaemia?

Answer 19

1 mg cyanocobalamin IM injections three times a week

In patients with both vitamin B12 and folate deficiencies, the vitamin B12 deficiency must be treated first to avoid subacute combined degeneration of spinal cord

Although both folate and B12 levels are low, B12 must be replaced first.
As the iron levels are within normal limits, there is no evidence of iron deficiency anaemia. As such, iron replacement is not required.

Question 20

A 60-year-old woman presents to her GP with whole-body itching which is worst after she has taken a bath, tingling and burning sensations in her hands and feet, and headaches. She has felt fatigued over the past year and a half, however, the symptoms of itching and tingling peripheries have only been present for the past 3 months. On examination, she is noted to have a palpable spleen which is 3cm below the costal angle. She has a full blood count which shows:

Hb 184 g/L Female: (115 - 160)
Platelets 380 * 109/L (150 - 400)
WBC 9.0 * 109/L (4.0 - 11.0)

What is the first-line management for this patient?

Answer 20

Phlebotomy

Venesection is the first-line treatment in polycythaemia vera to keep the haemoglobin in normal range

Question 21

This patient is presenting with symptoms and signs consistent with polycythaemia vera:

Answer 21

Pruritis (worst after taking showers or hot baths).
Tingling, burning, and numbness in arms, hands, and feet.
Headaches and lethargy.
Splenomegaly.
Elevated haemoglobin on full blood count.

Phlebotomy or venesection is performed to remove a patient’s blood in order to reduce the haemoglobin levels in patients. Initially, patients may need this procedure every week; however when the condition is under control, most patients require venesection every 6 to 12 weeks.

Question 22

Tom is an 8-year-old boy with known sickle cell disease who presents with very mild pain in his lower back for 2 days. His observations include a blood pressure of 95/60 mmHg, heart rate of 108 bpm, respiratory rate of 32/min and a temperature of 38.1 degrees centigrade. The examination is normal and there is no obvious source of infection. He is in mild pain and is already taking regular paracetamol and ibuprofen. What would be the correct management?

Answer 22

Admit urgently

Question 23

A 25-year-old woman attends the haematology clinic with a past medical history of antiphospholipid syndrome. She informs you that she is pregnant at 12 weeks gestation. She has had a previous deep vein thrombosis associated with antiphospholipid syndrome (APS) for which she completed a 6-month course of warfarin.

How should she be managed during pregnancy?

Answer 23

Aspirin and LMWH

The patient has had a previous VTE associated with antiphospholipid syndrome (APLS) and therefore has an extremely high risk of VTE during pregnancy. Women with VTE associated with antiphospholipid syndrome (APS) should be offered thromboprophylaxis with higher dose LMWH (either 50%, 75% or full treatment dose) antenatally and for 6 weeks postpartum or until returned to oral anticoagulant therapy after delivery. The addition of aspirin is also recommended to reduce the risk of pre-eclampsia.

Question 24

A 21-year-old male presents to the emergency department with a cough, fever and dyspnoea. On examination he is hypoxic. Pulmonary infiltrates are seen on chest x-ray. He has suffered with anaemia, jaundice and general weakness since the age of 3 months, as well as severe pain when exposed to cold conditions.

What is the most likely underlying condition?

Answer 24

Sickle cell disease

Acute chest syndrome is a complication of sickle-cell disease and presents with dyspnoea, chest pain, cough, hypoxia and new pulmonary infiltrates seen on chest x-ray

The presentation described here is an acute chest syndrome occurring in the context of a patient with sickle cell anaemia.

Acute chest syndrome is defined as new pulmonary infiltrates on chest x-ray along with dyspnoea, chest pain, cough or hypoxia. Sickle cell disease is insinuated in the question with the background of anaemia, jaundice, and vaso-occlusive crises (pain when exposed to cold).

Question 25

A 15-year-old girl presents with abdominal pain. She is normally fit and well and currently takes a combined oral contraceptive pill. The patient is accompanied by her mother, who is known to have hereditary spherocytosis. The pain is located in the upper abdomen and is episodic in nature, but has become severe today. There has been no change to her bowel habit and no nausea or vomiting. What is the most likely diagnosis?

Answer 25

Biliary colic

This patient has hereditary spherocytosis resulting in chronic haemolysis and gallstone formation. An important differential in a poorly patient with hereditary spherocytosis would be splenic rupture

Question 26

A 19-year-old male is about to start chemotherapy following a diagnosis of acute lymphocytic leukaemia. Before undergoing his first round of chemotherapy, the potential risks are explained to the patient, including the risk of tumour lysis syndrome.

What drug could be prescribed to reduce the risk of developing this compilation?

Answer 26

Allopurinol

Giving allopurinol or rasburicase prior to chemotherapy is a way to reduce the risk of developing tumour lysis syndrome

Allopurinol is correct as this drug can be given before chemotherapy to reduce the risk of tumour lysis syndrome. Allopurinol works by lowering serum urate levels in order to prevent the condition.

Question 27

You are clerking a 28-year-old in the emergency department. He complains of painful prolonged erection of the penis. He states that he has had the same issue on two previous occasions.

What is the likely underlying cause of his repeated presentations?

Answer 27

Sickle cell disease

Recurrent priapism can be seen in sickle cell disease

Although alcohol and illicit drug use can cause priapism sickle cell is known to cause recurrent attacks.

Question 28

A 35-year-old male patient who is known to have haemophilia A presents to the emergency department persistently haemorrhaging from an open fractured femur following an RTA, you choose to reverse the coagulopathy with cryoprecipitate.

Which of the following is present in cryoprecipitate?

Answer 28

Factor VIII
Cryoprecipitate contains factor VIII, fibrinogen, von Willebrand factor and factor XIII

Patients with haemophilia A are genetically deficient in factor VIII (factor IX for haemophilia B), which is what the cryoprecipitate would be used to replace in this instance

Question 29

A 35-year-old female who is 34 weeks pregnant presents with a swollen, painful right calf. A deep vein thrombosis is confirmed on Doppler scan. What is the preferred anticoagulant?

Answer 29

Subcutaneous low molecular weight heparin

Although teratogenic effects of warfarin are greater in the first trimester most clinicians would use low molecular weight heparin in this situation. Another factor to consider is the risk of peripartum haemorrhage and potential problems reversing the effects of warfarin if this occurred

Question 30

A 70-year-old gentleman comes to see you to discuss his recent blood tests, which have been done routinely three days ago as part of a health screen. He happens to currently be on day five of antibiotics for a community acquired pneumonia, for which he saw one of your colleagues. Other than this recent infection, he is completely fit and well, with no medical history and no new symptoms to report.

His renal function is normal. The remainder of his blood tests are shown below:

Hb 110 g/l
Platelets 540 * 109/l
WBC 13 * 109/l
MCV 76 * 109/l
Ferritin 330 * 109/l

All values were normal one year ago. What is the most likely explanation for his anaemia?

Answer 30

Iron deficiency anaemia
This gentleman has a microcytic anaemia, most commonly caused by iron deficiency. The history of this gentleman being unwell whilst his bloods were taken is important -ferritin goes up with inflammation, so the fact that it is normal on this blood test may be misleading. He requires further iron studies to test for true iron deficiency.

A question sometimes seen in exams gives a history of a normal haemoglobin level associated with a microcytosis. In patients not at risk of thalassaemia, this should raise the possibility of polycythaemia rubra vera which may cause an iron-deficiency secondary to bleeding.

New onset microcytic anaemia in elderly patients should be urgently investigated to exclude underlying malignancy.

*in beta-thalassaemia minor the microcytosis is often disproportionate to the anaemia

Question 31

A 76-year-old gentleman presents with a 1-month history of fatigue and 2kg of weight loss. He also complains of a ‘full stomach’ and he has noticed that he sometimes bleeds from his gums, which he’s never had before.

A blood film demonstrates ‘tear drop’ cells.

What is this most likely diagnosis?

Answer 31

Myelofibrosis

Myelofibrosis is associated with ‘tear drop’ poikilocytes on blood film

Tear drop cells are red blood cells with a tapered end. They are associated with thalassaemia, megaloblastic anaemia and myelofibrosis. This, coupled with the fact that the patient has constitutional symptoms (fatigue and weight loss), splenomegaly (indicated by the stomach fullness), and easy bleeding points towards myelofibrosis. This reduces the ability of the bone marrow to produce normal cells, thus causing thrombocytopenia, anaemia and extramedullary haematopoiesis in the spleen.

Question 32

Direct oral anticoagulant for DVT- What is the most appropriate duration of treatment?

Answer 32

6 months

Venous thromoboembolism - length of anticoagulation
provoked (e.g. recent surgery): 3 months
unprovoked: 6 months

Question 33

A 67-year-old man presents to the Emergency Department with fatigue and pain deep within his hips. His blood results are as follows:

Hb 108 g/L (135 - 180)
MCV 95 fl (80 - 100)
Platelets 106 * 10 9/L (150 - 400)
WBC 8.5 * 10 9/L (4.0 - 11.0)
Creatinine 143 µmol/L (55 - 120)
Adjusted calcium 3.02 mmol/L (2.2 - 2.7)
. Which SINGLE finding on a peripheral blood smear would be diagnostic in this case?

Answer 33

Rouleaux formation

‘CRAB’ features of multiple myeloma = hyperCalcaemia, Renal failure, Anaemia (and thrombocytopenia) and Bone fractures/lytic lesions

The patient’s clinical presentation, which includes symptoms of anaemia, thrombocytopenia, hypercalcaemia, and renal impairment, aligns with a diagnosis of multiple myeloma. In this disorder, rouleaux formation is commonly observed due to increased serum protein levels (such as immunoglobulins), resulting in the characteristic stacking of red blood cells resembling a stack of coins.

Question 34

Auer rods

Answer 34

These needle-shaped inclusions found within the cytoplasm of myeloid blasts indicate acute myeloid leukaemia and have no relevance to multiple myeloma or the clinical and laboratory findings in question.

Question 35

Howell-Jolly bodies

Answer 35

These remnants of cell nuclei within red blood cells typically manifest in patients with asplenia or severe haemolytic anaemia and do not match the patient’s symptoms or laboratory findings that suggest multiple myeloma.

Question 36

Red cell agglutination

Answer 36

This condition occurs predominantly in disorders such as cold agglutinin disease, where there is clumping of red blood cells together; it does not correspond with the characteristics suggestive of multiple myeloma detailed here.

Question 37

Spherocytosis

Answer 37

Defined by the presence of spherical red blood cells, spherocytosis usually arises from hereditary spherocytosis or autoimmune haemolytic anaemia and does not coincide with the clinical presentation or laboratory findings indicative of multiple myeloma.

Question 38

A 27-year-old woman presents to the Emergency Department with symptomatic menorrhagia. Within two minutes of commencing a transfusion with one unit of packed red cells, she develops concerning symptoms that lead to the cessation of the transfusion. The assessing doctor suspects an acute haemolytic transfusion reaction, which is later confirmed by a direct Coombs test.

What combination of symptoms is most likely to have developed in this woman?

Answer 38

Fever, abdominal pain and hypotension

The triad of angioedema, hypotension, and wheezing suggests an anaphylactic reaction rather than acute haemolysis. The combination of hypoxia and hypertension might imply a diagnosis of transfusion-associated circulatory overload. Meanwhile, the presence of hypoxia, fever, and hypotension could be indicative of a transfusion-related acute lung injury.

Question 39

develops a deep vein thrombosis (DVT) 10 days after having a hip replacement despite taking prophylactic dose low-molecular weight heparin (LMWH). What is the most appropriate anticoagulation strategy?

Answer 39

Switch to direct oral anticoagulant for 3 months

Venous thromoboembolism - length of anticoagulation
provoked (e.g. recent surgery): 3 months
unprovoked: 6 months

Question 40

A 36-year-old HIV- positive gentleman was referred by his GP to the haematology department with lymphadenopathy, fever and night sweats. Lymph node excision reveals Reed-Sternberg cells and a diagnosis of lymphocyte-depleted Hodgkin lymphoma. He asks you what his prognosis is likely to be. Which one of the following characteristics of this gentleman is associated with an improved prognosis?

Answer 40

Age <45 years old at diagnosis

Hodgkin’s lymphoma: signs of poor prognosis: B-symptoms, increasing age, male sex, stage IV disease and lymphocyte depleted subtype

Lymphocyte-depleted Hodgkin lymphoma is the rarest form of Hodgkin’s lymphoma as well as the most aggressive . It is typically seen in young adults aged 30-37 years of age. Risk factors include a family history and being immunocompromised. Treatment of Lymphocyte-depleted Hodgkin lymphoma is typically adjusted for prognostic factors and the cancer stage (Stage IV being associated with the worst prognosis).

Negative prognostic factors include:
The presence of B symptoms (night sweats, weight loss and fever)
Male gender
Being aged >45 years old at diagnosis
High WCC, low Hb, high ESR or low blood albumin

Question 41

A 58-year-old woman is brought into the emergency department with malaise and diarrhoea. She reports feeling shivery and achy for the past 3 days and has passed 4 watery stools in the past 24 hours. She is known to have breast cancer and is currently undergoing chemotherapy for this. Her last dose of doxorubicin and cyclophosphamide was 10 days ago. She has no allergies and takes no other medications. Her observations are heart rate 103/min, respiratory rate of 20/min with saturations of 100% in room air, blood pressure of 100/79mmHg, and temperature of 39.1ºC.

What is the appropriate first-line management for this patient while her blood culture result is pending?

Answer 41

Piperacillin with tazobactam (tazocin)

Piperacillin with tazobactam (Tazocin) is the empirical antibiotic of choice for neutropenic sepsis

This patient is presenting with features consistent with neutropenic sepsis:
Symptoms of malaise, diarrhoea, flu-like aching.
Observations showing mild tachycardia and a temperature >38ºC.
A history of chemotherapy within the past 7-14 days.

As she has no allergies, she should be managed with Tazocin (a combination of piperacillin, a broad-spectrum β-lactam antibiotic, and tazobactam, a β-lactamase inhibitor) until her blood cultures show a specific sensitivity.

Alternatively, neutropenic sepsis patients who are penicillin-allergic can be managed with vancomycin. These patients should also be given gentamicin, ciprofloxacin, or amikacin (dependent on local guidelines and the severity of the patient’s presentation).

Vancomycin can be added alongside Tazocin in neutropenic sepsis patients with high Early Warning Scores (NEWS). This is also indicated if there is a recent history of infection with MRSA, previous history of MRSA, or a suspected central line infection.

Question 42

A 54-year-old man presents with several weeks of itching all over the body and facial flushing. The itching is worse when having a shower. He denies any rash or other symptoms. He has no significant past medical history and takes no regular medication.

On examination, the face is slightly puffy and flushed in appearance. No other abnormal findings are noted. Observations are normal except for a blood pressure of 168/96 mmHg. Blood tests are performed:

Hb 193 g/L (135-180)
Platelets 525 * 109/L (150 - 400)
WBC 13.7 * 109/L (4.0 - 11.0)

What is the most likely diagnosis?

Answer 42

Polycythaemia vera

Raised haemoglobin, plethoric appearance, pruritus, splenomegaly, hypertension → ?polycythaemia vera

This is a myeloproliferative disorder characterised by an increase in red cell volume, hence the raised haemoglobin. It is often accompanied by overproduction of platelets and neutrophils. It is almost always due to a JAK2 mutation. Clinically, it presents with aquagenic pruritus, a plethoric appearance, hypertension and splenomegaly.

Question 43

A 50-year-old woman presents with petechiae, purpura and epistaxis. She had an upper respiratory tract infection 5 weeks ago. She does not have a family history of bleeding disorder. Her blood test showed:

Platelets 80 * 109/L (150 - 400)

Based on the most likely diagnosis, what is the first-line treatment for this patient?

Answer 43

First-line treatment for ITP is oral prednisolone

The patient presented with petechiae, purpura and epistaxis, with a blood result of thrombocytopenia. This is a typical picture of immune thrombocytopenic purpura (ITP). This is an autoimmune condition characterised by low platelets. The history of respiratory tract infection also hints at ITP. The first-line treatment for ITP is oral prednisolone.

Question 44

A 17-month-old child has been referred to the haematology team for painful swellings of the bones of the hands and feet, and a positive family history of sickle cell disease.

What mode of inheritance produces this condition?

Answer 44

Sickle cell anaemia is an autosomal recessive condition

Question 45

Support a diagnosis of iron-deficiency anaemia?

(TIBC = total iron-binding capacity)

Answer 45

Total iron-binding capacity (TIBC) + transferrin levels are typically raised in iron-deficiency anaemia

↓ Ferritin, ↑ total iron-binding capacity, ↓ serum iron, ↓ transferrin saturation

Question 46

A 62-year-old woman presents to the Emergency Department with a painful left leg, which has worsened over several hours. She has no other symptoms. Her past medical history includes asthma, hypertension and a laparoscopic cholecystectomy 10 weeks ago.

On examination, the diameter measured around the left calf is approximately 4cm larger than that of the right calf. There is no oedema.

What is the most appropriate initial investigation?

Answer 46

Proximal leg vein ultrasound

If a 2-level DVT Wells score is ≥ 2 points then arrange a proximal leg vein ultrasound scan within 4 hours

The suspicion here is that of deep vein thrombosis (DVT). A two-level Wells score should be calculated. In this case, the patient scores 1 for recent major surgery within 12 weeks and 1 for a calf swelling at least 3cm larger than the asymptomatic side. With a score of two or greater, a proximal leg vein scan should be arranged within 4 hours.

D-dimer would be appropriate if the Wells score were 1 or less, and if negative, would make the diagnosis unlikely. In this scenario, if ultrasound were not possible within 4 hours, a D-dimer could be performed and interim therapeutic anticoagulation given. However, the initial choice, if possible, is to perform an ultrasound scan within 4 hours.

Question 47

Elena, a 22-years old woman, presents to her GP with recurrent nosebleeds and unexplained bruising on her arms and legs. She tells you that her mother has always had a similar problem, but never had it looked at. In light of this, you decide to send her for a number of blood tests.

Given the most likely diagnosis, which of the following results would you expect to see?

Answer 47

Prolonged bleed time, normal platelet count, prolonged APTT

In VWD, bleeding time is increased but platelet levels are normal. In addition, APTT is prolonged

Von Willebrand’s disease is the most common genetic bleeding disorder, and is inherited in an autosomal dominant fashion. It behaves like a platelet disorder, as von Willebrand Factor (vWF) is required to promote platelet adhesion to the damaged endothelium. Patients therefore experience mucocutaneous bleeding after mild injury (e.g. nose-bleeds, bruising). Also, this means that bleeding time is prolonged, as they cannot adhere to form the platelet plug, but the actual platelet count itself is normal.

vWF also acts as a carrier molecule for factor VIII which is measured by APTT, and as a result, the APTT is prolonged. This is also seen in haemophilia A (factor VIII deficiency), but to a greater degree.

Question 48

A 27-year-old female of Afro-Caribbean origin presents to the oncology clinic following a referral by her general practitioner. She has been noticing some lumps on her neck that have been classified as painless, non-tender, asymmetrical lymphadenopathy. She complains of increasing night sweats and she noticed some pain when she drinks alcohol.

Given the most likely diagnosis, which one of the following features is associated with a poor prognosis (low chance of recovering)?

Answer 48

Night sweats

‘B’ symptoms in Hodgkin’s lymphoma are associated with a poor prognosis
weight loss > 10% in last 6 months
fever > 38ºC
night sweats

The correct answer is night sweats. The patient is presenting with painless, non-tender, asymmetrical lymphadenopathy. These features are indicative of a diagnosis of Hodgkin’s lymphoma. This malignancy can be associated or not with ‘B’ symptoms such as weight loss > 10% in the last 6 months, fever > 38ºC, and night sweats. The presence of at least one of these ‘B’ symptoms is associated with a poor prognosis.

Question 49

A 45-year-old woman is diagnosed with having a proximal deep vein thrombosis three weeks after being treated for a fractured femur secondary to a motorcycle accident. She is started on warfarin (initially covered with low molecular weight heparin) with a target INR of 2.0-3.0.

In addition to warfarin, which one of the following should also be offered to the patient?

Answer 49

No additional treatment other than routine care

Compression stockings should NOT be offered routinely to all patients with deep vein thrombosis

Question 50

A 45-year-old gentleman presents to the emergency department with nausea, sweating and severe central crushing chest pain which radiates to his left arm. His ECG shows widespread ST depression with T wave inversion. His blood tests identify a haemoglobin level of 75g/L. Which one of the following would be appropriate to treat his anaemia?

Answer 50

Transfusion of packed red cells
The transfusion threshold for patients with ACS is 80 g/L

This patient has presented with symptoms of ACS and his ECG changes confirm this (NSTEMI or unstable angina). His haemoglobin level is below the threshold of 80g/L for transfusion of red blood cells for patients with ACS. Hence it would be appropriate to give him an immediate transfusion. Anaemia can worsen ischaemia in ACS as there is less haemoglobin to carry oxygen, meaning the heart has to work harder and also receives less oxygen. Hence, it is important to provide immediate relief of severe anaemia in an ACS and the guidelines recommend aiming for a haemoglobin concentration target of 80-100 g/litre after transfusion.

Patients without ACS	 Transfusion threshold	70 g/L	 Target after transfusion	70-90 

Patients with ACS
Transfusion threshold 80 g/L
Target after transfusion 80-100g/L

Question 51

Which one of the following may be associated with an increased risk of venous thromboembolism?

Answer 51

Behcet’s syndrome. Behcet’s syndrome, also known as Behcet’s disease, is a rare and chronic condition that causes inflammation of the blood vessels (vasculitis) throughout the body. It can lead to numerous symptoms, including painful mouth sores, genital sores, and eye inflammation. Importantly for this question, it can increase the risk of venous thromboembolism due to the inflammation of the blood vessels. This inflammation can cause damage to the vessel walls leading to activation of the coagulation cascade and the formation of blood clots.