Haematology Flashcards
You visit a normally healthy 50-year-old woman who has become acutely breathless. She complains of sudden right sided sharp chest pain worsened by coughing and breathing. She has coughed up some blood.
Examination reveals a temperature of 37.8 °C, respiratory rate of 36 breaths/min with cyanosis, pulse 130 beats/min and blood pressure of 80/60 mmHg. A right-sided pleural rub is present. You admit her to hospital where she is diagnosed with a pulmonary embolus. After a few days, she is discharged well on apixaban.
For what MINIMUM time period would you advise her to remain on apixaban? Select ONE option only.
Select one:
A. 6 months
B. 3 months
C. 6 weeks
D. 12 months
E. 4 weeks
Answer: B. 3 months
Answer justification and feedback: The aim of anticoagulant treatment of patients following pulmonary embolism (PE) is to prevent fatal and non-fatal recurrent venous thromboembolic events. Treatment is usually continued for at least 3 months, but duration may be longer depending on whether the PE was unprovoked (no obvious, transient risk factor identified) or provoked (caused by an identifiable, transient, major risk factor).
The decision should be based on the balance between the person’s risk of venous thromboembolism (VTE) recurrence and their risk of bleeding.
The benefits of continuing anticoagulation treatment are likely to outweigh the risks in people with unprovoked DVT or PE, and a low bleeding risk and very often treatment may be continued for a total of 6 months - although the MINIMUM time is 3 months.
Resource: NICE. Venous Thromboembolic Diseases: diagnosis, management and thrombophilia testing. NG158. 2020 (updated 2023).
Which is the SINGLE MOST appropriate statement concerning anticoagulation with direct oral anticoagulants (DOACs) in comparison to warfarin? Select ONE option only.
Select one:
A. DOAC treatment for patients with chronic atrial fibrilation and high stroke risk leads to increased all cause mortality
B. DOAC treatment leads to a large reduction in all-cause mortality
C. DOAC treatment leads to a large reduction in the risk of haemorrhagic stroke
D. DOAC treatment of venous thromboembolism (VTE) reduces the risk of recurrent VTE
E. DOAC treatment reduces the risk of fatal bleeding
Answer: E. DOAC treatment reduces the risk of fatal bleeding
Answer justification and feedback: DOACs are now recommended as first line anticoagulation for stroke prevention in atrial fibrillation. A systematic review showed that, in atrial fibrillation, use of DOACs rather than warfarin leads to small reductions in all-cause mortality and haemorrhagic stroke.
There is little difference between warfarin and DOACs when used for the treatment of VTE.
Across indications the risk of fatal or major bleeding is reduced with DOACs but prescribers should be aware of the issues regarding the lack of available agents to reverse DOAC-associated haemorrhage.
Resource: Caldeira D, Rodrigues F, Barra M et al. Non-vitamin K antagonist oral anticoagulants and major bleeding-related fatality in patients with atrial fibrillation and venous thromboembolism: a systematic review and meta-analysis. Heart 2015; 101: 1204–1211.
The following statements relate to anticoagulant and antiplatelet drugs.
For each statement select the SINGLE MOST appropriate drug from the list. Each option may be used once, more than once or not at all.
A drug which is given orally and licensed for prophylaxis of venous thromboembolism following a total knee replacement.
A drug which can be used in patients who have had an ischaemic stroke if aspirin and clopidogrel are contraindicated or not tolerated.
A synthetic pentasaccharide that inhibits activated factor X, and is licensed for the treatment of deep vein thrombosis.
Options:
- Warfarin
- Dalteparin
- Dabigatran
- Dipyridamole
- Fondaparinux
Answer: 1. Dabigatran
2. Dipyridamole
3. Fondaparinux
Answer justification and feedback: Dabigatran is an oral direct thrombin inhibitor which is licensed for the prophylaxis of venous thromboembolism (VTE) following total hip replacement or total knee replacement surgery. It has a rapid onset of action and does not require therapeutic monitoring.
Dipyridamole can be used if aspirin and clopidogrel are contraindicated or not tolerated in ischaemic stroke.
Fondaparinux is synthetic pentasaccharide that inhibits activated factor X, which can be used for the treatment of deep vein thrombosis.
Resource: None specified
A 72-year-old hypertensive man with a mechanical heart valve takes warfarin. He had a right-sided nosebleed the night before, which soaked his pillow but has now stopped. He is haemodynamically stable and the INR is stable at 2.5.
What is the SINGLE MOST appropriate immediate course of action?
Select one:
A. Nasal packing
B. No further action required
C. Nasal cautery
D. Vitamin K
E. Stop warfarin
Answer: B. No further action required
Answer justification and feedback: No immediate action. It is important however that he has appropriate ‘safety netting’ and advice on first aid. As he is no longer bleeding, nasal packing is not required. Although proof of efficacy is not available, topical antiseptic ointments may be gently applied to the nasal mucosa with a cotton-tipped swab to prevent recurrence.
Given his current INR, he should be advised to continue warfarin as the risks of stopping warfarin (or reversing it with vitamin K) outweigh potential benefits.
Resource: None specified
A 58-year-old type 2 diabetic man with chronic kidney disease is found to have the following blood count at his routine diabetic check. His diabetes is moderately controlled and he is well in himself.
Hb 11.9 x 10^9/l (13–17)
WBC 5.6 x 10^9/l (4–11)
Neutrophils 3.0 x 10^9/l (2–7)
Lymphocytes 1.8 x 10^9/l (1–3)
Monocytes 0.8 x 10^9/l (0.2–1)
Platelets 378 x 10^9/l (150–400)
MCV 89 fl (80–100)
Haematocrit 0.5 l/l (0.4–0.5)
Ferritin 300 ng/ml (23–336)
What is the SINGLE MOST likely cause of his anaemia?
Select one:
A. Anaemia of chronic disease
B. Haemolysis
C. B12 deficiency
D. Iron deficiency
E. Folate deficiency
Answer: A. Anaemia of chronic disease
Answer justification and feedback: The low haemoglobin but normal mean corpuscular volume (MCV) indicate normocytic anaemia. In patients with chronic kidney disease, normochromic normocytic anaemia mainly develops from decreased renal synthesis of erythropoietin.
Iron deficiency typically causes microcytic anaemia with low ferritin. Folate and B12 deficiency is usually associated with macrocytic anaemia.
Resource: None specified
After a long flight, a 65-year-old man develops an uncomplicated deep vein thrombosis (DVT). He has no previous history of thrombosis and no other risk factors. He is started on apixaban and is considered to be at a low risk of further DVT.
According to NICE guidelines, what is the SINGLE MOST appropriate MINIMUM duration of treatment with apixaban?
Select one:
A. Four weeks
B. Six weeks
C. Two months
D. Three months
E. Six months
Answer: D. Three months
Answer justification and feedback: Direct-acting anticoagulants (DOACs) such as apixaban or rivaroxaban may be initiated in patients with confirmed proximal DVT and continued for at least three months. NICE recommends considering extending the anticoagulant beyond three months for patients with unprovoked proximal DVT if their risk of VTE recurrence is high and there is no additional risk of major bleeding.
Resource: NICE. Venous Thromboembolic Diseases: diagnosis, management and thrombophilia testing. NG158. 2020 (updated 2023).
A 67-year-old patient has some routine blood tests which show the following results. She is well and has no symptoms.
Total WCC 9.0 x10^9/L, Hb 100 g/L, Platelets 170 x10^9/L, MCV normal, Ferritin normal, Folate & B12 normal.
What is the most appropriate next step in this patientʼs management?
Select one:
A. Prescribe iron supplements
B. Faecal immunochemical test (FIT)
C. Refer urgently to Haematology
D. Refer urgently to Gastroenterology
E. No action required
Answer: B. Faecal immunochemical test (FIT)
Answer justification and feedback: This patient has anaemia without iron deficiency and is aged over 60. Therefore she should have a FIT test to look for occult blood which may be caused by a colorectal cancer.
Indications for FIT include: >60 with anaemia in the absence of iron deficiency, >50 with unexplained abdominal pain or weight loss, <60 with change in bowel habit or iron deficiency anaemia.
Resource: NICE. Suspected cancer: recognition and referral. NG12. 2015 (updated 2021).
A 60-year-old man has to fly on a long-distance flight next week lasting more than 16 hours. He is concerned about his risk of developing a DVT as he had a previous travel-related DVT four years ago. He is otherwise fit and healthy.
In addition to advice on general measures, which is the SINGLE MOST appropriate prophylactic medication?
Select one:
A. Aspirin
B. Low molecular weight heparin (LMWH)
C. Dipyridamole
D. Warfarin
E. Clopidogrel
Answer: B. Low molecular weight heparin (LMWH)
Answer justification and feedback: This man is at high risk of a travel-related DVT. Aspirin is not currently recommended. Compression stockings and mobility should be advised.
For those at high risk where travel is essential, LMWH can be offered as prophylaxis in addition to stockings, usually after discussion with a specialist.
Resource: RCGP. Curriculum Topic Guides: Population and planetary health. 2019.
NICE CKS. DVT prevention for travellers. 2018.
SIGN. Prevention and Management of Venous Thromboembolism: a national clinical guideline. 2010.
Cochrane review. Compression stockings for preventing DVT. Cochrane Database 2016; CD004002.
A 65-year-old man presents with back pain and fatigue. You order bloods:
Na 145, K 3.9, eGFR 52, Bilirubin 10, ALP 90, ALT 18, Calcium 2.9 mmol/l, Hb 132, WCC 2.0, PSA 1.2.
What is the most likely diagnosis?
Select one:
A. Osteoporosis
B. Mechanical back pain
C. Pott’s disease
D. Prostate cancer
E. Myeloma
Answer: E. Myeloma
Answer justification and feedback: The patient is over 60 with back pain, hypercalcaemia, and leucopenia, which is consistent with myeloma. According to guidance, this patient should urgently have serum protein electrophoresis and urine Bence-Jones protein testing.
Resource: None specified
A 67-year-old woman presents with fatigue. Bloods:
WCC 9.0, Hb 110 g/l, MCV 70.0 fl, Platelets 170.0, Ferritin 10 ng/ml, Folate 12.0 ng/ml, B12 623 pg/ml.
Which of the following options must be excluded?
Select one:
A. Chronic kidney disease
B. Colorectal cancer
C. Hereditary spherocytosis
D. Pernicious anaemia
E. Haematological malignancy
Answer: B. Colorectal cancer
Answer justification and feedback: This patient has microcytic anaemia with low ferritin — consistent with iron-deficiency anaemia. Colorectal cancer is a common cause. Pernicious anaemia leads to macrocytic anaemia with low B12. Hereditary spherocytosis is less likely and doesn’t explain low iron. Renal and haematological causes typically present differently.
Resource: None specified
A 39-year-old woman attends for results of a full blood count which reveals isolated macrocytosis.
What is the SINGLE MOST likely diagnosis?
Select one:
A. Menorrhagia
B. Bowel cancer
C. Hypersplenism
D. Vitamin B12 deficiency
E. Leukaemia
Answer: D. Vitamin B12 deficiency
Answer justification and feedback: Vitamin B12 and folate deficiencies are common causes of macrocytosis and macrocytic anaemia. The other options are more likely to cause microcytic or normocytic anaemia.
Resource: None specified
A 62-year-old lady has had seven months of back pain. Bloods show mild anaemia and a very mildly raised calcium.
Which SINGLE investigation would be MOST appropriate to aid diagnosis of myeloma?
Select one:
A. ESR
B. Haematinics
C. Magnesium
D. Vitamin D
E. CRP
Answer: A. ESR
Answer justification and feedback: This patient already has anaemia and hypercalcaemia which raise suspicion for myeloma. A raised ESR and a urine Bence-Jones protein test support the diagnosis. People over 60 with back pain should be screened for myeloma.
Resource: Smith S, Parkin H, Renwick S et al. Early detection of myeloma. InnovAiT 2021; 14(7): 415–421.
A patient on warfarin for antiphospholipid syndrome has a raised INR of 6.4 and a history of a brief nosebleed. She is otherwise well.
What is the SINGLE MOST appropriate action?
Select one:
A. Continue warfarin, check INR tomorrow
B. Attend emergency department
C. Emergency medical admission
D. See at out-of-hours centre
E. Stop warfarin, prescribe oral vitamin K
Answer: B. Attend emergency department
Answer justification and feedback: She needs to stop warfarin and attend ED for monitoring and IV phytomenadione (vitamin K). BNF guidance: INR 5.0–8.0 with minor bleeding requires IV vitamin K and stopping warfarin until INR < 5.0.
Resource: BNF. Oral anticoagulants.
A 51-year-old man presents with tiredness, weight loss, erectile dysfunction and bronze skin. Suspect haemochromatosis.
What is the MOST appropriate investigation?
Select one:
A. Anti-smooth muscle antibody
B. Ferritin
C. Anti-mitochondrial antibody
D. Cortisol
E. Ceruloplasmin
Answer: B. Ferritin
Answer justification and feedback: Haemochromatosis is diagnosed with ferritin and transferrin saturation. Anti-mitochondrial and smooth muscle antibodies relate to autoimmune liver disease. Ceruloplasmin is for Wilson’s disease.
Resource: Tang C–M. Abnormal liver function tests. InnovAiT 2019; 12(9): 507–515.
A 47-year-old man has night sweats, weight loss, fever, itchy skin, and a 2 cm non-tender cervical lymph node for 8 weeks.
What is the SINGLE MOST likely diagnosis?
Select one:
A. Motor neuron disease
B. Polycythaemia
C. Hypopituitarism
D. Hypothyroidism
E. Hodgkin’s lymphoma
Answer: E. Hodgkin’s lymphoma
Answer justification and feedback: Hodgkin’s lymphoma can present with systemic B symptoms (night sweats, weight loss), and painless lymphadenopathy. Painful lymph nodes after alcohol intake can also occur.
Resource: None specified
A 20-year-old woman from Thailand reports fatigue. Her periods are controlled by the contraceptive pill. Bloods:
Hb 113, WBC 5.6, Neutrophils 3.0, Platelets 378, MCV 59 fL, MCH 19.7 pg, Ferritin 65.
What is the SINGLE MOST likely cause of her anaemia?
Select one:
A. Chronic disease
B. Haemoglobinopathy
C. Iron deficiency
D. Haemolysis
E. Vitamin B12 deficiency
Answer: B. Haemoglobinopathy
Answer justification and feedback: This case suggests a haemoglobinopathy such as beta thalassaemia, which is more common in Southeast Asia. Beta thalassaemia can produce low haemoglobin and low MCV with a normal ferritin level. Iron deficiency would show low ferritin.
Resource: None specified
An 8-year-old boy presents with fatigue, pallor and easy bruising. On exam: petechiae and systolic murmur.
What is the MOST appropriate next step?
Select one:
A. Urgent echocardiogram
B. Same-day paediatric assessment
C. Routine paediatric referral
D. Two-week wait referral
E. Urgent blood test within 48 hours
Answer: B. Same-day paediatric assessment
Answer justification and feedback: This child has signs of acute leukaemia (pallor, petechiae, bruising). NICE recommends immediate specialist assessment in children with unexplained petechiae or hepatosplenomegaly.
Resource: NICE. Suspected cancer: recognition and referral. NG12. 2015 (updated 2021).
A 40-year-old male nurse reports fatigue and intermittent diarrhoea. Routine bloods show mild iron deficiency anaemia.
What is the SINGLE MOST appropriate investigation?
Select one:
A. Coeliac screen
B. Gastroscopy
C. PHQ-9
D. Bone marrow
E. Serum amylase
Answer: A. Coeliac screen
Answer justification and feedback: Coeliac disease should be excluded. IgA transglutaminase antibody is the test of choice. If rectal bleeding was present, a cancer pathway referral might also be warranted.
Resource: None specified
A 76-year-old man with atrial fibrillation and type 2 diabetes is on warfarin.
What is his SINGLE TARGET international normalised ratio (INR)?
Select one:
A. 2
B. 2.5
C. 3
D. 3.5
E. 4
Answer: B. 2.5
Answer justification and feedback: Patients with AF and CHA2DS2-VASc score ≥ 1 are considered for anticoagulation. Warfarin can be used if DOACs are not suitable. The target INR is 2.5 (range 2.0–3.0).
Resource: None specified
A 25-year-old woman seeks investigations due to a family history of haemophilia A.
Which ONE investigation is most likely to be abnormal?
Select one:
A. Full blood count
B. Prothrombin time
C. Activated partial thromboplastin time (aPTT)
D. Von Willebrand factor
E. Platelet count
Answer: C. Activated partial thromboplastin time
Answer justification and feedback: Patients with haemophilia A typically have a prolonged activated partial thromboplastin time (aPTT). Other parameters are usually normal.
Resource: None specified
A 67-year-old woman is diagnosed with vitamin B12 deficiency.
Which ONE of the following abnormal haematological results would be most typical in vitamin B12 deficiency?
A. Hb 107 g/L, MCV 77 fL
B. Hb 109 g/L, MCV 102 fL
C. Hb 110 g/L, MCV 89 fL
D. Hb 168 g/L, MCV 92 fL
E. Hb 170 g/L, MCV 103 fL
Answer: B. Hb 109 g/L, MCV 102 fL
Justification and Feedback: Typically, vitamin B12 deficiency will show a macrocytic anaemia on a blood film. However, if there is associated iron deficiency or other factors then this may alter the typical picture.
Which ONE of the following statements is true about the absorption of oral iron?
A. Taking iron more frequently helps absorption
B. Taking iron with tea inhibits absorption
C. Iron absorption is enhanced by the hormone hepcidin
D. Vitamin C is recommended to increase iron absorption
E. Iron absorption increases if it is taken with food
Answer: B. Taking iron with tea inhibits absorption
Justification and Feedback: Iron absorption reduces if the iron is taken within 60 minutes of intake of food or tea. Hepcidin increases after oral iron intake and inhibits further absorption. Vitamin C supplementation does not improve iron absorption outcomes.
Resources:
- BSG Guidelines for the Management of Iron Deficiency Anaemia in Adults (2021)
- JAMA Netw Open 2020; 3(11): e2023644
A 50-year-old woman becomes acutely breathless after a knee replacement.
What is the MINIMUM time period you would advise her to remain on apixaban?
A. 12 months
B. 4 weeks
C. 6 weeks
D. 6 months
E. 3 months
Answer: E. 3 months
Justification and Feedback: Treatment is continued for at least 3 months after a provoked PE if the course is uncomplicated and the provoking factor has resolved.
Resource: NICE NG158 (2020, updated 2023)
A 43-year-old man with thalassaemia had a splenectomy.
Which antibiotic is MOST appropriate for prophylaxis?
A. Phenoxymethylpenicillin
B. Doxycycline
C. Ciprofloxacin
D. Flucloxacillin
E. Erythromycin
Answer: A. Phenoxymethylpenicillin
Justification and Feedback: Prophylaxis with phenoxymethylpenicillin is recommended after splenectomy for at least 2 years.
Resource: Wong J. Thalassaemia. InnovAiT 2022; 15(3): 145–153
