Haematology PPQs Flashcards
Which feature is most characteristic of acute lymphoblastic anaemia (ALL)?
a. Anaemia and thrombocytopenia
b. Neutrophilia
c. Macrocytosis
d. Raised lymphocytes
Raised lymphocytes
Which of the following is expressed by vessel walls in their resting state and is anti-thrombotic?
a. Tissue factor
b. Thrombomodulin
c. Von Willebrand factor
Thrombomodulin
A man has gout and is kept up at night by it. His symptoms are relieved by ibuprofen, but when he stops taking it, the symptoms come back. His neighbour is on allopurinol, and he would like to be on it too. Which of these medications would need to be altered for them to be able to be prescribed allopurinol?
Mercaptopurine/ azathioprine
There are 5 special drug treatments. Which drug can be used to treat some malignancies and affects T cell activity?
a. Infliximab
b. Pembrolizumab (anti PD-1 on lymphocytes)
c. Rituximab
Pembrolizumab
What is targeted in Graft vs Host disease?
a. HLA
b. pre-existing antibodies in the recipient
c. mast cell degranulation
d. ischaemia of the donated organ
HLA
Which/What cancer can the Bruton Tyrosine kinase inhibitor ibrutinib be used in?
a. Chronic myeloid leukaemia (CML)
b. Acute myeloid leukaemia (AML)
c. Acute lymphoblastic leukaemia (ALL)
d. Chronic lymphoblastic leukaemia (CLL)
CLL
HTLV1 Virus lymphoma
Adult T cell lymphoma
Sickle cell patient, spleen not felt. Low reticulocytes, very anaemic.
a. Parvovirus B19
b. Splenic sequestration
c. Normal for SCD
d. Sickle cell crisis
Parvovirus B19
Red cell lysis, what ion is raised:
a. Potassium
b. Sodium
c. Calcium
d. Bicarbonate
Potassium
Acquired MAHA. What do you see?
a. Dat +ve spherocytes
b. Dat +ve fragments
c. Dat -ve spherocytes
d. Dat -ve fragments
e. Dat +ve smear cells
Dat -ve fragments
Lady has newborn baby. Dat +ve, spherocytes seen. Baby jaundiced. Lady is Group A Rhesus negative, Baby is Group O Rhesus positive. Why is baby jaundiced?
a. Hereditary spherocytosis
b. G6PD
c. ABO incompatibility
d. Rhesus disease
Rhesus disease
Treatment for CLL with p53 mutation. What is the first line treatment?
Ibrutinib BTK inhibitor
What is the mechanism of hyperacute allograft rejection?
Pre-formed antibodies attach the graft endothelium
Man with cyanotic heart disease has a haematocrit of 54% (high) and is found to be negative for JAK2 mutation, what is the cause of the high haematocrit?
Secondary polycythaemia
Transfusion threshold for platelets after trauma necessitating massive transfusion?
<10 <25 <75 <140
<75
What is the first-line treatment for CML
Imatinib
Bortezomib is a proteasome inhibitor, how does this work?
Inhibits intracellular protein degradation, build-up and amino acid shortage kills cell
A patient required an aortic valve replaced 3 months ago. They have now come back a few weeks later with jaundice, Hb-urea (haemoglobinuria), and raised reticulocytes. What is the cause?
Valve associated haemolytic anaemia
An African man with Burkitt’s lymphoma is given Rasburicase. He develops haematuria with irregularly contracted cells. What is the cause?
G6PD deficiency
A patient has a massive splenomegaly, and JAK2 V617F mutation with a leucoerythroblastic picture and tear-drop poikilocytes. What do they have?
Myelofibrosis
Person who had negative direct coombs test but who has anaemia (low Hb), and jaundice
MAHA
Person who had a DVT many years ago (or recurrent DVTs), presents with recurrent dark bruising, and swelling over the course of 5 years, and now had pain in their leg. What is the possible cause?
Post-thrombotic syndrome
Which coagulation factor is decreased first on administration of warfarin?
Factor 7
Lady with Multiple myeloma and restrictive cardiomyopathy. What will you see on heart biopsy?
Amyloid deposition
What additional virus apart from HIV and HBV are screened for in platelet donations to pregnant women?
CMV
Patient with low WCC and Plt and teardrop cells on film?
Myelofibrosis
A patient with renal impairment is on low molecular weight heparin, what do you measure to monitor this?
Anti-Xa assay
56 y/o lady with SLE, has spherocytes, low Hb, raised bilirubin how do you test for diagnosis? DAT or Osmotic fragility?
DAT because she has AIHA due to SLE
Cause of Neonatal thrombocytopenia?
Maternal idiopathic thrombocytopenia purpura
Which of these options causes DIC (in pregnancy)
Amniotic fluid embolism
An overweight individual with diabetes has longstanding bone/back pain. They are found to have paraprotein IgA ~8g/dl, and GFR 55mls/min/1.73m^2. FBC normal and albumin normal
Monoclonal gammopathy of undetermined significance
A German lady who is asymptomatic, has low neutrophils, but no abnormal cells on film
Chronic idiopathic neutropenia
Patient with IgM paraprotein and visual disturbances
Lymphoplasmacytic lymphoma (Waldenstrom’s macroglobulinaemia)
A man has spherocytes, polychromasia and reticulocytosis on blood film
Hereditary spherocytosis
An African lady’s doctor requests a sickle cell solubility test, after blood tests show low Hb and normal MCV. The test comes back positive with some clouding of the tested blood. What is the diagnosis?
Sickle cell trait
Haemolysis after antimalarials / malaria treatmen
G6PD deficiency
wafarin monitoring patient with AF
INR 2-3
INR target in Pt with prosthetic valve and AF
Pt with prosthetic valve and AF – INR 3-4
Someone having continuous unfractionated heparin monitoring?
aPTT
Myeloma complications:How would you manage each of the following complications? Hyperviscosity
Plasmapheresis
Myeloma complications:How would you manage each of the following complications? Prevention of pathological bone fractures
Bisphosphonates
Myeloma complications:How would you manage each of the following complications? :Spinal cord compression
Radiotherapy
Which test is used to detect beta thalassaemia?
High performance liquid chromatography
Reduced platelets in first trimester (24 x10^9/L)
ITP
A thalassemia patient presents with malaise and erectile dysfunction
– Transfusion-related haemosiderosis
Signs of acquired haemolytic anaemia?
Borderline raised MCV
High bilirubin
High LDH
Macrocytic anaemia
Expected results of obstructed jaundice
Very high ALP
Spherocytes are seen on a peripheral blood film?
DAT positive autoimmune haemolytic anaemia
AIHA first line treatment?
Prednisolone
DAT positive acquired haemolytic anaemia may be seen in associated with what?
CLL
Also alongside SLE and RA
In a patient with bilateral cervical lymphadenopathy - which disease would not be a differential?
Multiple myeloma
Multiple myeloma never has lymphadenopathy
It’s a disease of the bone marrow
Protein affects the kidneys and damage to bones such as spinal column etc.
Which of the following is not associated with a widened mediastinum?
Teratoma
Thymoma
Hodgkin lymphoma
B cell ALL
B cell non hodgkin lymphoma
B cell ALL
Treatment for Stage 1A Hodgkin lymphoma?
Chemotherapy, >80% cure rate
How is staging established in hodgkin lymphoma?
CT scan
Buzzwords for lung adenocarcinoma?
EGFR, ALK-1
Tumour markers in melanoma?
BRAF
Tumour markers for colon cancer?
APC, KRAS
Hurtle cells are seen in which condition?
→ Hashimoto’s thyroiditis
Psammoma bodies are seen in which thyroid cancer?
Papillary thyroid tumour
Lifting of the periosteum indicates which disease?
osteomyelitis
Soap bubble osteolysis
Fibrous dysplasia
Chinese letters
fibrous dysplasia
Shepherd’s crook deformity
Fibrous dysplasia
Codman’s triangle buzzword for what?
osteosarcoma
Onion skinning of periosteum buzzword for what?
Ewing’s sarcoma (in adolescence, very malignant!)
Small round blue cells?
Neprhoblastoma
Nests of epithelial cells?
Renal clear cell carcinoma
Cytokeratin immunofluorescence?
Epithelial marker
CD45 immunofluorescence
Lymphoid marker
Spotty necrosis + inflammatory infiltrate ?
Acute hepatitis
Portal inflammation, interface hepatitis (piecemeal necrosis), lobular inflammation?
Chronic hepatitis
concentric “onion skin” fibrosis around the bile duct and loss of bile ducts?
PSC??
Pancreatic calcification on abdo Xray
Chronic pancreatitis
White foci?
Fat necrosis in acute pancreatitis
Scoring System for renal cell carcinoma?
Renal cell carcinoma
Scoring system for metastatic melanoma?
Breslow thickness
Bacterial culture for H.Influenzae?
Chocolate agar
What is the Silver Stain for?
Pneumocystis Jirovecii
Auramine/Rhodamine stain for what?
Myobacterium TB
Charcoal Yeast stain is used for what?
Legionella Pneumophila
T(15:17)
PML
Tear drop poikilocytes
leukoerythroblastic anaemia, bone marrow infiltration
17p deletion
Bad prognosis in CLL
Skin pigmentation, leukoplakia, nail dystrophy + BM failure
Dyskeratosis Congenita
Japanese, caribbean, HTLV-1
Adult T cell leukaemia/lymphoma
BCL-2
→ Follicular lymphoma
Sudan black, myeloperoxidase
stain for myeloblasts (AML)
CD19, CD20 are markers for what cell?
B cell
CD138 are a marker of what cell?
Myeloma (plasma cells)
CD5+ and CD19+ are a marker of what?
Immature B cells
Just CD5
Mature B cells
TRAP (tartrate-resistant acid phosphatase), CD25 are seen in what?
Hairy Cell Leukaemia (CLL subtype)
Which malignant are eosinophils seen in?
Hodgkin’s
Which stain is used for melanin?
Fontana stain
Stain for Wilson’s disease?
Rhodanine
What is red degeneration?
Complication of fibroids in pregnancy. Red degeneration is one of the MOST COMMON complications of fibroids in pregnancy. Fibroids grow in pregnancy due to the hormones. As it grows, the fibroid can become ischaemic.
This manifests as acute pain, tenderness over the fibroid and vomiting
If severe, it can precipitate uterine contractions causing miscarriage or preterm labour
This requires treatment with potent analgesics (opiates) and IV fluids
Symptoms usually settle after a few days
How is red degeneration of fibroids diagnosed?
History and USS
How is retroversion of the uterus managed?
Urinary catheterisation. Leads to urinary retention until the location of the uterus changes.
Definition of UTI?
DEFINITION: > 105 colony forming units/mL in urine culture
Risk factors for VTE in pregnancy?
Obesity, previous DVT, thrombophilia, maternal age >35, severe varicose veins, smoking, multiple gestation, pre-eclampsia, prolonged bed rest
Anti-phospholipid syndrome (APS)
APS is the combination of lupus anticoagulant with or without anticardiolipin antibodies, with a history of recurrent miscarriage and/or thrombosis. It may be associated with SLE.
Women with a history of thrombotic events should be screened for thrombophilia.
If thrombophilia is present, thromboprophylaxis should be considered.
PE diagnosis
PE
Usually presents with mild SOB or inspiratory chest pain
The woman may be slightly tachycardic with mild pyrexia
More rarely, massive PE could cause sudden cardiorespiratory collapse
If suspected, ECG, CXR and ABG should be performed to exclude other diagnoses
You may investigate the presence of DVT using ultrasound
If PE is strongly suspected, a VQ scan or a CTPA may be performed
NOTE: D-dimer levels are physiologically elevated in pregnancy
First-line for DVT in pregnancy?
Compression ultrasound is the first investigation used in suspected DVT
How is the dose of LMWH calculated?
The therapeutic dose should be calculated based on the woman’s booking or early pregnancy weight
Treatment for massive PE?
Options include IV unfractionated heparin, thrombolytic therapy, thoracotomy or surgical embolectomy
IV unfractionated heparin is the preferred initial treatment in massive PE with cardiovascular compromise
Urgent portable echocardiogram or CTPA should be arranged
If massive PE is confirmed, immediate thrombolysis should be considered.
When should LMWH be stopped before delivery?
If delivery is planned, LMWH should be discontinued 24 hours before
Women who are at HIGH RISK OF HAEMORRHAGE who require continuous heparin should be managed with what?
IV unfractionated heparin
Prevention of Post-Thrombotic Syndrome
Prolonged use of LMWH (> 12 weeks) is associated with lower risk of post-thrombotic syndrome
Graduated elastic compression stockings also reducer risk
If alcohol abuse in pregnancy is suspected what should be done?
It may be necessary to involve social workers and arrange for formal psychiatric/addiction assessment
Definition of Polyhydramnios?
Commonly defined as AFI > 95th centile for gestation
Which type of breech is particularly high risk for vaginal delivery?
Footling
If extended, they may need to be delivered with what manoeuvre?
Pinnard’s manoeuvre
Management of Rhesus Disease in a Sensitised Woman
Middle cerebral artery Doppler scans - correlate with fetal anaemia
ABO incompatibility disease?
Occurs when the mother is group O and the baby is A or B
Diagnosis of hyperemesis gravidarum?
Diagnosed when there is a triad of:
More than 5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance
Severity should be assessed using Pregnancy-Unique Quantification of Emesis (PUQE)
Mild
MDT and discharge in hyperemesis gravidarum?
MDT: Can gain valuable input from midwives, nurses, dieticians, pharmacists, endocrinologists, nutritionists, gastroenterologists and a mental health team
Discharge:
Provide an individualised management plan
If symptoms continue into second and third trimester, should offer serial scans to monitor foetal growth
Advise about a risk of recurrence in future pregnancies
Other
Assess mental health status (refer to psychological support if necessary)
Advise adequate resting
Investigation for allergy
Test 1: Skin prick allergy testing (supports an allergy-focussed history and can confirm diagnosis); OR
o Test 2: Measurement of specific IgE antibodies (RAST)
Classification for croup?
Westley score classification
Difference between episodic and chronic migraine?
episodic = <15 days a month
Chronic = >15 days a month
stepwise management of migraine?
1st. paracetamol/ibuprofen
2nd. Nasal sumatriptan
3rd. Combination of the two
Consider anti-emetics (metoclopramide or prochlorperazine)
Follow-up in 1 month or return if symptoms worsen
Prophylaxis:
* Topiramate (risk of foetal malformations)
* Propranolol (not in asthmatics)
Investigations for migraine?
Identify cause - emotional problems (i.e. bullying), general health, etc.
· Consider headache diary (8 weeks) Optician referral
· Consider psychiatry referral, weight, height, BP
Ix for developmental delay?
Investigations:
o Metabolic, genetic, infection screen
IQ test
o ASD or ADHD testing
Presentations of NAI
Variety of Presentations:
o Bruising (on non-contact areas) Broken bones (spiral fractures of long bones; non-ambulant)
o Drowsiness (subdural haematoma) Neglect (unkempt)
o Failure to thrive STIs, recurrent UTIs
o History not consistent Torn frenulum labii superioris (tongue)
o Glove and stocking burn Anal fissures, encopresis
Investigations:
o Full body ± skeletal survey (have to note ALL blemishes on child’s body on a body map)
o Check Child Protection Register
o CT head scan
o Bloods and bone profile (rule out leukaemia, ITP, haemophilia)
o Fundoscopy (retinal haemorrhages)
Who is involved in NAI?
Who to get involved?
o Senior colleagues
o Named doctor for child protection
o Contact social services and make a formal referral
o Consider contacting the police (Child Abuse Investigation Team / CAIT)
Convene a case conference Place child’s name on child protection register
Give support to parents Ask for regular follow-up by paediatricians
o Consider contacting Multi-Agency Safeguarding Hub (MASH)
Includes a variety of people that help manage different aspects of a child’s life
What do you initially give a fitting child?
Oxygen - buccal midazolam if it continues over 5 minutes
hereditary spontaneous lip swelling and bilateral periorbital oedema
C1 esterase inhibitor deficiency (hereditary angioedema)
What can be used to diagnose post-streptococcus glomerulonephritis?
C3 and C4 levels?
Evanescent salmon pink rash: dx?
Listeriosis (neonate)
o Juvenile idiopathic arthritis
Management – cover for potential toxic shock syndrome?
Ceftriaxone + clindamycin
Describe lochia
Lochia
This is blood-stained uterine discharge comprising of blood and necrotic decidua
Only the top layer of decidua is sloughed off
THREE types of Lochia
Lochia Rubra - red coloured during the first few days after delivery (gradually changes to pink)
Lochia Serosa - becomes serous by the 2nd week
Lochia Alba - scanty yellow-white discharge lasting for 1 month
Treatment for perineal tear
Local cooling and topical anaesthetics (e.g. 5% lignocaine) provide short-term symptomatic relief
Regular paracetamol can offer effective analgesia
Diclofenac may also be added
Perineal tear infection ix?
Swabs for culture should be taken if infection is suspected and antibiotics should be started
Collections of pus should be drained
Spontaneous opening of repaired perineal tears and episiotomies is usually due to infection
Surgery can only be performed if there is no infection present
Treatment to prevent constipation after 3rd/4th degree tears?
These women should receive lactulose and ispaghula husk (Fybogel) or methylcellulose immediately after the repair, for a period of 2 weeks
Endometritis vs Retained products of conception
Endometritis - lower abdominal pain and a tender uterus with a closed internal os
Retained products of conception - crampy lower abdominal pain, a uterus larger than appropriate, open internal os and a history of a prolonged 3rd stage of labour
If the bleeding is HEAVY, they may require:
IV fluids or blood
Strong oxytocics (e.g. ergometrine)
Uterine evacuation
Antibiotics (if placental tissue is found)
If there is NO clear diagnosis, expectant management with empirical antibiotics is usually used
Other causes of secondary PPH:
Hormonal contraception
Bleeding disorders (e.g. von Willebrand disease)
Choriocarcinoma (RARE)
Genital Tract Infection/Puerperal Sepsis
Genital tract infection following delivery is called puerperal sepsis
NOTE: old names include milk fever, childbed fever
Aetiology
Mixed flora of low virulence normally colonises the vagina
Puerperal infection is usually polymicrobial and involve contaminants from the bowel
Placental separation exposes a large raw area (like an open wound)
Vaginal delivery is almost inevitably going to cause some lacerations in the genital tract
Prevention
Increased awareness of hygiene
Good surgical approach
Use of aseptic techniques
C-section patients should receive prophylactic antibiotics
A single intraoperative dose of antibiotics (co-amoxiclav or cephalosporin with metronidazole) is given before the skin incision
Management of puerperal sepsis?
MANAGEMENT
Mild to moderate infections can be treated with broad-spectrum antibiotics (e.g. co-amoxiclav or cephalosporin + metronidazole)
In SEVERE infections, the release of vasoactive mediators can lead to septic or endotoxic shock
Immediate high-dose, broad-spectrum antibiotics and IV fluid resuscitation should be given in an HDU
Necrotising fasciitis is rare but can arise from perineal tears, episiotomis and C-section wounds
Clostridium perfringens is usually identified
General signs of infection will be accompanied by extensive necrosis, crepitus and inflammation
Wide debridement of necrotic tissue under GA is absolutely essential to avoid mortality
Risk of reccurrance of puerperal psychosis?
Risk of recurrence in future pregnancy is 1 in 2
Women with previous puerperal psychosis should be considered for prophylactic lithium
