Hematology Oncology II Flashcards
What is the initial step in management for a patient with suspected epidural spinal cord compression?
IV glucocorticoids
glucocorticoids should be administered before MRI
What is the likely diagnosis in a chronic smoker that presents with dyspnea, weight loss, and face/arm swelling that is worst in the morning?
SVC syndrome
malignancy is the most common cause (often lung cancer and non-Hodgkin lymphoma); may also occur due to fibrosing mediastinitis or thrombosis from indwelling central venous catheters
What is the likely diagnosis in a middle-aged patient with pancytopenia and splenomegaly without lymphadenopathy and the peripheral smear below?
Hairy cell leukemia
What is the likely diagnosis in a patient that develops a fever, chills, and malaise two hours after starting RBC tranfusion? Coombs test is negative.
Febrile non-hemolytic transfusion reaction
due to cytokines released by residual leukocytes; the direct antiglobulin test is positive and plasma free hemoglobin is > 25 mg/dL in acute hemolytic reactions
What is the likely diagnosis in a patient that develops fever/chills, flank pain, hemoglobinuria, and DIC 30 minutes after starting RBC tranfusion?
Acute hemolytic transfusion reaction
hemoglobinuria is a helpful clue that you’re dealing with an acute hemolytic transfusion rather than an allergic reaction
What is the likely diagnosis in a patient that develops wheezing, respiratory distress, and hypotension minutes after reciving a pRBC transfusion?
Anaphylactic reaction
more common in individuals with IgA deficiency
What is the likely diagnosis in a patient that presents 5 days post-CABG with large purple-black patches surrounded by erythema in the periumbilical area by sites of heparin injection?
Type 2 heparin-induced thrombocytopenia (HIT)
HIT should be suspected if there is a drop in platelets by > 50% or a new thrombus within 5-10 days of heparin initiation (may occur earlier in patients previously exposed to heparin)
What is the likely diagnosis in a patient that received a bone marrow transplantation from a sibling that develops a maculopapular rash, bloody diarrhea, and elevated LFTs after two weeks?
Graft-versus-host disease (GVHD)
due to recognition of host HLA-antigens by donor T-cells; typically affects the skin, intestine, and liver
What is the likely diagnosis in a patient with a facial rash that worsens with sun exposure and a history of DVT and 2 miscarriages?
Anti-phospholipid syndrome
more common in patients with SLE but can occur on its own; diagnosis requires clinical symptoms and presence of an antibody (e.g. antiphospholipid, anticardiolipin, or beta-2 glycoprotein-1 antibody)
What is the likely diagnosis in a patient with a history of prostate cancer that presents with severe back pain, decreased lower extremity DTRs, and urinary retention?
Epidural spinal cord compression
What is the likely diagnosis in a patient with a signficant smoking history that presents with daytime headaches, dizziness, and nausea? CBC reveals elevated hemoglobin levels. The patient works in a parking garage.
Carbon monoxide poisoning
chronic tissue hypoxia stimulates the kidney to produce more EPO, resulting in secondary polycythemia
What is the likely diagnosis in a patient with abdominal pain, dark urine, and hepatic vein thrombosis with evidence of hemolytic anemia on laboratory exam?
Paroxysmal nocturnal hemoglobinuria
the combination of hemolytic anemia, cytopenias, and hypercoaguable state is suspicious for PNH
What is the likely diagnosis in a patient with acute lymphoblastic leukemia that develops premature ventricular beats and acute kidney injury after initiating chemotherapy?
Tumor lysis syndrome
What is the likely diagnosis in a patient with anemia, painful osteolytic lesions, hypercalcemia, and recurrent infections?
Multiple myeloma
manifestations of MM may be remembered with the mnemonic CRAB: hyperCalcemia, Renal complications, Anemia, Bone lytic lesions
What is the likely diagnosis in a patient with brownish skin pigmentation, elevated fasting glucose, and elevated LFTs?
Hereditary hemochromatosis
other common manifestations include hypogonadism, arthralgias, and hepatomegaly
What is the likely diagnosis in a patient with epistaxis, red blanchable papules on the lips, digital clubbing and isolated polycythemia on laboratory exam?
Hereditary telangiectasia (Osler-Weber-Rendu syndrome)
associated with widespread AV malformations; AVMs in the lung can result in right-to-left shunting with chronic hypoxemia (clubbing), reactive polycythemia, and hemoptysis
What is the likely diagnosis in a patient with hemolytic anemia with an increased MCHC and negative Coombs test?
Hereditary spherocytosis
increased MCHC is classic for hereditary spherocytosis
What is the likely diagnosis in a patient with night sweats, weight loss, and splenomegaly? Laboratory exam reveals leukocytosis with increased levels of basophils and myelocytes.
Chronic myeloid leukemia
high myelocyte count and basophilia favors diagnosis of CML > leukemoid reaction (normal basophil levels and higher metamyelocyte count)
What is the likely diagnosis in a patient with pruritus, especially after bathing, splenomegaly, headaches, and pancytosis on laboratory exam?
Polycythemia vera
almost always caused by a JAK2 mutation
What is the likely diagnosis in a patient with recurrent hemarthrosis after mild trauma and a family history significant for a maternal uncle with a similar issue?
Hemophilia A or B
i.e. factor VIII or IX deficiency, respectively
What is the likely diagnosis in a young adult female with prolonged bleeding and ecchymoses and isolated thrombocytopenia on laboratory exam?
Idiopathic thrombocytopenic purpura (ITP)
diagnosis of exclusion; due to production of IgG autoantibodies against platelet membrane glycoproteins
What is the likely diagnosis in a young adult with worsening knee pain refractory to NSAID therapy and an expansile lytic area in the epiphysis of the distal femur identified on X-ray?
Giant cell tumor of bone (osteoclastoma)
X-ray demonstrates classic “soap-bubble” appearance
What is the likely diagnosis in a young male that presents with irritability, aggressive behavior, and gynecomastia with isolated polycythemia on laboratory exam?
Androgen abuse
mechanism underlying polycythemia is not well understood
What is the likely diagnosis in an adult African-American patient that presents with splenomegaly and scleral icterus two weeks after having a URI treated with amoxicillin? Peripheral blood smear reveals spherocytosis.
Autoimmune hemolytic anemia
sickle cell disease is less likely given the splenomegaly and spherocytes; AIHA may be precipitated by viral infections and penicillins
What is the likely diagnosis in an African-American male that develops dark urine, fatigue, and jaundice after being treated with TMP-SMX? Peripheral smear reveals bite cells, but a G6PD activity assay is normal.
G6PD deficiency
most erythrocytes with severe G6PD deficiency are hemolyzed early during the acute episodes, thus the G6PD assay may initially be abnormally normal; it is best to wait 3 months after the episode before re-testing
What is the likely diagnosis in an African-American male that presents with fever, jaundice, dark urine and the peripheral smear below?
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
What is the likely diagnosis in an African-American patient that presents with polyuria and nocturia? Serum Na+ levels and urinalysis are normal.
Hyposthenuria (secondary to sickle cell trait)
i.e. inability of the kidney to concentrate urine due to RBC sickling in the vasa rectae of the inner medulla, which impairs countercurrent exchange and free water absorption (also occurs with sickle cell disease); normal serum Na+ levels helps differentiate from diabetes insipidus (high Na+) and primary polydipsia (low Na+)
What is the likely diagnosis in an alcoholic patient that begins bleeding from an IV site on post-operative day 7 after having an emergency surgery? Laboratory exam reveals anemia with elevated PT/PTT and normal platelet counts.
Vitamin K deficiency
acutely ill patients with underlying liver disease can become vitamin K deficient in 7 - 10 days
What is the likely diagnosis in an alcoholic vegan patient being treated with thiamine and folate for anemia that develops recurrent falls and increasing forgetfulness?
Vitamin B12 deficiency/subacute combined degeneration
folic acid supplementation for patients with vitamin B12 deficiency leads to rapid progression of neurologic complications
There is a risk that if folic acid is given to people who have undiagnosed deficiency of vitamin B12 it may lead to neurological damage. Vitamin B12 deficiency produces both an anaemia identical to that of folate deficiency but also causes irreversible damage to the central and peripheral nervous systems. Folic acid will correct the anaemia of vitamin B12 deficiency and so delay diagnosis but will not prevent progression to neurological damage. For this reason trials of folic acid supplements may involve simultaneous administration of vitamin B12.
What is the likely diagnosis in an asymptomatic Italian male that is found to have microcytic anemia with an abnormally high HbA2 on routine laboratory testing?
Beta-thalassemia minor
common in those of Mediterranean descent; think about thalassemia if a microcytic, hypochromic anemia doesn’t respond to iron therapy
What is the likely diagnosis in an elderly patient that presents with headaches, blurry vision, hepatosplenomegaly? Serum protein electrophoresis reveals a sharp M-spike of IgM.
Waldenstrom macroglobulinemia
typically presents with symptoms of hyperviscosity, neuropathy, and cryoglobulinemia
What is the likely diagnosis in an elderly patient with recurrent infections and with hepatosplenomegaly, lymphadenopathy, and marked lymphocytosis on physical/laboratory exam?
Chronic lymphocytic leukemia (CLL)
recurrent infection due to hypogammaglobulinemia from monoclonality
What is the likely diagnosis in an elderly patient with significant smoking history that presents with a hard, non-tender submandibular lymph node and occasional ear pain? Physical exam is otherwise unremarkable.
Squamous cell carcinoma
non-tender, solitary nodes in the head and neck in a patient with a significant smoking history are most likely to be SCC
What is the likely underlying cause of anemia in a patient with a history of gastrectomy that presents with a shiny tongue, pale palmar creases, and laboratory evidence of hemolysis?
Vitamin B12 deficiency (impaired DNA synthesis)
deficiency due to loss of intrinsic factor; high numbers of immature megaloblasts in the bone marrow results in increased intramedullary hemolysis, thus causing indirect hyperbilirubinemia and elevated LDH
What is the likely underlying cause of microcytic anemia in a patient with chronic kidney disease that recently began erythropoietin therapy?
Iron deficiency
the erythropoietin-induced surge in RBC production can precipitate iron deficiency
What is the likely underlying cause of vitamin B12 deficiency in a Caucasian male with fatigue, atrophic glossitis, vitiligo, and a vegan diet x5 months?
Pernicious anemia
pernicious anemia is the most common cause of vitamin B12 deficiency; it would take 4 - 5 years of a vegan diet before B12 deficiency develops
What is the likely underlying etiology of anemia in an elderly patient with fatigue, lymphadenopathy, and splenomegaly?
Bone marrow infiltration (e.g. lymphoma, leukemia)
