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NEW HAEM 2 Flashcards

1
Q

Multiple myeloma aetiology

A

Malignant proliferation of plasma cells
Increased production of Ig - Paraproteins
Accumulation in the renal system - Bence-Jones proteins

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2
Q

Multiple myeloma clinical features

A

CRAB-E

Calcium - Hypercalcaemia - Increased osteoclast activity

  • GROANS
  • STONES
  • MOANS
  • THRONES
  • BONES

Renal (AKI) - Light chain deposition within renal tubules - Bence-Jones protein

  • Dehydration
  • Increasing thirst

Anaemia - Pancytopenia

Bones - BM infiltration by plasma cells + Cytokine mediated osteoclasts

  • Lytic bone lesions
  • Back pain
  • Fragility fractures
  • Raindrop skull

ESR ^ - Increased risk of VTE

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3
Q

Multiple myeloma investigations

A 
BM biopsy - Monoclonal plasma cells
Serum/urine electrophoresis - Monoclonal paraprotein
Calcium profile - Isolated calcium ^
U&E - Urea/creatinine ^
FBC - Pancytopenia
ESR
Blood film - Rouleaux formation

Skeletal survey - WBCT / MRI

  • Raindrop skull - Numerous dark spots seen on XR
  • Osteopenia
  • Osteolytic lesions
  • Pathological fractures
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4
Q

Multiple myeloma diagnosis

A
  1. Monoclonal plasma cells in BM
  2. Monoclonal proteins within serum/urine on electrophoresis
  3. Evidence of end-organ damage - Hypercalcaemia, AKI, etc.
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5
Q

Multiple myeloma management

A

Induction therapy
BM transplant

Manage symptoms

  • Hypercalcaemia - Hydrate + Bisphosphonates
  • Hyperviscosity - VTE prophylaxis (Aspirin)
  • Renal - Hydrate
  • Infections - Vaccinations + Ig
  • Fatigue - EPO
  • Pain - Analgesia
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6
Q

Hodgkin’s lymphoma aetiology

A

Malignant proliferation of lymphocytes
20-30
60-70

Risk factors

  • Family history
  • T-cell disorders
  • EBV
  • H.Pylori
  • Ionising radiation
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7
Q

Hodgkin’s lymphoma clinical features and investigations

A 
Painless lymphadenopathy - More painful after drinking alcohol
SOB
Cough + Haemoptysis 
Hepatosplenomegaly 
B-symptoms

Investigations

  • FBC - Hb and Pt - Low
  • ESR ^
  • CXR - Mediastinal mass
  • PET-CT - Staging
  • USS + Lymph node biopsy - Reed Sternberg cells
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8
Q

Hodgkin’s lymphoma staging and management

A 
Ann-Arbor classification
1. Single lymph node
2. 2 or more lymph nodes on the same side of the diaphragm
3. Nodes on either side of the diaphragm
4. Metastatic spread beyond lymph nodes
A. No systemic symptoms
B. Systemic symptoms

Management - Chemo/Radio - ABVD

  • Doxorubicin - Adriamycin
  • Bleomycin
  • Vinblastine
  • Dacarbazine
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9
Q

Non-Hodgkin’s lymphoma aetiology

A

Malignant proliferation of lymphocytes
B-cells or T-cells
1/3 cases over the age of 75

Risk factors

  • Caucasian
  • History of viral infection - EBV
  • Family history
  • Certain chemical agents - Pesticides / solvents
  • Chemo/Radio
  • Immunodeficiency - Transplant, HIV, DM
  • AI disease - Sjogren’s, SLE, Coeliac
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10
Q

NHL clinical features

A

Painless lymphadenopathy
Hepatosplenomegaly
Testicular mass

B-symptoms

Extranodal disease - More common in NHL

  • Gastric - Dyspepsia, dysphagia, weight loss, abdo pain
  • Bone marrow - Pancytopenia, bone pain
  • Lungs
  • Skin
  • CNS - Nerve palsies
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11
Q

NHL investigations and management

A

FBC - Pancytopenia
Blood film - Nucleated RBCs + Left shift
USS + Lymph node biopsy
LDH ^

Staging - Ann-Arbor

Management - RCHOP 21 days

  • Rituximab
  • Cyclophosphamide
  • H - Doxorubicin
  • O - Vincristine
  • Prednisolone
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12
Q

AML

A

Clinical features - BM failure

  • Anaemia
  • Neutropenia
  • Thrombocytopenia
  • Hepatosplenomegaly
  • Bone pain
  • Lymphadenopathy

Investigations

  • FBC - Macrocytic pancytopenia
  • Blood film - Blasts + Auer rods
  • BM biopsy - Blasts + Auer rods

Classification - French-American-British - FAB

Management - Chemo/Radio

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13
Q

ALL

A

Acute leukaemia in children

Clinical features

  • Pancytopenia
  • Hepatosplenomegaly
  • Bone pain
  • Fever
  • Testicular swelling

Types

  • Common - 75%
  • T-cell only - 20%
  • B-cell only - 5%

Investigations

  • FBC - Pancytopenia
  • Blood film - Leukaemic lymphoblasts
  • BM biopsy - Lymphoblast infiltration

Management - Chemo/Radio

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14
Q

CML aetiology and clinical features

A

Philadelphia chromosome!
Malignant clonal disorder of haematopoietic stem cells

Clinical features - 60-70

  • Anaemia
  • Weight loss
  • Diaphoresis
  • Splenomegaly - Abdo discomfort
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15
Q

CML investigations and management

A

FBC

  • Anaemia
  • WCC ^
  • Thrombocytopenia

Blood film

  • Maturing myeloid cells
  • Basophils
  • Eosinophils

BM biopsy - Granulating hyperplasia

Genetic testing - Philadelphia chromosome

Management - Chemo/Radio

  • Imatinib - Tyrosine kinase inhibitor
  • Hydroxyurea
  • Interferon-Alpha
  • BM transplant
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16
Q

CLL

A

Monoclonal proliferation of well-differentiated lymphocytes
Almost always B cells

Clinical features - Asymptomatic

  • Anaemia
  • Lymphadenopathy
  • Splenomegaly

Investigations

  • FBC - Anaemia + WCC ^
  • Blood film - Smudge/smear cells
  • Immunophenotyping

Management - Chemo/Radio

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17
Q

DVT clinical features

A

May occur in upper extremities

  • Portal vein
  • Mesenteric vein
  • Ovarian vein
  • Retinal vein
  • Cerebral venous sinus

Clinical features

  • Calf swelling
  • Localised pain along deep venous system
  • Asymmetric oedema
  • Prominent superficial veins
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18
Q

Wells score

A

Wells score

  • Active cancer - 1
  • Calf swelling > 3cm - 1
  • Prominent superficial veins - 1
  • Pitting oedema - 1
  • Swelling of entire leg - 1
  • Localised pain - 1
  • Immobilisation - 1
  • Bed rest > 3 days or surgery with GA in last 12 weeks - 1
  • Previous DVT/PE - 1
  • Alternative diagnosis more likely (-2)
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19
Q

DVT investigations and management

A

Wells score
D-dimer if Wells < 2
USS if Wells > 2 or D-dimer +ve

USS not available within 4 hours - Anticoagulate - Rivaroxaban

Management - Anticoagulate - 3 months if provoked, 6 months if unprovoked

  • DOAC - Rivaroxaban
  • Renal impairment - LMWH
20
Q

Antiplatelets

A

Always assess HASBLED!

ACS/PCI

  1. Aspirin - Lifelong
  2. Ticagrelor - 12 months
  3. Clopidogrel - Lifelong

Ischaemic stroke / TIA

  1. Clopidogrel - Lifelong
  2. Aspirin - Lifelong
  3. Dipyridamole - Lifelong

PAD

  1. Clopidogrel - Lifelong
  2. Aspirin - Lifelong
21
Q

DIC aetiology

A

Activation of coagulation pathways
Intravascular thrombi
Platelet and clotting factors depleted
Thrombi = Vascular obstruction and multi-organ failure

Spontaneous bleeding may occur

Triggers

  • Sepsis
  • Major trauma
  • Obstetric complications - Amniotic fluid embolism, haemolysis, HELLP
  • Malignancy
  • Major vascular disorders
22
Q

DIC clinical features

A

Systemic signs of circulatory collapse

  • Oliguria
  • Tachycardia
  • Hypotension

Purpura fulminans, gangrene, acral cyanosis
Delirium / Coma
Petechiae, ecchymosis, oozing, haematuria

23
Q

DIC investigations and management

A 
Platelets - Low
PT ^
aPTT ^ 
Bleeding time ^
Fibrinogen - Low
D-dimer ^
Blood film - Shistocytes - Microangiopathic haemolytic anaemia

Management - Treat cause + Transfusion

  • Platelets
  • FFP
  • Cryoprecipitates
  • Fibrinogen concentrates
24
Q

High INR

A

Major bleeding

  • Stop Warfarin
  • Vitamin K - 5mg IV
  • Prothrombin complex concentrate

INR > 8

  • Stop Warfarin
  • Vitamin K - 1-5mg (PO if stable, IV if bleeding)
  • Check INR after 24 hours
  • Restart Warfarin when INR < 5

INR 5-8 + Minor bleeding

  • Stop Warfarin
  • Vitamin K - 1-3mg IV
  • Restart Warfarin when INR < 5

INR 5-8 - No bleeding

  • Withhold 1 or 2 doses of Warfarin
  • Reduce subsequent maintenance dose
25
Overdose management ``` Paracetamol Salicylate Opioid Benzos Tricyclics Lithium Warfarin Heparin BBs Digoxin ```
Paracetamol - Activated charcoal < 1 hour - NAC Salicylate - Urinary alkalisation - IV bicarb - Haemodialysis Opioid - Naloxone Benzos - Flumazenil (seizure risk) Tricyclics - IV bicarb Lithium - Volume resus - NaCl - Haemodialysis Warfarin - Vitamin K + Prothrombin Heparin - Protamine sulphate BBs - Bradycardia - Atropine - Resistant - Glucagon Digoxin - Digoxin-specific antibody fragments
26
Poisoning management ``` Ethylene glycol Organophosphate Iron Lead CO Cyanide ```
Ethylene glycol / Methanol - Fomepizole - Ethanol - Haemodialysis Organophosphate insecticides - Atropine Iron - Desferroxamine Lead - Dimercaprol - Calcium edetate CO - Hyperbaric 100% O2 Cyanide - Hydroxycobalamin - Amyl nitrate / Sodium nitrate / Sodium thiosulphate
27
ITP Evan's syndrome
Immune thrombocytopenia - Well patient with thrombocytopenia - Autoimmine - Adults - Chronic - Children - Acute following infection or vaccination Clinical features - Incidental finding? - Petichae / Purpura - Bleeding - Epistaxis Investigations - Isolated platelet count < 100 Management - Pred PO - IVIG - Children - Platelet transfusion Evan's syndrome - ITP + AIHA
28
TTP aetiology and clinical features
Thrombotic thrombocytopenic purpura - Unwell patient with thrombocytopenia - Antibodies against enzyme that cleaves vWF - Large vWF multimers leading to platelet aggregation Clinical features - PENTAD 1. Microangiopathic haemolytic anaemia 2. Thrombocytopenic purpura 3. Neuro dysfunction 4. Renal dysfunction 5. Fever
29
TTP investigations and management
``` FBC/LFT - Haemolytic anaemia Platelets - Low Blood film - Shistocytes Urinalysis - Proteinuria Urea and creatinine ^ ``` Management - Plasma exchange - Prednisolone PO
30
Lymphadenopathy DDx
Infective - Infectious mononucleosis - EBV - HIV - Eczema - Rubella - Toxoplasmosis - CMV - TB - Roseola infantum Neoplastic - Leukaemia / Lymphoma Others - AI - SLE/RA - Graft vs host disease - Sarcoidosis Drugs - Phenytoin - Allopurinol - Isoniazid
31
EBV clinical features
HHV4 1. Fever 2. Pharyngitis 3. Lymphadenopathy ``` Malaise Palatal petechiae Splenomegaly - Risk of rupture Haemolytic anaemia Maculopapular rash in patients who take amoxicillin! ```
32
EBV investigations and management
FBC - Lymphocytosis + Haemolytic anaemia EBV-specific antibodies Monospot test - Heterophile antibodies - Non-specific LFTs ^ Management - Supportive - Resolves in 2-4 weeks - Avoid sport for 8 weeks - Risk of splenic rupture - Airway obstruction - Pred - Thrombocytopenia - Pred or IVIG
33
CMV aetiology
B-Herpes virus Asymptomatic if normal immune function Infected cells have "owls eye" appearance Risk factors - Immunocompromise
34
CMV manifestations
Congenital CMV - Growth retardation - Pinpoint petechial "blueberry muffin" skin lesions - Microcephaly - SN deafness - Encephalitis - Seizures - Hepatosplenomegaly CMV mononucleosis CMV retinitis - HIV patients with low CD4 < 50 - Blurred vision - Fundoscopy - Retinal haemorrhages and necrosis - Pizza retina - Treatment - IV Ganciclovir CMV encephalopathy - HIV patients with low CD4 < 50 CMV pneumonitis CMV colitis
35
CMV | Other clinical features / investigations / management
Fever Malaise N/V Diarrhoea FBC - Immunocompetent - Lymphocytosis - Immunocompromised - Pancytopenia LFTs ^ CMV serology CD4 count CXR Management - Immunocompetent - Supportive - Immunocompromised - IV Ganciclovir
36
HIV aetiology
Retrovirus Destruction of CD4 cells AIDS - Develops over 10-15 years IVDU Unprotected sex Needle-stick injury Vertical transmission
37
HIV investigations and management
HIV PCR P24 antigen tests Antiretroviral therapy Counselling Manage comorbidities Prophylaxis - Vaccinations - Live vaccines CI - Pneumococcal - Meningococcal - Influenza - Hep B - HPV - DTP
38
HIV vertical transmission
25-30% Factors to reduce risk of transmission... - Maternal ART - Bottle feeding Method of delivery - Viral load < 50 - Vaginal - Viral load > 50 - CS + Zidovudine infusion 4 hours prior Neonatal ART - Maternal viral load < 50 - Zidovudine PO - Maternal viral load > 50 - Triple ART for 4-6 weeks
39
Malaria aetiology and protective factors
1. Plasmodium falciparum 2. Plasmodium vivax - Benign 3. Plasmodium ovale - Benign 4. Plasmodium malariae - Benign Protective factors - Sickle-cell trait - G6PD deficiency - HLA-B53 - Absence of duffy antigens Risk factors - Travel to endemic areas - Tropics
40
Malaria clinical features and investigations
``` Fever > 39 Headache Weakness Myalgia Arthralgia Anorexia Diarrhoea ``` ``` Blood film - Schizonts Rapid diagnostic tests - RDTs FBC - Anaemia and thrombocytopenia BM - Hypoglycaemia ABG - Acidosis ```
41
Malaria management and complications
Chloroquine Complications - Cerebral malaria - Seizures/coma - Acute renal failure - ARDS - Hypoglycaemia - DIC
42
Haemophilia aetiology and presentation
X-linked recessive A - Factor 8 deficiency B - Factor 9 deficiency Neonates - IC haemorrhage - Bleeding post-circumcision - Heel-prick oozing Bleeding - Haemarthrosis - Post-dental - Post-surgery - Haematomas
43
Haemophilia investigations and management
aPTT ^ Everything else = Normal Management - A - Factor 8 - B - Factor 9 - FFP Avoid NSAIDS
44
VWD aetiology and pathophysiology
AD VWF - Promotes platelet adhesion to damaged endothelium - Factor 8 CARRIER 1. Partial reduction 2. Abnormal form 3. Total lack - AR inheritance
45
VWD presentation / investigations / management
Bleeding Bruising Epistaxis Bleeding time ^ APTT ^ Factor 8 - LOW Desmopressin Tranexamic acid if bleeding Factor 8
46
HIV clinical features
Seroconversion - Sore throat - Lymphadenopathy - Malaise, myalgia, arthralgia - Diarrhoea - MP rash - Mouth ulcers
47
HIV complications
Oral thrush Shingles Hairy leukopenia Kaposi's sarcoma ``` Cryptosporidosis Toxoplasmosis Progressive multifocal leukoencephalopathy Pneumonia - Pneumocystitis jiroveci HIV dementia ``` Aspergillosis Oesophageal candidiasis Cryptococcal meningitis Primary CNS lymphoma CMV retinitis

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