Oxford Handbook Flashcards
A 55-year-old man is receiving a transfusion of packed red cells
during his recovery from colorectal surgery. He has suddenly developed
a fever 30min into the transfusion. T 38.3 ° C, HR 90bpm, BP 125/70mmHg, SaO 2 98% on air. The transfusion has been stopped. Which single development should make the junior doctor most wary about restarting the transfusion?
A Pruritus
B Shivering
C Systolic BP <105mmHg
D Temperature >38.5 ° C
E Urticaria
C
- increasing hypotension (with fever) is the most worrying sign as it heralds sepsis (bacterial contamination) or an acute haemolytic reaction and warrants stopping the transfusion and urgent discussion with a haemotologist and a microbiologist.
- As this man’s temperature is already raised, it would be a fall in the blood pressure that would be the most worrying development
- A+E ==> represent allergic reactions - in these cases, the transfusin could be slowed with the addition of chlorphenamine 10mg IM/IV and close monitoring
- B ==> shivering is seen with fever in non-hemolytic reactions and can be treated by slowing the transfusion and giving paracetamol
A 23-year-old woman has been feeling tired and lethargic for the
past 18 months. She occasionally feels dizzy on standing and is generally
weak. She is otherwise well. Hb 95g/L, MCV 69fL. Which is the single most appropriate further investigation to confirm the diagnosis?
A Hb electrophoresis
B HbA 2 level
C Serum iron + ferritin
D Thyroid function tests
E Vitamin B 12 + folate levels
C
It is not enough to know that a patient is anaemic. Before presenting such a
fi nding on a ward round, it is vital to know what ‘type’ of anaemia it is. The
first step to doing this is to look at the MCV. Diff erent MCVs suggest different reasons behind the anaemia and so prompt the next stage in investigations:
● A raised MCV (>100fL) should be followed up with thyroid function
tests ( D ), liver function tests, reticulocytes, and vitamin B 12 and folate
levels ( E ).
● A normal MCV should prompt examination of the rest of the blood
count including platelets along with renal function.
● A low MCV (<75fL) is most commonly indicative of iron deficiency,
especially—as in this case—where it may be associated with menorrhagia.
Low serum iron and ferritin with a raised total iron-binding
capacity (TIBC) and transferrin would seal the diagnosis. If there is no
convincing source of iron loss, then it is important to investigate the
gastrointestinal tract: an incidental microcytic anaemia can be the way
in which a tumour of the caecum or ascending colon presents.
A Hb electrophoresis would also be useful in the exploration of a possible
thalassaemia, as it would in the diagnosis of sickle cell disease. Whilst
thalassaemia minor can present with minor symptoms, it would be very
unlikely for sickle cell disorders to do so (admittedly sickle cell trait might,
but usually acutely in specifi c precipitating situations—such as hypoxic
environments—rather than the more gradual presentation in this case).
B HbA 2 is one of the three main types of haemoglobin in adult blood. If
iron studies were inconclusive in this case, then this may be a reasonable
test to run, as high levels of HbA 2 against a backdrop of a microcytic
anaemia can occur in the relatively benign β -thalassaemia minor.
A 72-year-old woman has been breathless and unwell for the past
week. She is admitted to hospital and started on IV antibiotics for a
chest infection. She has ischaemic heart disease and atrial fibrillation, and
is on warfarin 2mg once daily. The on-call junior doctor is asked to check
her blood results after she is moved to the medical ward. Her INR is 6.6.
Which is the single most appropriate management?
A Fresh frozen plasma (FFP) 2U IV
B Reduce warfarin dose to 0.5mg
C Stop antibiotics
D Stop warfarin and monitor INR
E Vitamin K 5mg IV
D
- This is a common dilemma for the junior doctor.
- With such a high INR, it may be tempting to reverse it, but in the absence of bleeding, the British Society of Haematology guidelines state that readings <8 just need to be watched while warfarin is withheld.
- If the INR is >8 and/r there is minor bleeding then the agent of choice for reversal is vitamin K (0.5 mg IV or 5mg PO)
- If there is major bleeding then vitamin K 5-10 mg may be needed
- FFP - has only a partial effect - is not the optimal treatment and should never be used for the reversal of warfarin over anticoagulation in the absence of severe bleeding
- Warfarin sohuld be stopped and restarted once the INR <5
- Some antibiotics do indeed interfere with the INR (ciprofloxacin and erythromycin - enzyme inhibitors) and rifampicin (enzyme inducer) but this patient is in hospital for treatment of sepsis and it is the warfarin that should be stopped
A 68-year-old woman has had a swelling in her neck, weight loss,
and night sweats for 6 months. Her family doctor refers her for
investigations as an in-patient. After 72h on the ward she asks one of the
doctors if she can read through her medical notes. Which is the single
most appropriate response to her request?
A Allow the patient to take the notes whenever she likes
B Copy the parts of the notes that would be relevant to the patient
C Discuss the request with the hospital’s information guardian
D Refuse as all medical notes are confidential
E Write a summary of the notes for the patient but withhold the
original
C
A patient has a right of access to their medical notes under the Data
Protection Act 1998. There is no reason for this patient not to be allowed
access to her notes and this should be made clear to her. It is also, however,
important to weigh her right with the Caldicott principles. These
were put in place to ensure maximum safety of confi dential information.
In order to implement these principles, every hospital should have a designated Caldicott Guardian (often the medical director).
A Caldicott Guardian is a senior person responsible for protecting the
confi dentiality of patient and service-user information and enabling
appropriate information-sharing. The Guardian plays a key role in ensuring
that the National Health Service (NHS), Councils with Social Services
responsibilities, and partner organizations satisfy the highest practicable
standards for handling patient-identifi able information.
In this case, therefore—as with all such cases—it is sensible to contact
the Guardian for a brief discussion of the situation whilst reassuring the
patient that their rights will be respected.
A 52-year-old man has been feeling lethargic over the past year.
He has had intermittent abdominal pain and has lost 5kg. His initial
blood results are: Hb 106g/L, MCV 106fL, vitamin B 12 305ng/L, folate 1.4mg/L, ferritin 110mg/L. Which is the single most appropriate further investigation to establish the diagnosis?
A Anti-endomysial antibodies
B Anti-gastric parietal cell antibodies
C Liver function tests
D Peripheral blood film
E Thyroid function tests
A
- This man is anaemic due to folate deficiency.
- In this age group it is important to exclude malabsorption, specifically coeliac disease as the cause
- B - The presence of these antibodies is seen in pernicious anaemia, in which there is a lack of intrinsic factor and thus an inability to absorb vitamin B12 in the terminal ileum
- C - Useful but would not be diagnostic
- D - More useful in the investigation of a pancytopenia than a folate deficiency
- E -Hypothyroidism can cause symptoms of lethargy and a macrocytic anaemia but is not related to vitamin deficiencies.
A 75-year-old man has had lower back pain for over a year. It has
got progressively worse and he has now noticed new pains in his
right thigh and left arm. He is normally fit and well but has of late suffered
repeated chest infections. Which single set of investigations would be the
most likely to confirm the underlying diagnosis?
A Bone marrow aspirate + immunoglobulin profile
B Digital rectal examination + prostate-specifi c antigen (PSA)
C Erythrocyte sedimentation rate + rheumatoid factor
D Full blood count + vitamin B 12 , folate + ferritin
E Liver function tests + calcium
A
- This man has worsening back pain with other bony pain along with the suggestion of immunosuppresion
- C-E would all provide useful but not diagnostic information for this presentation
- A would be desirable in the diagnosis of myeloma whilst B would detect the majority of prostate malignancies
- It is difficult to find reasons that totally exclude prostate cancer as the cause here but the lack of urinary symptoms would certainly be one.
- The other would be that the history is textbook for myeloma (unexplained backache + pathological fractures + recurrent bacterial infections)
- The work up of this patient should, however certainly include a digital rectal examination and a blood test for PSA but diagnosis would be confirmed by finding increased plasma cells on bone marrow aspiration
A 42-year-old woman has been increasingly tired over the past
6 months. She has felt faint on exertion with occasional palpitations.
She admits to feeling irritable and rather low. Her skin and conjunctivae
are pale. Hb 92g/L, MCV 102fL. Film: hypersegmented polymorphs.
Which is the single most likely cause of the woman’s symptoms?
A Alcoholism
B Liver disease
C Myxoedema
D Pernicious anaemia
E Pregnancy
D
When anaemia with a high MCV is detected, the important tests to run
include thyroid function tests, vitamin B 12 and folate levels, and reticulocytes.
Added to these, a peripheral blood fi lm can provide important information
about the individual cells. Although all of the options given can cause a macrocytic anaemia, only option D would show hypersegmented polymorphs
on the blood film (all other options cause non-megaloblastic macrocytic
anaemias, i.e. liver disease showing ‘target cells’ on the blood film).
The characteristic appearance of these polymorphs—large with multiple
segments—is because the rate at which the nucleus develops is slower
than the rate at which the cytoplasm develops. The delay in the nucleus
developing is due to a lack of folate and/or vitamin B 12 , which are necessary
for DNA synthesis. When these cells are detected in the bone marrow,
they are referred to as megaloblasts.
Pernicious anaemia is the most common cause of a macrocytosis with
megaloblastic bone marrow. Symptoms stem from the inability of the gut
to absorb vitamin B 12 due to a lack of secretion of intrinsic factor (following
an autoimmune atrophic gastritis). Treatment is therefore to replenish
stores of the vitamin by IM injections.
A 66-year-old man has felt increasingly tired over the past
18 months. He has also been intermittently dizzy and complains of
a sore tongue. He is pale and has a swollen red tongue.
Hb 99g/L, MCV 105fL, WCC 6.2 × 10 9 /L, platelets 265 × 10 9 /L. Which single pair of investigations is most likely to confi rm the diagnosis?
A Ferritin + total iron-binding capacity
B Folate + thyroid function tests
C Lactate dehydrogenase + reticulocytes
D Peripheral blood fi lm + bone marrow aspirate
E Vitamin B 12 + anti-gastric parietal cell antibodies
E
- A,B C and E would all be reasonable and useful investigations into anaemia although only B and E are targeted specifically at macrocytic anaemia
- A would be useful for microcytic anaemia of iron deficiency, whilst reticulocytes do cause a macrocytosis but in response to other event such as haemoylsis and haemorrhage.
- Given the specificity of the clinical signs (a ‘swollen red tongue’) diagnosis would be confirmed by low vitamin B12 levels and the antibodies to gastric parietal cells that characterise pernicious anaemia.
- Only D would be inappropriate in this instance - it would be indicated in a case of pancytopenia to explore the possibility of haemotological malignancy.
A 72-year-old man has a sudden onset of pain in the right side of
his chest. He recalls no trauma to the area and is surprised when
he is told he has fractured ribs. He also has pain in his lower back and has
had two admissions to hospital in the past 6 months with chest infections.
Which single cell type is most likely to be proliferating?
A Germinal centre B cell
B IgM-secreting cell
C Mature B lymphocyte
D Myeloid cell
E Plasma cell
E
Osteolytic bone lesions can cause unexplained backache with pathological
fractures. Immunoparesis from monoclonal proliferation of plasma
cells and marrow infi ltration can lead to intermittent infections. Both of
these features are suggestive of myeloma.
A This is Hodgkin’s/non-Hodgkin’s lymphoma.
B This is Waldenstr ö m’s macroglobulinaemia.
C This is B-cell lymphoma.
D This is acute/chronic myeloid leukaemia.
A 54-year-old woman has had bleeding from her gums daily for
the past 2 weeks. She has also suffered four nosebleeds during
this time. Over the past month or so, she has had a burning pain in her
hands and feet with a throbbing in the tips of her fingers and toes, as well
as an intermittent headache. Which single cell type is most likely to be
proliferating?
A Blast cell from marrow myeloid
B IgM-secreting cell
C Lymphoid progenitor cell
D Megakaryocyte
E Plasma cell
D
This woman is suffering with bleeding and the symptoms of microvascular
occlusion. This is due to essential thrombocythaemia (high levels of
platelets) that are derived from a clonal proliferation of megakaryocytes
and so do not function normally.
A This is acute/chronic myeloid leukaemia.
B This is Waldenstr ö m’s macroglobulinaemia.
C This is acute/chronic lymphoblastic leukaemia.
E This is myeloma.
A 19-year-old woman has been in severe pain for the past 12h.
It started in her left hip and has moved down her thigh. She is
doubled over in agony and confi ned to bed. She has experienced similar
episodes intermittently over the years. Paracetamol and codeine do little
to relieve the pain and it is only after morphine 20mg SC that there is any
improvement. Hb 77g/L, MCV 86fL. Which is the single most appropriate explanation for her pain?
A Infarction of the bone marrow
B Localized tissue hypoxia due to anaemia
C Pathological bone fracture
D Pooling of red blood cells in the liver and spleen
E Sudden reduction in bone marrow production of red blood cells
A
This woman is having a painful crisis, common to sickle cell disease (SCD).
For some reason (often idiopathic, but can be hypoxaemia, dehydration,
or infection), the microvasculature becomes occluded by a backlog of
abnormally shaped red blood cells. This results in ischaemia and then
infarction of the red bone marrow, and the characteristic deep-seated
bone pain that can only be relieved by high-dose opioids. E refers to an
aplastic crisis, whilst D refers to a sequestration crisis—both complications
of SCD in which much more severe anaemia than in this case would
be expected.
A 62-year-old woman has had a high temperature for the past 3h.
Other than a slightly sore throat and a general feeling of tiredness
she has no real symptoms of note. Eight days previously she completed
her first cycle of chemotherapy for carcinoma of the breast.
T 38.4 ° C, HR 110bpm, BP 95/65mmHg. Blood and urine samples are sent for culture. Which is the single most appropriate next stage in her treatment?
A Await the results of the blood tests before starting any treatment
B Discharge home and contact if the cultures grow anything
C Discharge home on oral antibiotics
D Observe for 24h on intravenous fluids
E Start broad-spectrum intravenous antibiotics
E
Between 7 and 10 days post chemotherapy is when the bone marrow is
likely to be at its ‘nadir’. A fever occurring at this time—even before the
results of the full blood count are known—should be treated as neutropenic
sepsis, even if symptoms are mild or even absent. Treatment is to
send off all cultures and to start broad-spectrum intravenous antibiotics.
If the patient remains well, no clear focus of sepsis declares itself, and the
cultures return negative, then they may be discharged.
A 72-year-old woman has been feeling tired and lethargic for the
past 2 years. Her doctor performs a range of blood tests, the
majority of which are within normal limits. However, she is referred to
the haematologists due to the presence in her serum of a ‘monoclonal
protein’. Which single additional feature should offer the most reassurance that the condition is not yet serious?
A Bone marrow concentration of monoclonal plasma cells >10%
B Clotting profi le is within normal limits
C LDH is within normal limits
D Monoclonal protein is of IgM type
E Serum concentration of monoclonal protein <30g/L
E
It is very common to find a monoclonal protein in the serum of those over
50 years old. However, in the absence of end-organ damage (anaemia,
hypercalcaemia, lytic bone lesions, renal failure, hyperviscosity), if the
concentration is low (<30g/L), it is described as an asymptomatic plasma
cell dyscrasia and labelled as monoclonal gammopathy of uncertain signifi
cance (MGUS). However, if the concentration is high, if the bone marrow
concentration of monoclonal plasma cells is >10%, and as end-organ
damage appears, it transforms into something more malignant—depending
on the class of protein involved, either a multiple myeloma, amyloid,
or Waldenström’s macroglobulinaemia. Consequently, MGUS does need
to be followed up, but infrequently and by serial measurements of the
serum monoclonal protein concentration.
A 62-year-old man has felt generally unwell for the past 3 months.
His main problem is a widespread, intractable itch, but he has
also lost his appetite and thus more than 5kg. He is lethargic and low in
mood, and suffers from intermittent fevers with sweats at night. There is
an enlarged, rubbery left cervical lymph node that is non-tender to palpation.
Which is the single most likely cause of this man’s symptoms?
A B-cell malignancy
B Bone marrow malignancy
C Myeloid cell malignancy
D Plasma cell malignancy
E T-cell malignancy
A
The symptoms described are classical B-cell symptoms. These are found in
malignancies of lymphocytes such as lymphoma and chronic lymphocytic
leukaemia (CLL) and generally involves B cells more than T cells.
A 33-year-old man has a routine pre-employment medical
examination. He is asymptomatic but has sickle cell disease. T 36.7 ° C, HR 65bpm, BP 122/78mmHg. Hb 81g/L, MCV 88fL. His chest is clear and heart sounds are normal. Which is the single most appropriate explanation for why he is not short of breath?
A Due to chronic haemolysis, the Hb is diluted and actually much higher
B His cardiac output has been able to increase over time to
compensate
C His MCV is within normal limits
D His oxygen dissociation curve is shifted to the right
E His vital capacity has been able to increase over time to compensate
D
The oxygen dissociation curve illustrates the relationship between PaO 2
and SaO 2 ( Figure 6.2 ). The standard curve is calculated for normal adult
HbA. The curves for foetal HbF and HbSS in sickle cell disease (SCD)
occupy diff erent positions.
In SCD, the dissociation curve is shifted to the right, indicating that the Hb
has a lower affi nity for oxygen and can therefore more easily release it to
the tissues. As a result, lower levels of Hb can be well tolerated.
A There is chronic haemolysis in SCD but this does not cause haemodilution;
rather, it causes a rise in bilirubin and reticulocytes.
B An increase in cardiac output is seen in some conditions (e.g. hyperthyroidism, Paget’s disease, and multiple myeloma) as a response to increased demands, but not in SCD.
C Having a ‘normal’ MCV does not preclude breathlessness.
E If anything, a man this age with SCD is likely to have a restrictive lung
defect due to recurrent episodes of pulmonary vaso-occlusion.
