PassMed Learning Points Flashcards
Which indications would cause you to refer immediately for specialist referral suspecting leukaemia, in children up to 25yrs []
- Unexplained petachiae
- Hepatosplenomegaly
- Unexplained bleeding / bruising
- Pallor
- Unexplained fever
- Unexplained persistent infections
- Generalised lymphadenopathy
Most common causes of massive splenomegaly in UK? [2]
Most common causes of massive splenomegaly in UK = CML/myelofibrosis
Which patient population is at increased risk of acute lymphoid leukaemia? [1]
Downs syndrome
What would you do if a patient has a 2-level Wells score < 1 and suspect DVT / PE? [1]
Arrange D-dimer and prescribe anticoagulation if wait for results is greater than 4 hrs
What are the 4 stages for HL staging for Ann-Arbor staging? [4]
Stage I
- Single LN
Stage II
- 2+ LN on same side of diaphragm
Stage III:
- LNs on both sides of diaphragm
Stage IV:
- Spread beyond LN
A: No systemic symptoms other than pruiritis
B: Weight loss (> 10 %); fever >38; night sweats)
Which B symptom indicates a poor prognosis for HL? [1]
night sweats
What is the MoA of rivaroxaban? [1]
Direct factor Xa inhibitor
What is the empirical antibiotic of choice for neutropenic sepsis? [2]
IV Piperacillin with tazobactam
What is a common complication of cancer therapy (particularly chemo)? [1]
Neutropenic sepsis
What neutrophil levels indicate neutropenic sepsis? [1]
What other signs do you need? [2]
< 0.5
AND one of:
- Temp > 38
- Other signs or symptoms of significant sepsis
How do you reverse minor allergic reactions in blood transfusions? [2]
Urticaria and pruritus without evidence of haemodynamic instability
Stop transfusion;
Give an antihistamine
Which electrolyte changes indicate tumour lysis syndrome? [4]
What else do you need for a diagnosis? [3]
Electrolyte changes:
* Uric acid > 475 or 25% increase
* K > 6 or 25% increase
* Phosphate > 1.125 or 25% increase
* Calcium < 1.75 or 25% increase
Positive clinical TLS signs:
- Increased serum creatitine (1.5x upper limit of normal)
- Cardiac arrythmia / sudden death
- Seizure
What is the diagnositic investigation of choice for suspected NHL? [1]
Excisional node biopsy
How do you remember the most important symptoms / complications of myeloma? [6]
CRABBI:
- Calcium raised
- Renal failure
- Anaemia
- Bone pain
- Bleeding
- Infection
Describe what is meant by a rouleaux formation [1]
The RBC’s here have stacked together in long chains.
Name this haemological abnormalilty [1]
rouleaux formation: the RBC’s here have stacked together in long chains.
Which pathology does a rouleaux formation indicate? [1]
Myeloma
A patient undergoes a biopsy of a mass in their ceceum. It exhbitis a ‘starry sky’ pattern. What is the most likely infection? [1]
EBV: causes Burkitt’s lymphoma
Which lymph nodes does Burkitt’s lymphoma typically present in? [1]
Abdomen and mesenteric lymph nodes
Burkitt’s lymphoma typically causes what complication? [1]
Tumour lysis syndrome
Basophilic stippling of red blood cells indicates which form of anaemia? [1]
Sideroblastic anaemia (where RBC fail to form haem: leads to deposits of Fe in the mitochondira that forms a ring around the nucleus called a ring sideroblast)
DVT investigation: if the scan is negative, but the D-dimer is positive what is the next appropriate steps in patient management? [2]
stop anticoagulation and repeat scan in 1 week
What is the mechanism of action of dabigatran?
Direct thrombin inhibitor
Protein C inhibitor
Direct factor Xa inhibitor
Direct antithrombin III inhibitor
Factor II, VII, IX and X inhibitor
What is the mechanism of action of dabigatran?
Direct thrombin inhibitor
Protein C inhibitor
Direct factor Xa inhibitor
Direct antithrombin III inhibitor
Factor II, VII, IX and X inhibitor
What blood film results would indicate chronic leukocytic leukaemia (CLL)? [2]
Smear cells
small/medium-sized lymphocytes
What are four complications of CLL? [4]
- anaemia
- hypogammaglobulinaemia leading to recurrent infections
- warm autoimmune haemolytic anaemia in 10-15% of patients
- transformation to high-grade lymphoma (Richter’s transformation)
Describe what is meant by Richters transformation [1]
Ritcher’s transformation occurs when leukaemia cells enter the lymph node and change into a high-grade, fast-growing non-Hodgkin’s lymphoma. Patients often become unwell very suddenly.
Ritcher’s transformation occurs when leukaemia cells enter the lymph node and change into a high-grade, fast-growing non-Hodgkin’s lymphoma. Patients often become unwell very suddenly.
What are the indications that this is occurring? [6]
Ritcher’s transformation is indicated by one of the following symptoms:
* lymph node swelling
* fever without infection
* weight loss
* night sweats
* nausea
* abdominal pain
How many weeks either side of an operation should you stop / start the COCP? [2]
Is it 4 weeks prior and 2 weeks post
STOP the COCP (4 letters) 4 Weeks before an OP
A 6-month-old boy is brought to the GP by his father, who is concerned about his growth. He says that his son is very pale, and seems to get tired easily when playing. His son has also always had difficulty feeding and is very ‘fussy,’ in addition to having very loose stools and regular fevers without cold symptoms. The GP performs an examination and determines that the child has hepatosplenomegaly. Pending further investigations, he makes the provisional diagnosis of beta thalassaemia major.
What laboratory finding is most consistent with the provisional diagnosis?
Absent HbA2
Macrocytic anaemia
Raised HbA
Raised HbA2
Reduced HbF
A 6-month-old boy is brought to the GP by his father, who is concerned about his growth. He says that his son is very pale, and seems to get tired easily when playing. His son has also always had difficulty feeding and is very ‘fussy,’ in addition to having very loose stools and regular fevers without cold symptoms. The GP performs an examination and determines that the child has hepatosplenomegaly. Pending further investigations, he makes the provisional diagnosis of beta thalassaemia major.
What laboratory finding is most consistent with the provisional diagnosis?
Absent HbA2
Macrocytic anaemia
Raised HbA
Raised HbA2
Reduced HbF
Major:
* HbA2 & HbF raised
* HbA absent
In patients with both vitamin B12 and folate deficiencies, the [] deficiency must be treated first to avoid subacute combined degeneration of spinal cord
In patients with both vitamin B12 and folate deficiencies, the vitamin B12 deficiency must be treated first to avoid subacute combined degeneration of spinal cord
How do you differentiate between TRALI and TACO? [2]
TRALI is differentiated from TACO by the presence of hypotension in TRALI vs hypertension in TACO
This patient is most likely suffering from what? [1]
Lead poisoning
IgA deficiency increases the risk of what pathology associated with blood transfusions? [1]
IgA deficiency increases the risk of anaphylactic blood transfusion reactions
You suspect a deep vein thrombosis (DVT). She is clinically stable and the radiology department informs you it will be at least 5 hours until they can carry out an ultrasound doppler scan. A D-dimer is awaited.
What is the most appropriate management for Mrs Smith?
Commence her on low-molecular-weight heparin (LMWH) prophylaxis
Commence her on a direct oral anti-coagulant (DOAC)
Commence her on treatment dose LMWH
Discharge her and ask her to return the next day for her scan
Wait until the ultrasound doppler can be performed
Commence her on a direct oral anti-coagulant (DOAC)
If investigating a suspected DVT, and either the D-dimer or scan cannot be done within 4 hours, then start a DOAC
[] is the most common inherited clotting disorder
Von Willebrand’s disease is the most common inherited clotting disorder
How does polycythaemia vera typically present? [4]
Raised haemoglobin, plethoric appearance, pruritus, splenomegaly, hypertension
You also perform a blood film and your consultant notes the presence of bite cells and blister cells.
What is the most likely diagnosis?
Pyruvate kinase deficiency
Hereditary spherocytosis
Pyrimidine 5’ nucleotidase deficiency
Autoimmune haemolytic anaemia
G6PD deficiency
You also perform a blood film and your consultant notes the presence of bite cells and blister cells.
G6PD deficiency
Have a Bite of Heinz Fava beans.
=>
Bite cells. Heinz bodies. Fava beans.
Which infective organism may trigger an aplastic crisis in patients with hereditary spherocytosis? [1]
Parvovirus infection may trigger an aplastic crisis in patients with hereditary spherocytosis
Coagulase-negative, Gram-positive bacteria such as [] are the most common cause of neutropenic sepsis
Coagulase-negative, Gram-positive bacteria such as Staphylococcus epidermidis are the most common cause of neutropenic sepsis
A patient presents with episodic pruritus over the last 6 months. These symptoms are worse after taking a hot bath.
What is the most likely diagnosis? [1]
polycythaemia vera
How would beta thalassemia trait present from blood tests? [2]
- Raised HbA2
- Microcytic anaemia; MCV < 55
Beta thalassaemia major can also present with disproportionate microcytic anaemia however the anaemia would be marked, and the patient would be transfusion dependent.
He initially presented to his general practitioner with a painless, rapidly enlarging cervical mass. An excisional node biopsy revealed a ‘starry sky’ pattern. He has commenced chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone. The specialist wants to co-prescribe a medication that has been demonstrated to improve outcomes in patients with this diagnosis.
What should be prescribed?
Bezlotoxumab
Denosumab
Infliximab
Interferon-alpha
Rituximab
He initially presented to his general practitioner with a painless, rapidly enlarging cervical mass. An excisional node biopsy revealed a ‘starry sky’ pattern. He has commenced chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone. The specialist wants to co-prescribe a medication that has been demonstrated to improve outcomes in patients with this diagnosis.
What should be prescribed?
Rituximab
Rituximab is used in combination with conventional chemotherapy regimes (e.g. CHOP) for a variety of types of non-Hodgkin’s lymphoma
What is reversal agent for rivaroxaban and apixaban? [1]
Rivaroxaban and apixaban can be reversed by andexanet alfa
A patient presenting with a pathological fracture, renal dysfunction and anaemia are very suggestive of [], especially in an elderly patient.
The pathological fracture, renal dysfunction and anaemia are very suggestive of multiple myeloma, especially in an elderly patient.
Bence Jones proteins (BJP) are detected in the urine
This is indicative of which pathology? [1]
Multiple myeloma
High uric acid + renal impairment following chemotherapy → []?
High uric acid + renal impairment following chemotherapy → tumour lysis syndrome
A patient with a high chance of suffering from tumour lysis syndrome should be treated prophylactically with what? [2]
They should be treated prophylactically with IV allopurinol or IV rasburicase
A patient has excessive bleeding that is suspected to be related to their dabigatran use.
What is the reversal agent? [1]
Dabigatran reversal: Idarucizumab
What is the first line treatment for CML? [1]
A tyrosine kinase inhibitor such as Imatinib
What is a pneumonic for figuring out the pathology for when a patient has too much clotting? [4]
Too much clotting: CLOT
C- C/S deficiency
L - Leiden (factor V)
O - Odd (mutated) prO-thrombin
T - anTi-thrombin III deficiency
What is a pneumonic for figuring out the pathology for when a patient has too much bleeding? [5]
Too much bleeding: I BLED
I - ITP, ATP, TTP
B - B/A Haemophilias
L - Low vitamin K, clotting factors
E - Eponym: vWD
D - DIC & Drugs
A combination of thromboembolism and bleeding in a young woman should raise the possibility of [?]
A combination of thromboembolism and bleeding in a young woman should raise the possibility of antiphospholipid syndrome
State how VWD, Haemophilia and Vitamin K deficiency change PT, APTT and Bleeding time [9]
Describe the haematological abnormalities that occur with lead poisoning [2]
Haematological abnormalities include a microcytic anaemia and basophilic stippling as demonstrated in this case
Describe the clinical features that occur with lead poisoning [4]
classically presents with:
- abdominal pain
- constipation
- peripheral neuropathy (mainly motor)
- neuropsychiatric features.
A patient presents with schistocytes and thrombocytopenia on a blood film and a history of fever, anaemia, dehydration and a feeling different mentally
What is the most likely diagnosis? [1]
Thrombocytic thrombocytopenic purpura (TTP)
Presents as FAT RN:
Fever
Anaemia
Thrombocytopenia
Renal problems
Neuro problems
G6PD causes what abnormality on a blood film? [1]
Heinz bodies
Beta thalassemia intermediate presents with what blood film change? [1]
Tear drops
Howell Jowell bodies indicate which pathology? [1]
SCA
Tear drops (dracocytes) on a blood film can be attributed to which pathologies? [4]
myelofibrosis
beta thalassemia
megaloblastic anemia
Cancer in the bone marrow
(Severe iron deficiency)
SCA presents with what changes to a blood film? [2]
target cells
Howell-Jolly bodies
Arrow: HJB
What is a Howell-Jolly body? [1]
How do these differentiate between Pappenheimer bodies? [1]
Howell-Jolly Bodies:
- small round purple inclusions in RBCs about 1 μm in diameter
- Howell-Jolly bodies are larger in size, have smooth outlines, typically one per RBC, and are comprised of DNA.
Pappenheimer bodies:
- Blue-purple granules, < 1 um diameter, at cell periphery; may form doublets, iron stain positive, DNA stain negative
What is the Hb transfusion threshold for normal people? [1]
& Those with ACS? [1]
Normal: Hb < 70
With ACS: Hb < 80
Describe the difference between VWD and Haemophilia in terms of tissue type affected [2]
VWD:
- Mucocutaneous bleeds (e.g. epistaxis; menorrhagia; easy bruising)
Haemophilia:
- Deep tissue (hemarthrosis)
What impact does factor VIII deficiency have on APTT? [1]
Factor VIII deficiency (seen in Haem. A) causes increase in APTT
Spontaneous bleeding is more likely associated with Haem or VWD? [1]
Prolonged bleeding is more likely associated with Haem or VWD? [1]
Spontaneous bleeding is more likely associated with VWD
Prolonged bleeding is more likely associated with Haemophilia
In which clinical scenario with SCA would you perform an exchange transfusion and not a blood transfusion? [1]
If the Hb is still relatively high (~90); otherwise risk of being too concentrated and causing clots
An 18-year-old male presents with several months of fevers, night sweats and 20 lb weight loss. A computerised tomography scan reveals mediastinal lymphadenopathy and a biopsy is performed. Genetic analysis of the biopsied lesion reveals a translocation between chromosomes 14 and 18.
Which protein is likely to be overexpressed as a result of this translocation?
c-Myc
bcr-abl
bcl-2
Ewsr1-fli1
bcl-6
bcl-2
A 74-year-old male presents to his General Practitioner with a history of 10-kg weight loss over the past six months and fevers. He has no history of cough or foreign travel. He takes no regular medication except for emollients prescribed recently for itchy skin. He does not smoke and has stopped drinking, as this causes pain in his neck. On examination, he is noted to have normal cardiovascular and respiratory systems and no organomegaly on palpation of the abdomen. He is found to have two golf ball-sized cervical lymph nodes on the right.
Given the suspected diagnosis, which of the following is most likely to be used in managing this patient?
Azacitidine
Radiotherapy
Rifampicin
Rituximab
Stem cell transplant
A 74-year-old male presents to his General Practitioner with a history of 10-kg weight loss over the past six months and fevers. He has no history of cough or foreign travel. He takes no regular medication except for emollients prescribed recently for itchy skin. He does not smoke and has stopped drinking, as this causes pain in his neck. On examination, he is noted to have normal cardiovascular and respiratory systems and no organomegaly on palpation of the abdomen. He is found to have two golf ball-sized cervical lymph nodes on the right.
Given the suspected diagnosis, which of the following is most likely to be used in managing this patient?
Azacitidine
Radiotherapy
Rifampicin
Rituximab
Stem cell transplant
A 75-year-old male presents to his General Practitioner with increasing back pain and shortness of breath. A lumbar spine radiograph reveals multiple osteolytic lesions and prompts further investigation. The patient is found to have mild anaemia, thrombocytopenia, hypercalcaemia and a raised creatinine. Serum protein electrophoresis reveals a monoclonal band of protein.
What is most likely to be seen on blood film?
Schistocytes
Howell Jolly bodies
Spherocytes
Blasts
Rouleaux formation
A 75-year-old male presents to his General Practitioner with increasing back pain and shortness of breath. A lumbar spine radiograph reveals multiple osteolytic lesions and prompts further investigation. The patient is found to have mild anaemia, thrombocytopenia, hypercalcaemia and a raised creatinine. Serum protein electrophoresis reveals a monoclonal band of protein.
What is most likely to be seen on blood film?
Schistocytes
Howell Jolly bodies
Spherocytes
Blasts
Rouleaux formation
A 65-year-old female presented with fever and body aches for six months. Her blood tests revealed a haemoglobin level of 110 g/l and an erythrocyte sedimentation rate (ESR) of 121 mm in the first hour. Serum protein electrophoresis revealed an M band in the gamma globulin region with a total IgG level of 70 g/l. Bone marrow biopsy shows plasma cells in the marrow of 11%. A skeletal survey reveals no abnormalities. Other blood tests revealed:
Test Parameter Normal range
Calcium 2.60 mmol/l 2.20–2.60 mmol/l
Creatinine 119 μmol/l 50–120 μmol/l
Phosphate 1.30 mmol/l 0.70–1.40 mmol/l
Potassium (K+) 4.6 mmol/l 3.5–5.0 mmol/l
Lactate dehydrogenase 399 IU/l 100–190 IU/l
Her body weight was 71 kg.
What is the most likely diagnosis?
Multiple myeloma
Smouldering myeloma
Monoclonal gammopathy of unknown significance (MGUS)
Non-secretory myeloma
Plasma cell leukaemia
Smouldering myeloma
A 28-year-old female has a postpartum haemorrhage four hours after delivery of her first child via elective Caesarean section. The patient is resuscitated, and bloods are sent off for urgent analysis. Test results reveal: increased prothrombin time, increased active partial thromboplastin time, low haemoglobin, normal white cell count and low fibrinogen.
What is the most likely diagnosis?
HELLP syndrome
Warfarin overdose
Disseminated intravascular coagulation
Haemolytic uraemic syndrome
Thrombotic thrombocytopaenic purpura
A 28-year-old female has a postpartum haemorrhage four hours after delivery of her first child via elective Caesarean section. The patient is resuscitated, and bloods are sent off for urgent analysis. Test results reveal: increased prothrombin time, increased active partial thromboplastin time, low haemoglobin, normal white cell count and low fibrinogen.
What is the most likely diagnosis?
HELLP syndrome
Warfarin overdose
Disseminated intravascular coagulation
Haemolytic uraemic syndrome
Thrombotic thrombocytopaenic purpura
A six-year-old female is brought to the Emergency Department in December because she had a high fever (up to 40 °C) for the past three days, vomiting and night sweats. For the last four weeks, she has been lethargic and has sweated through her pyjamas almost every night. She has had several nosebleeds in this period, which her parents attributed to dry air from the heater. She has also been complaining that her back hurts. On examination, her temperature is 39.5 °C, her heart rate 140 bpm, her blood pressure 80/60 mmHg and her respiratory rate 20 breaths/minute. She appears acutely ill, and you notice small petechiae on her abdomen.
Which of the following would examination of peripheral lymphocytes most likely show?
A clonal population of mature B cells
A clonal population of immature cells expressing terminal deoxynucleotidyl transferase (TdT)
A clonal population of immature cells with intracytoplasmic dark pink rods
Lymphocytes with thin projections of the cytoplasm
A chromosomal translocation that leads to a constitutively active tyrosine kinase
A six-year-old female is brought to the Emergency Department in December because she had a high fever (up to 40 °C) for the past three days, vomiting and night sweats. For the last four weeks, she has been lethargic and has sweated through her pyjamas almost every night. She has had several nosebleeds in this period, which her parents attributed to dry air from the heater. She has also been complaining that her back hurts. On examination, her temperature is 39.5 °C, her heart rate 140 bpm, her blood pressure 80/60 mmHg and her respiratory rate 20 breaths/minute. She appears acutely ill, and you notice small petechiae on her abdomen.
Which of the following would examination of peripheral lymphocytes most likely show?
A clonal population of mature B cells
A clonal population of immature cells expressing terminal deoxynucleotidyl transferase (TdT)
A clonal population of immature cells with intracytoplasmic dark pink rods
Lymphocytes with thin projections of the cytoplasm
A chromosomal translocation that leads to a constitutively active tyrosine kinase
A 23-year-old female has been referred to the Haematology Clinic by her General Practitioner (GP). She has been experiencing pallor and fatigue for the last few weeks, with a full blood count showing anaemia (haemoglobin of 86 g/l). She also suffers from painful cyanosis of her fingers and toes, which was why she initially saw her GP. The GP ordered a peripheral blood smear, the results of which came back when the patient was seen in the Haematology Clinic. Her direct antiglobulin test (DAT) is positive, with both immunoglobulin G (IgG) and C3 present.
What is most likely to be seen on a peripheral blood smear?
Bite cells
Howell-Jolly bodies
Rouleaux cells
Siderocyte
Spherocytes
A 23-year-old female has been referred to the Haematology Clinic by her General Practitioner (GP). She has been experiencing pallor and fatigue for the last few weeks, with a full blood count showing anaemia (haemoglobin of 86 g/l). She also suffers from painful cyanosis of her fingers and toes, which was why she initially saw her GP. The GP ordered a peripheral blood smear, the results of which came back when the patient was seen in the Haematology Clinic. Her direct antiglobulin test (DAT) is positive, with both immunoglobulin G (IgG) and C3 present.
What is most likely to be seen on a peripheral blood smear?
Bite cells
Howell-Jolly bodies
Rouleaux cells
Siderocyte
Spherocytes
A patient presents with a thyoma.
What are the top differentials for patients with thyomas? [5]
- myasthenia gravis (30-40% of patients with thymoma; think also about muscle weakness)
- red cell aplasia
- dermatomyositis
- also : SLE, SIADH
Erythema infectiosum, also known as fifth disease, is a common viral exanthem caused by []
Erythema infectiosum, also known as fifth disease, is a common viral exanthem caused by parvovirus B19.
A 77-year-old male presents to the haematology clinic after being referred by his general practitioner with general malaise and abnormal blood results. It has been present for the last three months, accompanied by an unplanned weight loss. On examination, the patient looks malnourished, with pale conjunctivae, increased pulse and splenomegaly. The doctor decides to order some blood tests that show the following:
Which one of the following is the most appropriate treatment for this patient?
Adalimumab
Etanercept
Imatinib
Infliximab
Methotrexate
Imatinib
CLL
Anaemia
ALL
CML
CLL
BCR-ABL fusion protein
The Philadelphia chromosome is present in more than 95% of patients with chronic myeloid leukaemia (CML). It is due to a translocation between the long arm of chromosome 9 and 22 - t(9:22)(q34; q11). This results in part of the ABL proto-oncogene from chromosome 9 being fused with the BCR gene from chromosome 22. The resulting BCR-ABL gene codes for a fusion protein that has tyrosine kinase activity in excess of normal.
t(9:22)
Decreased leukocyte alkaline phosphatase
CML
inhibitor of the tyrosine kinase associated with the BCR-ABL defect
hypogammaglobulinaemia
