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Haematology Month End Exam
2014
A 34-year-old female with a past medical history of sickle cell anemia presents
with a 5-day history of fatigue, lethargy, and shortness of breath. She denies
chest pain or
bone pain. She has had no recent travel. Of note, the patients 4-year-old
daughter had a cold 2 weeks before the presentation. On examination she
has pale conjunctiva, is anicteric, and is mildly tachycardic. Abdominal
examination is unremarkable. Laboratories show a hemoglobin of 3 g/dL;
her baseline is 8 g/dL. The white blood cell count and platelets are normal.
Reticulocyte count is undetectable. Total bilirubin is 1.4 mg/dL. Lactic
dehydrogenase is at the upper limits of the normal range.
Peripheral blood smear shows a few sickled cells but a total absence of
reticulocytes. The patient is given a transfusion of 2 units of packed red
blood cells and admitted to the hospital. A bone marrow biopsy shows a
normal myeloid series but an absence of erythroid precursors. Cytogenetics
are normal. What is the most appropriate next management step?
A. Make arrangements for exchange transfusion.
B. Tissue type her siblings for a possible bone marrow transplant.
C. Check parvovirus titers.
D. Start prednisone and cyclosporine.
E. Start broad-spectrum antibiotics.
A 52-year-old woman is bought to AIMS OPD by her carer who has become
concerned after noticing that the patients gums have progressively become
more prominent over the last few months. She tried to take the patient to the
dentist but no NHS dental appointments were available. The patient lives in a
home since she has learning difficulties.
Her past medical history is unremarkable except for three infections in the last 6
weeks. The carer has also noticed that recently the patient has become
increasingly fatigued by even the lightest of activities and is commonly short
of breath on exertion. She is not currently on any medications but has taken
various courses of antibiotics recently.
On examination, she is noted to be anaemic and have multiple bruises over her
body. She has hypertrophic bleeding gums and on auscultation of the heart,
she is found to have a flow murmur. She has mild splenomegaly on palpation
of her abdomen. Routine blood tests were requested and confirmed the
presence of anaemia, a raised white cell count, low neutrophil count and
thrombocytopenia. A blood film shows increased numbers of blast cells and
the presence of Auer rods.
What is the most likely diagnosis?
1. Acute myeloid leukaemia (AML)
2. Chronic myeloid leukaemia (CML)
3. Acute lymphoblastic leukaemia (ALL)
4. Chronic lymphoid leukaemia (CML)
5. Chronic myelomonocytic leukaemia (CMML)
A 30-year-old woman admitted in DMCH with the history of Rat killer poison
intake 2hrs ago.
Her physical examination was unremarkable. Initial test reveals :Normal
After 3 days of conservative management her physical examination shows
ecchymoses on her arms. Her urine is bloody in appearance, but no clots
are present. After flushing the bladder with 100 mL of sterile saline, the
urine returns with a slight pink hue only. A urinalysis shows 35 white blood
cells per high power field and many red blood cells per high power field.
There are no bacteria present. The international normalized ratio (INR) is
7.0.
What is the best approach to treatment of this patients coagulopathy?
An 18-year-old girl presents AIMS neurology with sudden onset dysarthria and
right-sided weakness. You see her 12 hours after the event and her symptoms
have now resolved. She is on the oral contraceptive pill. She is in full time
education and smokes 510 cigarettes daily. Alcohol intake is minimal. She
lives with her parents. Family history is unremarkable other than a possible
deep vein thrombosis in an aunt. Examination is unremarkable other than a
lacy rash over her thighs and a grade II ejection systolic murmur.
Computed tomography of the brain performed 2 hours after admission is
unremarkable. Results of blood tests shown below:
haemoglobin (Hb) 12.3 g/dl
white cell count (WCC) 3.5 x 109/l
Platelets 135 x 109/l
activated partial thromboplastin time (APTT) 45 s (3040)
What is the most likely cause of the rash?
1. Erythaema ab igne
2. Erythaema chronicum migrans
3. Livedo reticularis
4. Erythroderma
5. Erythaema multiforme
Dr. Badhon is called to see a 40-year-old woman who has become acutely short of
breath. She had a total knee replacement the previous day, which was
uncomplicated. In the notes it is documented that she had a non-haemolytic
febrile reaction this morning during a single unit blood transfusion, which
responded rapidly to hydrocortisone and chlorpheniramine. She has received
no additional intravenous fluids. She has no previous medical history of note.
She works part time as an aerobics instructor and has four children. She does
not smoke.
On examination she is acutely short of breath, with a respiratory rate of 45
breaths per minute at rest. She is using accessory muscles and is clearly
exhausted. Auscultation of the chest reveals widespread crackles. She has
expectorated a small amount of frothy sputum. She is afebrile, blood pressure
150/90 mmHg, pulse 130 regular. Electrocardiogram is normal. Chest X-ray
shows widespread alveolar shadowing. Heart size is normal. FBC and RFT are
normal. Dr.Badhon thought its not his case & so he referred the case to Dr. Iffa,
dept of hematology, AIMS.
What Dr.Iffa should tell about the diagnosis?
A. Transfusion related acute lung injury
B. Acute pulmonary oedema due to fluid overload from too rapid blood
transfusion
C. Hospital acquired bronchopneumonia
D. Massive pulmonary embolism
E. Adult respiratory distress syndrome secondary to septicaemia
A 70-year-old man is admitted to the cardiac care unit for complaints of chest
pressure occurring at rest radiating to his left arm with associated diaphoresis and
presyncope.
His admission electrocardiogram (ECG) showed ST depressions in V4V6. The chest
pain and ECG
changes resolve with sublingual nitroglycerin. He is treated with IV heparin, aspirin,
metoprolol, and lisinopril. His cardiac catheterization shows 90% occlusion of the
left anterior descending artery, 80% occlusion of the distal circumflex artery, and
99% occlusion of the right coronary artery. He remains in the cardiac care unit
awaiting coronary artery bypass. He has a history of rheumatic
heart disease and underwent mechanical mitral valve replacement at age 58. On
admission, his hemoglobin is 12.2 g/dL, hematocrit 37.1%, white blood cell (WBC)
count 9800/L, and platelet count 240,000/L. His creatinine is 1.7 mg/dL. On the
fourth hospital day, his hemoglobin is
10.0, hematocrit 31%, WBC count 7600/L, and platelet count 112,000/L. His
creatinine has risen to 2.9 mg/dL after the cardiac catheterization.
What is the most appropriate treatment of the patient at this time?
A. Continue heparin and give a platelet transfusion.
B. Discontinue heparin infusion and start argatroban.
C. Discontinue heparin and start lepirudin.
D. Discontinue heparin and start warfarin.
E. Send serum to assess for the presence of heparinplatelet factor 4 (PF4) IgG
antibody and continue heparin.
Dr Hasina is the chief consultant of Cardiology HDU. She is asked to see a 60-year-old
man on the High Dependency Unit. He underwent coronary artery bypass 7 days
ago and has developed some necrotic ulcers on his abdominal wall. He has had two
myocardial infarctions in the last year. He was otherwise recovering well postoperatively. He is on intravenous un-fractionated heparin, aspirin, atenolol and
lisinopril. Examination shows a breathless, cyanosed man, with tachycardia and a
clear chest. His left leg is swollen and mottled. Chest X-ray is clear. Blood tests
show:
haemoglobin (Hb) 10.3 g/dl
white cell count (WCC) 5.3 x 109/l
platelets 35 x 109/l
blood film confirms low platelet count
activated partial thromboplastin time (APTT) 42 s (3040s)
What decision Hasina should give?
1. Give a unit of platelets to attain a platelet count of > 50 x 109/l
2. Change to low molecular weight heparin
3. Stop all heparin including flushes to cannulae until the platelet count returns to
normal
4. Stop heparin and start anticoagulation with danaparoid until the platelet count
returns to normal
5. Stop heparin and start anticoagulation with warfarin, once a thrombophilia test
had ruled out protein C or S deficiency
A 70-year-old woman presents with fatigue and confusion that has come on
gradually over several weeks. She is a retired secondary school teacher who
was still tutoring on a part-time basis until 3 months ago, but has recently
become reliant on family and neighbours for basic self-care. She has no
previous medical history of note and is taking only antacids for occasional
dyspepsia. She was brought to Dr Kamrul, director of Neurology, AIMS. On
examination she is disorientated; tone power and reflexes are all within
normal limits. Plantar responses are down going. Funduscopy shows
prominent retinal veins but is otherwise normal. There are bi-basal crackles
at both bases. Blood tests are shown below:
haemoglobin (Hb) 9.5 g/dl
What test was given by Kamrul?
white cell count (WCC) 5.3 x 109/l
1. Plasma viscosity
Platelets 120 x 109/l
2. Skeletal survey
Urea 10.3 mmol/l (2.57.5)
3. Serum protein electrophoresis
4. Urine for BenceJones protein
Bilirubin 21 mol/l (122)
5. Bone marrow trephine
Albumin 29g/l (3749)
Protein 113 (6076) g/l
erythrocyte sedimentation rate 95 mm/1st hour
calcium 2.3 mmol/l (2.22.6)
Kamrul gave a single test that established the likely cause of confusion.
An 84-year old man presents to hematology dept of AIMS with easy bruising of three
months duration. He was previously fit and well, but has lost a stone in weight
recently. He is on no medication and has no allergies. Direct questioning is
unremarkable other than some symptoms of prostatism. Examination shows him to
be icteric, with multiple bruising.
Investigations are shown below:
Hb 8.0 g/dl
WCC 33.7 x 109/l
Platelets 56 x 109/l
Activated partial thromboplastin time 48 s (3040)
Fibrinogen 0.9 g/l (1.85.4)
Bilirubin 35 mol/l
Blood film shows schistocytes, nucleated red blood cells, metamyelocytes and
myelocytes.
What is the most likely diagnosis?
i.
Prostate cancer
ii.
Chronic myeloid leukaemia
iii. Myelofibrosis
iv. Thrombotic thrombocytopenic purpura
v.
Haemolytic uraemic syndrome
Her brother died from sickle-cell disease 1 year ago. Investigations have in the past
been unremarkable and the pain has been put down to painful vaso-occlusive
crises. On examination she is in extreme pain and distress with widespread
guarding over the abdomen.
haemoglobin (Hb) 5.4 g/dl
white cell count (WCC) 6.3 x 109/l
platelets 403 x 109/l
bilirubin 135 mol/l (122)
alkaline phosphatase 235 U/l
What do you think is the most likely cause of this patients abdominal pain?
1. Splenic sequestration crisis
2. Vaso-occlusive sickle-cell crisis
3. Gallstones
4. Mesenteric infarction
5. Splenic infarction
A 19-year-old female student presents with marked bruising and gum bleeding of 3
days duration. She has no previous medical history of note and is on no regular
medication. Examination shows wide spread bruising and marked gingival bleeding.
Temperature is 37.1oC, blood pressure 120/75 mmHg and pulse 93 beats per
minute (bpm). Chest is clear and abdominal examination is normal. Investigations
are shown below:
haemoglobin (Hb) 10.3 g/dl
white cell count (WCC) 2.3 x 109/l
platelets 7 x 109/l
fibrinogen 0.9 g/l (1.85.4)
prothrombin time 20.3 s (11.515.5)
activated partial thromboplastin time (APTT) 53 s (3040s )
D dimers 3.2 mg/l (< 0.5)
blood film shows occasional atypical pro-myelocytes packed with azurophilic granules
What is the best treatment?
1. All-trans-retinoic acid
2. Epsilon aminocaproic acid
3. Tranexamic acid
4. Aprotonin
5. Low-dose heparin