Transcript Haematology /Oncology

Haematology Master Class
Dr Bill Renwick
May 2010
Question 1.
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A 47 year old married accounts clerk presents to his local general
practitioner complaining of fatigue and exertional dyspnoea. His past history
is well known to the GP and includes hypertension and hyperlipidaemia.
Current medications include:
Low dose aspirin
Methyldopa
Simvastatin
On Examination he is pale with mild icterus. There is no lymphadenopathy
or organomegaly. He is afebrile and BP is 120/80.
The following blood tests are arranged and the results are as follows.
Full Blood Examination
– Hb 80 g/dl - (130-180) g/dL
– WCC – 8 x 109/L (4.0-11.0) x 109/L
– Platelets – 300 - (150-400 x 109/L)
Reticulocyte count – 6% ( normal= <2.5%)
Blood Film – many spherocytes are seen
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LFTs
ALT – 30 (<55 IU/L)
AST-28 (0-40 IU/L)
Gamma GT-37 (<50 IU/L)
Total Bilirubin- 50 (0-19 ) mmol/L)
• Which of the following test sets will aid diagnosis ?
• a) Iron Studies, Upper Gastrointestinal Endoscopy
• b) Direct antiglobulin test ( direct Coombs test) , LDH, Haptoglobins
• c) B12, Floate, anti gastric intrinsic factor antibody , anti gastric
parietal cell antibody and fasting gastrin
• d) Upper gastrointestinal ultrasound, amylase and blood sugar.
Question 2.
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You are the intern on a receiving orthopaedic unit one Sunday evening. You
are asked to admit Mrs Ivy Jones, a 73 year old lady who is having a total
hip replacement first on the list on Monday morning.
As part of your admission assessment you requested a clotting profile
The results are as follows:
APTT – 42 seconds ( normal < 37 secs)
INR – 1.1 ( normal< 1.3)
Fibrinogen – 2.4 ( normal > 2.0 )
In light of these results what would the most appropriate next step be?
a) Allow the procedure to proceed – the APTT is only mildly prolonged.
b) Exclude that Mrs Jones is on warfarin
c) Cancel the case pending further investigation of the prolonged APTT
d) These findings are consistent with a lupus inhibitor so the case can
proceed
Question 3.
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As the covering night RMO you are asked to see Ms. Proster, an 86 year
old lay who has been in hospital for 10 days with pneumonia. Four days ago
she fell from bed and fractured her ankle which requires open reduction and
internal fixation ( ORIF). She is now well enough to have the operation but
because of her age and co-morbidities she will have the procedure under a
spinal anaesthetic.
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The nursing staff have called you to come and review her pre op blood
tests that the day RMO didn’t get around to.
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The results are:
APTT 42 seconds ( < 37 seconds)
INR – 1.1 ( n <1.3 seconds)
Fibrinogen – 2.4 ( n > 2.0)
Question 3.
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Which of the following should you do?
a) Allow the operation to proceed as the clotting and haemostatic
abnormality is mild.
b) Check to see if the patient is on prophylactic dose heparin and advise
both the lab and the anaesthetist of this.
c) Check when her warfarin was ceased and request Fresh Frozen
Plasma ( FFP) from the lab.
d) Check if the patient is on Aspirin and with-hold the dose prior to surgery.
Question 4.
• You are doing your intern rotation in the emergency department of a
country hospital. A 34 year old musician presents febrile and unwell.
His accompanying family report that he is in the middle of cycles of
chemotherapy for non hodgkins lymphoma. His last doses of
intravenous chemotherapy were in the oncology day ward one week
ago.
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The most appropriate management of this patient is
a) admission for intravenous antibiotics post cultures.
b) Discharge with phone follow up the next day
c) Work up for sepsis and arrange clinic review for results
d) Home on oral antibiotics after appropriate cultures.
Question 5.
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A 75 year old visits a new GP. She has been widowed for 10 years and lives
alone. Her main complaint today is increasing fatigue and shortness of
breath on exertion. She is increasingly immobile due to worsening
osteoarthritis. She is now essentially housebound and receives monthly
visits from her only daughter.
A number of investigations are done and she returns for the results
FBE – Hb – 65 g/dl (115–150g/dL)
MCV - 105
WCC – 3.5 (4–11x109/L)
neutrophil – 1.8x109/L (2.0–8.0x109/L)
Platelets – 112 (150–400x109/L)
Blood Film – there are some oval macrocytes and neutrophil
hypersegmentation.
Question 5.
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The most likely diagnosis is
a) Hypothyroidism
b) Iron deficiency
d) B12 and folate deficiency
e) Blood loss
Question 6.
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A 19 year old supermarket packer presents to the LMO with epistaxis. She
notes several bruises that have appears over the last few days in the
absence of apparent trauma.
On questioning she recalls a flu like illness several weeks ago. She is on no
current medications. Past history is unremarkable.
On examination – there are numerous pre tibial and truncal petechiae,
cervical lymphadenopathy and mild splenomegaly.
The most likely diagnosis is
a) Thrombotic Thrombocytopenic Purpura
b) Non-Hodgkin Lymphoma
c) Von Willebrand’s Disease
d) Immune Thrombocytopenia
Question 7.
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Investigations reveal the following:
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Blood film – there is no microangiopathy . Numerous atypical lymphocytes
are noted.
FBE – Hb – 120 - (115–140 gldL)
WCC – 10.00 x 109/L (4.0–11.0x109/L)
Platelets -2x109/L (150–400x109/L)
• The next most appropriate investigation is?
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a) Bone marrow aspirate and trephine
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b) Monospot test
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c) Factor 8 assay and von Willebrand’s antigen level
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d) CT neck / chest and pelvis
Question 8.
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68 man for routine surgery noted to have non-tender cervical lymph nodes.
FBE
Hb 125 ( 130 -175)
WCC 19.5 neutrophils 2.5 lymphocytes 16.2
Platelets 213.
Film increased lymph and ‘smear cells’
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Most likely diagnosis?
a)
Follicular Non-Hodgkin Lymphoma
b)
Acute Lymphoblastic Leukaemia
c)
Chronic Lymphocytic Leukaemia
d)
Hodgkin Lymphoma
Question 9.
• Intravenous infusion of which of the following blood components is
most likely to be associated with a septic transfusion reaction?
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a) Red cell concentrate.
b) Fresh frozen plasma.
c) Pooled gammaglobulin.
d) Platelet concentrate.
e) Cryoprecipitate.
Question 10.
• A previously well 37 man presents with lethargy and easy bruising
over several weeks.
• Examination – occasional bruises.
• FBE Hb 125 (130-175), MCV 82 (80-96), WCC 8.8 (4.0-11.0),
Platelets 1060 (150-400).
• Film shows numerous platelets, many large forms.
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Most likely Dx is:
A. Essential thrombocythaemia.
B. Occult haemorrhage.
C. Primary myelofibrosis.
D. Occult carcinoma.
E. Chronic myeloid leukaemia.
Question 11.
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67 man Hx smoking with new angina.
Ex – plethoric / hypertensive
FBE Hb 205 (128-175), Hct 57% (36-50), MCV 78 (80-97),
WCC 11.6 ne 9.5 (1.5-6) ly 0.6 (0.7-3.15) eo 0.8 (0.0-0.4) bas 0.4 (0-0.15)
Plts 499 (150-396), Red cell mass 39 mL/kg (28-35), plasma vol 49 ml/kg
(40-50), se EPO 4.9 (4.8-21.9)
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Most likely explanation:
A. Carcinoma of lung.
B. High affinity haemoglobin.
C. Dehydration.
D. COPD.
E. Polycythaemia vera.
Question 12.
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28 man presents with fractured ankle. Routine blood tests reveal:
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FBE Hb 115 (130-175) RCC 5.6 (4.0-5.4)
MCV 62 (80-96)
WCC 12.5 (4.0-11.0) Platelets 390 (150-400)
Ferritin 95 ( 15-200)
Thalassaemia screen
HPLC HbA2 5.2% (1.8-3.5) HbF 1.2% (0-2.0) HbH prep neg
HbElectrophoresis - no abnormal bands
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Most likely cause?
A. Beta-thalassaemia trait.
B. Chronic blood loss.
C. Anaemia of chronic disease.
D. Congenital sideroblastosis.
E. Sickle cell trait.
Question 13
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75 year old lady presents to ED following a fall. She has a history of AF and
embolic CVA for which she takes warfarin.
She has some bruises on her shins and a BP of 170/80 but is otherwise
well. No other findings on examination. No bleeding.
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Routine investigations in ED show creatinine 170 and INR 7.1.
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What is the most appropriate management of her raised INR?
a) Withhold warfarin
b) Withhold warfarin + give vitamin K
c) Withhold warfarin + give vitamin K + prothrombin complex
d) Withhold warfarin + give vitamin K + FFP + prothrombin complex
e) Withhold warfarin + give FFP + prothrombin complex