Haem 12 & 13 - Tutorial Flashcards
CASE 1
Woman
68-year-old
Northern European
Goes to G.P.
PC/HxPC/Examination
- tiredness
- shortness of breath
- ankle swelling
- numbness of her feet
- tingling in her toes
- pale
- reduced sensation in her feet and legs
Explanation of Case 1
- Anaemia*
- Numbness of feet
Full Blood Count
- Low Hb therefore definitely anaemia
- Low WBC slightly
- High MCV
- Platelets a little bit low
Therefore, macrocytic anaemia
Can be due to
- B12 deficiency
- Folate deficiency
- Alcohol
Blood Film
- anisocytosis
- poikilocytosis
- oval macrocytes
- hypersegmented neutrophils
Neutrophils are only meant to have 5 segments
Having more segments is to do with B12 deficiency
Measure B12 and Folate in blood
B12 deficiency can cause peripheral neuropathy hence why she has tingling
Could be due to:
- Pernicious anaemia - autoimmune, make antibodies against intrinsic factor or to parietal cells that make intrinsic factor
- Problem with GI tract causing malabsorption
Could check antibodies or do shilling test
Treat with injected B12
CASE 2
Woman
56-year-old
Irish
Presents to her G.P.
PC/HxPC/Examination
- extreme tiredness
- lethargy
- breathlessness at rest, which is worse on exertion
- ankle swelling at the end of the day
- bowel symptoms
- In the last 6 months she has suffered intermittent diarrhoea and constipation and vague abdominal pain
- has lost 5kg in weight
Blood Count shows:
Explanation of Case 2
Anaemia
Full Blood Count
- Normal RBCs
- Normal WBCs
- Low Hb
- Platelets high
- Microcytic Anaemia*
- Could be due to low iron
Platelets can be high if there’s bleeding elsewhere in the body
6 months is a suspiciously long amount of time
Could be due to:
- Bowel Cancer
As if she has changed her diet/heavy menstruation
She has noticed no bleeding, but she could be bleeding and it has come out black
She is post-menopausal
She is not vegetarian
Investigations To Do
Check her iron
Colonoscopy
CASE 3
Woman
45-year-old
Attended Rheumatology Out-patients
PC/HxPC/Examination
- said that her joints had flared up
- felt dreadful
- severe rheumatoid arthritis of 7 years duration
- taken a variety of drugs including aspirin, non-steroidal anti-inflammatory agents and corticosteroids
- previous year she had been given a course of gold injections
Full Blood Count and Other Tests:
Explanation of Case 3
Gold injections for arthritis
Anaemia
Full Blood Count and Other Tests
- Low MCV
- Raised platelets due to inflammation
- High Erythrocyte Sedimentation Rate due to severed inflammation or infection
- Low iron
- Low transferrin
- Normal ferritin
Microcytic anaemia
Differential
Microcytic Anaemia could be due to:
- low iron deficiency
- anaemia of chronic disease
Normal ferritin
- does not exclude iron deficiency
- because it is an acute phase protein which can go up in inflammation
When iron deficient
- more transferrin is made to try and get as much iron as possible
- however, transferrin is low here
Therefore, is anaemia of chronic disease not iron deficiency anaemia
CASE 4
Male
5-year-old
English
PC/HxPC/Examination
- previously healthy
- several days of diarrhoea
- a week later his mother noticed that he was quite pale and listless and was passing dark urine
- she took him to GP
- found his pulse rate was 120/minute
- slightly yellow sclerae
- referred him to a paediatric A&E department
Explanation of Case 4
Examination
High pulse
Yellow sclerae points to jaundice
Jaundice causes are:
- pre hepatic: overload of bilirubin because of hemolysis
- hepatic: autoimmune, hep b etc
- post hepatic: gall bladder, pancreatic cancer
Diarrhoea
Pale
Tests to Do
Test for bilirubin for jaundice
Full blood count for anaemia
Full Blood Count
- Normal MCV
- High reticulocytes
- Immature RBCs which are the body’s compensation for sudden anaemia
Blood Film
- Bigger and bluer reticulocytes
- Not hepatic jaundice
Differential
ALP goes up in post hepatic but in this case it’s not (even though it is above normal range)
- ALP is a liver enzyme but it’s also found in bones
- Children’s bones are growing which is why ALP is high because the normal range is for adults
LDH is high
- goes up in any red cell hemolysis
Therefore, he definitely has jaundice and haemolytic anaemia
High creatinine
Points to haemolytic uraemic syndrome following e.coli Infection
- Haemolysis due to E. coli releasing toxins
CASE 5
Woman
19-year-old
Cypriot
PC/HxPC/Examination
- has recently married
- comes for preconceptual advice on her grandmother’s advice
- her 25-year-old cousin has required blood transfusion all her life
- her grandmother is afraid there is something ‘running in the family’.
Full Blood Count
Explanation of Case 5
Blood transfusion all her life
- cousin had thalassemia
Full Blood Count:
- Hb little bit low
- Low MCV
- WBC normal
Microcytic anaemia
Due to thalassemia
Investigations To Do
Serum ferritin to check for low iron
Hb electrophoresis to check for thalassemia
Investigations
- Normal ferritin
- Raised HbA2
Beta Thalassemia, high HbA2
Alpha Thalassemia, low HbA2
Next Investigations To Do
Test her husband to see if their children will potentially get Beta Thalassaemia Major
This woman only has Beta Thalassaemia trait
