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MRCP Part 1 > Haem, Onc, Palliative Care > Flashcards

Haem, Onc, Palliative Care Flashcards

1
Q

What causes a normocytic anaemia?

A

Anaemia without altered RBC structure

Anaemia of chronic disease

Acute blood loss

Aplastic anaemia

Haemolytic anaemia

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2
Q

What are the causes of microcytic anaemia

A

Thalassaemia: AR defects of haem chains

Anaemic of chronic disease

Iron deficency:can also be normocytic

Lead poisoning: blocks heme synthesising enzymes

Sideroblastic: Iron wont fit into RBCs

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3
Q

How do you investigate iron deficiency anaemia?

A

FBCs showing low Hb, can confirm if low ferritin

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4
Q

What is the initial management of iron deficiency anaemia?

A
  1. oral iron

+ IV iron or blood transfusion

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5
Q

For anaemia, when do you refer to…

Haematology

A

Supplementation fails to increase by 20g/L over 2-4 weeks and no GI or Gynae criteria

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6
Q

Paraesthesia, changes to mood and vision+/- mild jaundice suggests which anaemia?

A

B12 deficiency

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7
Q

What investigations suggest B12 deficiency

A

Macrocytic anaemia

Hypersegmented polymorphs

Low cobalamin is B12, low folate is folate

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8
Q

How do you treat B12 deficiency?

A

No neuro: IM hydroxycobalamin 3x day 2 weeks; 1 per 3 months afterwards

Neuro: IM 1mg every other day until improves

TREAT B12 BEFORE FOLATE

give folic acid 5mg day 4 months

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9
Q

When do you refer a vit B12 deficiency to…

Haem

Gastro

A

Haem: Uncertain, malignancy, resistant to treatment

Gastro: IBD, malabsorption, GI malignancy

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10
Q

How doe sickle cell present on…

FBC

Blood film

A

Microcytic anaemia

Sickle cells, howell-Jolly bodies

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11
Q

Outline the inheritance of sickle cell anaemia

A

AR inheritance of HbS instead of A.

One gene casues trait

Two causes disease

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12
Q

Compare vaso-occlusive, splenic sequestration, aplastic crisis and acute chest syndrome in terms of…

Pain

Associated symptoms

Lab findings

A

VOC // SS // AC // ACS

Localised pain // abdo pain // painless // painless

Fever, priapism // HSM, hypotension // infective Hx // Resp symptoms

Raised Hc // Severe anaemia // severe anaemia // Infiltrates on X-ray

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13
Q

How do you treat sickle cell crises?

A

Admit

Treat infection

IV fluids

Keep warm

Analgesia

Aspirate if priapism

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14
Q

What prophylaxis is given to sickle cell patients

A

Penicillin 3m-5yrs

PPV23 every 5 years

MenB + ACWY then another MenB 4 weeks later

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15
Q

What patient features might point towards thalassaemia?

A

Pronounced forehead and jaw

Jaundice, gallstone, splenomegaly

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16
Q

How do you diagnose thalassaemia?

A

Haem electrophoresis

DNA testing

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17
Q

How do you treat thalassaemia that is

alpha

Beta…

minor

intermedia

major

A

Alpha: monitor. Transfusions and bone marrow transplant potentially.

Bm: Conservative

BI: monitor + transfuse

BM: regular transfusion, chelation and splenectomy. Bone transplant can be curative

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18
Q

Anaemia + gallstones + large spleen

Blood film…

Diagnose and treat

A

Hereditary spherocytosis

Folate supplementation + splenectomy

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19
Q

Patient with PMHx of infections + jaundice after eating beans

A

G6PD deficiency

Heinz enzyme assay to confirm

Avoid triggers

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20
Q

What are the features of leukaemia?

A

Abnormal bruising

Splenomegaly, lymphadenopathy

Palness, fever, fatigue

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21
Q

Where suspected, what are the 1st line and GS test in leukaemia?

A

1st: <48hr FBC

GS: Bone marrow biopsy

+ blood film biopsy

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22
Q

How are the leukaemias distributed by age?

A

ALL CLLmates have CMMon AMbitions

ALL: <5s, >45s

CLL: Over 55

CML: Over 65

AML: Over 75

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23
Q

How can ALL, CLL, AML and CML be differentiate based on

Clinical history

Blood results

A

ALL: Children, Down’s syndrome, Blast cells (left)

CLL: Most common in adults, Smudge cells (right

AML: Myeloproliferative, Auer rods (middle)

CML: Raised WCC/low Hb, plts, pancyto

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24
Q

How do you treat leukaemia?

A

Chemo and steroids

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25
Q

What are the general features of a lymphoma?

A

Painless, assymetrical lymphadenopathy

+ systemic B symptoms

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26
Q

How do NHL and HL differ on…

Age

Symptoms

Cells

Associations

A

NHL // HL

>75s // 20s, 70s

Early B symptoms, extra-nodal disease // painful nodes on alcohol

Depends on subtype // Reed sternberg cells

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27
Q

How is Lymphoma confirmed?

A

Lymph node biopsy

+CT/MRI/PET

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28
Q

What is myeloma and its subgroups

A

Plasma cell malignancy resulting in excess antibody production

MGUS: Raised antibodies without specific infection

Multiple myeloma: affected multiple sites

Smouldering: MGUS progression with higher Ig levels; waldenstrom’s if specifically IgM raised

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29
Q

>60s presents with bone pain.

Bloods show rasied calcium, total protein and renal impairment

What is the diagnosis

A

myeloma

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30
Q

What investigations are performed in suspected myeloma?

A

Monoclonal IgM or IgA in serum and urine (BJ proteins)

Increased plasma cells on bone marrow biopsy

Whole body MRI for bone lesions

+ ‘tear-drop skull’ on X-ray

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31
Q

B symptoms + splenomegaly + the following bloods indicate what?

Raised Hb

Raised platelets

Low Hb, abnormal platelets + WCC, teardrop RBCs

A

Myeloproliferative disorders

Polycythaemia vera

Essential thrombocytopaenia

Myelofibrosis

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32
Q

How do you treat…

Polycythaemia vera

Essential thrombocytopaenia

MF

A

PC: Venesection, chemo

ET: chemo

MF: Chemo + stem cell transplant

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33
Q

How do you stage Hodgkin’s lymphoma?

A

Ann-Arbor staging

I: Single lymph node

II: 2 or more nodes/regions on same diaphragm side

III: Nodes on both sides of diaphragm

IV: Spread beyond lymph nodes

+ A: Pruritis only

B: >10% weight loss, fever >38 degrees, night sweats

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34
Q

What are the diagnostic criteria for myeloma

A

Factor: Major // minor

Imaging: Plasmacytoma // osteolytic lesions

Plasma cells: 30% // 10-30%

M protein: Elevated // minor elevations

+ low antibody levels for minor

NEED 1 MAJOR + 1 MINOR / 3 MINOR

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35
Q

What are the subtypes of non-hodgkin’s lymphoma and their associations?

A

Burkitt’s: EBV, tumour lysis, ‘starry sky’ histology

MALT: H. pylori, perigastric tissue

Diffuse B cell: rapidly growing painless mass in >65yrs

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36
Q

Muscle cramps in a NHL patient just starting chemo suggests what and how is it prevented?

A

Tumour lysis syndrome in burkitt’s lymphoma

Give rasburicase to prevent uric acid –> allantoin

Allopurinol is alternative

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37
Q

Infant experiencing painful swelling in hands and feet in absence of other pathology suggests what?

A

Thrombotic crises

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38
Q

How can you distinguish ITP, TTP and DIC in terms of…

Symptoms

Labs

Cells

A

ITP // TTP // DIC

Bleeding // ‘The Terrible Pentad’* // Bleeding, sepsis

high bleed time // high bleed, low platelets // high bleed, low platelets + D-dimer

none // schistocytes // schistocytes

39
Q

Polycythaemia rubra vera is most likely to convert into which cancer?

A

AML or myelofibrosis

40
Q

What test confirms the diagnosis if spherocytes are found on blood film?

A

DIRECT coomb’s test

confirms diagnosis of haemolytic anaemia

41
Q

What is offered for palliative pain intially?

A

Unless co-morbidities…
20-30mg MR morphine daily + 5mg breakthrough pain
+ Laxatives
Nausea and drowsiness should be transient

42
Q

What should be offered as therapy for those with renal impairment?

A

Mild-mod: Oxycodone

Severe: Buprenorphine, fentanyl, alfentanil

43
Q

What pain relief is available for bone pain?

A

Strong opioids
Bisphosphonates
Radiotherapy

44
Q

How much should you increase an opioid dose?

A

30-50%

45
Q

How do you convert between
oral codeine and morphine
Oral tramadol and oral morphine

A

Divide both instances by 10

46
Q

How do you convert…
Oral morphine to SC morphine
Oral morphine to SC diamorphine
Oral oxycodone to SC diamorphine

A

/2
/3
/1.5

47
Q

How much oral morphine are the following equal to…
TD fentanyl 12ug
TD buprenorphine 10mg

A

30mg

24mg

48
Q

If a palliative patient is agitated or confused what do you give
1st line
Alternatives
If in terminal phase

A

Haloperidol
-promazines
midazolam

49
Q

Antiemesis for GI related stasis

A

Metoclopramide (unless prokinesis will worsen eg obstruction)
Domperidone

50
Q

Antiemesis for chemical nausea (eg chemo)

A

Correct the cause first

Ondansetron/haloperidol/levomepromazine

51
Q

Antiemesis for visceral/serosal causes of nausea

A

Cyclizine, levopromazine

+ Anti-cholinerigcs eg hyoscine

52
Q

Antiemesis for raised intracranial pressure

A

Cyclizine for nausea
Dexamethasone can be used
Radiotherapy to reduce mass effect

53
Q

Antiemesis for vestibular nausea

A

Cyclizine

Metoclopramide/prochlorperazine if refractory

54
Q

Antiemesis for anxiety/pain (cortical)

A

Antiemesis for anxiety/pain (cortical)

55
Q

For syringe drivers what is…
Used for respiratory secretions
the choice for pain
the drug that can cause interactions most generally

A

Hyoscine, glycopyrronium
Diamorphine
Cyclizine

56
Q

What is good for mouth pain in palliative care
Generally
With evidence of gum disease

A

Benzydamine hydrochloride

57
Q

What can you give for hiccups in palliative care

A

Chlorpromazine or haloperidol

58
Q

What are the top 5 cancers in terms of:
Prevalence
Mortality

A

Prevalence // Mortality
1. Breast // Lung
2. Lung // Colorecal
3. Colorectal // Breast
4. Prostate // Prostate
5. Bladder // Pancreas

59
Q

What biomarker indicates poor prognosis in myeloma

A

Raised B2 microglobulin

60
Q

How can you differentiate G6PD and hereditary spherocytosis

A

G6PD // Hereditary spherocystosis
Both: Neonatal jaundice + gallstones
Haemolysis: Drugs/infection // chronic
Inheritance: X-linked // AD
Splenomegaly: Less common // more common
Blood film: Heinz bodies // spherocytes
Diagnostic test: G6PD enzyme activity // EMA binding

61
Q

How is the does the BCR-ABL protein…
Come about
Affect cell activity

A

Translocation of philadelphia chromosome (9:22)(Q34;Q11)

Creates abnormally active tyrosine kinase
Subsequent phosphorylation leads to continuous cell division and proliferation.results

62
Q

What cancer are the following markers linked to
CA15-3
CA19-9
CA125
CEA
AFP

A

Breast
Pancreatic
Ovarian
Colorectal
Hepatocellular

63
Q

What is the universal donor of FFP

A

AB (does not contain antibodies)

64
Q

What primary immunodeficiencies are neutrophil disorders

A

Chronic granulomatous disease: NADPH oxidase reduces phagocytic ROS
Chediak-Higashi: microtubule defect reduces phagocytosis
Leukocyte adhesion deficiency

65
Q

What drugs can induce symptoms in G6PD

A

Anti-malarials
Cipro
Sulph-group drugs

66
Q

Which neutrophil disorder are the following
Recurrent pneumonia due to catalase +ve bacteria
Partial albinism + bacterial infections + giant granules in neutrophils
Recurrent infections + delayed umbilical cord sloughing + absence of neutrophils at infection sites

A

Chronic granulomatous disease
Chediak Highashi syndrome
Leukocyte adhesion deficiency

67
Q

What are the primary B cell disoders

A

Common variable ID: low IgA/G/M
Bruton’s congenital agammaglobulinaemia: X-linked recessive + absent B cells + reduced IgG
Selective immunoglobulin A ID: Severe reactions to blood transfusions + positive coeliac testing

68
Q

What T cell disorder causes primary immunodeficiency?

A

DiGeorge: Cleft palate + Tetralogy of Fallot + learning needs

69
Q

What are the combined B+T cell primary immunodeficiencies

A

SCID WAS Ataxic
SCID: Reduced T cell receptor excision
Wiskott-Aldrich: X-linked recessive + eczema + low IgM
Ataxic telangectasia: Autosomal recessive

70
Q

What blood film result can be seen in lead poisoning

A

Basophilic stippling

71
Q

What are the following translocations associated with
9;22
15;17
8;14
11;14
14;18

A

9;22: CML, poor prognosis in AML
15;17: APML
8;14: Burkitt’s lymphoma (Burkitt has 8 letters)
11;14: Mantle cell lymphoma
14;18: follicular lymphoma (18 as most letters)

72
Q

What is the key investigation in chronic lymphocytic leukaemia?

A

Immunophenotyping

73
Q

Which haemolytic anaemias are
Intravascular
Extravascular

A

Intra: MRCGP
Mismatched transfusion
Red cell fragmentation: DIC, HUS, TTP
Cold AIHA
G6PD deficiency
Paroxysmal nocturnal haemoglobinuria

Extra: 4 Hs
HDNB
Hereditary spherocytosis
Haemoglobinopathies
Hot (warm) AIHA

74
Q

What is the most common organisms (by lab grouping) in neutropaenic sepsis?

A

Gram positive, coag negative bacteria

75
Q

What cancer is BRCA2 associated with in men

A

Prostate

76
Q

Which chemotherapies cause
Haemorrhagic cystitis
Lung fibrosis
Cardiomyopathy
Lung + liver fibrosis
Dermatitis
Ataxia
Periperhal neuropathy + paralytic ileus
Nerve damage + low magnesium

A

Cyclophosphamide
Bleomycin
Antracyclines (doxorubicin)
Methotrexate
5-FU
Cytarabine (cytara-been drinking too much = ataxia)
Vincristine/vinblastine
Cisplatin

77
Q

Which chemotherapies DO NOT cause myelosuppression

A

Bleomycin
Anthracyclines
Docetaxel
Cisplatin

78
Q

What is the first line treatment for ITP

A

Oral prednisolone

79
Q

What is the most common inherited
Bleeding disorder
Thrombophilia

A

Von Willebrand’s (Reduced platelet activity + factor VIII)
Factor V leiden (activated protein C resistance)

80
Q

What are contraindications to platelet transfusions?

A

Chronic bone marrow failure
Thrombocytopaenias: Heparin, Autoimmune, TTP

80
Q

What is the threshold for platelet transfusion
Stable
Unwell
Pre-op

A

10
30
50

81
Q

Outline the ECOG score

A

0: Independent
1: Restricted to light work
2: Ambulatory but unable to work; >50% up and about
3: Limited selfcare, <50% up and about
4: Completely disabled, bedbound
5: Dead

82
Q

What haem condition sees angioedema without urticaria +/- preceding macular rash
What serial blood markers are useful
How do you treat

A

Hereditary angioedema
C1-INH, C2-4 low
C1 inhibitor concentrate/FFP

83
Q

What are the risk factors of cervical cancer

A

HPV
Huffing cigs
HIV

84
Q

What condition is a result of failure to cleave vWF normally

A

TTP

85
Q

What is a leukaemoid reaction and how is it differentiated from CML

A

Presence of immature cells in peripheral blood due to increased strain on bone marrow production (haemolysis, haemorrhage, cancer)
Leukaemoid // CML
l-ALP: High // low
toxic granulation of WCC // none
left shift (<3 segments) // no left shift of neutrophils

86
Q

What is the rarest thrombophilia?

A

Antithrombin III deficiency (highest VTE risk though)

87
Q

How can you quickly determine from lab values which bleeding disorder you have?

A

Haemophilia (1 word): APTT
vWB: APTT, PT
DIC (3 words): APTT, PT, BT

87
Q

How can vWB, haemophilia, antiphospholipid syndrome be differentiated since it causes prolonged APTT

A

vWB // haemophilia
// low factor XIII (A) or IX (B)

88
Q

Why are anaphylaxis patients observed for a day?

A

Biphasic reactions 20% patients

89
Q

What blood test findings indicate thalassaemia
How can alpha and B be distinguished

A

Disproportionate microcytic anaemia
Electrophoresis: Normal in A, HBA2 raised in B

90
Q

Raised K, PO4, Uric acid + low Ca indicates what post chemo?
When is it deemed clinically worrying?
How is it managed?

A

Tumour lysis syndrome
Clinical: 1.5 creat, cardiac arrhythmia, seizure
IV fluids, + rasburicase (uric acid –> allantoin) OR allopurinol; this helps excretion of salts

91
Q

Hamolytic anaemia with thrombosis + dark urine in morning suggests what?
What test would confirm
How is it treated?

A

PNH
Flow cytometry of CD59+55
Blood products + anticoag

92
Q
A

MRCP Part 1 (32 decks)

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