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3B > NEW HAEM 2 > Flashcards

NEW HAEM 2 Flashcards

1
Q

Multiple myeloma aetiology

A

Malignant proliferation of plasma cells
Increased production of Ig - Paraproteins
Accumulation in the renal system - Bence-Jones proteins

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2
Q

Multiple myeloma clinical features

A

CRAB-E

Calcium - Hypercalcaemia - Increased osteoclast activity

  • GROANS
  • STONES
  • MOANS
  • THRONES
  • BONES

Renal (AKI) - Light chain deposition within renal tubules - Bence-Jones protein

  • Dehydration
  • Increasing thirst

Anaemia - Pancytopenia

Bones - BM infiltration by plasma cells + Cytokine mediated osteoclasts

  • Lytic bone lesions
  • Back pain
  • Fragility fractures
  • Raindrop skull

ESR ^ - Increased risk of VTE

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3
Q

Multiple myeloma investigations

A 
BM biopsy - Monoclonal plasma cells
Serum/urine electrophoresis - Monoclonal paraprotein
Calcium profile - Isolated calcium ^
U&E - Urea/creatinine ^
FBC - Pancytopenia
ESR
Blood film - Rouleaux formation

Skeletal survey - WBCT / MRI

  • Raindrop skull - Numerous dark spots seen on XR
  • Osteopenia
  • Osteolytic lesions
  • Pathological fractures
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4
Q

Multiple myeloma diagnosis

A
  1. Monoclonal plasma cells in BM
  2. Monoclonal proteins within serum/urine on electrophoresis
  3. Evidence of end-organ damage - Hypercalcaemia, AKI, etc.
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5
Q

Multiple myeloma management

A

Induction therapy
BM transplant

Manage symptoms

  • Hypercalcaemia - Hydrate + Bisphosphonates
  • Hyperviscosity - VTE prophylaxis (Aspirin)
  • Renal - Hydrate
  • Infections - Vaccinations + Ig
  • Fatigue - EPO
  • Pain - Analgesia
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6
Q

Hodgkin’s lymphoma aetiology

A

Malignant proliferation of lymphocytes
20-30
60-70

Risk factors

  • Family history
  • T-cell disorders
  • EBV
  • H.Pylori
  • Ionising radiation
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7
Q

Hodgkin’s lymphoma clinical features and investigations

A 
Painless lymphadenopathy - More painful after drinking alcohol
SOB
Cough + Haemoptysis 
Hepatosplenomegaly 
B-symptoms

Investigations

  • FBC - Hb and Pt - Low
  • ESR ^
  • CXR - Mediastinal mass
  • PET-CT - Staging
  • USS + Lymph node biopsy - Reed Sternberg cells
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8
Q

Hodgkin’s lymphoma staging and management

A 
Ann-Arbor classification
1. Single lymph node
2. 2 or more lymph nodes on the same side of the diaphragm
3. Nodes on either side of the diaphragm
4. Metastatic spread beyond lymph nodes
A. No systemic symptoms
B. Systemic symptoms

Management - Chemo/Radio - ABVD

  • Doxorubicin - Adriamycin
  • Bleomycin
  • Vinblastine
  • Dacarbazine
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9
Q

Non-Hodgkin’s lymphoma aetiology

A

Malignant proliferation of lymphocytes
B-cells or T-cells
1/3 cases over the age of 75

Risk factors

  • Caucasian
  • History of viral infection - EBV
  • Family history
  • Certain chemical agents - Pesticides / solvents
  • Chemo/Radio
  • Immunodeficiency - Transplant, HIV, DM
  • AI disease - Sjogren’s, SLE, Coeliac
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10
Q

NHL clinical features

A

Painless lymphadenopathy
Hepatosplenomegaly
Testicular mass

B-symptoms

Extranodal disease - More common in NHL

  • Gastric - Dyspepsia, dysphagia, weight loss, abdo pain
  • Bone marrow - Pancytopenia, bone pain
  • Lungs
  • Skin
  • CNS - Nerve palsies
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11
Q

NHL investigations and management

A

FBC - Pancytopenia
Blood film - Nucleated RBCs + Left shift
USS + Lymph node biopsy
LDH ^

Staging - Ann-Arbor

Management - RCHOP 21 days

  • Rituximab
  • Cyclophosphamide
  • H - Doxorubicin
  • O - Vincristine
  • Prednisolone
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12
Q

AML

A

Clinical features - BM failure

  • Anaemia
  • Neutropenia
  • Thrombocytopenia
  • Hepatosplenomegaly
  • Bone pain
  • Lymphadenopathy

Investigations

  • FBC - Macrocytic pancytopenia
  • Blood film - Blasts + Auer rods
  • BM biopsy - Blasts + Auer rods

Classification - French-American-British - FAB

Management - Chemo/Radio

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13
Q

ALL

A

Acute leukaemia in children

Clinical features

  • Pancytopenia
  • Hepatosplenomegaly
  • Bone pain
  • Fever
  • Testicular swelling

Types

  • Common - 75%
  • T-cell only - 20%
  • B-cell only - 5%

Investigations

  • FBC - Pancytopenia
  • Blood film - Leukaemic lymphoblasts
  • BM biopsy - Lymphoblast infiltration

Management - Chemo/Radio

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14
Q

CML aetiology and clinical features

A

Philadelphia chromosome!
Malignant clonal disorder of haematopoietic stem cells

Clinical features - 60-70

  • Anaemia
  • Weight loss
  • Diaphoresis
  • Splenomegaly - Abdo discomfort
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15
Q

CML investigations and management

A

FBC

  • Anaemia
  • WCC ^
  • Thrombocytopenia

Blood film

  • Maturing myeloid cells
  • Basophils
  • Eosinophils

BM biopsy - Granulating hyperplasia

Genetic testing - Philadelphia chromosome

Management - Chemo/Radio

  • Imatinib - Tyrosine kinase inhibitor
  • Hydroxyurea
  • Interferon-Alpha
  • BM transplant
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16
Q

CLL

A

Monoclonal proliferation of well-differentiated lymphocytes
Almost always B cells

Clinical features - Asymptomatic

  • Anaemia
  • Lymphadenopathy
  • Splenomegaly

Investigations

  • FBC - Anaemia + WCC ^
  • Blood film - Smudge/smear cells
  • Immunophenotyping

Management - Chemo/Radio

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17
Q

DVT clinical features

A

May occur in upper extremities

  • Portal vein
  • Mesenteric vein
  • Ovarian vein
  • Retinal vein
  • Cerebral venous sinus

Clinical features

  • Calf swelling
  • Localised pain along deep venous system
  • Asymmetric oedema
  • Prominent superficial veins
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18
Q

Wells score

A

Wells score

  • Active cancer - 1
  • Calf swelling > 3cm - 1
  • Prominent superficial veins - 1
  • Pitting oedema - 1
  • Swelling of entire leg - 1
  • Localised pain - 1
  • Immobilisation - 1
  • Bed rest > 3 days or surgery with GA in last 12 weeks - 1
  • Previous DVT/PE - 1
  • Alternative diagnosis more likely (-2)
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19
Q

DVT investigations and management

A

Wells score
D-dimer if Wells < 2
USS if Wells > 2 or D-dimer +ve

USS not available within 4 hours - Anticoagulate - Rivaroxaban

Management - Anticoagulate - 3 months if provoked, 6 months if unprovoked

  • DOAC - Rivaroxaban
  • Renal impairment - LMWH
20
Q

Antiplatelets

A

Always assess HASBLED!

ACS/PCI

  1. Aspirin - Lifelong
  2. Ticagrelor - 12 months
  3. Clopidogrel - Lifelong

Ischaemic stroke / TIA

  1. Clopidogrel - Lifelong
  2. Aspirin - Lifelong
  3. Dipyridamole - Lifelong

PAD

  1. Clopidogrel - Lifelong
  2. Aspirin - Lifelong
21
Q

DIC aetiology

A

Activation of coagulation pathways
Intravascular thrombi
Platelet and clotting factors depleted
Thrombi = Vascular obstruction and multi-organ failure

Spontaneous bleeding may occur

Triggers

  • Sepsis
  • Major trauma
  • Obstetric complications - Amniotic fluid embolism, haemolysis, HELLP
  • Malignancy
  • Major vascular disorders
22
Q

DIC clinical features

A

Systemic signs of circulatory collapse

  • Oliguria
  • Tachycardia
  • Hypotension

Purpura fulminans, gangrene, acral cyanosis
Delirium / Coma
Petechiae, ecchymosis, oozing, haematuria

23
Q

DIC investigations and management

A 
Platelets - Low
PT ^
aPTT ^ 
Bleeding time ^
Fibrinogen - Low
D-dimer ^
Blood film - Shistocytes - Microangiopathic haemolytic anaemia

Management - Treat cause + Transfusion

  • Platelets
  • FFP
  • Cryoprecipitates
  • Fibrinogen concentrates
24
Q

High INR

A

Major bleeding

  • Stop Warfarin
  • Vitamin K - 5mg IV
  • Prothrombin complex concentrate

INR > 8

  • Stop Warfarin
  • Vitamin K - 1-5mg (PO if stable, IV if bleeding)
  • Check INR after 24 hours
  • Restart Warfarin when INR < 5

INR 5-8 + Minor bleeding

  • Stop Warfarin
  • Vitamin K - 1-3mg IV
  • Restart Warfarin when INR < 5

INR 5-8 - No bleeding

  • Withhold 1 or 2 doses of Warfarin
  • Reduce subsequent maintenance dose
25
Q

Overdose management

Paracetamol
Salicylate
Opioid
Benzos
Tricyclics
Lithium
Warfarin
Heparin
BBs
Digoxin
A

Paracetamol

  • Activated charcoal < 1 hour
  • NAC

Salicylate

  • Urinary alkalisation - IV bicarb
  • Haemodialysis

Opioid - Naloxone

Benzos - Flumazenil (seizure risk)

Tricyclics - IV bicarb

Lithium

  • Volume resus - NaCl
  • Haemodialysis

Warfarin - Vitamin K + Prothrombin

Heparin - Protamine sulphate

BBs

  • Bradycardia - Atropine
  • Resistant - Glucagon

Digoxin - Digoxin-specific antibody fragments

26
Q

Poisoning management

Ethylene glycol
Organophosphate
Iron
Lead
CO
Cyanide
A

Ethylene glycol / Methanol

  • Fomepizole
  • Ethanol
  • Haemodialysis

Organophosphate insecticides - Atropine

Iron - Desferroxamine

Lead

  • Dimercaprol
  • Calcium edetate

CO - Hyperbaric 100% O2

Cyanide

  • Hydroxycobalamin
  • Amyl nitrate / Sodium nitrate / Sodium thiosulphate
27
Q

ITP

Evan’s syndrome

A

Immune thrombocytopenia - Well patient with thrombocytopenia

  • Autoimmine
  • Adults - Chronic
  • Children - Acute following infection or vaccination

Clinical features - Incidental finding?

  • Petichae / Purpura
  • Bleeding - Epistaxis

Investigations - Isolated platelet count < 100

Management

  • Pred PO
  • IVIG
  • Children - Platelet transfusion

Evan’s syndrome - ITP + AIHA

28
Q

TTP aetiology and clinical features

A

Thrombotic thrombocytopenic purpura - Unwell patient with thrombocytopenia

  • Antibodies against enzyme that cleaves vWF
  • Large vWF multimers leading to platelet aggregation

Clinical features - PENTAD

  1. Microangiopathic haemolytic anaemia
  2. Thrombocytopenic purpura
  3. Neuro dysfunction
  4. Renal dysfunction
  5. Fever
29
Q

TTP investigations and management

A 
FBC/LFT - Haemolytic anaemia
Platelets - Low
Blood film - Shistocytes
Urinalysis - Proteinuria
Urea and creatinine ^

Management

  • Plasma exchange
  • Prednisolone PO
30
Q

Lymphadenopathy DDx

A

Infective

  • Infectious mononucleosis - EBV
  • HIV
  • Eczema
  • Rubella
  • Toxoplasmosis
  • CMV
  • TB
  • Roseola infantum

Neoplastic - Leukaemia / Lymphoma

Others

  • AI - SLE/RA
  • Graft vs host disease
  • Sarcoidosis

Drugs

  • Phenytoin
  • Allopurinol
  • Isoniazid
31
Q

EBV clinical features

A

HHV4

  1. Fever
  2. Pharyngitis
  3. Lymphadenopathy
Malaise
Palatal petechiae
Splenomegaly - Risk of rupture
Haemolytic anaemia
Maculopapular rash in patients who take amoxicillin!
32
Q

EBV investigations and management

A

FBC - Lymphocytosis + Haemolytic anaemia
EBV-specific antibodies
Monospot test - Heterophile antibodies - Non-specific
LFTs ^

Management - Supportive - Resolves in 2-4 weeks

  • Avoid sport for 8 weeks - Risk of splenic rupture
  • Airway obstruction - Pred
  • Thrombocytopenia - Pred or IVIG
33
Q

CMV aetiology

A

B-Herpes virus

Asymptomatic if normal immune function

Infected cells have “owls eye” appearance

Risk factors - Immunocompromise

34
Q

CMV manifestations

A

Congenital CMV

  • Growth retardation
  • Pinpoint petechial “blueberry muffin” skin lesions
  • Microcephaly
  • SN deafness
  • Encephalitis - Seizures
  • Hepatosplenomegaly

CMV mononucleosis

CMV retinitis

  • HIV patients with low CD4 < 50
  • Blurred vision
  • Fundoscopy - Retinal haemorrhages and necrosis - Pizza retina
  • Treatment - IV Ganciclovir

CMV encephalopathy - HIV patients with low CD4 < 50

CMV pneumonitis
CMV colitis

35
Q

CMV

Other clinical features / investigations / management

A

Fever
Malaise
N/V
Diarrhoea

FBC

  • Immunocompetent - Lymphocytosis
  • Immunocompromised - Pancytopenia

LFTs ^
CMV serology
CD4 count
CXR

Management

  • Immunocompetent - Supportive
  • Immunocompromised - IV Ganciclovir
36
Q

HIV aetiology

A

Retrovirus
Destruction of CD4 cells
AIDS - Develops over 10-15 years

IVDU
Unprotected sex
Needle-stick injury
Vertical transmission

37
Q

HIV investigations and management

A

HIV PCR
P24 antigen tests

Antiretroviral therapy
Counselling
Manage comorbidities

Prophylaxis - Vaccinations - Live vaccines CI

  • Pneumococcal
  • Meningococcal
  • Influenza
  • Hep B
  • HPV
  • DTP
38
Q

HIV vertical transmission

A

25-30%

Factors to reduce risk of transmission…

  • Maternal ART
  • Bottle feeding

Method of delivery

  • Viral load < 50 - Vaginal
  • Viral load > 50 - CS + Zidovudine infusion 4 hours prior

Neonatal ART

  • Maternal viral load < 50 - Zidovudine PO
  • Maternal viral load > 50 - Triple ART for 4-6 weeks
39
Q

Malaria aetiology and protective factors

A
  1. Plasmodium falciparum
  2. Plasmodium vivax - Benign
  3. Plasmodium ovale - Benign
  4. Plasmodium malariae - Benign

Protective factors

  • Sickle-cell trait
  • G6PD deficiency
  • HLA-B53
  • Absence of duffy antigens

Risk factors - Travel to endemic areas - Tropics

40
Q

Malaria clinical features and investigations

A 
Fever > 39
Headache
Weakness
Myalgia
Arthralgia
Anorexia
Diarrhoea
Blood film - Schizonts
Rapid diagnostic tests - RDTs
FBC - Anaemia and thrombocytopenia
BM - Hypoglycaemia
ABG - Acidosis
41
Q

Malaria management and complications

A

Chloroquine

Complications

  • Cerebral malaria - Seizures/coma
  • Acute renal failure
  • ARDS
  • Hypoglycaemia
  • DIC
42
Q

Haemophilia aetiology and presentation

A

X-linked recessive

A - Factor 8 deficiency
B - Factor 9 deficiency

Neonates

  • IC haemorrhage
  • Bleeding post-circumcision
  • Heel-prick oozing

Bleeding

  • Haemarthrosis
  • Post-dental
  • Post-surgery
  • Haematomas
43
Q

Haemophilia investigations and management

A

aPTT ^
Everything else = Normal

Management

  • A - Factor 8
  • B - Factor 9
  • FFP

Avoid NSAIDS

44
Q

VWD aetiology and pathophysiology

A

AD

VWF

  • Promotes platelet adhesion to damaged endothelium
  • Factor 8 CARRIER
  1. Partial reduction
  2. Abnormal form
  3. Total lack - AR inheritance
45
Q

VWD presentation / investigations / management

A

Bleeding
Bruising
Epistaxis

Bleeding time ^
APTT ^
Factor 8 - LOW

Desmopressin
Tranexamic acid if bleeding
Factor 8

46
Q

HIV clinical features

A

Seroconversion

  • Sore throat
  • Lymphadenopathy
  • Malaise, myalgia, arthralgia
  • Diarrhoea
  • MP rash
  • Mouth ulcers
47
Q

HIV complications

A

Oral thrush
Shingles
Hairy leukopenia
Kaposi’s sarcoma

Cryptosporidosis 
Toxoplasmosis 
Progressive multifocal leukoencephalopathy 
Pneumonia - Pneumocystitis jiroveci
HIV dementia

Aspergillosis
Oesophageal candidiasis
Cryptococcal meningitis
Primary CNS lymphoma

CMV retinitis

3B (23 decks)

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