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Question 1
Correct
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A 35-year-old woman presents to her General Practitioner complaining of fatigue and lack of energy. She has a 1-year history of heavy menstrual bleeding with excessive blood loss. She is clinically anaemic.
Investigations:
Investigation Result Normal value
Haemoglobin (Hb) 102 g/l 115–155 g/l
Haematocrit 28% 36–47%
Mean corpuscular volume (MCV) 70 fl 80–100 fl
Mean cell haemoglobin (MCH) 25 pg 28–32 pg
Mean corpuscular haemoglobin volume (MCHC) 300 g/l 320–350 g/d
White cell count (WCC) 7.5 × 109/l 4.0–11.0× 109/l
Platelets (PLT) 400× 109/l 150–400× 109/l
What is the most appropriate dietary advice for this patient?
Select the SINGLE advice option from the list below.Your Answer: She should increase her intake of vitamin C-rich and iron-rich food
Explanation:To address her iron-deficiency anaemia, the patient should consume more foods rich in vitamin C and iron. Vitamin C can increase iron absorption by up to 10 times and maintain iron in its ferrous form. However, she should avoid breakfast cereals and white breads as they are often fortified with iron. Tea should also be avoided during meals or when taking iron supplements as it contains tannin, which reduces iron absorption. While a vegetarian diet can still provide non-haem iron, it is important to consume a variety of iron-rich plant-based foods. A gluten-free diet is only necessary if coeliac disease is present, which is unlikely in this case as the patient’s iron-deficiency anaemia is likely due to menorrhagia.
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This question is part of the following fields:
- Haematology/Oncology
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Question 2
Correct
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A 32-year-old female presents with a purpuric rash on the back of her legs, frequent nose bleeds, and menorrhagia. She is currently taking Microgynon 30. A full blood count reveals Hb of 11.7 g/dl, platelets of 62 * 109/l, and WCC of 5.3 * 109/l. What is the probable diagnosis?
Your Answer: Idiopathic thrombocytopenic purpura
Explanation:A diagnosis of ITP is suggested by the presence of isolated thrombocytopenia in a healthy patient. Blood dyscrasias are not typically caused by the use of combined oral contraceptive pills.
Understanding Immune Thrombocytopenia (ITP) in Adults
Immune thrombocytopenia (ITP) is a condition where the immune system attacks and reduces the number of platelets in the blood. This is caused by antibodies targeting the glycoprotein IIb/IIIa or Ib-V-IX complex. While children with ITP usually experience acute thrombocytopenia after an infection or vaccination, adults tend to have a more chronic form of the condition. ITP is more common in older females and may be detected incidentally during routine blood tests. Symptoms may include petechiae, purpura, and bleeding, but catastrophic bleeding is not a common presentation.
To diagnose ITP, a full blood count and blood film are typically performed. While a bone marrow examination is no longer routinely used, antiplatelet antibody testing may be done, although it has poor sensitivity and does not affect clinical management. The first-line treatment for ITP is oral prednisolone, but pooled normal human immunoglobulin (IVIG) may also be used if active bleeding or an urgent invasive procedure is required. Splenectomy is now less commonly used as a treatment option.
In some cases, ITP may be associated with autoimmune haemolytic anaemia (AIHA), which is known as Evan’s syndrome. It is important for individuals with ITP to work closely with their healthcare provider to manage their condition and prevent complications.
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This question is part of the following fields:
- Haematology/Oncology
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Question 3
Correct
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A 25-year-old woman presents to the antenatal clinic for her booking visit. She speaks very little English and is 20 weeks' pregnant in her first pregnancy. No medical history of note can be obtained.
Investigations:
Investigation Result Normal values
Haemoglobin (Hb) 101 g/l 115–155 g/l
Haematocrit 38% 40–54%
Red blood cell count (RBC) 5.24 × 1012/l 4.0–5.0 × 1012/l
Mean corpuscular volume (MCV) 63 fl 80–100 fl
Mean corpuscular Hb (McHb) 20 pg 27–32 pg
Mean corpuscular Hb concentration 32 g/dl 32–36 g/dl
White cell count (WCC) 6.9 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 241 × 109/l 150–400 × 109/l
Foetal Hb (HbF) 0.6% < 1%
Haemoglobin A2 (HbA2) 4.5% 1.5–3.5%
Which of the following is the most likely cause of her anaemia?Your Answer: β-Thalassaemia trait
Explanation:Understanding β-Thalassaemia Trait: Symptoms, Diagnosis, and Implications for Pregnancy
β-Thalassaemia trait is a genetic condition that can cause microcytic/hypochromic anaemia with a raised RBC and normal MCHC. This condition is often asymptomatic and can be diagnosed through a blood test that shows raised HbA2 levels. It is important to distinguish β-thalassaemia trait from other conditions that can cause similar symptoms, such as folic acid deficiency, sickle-cell anaemia, α-thalassaemia trait, and iron deficiency.
If both parents have β-thalassaemia trait, there is a 25% chance of producing a child with β-thalassaemia major, a more severe form of the condition that can cause serious health problems. Therefore, it is important to screen both partners for β-thalassaemia trait before planning a pregnancy.
In summary, understanding β-thalassaemia trait and its implications for pregnancy can help individuals make informed decisions about their reproductive health.
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This question is part of the following fields:
- Haematology/Oncology
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Question 4
Correct
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A 15-year-old Afro-Caribbean girl arrives at the emergency department with complaints of left hip pain. There is no history of recent trauma, but the patient has a medical history of sickle cell disease and has been admitted multiple times in the past with similar symptoms. What is the appropriate management plan for this patient?
Your Answer: Painkillers, oxygen and IV fluids
Explanation:To effectively manage sickle cell crisis, it is essential to administer analgesia, oxygen, and IV fluids. In addition, antibiotics may be necessary if an infection is suspected, and transfusion may be required if the patient’s Hb levels are low.
It is not advisable to simply monitor patients without providing any treatment, as this would result in significant pain and discomfort.
The most effective approach involves a combination of oxygen, fluids, and analgesia. Pain management is crucial, as the blockage of blood vessels by sickle-shaped red blood cells prevents the delivery of oxygen and blood to the tissues, resulting in pain. Oxygen supplementation is necessary to alleviate this pain, and IV fluids can help to slow or halt the sickling process. None of these components alone would be sufficient in managing pain, but together they form a comprehensive approach to pain management.
Managing Sickle-Cell Crises
Sickle-cell crises can be managed through various interventions. General management includes providing analgesia, rehydration, and oxygen. Antibiotics may also be considered if there is evidence of infection. Blood transfusion may be necessary for severe or symptomatic anemia, pregnancy, or pre-operative cases. However, it is important not to rapidly reduce the percentage of Hb S containing cells.
In cases of acute vaso-occlusive crisis, such as stroke, acute chest syndrome, multiorgan failure, or splenic sequestration crisis, exchange transfusion may be necessary. This involves rapidly reducing the percentage of Hb S containing cells. It is important to note that the management of sickle-cell crises should be tailored to the individual patient’s needs and medical history. Proper management can help alleviate symptoms and prevent complications.
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This question is part of the following fields:
- Haematology/Oncology
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Question 5
Correct
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A 70-year-old man with metastatic prostate cancer is experiencing increased pain and vomiting while taking morphine sulphate 60mg bd. It has been decided to switch to subcutaneous administration. What is the recommended 24-hour dose of morphine for continuous subcutaneous infusion?
Your Answer: 60mg
Explanation:In this scenario, the BNF suggests administering half of the oral dose of morphine when using the parenteral route (subcutaneous, intramuscular, or intravenous). If the patient is no longer able to swallow, a continuous subcutaneous infusion of morphine is typically given.
Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting treatment with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects are usually transient, such as nausea and drowsiness, but constipation can persist. In addition to strong opioids, bisphosphonates, and radiotherapy, denosumab may be used to treat metastatic bone pain.
Overall, the guidelines recommend starting with regular oral morphine and adjusting the dose as needed. Laxatives should be prescribed to prevent constipation, and antiemetics may be needed for nausea. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and referral to a clinical oncologist should be considered. Conversion factors between opioids are provided, and the next dose should be increased by 30-50% when adjusting the dose. Opioid side-effects are usually transient, but constipation can persist. Denosumab may also be used to treat metastatic bone pain.
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This question is part of the following fields:
- Haematology/Oncology
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Question 6
Correct
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A 16-year-old girl comes to the clinic with a palpable purpuric rash on her lower limbs and polyarthralgia after experiencing a recent sore throat. What is the probable diagnosis?
Your Answer: Henoch-Schonlein purpura
Explanation:Understanding Henoch-Schonlein Purpura
Henoch-Schonlein purpura (HSP) is a type of small vessel vasculitis that is mediated by IgA. It is often associated with IgA nephropathy, also known as Berger’s disease. HSP is commonly observed in children following an infection.
The condition is characterized by a palpable purpuric rash, which is accompanied by localized oedema over the buttocks and extensor surfaces of the arms and legs. Other symptoms include abdominal pain, polyarthritis, and features of IgA nephropathy such as haematuria and renal failure.
Treatment for HSP involves analgesia for arthralgia, while management of nephropathy is generally supportive. There is inconsistent evidence for the use of steroids and immunosuppressants.
The prognosis for HSP is usually excellent, especially in children without renal involvement. The condition is self-limiting, but around one-third of patients may experience a relapse. It is important to monitor blood pressure and urinalysis to detect any progressive renal involvement.
Overall, understanding Henoch-Schonlein purpura is crucial for prompt diagnosis and management of the condition.
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This question is part of the following fields:
- Haematology/Oncology
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Question 7
Incorrect
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A 7-year-old boy who has haemophilia A presents to the Emergency Department after falling off a skateboard and hitting his head. He is drowsy and confused with a Glasgow Coma Score of 9.
What would be the next most appropriate step in this patient’s management?
Your Answer: Transfer immediately for computed tomography (CT) scan of his head
Correct Answer: Immediate administration of factor VIII
Explanation:Immediate Treatment for Serious Bleeding in Patients with Haemophilia
Serious or life-threatening bleeding in patients with haemophilia requires immediate evaluation and therapy with replacement factor. The immediate goal is to raise the activity of the deficient factor to a level sufficient to achieve haemostasis. For patients with potentially serious or life-threatening bleeding, treatment should be initiated immediately, even before completing diagnostic assessment.
In the case of haemophilia A, factor VIII must be replaced. Waiting to find out factor VIII levels prior to administering it could lead to further bleeding. Therefore, immediate administration of factor VIII is the most appropriate option.
While obtaining imaging of the head may be useful, the main objective is to obtain rapid haemostasis. Thus, transferring the patient immediately for a CT scan of the head is not the first action to take.
In a patient with haemophilia, evacuation of a clot may lead to further potentially catastrophic bleeding. If surgery is required, the patient must have adequate levels of factor VIII present to achieve haemostasis. Therefore, transferring the patient to the theatre for evacuation of an intracranial haematoma should not be the first action taken.
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This question is part of the following fields:
- Haematology/Oncology
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Question 8
Incorrect
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A 50-year-old woman is found to have a proximal deep vein thrombosis four weeks after undergoing surgery for a broken ankle. She is prescribed warfarin (initially accompanied by low molecular weight heparin) with a desired INR range of 2.0-3.0. What other treatment option should be presented to this patient?
Your Answer: A chest x-ray, urinalysis and blood tests including thromobphilia screening
Correct Answer: No additional treatment other than routine care
Explanation:Post-Thrombotic Syndrome: A Complication of Deep Vein Thrombosis
Post-thrombotic syndrome is a clinical syndrome that may develop following a deep vein thrombosis (DVT). It is caused by venous outflow obstruction and venous insufficiency, which leads to chronic venous hypertension. Patients with post-thrombotic syndrome may experience painful, heavy calves, pruritus, swelling, varicose veins, and venous ulceration.
In the past, compression stockings were offered to patients with DVT to reduce the risk of post-thrombotic syndrome. However, current recommendations state that elastic graduated compression stockings should not be used to prevent post-thrombotic syndrome or VTE recurrence after a proximal DVT. This recommendation does not cover the use of elastic stockings for the management of leg symptoms after DVT.
Once post-thrombotic syndrome has developed, compression stockings are a recommended treatment. Other recommendations include keeping the leg elevated. It is important for healthcare providers to recognize the potential complications of DVT and to provide appropriate management to prevent the development of post-thrombotic syndrome.
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This question is part of the following fields:
- Haematology/Oncology
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Question 9
Correct
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A 38-year-old woman of Afro-Caribbean origin presents to the Oncology Clinic under the 2-week-wait pathway. She has been noticing some lumps on her neck that are classified as painless, nontender, asymmetrical lymphadenopathy. She complains of increasing night sweats and has noticed some pain when drinking alcohol.
Given the likely diagnosis, which one of the following features is associated with a poor prognosis?Your Answer: Night sweats
Explanation:Understanding Hodgkin’s Lymphoma: Symptoms and Prognosis Factors
Hodgkin’s lymphoma is a type of cancer that affects the lymphatic system. One of the most common symptoms of this malignancy is painless, non-tender, asymmetrical lymphadenopathy. However, the presence of night sweats, fever, and weight loss can also indicate a diagnosis of Hodgkin’s lymphoma. Patients of Afro-Caribbean origin may have a worse prognosis in acute lymphoblastic leukaemia, but not in Hodgkin’s lymphoma. Alcohol-induced pain is a characteristic feature of some cases of Hodgkin’s lymphoma, but it has not been associated with a poor prognosis. Asymmetrical lymphadenopathy is a typical feature of Hodgkin’s lymphoma and has not been linked to a worse prognosis. Finally, while female sex has not been associated with poor prognosis, some studies suggest that male sex could be connected with a poorer outcome.
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This question is part of the following fields:
- Haematology/Oncology
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Question 10
Correct
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A 43-year-old man is being evaluated for anemia by his primary care physician. He has been experiencing mild shortness of breath for the past 3 months. His medical history is significant for a previous diagnosis of polymyalgia rheumatica.
The results of his recent blood tests are as follows:
- Hemoglobin (Hb): 98 g/L (Male: 135-180, Female: 115-160)
- Mean Corpuscular Volume (MCV): 77 fl (76-95 fl)
- Ferritin: 195 ng/mL (20-230)
- Total Iron Binding Capacity: 610 µg/dL (250-450)
What is the most probable diagnosis?Your Answer: Iron deficient anaemia
Explanation:The patient’s anaemia is complex and could have multiple causes. The anaemia is microcytic/normocytic and is accompanied by normal ferritin levels and elevated TIBC. However, the patient also has polymyalgia rheumatica, an inflammatory disorder that can affect ferritin levels. Ferritin is an acute-phase reactant and can be elevated in inflammation, making it an unreliable measurement.
Iron-deficient anaemia typically presents as microcytic with high TIBC levels. The high TIBC is due to the body’s ability to transport iron despite low iron levels. Iron-deficient anaemia also has low ferritin levels, but this may not be the case in this patient due to their chronic inflammatory condition. Therefore, iron-deficient anaemia is the most likely diagnosis due to the high TIBC levels.
Anaemia of chronic disease is also normocytic but typically has low or normal TIBC levels. This is because iron is trapped in inflammatory tissue and not available for use, reducing the body’s ability to transport free iron.
B12 deficiency results in macrocytic anaemia, which is not the case in this patient. Haemolytic anaemia is a rare form of anaemia that results in normocytic anaemia and does not explain the abnormalities in iron studies seen in this patient.
Iron Studies: Understanding the Different Tests
Iron studies are a group of laboratory tests that help evaluate a person’s iron status. These tests include serum iron, total iron binding capacity (TIBC), transferrin, transferrin saturation, and ferritin. Serum iron measures the amount of iron in the blood, while TIBC measures the amount of iron that can bind to transferrin, a protein that transports iron in the blood. Transferrin saturation is calculated by dividing serum iron by TIBC, and it reflects the percentage of transferrin that is saturated with iron. Ferritin, on the other hand, is a protein that stores iron in the body, and its level in the blood can indicate the amount of iron stored in the body.
In iron deficiency anaemia (IDA), the levels of serum iron and transferrin saturation are low, while TIBC and transferrin are high. Ferritin levels are also low in IDA. However, in pregnancy and in the presence of oestrogen, transferrin levels may be elevated. Inflammatory disorders, on the other hand, can cause an increase in ferritin levels.
Other rarer tests that may be used to evaluate iron status include transferrin receptors, which are increased in IDA, and tests for anaemia of chronic disease, which is a normochromic/hypochromic, normocytic anaemia characterized by reduced serum and TIBC levels and normal or raised ferritin levels. Understanding these different tests can help healthcare providers diagnose and manage iron-related disorders.
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This question is part of the following fields:
- Haematology/Oncology
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