1. Pattern Recognition in Haematology
Laith Tafesh F1

2. Aims of this session Focus on MCQs NOT preparation for MOSLERs
Haematology by pattern recognition
NOT ins and outs of disease process – though this helps with memory

3. MCQ1
A 67 year old gentlemen presents with a five week history of lethargy and lower back pain. In the last three days, his wife has noticed that he has become increasingly confused. Initial bloods on arrival to MAU are as follows:
Hb – 75
Ca – 3.5
WCC – 3.5
Creatinine – 220
Platelets - 120
Urea – 14.5
Na – 140
PTH – low
K – 4
LFTs – normal
Which of the following would be the most appropriate initial investigation considering the most likely diagnosis?
Renal biopsy
Skeletal survey
Serum electrophoresis and free light chains
CT chest, abdomen, pelvis
Bone marrow biopsy

4. MCQ1
A 67 year old gentlemen presents with a five week history of lethargy and lower back pain. In the last three days, his wife has noticed that he has become increasingly confused. Initial bloods on arrival to MAU are as follows:
Hb – 75
Ca – 3.5
WCC – 3.5
Creatinine – 220
Platelets - 120
Urea – 14.5
Na – 140
PTH – low
K – 4
LFTs – normal
Which of the following would be the most appropriate initial investigation considering the most likely diagnosis?
Renal biopsy
Skeletal survey
Serum electrophoresis and free light chains
CT chest, abdomen, pelvis
Bone marrow biopsy

5. Multiple Myeloma - Overview
Plasma cell malignancy
Characterised by presence of paraprotein (monoclonal immunoglobulin or light chain)
End organ damage

6. Multiple Myeloma - CRAB
C – Hypercalcaemia
R – Renal impairment
A – Anaemia (and pancytopenia)
B – Bone pathology (e.g. lytic lesions, bone pain)

7. Multiple Myeloma – Key Investigations
Laboratory (Bloods):
Serum electrophoresis – monoclonal band (paraprotein)
Serum free light chains
U/Es – renal impairment
Calcium
FBC – anaemia/pancytopenia
Imaging:
Skeletal survey – looking for lytic lesions (e.g. ‘pepper pot’ skull)
Diagnostic: bone marrow aspirate + trephine
NB: various other Ix, but above are probably most important to know

8. MCQ2
A 75 year old lady presents to her GP with a five month history of generalised fatigue and weight loss. On examination, she has cervical and inguinal lymphadenopathy, and she also has significant hepatosplenomegaly. The GP performs a FBC, which reveals the following:
Hb – Platelets – 190
WCC – Lymphocyte count – 18
Neutrophil count – 1.5
Which of the following is the most likely diagnosis?
Hodgkin’s lymphoma
Diffuse large B-cell lymphoma
Myelofibrosis
Acute lymphoblastic leukaemia
Chronic lymphocytic leukaemia

9. MCQ2
A 75 year old lady presents to her GP with a five month history of generalised fatigue and weight loss. On examination, she has cervical and inguinal lymphadenopathy, and she also has significant hepatosplenomegaly. The GP performs a FBC, which reveals the following:
Hb – Platelets – 190
WCC – Lymphocyte count – 18
Neutrophil count – 1.5
Which of the following is the most likely diagnosis?
Hodgkin’s lymphoma
Diffuse large B-cell lymphoma
Myelofibrosis
Acute lymphoblastic leukaemia
Chronic lymphocytic leukaemia

10. Chronic lymphocytic leukaemia
Failure of apoptosis => accumulation of mature B cells
Complications
Autoimmune haemolytic anaemia
Bone marrow failure (infiltration)
Immunodefiency (hypogammaglobulinaemia) => infection

11. Significant Lymphocytosis Chronic Lymphocytic Leukaemia
Elderly
Lymphadenopathy/ Hepatosplenomegaly
Significant Lymphocytosis
Chronic Lymphocytic Leukaemia

12. MCQ3
A 45 year old gentleman with acute myeloid leukaemia has gone through successful induction chemotherapy and is currently in remission. His haematologist has referred him for stem cell transplantation. His two siblings are being tested to see if they’re a suitable match to serve as stem cell donors. Which of the following is the most important factor in determining donor-recipient compatability?
Sex
Age
HLA typing
ABO blood group
RhD blood group

13. MCQ3
A 45 year old gentleman with acute myeloid leukaemia has gone through successful induction chemotherapy and is currently in remission. His haematologist has referred him for stem cell transplantation. His two siblings are being tested to see if they’re a suitable match to serve as stem cell donors. Which of the following is the most important factor in determining donor-recipient compatability?
Sex
Age
HLA typing
ABO blood group
RhD blood group

14. Haemopoeitic stem cell transplantation
Autologous vs allogeneic
MRD vs MUD
Benign and malignant disorders
Allows intensive chemotherapy
HLA typing – 12 alleles
Major morbidity and mortality
Complications
GvHD (acute and chronic)
Infection

15. MCQ4
A 65 year old, previously fit and well, lady presents to her GP with progressive shortness of breath, lightheadedness and jaundice. Bloods are taken which reveal the following:
Blood film reveals spherocytes.
Which of the following investigations is most likely to be diagnostic?
Direct antiglobulin test
Chromium labeling
Bone marrow aspirate
Bone marrow trephine
US liver
Hb – 78
LDH – 800
WCC – 5
Bili – 58
Platelets - 230
ALP – 120
Reticulocytes
ALT– 25

16. MCQ4
A 65 year old, previously fit and well, lady presents to her GP with progressive shortness of breath, lightheadedness and jaundice. Bloods are taken which reveal the following:
Blood film reveals spherocytes.
Which of the following investigations is most likely to be diagnostic?
Direct antiglobulin test
Chromium labeling
Bone marrow aspirate
Bone marrow trephine
US liver
Hb – 78
LDH – 800
WCC – 5
Bili – 58
Platelets - 230
ALP – 120
Reticulocytes
ALT– 25

17. Haemolytic anaemia Premature red cell breakdown Acquired vs hereditary
Immune vs non-immune
Autoimmune haemolytic anaemia – idiopathic or secondary to lymphoproliferative disorders or autoimmune disease

18. Features in investigations
Increased red cell breakdown: anaemia, hyperbilirubinaemia, raised LDH
Compensatory increased red cell production: raised reticulocyte count
Blood film
Spherocytes – hereditary spherocytosis, autoimmune haemolytic anaemia
Schistocytes – MAHA
Sickle cells – sickle cell disease
Direct antiglobulin test (direct Coombs test)

19. MCQ5
A 29 year old pregnant lady presents to the emergency department at 29 weeks gestation. She has developed sudden onset abdominal pain with severe vaginal bleeding. Placental abruption is suspected and bloods are taken in the resuscitation room.
Hb – 85 APTT - 70
Platelets – 10 PT - 42
WCC – 6 Fibrinogen 0.5
Which of the following investigations would be most useful in confirming the most likely diagnosis?
Bleeding time
Thrombin time
D-dimer
Factor XIII assay
Factor IX assay

20. MCQ5
A 29 year old pregnant lady presents to the emergency department at 29 weeks gestation. She has developed sudden onset abdominal pain with severe vaginal bleeding. Placental abruption is suspected and bloods are taken in the resuscitation room.
Hb – 85 APTT - 70
Platelets – 10 PT - 42
WCC – 6 Fibrinogen 0.5
Which of the following investigations would be most useful in confirming the most likely diagnosis?
Bleeding time
Thrombin time
D-dimer
Factor XIII assay
Factor IX assay

21. Coagulation Prolonged PT (extrinsic system)
Warfarin, vitamin K deficiency, liver disease
Prolonged APTT (intrinsic system)
Haemophilia A and B, lupus anticoagulant, heparin
DIC: ↑APTT, ↑PT, ↓Fibrinogen, ↑D-dimer, ↓Platelets

22. MCQ6
A 52 year old gentleman presents to his GP with a six month history of abdominal fullness, weight loss and fevers. Examination reveals massive splenomegaly. Blood counts reveal severe leukocytosis (WCC 110) with marked neutrophilia. Hb is 112 and platelet count is 320. Cytogenetics is likely to demonstrate a reciprocal translocation between which two chromosomes?
8 and 15
2 and 21
3 and 14
6 and 16
9 and 22

23. MCQ6
A 52 year old gentleman presents to his GP with a six month history of abdominal fullness, weight loss and fevers. Examination reveals massive splenomegaly. Blood counts reveal severe leukocytosis (WCC 110) with marked neutrophilia. Hb is 112 and platelet count is 320. Cytogenetics is likely to demonstrate a reciprocal translocation between which two chromosomes?
8 and 15
2 and 21
3 and 14
6 and 16
9 and 22

24. Chronic Myeloid Leukaemia
Myeloproliferative neoplasm
Hepatosplenomegaly
Usually ↑↑↑WCC with raised neutrophil count
Philadelphia chromosome – reciprocal translocation between 9 and 22
BCR/ABL fusion gene
Chronic, accelerated, blast transformation
TKI, e.g. imatinib

25. MCQ7
A 45 year old lady presents to A+E with intractable epistaxis. She has also been feeling gradually more lethargic over the last few weeks. Observations are stable and the patient is haemodynamically stable. The clerking doctor performs bloods, which reveal the following:
Hb – 83
MCV – 95
WCC – 0.6
Neutrophils – 0.2
Platelets – 9
Reticulocyte count - 5
Coagulation screen – normal
Other than severe neutropenia and thrombocytopenia, the blood film does not reveal anything significant.
Which of the following is the most appropriate first line investigation?
Bone marrow biopsy
B12/folate
CT chest, abdomen, pelvis
Direct antiglobulin test
Platelet function tests

26. MCQ7
A 45 year old lady presents to A+E with intractable epistaxis. She has also been feeling gradually more lethargic over the last few weeks. Observations are stable and the patient is haemodynamically stable. The clerking doctor performs bloods, which reveal the following:
Hb – 83
MCV – 95
WCC – 0.6
Neutrophils – 0.2
Platelets – 9
Reticulocyte count - 5
Coagulation screen – normal
Other than severe neutropenia and thrombocytopenia, the blood film does not reveal anything significant.
Which of the following is the most appropriate first line investigation?
Bone marrow biopsy
B12/folate
CT chest, abdomen, pelvis
Direct antiglobulin test
Platelet function tests

27. Pancytopenia Increased peripheral destruction
Hypersplenism, sepsis, autoimmune disease
Decreased marrow production, i.e. bone marrow failure
ALWAYS RULE OUT B12/FOLATE DEFICIENCY IN PANCYTOPENIA

28. Megaloblastic anaemia
Bone marrow failure
Hypocellular marrow
Aplastic anaemia
MDS
Hypercellular marrow
Infiltration
Megaloblastic anaemia

29. MCQ8
A 69 year old patient who has renal anaemia and a haemoglobin of 73 is receiving a unit of red blood cells for relief of symptoms of anaemia. An hour into the blood transfusion, the nursing staff call you as he has become pyrexial. All other observations are normal and systemic examination is unremarkable. The patient feels shivery. What type of transfusion reaction does this likely represent?
Acute haemolytic reaction
Bacterial contamination
Non-haemolytic febrile transfusion reaction
Mild allergic reaction
Anaphylaxis

30. MCQ8
A 69 year old patient who has renal anaemia and a haemoglobin of 73 is receiving a unit of red blood cells for relief of symptoms of anaemia. An hour into the blood transfusion, the nursing staff call you as he has become pyrexial. All other observations are normal and systemic examination is unremarkable. The patient feels shivery. What type of transfusion reaction does this likely represent?
Acute haemolytic reaction
Bacterial contamination
Non-haemolytic febrile transfusion reaction
Mild allergic reaction
Anaphylaxis

31. Transfusion reactions
Acute haemolytic transfusion reaction (ABO incompatibility)
Bacterial contamination – septic signs
Anaphylaxis – ABC problems
Allergic reaction – urticaria, itch, low grade pyrexia
Febrile reaction – pyrexia, shivery
TACO – fluid overload secondary to transfusion
TRALI – ARDS secondary to transfusion

32. MCQ9
A 24 year old lady with night sweats and lymphadenopathy is referred to the haematology clinic by her GP. The haematologists organise a lymph node biopsy, which reveals Reed-Sternberg cells. What is the most likely diagnosis?
Non-Hodgkin’s lymphoma
Hodgkin’s lymphoma
Chronic lymphocytic leukaemia
Acute lymphoblastic leukaemia
Glandular fever

33. MCQ9
A 24 year old lady with night sweats and lymphadenopathy is referred to the haematology clinic by her GP. The haematologists organise a lymph node biopsy, which reveals Reed-Sternberg cells. What is the most likely diagnosis?
Non-Hodgkin’s lymphoma
Hodgkin’s lymphoma
Chronic lymphocytic leukaemia
Acute lymphoblastic leukaemia
Glandular fever

34. Lymphoma Hodgkin’s lymphoma – Reed-Sternberg cell
Non-Hodgkin’s – main subtypes
Highly specialist subject – stick to basics for finals
Malignant proliferation of lymphocytes – accumulate in lymphatic system
B symptoms – fever >38, drenching night sweats, weight loss >10% in six months

35. MCQ10
A 70 year old gentleman is admitted to A+E with a GCS of 9 (M4, V3, E2) following a fall and head injury. The patient is on warfarin for atrial fibrillation. What is the most appropriate first step to take with regards to the management of this patient?
Urgent CT head
Administer prothrombin complex concentrate
Administer IV vitamin K
Urgent neurosurgical intervention
Administer fresh frozen plasma

36. MCQ10
A 70 year old gentleman is admitted to A+E with a GCS of 9 (M4, V3, E2) following a fall and head injury. The patient is on warfarin for atrial fibrillation. What is the most appropriate first step to take with regards to the management of this patient?
Urgent CT head
Administer prothrombin complex concentrate
Administer IV vitamin K
Urgent neurosurgical intervention
Administer fresh frozen plasma

37. Warfarin Vitamin K antagonist
Indications: AF, VTE, mechanical heart valves
INR target range – varies depending on indication (usually 2-3)
Reversal: vitamin K (delayed onset), prothrombin complex concentrate (rapid onset but temporary effect)

38. Reversal - Bleeding Guidelines vary depending on Trust
Life threatening bleed: Beriplex + IV vitamin K
Significant bleed (haemodynamically stable): IV vitamin K
Minor bleed: oral vitamin K

39. Reversal – No bleeding INR >8: oral vitamin K
INR 5-7.9: omit or reduce dose, oral vitamin K if high risk

40. Summary Focus on haematology MCQs
Unlikely to get in MOSLERs – except maybe splenomegaly
Learn to recognise patterns