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Summary

In this on-demand teaching session, Sarah, an internal medicine trainee from Nottingham, offers an overview of hematology as well as a focus on revising for exams. Going through a history of hematology, examination of relevant physical symptoms, and differentials for high and low indicators in your FBC. She will also explore the causes of lymphadenopathy, splenomegaly, and hepatomegaly as well as discuss infections, polycythemia, and anemia. With the help of sponsors for the webinar, Mind the Glebe Wesleyan, medical professionals can get prepared for the foundation year transition and find out more.

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Description

This is the third session of a 3 month series in Medicine as part of the Mind the Bleep Final Year Series team focussing on key topics that will come up in final year medical student finals. This session is on Haematology by Dr Sarah Halligan, focussing on common haematology conditions assessed in finals and some SBA questions to test your knowledge.

Event time 7pm-8pm

Learning objectives

Learning Objectives

  1. Learn to recognise the signs and symptoms of hematological conditions.
  2. Understand the physical examination techniques that are used to assess patients with hematological conditions.
  3. Recognize typical differential diagnoses of symptoms found during examination and understand which may require further investigation.
  4. Learn the causes of significant changes in the Full Blood Count (FBC) and the corresponding clinical management.
  5. Analyze and discuss real-life cases and typical examination questions related to hematology.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

you're alive now. Okay, great. Okay. Um hi, everyone. My name's Sarah. I'm a internal medicine trainee, Nottingham. I'm doing a session today on hematology, Uh, with a focus on sort of revising for finals. Can everyone can people hear me? Can everyone hear me? I don't know if someone wants to just message just to say they can hear me, OK, Brilliant. Um, so, yeah, I just wanted to, um, sort of give a overview of hematology as much as I can in our, um, so, Yeah, like I say, I'm an internal medicine trainee. I'm not actually hematologist. So just disclaimer. If you ask me any, like, really complicated questions at the end, I don't know if I'll be able to answer all of them, but I'll do my best. Okay, So just firstly, the word from our sponsor, uh, for they sponsor our webinars and mind the Glebe Wesleyan, Um, they basically just wanted to I just wanted to put in a word for them, and they help prepare you for your transition to your first foundation year. There's a QR code here if you want to find out more about that. Yeah. Okay, So this is the structure of what I wanted to go through. So I'm again. I'm trying to make it kind of exam, like high yield exam stuff. So I thought I'd start off with kind of bosque stuff, um, for hematology history and examination, Um, and also going over blood tests because blood tests are obviously a big part of hematology questions. Usually, um, a bit on anemia, because that's quite a big topic. A bit on coagulation and a bit of high Some other high yield stuff at the end. And also some exam questions that we can go through together. So, um, starting with the history, Um, basically, the main things you want to ask in a hematology history are for first of all, symptoms of anemia. So those are things like the most common ones of fatigue, shortness of breath, dizziness, palpitations. You might might also get other things like chest pain. Another big one that you, you know, especially like red flag symptoms from malignancy. So night sweats, weight loss, weird lumps and bumps and raised lymph nodes. Fevers, um, and then another big one is infection. Because obviously, if you're hematology patient with low white cell count for whatever reason, like leukemia. Um, you might be getting a lot of infections, so, you know, ask about, uh, getting lots of coughs and colds. Um, and then another one is bruising and bleeding. So if you kind of, like, think in your head of the what do hematology conditions affect? You know, platelets, red blood cells, white blood cells. So it's asking about those things. Um, Also a few other things that you can ask about that might be relevant diet if you're thinking about nutrient deficiencies like folate and things like that Drugs. So, like, there's some drugs that can cause, uh, bone marrow suppression and neutropenia like, for example, like methotrexate or carbimazole. Um, family history. If you're thinking of down the lines of any of the genetic hematology conditions and then also social history, Um, for example, alcohol can cause a macro citosis smoke. Like chronic smoking history can cause polycythemia a secondary polycythemia and also travel for things like malaria. Um, so examination. I just thought I put a few things that you could look for on inspection in hematology. Um, so the first picture on the top left, um, is jaundice, which you can get in hemolytic anemia. Um, on the right to that is, um I mean, this could be a few different things, but this is supposed to be plethora that you can get in polycythemia. Um, and then on the top, right? We've got angular colitis, which you can get in iron deficiency and bottom left. Um, it's kind of hard to see on the slide, but that would be per purer. So, um, that you can get from low platelets. Um, then we've also got the, you know, like under eyelid. Sign for anemia, which is isn't very accurate, but it's kind of one of those things that you should do in your Rosky exam and then bottom, right, um is someone with some thrush which a lot of hematology patient's like The ones with malignancy can be immunocompromised, so they might often have a thrush. So with hematology power patient, Obviously, it's not one of those specialties where there's a huge amount of examination to do but basically examine the lymph nodes. And the spleen is the main thing. Um, so make sure you know your anatomy of like, the lymph nodes in the neck. Um, and in the armpits. Um, in real life use usually do the sort of, like groin lymph nodes as well, but probably not in the Osti. Um, and then also that you can mention it. And then the spleen is enlarged. It will go on to courses of splenomegaly in a little bit, but just to reminder that it kind of goes down to the right so it doesn't just go straight down, It can kind of go right across to the past your belly button to the other side of your abdomen. So always make sure you start from the bottom right of your of the abdomen. When you're examining for the spleen, Um, and then hepatomegaly as well can be caused by a few hematological conditions. So because again, I want it to be quite exam focused. I thought we'd go through some differentials for things you might find on examination of a patient in your ski or clinical exam. Um, so for lymphadenopathy, which is basically just in large lymph nodes, um, the most common thing is infections. So, like they're reacting. That's a reactive thing to infection, which the classic thing is like EBV. But it can really be any infection like it could just be tonsillitis or something. Um, more uncommon, But obviously important is lymphoma's metastases, especially from like lung and breast. Um, and inflammation as well, Like Lupus can also cause your lymph nodes to go up. Then splenomegaly is like, um, again, a lot of things can cause it. Um, the classic thing is, if it's massive, like a really, really big spleen that's causing a lot of symptoms like it might cause symptoms of, like bloating, abdominal pain. Um, it's usually going to be one of three things, which is CML, milo, fibrosis and malaria. But a lot of different things can cause sort of a mild to moderate splenomegaly. So, like basically any any cause of him all icis like, um, any of the hemolytic anemia's can cause splenomegaly. And then also, uh, lymphomas, leukemias, um, myeloproliferative disorders. Um, and also, um, obviously, from a sort of a gastro point of view, if you have liver cirrhosis that can cause portal hypertension, which will then cause a large spleen. And then there's some, like rare, uh, infiltrative disorders like amyloidosis. And I thought I'd also just mentioned hepatomegaly as well, because it can. It's usually more of a gastro thing with hepatomegaly, but it can be enlarged if you've got a lot of hemolysis going on. Um, Hemolysis can happen in the liver. Um, and so in, like some severe Hamal icis or in some myeloproliferative disorders, you can have an enlarged liver as well as an enlarged spleen. So something to look out for. So going on to the full blood count. So, um, I thought I'd just go through, like the main things that you look for on a on a full blood count and probably the most common things that you get in an exam question or like a multiple choice question or whatever. Um, so we can go through like, methodically, um, what causes a high whatever and what causes a low whatever. So firstly, with the hemoglobin is probably usually the first thing you look at. Obviously, if the hemoglobin is low, you're worried they have anemia that has many causes, which we'll go on to look into. But essentially, um, if you see that the hemoglobin's low, the next thing you should do is look at the MCV, which is basically the site. It's the mean cell volume. So it's the size of the cell, um, the red blood cell. And also look into hematinic. See as well. Um, that stuff, like the iron levels, the B 12 and folate levels if the hemoglobin's high, you're thinking about polycythemia. And that split into primary and secondary polycythemia now secondary is much more common. Um, but I think a lot of people tend to just jump to straight. Oh, it must be primary, which is polycythemia rubra Vera. That is actually obviously quite rare. And whereas you can get a secondary polycythemia from anything that can cause like prolonged hypoxia in you, so things like COPD smoking and you can also and you can also get it from EPO abuse as well. So, like erythropoietin, which will cause your red blood cells to your hemoglobin to rise. And with polycythemia, you should look. If you see a high hemoglobin, you should look at the hematocrit because the hematocrit will used to be raised as well and then neutrophils. So neutrophils make up most of the white blood cells in the blood. Um, and they are often low in infection, but they can also be high an infection which is kind of annoying. But with infection where it's low, it's usually going to be a viral infection or sometimes TV. Um, in most bacterial infections, the neutrophils will be high. Um, so, yeah, your standard back to your infections, like pneumonia and things like that. It can also react to surgery, information, malignancy pretty much anything. And they can also be high in steroid use as well. So if you see raised neutrophil count, always just check if they're, you know, might be on prednisolone or something like that. Um, other causes of low neutrophils, obviously also drugs excited toxics, chemotherapy, basically, um, looking at for neutropenic sepsis, which again will do further in the talk, Um, and in certain ethnicities. And you can also have a just slightly lower neutrophil count as well. I think Afro Caribbean is one is one that can cause a slightly lower neutrophil count. Um, and also autoimmune diseases as well. Um, with the lymphocytes, um, they can also be, um, raised an infection, but it's more likely to be a viral infection. The classic one again being e b v um, and it can also be high in chronic infections like TB. Um, whereas it can be low. Um, after surgery and trauma Another. I didn't put it here, actually, but it's kind of classically, uh, low in covid as well. Um, also HIV, um, and autoimmune disease again. Um, and if you see someone with a really, really high lymphocyte count, but their neutrophils are normal, Um, there's also the possibility that could be cll. So chronic lymphocytic leukemia that classically causes a very, very high lymphocyte count and then moving on to platelets. I thought I had to have a whole page for this because there's quite a lot of causes of low and high platelets. So when you've got low platelets, uh, first of all, you've got to check that You've got to be sure that it's a real result, because platelets can be low due to like clots forming in the blood bottle and the all the platelets, like clumping together. And that will basically mean the machine reads it as lower than it actually is. So make sure it is actually a true result. So maybe, like repeat the test. Um, basically, the platelets can be low for two main reasons. Either they're not being produced enough. So failure of marrow production and that's obviously like can be a lot of different causes, like malignancy, chemotherapy. Um, but in those causes, often you'll have low levels of other things as well, like low hemoglobin, low white cells. Or it can be due to being platelets being destroyed. So things like immune thrombocytopenia infection. Um, if you have quite a severe infection, you can often have the platelets drop, like in sepsis. Um, d I C T T p. And also drug induced heparin is the classic one. So heparin induced thrombocytopenia, um, and then the one that sometimes can be the case. If you've got a really big spleen, your platelets can pull in the spleen. So, um, in spelling regularly, it can be quite common to have a thrombo cytopenia. Um, whereas high, um, again, A lot of people like to jump to oh, high platelets. They must have essential thrombocythemia, which is a myeloproliferative disorder. But it's by far more common to be a reactive thing because platelets can go up for due to infection due to surgery due to malignancy, information, iron deficiency, pretty much anything any sort of insult, your body can cause your platelets to go up, So obviously, then you kind of expect them to then fall again after the the infection or whatever it is is over. But if you've got an isolated high platelets and nothing else is going on and nothing else is raised in the blood, so you might you might be thinking of essential thrombocythemia or essential thrombocytosis. It has different names, and it can also be raised in the other myeloproliferative disorders as well. Um, like in, uh, polycythemia Vera and Milo fibrosis. So that's kind of like the basic full blood count. I'm going to go over some other things as we go along, but I thought would also touch on anemia and just how to approach anemia. Because anemia is so common, it's commonly asked about an exams as well. And it's also going to be like one of the most common things you see as a junior doctor as well, like hematology wise, because generally you're not going to really see things like, uh, the malignancies as much unless you're on a specific hematology job. Whereas you are going to see people. Patient's with anemia, probably like almost every day, so I'm not gonna go to into this because that's something you can do in your own time. But basically, generally you need to know kind of what happens to the blood cells to kind of know what's going on with anemia. So this is how this is just kind of a summary of how red blood cells made, um, in the bone marrow, they go through this little journey to become a reticular site, and then the reticular site is kind of like the last stage before it becomes a fully mature red blood cell. Um, and the particular sites are kind of like released from the marrow a little bit early, and they kind of float around as articulate for a day, and then they mature into a retro site. So you always have, like, a little amount of reticular sites in your blood, but it shouldn't be a huge amount. And then the red blood cell, um, goes around your blood for about 100 and 20 days, and then it gets destroyed. After that, um, one of the big places where that happens is the spleen. Um, and then in this is on the right is what red blood cell. Looks like what? What it should look like if it's got the right, uh, membrane and everything. And then inside, like the what makes it up. The red blood cell is there's he molecules you have, um we have two alpha chains and to be to change the hemoglobin and then they have the iron atom on the inside. So, basically again, what can go wrong, too? Cause anemia? It's basically Either you're losing blood, you're not producing enough red blood cells or your red blood cells are being destroyed too quickly. So that's kind of how I break it down anyway. And then I broke it down further in this slide, which looks a bit scary at first, but basically it's just looking into. So on the left we have decreased production, and that basically means you're not being able to make them enough. And that can be. The main reasons for that is, either. You've not got enough nutrients to actually make the red blood cells, so that's where things like iron deficiency. B 12 deficiency. Um, you have reduced bone marrow that's able to make the red blood cells, so things like leukemia, malignancy you know, side toxics, that kind of thing. Or you're unable to make them because of inflammation. And that's things like, you know, your anemia of chronic disease. Um or also, you can't really make red blood cells properly in thalassemia because you don't have the right. The hemoglobin isn't right. And then with increased destruction. And that's hemolysis iss. So these are all hemolytic anemia is on the right hand side. I further split them down into intrinsic. So that means a problem with the red blood cell or extrinsic, which means it's a problem outside the red blood cell. So the intrinsic ones you can either have you can have problem with the hemoglobin formation, which would be your, uh, thalassemia sickle cell anemia. You can have problem with the red blood cell membrane, so it's not. The membrane doesn't form properly, which means that the cell is the wrong shape, and then it gets, uh, destroyed. So that's your hereditary spherocytosis ISS. Or you can have a problem with the metabolism, which is G six PD uh, peek a deficiency. Uh, all those weird and wonderful things. Um, and for the extrinsic ones, it's either antibody mediators which would be, uh, autoimmune hemolytic anemia or your transfusion reactions, like incompatibility reactions. Or it can be a mechanical trauma to the red blood cell. Um, because of things like, you know, like fiber and strands and stuff in the blood vessels, like break them up. And that's basically TTP or D i. C You know, the really bad ones. So, um, what do you do when you have a suspected anemia? So, like I said before, um, you look at the MCV. So, um, you probably already know this because it's already like a kind of a basic thing that you learn in med school. But I think it's good to go over. So, um, low MCV, most commonly iron deficiency can also be thalassemia or thalassemia, trait or anemia of chronic disease. Um, there are some rarer causes, um, like lead poisoning and things, But you wouldn't go straight to those. Um, the hookworm is more common worldwide, just not common in the UK um, a normal MCV. So the cells are like the normal the normal size. Um, that can also be anemia of chronic disease. It can also be acute blood loss. It could be because your plasma volume is increased compared to your red blood cell volume. And that happens in, like, obviously, if your fluid overloaded if you're pregnant, your plasma volume goes up. Um, and it can also be, um, mixed. Um, So, for example, if you have an iron deficiency and B 12 deficiency at the same time, you're gonna have lots of small cells. But you might also have some big cells, um, red blood cells. So the overall, on average, you're going to have a normal MCV. But your red blood cell distribution is going to be increased. And that's another thing that you get on the full blood count so you can always look at that. And then also, hemolysis can have a normal MCV, um, and then a high MCV. The classic is the B 12 folate deficiencies. The megaloblast ick anemia's, um and then also it can be caused by alcohol excess, uh, liver disease and hypothyroidism. Um, and I thought also just shoved the box about reticular sites in here because I think people don't understand reticular sites. Uh, very well, generally. So, like I said before, reticular site is the last step before it becomes a red blood cell, and it's usually only in the blood for about a day. If your reticular sites are low, that means your bones aren't producing enough red blood cells because it's not even trying to produce particular sites. There's just nothing going on if your reticular sites are high, so like a high percentage of your blood. And um, sorry, I can't remember the reference ranges right now, but, yeah, you can look that up with a high reticulocyte count. Um, that implies that the bone marrow is working really hard to produce more cells. So with high reticulocyte count, the problem is probably outside. The bone marrow is it probably means you've got him all icis bleeding and the bone marrow is like, Oh my God, I need to make more cells And it's trying its best. But, um, so that's basically how I look at the ridiculous, Like how anyway? So it kind of helps narrow down where the problem is coming from. So I thought I'd just go quickly into the most common ones. So iron deficiency anemia, um, is very common, but very important. Um, it's important to remember, though it's not a diagnosis in itself. You need to think about the underlying cause. The underlying cause will depend also on the patient and what symptoms they've been having, what age they are, what risk factors they have. So, for example, if you have a a 60 year old man, come in and he's got iron deficiency anemia and you ask him about his symptoms and he says he's been having black stool or bleeding from the rectum, you're gonna be worried that it might be due to a malignancy or maybe a gastric ulcer. But he'll need more investigations. If you have a young woman who says she has really heavy periods, you might think it's because she's got menorrhagia heavy periods. Um, so it kind of depends on the situation. Um, but you should always be considering what's causing this in any patient's you have, and you should also consider further investigations. Another one is silly wealth. Malabsorption is like celiac disease is something you could consider as well, and it's also very common in pregnancy as well. Our infancy, Um, so and I just put the sort of ferritin iron, total iron binding capacity things there because that helps differentiate it between iron deficiency, anemia and anemia of chronic disease. So in iron deficiency anemia, the total iron binding capacity is high Because your blood has the capacity, this is how I think of it. Your blood has the capacity to carry all iron, but it just doesn't have enough iron. Um, whereas in, uh, anemia of chronic disease, it won't be high because it'll be low because anemia of chronic disease, you on your body potentially has the iron, but it just can't utilize it very well is kind of how I understand it. So the treatment for iron deficiency anemia again like this is just managing the anemia itself. It's not looking into the underlying cause, which you also need to do is usually oral iron. But common side effects from that is like nausea, diarrhoea, constipation, lots of GI stuff so people don't like taking them a lot of the time. It's also important to remember that oral iron can cause your stool to go darker, so sometimes patient's will freak out and think that they're bleeding or the doctors will freak out and think they're bleeding because they got dark stool. But it could just be because of the oral iron, So it's something to bear in mind. Um, IV iron is also an option, especially if they're very anemic and need. It quite need results quite quickly, or if they have quite bad side effects from the oral iron and then mega Bostic anemia. So this is, uh, basically folate or B 12 deficiency, because folate and B 12 are needed for the synthesis synthesis of D N. A. Um, when you don't have enough of those, you get delayed maturation of the red blood cells, and they basically come out into the blood as big sort of misshapen cells. And they're not working efficiently. Um, so with B 12 deficiency, um, I've put where there are each of them absorbed because that will affect causes. And then so, for example, B 12 deficiency that's absorbed in the in the terminal ileum. That's where quite often crones can affect so Crohn's can be a cause of B 12 deficiency. Um, there's also pernicious anemia, which is kind of the plastic cause of B 12 deficiency, where you get antibodies against your parietal cells, and the thing you have to worry about with B 12 is the sub acute combined degeneration where the dorsal natural columns of the spine get affected and you can get like unsteady gait and lots of other symptoms. Um, and with folate deficiency, you should never replace that before B 12, because that can precipitate, uh, demomination of the cord. So that's something you should always always bear in mind. So if folate is absorbed in the duodenum and jejunum, it's often found in leafy greens. So with B 12, it's quite unlikely for it to be a dietary insufficiency. Um, like veganism is kind of like supposed to be a risk factor for B 12 deficiency, but a lot of foods even, you know, vegan foods are fortified with B 12, so it's quite unlikely. Whereas folate you can get from dietary quite often because people just aren't eating their vegetables and things, Um, and also again, malabsorption celiac. Um, it affects the small bowel and affects the absorption of folate. Um, and um, you can also have an increased requirement as well. So hemolytic anemia, you're making a lot more cells and need more follow and again in pregnancy is the same thing. You're like creating a person so you need more folic acid. And that's why it's good idea to take folic acid in pregnancy as well. Um, so, yeah, with B 12, it's quite often an injection that you, um, treat it with, especially if you think they have pernicious anemia or, you know, an absorption problem of the B 12, whereas folate is usually a tablet. And this is just a nice little picture of, um, megaloblast anemia with the kind of like round red blood cells. And there's that purple thing, um, is a multi lobed neutrophil, which you also get in megaloblast. Okay, anemia. Um, I also thought I don't have time obviously to go through, like, every different cause of him all icis. Um, but I thought I just do a general over overview of him all icis and when, when to suspect someone might have hemolytic anemia as opposed to, like, a different type of anemia. So, obviously, hemolysis is when the red blood cells get destroyed prematurely. Um, it can happen in the blood stream, which is intravascular or outside it. That would be like in the spleen and the liver mostly. Um, so the symptoms they get is basically the same for other anemia's. So they're still going to have, like, fatigue, shortness of breath. But they might also have jaundice. Um, they might also have splenomegaly if lots of hemolysis is happening in the spleen. And if they're a child of pollicis. So, for example, um, in, like, thalassemia, Um and they're having a lot of hemolysis going on. That means their bone marrow will be working extra hard to produce particular sites new red blood cells, as I was saying earlier, and that can cause skeletal abnormalities because the bone marrow basically like expands. Um, and that's kind of what that picture of the boy is supposed to be. Um, he's got, like, a frontal bossing. Um, it's often enormous attic anemia and the things to look out for on the blood blood count is, uh, and this will be included in your like, hemolysis screen. If you do, one would be increased reticular sites, uh, raised bilirubin because that's like a breakdown product of red blood cells and raised ldh, whereas the haptoglobin is decreased. I see a lot of people get confused and think haptoglobin Swiss be increased as well because, like everything else has increased in the hemolytic screen. Perhaps a global is something that binds to free hemoglobin in the plasma. So when there's lots of human low been floating around, it will bind to it and it will decrease. And then there's also the direct antiglobulin test, or DAT for short. And that is a test that they do to check for basically autoimmune hemolytic anemia because it detects antibodies on the red blood cells. So, uh, hematologist will often ask you to do a dat test as well. Um, if you suspect pollicis so then I thought I'd go onto clotting as well. Um, just like a kind of brief overview of clotting again, I can't do everything in this short amount of time, but basically clotting. Um, first of all, when you have some sort of bleed going on, you have vase a constriction. Um, so the vessels will blood vessels Lovaza constrict. Then you have a platelet plug form. That's primary homeostasis. Is the platelets forming a plug and then you go onto the calculation cascade, which makes the fiber in clot. Okay, so that's basically like the steps, and that's kind of, you know, things can go wrong with the platelet level and things can go wrong at the calculation cascade level. Um, I'm not going to go through the whole cascade because no one has time for that. But, um, if you do want to go through it and, like, get it in your head a bit more, Um, I recommend, like just watching like YouTube videos on it, because that's what helped me when I was trying to learn it. Like Khan Academy and things like that have good videos on the calculation cascade. But basically, from an exam perspective, you need to know that the extrinsic pathway is, um, measured with the prothrombin time. Um, and the extrinsic pathway basically involves tissue factor factor seven. And then that goes into the common pathway the intrinsic pathway. Um, that has more factors involved that's measured with the A P. T. T. And then again, after that's all activated, that goes into the common pathway So the extrinsic and the intrinsic kind of like converge together to go to the common pathway. The common pathway is when 10 fact 10 gets activated. That leads to prothrombin being conversed into thrombin, which then leads to fibrinogen being converted into vibrant and vibrant is what causes the clot. So that's kind of what I'm going to go through today, because we're not going to go through the whole We're not gonna have time to go through the whole thing, But basically, prothrombin time or the iron are like the iron are is like a standardized test of prothrombin time. So it's essentially the same thing. Um is the extrinsic pathway and then the a p t. T is the intrinsic pathway. Um, is what you have to remember, so it's actually a bit more complicated. So again, going into your blood tests, um, pro causes of prolonged aptt and causes of a prolonged PT now aptt, um is also going to be affected by, like, overall clotting problems. So if you have, like, a really, um, hi warfarin level, you probably will get a prolonged aptt as well. So that's why I have put it in the Aptt column as well. But generally it's for exams you to know that heparin causes a prolonged aptt, whereas warfarin causes a prolonged PT um, and other causes of a prolonged PTR vitamin K deficiency liver disease. D. I see. Um aptt also includes other factors such as Factor eight and factor nine. So, therefore, in Hemimelia will cause a prolonged aptt. And von Willebrand disease can also cause a prolonged aptt, though it's usually not going to be as like severely prolonged as it is in hemophilia, because von willebrand factor sort of pairs up with factor eight. So it's affected by factor eight. So, um, yeah, those are sort of the main things causes that you'll have to think about for exams, um, and just generally. So I just thought I'd go into thrombosis a little bit, but again, there's a lot to cover. But essentially, when you've got a person with a clot, whether it's a P or a DVT or ever think about your virtuals triad, you have lots of lots of different reasons where why someone might be more prone to thrombosis. Um, so don't go straight to Oh my gosh, they must have thrombophilia like factor five Leiden. Whatever. Because there's so many different causes. You have a gym, mobility, obesity, pregnancy, uh, malignancy, lots and lots of different things that can cause you to have a clot. So you always think about all these things in the patient. Um, And when? When you're trying to decide whether this clot was provoked or not, Um so thrombophilia just like briefly touching on it, Um, you're more likely suspect to suspect it. If you've got a young patient to say, like I think it's under 40 who has a clot. If you have someone who's having recurrent clots, uh, or if you have someone who has a clot in an unusual sight. So, for example, like in the brain or something, Um, it's always a good idea to check the full blood count check for if they've got polycythemia, which also increase your risk of clotting or essential thrombocytosis iss. Um, the most common inherited cause, or from Ophelia is Factor five Leiden, which causes a protein C resistance. Um, and the most common acquired cause is anti phospholipids syndrome, which, as you probably know, is associated with Lupus, and you can check all those antibodies and everything. But, um, generally hematologists don't really like you checking screening for thrombophilia because generally it doesn't actually change the management of the patient, because unless you're going to stick them on like warfarin or Duac for life, you know it's not doesn't really change their management to know if they've got factor five Leiden or anything. So they have quite high threshold threshold for testing for it. Um, I thought I just again This is kind of like for high yield exam stuff go over the type of transfusion emergencies. I also think people get quite confused with these sometimes. So I've made, like a table that you can like, take a photo of or whatever if you want to look at it later. But essentially the most important reaction to know is obviously the hemolytic transfusion reaction. And that's when you have incompatible blood. So, like you've been given the wrong blood type, basically, that will happen very fast. They'll have lots of usually dramatic symptoms, like chest pain, vomiting. They'll get like low BP. They'll get tachycardic. They might have a really high fever. And in these ones, if you suspect it at all, just stop the transfusion. You need to make sure you have the, uh, what's it called like the bag of blood, and check that it's the right idea on it and everything, and you need to tell the blood bank as well. If you think that this happened? Because they'll need to check their records and everything. Um, and again, this is kind of like a supportive management thing. So you have to, um, give fluids. You have to give oxygen potentially hydrocortisone. Um, definitely. Don't try and handle this by yourself. You're a new doctor. Get senior involvement. That probably might need icu involvement. Um, you definitely need to take some more bloods as well. So, like take more group and saves check for blood count and everything, and then you have the non hemolytic transfusion reactions. Um, something's class is an allergic reaction as under this as well, because I guess, technically all the other ones are nonhemolytic. But I've got it as its own thing here. So this is like things like federal reactions. And that's usually caused by like, uh, antibodies in the, um, antibodies to, like white blood cells in the donor, um, in the recipient blood and they get fevers. But usually, most guidelines again, guidelines differ depending on where you look but usually below 40. See if it's above 40. See, you'll be worried that it's maybe actually a hemolytic transfusion reaction. Um, and they'll usually not have any signs of shock. They'll just be feverish. Um, in this case, usually you can just slow the transfusion and give paracetamol. Obviously, if you're in, you're in any doubt just call a senior or hematology, uh, doctor, um, and then you've got your allergic reactions. So people getting, uh, carrier, which, if it's if it's just a mild rash itch carrier, you can slow down the transfusion and give potentially give hydrocortisone and chlorphenamine. Um, but I think in reality, a lot of people would just stop it. Um, and it's definitely if they've got anaphylaxis. Um, you'd stop it, um, and treat for anaphylaxis. Obviously, um, hydrocortisone and everything. Um um, for transfusion associated circulatory overload. Taco, um, that essentially just presents, like, pulmonary edema. So if you got to think, uh, in anyone who has become a short of breath during a transfusion raised JVP, crackly lungs, um, swollen legs, you know, all those sort of things to spec taco. And, um, you can potentially slow the transfusion down. And, um, you can also sometimes give, like, few furosemide between transfusions. Um, it's usually a good idea to think about this risk before prescribing any blood to a patient. So if you've got patient, who's very old, very little has a history of heart failure. Always think about that before prescribing blood and prescribe it over a longer period of time. Um, if you can. And then the last one I've got here Transfusion related acute lung injury. So trolley, Um, that is basically, like a a r d s like acute reaction in the lungs to transfusion. So they'll get really bad respiratory distress. They'll be hypoxic. And on the chest X ray, they'll have some infiltrates, and they'll be feverish. Um, so in that, uh, situation, you would stop the transfusion, uh, give oxygen and again, senior help again. They'll probably need like, I see you, uh, involvement because they'll be very sick. So that's just a brief overview of transfusion emergencies. And then another thing that I felt like I could not cover because it's so important is neutropenic sepsis, neutropenia, um, usually defined as between 0.5 to 1, uh, neutrophil, um, on the blood test and severe is less than 0.5. Um, basically, you've got to be thinking about this in patient's who are on chemotherapy is the main one or advanced cancer Immuno suppressed people on, you know, carbimazole, you know anything like that? Just make sure you have the possibility of each premier in your mind If one of these patient's if someone on chemo comes to you and they have a fever or they have, you know, generally unwell, sore throat, etcetera Um, you've got to have, um and then once, if you have the blood results back and you see that patient's neutropenic, you've got to have a very low threshold for treating for neutropenic sepsis. Um, because some, um, definitions say that you have to have a fever. Um, but you don't like some patient's will not have fever. Um, it might be very, very subtle signs and symptoms as well, because some patient's well, because the patient's don't have any neutrophils, they're not actually getting a very good immune response to the infection. So therefore, some of the signs, like a big, juicy cough, whatever might not be there in the neutropenic patient because they just aren't having that inflammatory response. If that makes sense, So, um, they might just be a little bit tired. They might be a bit confused especially if they're elderly. Um, but make sure you do examine thoroughly check lines, especially a lot of hematology. Patient's will have, like, pick lines and things in their arms. Make sure that they're not, you know, inflamed or infected. Um, make sure you listen to their chest. Do urine dip, do a chest X ray, all that sort of stuff. But the most important thing is, as soon as you suspect it, make sure you start them on broad spectrum antibiotics, Um, something like to see us in. This will depend on your hospital, though. And make sure you take cultures. Um, including from any lines that they have, um, and do your sepsis. Six, um, like you would for any other septic patient's. Another thing you can consider in neutropenic sepsis is G CSF, which is an injection that can basically stimulate your bone marrow to produce more neutrophils. But it's very important that you do not do that by yourself. Make sure you speak. You speak to him first because there's some situations where you wouldn't want to use it. Um, like in myeloid leukemias, it can actually stimulate you to produce more cancer cells, which you definitely don't want to do that. Um, it's just something to bear in mind to consider. So yeah, the main. The main thing is antibiotics as soon as possible. Um, and then from a cancer port point of view, I thought I'd just quickly go over multiple myeloma as well, because that's kind of the most common hematological cancer that will come up in exams. And you'll commonly see it, um, day to day as well, because it's quite common. Cancer. Um, always suspected if you've got patient who is fairly elderly and has a raised calcium and has worsening renal failure, that's kind of the pattern you need to look out for. Um, as you probably heard before the acronym um, it's often used for myeloma. Symptoms or signs is crab. So you've got hypercalcemia, renal failure, anemia and bone lesion's because basically what happens is you get a plasma cell clone. This replicates. It makes one type of immunoglobulin, but it's not a good immunoglobulin. It's rubbish and doesn't actually help you of infection, and it also damages your kidneys. Um, and also your bone marrow ends up being crowded out essentially by the plasma cell clones and you get anemia, low platelets and low immunity, and it also causes osteoclasts activation, which is why you get the lytic bone lesion. So down here, I've got the, um, skull Pepper Potts skull. I think it's called called Where You Get Lytic Lesions in the Skull, but it can. It can happen anywhere. Um, and then another kind of classic sign that you might get asked about exams is this. It's like on the blood film you get the red blood cells kind of stacking on top of each other like that. It's called like a rouleau formation. Um, I don't know if that's how you say it, but that's like a classic sign to look out for. Um so symptom wise, they'll often present with bone pain, often in their back or their ribs. And they might get pathological fractures as well. Um, anemia symptoms again, which we've been over bleeding symptoms, infections. And also they can get symptoms from high calcium. Um, classically. That's the kind of bones groans, uh, signs. But I think in real life people of high calcium they're often confused. They get. It's quite common cause of confusion in cancer patients', and they might just be, like, very thirsty and and going to the toilet a lot, peeing a lot. So look out for those symptoms. Um, and a complication of mark multiple myeloma is amyloidosis. Um, and then just a few quick, um, examination sort of nuggets of information for the other, like leukemias. Basically, Um, so in a ML, the classic sign is our rods, and that's in the myeloid blast cells. Um, and they're like a little basically just a little rod. And that's very, very specific for AML. And so if they say someone's got al rods on your exam question, you're putting a ML um, and A M l and A. L L both present with quite acute anemia infection hemorrhage because they're acute leukemias A l l is the one that happens more in childhood, Whereas AML happens more in adults. CML is the one that's associated with Philadelphia chromosome translocation and therefore the B c r a B l gene. Um, it's also the one that presents with massive splenomegaly, so they'll often present with signs of a big spleen. They'll have raised white cell count as well. Um, and that the CML and see el elbow present a bit more. Chronically CML has the sort of chronic phase for a while, and then it will suddenly accelerate and they'll deteriorate. Cll um that's the one I was talking about earlier that can cause a really raised high lymphocyte count. Um, on the blood film as well. Um, it often has smear or smudge cells, which is basically, like, kind of remnants of the lymphocytes that kind of just been like smushed under the slide. Um, and that's very it's a very common malignancy, and they're often elderly, and they're often asymptomatic, and they can be a symptomatic for years and years and years. So they're often just on a watch and wait, um pathway and not under any treatment. So for medical school exams, I'd say, like those are the main things you need to know about the leukemias. So I thought we'd go onto questions. Now, I've just got a few questions at the end to just sort of test your knowledge, which I think we can do on the polls. Um Oh, okay. Yeah. So, um, this is a 56 year old man who's presented with fatigue and weight loss. He has um, hemoglobin, 100 and five and has a low MCV. So it's low. And he also says his stools been darker than usual. Um, for the last, let's say a month, what's the most likely type of anemia? Um, have you have you all got the pole up? Oh, yeah. Sorry. I can see it now. Um, I'll just give a few more minutes for other people to answer if they want to. Yeah. So, yeah, started with a pretty easy one. I'm glad most people have said, um, iron deficiency. Um, it's a which is the correct answer is iron deficiency. So he's kind of like a bit of a walking red flag there. Like he's, um He's got the symptoms anemia. He's got low hemoglobin, and he's got low MCV. Um, and he says his stools been darker than usual recently. Something you definitely want to rule out is a, uh, g I malignancy. Um it could also be caused by other causes of bleeding like an ulcer, like a gastric ulcer or something. But you definitely want to rule out malignancy. Especially because he's got weight loss. So the next question Oh, this is a man with a 26 year old man who has a prolonged bleeding. Um, after having his wisdom tooth out, um, he says his dad had a bleeding disorder. Um, his blood test shows that he's got a normal hemoglobin, but his aptt is prolonged and his PT is normal. Um, what is the most likely diagnosis in this man? So he's got prolonged bleeding. He's got a prolonged aptt, and he's got normal PT. He says his dad had a bleeding disorder. Um, kept it quite vague. Sorry. So, yeah, let's just see what people are saying. I'll just give it a couple. Well, a minute or two more just for people to answer, This one's a little bit harder. Okay, So, um, with this one, the answer is one willebrand's disease. Now the reason that isn't hemophilia A is because, um, usually there's a few reasons Hemimelia a can have different severity ease, but generally it would present earlier than 26. Not always, but generally, Um, Secondly, it's more likely to have bleeding such as like bleeding into joints. Um, sort of more bigger bleeds than that, whereas this is more of like a like a, uh, what's the word like a sort of mucosil bleed that's been precipitated by something but the main. The other reason as well. It's because he says his dad had a bleeding disorder. Now, with the inheritance of these two conditions is different. So von Willebrand's It's autosomal dominant so it can be passed down from parent to child. Uh, whatever gender. Um, if you have hemimelia a, um, it's X linked, which means it actually can't be passed down from a dad to his son because it's on the X chromosome. So the dad would not pass his X chromosome to the sun. So it's usually hemophilia is usually only, uh, sort of passed on to Children by the mum because it's on the X chromosome. So I hope that makes sense. Um, and I think people get caught out by the fact that that aptt is prolonged. But, like, as I say earlier, uh, factor eight can be, um uh, it's kind of, uh, what's the word? It's associated with von Willebrand's So factor. Eight, um, can be, uh, affected in von Willebrand's disease, so your a P T. T can be prolonged, so I hope that makes sense. But it's It's Yeah, inheritance stuff is quite tricky. So the next one is a bonus question about the same person. So, um, this is if that man with von Willebrand's had more significant bleeding. Uh, what could you do to help stop the bleeding? And we've got a few options there. We've got fact nine concentrates. We've got platelet transfusion. Got desmopressin vitamin K or G CSF. Just that a few more people answer. Okay, so, um yeah, the majority said desmopressin, which is correct. Uh, desmopressin can stimulate release of on willebrand factor from stores in your body. So it's good for people with von Willebrand's who have the non severe types you can. Really. There's a really severe, rare type of von Willebrand's. We don't have any formula brand at all from von Willebrand factor at all, which obviously desmopressin wouldn't work on you then, but we're going to assume this guy has one of the more common types where you do have a bit of von willebrand factor. Um, factor nine concentrate wouldn't help because factor nine isn't really associated with one willebrand factor, whereas factor eight is so that a factor eight concentrate could help with bleeding. Platelet transfusion wouldn't really do anything because it's not really a problem with his his platelets as such, um, and Vitamin K is obviously that's for, um, warfarin bleeding to do with warfarin. Um, and G CSF is something that's to stimulate neutrophil production. So question three. Um, this is an eight year old child brought in by her mum because her mom's noticed a rash. Um, the child has no past medical history, but did have a chest infection one week ago. So on her bloods, her hemoglobin is normal, but her platelets are quite low at seven. Her white cells are normal. What's the most likely cause of her rash? And there there's a picture there if you can hopefully see it. So it's like a kind of dot e. God, I'm bad at describing. Ratters is like a dot e read a rough immitis, um, rash. Yeah, and her platelets are very low. Uh, just get a minute for a few more people to answer. Yeah. Okay. Um, so the majority how of you have said immune thrombocytopenia, which is the correct answer. So, um, the reason it's immune thrombocytopenia, which is a for sure. I T p. Um, it's quite common in Children, especially after infection. So, um, this child has had an infection quite recently. It can be kind of like triggered by that. And in this condition, you get an isolated low platelet, and it often drops to being very, very low. Like in this case, um, and where is the rest of your blood counts? Usually kind of. Okay. And she's got this rash, which is purpura, basically, uh, from the low platelets. Um, in, um, a l l You'd probably expect other bits of the full blood count to be deranged as well, because it wouldn't just be affecting the platelets. Um, it's not von Willebrand's disease, because, yeah, that wouldn't normally cause a low platelet count. Um, and reactive from recite opinion to infection. Like I said earlier in the talk, that definitely that can cause a low platelet. Um, so it's, um, not a bad differential, but it wouldn't normally cause such a low platelet count. And you would probably expect other part again. You probably expect, like, her white cells to still be up if she was still having, like, an infection going on. So yeah. Um, d i c she, um, again, probably be more derangement of the, uh, rest of bloods. And also, it's just less likely because it's it's quite a rare condition. Um and well, I guess I didn't actually say that she felt well, but she'd probably have more symptoms than just a rash. She'd probably be very ill if it was D I c. That's that one. I think we we have six questions in total. So nearly done. Um, So this is a 75 year old man who has a history of type two diabetes, hypertension and heart failure. He presents with fatigue. His hemoglobin is 56. So pretty low, normal range is 100 and 30 to 100 and 70. So he sent to hospital and has to He's prescribed two units of blood halfway through the second unit. He becomes very short of breath, and on examination, he has crackles to both both lung bases and his, uh, JVP is raised. Um, so what's the most likely diagnosis out of these hope? I've put enough information for it to make sense. So he's had he's halfway through a second unit of red blood cells and he becomes short of breath, has crackles to his lungs and the JVP is raised. Yes. So the majority of you said Taco, um which is what? I was kind of getting out with this. Um, he's got a past medical history of of a heart failure. Um, and he's, um, become quite breathless and has crackles. And his JVP x rays, which are kind of the JVP being raised, is kind of the sign that he might be fluid overloaded. He's prone to that anyway, because he's got heart failure. Um, you definitely could. You could argue that it could be trolley. Um, but in his situation, it's probably more likely to be taco overall because of his past little history And because, um, he's probably had these units quite quickly because his hemoglobin was so low. Um, so, yeah, I hope that makes sense. Um, so question five out of six. Um, this is a 70 year old woman, and she has a routine blood test. Um, she's found to have very high lymphocytes at 22. Um, the rest of her full blood count is pretty normal. She's got normal hemoglobin. Um, platelets, obviously. White cells are high as well. But that includes the lymphocytes in that her neutrophils are normal, but her lymphocytes are high. Her blood film shows smudge cells and large lymphocytes. And there's a nice picture of them there. Um, so does anyone remember which cancer I said had smudge cells? Yeah, so it looks like, uh, people have remembered pretty well. So this is CLL. Like I said, um, it causes classically raised lymphocytes and also can have smudge cells on the blood film. Um, so, yeah, if you see those two things an exam question, definitely think cll. So well done, guys. And then the last question, um, 67 year old man has fatigue and night sweats for the last three months. Um, he complains that he feels full and bloated very quickly when he's eating, so he doesn't have to eat much to suddenly feel quite full on examination, he looks pale and his spleen is enlarged down to the umbilicus with mild hepatomegaly on the blood film. You see, teardrop cells and I haven't actually mentioned teardrop cells in this talk, but I'm hoping maybe some people might be able to piece it together. So he's got a very big spleen is kind of my hint as well. Yeah. Okay. Yeah. So the majority of you have got the answer, which is Milo fibrosis. Um, Milo Fibrosis is one of the sort of myeloproliferative disorders, and it classically causes. It's one. It's one of the causes of massive splenomegaly. Uh, so if you see someone with a really big spleen, you're thinking like the CML or mild fibrosis or malaria. So, um, he has the kind of the mino fibrosis usually presents with kind of, like quite vague symptoms, like fatigue and night sweats. Um, and it, classically on the blood film causes teardrop cells, which is like, basically like, um, red blood cells that are basically teardrops shaped because they've kind of have to be squeezed out of this really fibrotic marrow. So they kind of, uh, become a bit squashed at one end. So, yeah, those are all my questions. So thank you so much everyone for coming. I hope it's at least been a little bit helpful. Um, if anyone wants to ask me any questions in the chat that can, um and also please, um, if you have time, fill out the feedback and you'll get a certificate for your, uh, for attending. If you fill out the feedback form, that's great. Thanks, Sarah. If people can give, uh, Sarah or the feedback so you can scan the QR code or I've put the link in the chat there that'll be really useful for planning future sessions. That would be great. All right. What's everyone? Everyone? Yeah.