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Then go to your powerpoint presentation. Um Yeah. Can you see that now? Yes, I can see it now. Yeah. So this is your first question, just read it through. So this other question, I think most of the questions are designed uh and as a practical aspect of it, not much of a theory and uh your judgment and with your background knowledge from the uh training, you apply those basically and just based on the current evidence, basically. OK. So I will read it through this 45 year old woman um uh reviewed shortly being diagnosed pulmonary embolism. OK. Around two weeks ago, admitted the severe community acquired pneumonia uh resulted in being ventilated and uh admitted to it. OK. And she respond well to the antibiotics but shortly before the discharge, uh short of breath again, OK. The CT P requested showed palm embolism. OK. And she started the immediate Deltar, what would be the most appropriate next step? So, um um how do I see the response from uh your, I think. So the options, if you go messages, you can see the charts that are coming up. OK. Yeah. So, but I'd have to swap the screen in between. So it's all right. So you can just, so what we were doing is for questions, we were just giving a minute for people to answer and just going ahead with the explanation because it's a good, it's a good idea. Ok, so I'll just give you some options there. You see. So, so this one option, stop Delta and start bar or coag for six weeks or stop uh Heparin and for three months um for six months, keep on the OK. So that are the options and what is the most appropriate in this sort of a setting? And why? OK. So have a think and uh who would think? What, what is the best way for? What can I just, I'll give you a couple of minutes. Are you able to see the, the questions or you want me to put these questions on? Um I think you can put the questions on um and just, I think you can just give it a minute and then just continue with the answer. If anyone knows, I'm sure they'll answer um as B right now. And number two. Yeah. Yeah, I think, yeah, I think that's the basic because you, what you have to dissect is that this is a provoked, provoked, pulmonary embolism, provoked by community acquired pneumonia. OK. And uh so what is the current? Just read into the nice guidance. There is a good, nice guidance on uh on P management of one P embolism. I think most of the questions they take from that particular area, I think from the hematology bit. So uh yes, the answer is the, the second one b uh three months so provoked. Yes. Um, short term anticoagulation, unprovoked. I think there is an option. Some different options are available. Ok. So unprovoked. A pe um depending upon the individual and the background circumstances, the duration varies. Ok. Um Because what we need to assess at the end of anticoagulation is what is the risk of recurrence in an unprovoked clot? Ok. So that part is a bit different. But um um yeah, this is the um right hand. So it's quite straightforward one. OK. Um The next one is the uh 43 year old attend to GP for recurrent infections, reduced appetite and fullness in the abdomen and she has got a history of celiac disease. Ok. Um So uh which of the following would be seen in the blood film? This is one of the questions from the question bank, you see. So that's why I'm just putting that. Um this is basophilic sting, Hanes bodies, owl jolly bodies, the AOP sites. So uh read uh I think we may have to know what is the background of celiac disease. OK. What can I do? So someone's answered c the third option. That's right. Yeah. Do you know why? Or anybody can tell me why? Um Celiac disease, I don't know whether you were, you know, it is associated with hyposplenism. Ok. Basophilic stripling. What is it? It is just only uh inclusion bodies in the red cells of remnants of ribosomes. Ok. You usually see that in, in some, in people with uh uh myelodysplastic syndrome, like poisoning, sideroblastic anemia, et cetera. So any of this erythropoiesis, you will get that kind of approach. OK. Um Hanes bodies is again, it's different. It is a remnant of hemoglobin. Basically, whenever there is an oxidative hemolysis and you may have remnant of the Heinz bodies in the periphery of the rats. So how all bodies is, is something different. Uh It's uh it's um a part of the ribosomes which is it is enclosed in the, in into the um red cells is a part of your rectal maturation. This whole jolly body, this body should disappear, it should be removed by spleen normally. OK. But that, that doesn't happen because celiac disease associated with uh hyposplenism is a possibility. That's how you link it. Basically. Yeah. OK. So spherocytes in ocys, basically, it's a uh you see that in people with myelofibrosis or any other dy erythropoiesis, spherocytes, usually you see in hemolysis or hemolytic anemia. OK. Hereditary or auto. OK. This is 50 year old Chap Hodgkins needing transfusion. The team requested a radiated blood products which you all should know and the regular blood product can you know the products because of the background Hodgkin's. Um you will know that. Um why do we needed to do this transfusion related overload, transfusion associated gvhd further reduced risk of infection or a hemolytic transfusion reactions. So this is all straightforward. You're, you're, you'd be doing this on a daily basis now, isn't it? So most of the wards we have uh a sort of a poster each other uh conditions you should suspect uh they should, you should ask for products. OK. So the answer is over here someone's answer, right? Yeah. So why? Because by that's correct because when you donate blood, you will normally, when at the time of donation, they run it through a filter to take out all the white cells and whatever the rest is, the one which is being provided for TB to transfuse. But this also will contain about at least five times 10 to the power of nine white cells. OK? So essentially uh most of the people with a good immune system or good T cell function because T cell is the antigen recognizing cell. OK? For example, when you have a flu jab, flu jab has a remnant of virus and that recognizes recognized by the um T cell and T cell talk to B cell to produce antibodies. OK. So any uh abnormality of the T cell function, um uh uh you will have problems with um uh transfusion associated gvhd. OK. For example, Hodgkin's disease and will have uh T cell dysfunction. So if you transfuse people with uh T cell dysfunction with the red, with a white cell with a red cell which containing some amount of white cells, they will not mount uh enough um sort of uh re recognize that particular um uh white cell and these white cell will attack the host environment, the bone marrow and cause severe cytopenia and sometimes it is lifethreatening. Ok. And mortality rate is be very high. It's quite rare nowadays because we are always pretty, quite switched on. So there are some conditions um where you should provide a radiator blood products, one as Hodgkin's and or anybody who has with the chemotherapy which in which has urine analogs, um bendamustine and uh fluid therapy, et cetera. So you important to know what is the uh background of um this particular patient before we could suggest a transfusion, posttransplant therapy. All these people have a severe T cell dysfunction. OK. So it's just uh one of the irradiated blood products. That's the, that is the background of um uh transfusion associated uh uh GBH D. There is another 14 year old boy with the developing hemarthrosis. Ok, young boy with pain and um his is high factor activity is normal, likely diagnosis. So you can just go by kind of exclusion if you go one by one. You see. So um so he still has uh prolonged A PTT, so prolonged A PTT, the coagulate. If you remember the coagulation pathway, there are a few things we need to think of. One is the um 10 is the common pathway, isn't it? Yeah. So what would be the choice of the answer here? And majority of people would suggest apo A but they would expect factor rate to be low. So it's hemophilia B OK. Factor nine can be low. And that's also other common as antithrombin three deficiency is not a bleeding disorder. It's a clotting kind of a disorder, isn't it? And uh one B brain disease again, it's, it's uh um you, you will have some changes in the clotting screen. Ok. So he is clotting screen is good. So the answer would be hemophilia B. OK. This next uh question is 15 year old girl referred to hematology periods three years ago, prolonged, um responded poorly to tex acid and pills. Ok. So what do they have there? So any, any ideas usually because if it is in a hemophilia A and B, if they would have manifested much earlier? Ok. And ITP is unlikely because your platelet count is normal. So the, the um the answer would be the Von will brand disease because that's how they usually present to you see they, so sometimes what happens on bra disease is the one factor which is low. There are different types. If it is very low, they may not have a spontaneous bleeding unless they have a surgery and operations or anything of that sort. Ok. So you can select these answers by exclusion. Because if you're saying, uh usually these people, you've got a hemophilia A and B, they would present much earlier in the, in the where she presented only very late. So most appropriate answer would be the 1 mg disease. OK. And this is another 50 year old investigated for weight loss and anemia. Past there is no significant past medical history, clinical examination, real massive spleen, OK, associated with the pale conjunctiva. So that, that's what a massive spleen and pale. That means there is anemia and a huge spleen. And if you look at the blood picture, the patient has anemia, platelet count is high, vital count is high blood film showed leukocytosis with all stages of granulocytes maturation C OK. And so usually in that blood film, usually they will give you a little more information in ideal setting. OK. So here we have a patient with a high white cell count with mild anemia. So, and if you see all the stages of um granulocyte maturation in the peripheral blood, that is not normal. Ok. Um So, oh, what are the likely diagnosis here? Ok. Any gas we've gotten on some chronic myelo leukemia. Usually it's called CLL, you will have a high lymphocyte and they would have mentioned that. Ok. Um So, chronic chronic myeloid leukemia would be the right and this is the, this is a condition where uh you have um the translocation of nine and 22. Um So part of the uh nine go and this part of the 22 gets translocated and that creates um uh oncogene. OK. So that oncogene causes the leukemia. So uh in that, what happens is that uh uh in the maturation stage, you will have um um all the stages of maturation which is produced in excess. OK. So you'll have myelocytes, metamyelocytes. OK? And esoph basically, everything is increased in the bone marrow and that spills over into your peripheral circulation, which can be seen in the peripheral blood. So usually they report as myocytes metamyelocytes and basophils in the peripheral blood, such a high white cell count, large pain. Yes. Uh And you suspect C ML and how would you confirm these conditions? You can do peripheral blood for, you can check for the BCR ABL. You know that is the um translocation we can pick up by fish analysis in the peripheral blood. So the next question is that what, how do you diagnose with this? The next step would be um the fish analysis uh for be ra in the peripheral blood. So that gives you the diagnosis. OK. This is an a and a review 63 year old man presented with the fracture femur anticoagulation for atrial fibrillation and you're asked to reverse the anticoagulation. So it is suitable for the eight which of the following anticoagulant repair repairing is correct. Just uh which pairing is correct. Probably those who worked in A&E will know because there is a stock always should be there in the A&E um, it's number four D. Ok. Depran has called an antidote. Ok, available. Ok. But now there is a new antidote available for other Rivaroxaban and Aaban. Ok. Um, and it's called, and it is available to use. Uh but it's only nice approved indication is only lifethreatening, gastrointestinal bleed. Ok. So not um it is not approved for any other sort of uh because it is very expensive. I think it's around 10 10,000 lbs for one dose. Ok. So it is policed by the pharmacy. So even if you prescribe it, uh you may, you may not get it delivered or sometimes it might come, the money might come from your direct rate. Ok? So um usually um the index uh is available now solely used in lifethreatening, gastrointestinal bleed, not even in a lifethreatening um intracerebral bleed. So nice does not approve. So just to keep that in mind, ok. This is 61 year old woman comes for a review. Um She finished a course of warfarin of being diagnosed with the unprovoked proximal DVT for the past few weeks experiences heaviness, aching in the same leg is associated with itch and some swelling. Although this seems to go down each night. Past medical history of note includes osteoarthritis type two diabetes. So these are the um examination findings, some discoloration and circumstance. The there's no difference in the circumference of the calves temperature. Is there? What do you think the possibilities are recurrent DVT, post thrombotic syndrome, cellulitis, Baker cyst. What do you think? Um We've gotten BS the answer, do it. Yes, that's why, why, why it is not DVT? Because there is no obvious um, swelling difference. So that is the most appropriate answer would be post thrombotic syndrome because one clue there is that um the swelling goes down when people lie down. So that means, you know, it's, it's post thrombotic syndrome. They used to recommend the compression stockings in all the DVT. Uh But I think the recent nice, I think they don't recommend that as a, as a repeal. Ok. That is the wording in the, if you look at the nice guidance, DVT, um guidance say they don't recommend nowadays the compression stockings, but they used to do that previously. So just they might be at a question in that as well sometimes. Ok. Um So yeah, so this is another one. If you want to have a break, just let me know. Ok, so I'll do, I'll just keep on going. Let Mario, you just let me know for sure. So yeah, so this next question is um 27 year old uh with uh dyspnea associated with the pia chest pain drama uh is elevated CT P shows following bra past medical history includes um giving birth uh 12 months ago, full term anxiety. Um She has a family history of uh DVT two B is, so this is a bit tricky um question. So most likely underlying. So where will you put your money on, given that history? So, in that history, what, what do you utilize the history? So there is a, uh inheritance, isn't it? My mother has got the, this kind of, um, DVT, there's one A on Factor Five Laden. Yes. Yeah. Correct. That's right. Yeah, because, um, that is one of the commonest, if you look at the um uh commonest um thrombophilic conditions in, particularly in the Europe is factor eight and, and prothrombin gene mutation. OK. And so that, that on, on that basis, yes, but not all the factor five A and will have clots. Ok. So if she has had a factor 58 and she had a successful pregnancy without any um uh DVTs, OK. Um Because uh pregnancy will have increased risk of clot because the estrogen surge and increased clotting factors towards the end of pregnancy. Ok. And those who have any other thrombophilia, they stand a little higher, higher chance of um thrombosis. But in the clue in this is probably the commonest in this area is Factor Five Laden. OK. And prothrombin gene mutation is not that common compared to. So if you look at that, um prevalence is factor five. And so based on that, that's what probably, which shows the answer. OK. And um so read around that a little bit. Um This next question 21 year old pre to their GP with what they suspect is tonsillitis and currently fever and tonsil 33 similar picture in the last eight months. Examination, cervical lymphadenopathy, tonsil, exudative course of oxy penicillin, blood vessels taken. And on day five, this is a picture. I can't see that. Yeah, it doesn't show much. It just show probably some leukocytosis, isn't it? And what is the question there? Yeah. I don't know. Sorry. Just forget that. I can't get that question out. He went somewhere else or? Yeah, basically this is uh glandular fever picture. Ok. It still can have mild um lymphocytosis with a neutropenia. Ok. The blood picture um showed um the blood film showed some activated lymphocytes. So that is supposed to mention that. But unfortunately, it's not there. Forget about that. This is another 62 year old woman presents to emergency department, painful left leg which has worsened over the last few hours. No other symptoms past medical history is there on examination that I need to measure around its eye? It's quite straightforward, isn't it? So what will be the most appropriate next ultrasound, isn't it? So, it's a straightforward one. I don't know which straightforward one. Um Afro Carribean 27 year old was sent to the Oncology Clinic following referral by GP. She has been noticing um some lumps in her neck, painless nontender, asymmetrical complaints of increasing night sweats. You notice some pain uh when he drinks alcohol. So that is a cla that's a classic history. Ok. Um, in a young patient comes with that particular history, alcohol induced pain, most likely diagnosis. You all know that, isn't it? Yeah. But uh what gives you the poor prognosis? Ok. So which will give the poor prognosis. So, so that when you look at the, this, this is particularly, this is a hodgkin's lymphoma presence, ok? Um The adverse factors are being a male, being, having night sweats, bee symptoms, all these adverse features. Ok. So in that um answers, which feature is associated with poor prognosis is the night sweats. Ok. So, uh if you look at the staging of the lymphomas, um these are a few factors you look for, ok, age um and age as well. Ok. Age more than 45 and uh night sweats, nails high risk features. Ok. Um Next is Hodgkin's lymphoma patients. 35 year old has first day of his chemotherapy. And since then not feeling well, um the doctor on the ward checked his un and found some abnormalities, hyperkalemia, hyperphosphatemia, hypocalcemia. And which of the following use as a prolex against the complication this man has suffered. So, you know what we are talking about, isn't it? So this is what would be the answer. The answer is the allopurinol because this is a typical presentation of tumor lysis syndrome because when you have a large amount of tumor, when you give chemotherapy, the tumor gets destroyed and the las is intra cellular components into the circulation. Ok. So potassium is an intracellular uh molecule, isn't it? So that is why it causes hyperkalemia. Ok. Uh hyperphosphatemia because if you look at the nuclear material, what do they have? They have, they called chromatin and they are, when you stretch out, they have phosphate bonds, isn't it? So that's why it's source of phosphate. So that's why it causes hypophosphatemia. Ok? And the phosphate goes high, it pick up up all the calcium. So it can cause hypocalcemia. So this is the combination is the biochemical features of the tumor lysis syndrome. Ok. So it can cause renal failure and it's uh life threating. So, um there's other medication, usually we give hydrate and give allopurinol uh to reduce the risk of having tumor lysis symptoms. So, read around the tumor lysis syndrome. Um So that will give you a better idea. Ok. So this is a question on the tumor lysis syndrome. This is a 60 year old woman presents with the GP whole body itching. So that is an and after a hot shower, tingling and et cetera. So that is a typical history. Ok. So you don't need to have an answer to find uh you know, the choices of uh you know, the um multiple choice to decide what is the diagnosis going to be because uh it's going to be a quite straightforward one for you guys. Um She's got fatigue for the last few years and um tingling peripheries, etcetera. On examination, not have spleen three centimeter costal margin. And the blood, blood picture shows hemoglobin, high platelets, normal W BC is. Ok. What will be the first line of management in this patient? What can we give her first, first line it's going to be. And so, yeah, good doctor. Yeah. Ok. Um Yeah. So these symptoms are typically because that is the um catch the the itching. The above typically in um uh in a myeloproliferative neoplasm polycythemia. So they are symptomatic. So, phlebotomy. Ok. We need to maintain um usually they provide look at the hematocrit value. So anybody with um when would you suggest investigating high red cell count or polycythemia? Say in a male if they have the hematocrit or PC of not no more, more than naught 0.52 on two readings, two separate readings. Then you investigate below that it is not recommended to investigate. Ok. In a female, it is not 0.49 roughly. So this if that is high and of course, you should look for other secondary causes for polycythemia. Ok. For example, any problem with the lung disorder, hypoxic lung injury or can give you high. Ok. And they are important things to investigate if you see any patients with polycythemia, is that any erythropoietin secreting tumor? Ok. So for example, any renal tumor which secretes erythropoietin they can present with polycythemia. So the initial investigation for any polycythemia should include an ultrasound or some of them. You may each other. Um, someone's asked if you can repeat about the hematocrit values in a male. If it is not 0.52 or above, on two occasions, you should consider investigation. Ok. In a female, it is not 0.49. So that is the general recommendation when you should invest, not all the other you don't necessarily investigate but um find out why uh this, this is high. OK. And what is the common genetic test? You do? You all know that, isn't it? Check two? I hope you all know that, isn't it? So I can't, I can't see any reply because I'm just assuming. So, yeah, so jak two mutation analysis uh is the one we need to do the first line and you should do the um uh some form, some form of imaging to look at the kidneys for exclud tumor. Ok. So that's important for as a first line investigation and erythropoietin because in a secondary polycythemia erythropoietin will be high. Ok. Ok. Um 2325 year old attend hematology clinic with past history of antiphospholipid syndrome. And uh she informed that she is pregnant and she had a previous DVT associated syndrome and she's completed six months of warfarin. How should you be managed during pregnancy? So this is basically they are asking you to read the antiphospholipid drug. Uh the guidance, it's under the rheumatoid syndromes. It's under the Rheumatology agreement, but there is a guidance there and how you treat. And so just when you find time, just read, what are the current recommendations? Ok. Ok. During pregnancy, yes, the recurrent recommendation is the number a aspirin and occurring during pregnancy. Ok. Um So that is the uh recommendation. The anybody with the antiphospholipid syndrome having any venous thromboembolism. The choice of anticoagulation should be should warfarin because the wax will not be effective to reduce the risk of recurrence. Uh in the stro embolism in people with antiphospholipid syndrome. Ok. So may not be effective. And someone's asked a question if someone has positive antiphospholipid antibodies, but no history of miscarriage or BTE. Are they managed the same? No, you don't, you don't because if you look at that, sometimes it may disappear. Uh So you don't need to treat them unless they have any history of established history of thrombosis. They don't need any um sort of anticoagulation because uh uh you know what is antiphospholipid antibody is just an autoantibody. Ok. Anybody with autoimmune tendency may have an antibody. You see. So that doesn't mean that uh they need to be on anticoagulation because if you screen the normal population, there will be many. So you can't possibly anticoagulate all of them. So anybody with a history. Yes. Otherwise, no, you don't need to. Ok. OK. So that's the antiphospholipid, right? Several weeks of itching 5754 year old uh or the body, facial itching, worse when taking a shower. So you know the diagnosis, ok, on examination face, slightly puffy flush appearance, normal finding observations. There most likely diagnosis is straightforward, isn't it? Polycythemia? Ok. Quite straightforward if you look at um um they, you know most of the questions ideally, you know, to differentiate um hematocrit value would be most useful rather than just the hemoglobin. Ok. Um But yeah, these are quite straightforward, simple ones, 23 year old presents with the lethargy. These are the results hemoglobin. OK. White cell M CV. 65 H pa two 4.5. OK. Normal is less than three. OK. Hemoglobin is reasonable. But what what is more staring at you is the M CMC V is quite low. OK. So this is basically the differential diagnosis for microcytic picture. There are only few three things you should, should remember the commonest design deficiency. The next one is you can have uh anemia of inflammation, still kind of microcytic picture. Then you can have hemoglobinopathy. OK. These are the three things you should think of. If there is microcytosis. If this is the iron deficiency, then you would expect hemoglobin will be much lower because for the M CV of 65 you would expect a hemoglobin will be much lower. OK? Maybe seven or eight or something. OK. Um The fact that they gave a two there, that means they're suspecting some hemoglobinopathy. OK. So this is a typical picture of probably a lym trait. Ok. So a HP two level will be a little higher. They have microcytosis. They do present with this tiredness, but I don't think anything can be done because the hemoglobin is stable. So they will suggest any transfusions or anything. Just uh thalassemia trait. Um What is the implication? They don't have much of a clinical implication per se for the patient. But if she is planning to have a family, it is important to screen the partner or husband for similar conditions because um if the partner has a thalassemia trait, et cetera, that the increased risk of Children having the thalassemia major is very high. Ok. So that counseling needs to be done. So that should usually happen in the big by free sector or the GP in the primary care setting setting. OK, whenever you have and there is a national screening program as well. So um just be familiarized with that. Ok. So actually they will not have any clinical implication per se to the patient. Uh It's not major, major means you have severe anemia. Ok. Sickle doesn't behave this way. OK. And the answer is a bit of thalassemia trait. OK. Here, sperocytosis is totally different conditions. You know that, OK, it's not leukemia. OK. So the catch is that a two they give you is likely some of some of the uh thalassemia trait. OK. So the catch here is in that picture is that if you look at now, if you start looking at the blood picture in iron deficiency, you try and analyze the MCV in relation to the hemoglobin. OK. Just keep an eye on that and see if we can predict which is going to be that, which is. So for example, you, you know, this is a probably a high, I don't know whether this area is a high prevalence area but where there is a high prevalence for the thalassemia, um uh you will sign microcytic picture but look at the hemoglobin and RBC count. If you find the RBC count or hemoglobin is high or close to normal with a severely low M CV, suspect thalassemia. OK? Um But if it is iron deficiency, you need iron to produce red cells. So if there is iron deficiency, your red cell count will be low. So they will be anemic. So in proportion to be low, low MCV, your hemoglobin also will be low. So that is a kind usually. So uh just have a look all of the, any of the blood picture in the future when you see, just try and analyze. OK. Um Next is 45 year old diagnosed DVT three weeks after being treated for fracture. So they are saying that is a provoked DVT. OK. And she started on Warfarin uh usually covered mole in addition to what, which one of the following should be offered. Yeah, this is a question. I think we have already got through that, isn't it? Um What will be the answer anybody can come in? Yes. Ok. The answer should be no additional treatment. That is what the current guidance says. Ok. Um It is a natural tendency to suggest compression stocking. As I said earlier, I used to say there is compression stockings, it is suggested, but if you look at the nice guidance now they don't suggest no additional treatment other than r care, that's what the answer they want. Ok. Um So yeah, 22 year old woman g presented to the GP with the nosebleeds. Ok. Unexplained bruising on her arms and legs and mother has similar problem but never looked it again in the light of this. You decide to do a number of blood test. Um Yeah. What would you choose? What would be the most likely thing you think of possibility? What are the bleeding disorder? You might think of a? Ok, daytime. So what was your, what was your thought the diagnosis would be? They said B yeah. So that's what they, they changed it to B ok. Yeah. Um Yeah, that's correct. Yeah, that's correct. See, see these, these people want, what are the common things? You see, they don't ask you anything. Um, high fund us. So the common things first. So that's what you expected to know? Ok. So what are the commonest? What are the, the history says it is inherited, isn't it? Ok. So your mother has it, she has it and um unexplained bruising in arm. So it's one. So you will see normal platelet count. But there are, if you look at the more detail, there are some blood type, we have your platelets. So that's different. But you don't necessarily need to know for you if you know that long bleeding time, normal platelets and adity, that should be the answer. So your suspected diagnosis is one blood brand. Ok? And you expect to see this picture? Ok. Yeah, so I'll just show you some um bleeding and clotting. Uh No, so the PTA PT let me just take one on my file. Hold on, you can see all my folder now. Yes, we can see your screen. Pull out one of the I'll show you something because it may be a good idea to just have a look. These are the few advices here um for the clotting you want, you can just take that. I don't know where I left it. Yeah, that one. Can you see that? Yes, we can see it. Yeah. Can you just anybody can screenshot and send it to them just to get an idea if you revise and it will be useful for you guys when you practice in A&E May you wherever, I don't know how to send it to you guys. Sure, I can do that. Um Anyway, this will be published online. So then they can take a look whenever they want just to get an idea. Um you know, you will come across these, these questions very often. You see. So you'll wonder what to do. So just have a look. Ok. As an artery. Ok. So did we do that? Yeah, I need that. Give me, yeah, after complicated revision of a total hip replacement, eight year old lady receives two units of correct. Ok. So and she has a history of heart failure. Currently take Busone Ramipril fursemide, what should be prescribed? What should be prescribed in between units? You know that isn't it? So what they're talking about is um transfusion associated cardiac overload. Ok. That could, ok. It is a very important things before each transfusions, you ask yourself, does this patient need transfusion? Ok. So um it's important to assess uh their uh fluid status and the weight and height and weight, et cetera because you for a tiny 35 or 35 kg or 40 kg lady, they may not need two units or. So you need to look into the patient before you prescribe. Ok. It's very important. So, and if you look at the hemo, there is a hemovigilance called shot. I don't know whether you're aware of that. So if you look at that the majority of the transfusion related incidents uh is um you know, one of them is t that is transfusion associated cardiac overload. Ok. So um when you prescribe, you assess, make an assessment fluid status because red cell is quite, you know, uh, it's still good volume is around 505 good amount of MS in it. So it's important to, uh, look into that part of it. Ok. So the answer here should be sta sta dose of furosemide in between. Ok. Um, 65 year old woman with fatigue, paresthesia in her hands and feet, unsteady gait, uh, developed symptoms developed over many months or despite looking at your virus diet is limited and is secure. Um B12 folate deficiency, isn't it? Yeah. Ok. Macrocytic picture. Ok. What would you do? Which one is best? Which, which, what would you give first and why you should use administer B12? Ok. And um because for example, if you see if you just replace the folic acid first, uh what happens is that um it can exacerbate the severe B12 deficiency and it can cause a uh subacute combined, you know, neurological disorder with that. So it's important you replenish b12 fist. Ok. Then followed by uh folic acid. Ok. So that is why we just wanted to make you aware of that. So that aspect of it. Ok. 67 year old male present to the emergency department, fatigue pain and deep in his hips, BP. Can you see anything there? So he's got mild anemia, platelets are low. Ok. And what is calcium is high, isn't it? Ok. Creatinine is high, calcium high. So uh what are the which other, which line, you're going to think in terms of which conditions you might see this kind of picture. You got hypercalcemia and renal failure, anemia. Which one would you see your diagnostic of that? Depends on what you suspect. You see someone multiple myeloma. Very good, very good. Yeah, so it's a, it's a typical picture, isn't it? So what will you, what will you find in the blood picture? Um D is so, so given, yeah, the rule of formation because what is the rule of formation? Basically, you will have because of the myeloma, you'll have a lot of abnormal immunoglobulin circulating. So we got a lot of immunoglobulin circulating that s stick together, the red cells stick together quicker. OK. So you will see that uh in, in your peripheral blood. Yeah. So this, these are typically this all they present and M multiple myeloma, there are different types, you know, common as IG A IgG and uh I GT um those who have IgM paraprotein, they're more of uh lymphoma lineage rather than myeloma. OK. Um But IgG, IGA IgG is all myeloma side of things and, but it's all part of the basal lineage. OK. If you look at the development, basically um B cells, some of them go into what is called memory cells. That's how they memorize your previous infections and all that. OK. Some make uh uh differentiate into plasma cells. OK. So that's why um um it happens. So it's a part of the basal lineage, basically. Ok. Um So yes, the answer is uh the d um next is 45 year old gentleman presents to the emergency department, nausea, sweating, uh central crushing chest pain. So he's got an acute um coronary syndrome. Uh ST widespread ST depression t wave inversion. And the blood test identify hemoglobin of 75 which one of the following would be appropriate to treat this anemia, orly transitional taxes, driving a sign delayed and ECG returns to normal parks. Cool. What would you do? It's a clinical judgment, isn't it? Anybody transfusions of pas because that's a clinical situation. So given that information, what is your differential is that he's going on a ac that your current recent drug, isn't it? And hemoglobin is low and what happens if you just leave the hemoglobin at that level? The myocardial hypoxia will be worsened? Ok. So in that way, it is reasonable to decide transfusion to support, you know, to improve his hemoglobin. Ok. So that's important. So that is a, that is a rational any intervention you do in the clinical practice? Ask yourself uh what is the risk involved? What is the benefit? And if you've got an answer in the, with the, with this clinical picture, it's got ast depression and before it goes into ST elevation M I and these that changes could be partially contributed by atherosclerosis as well as the anemia. So the anemia part you can correct isn't it. So, so in that way, it is reasonable to transfuse a badly. Ok. 45 year old gentleman in um, the emergency department, nausea, sweating. So this we already done that. So this is a repetition. 36 year old lady undergo operation due due to undergo surgery for hernia. Currently only taking combined oral contraceptive pills with no medication. What should be the patient advised to do regarding the medication prior to her operation? Any guess any ideas? So, these are common things you come across, isn't it? What is the, um, the, what do they, they say combined contraceptive pills? So, what we need to think is that we can ask yourself, is that what is the risk involved with the combined contraceptive pills? Ok. The combined contraceptive pills with the general population, the risk of, um, venous thromboembolism makes her about four fold high. Ok. And so even, even with the normal, um, in the normal population, those who have got thrombophilia will be higher than that. It, so what is the general recommendation is that if you're planning for the surgery, planned surgery, stop taking the pill, at least for, at least, let's say four weeks. Is there anything to four weeks before operation? Yeah, that's correct. Yeah, four weeks before. So you stop, ideally they say stop taking at, at least four weeks, then, um, go for the surgery and, uh, usually depending upon the surgery, if it is, uh, um, orthopedic surgery, um, then you would uh want post or prophylaxis, isn't it to be? Um, so yeah, this is the recommendation they say at least four weeks before if it is a combined pill. Ok. Uh 71 year old man admitted with orthopedic board following le left and he has a history of hypertension type two diabetes, chronic myelo leukemia. Ok. A nurse asked you to review patients urgently as she's concerned about, he's confused. BP is low. Heart rate is high and 10 ml urine, urine and r and although through the catheter and nurse has noticed urine catheters B is being bright red. Ok. On examination, uh some te particle bruising over his arms and slowly oozing from the peripheral cannula. Ok. And what, what would you expect to see in his blood results? So all the surgeons in the in the team, what do you think he may have in that scenario? What, what is bleeding from everywhere, isn't it? He bleeding internal bleeding, he's got the BP is low. Heart rate is high and um he's got bleeding in the urine. Um So he's bleeding from everywhere. So I see. Yeah. Very good. Yes. So I, so what would you expect in ad I? So that's what you're supposed to choose. Ok. Yeah. So, and it's the answer is a that's given. Yeah. Yeah. Yeah. Ok. So that's the main thing. So that is if you look at um um the there is AD IC score on the web, you can utilize that as well. OK. To see whether what is the risk involved, et cetera. So, yes, this is a typical picture. Um uh you, you in the card, you will have platelets going low fibrogen used up and prod how do you treat? What did you do? Basically the treat the reason because the reason you need to find out what is the reason for that? Um D IC here it is the surgery. So we have to settle that down. What is the insult he has had? Ok. And uh if there is bleeding support with transfusions, for example, if the F FP with the PTA PTT is high with FFP transfusion and keep the fiber no, at least more than 1.5 with cryoprecipitate infusion and support red cells. Still, the acute event is um dissolved. Ok? Um Next is 76 year old gentleman with one month history of fatigue, weight loss, fullness in the stomach and some bleeding gums. He never had this before. Blood flu shows the clear drops. Yeah. So this is just to um uh let you know that if you see teardrop size, it's, it's uh most likely you need to suspect myelofibrosis. Ok. So that's what they um say the tear drop says you should suspect and that picture fits in with that weight loss, night sweats, fullness, fullness in the stomach is because of the large spleen. Ok. Uh What is myelofibrosis? This is again one of the myeloproliferative neoplasm. Um you have uh they may have some mutations which is uh resulting in increased red cell increase cell production. Basically, you will have a um high cell count, high white cell platelets, et cetera. But over a period of time because of this overactive bone marrow, if you release lots of chemicals, fibroblasts, et cetera over a period of years and it causes myelofibrosis. Ok. So when you see myofibrosis, there are, it's a spectrum earlier, you will see a proliferative phase where you will have high um white cell count, then that dies down towards the end, you will see uh cytopenia. Ok. So when that can, that happens, what happens, you need to have extramedullary erythropoiesis because you need to, you need to have more cells, you know, in the system. So your spleen starts to produce more. So that is why your spleen becomes weaker towards the end. Makes sense. So, splenomegaly or hepatomegaly in this sort of situation is because of extramedullary hemato poison because the spleen has got um um hematophytic tissue, isn't it? So, um so yeah, but when you see teardrop in the picture, consider myelofibrosis is sus suspected. Ok. And how will you diagnose myelofibrosis is diagnosed with the bone marrow. Ok. 21 year old male person, two emergency department with cough fever, dyspnea. Examination is hypoxic pulmonary infiltrates and suffered anemia and jaundice. General weakness since the age of three and, uh, severe pain exposure to cold. So, that's a typical picture it in it. And, um, you know, what is the most likely of lying condition? It's sickle, isn't it? So, it's, it's a typical presentation, isn't it? Um, since childhood. And, um, s and so read about the, because they, I think when I saw this, the bank and they've got the lots of questions on the sick, sickle cell, uh, you know, the chest syndrome, sequestrations and all that. So there were a lot of questions on that I could see. So just get familiarized with that as uh at your level, what you're supposed to know, you don't need to know in great depth. Ok. But just to make sure that to recognize this is a possibility. Ok. Um So there are lots of clue there in the history to see what is the diagnosis is probably infiltrates anemia and jaundice since the age of three months, you got pain. So it's all quite straightforward question. Um 60 year old woman develops DVT 10 days after having a hip replacement despite taking prophylactic dose of tinzaparin or no heparin. And she has no significant past medical history of note, other than osteoarthritis after being diagnosed, I'll start her on heparin most appropriate anticoagulation strategy. So it is a provoked, isn't it? So continue the only for three months, six months, what, what you do? So, so you have to establish as a provoked. So it's a standard practice to give uh you know, three months anticoagulation. Now, given these um options, I would go for direct oral anticoagulant for about three months. Ok. And that's the recommendations. 36 year old HIV, positive referred to GP to hematology for lymphadenopathy fever, night sweats, lymph node, biopsy, ring, ring, ring and lymphocyte depleted hch. Um He asks you what prognosis likely, which are the following characters? Gentlemen, is, so they improve prognosis. OK. Which has got an improved prognosis in that. A. Ok. If he is less than 45 that is the good prognosis. All the others has got a worse prognosis. Ok. Being a male night sweats and deplete fever, it's all these symptoms, isn't it? Weight loss, night has these symptoms. So they all adverse factors. Ok. 43 year old gentleman, currently an inpatient on a surgical ward for acute pancreatitis develops episodic axis. Blood test taken is showing that platelets are low, thrombi time high. A pity is high fibrinog is low. It's quite straightforward, isn't it? What would you expect on the blood flow? Elliptocytes, hes bodies, schistocytes, spherocytes. It is schistocytes. It is, it is the fragmented red cells. It's called schistocytes. What happens when you have ad IC it will cause fibrin meshwork inside your blood circulation. So the red cell has to pass through the fibrin mesh, it gets cleaved. So it causes sy. So that is what is called uh sy. So and so would that be schistocytes. But would that be ok? Because I think you're near the time now. Yes, Doctor Duo, of course. Um, thank you so much, Doctor Duo for giving this presentation. Um I'm sure it's been helpful for everyone. Um I'm just gonna send the feedback form so we'll send it out um, in a week or so. Ok. Ok. That's fine. I hope it was useful. Ok. All the best for your no exams. Uh, please do fill in the feedbacks forms, please. Um, thank you again, doctor. Um, I know it's been a hectic week and you're on call. Thank you so much for taking the time. No problem. Ok. You take care. Bye bye, bye-bye. Right. So we're just gonna go offline. Uh, please do fill in the feedback form for all the feedback forms for the day. Um, we'll come back in around 15 minutes at 515 if that's all right. Um, we have psychiatry next at 5 1545 minutes.