Hematology/Oncology Review
March 2010
Case 1
• 55 yo M CC: “check-up”
• HPI: Feeling tired lately but has lots of stress at home
and work and is not sleeping well. Recurrent epigastric
pain and headaches and takes yasud to improve the
pain. Otherwise no complaints.
• FH: no history of anemia
• SH: drinks 3 beers per day, smokes 1 ppd
• PE: pale conjunctiva, mild epigastric tenderness,
remainder of exam is normal.
• Lab: Hematocrit 28%
Case 1
• What is the most likely cause of his anemia?
A. Chronic disease
B. Iron deficiency
C. Macrocytic anemia
D. Multiple myeloma (MM)
E. Thalassemia
Case 1
• What will you do first to manage his anemia?
A. Colonoscopy
B. Gastroscopy
C. Blood transfusion
D. Iron tablets and follow-up in one month
F. Tell him to stop drinking and follow-up in one
month
Case 2
28 yo F
CC: shortness of breath and chest pain.
HPI: Symptoms began 5 minutes ago shortly after coughing
up blook-streaked sputum. Chest pain on the right side and
is sharp, stabbing, and increases with inspiration.
Has been hospitalized for three days for nephrotic
syndrome. Had high ASO titer on admission.
PMH: no prior nephrotic syndrome, none
PE: VS T: 38°C BP: 120/55, RR: 30 breaths/min, HR: 125
beats/min; appears anxious, lungs with decreased BS at
right mid-field, 3+ edema to thighs bilaterally
CXR: pulmonary edema bilaterally
Current meds: furosemide, prednisone, and analpril.
Case 2
• What investigations do you order?
Case 2 What are risk factors for
pulmonary embolism/DVT?
Genetic Immobilization , extended travel
Factor V Leiden mutation Tamoxifen, Bevacizumab,
Prothrombin gene mutation Thalidomide, Lenalidomide
Protein S deficiency Congestive failure
Protein C deficiency Antiphospholipid antibody syndrome
Antithrombin (AT) deficiency Myeloproliferative disorders
Essential thrombocythemia
Acquired disorders
Paroxysmal nocturnal hemoglobinuria
Malignancy
Presence of a central venous catheter
Inflammatory bowel disease
Surgery, especially orthopedic Hyperviscosity
Trauma Waldenstrom's macroglobulinemia
IV drug use Multiple myeloma
Pregnancy Marked leukocytosis in acute
Oral contraceptives leukemia
Hormone replacement therapy Sickle cell anemia
Nephrotic syndrome HIV/AIDS
Case 3
• 35 yo F
• CC: confusion
• HPI: Husband brings to ED and says she has had fever,
generalized malaise, headache and arthralgias for the last 4
days. When she woke up this morning, she did not know
where she was or know her husband.
• PMH: none Medications: none
• SH: works as nurse, no alcohol or tobacco
• PE: VS BP 165/95 HR 101 T 38.6°C RR 15
• Skin: jaundiced, nonpalpable purpura covering the lower
extremities.
• Lungs: clear
• Heart: S1 and S2 normal, no murmurs, rubs, gallops
• Abdomen: soft, nontender. 9-cm liver span. Spleen palpable
3.5 cm below the left costal margin. No masses.
Case 3
• Hgb 9.1 g/dL
• Hct 27%
• Mean corpuscular volume 84
• Platelet count 11,000
• WBC 9800
• Prothrombin time (PT)14 seconds
• Partial thromboplastin time (PTT) 37 seconds
• Reticulocyte count 11%
• Bilirubin, total 1.9
• Bilirubin, direct 0.2 mg/dL
• Blood urea nitrogen 30 mg/dL
• Creatinine 2.8 mg/dL
• Lactate dehydrogenase 900 U/L
• Beta-human chorionic gonadotropin: Negative
Case 3
• What tests do you want to order?
Case 3
Case 3
What is the most likely diagnosis?
A.Disseminated intravascular coagulation (DIC)
B.Aspirin toxicity
C.Hemolytic uremic syndrome (HUS)
D.Idiopathic thrombocytopenic purpura
E. Thrombotic thrombocytopenic purpura (TTP)
What are the 5 classic findings of TTP?
• Fever
• Microangiopathic hemolytic anemia
• Thrombocytopenia
• Renal dysfunction
• Neurologic abnormalities
Case 3
• Which of the following is correct?
A. She needs to have an immediate platelet
transfusion to prevent intracerebral hemorrhage.
B. Most patients survive TTP without specific
treatment.
C. Patients with TTP have anti-platelets auto-
antibodies.
D. Plasma exchange is the preferred therapy but is not
available in Laos.
E. Adults are more likely than children to have
diarrheal illness prior to the onset of hematologic
problems.
Case 4
• 68 yo M
• CC: low back pain and fatigue
• HPI: left hip pain started after working in
fields but has been progressive; has been very
fatigued and dyspneic and must rest often
while working; weight loss of 6 kg in the last
month. Recent constipation. Wife says
patient is getting shorter
• PMH: passed a kidney stone 1 month ago
Case 4
• PE: 140/95 HR 85 T 37 RR 14
• Gen: thin, tired appearing but NAD
• HEENT: pale conjunctive
• Lungs: clear
• Heart: RRR, nl S1/S2 no r/m/g
• Abd: distended with diffuse mild tenderness, no
guarding or rebound, hypoactive bowel sounds
• Extr: tenderness to palpation lumbar vertebrae
Case 4
• Peripheral blood smear
Case 4
• What is the most likely cause of the patient’s
bone pain?
A. Paget’s disease
B. Osteomyelitis
C. Unknown traumatic fracture
D. Metastatic prostate cancer
E. Multiple myeloma
Case 4
How do you confirm your suspected diagnosis?
A.Bone biopsy and culture of spine lesion
B.Bone marrow biopsy
C.Hemoglobin electrophoresis
D.CT scan of pelvis
E. Prostate biopsy
Case 4
Which of the following laboratories findings
would you NOT expect?
A. Hgb 9.1 with MCV 84
B. Calcium 11.5 with albumin 3.5
C. Total protein 10.8
D. Alkaline phosphatase 355
E. GGT 400
F. Creatinine 2.4
Case 5
• 26 yo M prolonged bleeding after tooth. The patient
has no complaints and no prior history of bleeding
complications.
• WBC count = 8000/mm3
Hemoglobin = 15.4 g/dL
Platelet count = 190,000/mm3
Platelet morphology = normal
Prothrombin time (PT) = normal
Activated partial thromboplastin time (APTT) = normal
Bleeding time = prolonged
Factor IX level = normal
Case 5
Which of the following is the most likely cause
of these findings?
A.Aspirin use
B.Idiopathic thrombocytopenic purpura (ITP)
C.Factor VIII deficiency (hemophilia A)
D.Vitamin K deficiency
E. Factor IX deficiency (hemophilia B)
Vitamin K
dependent
Case 6
• 23 yo M in ICU after motorcycle accident.
Severe crush injury to his left leg requiring
amputation.
• Developed gram-negative sepsis post-
operatively.
• On Day #4, significant bleeding from IV sites,
urethra around foley, gingiva and nose. Many
petechiae and bullae on extremities.
Case 6
• Leukocyte count 17,000/mm3
• Hemoglobin (Hb) 7.9 g/dL
• Hematocrit 26%
• Mean corpuscular volume (MCV) 82
• Platelet count 12,500
• Prothrombin time (PT) 19 seconds
• Partial thromboplastin time (PTT) 52 seconds
• Blood urea nitrogen 40 mg/dL
• Creatinine 3.8 mg/dL
Case 6
What is the most likely diagnosis?
A.Disseminated intravascular coagulation (DIC)
B.Drug-induced thrombocytopenia)
C.Hemolytic uremic syndrome
D.Idiopathic thrombocytopenic purpura
E. Thrombotic thrombocytopenic purpura
Case 7
• 40 yo M
• CC: left supraclavicular mass
• HPI: Mobile, soft, and non-tender mass that is
slowly enlarging over the last two months.
Was 1 cm 2 weeks ago, now is 3 cm.
• ROS: negative except for a few upper
respiratory tract infections over the past six
months.
• No other masses identified.
Case 7
• Which of the following is the most appropriate
next step?
A. Oral antibiotics
B. IV antibiotics
C. Oral steroids
D. IV steroids
E. Excisional biopsy of the mass
F. Fine-needle aspirate of the mass
G. Tell him everything is okay
Case 8
• 21 yo M CC: sore throat and rash
• HPI: Started 5 days and associated with fatigue and
malaise and lymphadenopathy. Fevers to to 38.7°C. His
girlfriend had similar symptoms 3 weeks ago and he is
started taking her leftover amoxicillin one day after the
sore throat started. The next day he developed an
erythematous maculopapular rash over his entire body.
• Allergies: no known drug allergies
• SH: drinks 8-10 drinks per week, smokes 1 ppd. He has
one current sexual partner that he has been monogamous
with for the last 2 years and uses condoms regularly.
• Exam: bilateral cervical lymphadenopathy and pharyngeal
erythema.
Case 8
• What is the most likely cause of these
findings?
A. Cytomegalovirus infection (CMV)
B. Epstein-Barr Virus infection (EBV)
C. Hepatitis B virus (HBV) infection
D. Human immunodeficiency virus (HIV) infection
E. Varicella zoster virus infection
Case 8
• What is the most likely reason he has a rash?
A. Allergy to amoxicillin
B. Sunsensitivity with antibiotic
C. Idiosyncratic reaction of EBV with amoxicillin
D. Insect bites
E. Thrombocytopenia
Case 8
• How might you make this diagnosis in a
district hospital?
A. Neutrophilia and bands
B. Lymphocytosis and atypical lymphocytes
C. Gram stain of blood
D. Microcytic anemia and hematuria
E. Thrombocytopenia
Case 8
• What possible complication of this illness
should this patient be warned about?
A. Pulmonary embolism
B. Ludwig angina
C. Parapharyngeal abscess
D. Splenic rupture
E. Toxic megacolon
Case 9
• 59 yo F CC: epistaxis
• HPI: 5th episode of epistaxis in last one month. No trauma, no prior
bleeding problems. Otherwise feels well.
• PMH: none
• Meds: daily multivitamin Allergies: none
• SH: no EtOH, no tobaccoo, works as secretary.
• PE: dried blood in nares but no other visible abnormalities in nose.
There are several purpura on the lower leg. The abdomen is soft
and nontender. No hepatosplenomegaly.
• Hgb 13.2 WBC 5.4 Plt 12
• PT 13 seconds PTT 32 seconds
• Bone marrow biopsy: normal cellularity and increased
megakaryocytes.
• Immunoassay for antiplatelet antibodies: positive
Case 9
What is the most likely diagnosis?
A.Disseminated intravascular coagulation (DIC)
B.Drug-induced thrombocytopenia)
C.Hemolytic uremic syndrome
D.Idiopathic thrombocytopenic purpura
E. Thrombotic thrombocytopenic purpura
Case 9
• If left untreated, what is the patient most at
risk of dying from?
A. Congestive heart failure (CHF)
B. Hypovolemic shock
C. Intracranial hemorrhage
D. Myocardial infarction (MI)
E. Overwhelming sepsis
Case 9
What is the next most appropriate step for
treatment?
A. Prednisolone 1 mg/kg daily
B. Cyclophosphamide 2 mg/kg daily
C. Splenectomy
D. Aspirin
E. Whole blood transfusion
Case 10
• 34 yo F
• CC: shortness of breath
• HPI: SOB began suddenly 48 hours
ago with pleuritic chest pain.
• PMH:
– DVT x 2 during pregnancies.
– Spontaneous abortion x 5 (weeks 24,
28, 16, 14, 12)
• PE: lace-like rash on her body
Case 10
What abnormal laboratory finding would
support your diagnosis?
A. Elevated antinuclear antibody
B. Elevated partial prothrombin time (PPT)
C. Elevated platelet count
D. Erythrocytosis
E. Polycythemia vera
Case 11
• 14 yo M
• Colicky abdominal pain and watery diarrhea for one
week. Two days before admission became very sleepy
and acted strangely. New onset headaches.
• SH: no tobacco, EtOH occasionally, works at his
father’s car repair shop
• Exam: pale conjunctiva; speech and movements are
slow. Head circumference and body status are normal
for his age. His reflexes are brisk, but he has normal
strength, tone, and sensation throughout.
Case 11
microcytic hypochromic anemia with basophilic stippling
Case 11
What is the diagnostic test of choice?
A. Serum manganese level
B. Urinary copper level
C. Urinary organophosphate level
D. Urinary porphobilinogen level
E. Urine lead level
Case 11
• What other signs and symptoms might he
have?
