Haematology 🔴

A 43 year old man presents to the GP surgery following his blood test results. His blood test shows the following:

Haemoglobin 110 g/L (130-180)

MCV 103 FL (76-96)

Folate 1.2 mcg/L(2.0-11.0)

Vitamin B12 200 ng/L (150-700)

He initially presented to the GP with ongoing symptoms of tiredness. He would like to try a vegan diet going forward. Which types of foods should he be encouraged to eat?

A 65 year old man presents with back pain. Abdominal examination reveals splenomegaly. Blood report shows the following:

Haemoglobin 102 g/L (130-180)

White cell count 122 x 10^9/L (4-11)

Platelets 122 x 10^9/L (150-400)

He has been found to have Philadelphia chromosome on cytogenetic analysis. What is the SINGLE most likely diagnosis?

A 4 year old boy presents with fever, pallor, and decreased appetite. On examination, there are palpable non-tender nodules along the deep cervical chain in the neck. He has a history of recurrent throat infections. His mother describes him as always feeling tired. On examination, splenomegaly was noted. Blood results show:

Haemoglobin 90 g/L ((130-180) MCV 80 fl (76-96)

White cell count 2 x 10^9/L (4-11)

Platelets 110 x 10^9/L (150-400)

What is the SINGLE most likely diagnosis?

A 79 year old woman complains of a new onset of lower and upper back pain which began 3 months ago. She describes feeling very lethargic over the past few months. She describes a loss of appetite and weight loss. Her blood tests show:

Haemoglobin 81 g/L 115-160)

White cell count 4 10^9/L (4-11)

Serum urea 9.5 mmol/L (2.0-7)

Serum creatinine 298 μmol/L (70-150)

eGFR 28 mL/min (>90)

What SINGLE investigation is most likely to lead to a diagnosis?

A 54 year old woman is diagnosed with deep vein thrombosis after taking a long haul flight. She is started on warfarin as she is being investigated for anti-phospholipid syndrome. What is the target INR for her?

A 65 year old man is seen in the GP surgery for his medication review. He has a history of an ischaemic stroke 2 months ago. He also has a medical history of type 2 diabetes mellitus and hypertension. His regular medications include amlodipine, metformin, clopidogrel and atorvastatin. His ECG is seen below.

A zoomed-in image of lead II can be seen below:

What is the most appropriate measure to prevent further strokes?

A 4 year old boy presents with haemarthrosis following a minor fall. His maternal grandfather has a similar bleeding problem. What is the SINGLE most likely mode of inheritance?

A 59 year old smoker who recently underwent a hip replacement surgery 2 days ago, has a swollen and tender left leg. The diameter of his left calf is higher than the right calf. Passive movements cause pain. The calf is tender to touch. What is the SINGLE most likely diagnosis?

A 78 year old man is seen in the community with swelling and pain on his foot, ankle and calf for the past 2 days. On examination, his left calf is 3.5 cm larger than his right calf and there is pitting oedema on confined to the left leg. He has no significant medical history. He has a temperature of 37.3°C, respiratory rate of 15 breaths/minute and a heart rate if 60 beats/minute. Below is a picture of his legs.

His creatinine clearance is 97 mL/min (normal: 97-137) and he weighs 85 kg. What is the SINGLE most appropriate management?

A 55 year old man complains of headache and visual disturbances. He has a history of hypertension. He also reports itching after a hot bath and burning sensation in his finger and toes. He is noted to have mass in the left upper quadrant. Blood report shows the following:

Haemoglobin 202 g/L

White cell count 19 x 10^9/L

Platelets 502 x 10^9/L

Erythropoietin is normal

What is the SINGLE most likely diagnosis?

A 12 year old boy has sudden development of purpura 2 weeks after an upper respiratory tract infection. His blood results show the following:

Haemoglobin 119 g/L (130-180)

White cell count 6.8 x 10^9/L (4-11)

Platelets 35 x 10^9/L  (150-400)

Prothrombin time 12 seconds (10-14)

Activated partial thromboplastin time 41 seconds (35-45)

Bleeding time 10 minutes (3-9)

What is the SINGLE most likely diagnosis?

A 33 year old woman has acute swelling of her entire right leg a day after her C-section. The swelling starts at the level just above the inguinal ligament. She also has back and buttock pain. What is the most likely reason for her symptoms?

A 45 year old woman who is taking medication for the treatment of rheumatoid arthritis presents with dizziness, fatigability and lack of energy. Blood results show.

Haemoglobin 80 g/L

Mean cell volume (MCV) 106 fL

What is the SINGLE most likely cause of her anaemia?

A 30 year old woman presents with complaints of lethargy and frequent infections. On examination, her spleen is not palpable and there are no associated lymphadenopathy. A full blood count reveals the following:

Haemoglobin 85 g/L

White cell count 2.2 x 10^9/L

Platelets 26 x 10^9/L

What tissue biopsy will you do to prove the diagnosis?

A 39 year old pregnant woman who is 36 week gestation has acute abdominal pain and is rushed for immediate C-section. Her blood pressure was reported to be 110/60 mmHg. Her blood tests show:

Haemoglobin 101 g/L (115-160)

White cell count 9.8 x 10^9/L (4-11)

Platelets 60 x 10^9/L (150-400)

Activated partial thromboplastin time 61 seconds (35-45)

Prothrombin time 29 seconds (10-14)

Fibrinogen 0.6 g/L (2.0-4.0)

Bilirubin 22 μmol/L (3-17)

What is the SINGLE most likely diagnosis?

A 6 year old boy is brought to the hospital by his mother with bleeding from his gums and nose. His mother complains that he has been having recurrent sore throats that come and go in the last couple of months. Pale conjunctivae are noticed on examination. Blood results show:

Haemoglobin 88 g/L ((130-180)

MCV 92 fl (76-96)

White cell count 3.1 x 10^9/L (4-11)

Platelets 70 x 10^9/L (150-400)

What is the SINGLE most likely single cell type associated with his diagnosis?

A 61 year old man attends the Emergency Department with sudden onset severe abdominal pain. The pain started several hours ago. He looks pale. He has a history of an abdominal aortic aneurysm which was seen 2 months ago on an ultrasound scan and is awaiting surgery. He has a mechanical aortic valve replacement 7 years ago and takes regular warfarin. His blood pressure is 98/65 mmHg and pulse rate is 120 beats/minute. What is the SINGLE most appropriate management?

A 50 year old woman is investigated for anaemia. She has no past medical history of note. Clinical examination reveals massive splenomegaly associated with pale conjunctivae. A full blood count was requested and results show:

Haemoglobin 105 g/L

White cell count 62 x 10^9/L

Platelets 803 x 10^9/L

What is the SINGLE most likely diagnosis?

A 71 year old man has been having bleeding hypertrophic gums. He has spontaneous haematomas and purpura on his arms, legs and trunk. He has been feeling lethargic for several months. He has been abusing alcohol for the past several years. He is malnourished. He lives alone and does not have any family members to support him. On examination, his gums are friable and there are petechiae on the mucosae. He has noticeable pallor on his face and palms. What is the SINGLE most likely deficiency?

A 22 year old Greek man presents with rapid symptoms of anaemia and jaundice following treatment of malaria. He is noted to have Heinz bodies on a blood film. What is the SINGLE most likely diagnosis?

A 16 year old girl presents to the GP surgery with the complaint of a lump in her neck. She is well at present; however, she reports that as of late, she has been tiring more easily than usual. On examination, a 2 x 2 cm non-tender, rubbery anterior cervical lymph node is palpable along with other mildly enlarged lymph nodes of the neck, axilla and groin. Her body temperature is 37.4°C. Which of the following is the most appropriate diagnostic investigation?

A 18 year old boy presents with a lump on his neck which has been enlarging in size over the few weeks. He feels fatigue and describes frequent night sweats. He has been told by his family members that he looks thinner over the past month. He denies recent travels abroad. On examination, he has a 3 cm non-tender lump in the right side of the neck and an enlarged spleen an abdominal examination. He has a temperature of 38.4°C. What is the SINGLE most likely diagnosis?

A 32 year old man presents with fatigue, weakness, weight loss. On examination, cervical lymphadenopathy and splenomegaly is noted. What is the SINGLE most likely diagnosis?

A 69 year old woman has a lump on her anterior neck which is painless and non-mobile which she first noticed 6 months ago. She also has swelling of her anterior cervical, supraclavicular and axillary lymph nodes. She has a history of weight loss and extreme fatigue for the past several months. She was subsequently seen by the haematology team who requested several investigations which results are shown below:

Haemoglobin 115 (115-160 g/L)

Platelets 290 x 10^9/L (150-400 x 10″/L)

White cell count 29.4 x 10^9/L (4-11 x 10°/L)

Neutrophils 7 x 10^9/L (2-7.5 x 10″/L)

Lymphocytes 22 x 10^9/L (1.3-3.5 x 10″/L)

Eosinophils 0.33 x 10^9/L (0.04-0.44 x 10″/L)

Basophils 0.09 x 10^9/L (0.0-0.10 x 10°/L)

A peripheral blood smear shows an abundance of smudge cells.

What is the SINGLE most likely diagnosis?

A 53 year old woman has been feeling lethargic over the past few months. She suffers from chronic rheumatoid arthritis and has been taking methotrexate for the past 12 years. She also takes naproxen occasionally for her pain. Blood results show:

Haemoglobin 83 g/L (115-160)

Mean cell volume (MCV) 70 fL (76-96)

What is the SINGLE most likely cause of her tiredness?

A 4 year old boy has a cough and arthritis followed by a rash on legs which are non- blanching on glass test. He has no history of a fever. His blood tests show.

Haemoglobin 120 g/L (130-180)

White cell count 6.3 x 10^9/L (4-11)

Platelets 259 x 10^9/L (150-400)

Prothrombin time 13 seconds (10-14)

Activated partial thromboplastin time 35 seconds (35-45)

What is the SINGLE most likely diagnosis?

A 58 year old woman has clarithromycin prescribed for a chest infection. Her past medical history is significant for a mitral valve replacement twenty years ago and she thus takes regular warfarin. She also suffers from trigeminal neuralgia which she started carbamazepine 3 weeks ago. Her regular medications also include amlodipine, atorvastatin and bisoprolol. Today, her international normalised ratio (INR) is found to be 1.3 (target for mechanical heart valves >3). Which of the following is the SINGLE most likely drug to have interacted with warfarin to give this blood result?

A 51 year old man complains of lethargy tiredness and pruritus. The pruritus is worse after he takes a hot shower. He also says that he feels a burning sensation in his fingers and toes. Splenomegaly was found during an abdominal examination. His medical history is significant for gout. What is the SINGLE most likely diagnosis?

A 41 year old woman has been feeling lethargic over the past few months. She has no significant medical history. Her blood test reveals the following:

Haemoglobin 91 g/L (115-160)

Mean cell volume (MCV) 109 FL (76-96)

Mean cell haemoglobin concentration (MCHC) 366 g/L (300-360)

Ferritin 12 ng/ml (20-300)

Vitamin B12 80 ng/L/160-800)

Folate 2.0 ng/L (>2.7)

Vitamin D 62 nmol/L (60-105)

What is the SINGLE most appropriate medication to start first?

A 41 year old man has fatigue and palpitations. Physical examination reveals a red sore tongue, angular stomatitis and koilonychia. His blood tests show:

Haemoglobin 85 g/L (115-160)

Mean cell volume 75 fL (76-96)

What is the SINGLE most likely diagnosis?

A 33 year old woman complains of tiredness for the last 3 months, On routine blood test, she is found to have a haemoglobin of 85 g/L, low mean cell volume, and low ferritin. What is the SINGLE most likely diagnosis?

A 67 year old man with a history of weight loss complains of hoarseness of voice. He has a localized rapidly enlarging lymphadenopathy on his lower anterior neck. He complains of drenching night sweats and fever. A chest X-ray reveals opacity in the right upper mediastinum. He denies any history of difficulty breathing. What is the SINGLE most appropriate investigation?

A 3 year old boy from Bangladesh attends the GP surgery with his mother with concerns of lethargy. They have just moved from Bangladesh to the UK 3 months ago. His nursery had pointed out that he seems more tired than other children his age. His diet mostly consists of drinking milk with very little solid foods. On examination, he looks pale. A blood test was requested of which the following results show.

Haemoglobin 85 g/L (130-180)

Mean cell volume 72 fL (76-96)

Mean cell haemoglobin concentration 295 g/L (300-360)

What is the SINGLE most likely diagnosis?

A 7 year old boy has recurrent episodes of spontaneous bleeding into his knee joints and muscles. Factor IX was found deficient. What is the SINGLE most likely diagnosis?

A 62 year old man presents with bone pain at his ribs and back pain which have been present for the last couple of months. He has been feeling tired lately and finds himself always thirsty. Blood test were requested on his last visit which shows:

Haemoglobin 91 g/L 130-180)

Serum calcium 3.18 mmol/l (2.1-2.6)

Alkaline phosphatase (ALP) 118 U/L (30-150)

Erythrocyte sedimentation rate (ESR) 88 mm/h eGFR 45

What cell type is most likely to be found in abundance in the bone marrow?

A 45 year old man presents with a lump in the posterior triangle of his neck. It has been growing for the past few months. He also complains of having drenching night sweats, unexplained fever and weight loss. Lymph nodes are palpable at the supraclavicular region. What is the SINGLE most likely diagnosis?

A 75 year old woman has worsening swelling of her right leg for the past 7 days. There is pain on her calf and shin of her right leg. She has no shortness of breath or chest pain. She takes apixaban 2.5 mg once a day for a previous pulmonary embolism and deep venous thrombosis 3 years ago. On examination, her right mid-calf measures 47 cm and her left mid-calf measures 36 cm. There is pitting oedema confined to her right leg. Her pulse rate is 70 beats/minute, respiratory rate is 18 breaths/minute and her temperature is 37.2°C. Below is a photo of her leg.

What is the SINGLE most appropriate action?

A 25 year old lady has a chest infection in which she is receiving antibiotics for. She has shortness of breath, feels tired and weak. On examination she looks pale and purpura is seen on her legs. Blood results show the following:

Haemoglobin 76 g/L

White cell count 1.2 x 109/L

Neutrophils 0.3 x 109/L

Platelets 19 x 109/L

Reticulocytes 1%

Blood film morphology was unremarkable. A bone marrow aspirate shows a reduction in haemopoietic cells. What is the SINGLE most likely underlying diagnosis?

A 51 year old vegan presents with complaints of peripheral paresthesia, mild shortness of breath and fatigue. Examination reveals that she has angular stomatitis and a sore red tongue. What is the SINGLE most likely cell type to be seen on a blood film?

A 5 year old girl presents with pallor and features of renal failure. She has haematuria as well as proteinuria. The serum urea and creat are elevated. These symptoms started after an episode of bloody diarrhoea 4 days ago. What is the SINGLE most likely diagnosis?

A 12 year old girl complains of fatigue over the past 5 months. She has recently moved here from Greece. Her parents are bath Greek. A recent blood report shows the following:

Haemoglobin 98 g/L (115-160)

Mean cell volume 70 fL (76-96)

Mean cell haemoglobin concentration 280 g/L (300-360)

Serum ferritin 40 ng/ml (20-300)

Total iron-binding capacity 98 μmol/L (54-75)

Transferrin saturation low

What is the SINGLE most likely diagnosis?

A 53 year old man presents complaining of weight loss, lethargy, increasing abdominal discomfort and gout for the past year. On examination, the spleen is palpated 5 cm below the left castal margin. His blood tests show:

Haemoglobin 105 g/L (130-180)

White cell count 202 x 10^9/L (4-11)

85% neutrophils

Platelets 850 x 10^9/L (150-400)

Serum urea 5.5 mmol/L (2.0-7)

Serum creatinine 144 μmol/L (70-150)

What is the SINGLE most likely diagnosis?

A 42 year old woman with severe cough develops septicaemia and is admitted into the medical ward. She develops purpura all over her legs and arms over the past few hours. She has just arrived back from Australia 3 days ago by flight. She takes warfarin for her mechanical aortic valve. Her blood tests show:

Haemoglobin 118 g/L (115-160)

White cell count 15.8 x 10^9/L (4-11)

Platelets 28 x 10^9/L (150-400)

Activated partial thromboplastin time 63 seconds (35-45)

Prothrombin time 30 seconds (10-14)

Fibrinogen 0.5 g/L (2.0-4.0)

D-dimers 1900 ng/ml (< 500)

What is the SINGLE most likely diagnosis?

A 69 year old man presents with a 5 month history of lower back pain. He has no history of trauma to the back. His blood results show the following:

Haemoglobin 89 g/L (130-180)

White cell count 10 x 10^9/L (4-11)

Platelets 360 x 10^9/L (150-400)

Sodium 138 mmol/L (135-145)

Potassium 3.9 mmol/L (3.5-5)

Urea 6 mmol/L (20-7)

Creatinine 198 μmol/L (70-150)

eGFR 44 mL/min (>60)

Serum calcium 2.79 mmol/l (2.1-2.6)

Erythrocyte sedimentation rate (ESR) 98 mm/hr (<15)

CRP 9 mg/L (<10)

On examination, he is tender at LS. What is the SINGLE most likely diagnosis?

A 33 year old man complains of lethargy tiredness and pruritus. A diagnosis of polycythaemia vera was made. What is the SINGLE most appropriate management?

A 67 year old woman with a history of rheumatoid arthritis presents to her GP’s office with complaints of epigastric discomfort, especially after eating. She has been on long term methotrexate and NSAID therapy for her condition. On examination, she appears pale but seems otherwise well. A full blood count reveals the following:

Haemoglobin 105 g/L

MCV, MCH and MCHC are seen to be decreased

What is the SINGLE most likely diagnosis?

A 52 year old woman presents for a follow-up visit at the GP surgery to discuss her reports and plan her management. Her first visit was a week ago when she complained of feeling tired. She finds simple tasks such as going out to get her groceries exhausting and becomes slightly short of breath. She maintains a healthy lifestyle and diet and did not have a significant past medical history, and on assessment, was found to be pale and icteric. The investigations requested are available and are as follows.

Haemoglobin 88 g/L (115-160)

Mean cell volume 101 FL (76-96)

Mean cell haemoglobin concentration 365 g/L (300-360)

Lactate dehydrogenase 298 U/L (70-250)

Bilirubin 39 μmol/L (3-17)

Peripheral blood smear show spherocytes and polychromasia

Which of the following is the most appropriate next step in the investigation of this patient?

A 32 year old woman has just had a laparoscopic cholecystectomy a few hours ago. The nurse notices that she has a sore left leg with swollen varicose vein extending from the mid-thigh to the ankle. She informs the nurse that she has had this pain in her left leg before surgery. She has no calf tenderness or calf swelling. What is the SINGLE most appropriate action?

A 22 year old man is admitted to the hospital with lethargy. His medical history includes hereditary spherocytosis. His blood tests show.

Haemoglobin 51 g/L (130-180 g/L)

Reticulocytes 0.4% (0.8-2.0%)

What is the SINGLE most likely cause of his low haemoglobin and low reticulocytes?

A 20 year old woman has had bruising and petechiae for a week. She also reports frequent nose bleeds and menorrhagia but is otherwise well. A blood count showed:

Haemoglobin 119 g/L (130-180)

White cell count 6.3 x 10^9/L (4-11)

Neutrophils 3.1 x 10^9/L (2-7.5)

Platelets 39 x 10^9/L (150-400)

Mean cell volume (MCV) 74 fL (76-96)

Ferritin 15 ng/ml (20-300)

On examination, there are no lumps palpable on her neck. She is not on any medications. What is the SINGLE most likely diagnosis?

A 20 year old man presents with develops low back pain, shortness of breath and dizziness 7 days after taking primaquine to treat malaria. His past medical history is significant for neonatal jaundice. What is the SINGLE most likely diagnosis?

A 13 year old boy complains of a ‘pins and needles’ sensation in his feet. He does not suffer from any medical conditions and takes no regular medication. He denies any palpitations, shortness of breath or lightheadedness. On examination, his tongue appears to be swollen and inflamed. He has a BMI of 15 kg/m2. His full blood count shows the following:

Haemoglobin 80 g/L (130-180)

White cell count 5 x 10^9/L (4-11)

Platelets 350 x 10^9/L (150-400)

Mean cell volume (MCV) 108 fL (76-96)

A smear shows oval macrocytes and hypersegmented neutrophils. The patient mentions that he became vegan 5 years ago. In the morning, he only has time for a cup of tea before heading off to school. Further blood tests were requested. What is the SINGLE most appropriate treatment that this patient is likely to start?

A 7 year old boy presents with epistaxis of 2 hour duration. The bleeding has been controlled. His blood tests show:

Platelets 219 x 10^9/L

Prothrombin time 13 seconds

Activated partial thromboplastin time 42 seconds

Bleeding time is normal

What is the SINGLE most likely diagnosis?

A 63 year old woman with severe anaemia from a rectal bleed has a blood transfusion. Her observations pre-transfusion are as follows:

Temperature 37.1°C

Pulse rate 109 beats/minute

Respiratory rate 18 breaths/minute

SpO2

97%

Blood pressure 114/73 mmHg

4 hours post-transfusion, she starts to feel chills and rigors. Her observations are as follows:

Temperature 38.4°C

Pulse rate 99 beats/minute

Respiratory rate 17 breaths/minute

SpO2 95%

Blood pressure 120/78 mmHg

What is the SINGLE most likely diagnosis?

A 34 year old Turkish man has been feeling lethargic for the past few years. His blood test shows the following:

Haemoglobin 90 g/L (130-180)

Mean cell volume 68 fL (76-96)

Mean cell haemoglobin concentration 270 g/L (300-360)

Ferritin 150 ng/ml (20-300)

Total iron binding capacity (TBC) 350 mcg/dL (240 – 450)

What is the SINGLE most likely diagnosis?

A 20 year old man with sickle cell anaemia has shortness of breath, pallor, headache and lethargy. He has been having flu-like symptoms for the past week. For the past few days he has been having joint aches on his hands, wrist, knees and ankles. His initial blood tests show:

Haemoglobin 53 g/L

Infection with parvovirus B19 is suspected and further blood test have been sent for specific IgM and IgG antibodies to parvovirus B19. What is the SINGLE most likely diagnosis?

A 45 year old man presents fatigue. He is otherwise asymptomatic. Blood report shows the following:

Haemoglobin 82 g/L (130-180)

White cell count 132 x 10^9/L (4-11)

Platelets 550 x 10^9/L (150-400)

There was an increased number of neutrophils, basophils, eosinophils. Peripheral blood smear shows all stages of maturation. What is the SINGLE most likely diagnosis?

A 7 year old boy has recurrent episodes of spontaneous bleeding into his knee and elbow joints. Mild joint deformity is noted. Factor VIII/IX assay shows a decrease in factor VIII. What is the SINGLE most appropriate management?

A 28 year old man has sudden onset of bone pain. He also begins experiencing bleeding from his gums. Looking retrospectively, he notes a decreased energy level over past weeks. He feels dizzy and has dyspnoea on exertion. He looks pale and has numerous ecchymoses is seen over his body. Hepatosplenomegaly is noted. A full blood count shows WBC of 102 x 109/L. A bone marrow biopsy shows numerous blasts. What is the SINGLE most likely diagnosis?

A 50 year old man presents with fatigue, weight loss and complaints of abdominal fullness. An abdominal examination reveals splenomegaly extending towards the right iliac fossa.

Blood report shows the following:

Haemoglobin 82 g/L

White cell count 102 x 10^9/L

Platelets 160 x 10^9/L

The Philadelphia chromosome was positive on cytogenetic analysis. What is the SINGLE most likely diagnosis?

A 30 year old woman complains of tiredness, lethargy and constipation. On inspection, she has dry coarse skin, hair loss and cold peripheries. On examination, a diffuse and lobulated goitre can be palpated on her anterior neck. A full blood count and peripheral smear is done which shows a macrocytic anaemia. What is the SINGLE most likely diagnosis?

A 55 year old man presents with “rubbery painless lump on his neck. He also has significant weight loss over the past 6 months, fever and night sweats. The diagnosis of Hodgkin’s lymphoma was later confirmed with a lymph node excision biopsy. What type of cell is associated with Hodgkin’s lymphoma?

A 21 year old woman attends the GP surgery with fatigue over the past few months. She states that her menstrual bleeds have been particularly heavy in the past few months. Her menstrual cycles are regular 28-day cycles. Her menstrual bleeding last between 3 to 5 days. She takes tranexamic acid during the days that she bleeds heavy. Her heart rate is 85 beats/minute and blood pressure is 120/80 mmHg. A blood test was done which shows the following:

Haemoglobin 89 g/L (115-160)

Mean cell volume (MCV) 69 FL (76-96)

What is the SINGLE most appropriate management?

A 58 year old man has swelling and pain on his calf for the past 5 days. He has a history of 2 deep vein thrombosis 6 years and 8 years ago, and a pulmonary embolism 5 years ago. He was advised to take a prophylactic dose of rivaroxaban daily due to his high risk of recurrence of venous thromboembolism. On examination, his entire left leg is swollen and his left calf is 4 cm larger than his right. He has a temperature of 37.1°C, respiratory rate of 18 breaths/minute and a heart rate if 60 beats/minute. What is the SINGLE most appropriate management?

A 67 year old man presents to the Emergency Department with epistaxis that started an hour ago. There is no history of trauma. The nosebleed continues despite cautery and nasal packing. He takes warfarin for his atrial fibrillation. His pulse rate is 80 beats/minute and blood pressure is 110/70 mmHg. His blood results show an INR of 8.1 (target range 2-3). His haemoglobin is 125 g/L (130-180). What is the SINGLE most appropriate management?

A 75 year old male presents with enlarged cervical nodes which have been present for a few months. He has several recurrent infections over the last year. His conjunctiva is pale and he feels weak. He has been complaining of severe lethargy for many months. What is the SINGLE most likely cell type to be found on a blood smear of this patient?

A 17 year old girl has prolonged bleeding after a routine dental extraction. Her father and paternal grandmother have experienced similar problems. What is the SINGLE most likely mode of inheritance?

A 19 year old girl from African descent has a history of recurrent mild jaundice that occurs a few days after the onset of a fever. Between the episodes she is well. She had a recent course antibiotic for a urinary tract infection 7 days ago. She describes fatigue with worsening abdominal pain and lower back pain for the last few days. Her full blood count shows the following:

Haemoglobin 96 g/L

Mean cell haemoglobin concentration 330 g/L (300-360 g/L)

Mean cell volume (MCV) 80 (76-96 FL)

Heinz bodies, bite cells and reticulocytosis are found on a blood smear. What is the SINGLE most likely diagnosis?

A 51 year old woman has large bruising of her legs and epistaxis. She has been recently admitted for pneumonia and is treated with intravenous antibiotics. She has spontaneous bleeding at venepuncture sites. On examination, there is purpura throughout her legs and trunk. She has a temperature of 39.7°C, heart rate of 119 beats/minute, blood pressure of 100/80 mmHg, respiratory rate of 22 breaths/minute and an oxygen saturation of 96%

Her blood tests show:

Haemoglobin 101 g/L (115-160)

White cell count 18 x 10 /L (4-11)

Platelets 33 x 10^9/L (150-400)

Activated partial thromboplastin time 63 seconds (35-45)

Prothrombin time 26 seconds (10-14)

CRP 280 mg/L (<10)

What is the SINGLE most likely diagnosis?

A 35 year old first time donor suddenly passes out as she is donating blood. She is not known to have any medical problems in the past. Which of the following steps would be the least useful in managing this adverse event?

A 73 year old female patient presents with right-sided hemiplegia and aphasia in the Emergency Department. These symptoms began in the morning and resolved spontaneously within 6 hours. An ECG conducted in the hospital revealed atrial fibrillation. What is the SINGLE best scoring method to assess her need for anticoagulation to reduce her risk of future stroke?

A 71 year old man attends the GP with painless cervical lymph nodes. They have been present for the past 5 months. He has significant weight loss and reduced appetite over the past 3 months. His blood test reveal the following:

Haemoglobin 88 g/L (130-180)

White cell count 30 x 10^9/L (4-11)

Neutrophils 2.1 x 10^9/L (2-7.5)

Platelets 151 x 10^9/L (150-400)

A biopsy of the lymph nodes show manamorphic small irregular B lymphocytes. What is the SINGLE most likely diagnosis?

A 64 year old woman attends the clinic because she is feeling short of breath when walking. As part of the investigation of heart failure, an ECG was performed which showed atrial fibrillation. What is the SINGLE best scoring method to determine the need to start medications to prevent a stroke?

A 25 year old Greek man presents with dark red urine hours after eating fava beans. He is now very ill and has signs of shock. Spherocytes and red blood cell fragments are seen on blood film. What is the SINGLE most likely diagnosis?

A 52 year old lady has been suffering from chronic rheumatoid arthritis and is on methotrexate and naproxen. Her blood results show:

Haemoglobin 83 g/L

Mean cell volume (MCV) 70 fL

What is the SINGLE most likely cause?

A 51 year old man complains of headache and pruritus. He had a deep vein thrombosis recently. Recent blood report shows the following:

Haemoglobin 192 g/L

White cell count 15 x 10^9/L

Platelets 809 x 10^9/L

Erythropoietin was found to be low. What is the SINGLE most likely diagnosis?

A 51 year old male presents with malaise and tiredness. On physical exam, his spleen is noted to be approaching his right iliac fossa. No lymphadenopathy was noticed. What is the SINGLE most likely cell type to be seen on a blood smear?

A 34 year old male patient with established Burkitt’s lymphoma is undergoing chemotherapy. He is currently at week two of treatment. He complains of only passing very little amounts of urine in the past 24 hours and feeling more lethargic than usual. Upon routine blood testing, he was found to have the following lab values:

Potassium 5.9 mmol/L

Urea 18 mmol/L

Creatinine 289 μmol/L

Serum calcium (total) 1.9 mmol/L

What SINGLE most appropriate investigation will you perform to aid in management of this patient?

A 59 year old man was recently admitted to the hospital following an ischaemic stroke. He is found to be having atrial fibrillation on an ECG with a rate of 80 beats/minute. He does not feel palpitations. His blood pressure is 130/80 beats/minute. What is the SINGLE most appropriate long term medication to prescribe to prevent further strokes for this patient?

A 52 year old female has loss a few litres of blood during a hysterectomy. She is due for a blood transfusion. What is the SINGLE most likely test involved in the preparation of blood transfusion?

A 49 year old lady complains of headaches, dizziness and pruritus. She says that the pruritus is worsen after taking a hot bath. A recent FBC revealed that she has a haemoglobin of 192 g/L. What is the SINGLE most useful test to establish the diagnosis of polycythaemia rubra vera?

A 55 year old man complains of fatigue. A blood test shows:

Haemoglobin 82 g/L

Mean cell volume 107 FL

What is the SINGLE most likely diagnosis?

A 5 year old child has bleeding gums and sore throat for the last 3 months. He feels tired and lethargic all the time. His mom complains that he is not been his usual self over the past few months. He lacks energy and is sleeping most of the time. On examination, splenomegaly was noted. Blood results show:

Haemoglobin 78 g/L ((130-180)

White cell count 3 x 10^9/L (4-11)

Platelets 48 x 10^9/L (150-400)

What is the SINGLE most likely diagnosis?

A 69 year old man presents to the Emergency Department with sudden, severe abdominal pain radiating to his back. The pain started 6 hours ago. He was recently diagnosed with an abdominal aortic aneurysm and is awaiting surgery for this. He has had a mechanical aortic valve replacement 7 years ago and takes regular warfarin. He also takes bisoprolol and ramipril. His blood pressure is 98/65 mmHg and pulse rate is 120 beats/minute. His blood results show an INR of 4.2. His haemoglobin is 88 g/L. What is the SINGLE most appropriate management?

A 90 year old woman complains of lower back pain and lethargy which has been ongoing for the past few months. She has been saying that her mother is due to visit her today and that somebody must have broken her lower back as she is in agony. Her blood pressure is 160/95 mmHg. Her blood tests show:

Haemoglobin 91 g/L 115-160)

Serum urea 7.5 mmol/L (20-7)

Serum creatinine 293 μmol/L (70-150)

Serum calcium 3.02 mmol/l (2.1-2.6)

What SINGLE investigation is most likely to lead to a diagnosis?

A 36 year old female presents with a petechial rash and menorrhagia. Her physical examination is completely normal and she has no other complaints. A full blood count was done and reveals:

Haemoglobin 133 g/L (130-180)

White cell count 9 x 10^9/L (4-11)

Neutrophils 3.1 x 10^9/L (2-7.5)

Platelets 60 x 10^9/L (150-400)

What is the SINGLE most likely diagnosis?

A 55 year old man presents to the Emergency Department with epistaxis that started three hour ago. There is no history of trauma. The nosebleed continues despite cautery and nasal packing. He takes warfarin for his atrial fibrillation. His pulse rate is 130 beats/minute and blood pressure is 80/42 mmHg. His blood results show an INR of 7 (target range 2-3). What is the SINGLE most appropriate initial management?

A 65 year old man is brought by ambulance to the hospital for a suspected stroke. The patient is on warfarin as part of his management for atrial fibrillation. INR was ordered as part of a series of investigations and results have returned to show an INR of 7.9. A computed tomography scan was performed and reveals an intracranial haemorrhage. He currently has a blood pressure of 90/50 mmHg and a heart rate of 120 beats per minute. As part of the management for the high INR and bleeding, vitamin K was administered intravenously. What other products can be given as part of the management for warfarin overdose?

A 5 year old child presents with fever and pallor. His parents say he always feels tired and is not as active as the other children around his age. On examination, splenomegaly was noted. Blood results show

Haemoglobin 70 g/L ((130-180)

White cell count 2 x 10^9/L (4-11)

Platelets 42 x 10^9/L (150-400)

What is the SINGLE most likely diagnosis?

A 26 year old Greek man has recently recovered from a haemolytic episode 6 weeks ago. The haemolytic episode occurred a day after he ate a traditional Greek dish. Glucose-6- phosphate dehydrogenase deficiency is suspected. What is the SINGLE most definitive diagnostic test?

A 56 year old man has had a deep vein thrombosis (DVT) 3 weeks ago. He was seen in A&E and started on dabigatran. He wants to know if he needs to inform the Driver and Vehicle Licensing Agency (DVLA). He drives a car but has not been driving since the diagnosis of DVT. He is able to move his leg freely without any pain. What is the SINGLE most appropriate advice?

A 58 year old man had surgery for a hip fracture a few hours ago. He has no previous medical problems. He is likely to be immobile for the next few weeks. Which is the most appropriate action to reduce the risk of venous thromboembolism?

A 29 year old woman at 28 weeks gestation comes in for an antenatal visit. Her blood tests reveal

Haemoglobin 110 g/dL

MCHC normal range

MHC normal

What is the SINGLE best explanation for these blood results?

A 60 year old man has recently undergone a total gastrectomy for a malignant neoplasm. He is advised on the importance of vitamin B12 after the operation. What is the SINGLE most likely reason that he is advised this?

A 37 year old Italian woman has been feeling lethargic for the past two years. She had a full blood count a year ago which showed a haemoglobin of 95 g/L She was diagnosed with Crohn’s disease 6 months ago. Her blood test shows the following:

Haemoglobin 94 g/L (130-180)

White cell count 8 x 10^9/L (4-11)

Neutrophils 5.3 x 10^9/L (2-7.5)

Platelets 250 x 10^9/L (150-400)

Mean cell volume 64 FL (76-96)

Mean cell haemoglobin concentration 250 g/L (300-360)

Serum iron 90 mcg/dL (60 to 170)

Ferritin 260 ng/ml (20-300)

Transferrin saturation 302 mg/dl (204 to 360)

What is the SINGLE most likely diagnosis?

An INR result of a 64 year old man was found to be 6.3. The local haematology laboratory highlighted this finding and informed the clinic. The patient takes warfarin for atrial fibrillation. He is otherwise well with no active bleeding. What is the SINGLE most appropriate action?

A 63 year old man presents with back pain, polydipsia and polyuria which have been present for the last couple of weeks. He complains of being tired lately. He has recurrent nose bleeds which started 6 months ago. His previous full blood count shows a normochromic, normocytic anaemia. His eGFR was found to be 40. Monoclonal proteins were seen during further investigations of which he was referred to secondary care. What is the SINGLE most appropriate investigation to perform next that would lead to a diagnosis?

A 38 year old female presents with the complaint of worsening tiredness. She says that she first began to notice her increasing fatigability two weeks ago. On examination, she appears to be mildly jaundiced. No other significant signs appear on physical examination. Her heart rate is 79 beats/minute and her blood pressure is 120/70 mmHg. Baseline bloods were taken and the results are as follows:

Haemoglobin 92 g/L (130-180)

Mean cell volume (MCV) 103 fL (76-96)

White cell count (WCC) 8 x 10^9/L (4-11)

Bilirubin 29 μmol/L (3-17)

Alanine transferase (ALT) 21 U/L (5-35)

Aspartate transaminase (AST) 27 U/L (5-35)

Alkaline phosphatase (ALP) 140 U/L (30-150)

Gamma glutamyl transferase (GT) 39 u/L (8-60)

What is the SINGLE most appropriate diagnostic investigation for this patient?

A 10 year old boy is brought to the hospital with a rash over his buttocks associated with abdominal pain and vomiting. He is accompanied by his mother and stepfather. His mother had left him for the weekend with the stepfather and she was called to come back from holiday as he started to have blood in his urine with the rash. Social services have been notified. What is the most likely diagnosis?

A 49 year old woman with metastatic breast cancer has massive bleeding from a venepuncture site. She has a history of pulmonary embolism and takes warfarin.

Petechiae was noticed on her skin. Her blood tests show:

Haemoglobin 113 g/L (115-160)

White cell count 9.8 x 10^9/L (4-11)

Platelets 48 x 10^9/L (150-400)

Activated partial thromboplastin time 60 seconds (35-45)

Prothrombin time 30 seconds (10-14)

Bleeding time prolonged

Fibrin degradation products elevated

What is the SINGLE most likely diagnosis?

A 76 year old man is admitted after the diagnosis of stroke with left hemiplegia. He is bed-bound on admission and has a history of type 2 diabetes. He is expected to stay at the hospital for the next few weeks. What is the most appropriate measure to reduce the risk of venous thromboembolism?

A 55 year old HIV positive man presents with painless peripheral lymphadenopathy, fever, night sweats and weight loss. An abdominal examination reveals an enlarged spleen. What is the SINGLE most likely diagnosis?

A 45 year old man presents to the Emergency Department with epistaxis that started an hour ago. There is no history of trauma. The nosebleed continues despite cautery and nasal packing. He has a mechanical aortic valve replacement 8 years ago and takes regular warfarin. His pulse rate is 80 beats/minute and blood pressure is 110/70 mmHg. His blood results show an INR of 7 (target range 2-3). His haemoglobin is 111 g/L (130- 180). What is the SINGLE most appropriate management?

A 29 year old man has had abdominal pain and bloating for the past 6 months. He denies any fever. A blood test shows the following:

Haemoglobin 99 g/L (130-180)

Mean cell volume (MCV) 102 FL (76-96)

Ferritin 30 ng/ml (20-300)

Vitamin B12 180 ng/L(160-800)

Folate 1.0 ng/L (>2.7)

Which organ, if affected, could be responsible for his symptoms and blood test results?

A 63 year old man presents with extreme thirst that despite drinking fluids he still feels thirsty. He has been having a back ache for the last 4 months that is getting worse and feels tired all the time. During this time, he has noticed weight loss and mild breathlessness. His serum calcium was found to be elevated. A blood film was taken. What is the SINGLE most likely finding to be seen on a blood film?

A 13 year old girl has has mucosal bleeding and petechial rashes. She has been feeling tired lately. She looks pale. A blood count shows:

Haemoglobin 74 g/L

White cell count 1.9 x 10^9/L

Neutrophils 0.1 x 10^9/L

Platelets 24 x 10^9/L

Bload film morphology was unremarkable. Reticulocytes are absent. A bone marrow aspirate shows a gross reduction in all haemopoietic tissue that is replaced by fat spaces. What is the SINGLE most likely underlying diagnosis?

A 29 year old African American man has back pain and abdominal pain a few days following the treatment of malaria. His urine has become dark and his eyes have a yellowish tinge. He has had gallstones in the past. His past medical history includes jaundice when he was a neonate. What is the SINGLE most likely diagnosis?

A 53 year old man returns to the UK from North America with a 3 month history of fatigue, night sweats, fever, arthralgia, malaise and unexplained weight loss. He has drenching night sweats over the past few weeks. On examination, his spleen is enlarged and he has palpable lymph nodes in the supraclavicular region. His temperature is 38.2°C What is the SINGLE most likely diagnosis?

A 65 year old man has a routine full blood count which results are as follows:

Haemoglobin 195 g/L

Platelets 390 x 10^9/L

White cell count (total) 7.8 x 10^9/L

He is a chronic smoker. What is the SINGLE most likely diagnosis?

A 54 year old man has fatigue. A recent blood report shows the following:

Haemoglobin 90 g/L (115-160)

Mean cell volume 70 FL (76-96)

Mean cell haemoglobin concentration 290 g/L (300-360)

Serum ferritin 9 ng/ml (20-300)

Total iron-binding capacity 75 μmol/L (54-75)

What is the SINGLE most likely diagnosis?

A 4 year old boy presents with recurrent episodes of self limiting spontaneous bleeding into his arms and legs that occurs with minimal trauma. His blood tests show.

Prothrombin time 11 seconds

Activated partial thromboplastin time 69 seconds

Bleeding time is normal

What is the SINGLE most likely diagnosis?

A 22 year old woman complains of dizziness and fatigue. She take combined oral contraceptive pills and has light menstrual bleeding for a few days on every cycle. She denies any weight loss or weight gain. Her blood results show the following:

Haemoglobin 89 g/L (115-160)

Mean cell volume (MCV) 70 fL (76-96)

Ferritin 25 ng/ml (20-300)

Total iron binding capacity (TIBC) high

What is the SINGLE most appropriate investigation?

A 75 year old man has been having weight loss and fevers over the past 3 months. He has several enlarged cervical lymph nodes which are painless. His blood test reveal the following:

Haemoglobin 98 g/L (130-180)

White cell count 23 x 10^9/L (4-11)

Neutrophils 5.1 x 10^9/L (2-7.5)

Platelets 250 x 10^9/L (150-400)

A biopsy of the lymph nodes show large bi-nucleated cells with prominent nucleoli. What is the SINGLE most likely diagnosis?

A 26 year old male travelled from New York City to the United Kingdom after staying with his family for seven months. He presented to Accident & Emergency (A&E) three weeks later complaining of drenching night sweats and fever. Physical examination reveals the presence of an enlarged but non-tender lymph node in his neck. What is the SINGLE most likely diagnosis?

A 40 year old man has a mild fever and feels generally tired. He has marked weight loss over the last 6 months and has a bilateral white, vertically corrugated lesion on the lateral surfaces of the tongue. What is the SINGLE most likely diagnosis?

A 68 year old man presents to the GP surgery for a follow-up appointment to discuss his full blood count and liver function test reports. He initially complained of feeling excessively tired for the past 4 months, and did not have a significant past medical or surgical history. However, he noted that his partner passed away 2 years ago and he has been living on his own since. He mentioned that his diet has changed drastically, and he consumes microwavable food most of the time. He does not eat green vegetables. He also noted that he has been drinking alcohol mare often to deal with the loneliness.

Haemoglobin 100 g/L (130-180)

MCV 102 FL (76-96)

Platelets 139 x 10^9 (150-400)

Bilirubin 12 μmol/L (3-17)

Serum alanine transferase (ALT) 33 U/L (5-35)

Serum alkaline phosphatase (ALP) 140 U/L (30-150)

Gamma glutamyl transferase 62 U/L (8-60)

Which of the following investigations is the SINGLE best option to ascertain the cause of this patient’s symptoms and full blood count findings?

A 14 year old boy has recurrent throat infections. He feels tired and lethargic all the time. Blood results show:

Haemoglobin 72 g/L ((130-180)

White cell count 6 x 10^9/L (4-11)

Platelets 95 x 10^9/L (150-400)

Blood film shows blast cells. What is the SINGLE most likely diagnosis?

A 65 year old woman complains of lethargy and weakness over the past 6 months. Her blood pressure is 160/95 mmHg. On examination, she looks pale. A urine dipstick shows 2+ proteinuria. Her blood tests shows:

Haemoglobin 78 g/L 115-160)

Serum urea 9.5 mmol/L (2.0-7)

Serum creatinine 345 μmol/L (70-150)

Serum calcium 2.99 mmol/l (2.1-2.6)

eGFR 41 mL/min

What is the SINGLE most appropriate investigation?

A 50 year old man presents to his GP with the complaint of shortness of breath. He describes his shortness of breath as increasing in severity over the past few months. He is also noted to have a persistent cough. The patient also complains of lethargy and tiredness which he says started around three months ago. The patient’s past medical history is significant for migraine headaches which he takes non-steroidal anti- inflammatory medications for. He works as a production manager for a medium sized company and reports no undue stress in his personal or professional life. He drinks socially and smokes around 20 cigarettes a day for the past 30 years. A blood test was done and the results are as follows:

Haemoglobin 198 g/L

Platelets 250 x 10^9/L

White cell count (total) 9.8 x 10^9/L

Haematocrit 58%

What is the SINGLE most useful hormone level to test for to help establish a diagnosis?

A 21 year old man has episodic right upper quadrant pain. Abdominal ultrasound reveals gallstones. His father had a splenectomy when he was a child. His blood tests show:

Haemoglobin 91 g/L (130-180 g/L)

Mean cell haemoglobin concentration 369 g/L (300-360 g/L)

Platelets 250 x 10^9/L (150-400 x 10″/L)

White cell count 6.3 x 10^9/L (4-11 x 10″/L)

What is the SINGLE most likely diagnosis?

A 15 year old boy has marked pallor and jaundice. He has to receive regular blood transfusions to maintain his haemoglobin above a certain level. His medical history includes diabetes. He has obvious skull bassing and hepatosplenomegaly. What is the SINGLE most likely diagnosis?

A 22 year old woman attends the GP surgery with fatigue over the past few months. She states that her menstrual bleeds have been particularly heavy in the past 6 months. Her menstrual bleeding last between 7 to 9 days. She takes tranexamic acid during the days that she bleeds heavy. She is not actively bleeding at present. Her heart rate is 98 beats/minute and blood pressure is 110/80 mmHg. A blood test was done which shows the following:

Haemoglobin 69 g/L (115-160)

Mean cell volume (MCV) 68 fL (76-96)

What is the SINGLE most appropriate management?

A 48 year old woman has become increasingly fatigued over the past 10 months. Vitiligo of the hand was noted. Her blood tests show:

Haemoglobin 88 g/L White cell count 8 x 109/L

Platelets 245 x 10^9/L

Mean cell volume 130 fL

What is the SINGLE most likely diagnosis?

A 75 year old man with chronic back pain and lethargy for several months was referred to secondary care where further investigations were carried out. Amongst the investigations was a bone marrow biopsy which was reported as having abundance of plasma cells. What is the SINGLE most likely diagnosis?

A 15 year old girl was admitted with a chest infection. She was treated and her symptoms had regressed. She was brought again with fever and the same symptoms a few days later. It was found that all her blood works done in the hospital showed mild anaemia and thrombocytopenia. On examination, hepatosplenomegaly was found. What is the SINGLE most likely diagnosis?

A 65 year old man has been recently diagnosed with atrial fibrillation. He has suffered from a transient ischaemic attack 3 years ago. His medical history is significant for diabetes mellitus type 2. What is the SINGLE best scoring method to assess the need for anticoagulation?

A 15 year old boy is investigated after he bled excessively following a tooth extraction. He has always noted that he bruises easily with minimal trauma. His blood tests show:

Haemoglobin 120 g/L (130-180)

White cell count 7 x 10^9/L (4-11)

Platelets 168 x 10^9/L (150-400)

Prothrombin time 13 seconds

Activated partial thromboplastin time 81 seconds (35-45)

Reduced factor VIII levels

PFA-100 (Platelet Function Assay) within normal limits

Normal ristocetin-induced platelet aggregation

VWF antigen test is within normal limits

What is the SINGLE most likely diagnosis?

A 21 year old man presents with mild jaundice.

Haemoglobin 75 g/L

Reticulocytes 7%

There are spherocytes seen on the blood film. He has no past medical history of any significance. What is the SINGLE most appropriate investigation?

A 44 year old man presents with petechiae over his trunk, bruises on his body and gum bleeding. He noticed these symptoms a few weeks ago. He has been severely lethargic over the past few weeks. He is known to be a chronic alcoholic with an average of 40 to 60 units of alcohol a week for the past few years. What is the SINGLE most likely deficiency?

A 66 year old woman is confused, and lethargic. Her son reports gradual confusion over the last 4 months. On examination, she looks pale. Blood tests have been done which shows megaloblastic anaemia. Both B12 deficiency and folate deficiency were diagnosed on further investigation. What is the SINGLE most likely treatment for her anaemia?

A 39 year old woman presents with yellowing of her sclera and the complaint of feeling tired all the time. She has no other complaints however, she mentions that she had an upper respiratory tract infection a week ago. Her blood tests are as follows:

Haemoglobin: 95 g/L (130-180)

Bilirubin: 41 μmol/L (3-17)

Mean cell volume (MCV): 98 FL (76-96)

Alanine transferase (ALT): 25 U/L (5-35)

Aspartate transaminase (AST): 23 U/L (5-35)

Alkaline phosphatase (ALP): 72 U/L (30-150)

Gamma glutamyl transferase (GT): 33 u/L (8-60)

A peripheral blood smear is significant for polychromasia and scattered spherocytes but no fragmented red blood cells or target cells were seen. What is the SINGLE best diagnostic investigation?

A 69 year old male presented to Accident & Emergency following a fall. He had slipped and fallen in his home and his daughter had rushed him immediately to A&E. His past medical history is significant atrial fibrillation, which he takes warfarin and atenolol for. He complains of a severe headache which he says is getting worse. There is a small, tender bump on the right side of his head. His Glasgow coma scale score is 15/15. A CT scan was done which shows a 1 cm by 2 cm right sided cerebral haematoma. Blood tests were also done and the results are as follows:

Haemoglobin 158 g/L (130-180 g/L)

Platelets 253 x 10^9/L (150-400 x 10^9/L)

Prothrombin time (PT) 19 secs (10-14 secs)

Activated partial thromboplastin time (APTT) 39 secs (35-45 secs)

International normalized ratio (INR) 3.3 (0.8-1.2)

Following the results of the CT scan and the results of the blood tests, he was admitted and 5 mg of vitamin K1 was given intravenously. What is the SINGLE next best treatment for this patient?

A young couple of Afro-Caribbean origin visit their midwife for a routine booking appointment. The patient is concerned as she has sickle cell anaemia and is worried that she may pass the condition onto her baby. Her partner knows that he has sickle cell trait. What is the likelihood of her baby having sickle cell disease?

A 16 year old boy presents with a palpable rash on his buttocks and extensor surface of his arms and legs following a sore throat. He complains of joint stiffness, joint pains and crampy abdominal pain. On urine testing, microscopic haematuria and proteinuria are found. What is the SINGLE most probable diagnosis?

A 72 year old man with a background of vascular dementia living alone has been brought in by his daughter to the Emergency Department for the third time this month for bruising around the head, face and forearms. His son in law has been staying with him recently as he has not been able to manage alone. He is on warfarin for atrial fibrillation and is otherwise not taking any other medications. His blood results done in the department show the following:

Haemoglobin 82 g/L

White cell count 6 x 10^9/L

Platelets 450 x 10^9/L

Serum urea 7.5 mmol/L

Serum creatinine 166 μmol/L

International normalized ratio (INR) 1.1

What is the SINGLE most likely cause for these symptoms?

A 4 year old boy has a history of epistaxis. Prothrombin time, fibrinogen levels and van Willebrand factor are normal. Activated partial thromboplastin time (APTT) was found to be prolonged. His blood tests show.

Haemoglobin 112 g/L

White cell count 5 x 10^9/L

Platelets 250 x 10^9/L

What is the SINGLE most likely diagnosis?

A 44 year old Iranian man has been feeling lethargic aver the past 3 months. He has a history of bariatric surgery in Iran 3 years ago. He does not take any supplements. His blood test shows the following:

Haemoglobin 89 g/L (130-180)

Mean cell volume (MCV) 108 FL (76-96)

Ferritin 21 ng/ml (20-300)

Total iron binding capacity (TIBC) 244 mcg/dL (240 – 450)

What is the SINGLE most likely diagnosis?

A 35 year old man has fatigue, night sweats and a mild fever for the last month. Examination reveals painless cervical lymphadenopathy. Splenomegaly is noted on abdominal examination. He has significant weight loss. What is the SINGLE most likely diagnosis?

An 11 year old boy has an upper respiratory tract infection followed by a low-grade fever with erythematous macular rash, especially on the back of the legs. A few hours later, the macules evolve into purpuric lesions that are slightly raised and do not blanch on a glass test. He also complains of a headache and joint stiffness. His blood tests show.

Haemoglobin 130 g/L (130-180)

White cell count 4.1 x 10^9/L (4-11)

Platelets 211 x 10^9/L (150-400)

What is the SINGLE most likely diagnosis?

A 55 year old man had surgery for his right hip fracture a few hours ago. He has no previous medical problems. He is likely to be immobile for the next few weeks. Which is the most appropriate action to reduce the risk of venous thromboembolism?

A 34 year old woman developed a purpuric rash on the back of her legs. She also reports frequent nose bleeds and menorrhagia. A blood count shows:

Haemoglobin 119 g/L

White cell count 6.8 x 10^9/L

Platelets 59 x 10^9/L

What is the SINGLE most likely diagnosis?

A 5 year old boy has a massive swelling on his right knee after falling on the ground a day ago. He also has rashes on his buttocks which has appeared over the past few weeks. His blood tests show.

Haemoglobin 119 g/L (115-140)

White cell count 8 x 10^9/L (5.0-12.0 x 109)

Platelets 259 x 10^9/L (150-450 x 10°)

Prothrombin time 12 seconds (10-12)

Activated partial thromboplastin time 61 seconds (28.0-45.0)

Bleeding time normal

What is the SINGLE most likely diagnosis?

A 79 year old woman presents with a 6-month history of fatigue, night sweats, and weight loss. She has had a lower respiratory chest infection that has not improved despite 2 courses of antibiotics. On physical examination, she has a palpable lymph node in the left anterior part of the neck. The lymph node is firm and not tender.

Investigations:

Haemoglobin 100 g/L (115-160)

White cell count 22 x 10^9/L  (4-11)

Neutrophils 4.1 x 10^9/L (2-7.5)

Lymphocytes 18 (1.3-3.5 x 10^9/L)

Eosinophils 0.31 (0.04-0.44 x 10^9/L)

Basophils 0.18 (0.0-0.10 x 10^9/L)

Platelets 351 x 10^9/L (150-400)

A biopsy of the lymph node shows a thin sheet of large lymphoid cells with irregular nuclei and prominent nucleoli. Which of the following is the most likely diagnosis?

A 3 year old boy, born at term, with no significant family history, presents with epistaxis from a fall while playing with his siblings. The bleeding has been ongoing for an hour without stopping.

Haemoglobin 135 g/L (130-180)

White cell count 5 x 10^9/L (4-11)

Platelets 255 x 10^9/L (150-400)

Activated partial thromboplastin time (APTT) 46 secs (35-45)

Prothrombin time (PT) 10 secs (10-14)

Fibrinogen 3 g/L (2.0-4.0)

50:50 mix corrects.

Which is the most likely diagnosis?

A 55 year old man has been lethargic with paresthesia of the fingers over the past month. He also describes limb weakness. He does not take any alcohol. He underwent a gastric banding surgery 18 months ago. What is the most appropriate action?

A 55 year old woman with rheumatoid arthritis presents to her GP with a 2-month history of fatigue, shortness of breath, and pale skin. She has no other symptoms. She was diagnosed with rheumatoid arthritis 30 years ago. She does not take any regular medications except paracetamol. She has a 4 kg weight loss over the period of the 2 months due to a new diet. She denies any blood in her stools. She has no abdominal pain or changes in her bowel habit. Her physical examination is unremarkable.

Investigations:

Haemoglobin 80 g/L (115-160)

White cell count 11 x 10^9/L  (4-11)

Neutrophils 5.1 x 10^9/L (2-7.5)

Platelets 750 x 10^9/L (150-400)

Mean cell volume (MCV) 69 fL (76-96)

Mean cell haemoglobin concentration (MCHC) 279 g/L300-360)

Ferritin 750 ng/ml (20-300)

Vitamin B12 180 ng/L/160-800)

Folate 3.0 ng/L (>2.7)

Which is the most likely diagnosis?