HAEMATOLOGY
3
RD
YEAR MBBS
SPIRAL II
STUDY GUIDE 2014
SHIFA COLLEGE OF MEDICINE
CONTENTS
Introduction …………………………………………………………
3
Themes of the module ………………………………………
6
Table of Specification ………………………………………
7
CASES
Theme 1: Pallor …………………………………………………
10
Theme 2: Infection/Leukemia ……………………….
29
Theme 3: Bleed/Clot …………………………………………
57
Theme 4: Transfusion Medicine ……………………
66
Resources for learning …………………………………………
75
People to contact …………………………………………………
77
Glossary …………………………………………………………………
78
INTRODUCTION:
On behalf of my team, I welcome you on board. This four
week module of HAEMATOLOGY & TRANSFUSION
MEDICINE is the second level of learning basics of
CLINICAL HAEMATOLOGY.(Ist level, we have completed
in year I).The last & the third part of Haematology
undergrad curriculum will be taught during your fourth year
clerkship. This last part (4th year) is vertically integrated
to the third year part, along all themes but with more
emphasis on haematological malignancy, where you would
apply this basic knowledge in management including
diagnosis and treatment of blood disorders.
The module works around four basic themes of clinical
Haematology( you are already familiar with!!) PALLOR,
HAEMATOLOGICAL FEVER, BLEED/CLOT &
TRANSFUSION MEDICINE.
First Theme Pallor (6 days) would address all causes of
clinical anemia, getting into details of the parasitic causes,
structural defects of red cells and extracorpuscular causes
of anemia.
Second Theme of Haematological Fever(5 days) in the
module deals with, infectious causes of fever and blood
cell variations in detail (your subject of assessment this
year: microbiology).It also include an introduction to the
malignant causes of febrile illness in order to develop a
good differential ability in students for fever with blood
cell dyscrasias.
The Third Part(4 days) of the module would deal with the
concept of clinical bleed & basic clotting problems. The
concept of DVT you have already learnt in CVS module, so
here we would learn details of common clotting problems &
basics of “THROMBOPHILIA”
Fourth Section of the module is related to basic knowledge
of Transfusion Medicine(4 days).It was especially included
in undergrad curriculum, considering the clinical problems
faced by young doctors working independently/in a setup
where still some accountability exists in medical care!.
Availability & use of alternate blood groups & picking up
immediate transfusion reactions are two main objectives
addressed in this part of the module.
We will have our feedback in the middle and at the end of
the module.My team and I, are all the time available to
you (your study guide has our e-mails!!) during and even
after the module for any assistance in your learning and
we expect you to behave and show maximum interest
throughout the module. I hope and pray that you would
make best use of the learning aids available to you.
Happy learning & good luck!!
THEMES: HAEMATOLOGY
PALLOR
FEVER (INFECTION, LEUKEMIA)
BLEED/CLOT
TRANSFUSION MEDICINE (TRANSFUSION REACTIONS)
TABLE OF SPECIFICATION
ASSESSMENT
DAYS
MCQ
70%
SAQ
30%
IPE
30%
ALLOCATION
19 DAYS
THEMES
•
PALLOR
6 DAYS
•
HAEMATOLOGICAL FEVER
5 DAYS
•
BLEED & CLOT
4 DAYS
•
TRANSFUSION MEDICINE
4 DAYS
TABLE OF SPECIFICATION
Pallor
25%
Haematological Fever
45%
Bleed /Clot
15%
Transfusion Medicine
15%
OBJECTIVES
PALLOR
 Formulate differential diagnosis of anemia on the basis
of history and physical examination
 Order appropriate & specific laboratory tests (after
Interpreting peripheral film & CBC results) for
defining the etiology of anemia
 Manage different types of anemia in emergency
 Describe iron, folate & Vit B12, preparations
(hematinics) with regard to
Clinical use, Cost effectiveness, MOA & drug
interactions
 Advise parents/patients appropriately for long term
management of inherited types of anemias & Counsel
about genetic inheritance
Haematological Fever
Infection/leukemia
 Describe haematological aspects of infectious
fever(Malaria, Visceral Leishmaniasis, Typhoid fever,
Viral haemorrhagic fever, Dengue Fever with regard
to
pathogenesis,
clinical features
laboratory diagnosis
prevention
 Counsel about the prevention of Malaria & Leishmania
 Describe haematological aspects of infectious
fever(Malaria,Visceral Leishmaniasis, Typhoid fever,
Viral haemorrhagic fever, Dengue Fever with regard
to
 pathogenesis,
 clinical features
 laboratory diagnosis
 Prevention
 Counsel about the prevention of Malaria, &
Leishmania
• Suspect hematological malignancy on the basis of
history and physical examination
For fourth year level(vertical integration)
Describe various types of leukemias/lymphoma
• Order and interpret appropriate tests for precise
diagnosis (morphology, immunophenotyping,
cytochemistry & cytogenetics)
• Order and interpret appropriate staging work-up
(lymphoma, MPD & MDS)
• Describe the chemotherapeutic agents and their
disfiguring side effects
BLEED/CLOT
Counsel patients/ parents about the mode of inheritance
& advise long term management of Haemophilia
• Diagnose & Manage a case of snake bite
• Diagnose, counsel & manage a case of thrombophilia
• Prescribe basic drugs for a bleeding and thrombophilic
patient
Transfusion medicine
 Describe clinical application of blood group
compatibility
 State Judicious & appropriate use of blood components
& products
 State standardized screening tests for blood
 State the process of safe storage and transport of
blood and blood products
 Describe hazards of blood transfusion
 Appreciate the clinical presentation of immediate
transfusion reactions (hemolytic, allergic &
anaphylactic types)
 Show ethical & Social awareness about blood donation
(voluntary/ paid, donor deferral, cost of products)
CASES
THEME: PALLOR
IRON DEFICIENCY ANEMIA
MEGALOBLASTIC ANEMIA
THALASSEMIA MAJOR
SICKLE CELL ANEMIA.
APLASTIC ANEMIA
THEME: INFECTION/LEUKEMIA
MALARIA
VISCERAL LEISHMANIASIS
TYPHOID& PARATYPHOID FEVER
DENGUE HAEMORRHAGIC FEVER
HUMAN IMMUNODEFICIENCY VIRAL INFECTION
THEME:
IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP)
HAEMOPHILIA A
HAEMOPHILIA B
VON WILLEBRAND DISEASE
TTP/HUS
DIC
THEME:
BLOOD GROUPING & CROSS MATCH
VOLUNTARY & SAFE TRANSFUSION
ACUTE ALLERGIC TRANSFUSION REACTION
ACUTE HEMOLYTIC TRANSFUSION REACTION
THEME : PALLOR
(CASE 1)
IRON DEFICIENCY ANEMIA
PRESENTING COMPLAINTS
A 15 month old boy has presented in Pediatric OPD with C/O
lethargy and pallor. He is less playful and inactive for few
months.
HISTORY OF PRESENT COMPLAINT
The mother brings the toddler, as a visiting relative, who has
not seen the child for 5 months told his mother that the boy
appears very pale. He used to be an active & playful child but
now appears lethargic. There is no change in his sleeping
habits.
Upon enquiry, his mother told that he never had blood on his
diapers and no black or tarry stools. He is a picky eater,
taking small amounts of chicken, and some vegetables, but
loves milk and drinks six to eight bottles of whole milk per
day.
PAST MEDICAL HISTORY
Nothing significant
MEDICATIONS: No known allergy to any medicine
BIRTH HISTORY; normal vaginal delivery, born in a district
hospital, Fully vaccinated
FAMILY HISTORY
Elder and only sibling(boy) had the same complaints in his age
of being pale & lethargic
GENERAL PHYSICAL EXAMINATION:
VITAL SIGNS: TEMP 37.50C, BP 90/52, PULSE 145/min,
RR 16/min
Pale appearing, inactive toddler, holding a bottle, tearing and
eating paper
Eyes: No scleral icterus. Pale conjunctiva.
CENTRAL NERVOUS SYSTEM
Higher Mental Function: intact.
Motor and sensory system: intact.
No cranial nerve deficit.
CARDIOVASCULAR SYSTEM
Mild tachycardia , grade II systolic ejection murmur heard
best over the upper left sternal border.
RESPIRATORY SYSTEM
Normal vesicular breathing
GASTROINTESTINAL TRACT
Abdomen: No hepatosplenomegaly.
Rectal examination: Dark brown, soft stool, negative for
occult blood.
INVESTIGATIONS:
Laboratory investigations:
COMPLETE BLOOD COUNT:
WBC: 6,100/ul, Hgb: 6.2 g/dl, Hct: 19.8%, Plt : 589,000/ul,
MCV: 64 fl, RDW 17%.
RETICULOCYTE COUNT is 1.0%.
PERIPHERAL FILM: microcytosis, hypochromia, mild
anisocytosis and polychromasia. There is no basophilic
stippling.
Radiology :
NOT REQUIRED
Special investigations:
Serum Iron:
15ug/dl ( Male:
59-158 ug/dl,
female: 37-145 ug/dl)
TIBC:
Serum ferritin:
450ug/dl
4.25ng/ml
( 228-428 ug/dl)
(Male: 22.0-275.0ng/ml,
female : 5.0-204.0ng/ml)
Transferrin receptor study :
Normal
Critical questions/ study questions
Q.1 What measures can you take to prevent parasitic
infestation in Pakistani rural children?
Q.2 How can you ensure appropriate Iron intake in low
socioeconomic groups in your society?
(CASE: 2)
MEGALOBLASTIC ANEMIA
PRESENTING COMPLAINTS
A 52 year old female presents with pallor, tingling in hands
and feet and decrease sensation in feet.
HISTORY OF PRESENT COMPLAINT
Presents with pallor and tingling sensation in both feet. She is
a strict fad dieter.The complaints were progressive in onset
and were not accompanied by any fever or h/o seizures or
vertigo . No Hx of trauma and any transfusion. No H x of
unconsciousness or vomiting
PAST MEDICAL HISTORY
Nothing significant
Medications,allergy; nil
Hospitalization/surgery; nil
Birth history; normal vaginal birth
FAMILY HISTORY
Two brothers, one sister
Cardiac problem runs in the family
Sexual/ social hx; Nothing significant
GENERAL PHYSICAL EXAMINATION;
VITAL SIGNS: TEMP 38C, BP 120/80mm, PULSE 100/min,
RR 18/min
Eyes: No scleral icterus. Pale conjunctiva.
Mouth: No Dental caries. Satisfactory oral hygiene
CENTRAL NERVOUS SYSTEM
Higher Mental Function: intact.
No cranial nerves deficit.
Motor system: Gait with sensory ataxia.
Knee reflex Normal
Ankle jerk Absent
Upgoing planters bilateral
Sensory exam: impaired position and vibration sense in both
lower limbs.
CARDIOVASCULAR SYSTEM
Normal heart sounds.
RESPIRATORY SYSTEM
Normal vesicular breathing
GASTROINTESTINAL TRACT
Abdomen: No hepatosplenomegaly.
Rectal Examination: Dark brown, soft stool, negative for
occult blood.
INVESTIGATIONS;
Laboratory investigations:
COMPLETE BLOOD COUNT:
WBC 35,00/ul,100, Hgb 6.2 g/dl, Hct 27%,
Plt 139000/ul
PERIPHERAL FILM: Pancytopenia, Hypersegmented
neutrophils,
Radiology: Not Applicable
Special investigations:
Serum folate:
Red Cell folate:
10.0ng/ml
617/32ng/ml
Serum B12:
Schilling test:
Serum Bilirubin:
LDH level :
150.0pg/ml
(3.0-17 ng/ml)
(263-1028ng/ml)
(243-894pg/ml)
Positive
Raised
Raised
Intrinsic factor antibodies: Present
Critical questions/ study questions
Q.1 How can you preserve folates in diet?
Q.2 What are the common causes of megaloblastic anemia
in Pakistan?
(CASE: 3)
THALASSEMIA MAJOR
PRESENTING COMPLAINTS
A 08 month old boy presents with lethargy, marked pallor,
inactivity and abdominal distension.
HISTORY OF PRESENT COMPLAINT
08 month old infant presents with the marked pallor and
growth failure. There is also Hx of change in facial
appearance. Initially symptoms were less marked. But now
they have progressed further.
PAST MEDICAL HISTORY
Nothing significant
Medications, allergy; nil
Hospitalization/surgery; nil
Birth history; normal vaginal birth
FAMILY HISTORY
H/O of death of sibling at the age of 15 months diagnosed as
deficiency of blood
Sexual/ social hx; Not Applicable
GENERAL PHYSICAL EXAMINATION;
VITAL SIGNS: TEMP: 37.5C, BP 90/52, PULSE 140/min, RR
19/min
Pale appearing, inactive toddler,
Eyes: No scleral icterus. Markedly Pale Conjunctiva.
CENTRAL NERVOUS SYSTEM
Higher Mental Function: intact.
Motor and sensory system: intact.
No cranial nerves deficit.
CARDIOVASCULAR SYSTEM
Mild tachycardia as above, grade II/VI systolic ejection
murmur heard best over the upper left sternal border.
RESPIRATORY SYSTEM
Normal vesicular breathing
GASTROINTESTINAL TRACT
Abdomen: Moderate Hepatosplenomegaly. No ascites, Normal
Bowel sounds
Rectal Examination : Dark brown, soft stool, negative for
occult blood.
LABORATORY INVESTIGATIONS:
COMPLETE BLOOD COUNT:
Hb: 5gm/dl, TLC: 18,000/ul Platelet count of 150,000/ul.
RETICULOCYTE COUNT:
10%.
Peripheral Film: Marked poikilocytosis, anisocytosis,
microcytosis, hypochromia, polychromasia target cells, many
fragmented red cells, many NRBC.
Radiology : X-ray skull show crew cut appearance and
maxillary prominence
Special investigations:
HPLC :
HbF: 90%
HbA: 08%
HbA2:02%
Critical questions/ study questions
Q.1 What is the pathogenesis of Thalassemia?
Q.2 How is the disease prevalence related to socialcultural background of Pakistan?
Q.3 What can you do about poor children affected by the
disease?
CASE: 4
SICKLE CELL ANEMIA.
PRESENTING COMPLAINTS:
A 10-year-old male child presents in ER with C/O severe pain
"all over his body especially in his legs
HISTORY OF PRESENT COMPLAINT:
His mother brought him into the ED at 4 pm .She reported
that the pain began early that morning and had "gotten
worse." She reported that it was not relieved by his usual
doses of ibuprofen. He was given with strong IM pain killer.
He got only minimal pain relief after receiving the medication.
He reported that the slight relief was short-lived, and he
continued to complain of unbearable pain through the night.
PAST MEDICAL HISTORY:
His past history is significant with many such hospital
admissions and h/o repeated chest infections and a non
healing ulcer on his right ankle.
Medications, allergy; nil
Birth history; normal vaginal birth
FAMILY HISTORY
H/O of similar episodes of pain crisis and chest infection in
two of the 5 siblings.
Sexual/ social hx; Not Applicable
GENERAL PHYSICAL EXAMINATION;
VITAL SIGNS: TEMP: 37.5C, BP: 110/70mm, PULSE:
140/min, RR 19/min
Pale appearing child in agony oriented in time, space and
person having a chronic ulcer on right ankle.
Eyes: No scleral icterus. Markedly Pale Conjunctiva.
Mouth: Dental caries. Satisfactory Hygiene
CENTRAL NERVOUS SYSTEM
Higher Mental Function: intact.
Motor and sensory system: intact.
No cranial nerves deficit.
CARDIOVASCULAR SYSTEM
Moderate tachycardia , grade II/VI systolic murmur heard
best over the upper left sternal border.
RESPIRATORY SYSTEM
Normal Vesicular Breathing
GASTROINTESTINAL TRACT
Abdomen: Moderate Hepatosplenomegaly. No ascites, Normal
Bowel sounds
Rectal: Dark brown, soft stool, negative for occult blood.
LABORATORY INVESTIGATIONS:
COMPLETE BLOOD COUNT:
Hb: 5gm/dl, TLC: 12,000/ul Platelet count of 150,000/ul.
Reticulocyte Count:
12%.
Peripheral Film: Moderate poikilocytosis, anisocytosis,,
hypochromia, polychromasia target cells, many fragemented
and sickle red cells, many NRBC.
Radiology :
Special investigations:
Sickle Screening test: Positive
HPLC:
HbS 70%
HbF: 13%
HbA: 17%
Critical questions/ study questions
Q.1 Why does sickling occur at time of stress/infection?
Q.2 What is the confirmatory test for establishing sickle
trait?
CASE: 5
APLASTIC ANEMIA
PRESENTING COMPLAINT:
Bleeding from nose for past
2 hours
HISTORY OF PRESENTING COMPLAINT:
A previously healthy 3 year old girl presented to emergency
department with the complaint of severe bleeding from nose
for past 2 hours, which is poorly controlled by application of
pressure. There is no other associated complaint.
PAST MEDICAL/DRUGS HISTORY:
Patient had otitis media 3 months ago that improved after
treatment with chloramphenicol.
GENERAL PHYSICAL EXAMINATION:
Patient is well-oriented in time place and person.
All vital signs are within normal limits. However, examination is
remarkable for marked pallor, and numerous petechiae and
ecchymoses on her body.SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
Apex beat localized in left fifth intercostals space in midclavicular line. No abnormal sounds heard on auscultation.
RESPIRATORY SYSTEM:
Normal vesicular breathing. No rhonchi / crepitations.
GASTROINTESTINAL SYSTEM:
No tenderness. No hepatosplenomegaly. Bowel sounds normal.
CENTRAL NERVOUS SYSTEM:
No sensory, motor or cognitive deficit.
Laboratory Investigations
Complete Blood Count:
Hemoglobin
4.5 g/dL
Hematocrit
15%
MCV
80 fl
Total Leukocyte Count
2000/mm3
Reticulocyte Count
0.2%
Platelet Count
12,000/mm3
Bone Marrow Biopsy
Shows a hypocellular marrow, replaced by large amounts of
adipose tissue.
Critical questions/ study questions
Q.1 What are the common causes of Aplastic anemia in
Pakistan?
Q.2 What is the curative treatment for this disease &
how can every aplastic patient one get an access to this
Curative modality
Q.3 What are the side effects/hazards of Bone Marrow
transplant?
LEARNING OBJECTIVES
At the end of this theme of pallor, students should be
able to
1. formulate differential diagnosis of anemia on the basis of
history and physical examination
2. order appropriate & specific laboratory tests after
Interpreting peripheral film& CBC results, for defining the
etiology of anemia
3. describe iron, folate & Vit B12, preparations (hematinics)
regarding clinical use,cost effectiveness,MOA & drug
interactions
4. perform Complete Blood Counts(K,S)
5. manage different types of anemia in emergency & in
OPD(K,S)
6. diagnose and manage acute and chronic toxicity of iron(K,S)
7. advise parents/patients appropriately for long term
management of inherited types of anemias & Counsel about
their genetic inheritance (Community Health Advocate)
8. counsel & educate patients of deficiency anemia (diet in
anemia)
9. communicates professionally with patients, parents/
caretakers and with paramedical staff regarding treatment
and care of the patient,especially suffering from genetic
disorders.
THEME: 2
INFECTION (HAEMATOLOGICAL FEVER)
CASE 6
MALARIA I
PRESENTING COMPLAINT
Fever- 1week
Headache- 1 week
Myalgia- 1 week
HISTORY OF PRESENT COMPLAINT
Patient was in usual state of health one week back when
he started having complaints of high grade intermittent
fever associated with rigor and chills, headache and
bodyaches.
PAST MEDICAL HISTORY
Nothing significant
Medications, allergy: nil
Hospitalization/surgery: nil
Birth history: normal vaginal birth
FAMILY HISTORY
Nothing significant
Sexual/ social hx: Nothing significant
TRAVELING HISTORY
History of travelling from Nigeria 2 weeks back
GENERAL PHYSICAL EXAMINATION;
VITAL SIGNS: TEMP 1020F, BP 120/75mmHg, PULSE
90/min, RR 16/min
Patient febrile, appears lethargic. .
Eyes: No scleral icterus; Conjunctiva pale
Mouth: NAD
CENTRAL NERVOUS SYSTEM
Higher Mental Function: intact.
Motor and sensory system: intact.
No cranial nerves deficit.
CARDIOVASCULAR SYSTEM
Normal heart sounds.
RESPIRATORY SYSTEM
Normal vesicular breathing
GASTROINTESTINAL TRACT
INVESTIGATIONS:
Laboratory investigations:COMPLETE BLOOD COUNT:
WBC: 3,000/ul; Lymphocytes: 44%; Hb: 9.8 g/dl; Platelets:
62,000
ESR: mm/hr
LIVER FUNCTION TESTS: Within normal limits.
PROTHROMBIN TIME: 19 seconds
TOTAL SERUM PROTEINS: 93 g/L
SERUM UREA, CREATININE AND ELECTROLYTES:
SERUM LDH: 505 IU/L
Radiology:
ULTRASOUND ABDOMEN: Hepatosplenomegaly
Special investigations:
BLOOD CULTURES: Negative
WIDAL TEST: Negative
THICK AND THIN BLOOD FILMS FOR MALARIA:
CASE 7:
VISCERAL LEISHMANIASIS
PRESENTING COMPLAINT
A 33 year old male presents with remittent fever and
weakness.
HISTORY OF PRESENT COMPLAINT
A 33 year old previously healthy male from Kashmir presents
in ER with history of remittent fever for the past 2 months.
Fever usually comes in the evenings, and at times is
accompanied by sweating and chills. Patient also experiences
weakness, as well as slight discomfort in his upper abdomen.
PAST MEDICAL HISTORY
Nothing significant
Medications, allergy: nil
Hospitalization/surgery: nil
Birth history: normal vaginal birth
FAMILY HISTORY
Nothing significant
Sexual/ social hx: Nothing significant
GENERAL PHYSICAL EXAMINATION;
VITAL SIGNS: TEMP 38.5oC, BP 120/75mmHg, PULSE
90/min, RR 16/min
Patient febrile, appears lethargic. .
Eyes: No scleral icterus; Conjunctiva pale
Mouth: NAD
CENTRAL NERVOUS SYSTEM
Higher Mental Function: intact.
Motor and sensory system: intact.
No cranial nerves deficit.
CARDIOVASCULAR SYSTEM
Normal heart sounds.
RESPIRATORY SYSTEM
Normal vesicular breathing
GASTROINTESTINAL TRACT
Abdomen: Liver palpable 1 cm below costal margin; Spleen
palpable 3 cm below costal margin.
Rectal: Soft, brown stool seen in rectum. No bleeding or
melena.
INVESTIGATIONS:
Laboratory investigations:COMPLETE BLOOD COUNT:
WBC: 3,000/ul; Lymphocytes: 44%; Hb: 9.8 g/dl; Platelets:
62,000
ESR: 98 mm/hr
LIVER FUNCTION TESTS: Within normal limits.
PROTHROMBIN TIME: 19 seconds
TOTAL SERUM PROTEINS: 93 g/L
SERUM UREA, CREATININE AND ELECTROLYTES: Within
normal limits.
SERUM LDH: 505 IU/L
Radiology:
ULTRASOUND ABDOMEN: Hepatosplenomegaly
Special investigations:
BLOOD CULTURES: Negative
WIDAL TEST: Negative
THICK AND THIN BLOOD FILMS FOR MALARIA:
Negative
BONE MARROW CYTOLOGY:
SPLENIC ASPIRATE:
Showed Leishmania amastigotes.
IMMUNOFLOURESCENT ASSAY FOR LEISHMANIA:
Positive (IgG titre of 1:2560)
FORMOL GEL RECTION: Positive
POST-HOSPITALISATION COURSE:
Treatment was started with Pentostam ( pentavelent antimony
derivative), 850mg/day for 21 days. On the third day of
therapy patients fever came down and he started to improve.
Patient left the hospital after 3 weeks, feeling very well and
being afebrile, along with much improved laboratory findings.
Follow-up was done in OPD, which registered complete
recovery of the patient.
Critical questions/ study questions
How would you prevent Dengue Epidemic in a city of 10,00,000
population?
What would you do to prevent MALARIA in your community?
What is your concept of ABSOLUTE NEUTROPENIA?
Why is it important to label a patient as NEUTROPENIC?
CASE: 9
TYPHOID FEVER
PRESENTING COMPLAINT
A 18 year old female presents with fever and fatigue.
HISTORY OF PRESENT COMPLAINT
An 18 year old previously healthy female from Islamabad
presents in OPD with history of fever and fatigue for the
past 15 days. This was accompanied by headache, weakness,
palpitations, abdominal pain and diarrhea a week later.
PAST MEDICAL HISTORY
Nothing significant
Medications, allergy: nil
Hospitalization/surgery: nil
Birth history: normal vaginal birth
FAMILY HISTORY
Nothing significant
Sexual/ social hx: Nothing significant
GENERAL PHYSICAL EXAMINATION;
VITAL SIGNS:
TEMP 39oC, BP 100/60mmHg, PULSE 92/min, RR 24/min
Apathic, pale young girl, appearing to be ill.
Eyes: No scleral icterus; Pale conjunctiva
Mouth: Dry lips; Dry, coated tongue.
CENTRAL NERVOUS SYSTEM
Higher Mental Function: Intact
Motor and sensory system: intact.
No cranial nerves deficit.
CARDIOVASCULAR SYSTEM
Normal heart sounds.
RESPIRATORY SYSTEM
Normal vesicular breathing.
GASTROINTESTINAL TRACT
Abdomen: Painful hepatomegaly (liver palpable 1 cm below
costal margin)
Rectal: No blood or melena.
LABORATORY INVESTIGATIONS:
COMPLETE BLOOD COUNT:
WBC: 2,500; Lymphocytes: 47%; Neutrophils: 43%;
Monocytes: 10%; Hb: 9.9 g/dl; Hematocrit: 27.8%; Platelets:
31,000
ESR: 30 mm/hr
CRP: 75 mg/dL
LIVER FUNCTION TESTS:
AST: 161 IU/dl; ALT: 67 IU/dl; Total Bilirubin: 2.05 mg/dl;
Direct Bilirubin: 1.65 mg/dl
PROTHROMBIN TIME: 16 seconds
SERUM UREA, CREATININE AND ELECTROLYTES: Within
normal limits
ANTI-HAV: Negative
ANTI-HCV: Negative
HBSAg: Negative
STOOL FOR OCCULT BLOOD: Positive
Radiology:
ULTRASOUND ABDOMEN: Hepatomegaly
SPECIAL INVESTIGATIONS:
WIDAL TEST:
Positive
BLOOD CULTURE:
Salmonella typhi colonies grown.
BIOCHEMICAL TESTS: Glucose fermentation; Negative
urease reaction; Negative indole test; H2S production.
POST-HOSPITALISATION COURSE:
Patient was started on oral Ciprofloxacin 500 mg twice a day.
This was accompanied adequate hydration by intravenous
fluids and symptomatic management. Fever disappeared at the
third day of hospital admission, and her labs also began to
improve. After two weeks of antibiotic treatment, the patient
was discharged with full recovery.
Critical questions/ study questions
Q.1 How is food handling directly related to spread of the
disease?
Q.2 What is the concept of chronic carrier in typhoid
infection?
CASE 10
DENGUE HEMORRHAGIC FEVER
PRESENTING COMPLAINT
A 25 year old male presents with fever, headache and
bleeding from nose.
HISTORY OF PRESENT COMPLAINT
A 25 year old previously healthy male from Islamabad
presents in ER with history of fever for the past 6 days. This
was accompanied by severe headache and generalized body
aches and pains, especially in both legs. Patient also had dry
cough. Six hours ago, he started having bleeding from both
sides of his nose. There was no history of trauma to nose.
PAST MEDICAL HISTORY
Nothing significant
Medications, allergy: nil
Hospitalization/surgery: nil
Birth history: normal vaginal birth
FAMILY HISTORY
Nothing significant
Sexual/ social hx: Nothing significant
GENERAL PHYSICAL EXAMINATION;
VITAL SIGNS: TEMP 38oC, BP 90/50mmHg, PULSE
110/min, RR 20/min
Anxious-looking, pale young man, slightly dyspneic, with
ecchymoses over his arms and abdomen.
Eyes: No scleral icterus; Pale conjunctiva
Mouth: NAD
CENTRAL NERVOUS SYSTEM
Higher Mental Function: Intact
Motor and sensory system: intact.
No cranial nerves deficit.
CARDIOVASCULAR SYSTEM
Mild tachycardia as above.
RESPIRATORY SYSTEM
Normal vesicular breathing. Mild tacypnea
GASTROINTESTINAL TRACT
Abdomen: No hepatosplenomegaly.
Rectal: No blood or melena.
INVESTIGATIONS:
Laboratory investigations:COMPLETE BLOOD COUNT:
WBC: 4,100; Hb: 8.1 g/dl; Hematocrit: 23.5%; Platelets:
5,000
LIVER FUNCTION TESTS:
AST: 30 IU/dL; ALT: 40 IU/dl; Alk. Phosph: 200 U/L
PROTHROMBIN TIME: 16.6 seconds
SERUM UREA, CREATININE AND ELECTROLYTES: Within
normal limits
ANTI-HAV: Negative
ANTI-HCV: Negative
HBsAg: Negative
Radiology: Not Required
Special Investigations:
Dengue IgM: Positive
CCVF PCR: Negative
POST-HOSPITALISATION COURSE:
Patient was put in strict isolation and was managed
aggressively with intravenous fluids, platelets and blood
transfusions. However, patient developed pulmonary
hemorrhage and hemoptysis as well. This progressed to shock,
respiratory acidosis and renal failure, and patient died 6 days
after admission.
Critical questions/ study questions
ACUTE LYMPHOBLASTIC LEUKEMIA
PRESENTING COMPLAINTS
A 4 year old boy presents with fever, fatigue and petechial
hemorrhages.
HISTORY OF PRESENT COMPLAINT
A young child was brought to pediatric clinic by his mother
with the complaint of fever for past 7 days. Fever was high
grade, and not accompanied by rigors or chills. However, the
boy was very lethargic, and got tired very easily. His mother
also noticed a rash on his body.
PAST MEDICAL HISTORY
Nothing significant
Medications,allergy; nil
Hospitalization/surgery; nil
Birth history; normal vaginal birth
FAMILY HISTORY
No significant family history.
Sexual/ social hx; N.A
GENERAL PHYSICAL EXAMINATION;
VITAL SIGNS: TEMP 100oF, BP 90/52, PULSE 145/min, RR
16/min
Pale appearing, lethargic child, appears to be unwell. Petechial
rash seen on the body.
Eyes: No scleral icterus. Pale conjunctiva.
Mouth: Nothing significant.
Lymph Nodes: Palpable cervical, axillary and inguinal lymph
nodes.
CENTRAL NERVOUS SYSTEM
Higher Mental Function: intact.
Motor and sensory system: intact.
No cranial nerves deficit.
CARDIOVASCULAR SYSTEM
Normal heart sounds. No added sound or murmur.
RESPIRATORY SYSTEM
Normal vesicular breathing
GASTROINTESTINAL TRACT
Abdomen: Mild hepatosplenomegaly.
Rectal: Dark brown, soft stool, negative for occult blood.
LABORATORY INVESTIGATIONS:
COMPLETE BLOOD COUNT:
WBC 30,000/ul, Hb 7.5 g/dl, Platelet 15x109/ul.
PERIPHERAL FILM: 70% blasts.
Radiology :
Ultrasound abdomen: Mild hepatosplenomegaly with abdominal
lymphadenopathy.
Special investigations:
Bone marrow biopsy: Hypercellularity & suppression of normal
hemopoiesis by monomorphic blasts having high N:C ratio &
condensed chromatin.
Cytochemistry: SBB negativity & granular positivity for PAS
stain by the blasts.
Bone marrow cytogenetics: Positive for t(9:22).
Immunophenotyping: Blasts positive for TdT, and negative for
CD 3, 5 and 7.
Critical questions/ study questions
Q.1 How is lymphadenopathy of malignancy differs from
that of infection?
Q.2 which signs/symptoms would raise the suspension of
leukemia in a febrile child
CASE 12:
HODGKIN’S DISEASE
CHIEF COMPLAINT
“I have had swollen glands with ‘knots’ in my neck for one year.
Each doctor’s visit I was given another antibiotic. I developed
bronchitis and pneumonia and the x-ray showed a mass.”
HISTORY OF PRESENT ILLNESS
Forty-four year old white female presents to a medical center
with a history of enlarged cervical and supraclavicular lymph
nodes on the right side of her neck for approximately one
year. Several courses of antibiotics were given for what was
thought to be an upper respiratory infection, bronchitis, or
sinus infection. The fatigue and swollen lymph nodes continued
to be a problem and several more courses of antibiotics were
given. Her neck continued to be swollen and sore on the right
side. The left side of her neck also became enlarged and
tender. She reports intermittent hoarseness for the past 3
months. a chest x-ray revealed a mediastinal mass. She then
underwent CT scan of the chest. A biopsy of the right
supraclavicular lymph node is done.
CURRENT HEALTH HABITS
Does not smoke or use recreational drugs.
PAST MEDICAL HISTORY
MEDICATIONS



Zoloft 50 mg once a day for depression.
Cozaar 50 mg once a day for hypertension.
Estrogen 1.25 mg for hormone replacement therapy.
Allergies.
States that Demerol and Morphine caused her arm to swell
and she felt like a truck was sitting on her chest. Instructed
by medical personnel to never take those medications again.
Family History.
Her maternal grandfather died from cancer. Doesn’t know
what type of cancer. Paternal aunt died from stomach cancer
around age 60. Another paternal aunt died from breast cancer
around the age of 40.
PERSONAL/SOCIAL HISTORY
44 year-old white female that teaches school and loves her
job.
PHYSICAL EXAM
General. Well-developed, well-nourished, well dressed woman
who appears anxious. Hair is nicely groomed and she is wearing
make-up. Vital signs: T-36.2 C., P-62, R-16, BP-122/84, Wt.78.4 kg., Ht.-162 cm.
Mental Status. Good spirits although clearly anxious and
mentions several times throughout the exam that she wants
us to cure her.
Skin, Hair, and Nails. Erythematous rash present on the
back of thighs with multiple scabbed areas. Rash is more
extensive on the left posterior thigh and extends across the
entire width of the thigh to the outer medial area beneath
the buttocks. Right thigh rash is smaller and extends to the
right outer posterior portion of the thigh beneath the
buttocks. Hair is dyed black and well groomed. No other
rashes noted on her body.
Head and Neck. Neck is swollen bilaterally and tender
especially at the site of the biopsy. Supraclavicular biopsy site
is healing well and the incision edges are pink with minimal
swelling. Bilateral supraclavicular lymphadenopathy present on
exam, the largest measuring 2.0 cm in diameter.
Throat and Mouth. No lesions. Oral mucosa is pink with
adequate saliva. Teeth are in good repair.
Respiratory. Breath sounds are clear and equal bilaterally.
Cardiac. Apical and radial pulses are equal bilaterally. S1 and
S2 with regular rhythm auscultated. Dorsalis pedis pulses and
posterior tibial pulses are strong bilaterally. Good capillary
refill present at less than two seconds. No murmurs noted.
Abdomen. Abdomen soft and flat with hypoactive bowel
sounds. Unable to palpate spleen or liver. No masses felt upon
palpation.
Musculoskeletal. Moves all extremities without difficulty.
Small fat pad present posterior to right medial malleolus.
Strong bilateral hand grips.
Neurological. Bilateral facial symmetry present. No drooping
of the eyelids or mouth. Tongue protrudes at midline.
Symmetrical smile present. Alert and oriented x 3. Cranial
nerves II-XII are intact.
DIFFERENTIAL DIAGNOSIS




Hodgkins disease
Non-Hodgkins Lymphoma
Malignancy of the mediastinum
Differential Diagnosis
DIAGNOSTIC
Complete blood count:
Hb
11g/dl
Hematocrit
15%
TLC 2000/mm3
Microscopic examination of lymph node biopsy
Microscopic examination of lymph node biopsy reveals
complete or partial effacement of lymph node architecture by
scattered large malignant cells known as Reed Sternberg cells
admixed with reactive cell infiltrate composed of variable
proportions of lymphocytes, histiocytes, Eosinophils and
plasma cells.
Adviced CT scans of chest, abdomen, pelvis & bone marrow
biopsy for staging of lymphoma
CASE 13:
NON HODGKINS LYMHOMA
CHIEF COMPLAINT
Painless Swelling in neck for one month.
HISTORY OF PRESENT ILLNESS
A 46 year old male presented to OPD with complaint of
swelling in front of neck for 6 months. It has enlarged rapidly
and now he also complaints of difficulty in swallowing and
hoarseness. Patient also has a small palpable nodule in groin.
He is know hypertensive and is taking medications regularly.
Biopsy of the neck swelling is taken and sent for
histopathology.
PERSONAL HISTORY
Does not smoke or use recreational drugs.
PAST MEDICAL HISTORY
MEDICATIONS Patient is on Anti hypertensive
medicatication.
Allergies. None
Family History. Father died of cardiac arrest.
PHYSICAL EXAM
General. Well-developed, well-nourished, well dressed man .
Vital signs: T-36.2 C., P-62, R-16, BP-122/84, Wt.-90 kg., Ht.210 cm.
Mental Status. Alert
Skin, Hair, and Nails. Normal
Head and Neck. A firm 6x8cm swelling in front of neck along
anterior cervical lymph node chain. Swelling is firm and
rubbery. Overlying skin is normal.A 2x2cm swelling in right
arm groin is palpated. Swelling is non tender and mobile.
Throat and Mouth. No lesions
. Respiratory. Breath sounds are clear and equal bilaterally.
Cardiac. Apical and radial pulses are equal bilaterally.
Abdomen. Abdomen soft and flat with normal bowel sounds.
Musculoskeletal. Normal
Neurological. Normal
DIFFERENTIAL DIAGNOSIS




Hodgkin’s disease
Non-Hodgkin’s Lymphoma
Thyroid enlargement
Causes of Cervical Lymphadenopathy
DIAGNOSTIC
Complete blood count:
Hb
11g/dl
Hematocrit
15%
TLC 2000/mm3
BIOPSY CERVICAL LYMPH NODE:
.
• FINDINGS OF BIOPSY: Nodes are replaced by
sheets of large atypical lymphoid cells,starry sky
appearance on low power.
• ADVICED: CT scan chest,abdomen and pelvis
• Excision biopsy of swelling in groin
Critical questions/ study questions
Q.1 What is the most common clinical presentation of
Burkitt Lymphoma
Q.2 How would you stage the disease?
Q.3 Why is it important to differentiate Hodgkin’s from
Non Hodgkin’s lymphoma?
At the end of this theme of Haematological
fever, students should be able to
1. describe haematological aspects of infectious
fever(Malaria, Visceral Leishmaniasis, Typhoid fever, Viral
haemorrhagic fever,Dengue Fever) with regard the
cause,pathogenesis,clinical features & laboratory diagnosis &
Prevention
2. suspect hematological malignancy on history and physical
examination
3. describe various types of leukemias/ lymphoma
4. identify various blood cells in peripheral blood smear (K &
S)
5. perform, interpret and correlate differential counts with
various clinical conditions (K & S)
6.counsel about
Leishmania
the
prevention
of
Malaria,
Dengue
&
7. counsel in detail the medical, social and financial aspects of
the disease & discuss multidisciplinary approach/problems
faced in the management of chronic ailment
8. refer patient to an appropriate center for management of
leukemia
9. communicates professionally with patients, parents/
caretakers and with paramedical staff regarding treatment
and care of the patient ,especially suffering from malignant
disorders
THEME: 3
CLOT & BLEED
CASE 14:
HAEMOPHILIA A
PRESENTING COMPLAINTS:
A one and a half year old boy presented in paeds OPD with
several small bruises on legs for 1 week and swelling in right
knee joint for last 3 days
HISTORY OF PRESENT COMPLAINT:
Patient was alright 1 week back when his mother noticed that
he has small bruises on his legs. Bruises were in different
stages of healing evident by different colors. Some were blue
and some were yellowish. Three days back he fell on the floor
which was followed by swelling in the knee joints. Knees were
painful on touching.
PAST MEDICAL HISTORY:
Excessive bleeding occurred at the time of umbilical cord
separation. His mother also gives H/O prolonged bleed after
minor trauma
Medications,allergy; nil
Birth history; normal vaginal birth
FAMILY HISTORY
One maternal uncle has some bleeding disorder. Two elder
sisters of the patient never had any H/O excessive bleeding .
Sexual/ social hx; Not Applicable
GENERAL PHYSICAL EXAMINATION;
VITAL SIGNS: TEMP: 37.5C, BP: 110/70mm, PULSE:
100/min, RR 19/min
A pale looking male infant, sitting comfortably in mothers lap,
showing several small bruises on legs and swollen right knee
Eyes: No scleral icterus. Markedly Pale Conjunctiva.
Mouth: Dental caries. Satisfactory Hygiene
CENTRAL NERVOUS SYSTEM
Higher Mental Function: intact.
Motor and sensory system: intact.
No cranial nerves deficit.
CARDIOVASCULAR SYSTEM
S1 S2 O ( normal heart sounds)
RESPIRATORY SYSTEM
Normal Vesicular Breathing
GASTROINTESTINAL TRACT
Abdomen: Moderate Hepatosplenomegaly. No ascites, Normal
Bowel sounds
Rectal: Dark brown, soft stool, negative for occult blood.
RHEUMATOLOGIC EXAMINATION
Tender Swollen right knee joint.
Over lying skin is normal in appearance but the temperature
of the skin is raised.
LABORATORY INVESTIGATIONS:
COMPLETE BLOOD COUNT:
Hb: 5gm/dl, TLC: 12,000/ul Platelet count of 150,000/ul.
Reticulocyte Count:
12%.
Peripheral Film: Moderate poikilocytosis, anisocytosis,,
hypochromia, polychromasia target cells, many fragemented
and sickle red cells, many NRBC.
Bleeding time……. Prolonged
Activated Partial thromboplastin time (APTT)
prolonged
Prothrombin time(PT)
Radiology :
12 Sec (normal)
No lytic lesion found in bones , synovium not
clear (blood in joint space)
Special investigations:
Factor VIII antigen
Factor VIII activity
Decreased
Decreased (1%)
Critical questions/ study questions
Q.1 What are different types of clinical bleed?
Q.2 How do you differentiate between Hemophilia A & B?
Q.3 What are microangiopathic hemolytic anemia(MAHA)?
Q.4 How do you clinically differentiate two different types?
CASE 15:
IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP)
PRESENTING COMPLAINTS:
A 4 year old girl presented in paeds OPD with generalized
petechiae for 3 to 4 days and nasal bleed for one day
HISTORY OF PRESENT COMPLAINT:
Patient was alright 13 days back when she developed fever
with flu which her family physician diagnosed as viral. She was
not given any antibiotics for that and she almost completely
recovered when her mother noticed that he has developed
small red spots all over her legs which soon progressed to
generalized lesions. She also noticed few bruises on her back.
But Now she had one episode of epistaxis from her nose. The
blood was fresh red in color and was about half cup in
quantity.
PAST MEDICAL HISTORY:
Nothing Significant
Medications,allergy; nil
Birth history; normal vaginal birth
FAMILY HISTORY:
Nothing significant
Sexual/ social hx; Not Applicable
GENERAL PHYSICAL EXAMINATION;
VITAL SIGNS: TEMP: 37.5C, BP: 110/70mm, PULSE:
100/min, RR 14/min
A pale looking, thin built female child, sitting comfortably ,
showing several small bruises on her back and legs covered
with petechiae
Eyes: No scleral icterus. Pale Conjunctiva.
Mouth: Dental caries. Satisfactory Hygiene
CENTRAL NERVOUS SYSTEM
Higher Mental Function: intact.
Motor and sensory system: intact.
No cranial nerves deficit.
CARDIOVASCULAR SYSTEM
S1 S2 O
RESPIRATORY SYSTEM
Normal Vesicular Breathing
GASTROINTESTINAL TRACT
Abdomen: No Hepatosplenomegaly. No ascites, Normal Bowel
sounds
Rectal: Unremarkable,Negative for occult blood.
RHEUMATOLOGIC EXAMINATION
NORMAL
INVESTIGATIONS:
LABORATORY INVESTIGATIONS:
COMPLETE BLOOD COUNT:
Hb: 10.5 gm/dl
30,000/ul.
Reticulocyte Count:
TLC: 14,000/ul
Platelet count
02%.
Peripheral Film: Moderate poikilocytosis, anisocytosis,,
hypochromia present on film
Bleeding time…….(15 minutes)
PROLONGED
Activated Partial thromboplastin time (APTT)
32 seconds
Prothrombin time(PT)
11 seconds
NORMAL
NORMAL
Radiology :
NOT APPLICABLE
Special investigations:
BONE MARROW EXAMINATION:
Bone marrow shows increased megakaryocytes and many young
forms seen on smear(peripheral blood & bone marrow findings
are consistent with peripheral destruction of platelets)
PT, APTT, Peripheral destruction of Platelets
Critical questions/ study questions
Q.1 How would you differentiate clinically between bleed
due to coagulopathy & Thrombopathy
Q.2 How does ITP in children differ from that in adults?
LEARNING OBJECTIVES
At the end of this theme of Bleed/clot the students should
be able to
1. formulate Differential diagnosis of
thrombopathic/coagulopathic bleed on the basis of history
and physical examination.
2. select & interpret laboratory tests to define
thrombopathic / & coagulopathic cause of generalised bleed
3. diagnose & Manage a case of snake bite
4. diagnose, counsel & manage a case of thrombophilia
5. manage a bleeding patient with coagulation defect
(hereditary/acquired)in emergency & in OPD setting (K,S)
6. advise parents/patients appropriately for long term
management of inherited coagulopathy & platelet functional
defects & Counsel about their genetic inheritance
7. provide guidance& advise for their long term management
8. communicates professionally with patients, parents/
caretakers and with paramedical staff regarding treatment
and care of the patient ,especially suffering from genetic
disorders
THEME:4
TRANSFUSION MEDICINE
CASE:16
ACUTE ALLERGIC TRANSFUSION REACTION
CASE .1 A diagnosed case of acute myeloid leukemia
presented with hemoglobin of 6.0gm/dl after induction
therapy. Oncologist ordered two packs of red cell
concentrate. After transfusion of 2nd pack of RCC the patient
started shivering and started having itching ist around I/V
line & then all over his body.
CASE.2 A 50 years old male was admitted in hospital with
fracture left femur, for which open reduction and internal
fixation was done. Patient lost considerable amount of blood
during his surgery, for which he was advised to be transfused
whole blood by the surgeon. His CBC showed Hb of 7.0g/l with
normochromic normocytic picture. Blood was typed and crossmatched, and the donor blood group was checked for
compatibility by the blood bank. His BP and pulse were
recorded before starting the transfusion.Patient had no
complaints at the time of starting the transfusion. Ten
minutes after starting the transfusion, patient started
complaining of chills, headache, generalized itching and
difficulty in breathing.
GENERAL PHYSICAL EXAMINATION
Patient was conscious and alert, well-oriented in time place
and person.
Febrile, with Temperature of 101oF, and respiratory rate of
30/min. Rest of the vital signs were within normal limits.
(BP: 110/80mm of Hg)
There were
SYSTEMIC EXAMINATION:
CENTRAL NERVOUS SYSTEM:
Apprehensive, anxious looking while no sensory, motor or
cognitive deficit.
CARDIOVASCULAR SYSTEM:
Normal heart sounds S1 and S2. No added sounds or murmurs.
RESPIRATORY SYSTEM:
Normal vesicular breathing. However respiratory rate
increased. No rhonchi or crepitations.
GASTROINTESTINAL SYSTEM:
No abdominal pain or distension. No vomiting or diarrhea. No
blood in stools.
GENITOURINARY SYSTEM: Normal urine output. No blood
in urine.
MUSCULOSKELETAL SYSTEM: Generalised shivering seen.
No other abnormality.
LABORATORY FINDINGS
His Complete Blood count was done, which did not show any
further drop of Hemoglobin
(6g/dl).His Serum Bilirubin was 1mg/dl(post transfusion)Donor
blood was typed again, which was found to be the same as the
recipient and repeat crossmatch was compatible.
Acute transfusion reaction
Critical questions/ study questions
Q.1 Which clinical features would differentiate allergic
transfusion reaction from hemolytic one?
CASE: 17
ACUTE HEMOLYTIC TRANSFUSION REACTION
HISTORY OF PRESENT ILLNESS
A 25 year old primigravida presented in emergency in labor.
Because of poor progress of labor with fetal distress, she was
taken for emergency Cesarean section. Post-operatively her
Hb was 7.5g, for which her obstetrician advised blood
transfusion. Blood was typed, cross-matched and sent to her
ward. The doctor on duty was not present to cross-check the
donor blood group, so the nurse decided to start the
transfusion by herself, since she had a lot of other work to
do. Patient had no complaint at the time of starting the
transfusion. However, 15 minutes later, patient started
complaining of generalized discomfort, chills, headache,
nausea and pain in her back.
General Physical Examination
Young patient lying on bed, shivering,looking pale and anxious,
with flushed cheeks.
Vital signs are remarkable for a temperature of 102oF, pulse
110/min and BP 90/60mmHg.
SYSTEMIC EXAMINATION
Central Nervous System: Patient apparently anxious and
restless. However, no sensory or motor deficit present.
Cardio Vascular System: Increased heart rate. No added
sounds or murmur.
Respiratory System: Increased respiratory rate, with
difficulty in breathing.
GastroIntestinal System: Pain in lumbar region of abdomen,
with nausea.
Urinary System: Blood seen in urine coming out from the
catheter.
Musculoskeletal System: Generalized shivering present. No
other abnormality
Laboratory Findings
Complete Blood Count:
Hemoglobin
6g/dl
Hematocrit
30%
RBCs
3 million/ul
Blood Group A negative
Indirect Coomb’s Test: Positive
Serum Bilirubin: 2.5mg/dl
Urine Routine Analysis: Positive for RBCs and hemoglobin.
Post Transfusion Cross Match & Grouping Of Donor &
Recipient The donor blood was typed again, and it was found
to be B positive & repeat cross match was incompatible
Post Transfusion shivering, Coomb’s test, cross match
Critical questions/ study questions
Q.1 What is your concept of “safe transfusion?”
Q.2 What do you think about “ voluntary blood donation”
Q.3 What are different blood groups & what is their
importance in clinical medicine?
Q.4 What are transfusion reactions? How do you categorize
them?
Q.5At which hemoglobin level we “MUST TRANSFUSE
RCC?”
LEARNING OBJECTIVES
TASKS: In 2nd spiral:
At the end of this section the students should be able to
describe clinical application of blood grouping system
Comprehend compatibility testing for two basic blood grouping
systems(ABO,RH system)
Comprehend standardized screening tests for blood
State the process of safe storage & transport of blood and blood
Components
Describe hazards of blood transfusion(immediate & delayed)
State Judicious & appropriate use of blood components & products
Identify the clinical presentation of immediate transfusion reactions
(hemolytic, allergic & anaphylactic types) (K,S)
Demonstrate ethical & Social awareness about blood donation
(voluntary/ paid, donor deferral, cost of products)
Asking PICO related to common problems in clinical transfusion
practice.
Learning Basic search principles on internet
Resource for learning including online web links
Book reference
Iron deficiency anemia
Davidson
pg no.1012 to 1013,1025 to 1027
Robbins and cotran
pg 643----646
Review of medical microbiology & virology by Warren Levinson
(edition 10)
Hook worm
pg 389-390
Megaloblastic anemia :PJ Komar
pg 397—403
Davidson
pg 1027—29
Robbins and Cotran
7th edition pg 638----643
Aplastic anemia
Robbins and Cotran
pg 647----649
PJ Kumar
pg 402----403
Davidson
pg 1054
Thalassemia
Robbins and Cotran
pg 632----638
Infection,Leukemias and lymphomas
Review of medical microbiology & virology by Warren
Levinson(edition 10)
Malaria
pg360-363
Leishmania
pg368-369
Salmonella(typhoid)
pg 140-142
Dengue fever
pg306
Acute lymphocytic leukemia
Robbins and Cotran
pg 690—700
Acute and chronic myeloid
Robbins and Cotran
pg 92----702
Lymphoma
Robbins and Cotran
pg 600----690
Bleeding disorders (HA,HB, ITP,DIC)
Robbins and Cotran
pg 649----658
Wintrobe’s clinical Haematology
pg1379-1425
Faculty Facilitating
Contacts:
Dr Ayesha Junaid
ayesha_junaid497@hotmail.com
Dr. Riffat Nadeem
rifatnahmad@yahoo.com
Dr.Zubaida Zain
zubaida.zain@yahoo.com
Dr. Abida Shaheen
abidashaheen97@yahoo.com
Dr. Tasneem Akhtar
doctasak@hotmail.com
Dr. Munir Malik
drmunir_iqbal@yahoo.com
Dr. Syeda Hanaa Fatima
backbone.chill@gmail.com
Dr. Kainat Nazir
drkainat01@hotmail.com
Dr. Muhammad Umer Farooq
umer.farooq150@yahoo.com
Dr. Ali Azeem
alinaqvi101@yahoo.com
Dr. Qurrat-Ul-Ain Kashif
pinkperal09@hotmail.com
Dr. Farhat Fatima
farhat.fatima19@live.com
Dr. Rayya Nadeem
rayyanadeem100@gmail.com
Dr. Arooj Anthoney
aroojpeter@gmail.com
Dr. Imran Khan Jahangir
imrankhanjahangir@yahoo.com
Dr. Shazia Irum
dr.shazia.irum@gmail.com
Dr. Munazza Ather
munazza.athar786@gmail.com
Dr. Sidra Mehmood
SidraMehmood@hotmail.com
Dr. Shumaila Hanif
shumailahanif54@yahoo.com
Dr. Ahmed Zameer
ahmedzamir73@yahoo.com
Dr. Umer Farooq
umer.farooq150@yahoo.com
Dr.Zubiya Aqib
zubia.aqib@gmail.com
GLOSSARY
www.nlm.nih.gov/medlineplus/mplusdictioary.html
www.online-medical-dictionary.org
www.medterms.com