Tutors Short Cases 1 8 With Answers 2018

Short case 1) A 21 year old female medical student presents with an acute purpuric
rash on her hands and legs. She is otherwise well but had some ‘viral symptoms’ 1
week before
Full Blood Count
White count 6.0 x109/l (NR 4.0-10.0) (normal WBC differential)

Haemoglobin 130 g/l
Platelets 05 x 109/l (NR 150-450)
Blood film shows only thrombocytopenia
Coagulation Screen
PTT Normal
PT Normal
Fibrinogen Normal
Platelets 05
1 What is the likely diagnosis

2 Explain the thrombocytopenia. Are platelets being produced? Are
platelets being destroyed?
3 Do you expect spleen to be enlarged?
4 Discuss treatment options.
ANSWERS, could be given to students after the CBL

1. ITP
2. Platelet destruction
3. Oddly the spleen is not enlarged in ITP. Platelets are probably too small
therefore spleen does not enlarge
4. Steroids. Possible splenectomy
Short case 2) A 21 year old female medical student presents to A & E with a 24 hour
history of flu-like symptoms and headache. She is pyrexial 40oC, is drowsy, has a
purpuric rash and nuchal rigidity.
Her coagulation screen shows

PTT prolonged
PT prolonged
Fibrinogen reduced
Platelets reduced
1 What term is used to describe her coagulopathy?

2 What is the cause of her symptoms?
3 What urgent investigations/procedures are required?
4 Describe the bacteria responsible for this condition
5 Describe treatment

1. DIC
2. Meningococcal septicaemia
3. LP, Blood cultures
4. neisseria meningitides
5. IV antibiotics
Short case 3) A 21 year old female medical student presents with exudation
tonsillitis, cervical lymphadenopathy, slightly enlarged spleen and temperature 40oC.
Full blood count
White count 15 x 109/l (NR 4-10)

Haemoglobin 130 g/l (NR 12-17)
Platelets 200 x 109/l (NR 150-450)
The WBC differential shows 50% atypical mononuclear cells.
1 What is the diagnosis?

2 What is causative organism?
3 Describe the tests used to diagnose this condition.
4 What is meant by the term heterophile antibodies
5 Should she be given Amoxicillin while awaiting confirmation of diagnosis
1. Infectious mononucleosis
2. EBV
3. monospot and EBV titres
4. Agglutinins appear in blood during IM infection that react with sheep
RBCs ie they react across species barriers.
5. No amoxicillin will cause a rash in IM patients. If diagnosis of IM is not
clear the patient could be given simple Penicillin V to cover against
potential Strep throat.
Short case 4) A 21 year old medical student presents with a facial rash (butterfly
distribution) and polyarthritis.
1 What is likely diagnosis?
Her coagulation screen shows

PTT Prolonged (did not correct with 20% normal plasma)
PT Normal
Fibrinogen Normal
Platelets Normal
2 What is the likely cause of her prolonged PTT

3 Does this patient have a bleeding tendency (ie, is there an increased risk of
bleeding?)
4 Does this patient have an increased risk of thrombosis?
1. SLE
2. Lupus anticoagulant
3. No. Oddly the patient has a thrombotic tendency NOT a bleeding
tendency
4. Yes. The laboratory abnormality does not correspond with the clinical
risks of thrombosis.
Short case 5) A 21 year old female medical student has just returned from a holiday
in Germany. She complained of bloody diarrhoea. She likes to eat raw bean sprouts.
She is anaemic, thrombocytopenic, uraemic and jaundiced
1 What is the likely diagnosis?

2 What is the likely causative organism?
3 Describe the expected RBC appearances.
4 Do you expect to detect bilirubin in her urine?
5 Would you expect to find any abnormalities of her PT and PTT?
1. HUS Haemolytic uraemic syndrome

2. E coli 0157
3. RBC fragmentation
4. No acholuric jaundice
5. No. Coagulation is not affected. Platelets are deposited in the renal
vessels. Fibrin strands form over the platelets and form a sieve that
breaks down the RBCs
Short case 6) A 21 year old female medical student presented with a 3 month history
of painless cervical lymphadenopathy. There was no history of weight loss, night
sweats or temperatures.
On examination she was found to have rubbery firm lymphadenopathy (nodes 2-3cm)
in L neck and supraclavicular fossa.
Biopsy showed this to be a lymphoma with the presence of Reed Sternberg (RS) cells.
1. Describe the RS cell

2. What type of lymphoma is present?
3. How do you establish the clinical stage of patients with lymphoma?
4. What are the different clinical stages of lymphoma?
5. Would this type of Lymphoma is more usually seen in older patients?
1. Large cells, abundant cytoplasm, 2 nuclear lobes each with prominent

nucleolus. Owl’s eye appearance
2. Hodgkin Lymphoma
3. History for B symptoms and Physical examination, CT scan and marrow
to determine Stages 1-4.
4. 1 = localised, 2 = 2 or more sites on same side of diaphragm, 3 = both sides
of diaphragm, 4 = widespread. Stage B = systemic symptoms i.e. weight
loss, night sweats or disease related pyrexias.
5. 5. Non Hodgkin Lymphoma
Short case 7) A 71 year old female patient (not a medical student) is found to have
painless cervical lymphadenopathy. She is otherwise well. She has rubbery nodes (1-
2cm) in all areas and splenomegaly of 2 fingerbreadths.
Full blood Count
White count 100 x 109/l (NR 4-10)

Haemoglobin 130 g/l (NR 12-17)
Platelets 200 x 109/l (NR 150-400)
The WBC differential shows 90 x 109/l lymphocytes. These are later shown to be B
cells.
1 What is the likely diagnosis?

2 Are the B lymphocytes polyclonal or monoclonal
3 How does this condition differ from the other chronic leukaemia
1. CLL Chronic Lymphatic Leukaemia

2. monoclonal B cells
3. does not change to acute leukaemia. It can progress but stays as CLL.
CML on the other hand has a tendency to change to acute leukaemia. Oddly
CML can change to AML or ALL
Short case 8) 70yr old man presents to A&E with sudden onset of severe low back
pain.
He has 3 months history of fatigue, but most recently develops polyuria and
polydipsia. Neurological examination normal
Investigations:
Haematology
Hb 100g/l (NR 130-180)
WBC 8.0 (NR 4-11)
Platelets 200 (NR 150-400)
ESR 110mm/hr (NR <20)
Blood film shows normochromic normocytic RBCs with marked RBC rouleaux.
Biochemistry
Urea 20mmol/l (NR 2.5-7.5)
Creatinine 200umol/l (NR 40-130)
Calcium 3.5mmol/l (NR 2.2-2.6)
Total protein 100g/l (NR 60-80)
Globulins 70g/l (NR 23-38)
Questions
1. What is the likely diagnosis?
2. What cells will be present in the Bone Marrow?
3. Why does the patient have raised calcium and back pain? What would it suggest if
the patient had numbness and weakness in legs with loss of sphincter control?
4. Why are urea and creatinine elevated? In view of the high calcium and renal
damage what treatment needs to be started urgently?
5. Why is the globulin level elevated? What is meant by the term 'paraprotein'?
6. What protein might you find in the urine?
7. What carcinomas (non-Haematological cancers) metastasise to bone?

1. Multiple Myeloma
2. Plasma cells……..derived from B lymphocytes……despite the name Myeloma
the cells are not derived from the myeloid stem cell.
3. Myeloma causes lytic bone lesions with calcium release. Patient is likely to
have had acute collapse of a vertebral body. Normal neurology would indicate
that the spinal cord is intact.
4. Myeloma kidney……can result from hypercalcaemia, infection or damage to
the kidneys by the paraprotein. Hypercalcaemia requires urgent IV rehydration.
5. The plasma cells release their Immunoglobulins……….called the paraprotein
6. Bence Jones, i.e. light chains
7. Lung, Prostate, Thyroid, Kidney, Breast……..LP Thomas Knows Best.

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Short case 1) A 21 year old female medical student presents with an acute purpuric

Full Blood Count

White count 6.0 x109/l (NR 4.0-10.0) (normal WBC differential)

Blood film shows only thrombocytopenia

1 What is the likely diagnosis

ANSWERS, could be given to students after the CBL

Her coagulation screen shows

1 What term is used to describe her coagulopathy?

ANSWERS, could be given to students after the CBL

Full blood count

White count 15 x 109/l (NR 4-10)

The WBC differential shows 50% atypical mononuclear cells.

1 What is the diagnosis?

ANSWERS, could be given to students after the CBL

1 What is likely diagnosis?

Her coagulation screen shows

2 What is the likely cause of her prolonged PTT

1 What is the likely diagnosis?

ANSWERS, could be given to students after the CBL

1. HUS Haemolytic uraemic syndrome

1. Describe the RS cell

ANSWERS, could be given to students after the CBL

1. Large cells, abundant cytoplasm, 2 nuclear lobes each with prominent

Full blood Count

White count 100 x 109/l (NR 4-10)

1 What is the likely diagnosis?

ANSWERS, could be given to students after the CBL

1. CLL Chronic Lymphatic Leukaemia

ANSWERS, could be given to students after the CBL

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