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W 1

A twenty eight year old cricketer, prior to going on tour for the West Indies for the first

time, has a routine physical examination and blood investigations. He has had nosignificant medical problems in the past. His only medications are multivitamins.

Physical examination is unremarkable.

Investigations Hb !".# g$dl% P&' (.)( l$l% W*& ).+ x !($l, Platelets --# x !($l.

-(/ 0eutrophils !.+12, 1!/ lymphocytes, 3/ monocytes (.(#)2, +/

eosinophils (.(#)22%

4iscuss possible causes of the abnormal laboratory findings shown here and further

investigations needed.

Pt has a lymphocytosis absolute count5 +."6!(72. He is also asymptomatic and on nomeds.

4ifferentials include

&hronic infections8 9b, toxoplasmosis, syph, HI'

Haematological malignancies8 &::, A::, 0H:;thers8 thyrotoxicosis

Investigations

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W 3

A twenty8year8old male presents to the hospital with a one8month history of recurrent

sore throat and fever and a three8day history of easy bruising. He admits to feelingunusually tired over the previous month.

>xamination revealed marked pallor of his mucous membranes. He had non8tenderhepatosplenomegaly. Petechiae and ecchymoses were seen, most marked on his trunk.

Bundoscopy revealed retinal haemorrhages.

InvestigationsHb ".( g$dl with normal red cell indices% W*& !!( x !($l%platelets "( x !($l.

4iscuss the differential diagnosis and further investigations necessary to

establish a definitive diagnosis.

Assessment of the peripheral blood smear revealed blasts with BA* :+ morphology.a. ;utline the further management of this patient.

b. 4iscuss the prognostic factors for this disease.

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W 4

Patient AP Age 1!years% Cale

c$o :umps in neck and groin, gradually increasing in siDe for the past " months.

;$> Cucous membrane E pale, mild icterus% generaliDed, bilateral lymphadenopathy.

Investigations:

Hb #.+ g$dl% W*& "1.# x !($:% Platelet !)- x !($:, 4iff !((/ lymphocytes%*lood film mild spherocytosis and polychromasia.

a. 4iscuss the diagnoses.

b. What is the stage of this patientFs diseasec. What further investigations are reGuired

d. 4iscuss the management of this patient

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W 5

Patient &9 Age -1years% Cale

c$o :eft abdominal fullness and pain for 1 months.

;$> Physical examination is unremarkable except for a mass in the left upper Guadrant

associated with mild tenderness. 9he mass extends to the umbilicus.

Investigations Hb . g$dl% W*& !)+ x !($: % platelets "() x !($: W*& 4iff

0eutrophil :ymphocyte Conocyte *ands Cyelocyte Cetamyelocyte *lasts

+!/

+.#+2

"/ 3.!2 !/ !.)+2 !+/

!3.()2

"(/ 3!2 / !+.3#2 +/

+.#)2

a. &omment on the information provided. What is the differential diagnosisb. 4iscuss

i. investigationii. management and

iii. possible outcomes2 for this patient.

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W 6

A seventy8year8old male presents with a five8month history of a lump in the left side of

his abdomen, which is gradually increasing in siDe. He also admits to lack of energy andweight loss over the same period.

Physical examination revealed a hard, craggy spleen, non8tender, extending to hisumbilicus. 9here was no hepatomegaly.

Investigations

Hb !+.( g$dl% P&' (.-1 l$l% C&H& --g$dl% W*& "( x !($l% Platelets 1"( x !($l.

Peripheral blood film :eucoerythroblastic

a. What is meant by the term leucoerythroblasticPeripheral blood film characterised by the presence of nucleated rbcs and

immature granulocytes.

b. In what conditions is this film appearance seen

&onditions associated with *C infiltration by fibrosis, malignancy or amyeloproliferative disorder. ItFs also seen in pts with significant underlying

infections, acute blood loss, haemolysis and sustained hypoxia.

When it occurs with tear drop poikilocytes and thrombocytosis, itFs most

commonly due to chronic idiopathic myelofibrosis.

When you see it with schistocytes and decreased platelets think haemolytic

disorders such as 99P.When you see it with basophilia and abnormal platelet morphology, think &C:.

c. What is the most likely diagnosis

Cyelofibrosis

d. What further investigations are needed to confirm the diagnosis

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W 7

A sixty8five year old female presents to A > with a history of headaches associated

with intermittent blurring of her vision for the past three months. ?he also complained ofpain and swelling of her right great toe for the past three weeks. Her past medical history

is unremarkable.

;n examination she was found to have an enlarged spleen extending ) cm below the left

costal margin. 9here was also swelling and tenderness of the metatarsal =oint of the right

great toe. Bundoscopy revealed engorgement of the retinal vessels

Investigations Hb !." g$dl % W*& !3 x !($lbarely% platelets 1"( x !($l .

a. &omment on the results given above and discuss possible causes.>levation of Hb, slight increase in W*&, thrombocytosis J clinical features

hyperviscosity syndrome2 P@'

4ifferentials

b. What further investigations are neededHaem

&hem path

;ther

c. How would you further manage this patient

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W 8

Patient '* Age )- years% Bemale

c$o :eft8sided abdominal pain for one week, persistent, relieved by analgesics.

Anorexia associated with weight loss, fever and night sweats for one month.

Polyuria and constipation are present.

;$> 9he abnormal findings on physical examination include right cervical

Adenopathy largest +." x !." cm2 and bilateral inguinal adenopathylargest ! x ! cm2, hepatosplenomegaly.

Investigations: Hb !-. g$dl% W*& )1 x !($:% platelet !3- x !($:

W*& 4iff

0eutrophil :ymph &lover leaf cell &leaved cell >osinophil

+(/ 3/ -) +(/ )!/ +(- !+/ "

a. 4iscuss the most likely diagnosis.Calignant lymphoma8 0on8hodgkinFs. Presence of clover leaf cells

suggests A9::.

b. 4iscuss the aetiology of this disease

Assoc. with H9:'! infection

c. What is the prognosis of this patient?tage III?*

9ype chronic8 +yr survival rate5 "+.)/

d. How will you manage this patient

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W 9

A -(8year8old male, known to be HI' positive for the past five years, presents with a

history of swellings in his neck for the past two months, which have been progressivelyincreasing in siDe. He also admits to having fever and drenching night sweats over the

same period.

;n examination he was found to have generaliDed lymphadenopathy, ranging in siDe from

+cm 8 ) cm.

Investigations:

Hb !(." g$dl% W*& ).( x !($l with a normal differential% platelets !"( x !($l.

4iscuss the differential diagnoses, further investigations and management of this patient.

Pt is anaemic and leukopenic. ?welling could be due to the HI' virus itself, it could be

due to an infection eg. An opportunistic infection2 or it could be associated with a

lymphoma. 9he constitutional symptoms makes the lymphoma diagnosis the most likelyone.

HI' is associated with three types of lymphomas, systemic, primary &0? or primaryeffusion lymphoma

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W 10

A -+ year8old woman notices a swelling in her neck one morning while showering. ?he

has no other symptoms. ?he visits her private practitioner when the swelling persists for+ months, who detects cervical adenopathy and does the following investigations

Investigations Hb !+ g$dl% W*& 1." x !(

$: normal differential2%platelet +(( x !($:% >?@ " mm$hr% :iver function tests are normal.

4iscuss the differential diagnoses, investigations and management of this patient.

Painless cervical lymphadenopathy J elevated >?@

:ocaliDed infection, primary tumor8 0H:, H4, secondary.

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W 11

Patient :C Age 1) year% Bemale

c$o Pain in right knee and ribs for - months. Pain is aggravated by movement and not

relieved by analgesia.

;$> Physical examination is unremarkable except for tenderness over the chest wall.

Investigations Hb !(.+ g$dl% W*& -.1 x !($:% 4ifferential E neutrophils 38% 1.36,

lymphocytes ""/ !.#, monocytes 3/ (.+", platelets !)" x !($:.

&hest K8ray E multiple lytic lesions noted in several ribs

a. 4iscuss the differential diagnoses, investigations and management reGuired in

in this patient.

4ifferentials multiple myeloma, mets to bone,

Investigations

Haem &hem Path ;ther

Burther 9wo days later, she develops lower back pain and complains of

constipation and urinary retention.

b. What is your assessment of the patientFs clinical findings

Hypercalcemia

c. 4iscuss the investigations and management.

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W12

A 138year8old woman is noted to have a swelling on the forehead which is increasing in

siDe over the last six months. ?he has no complaints and has only consulted her

physician about the swelling because of cosmetic reasons. B0A& of the mass issuggestive of a plasmacytoma.

4iscuss the further investigation and management of this patient.