HAEMATOLOGY 3RD YEAR MBBS SPIRAL II STUDY GUIDE 2014

SHIFA COLLEGE OF MEDICINE

CONTENTS

Introduction ………………………………………………………… 3Themes of the module ……………………………………… 6Table of Specification ……………………………………… 7CASESTheme 1: Pallor ………………………………………………… 10Theme 2: Infection/Leukemia ………………………. 29Theme 3: Bleed/Clot ………………………………………… 57Theme 4: Transfusion Medicine …………………… 66

Resources for learning ………………………………………… 75People to contact ………………………………………………… 77Glossary ………………………………………………………………… 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

PALLORFEVER (INFECTION, LEUKEMIA)BLEED/CLOT TRANSFUSION MEDICINE (TRANSFUSION REACTIONS)

TABLE OF SPECIFICATIONASSESSMENT MCQ 70% SAQ 30% IPE 30%DAYS ALLOCATION 19 DAYSTHEMES• 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%

OBJECTIVESPALLOR

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 FeverInfection/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)

CASESTHEME: PALLORIRON DEFICIENCY ANEMIAMEGALOBLASTIC ANEMIA THALASSEMIA MAJORSICKLE CELL ANEMIA. APLASTIC ANEMIATHEME: INFECTION/LEUKEMIAMALARIAVISCERAL LEISHMANIASISTYPHOID& PARATYPHOID FEVERDENGUE HAEMORRHAGIC FEVERHUMAN IMMUNODEFICIENCY VIRAL INFECTIONTHEME:IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP)HAEMOPHILIA AHAEMOPHILIA BVON WILLEBRAND DISEASE

TTP/HUSDICTHEME: BLOOD GROUPING & CROSS MATCH VOLUNTARY & SAFE TRANSFUSION ACUTE ALLERGIC TRANSFUSION REACTION ACUTE HEMOLYTIC TRANSFUSION REACTION

THEME : PALLOR

(CASE 1)IRON DEFICIENCY ANEMIAPRESENTING 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 medicineBIRTH HISTORY; normal vaginal delivery, born in a district hospital, Fully vaccinatedFAMILY HISTORY

Elder and only sibling(boy) had the same complaints in his age of being pale & lethargicGENERAL 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 breathingGASTROINTESTINAL 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 REQUIREDSpecial investigations: Serum Iron: 15ug/dl ( Male: 59-158 ug/dl, female: 37-145 ug/dl)TIBC: 450ug/dl ( 228-428 ug/dl)Serum ferritin: 4.25ng/ml (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 significantMedications,allergy; nil

Hospitalization/surgery; nilBirth history; normal vaginal birthFAMILY HISTORY

Two brothers, one sister Cardiac problem runs in the familySexual/ social hx; Nothing significantGENERAL PHYSICAL EXAMINATION;

VITAL SIGNS: TEMP 38C, BP 120/80mm, PULSE 100/min, RR 18/minEyes: No scleral icterus. Pale conjunctiva. Mouth: No Dental caries. Satisfactory oral hygieneCENTRAL NERVOUS SYSTEM

Higher Mental Function: intact. No cranial nerves deficit. Motor system: Gait with sensory ataxia. Knee reflex Normal Ankle jerk Absent Upgoing planters bilateralSensory exam: impaired position and vibration sense in both lower limbs.

CARDIOVASCULAR SYSTEM

Normal heart sounds. RESPIRATORY SYSTEM

Normal vesicular breathingGASTROINTESTINAL 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/ulPERIPHERAL FILM: Pancytopenia, Hypersegmented neutrophils,

Radiology: Not ApplicableSpecial investigations: Serum folate: 10.0ng/ml (3.0-17 ng/ml)Red Cell folate: 617/32ng/ml (263-1028ng/ml)Serum B12: 150.0pg/ml (243-894pg/ml)

Schilling test: Positive

Serum Bilirubin: Raised LDH level : 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 MAJORPRESENTING 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 significantMedications, allergy; nilHospitalization/surgery; nilBirth history; normal vaginal birth

FAMILY HISTORY

H/O of death of sibling at the age of 15 months diagnosed as deficiency of bloodSexual/ 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 breathingGASTROINTESTINAL TRACT

Abdomen: Moderate Hepatosplenomegaly. No ascites, Normal Bowel soundsRectal 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 questionsQ.1 What is the pathogenesis of Thalassemia?Q.2 How is the disease prevalence related to social-cultural 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; nilBirth history; normal vaginal birthFAMILY HISTORY

H/O of similar episodes of pain crisis and chest infection in two of the 5 siblings.Sexual/ social hx; Not ApplicableGENERAL 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 HygieneCENTRAL 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 BreathingGASTROINTESTINAL TRACT

Abdomen: Moderate Hepatosplenomegaly. No ascites, Normal Bowel soundsRectal: 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: PositiveHPLC: HbS 70% HbF: 13% HbA: 17%

Critical questions/ study questionsQ.1 Why does sickling occur at time of stress/infection?Q.2 What is the confirmatory test for establishing sickle trait?

CASE: 5

APLASTIC ANEMIAPRESENTING 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 mid-clavicular 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 InvestigationsComplete 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 BiopsyShows a hypocellular marrow, replaced by large amounts of adipose tissue.

Critical questions/ study questionsQ.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 OBJECTIVESAt 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: 2INFECTION (HAEMATOLOGICAL FEVER)

CASE 6MALARIA I PRESENTING COMPLAINTFever- 1weekHeadache- 1 weekMyalgia- 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 significantMedications, allergy: nilHospitalization/surgery: nilBirth history: normal vaginal birthFAMILY HISTORY

Nothing significantSexual/ social hx: Nothing significantTRAVELING HISTORY

History of travelling from Nigeria 2 weeks backGENERAL PHYSICAL EXAMINATION;

VITAL SIGNS: TEMP 1020F, BP 120/75mmHg, PULSE 90/min, RR 16/minPatient 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 breathingGASTROINTESTINAL TRACT

INVESTIGATIONS:

Laboratory investigations:-

COMPLETE BLOOD COUNT:

WBC: 3,000/ul; Lymphocytes: 44%; Hb: 9.8 g/dl; Platelets: 62,000ESR: mm/hrLIVER FUNCTION TESTS: Within normal limits.PROTHROMBIN TIME: 19 secondsTOTAL SERUM PROTEINS: 93 g/LSERUM UREA, CREATININE AND ELECTROLYTES:

SERUM LDH: 505 IU/LRadiology: ULTRASOUND ABDOMEN: HepatosplenomegalySpecial investigations: BLOOD CULTURES: NegativeWIDAL TEST: NegativeTHICK AND THIN BLOOD FILMS FOR MALARIA:

CASE 7:VISCERAL LEISHMANIASISPRESENTING 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 significantMedications, allergy: nilHospitalization/surgery: nilBirth history: normal vaginal birthFAMILY HISTORY

Nothing significantSexual/ social hx: Nothing significantGENERAL PHYSICAL EXAMINATION;

VITAL SIGNS: TEMP 38.5oC, BP 120/75mmHg, PULSE 90/min, RR 16/minPatient febrile, appears lethargic. . Eyes: No scleral icterus; Conjunctiva pale Mouth: NADCENTRAL NERVOUS SYSTEM

Higher Mental Function: intact.Motor and sensory system: intact. No cranial nerves deficit. CARDIOVASCULAR SYSTEM

Normal heart sounds. RESPIRATORY SYSTEM

Normal vesicular breathingGASTROINTESTINAL 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: 62,000ESR: 98 mm/hrLIVER FUNCTION TESTS: Within normal limits.PROTHROMBIN TIME: 19 secondsTOTAL SERUM PROTEINS: 93 g/LSERUM UREA, CREATININE AND ELECTROLYTES: Within normal limits.SERUM LDH: 505 IU/LRadiology: ULTRASOUND ABDOMEN: HepatosplenomegalySpecial investigations: BLOOD CULTURES: NegativeWIDAL TEST: NegativeTHICK 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: PositivePOST-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: 9TYPHOID FEVERPRESENTING 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 significantMedications, allergy: nilHospitalization/surgery: nilBirth history: normal vaginal birthFAMILY HISTORYNothing significantSexual/ 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 SYSTEMHigher Mental Function: IntactMotor and sensory system: intact. No cranial nerves deficit.

CARDIOVASCULAR SYSTEMNormal heart sounds. RESPIRATORY SYSTEMNormal vesicular breathing. GASTROINTESTINAL TRACTAbdomen: 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/hrCRP: 75 mg/dLLIVER 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: NegativeANTI-HCV: NegativeHBSAg: NegativeSTOOL FOR OCCULT BLOOD: PositiveRadiology: ULTRASOUND ABDOMEN: Hepatomegaly

SPECIAL INVESTIGATIONS: WIDAL TEST: PositiveBLOOD 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 questionsQ.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 10DENGUE HEMORRHAGIC FEVERPRESENTING COMPLAINT A 25 year old male presents with fever, headache and bleeding from nose. HISTORY OF PRESENT COMPLAINTA 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 HISTORYNothing significantMedications, allergy: nilHospitalization/surgery: nilBirth history: normal vaginal birthFAMILY HISTORYNothing significantSexual/ social hx: Nothing significantGENERAL 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: IntactMotor and sensory system: intact. No cranial nerves deficit. CARDIOVASCULAR SYSTEMMild tachycardia as above. RESPIRATORY SYSTEMNormal vesicular breathing. Mild tacypnea

GASTROINTESTINAL TRACTAbdomen: 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/LPROTHROMBIN TIME: 16.6 seconds

SERUM UREA, CREATININE AND ELECTROLYTES: Within normal limitsANTI-HAV: NegativeANTI-HCV: NegativeHBsAg: NegativeRadiology: Not RequiredSpecial Investigations: Dengue IgM: PositiveCCVF PCR: NegativePOST-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 LEUKEMIAPRESENTING 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 significantMedications,allergy; nilHospitalization/surgery; nilBirth history; normal vaginal birthFAMILY HISTORY

No significant family history.Sexual/ social hx; N.AGENERAL 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 breathingGASTROINTESTINAL 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/dlHematocrit 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. NoneFamily 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. AlertSkin, Hair, and Nails. NormalHead 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. NormalDIFFERENTIAL DIAGNOSIS

Hodgkin’s disease Non-Hodgkin’s Lymphoma Thyroid enlargement Causes of Cervical Lymphadenopathy

DIAGNOSTIC

Complete blood count:

Hb 11g/dlHematocrit 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 questionsQ.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 & Prevention2. 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 the prevention of Malaria, Dengue & Leishmania

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 leukemia9. communicates professionally with patients, parents/ caretakers and with paramedical staff regarding treatment and care of the patient ,especially suffering from malignant disordersTHEME: 3CLOT & BLEED

CASE 14:HAEMOPHILIA APRESENTING 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 traumaMedications,allergy; nilBirth history; normal vaginal birthFAMILY 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 ApplicableGENERAL PHYSICAL EXAMINATION;

VITAL SIGNS: TEMP: 37.5C, BP: 110/70mm, PULSE: 100/min, RR 19/minA 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 HygieneCENTRAL 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 BreathingGASTROINTESTINAL TRACT

Abdomen: Moderate Hepatosplenomegaly. No ascites, Normal Bowel soundsRectal: 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……. ProlongedActivated Partial thromboplastin time (APTT) prolonged Prothrombin time(PT) 12 Sec (normal)Radiology : No lytic lesion found in bones , synovium not clear (blood in joint space) Special investigations:

Factor VIII antigen Decreased Factor VIII activity Decreased (1%)

Critical questions/ study questionsQ.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 SignificantMedications,allergy; nilBirth history; normal vaginal birthFAMILY HISTORY:

Nothing significantSexual/ social hx; Not ApplicableGENERAL PHYSICAL EXAMINATION;

VITAL SIGNS: TEMP: 37.5C, BP: 110/70mm, PULSE: 100/min, RR 14/minA 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 HygieneCENTRAL NERVOUS SYSTEM

Higher Mental Function: intact. Motor and sensory system: intact. No cranial nerves deficit.

CARDIOVASCULAR SYSTEM

S1 S2 O

RESPIRATORY SYSTEM

Normal Vesicular BreathingGASTROINTESTINAL TRACT

Abdomen: No Hepatosplenomegaly. No ascites, Normal Bowel soundsRectal: Unremarkable,Negative for occult blood. RHEUMATOLOGIC EXAMINATIONNORMAL

INVESTIGATIONS:

LABORATORY INVESTIGATIONS:

COMPLETE BLOOD COUNT: Hb: 10.5 gm/dl TLC: 14,000/ul Platelet count 30,000/ul.

Reticulocyte Count: 02%. Peripheral Film: Moderate poikilocytosis, anisocytosis,, hypochromia present on film

Bleeding time…….(15 minutes) PROLONGEDActivated Partial thromboplastin time (APTT)

32 seconds NORMALProthrombin time(PT) 11 seconds NORMALRadiology : NOT APPLICABLESpecial 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 questionsQ.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 bite4. 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 disordersTHEME:4TRANSFUSION MEDICINE

CASE:16ACUTE ALLERGIC TRANSFUSION REACTIONCASE .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 cross-matched, 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 wereSYSTEMIC 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 FINDINGSHis 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 reactionCritical questions/ study questionsQ.1 Which clinical features would differentiate allergic transfusion reaction from hemolytic one?

CASE: 17ACUTE HEMOLYTIC TRANSFUSION REACTIONHISTORY 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 ExaminationYoung 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 EXAMINATIONCentral 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 FindingsComplete Blood Count: Hemoglobin 6g/dl Hematocrit 30% RBCs 3 million/ul Blood Group A negative

Indirect Coomb’s Test: PositiveSerum Bilirubin: 2.5mg/dlUrine 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 OBJECTIVESTASKS: 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 referenceIron deficiency anemiaDavidson pg no.1012 to 1013,1025 to 1027Robbins 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—403Davidson pg 1027—29Robbins and Cotran 7th edition pg 638----643Aplastic anemia Robbins and Cotran pg 647----649PJ Kumar pg 402----403Davidson pg 1054Thalassemia Robbins and Cotran pg 632----638Infection,Leukemias and lymphomas Review of medical microbiology & virology by Warren Levinson(edition 10) Malaria pg360-363 Leishmania pg368-369Salmonella(typhoid) pg 140-142Dengue fever pg306 Acute lymphocytic leukemia

Robbins and Cotran pg 690—700Acute and chronic myeloid Robbins and Cotran pg 92----702Lymphoma Robbins and Cotran pg 600----690

Bleeding disorders (HA,HB, ITP,DIC)Robbins and Cotran pg 649----658Wintrobe’s clinical Haematology pg1379-1425

Faculty FacilitatingContacts:Dr Ayesha Junaidayesha_junaid497@hotmail.comDr. Riffat Nadeemrifatnahmad@yahoo.comDr.Zubaida Zain zubaida.zain@yahoo.com Dr. Abida Shaheen

abidashaheen97@yahoo.comDr. Tasneem Akhtar doctasak@hotmail.comDr. Munir Malikdrmunir_iqbal@yahoo.comDr. Syeda Hanaa Fatimabackbone.chill@gmail.comDr. Kainat Nazirdrkainat01@hotmail.comDr. Muhammad Umer Farooq umer.farooq150@yahoo.comDr. Ali Azeemalinaqvi101@yahoo.comDr. Qurrat-Ul-Ain Kashifpinkperal09@hotmail.comDr. Farhat Fatimafarhat.fatima19@live.comDr. Rayya Nadeemrayyanadeem100@gmail.comDr. Arooj Anthoneyaroojpeter@gmail.comDr. Imran Khan Jahangir

imrankhanjahangir@yahoo.comDr. Shazia Irumdr.shazia.irum@gmail.comDr. Munazza Athermunazza.athar786@gmail.comDr. Sidra MehmoodSidraMehmood@hotmail.comDr. Shumaila Hanifshumailahanif54@yahoo.comDr. Ahmed Zameerahmedzamir73@yahoo.comDr. Umer Farooqumer.farooq150@yahoo.comDr.Zubiya Aqibzubia.aqib@gmail.com

GLOSSARY

www.nlm.nih.gov/medlineplus/mplusdictioary.htmlwww.online-medical-dictionary.orgwww.medterms.com