498. Diagnostic Hematology

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498. Diagnostic Hematology

 

 

CATEGORY: Medical & Medicine – 500 Courses

COURSE NUMBER: 498

FEES: 555/- INR only

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BOOKS/ MANUALS: Pages

Syllabus

1 Preliminary Concepts………………………………………………………………………………. 1
Modern Hematology in Context ………………………………………………………………. 1
The Broad Types of Hematological Disease and Their Tests ………………………… 3
Blood Diseases Characterized Essentially by Changes in the FBC …………….. 3
Diseases Characterized Essentially by Changes in the Hemostatic Screen …… 4
Problems and Limitations Found in Practice ……………………………………………… 4
Nomenclature………………………………………………………………………………………… 5
Basophilia …………………………………………………………………………………………. 5
Polycythemia and Erythrocytosis …………………………………………………………. 6
Pancytopenia …………………………………………………………………………………….. 7
Conventions Adopted …………………………………………………………………………….. 7
A Brief Overview of the Contents …………………………………………………………….. 8
Further Reading…………………………………………………………………………………….. 8
2 Blood Diseases and Their Diagnosis (1) ………………………………………………………. 9
The Nature of the Blood System ………………………………………………………………. 9
The Hematological System Is a Balanced System ………………………………….. 12
The Basic Pathology of the Hematological System ……………………………………. 14
The Pathology of the Blood Cell Sub-system (Clinical View) ………………….. 15
Types of Pathological Abnormality Affecting the Blood Cell Sub-system …….. 15
Disorders of the Plasma …………………………………………………………………….. 15
Quantitative Disorders of Production of Blood Cells …………………………….. 15
Qualitative Disorders of Blood Cells …………………………………………………… 17
Disorders of Circulating Blood Cells …………………………………………………… 18
Disorders of Hemoglobin ………………………………………………………………….. 20
The Nature of the First-Line Tests in Hematology ……………………………………. 21
A Brief Look at Laboratory Tests, with Particular Reference to
the First-Line Tests in Hematology …………………………………………………….. 21
The First-Line Tests ……………………………………………………………………………… 22
Understanding the FBC …………………………………………………………………….. 22
The Constituents of the FBC and Their Clinical Significance ………………….. 23
The Red Cells ………………………………………………………………………………….. 23
The White Cell Series ……………………………………………………………………………. 24
The Platelets ………………………………………………………………………………………… 24
The Role of Blood Film Morphology ……………………………………………………… 24
Case #1……………………………………………………………………………………………….. 25
The Subcomponent Red Cell Circulations ……………………………………………….. 27
Essential Nutrients Required by the Blood System ………………………………… 27

A Word of Warning Regarding Some Serum Levels ………………………………….. 29
Hemostasis and the Hemostatic Screen ……………………………………………………. 30
The Three Anatomical Elements (or Groups of Elements) ……………………… 32
The Three Procoagulant Processes ………………………………………………………….. 33
The Initiation of Hemostasis………………………………………………………………. 33
The Control of Local Thrombin Levels ……………………………………………….. 36
Destruction of Fibrin and Clotting Factors Outside the Area of Injury ……. 37
Clot Retraction and Dissolution …………………………………………………………. 37
Thrombin Production and Its Control …………………………………………………….. 38
An Integrated View of Hemostasis ………………………………………………………….. 39
The Role of the Flow of Blood in Hemostasis…………………………………………… 41
The Hemostatic Screen………………………………………………………………………….. 41
The Components of the Hemostatic Screen ………………………………………….. 42
The Bleeding Time and the Platelet Count ……………………………………………….. 42
The PT and PTT ………………………………………………………………………………. 43
The Thrombin Time …………………………………………………………………………. 44
Fibrinogen ………………………………………………………………………………………. 44
The Pathology of the Hemostatic System (Clinical View) …………………………… 44
The Functional Outline of the Hemostatic System ………………………………… 44
Types of Pathological Abnormality Affecting the Hemostatic
Sub-system ………………………………………………………………………………………. 44
The Pathogenesis of Disorders of Hemostasis …………………………………………… 45
Pathological Bleeding ……………………………………………………………………………. 45
Defects in the Procoagulant Mechanisms …………………………………………………. 45
Defects in Mechanisms Controlling Hemostasis ……………………………………….. 47
Pathological Thrombosis ………………………………………………………………………. 47
Summary …………………………………………………………………………………………….. 48
Exercise 2.1 A Quick Self-Test ……………………………………………………………. 49
Exercise 2.2 ……………………………………………………………………………………… 49
Answers ………………………………………………………………………………………….. 50
Further Reading…………………………………………………………………………………… 50
References …………………………………………………………………………………………… 50
3 Blood Diseases and Their Diagnosis (2) …………………………………………………….. 51
The Nature and Value of Laboratory Tests in Hematology ………………………… 51
‘‘Normal’’ and ‘‘Normal Ranges’’ ……………………………………………………………. 53
Variation, Uncertainty of Measurement, Reliability, and Quality Control ……. 54
Specimen Management …………………………………………………………………………. 55
Environmental and Physiological Causes of Pre-analytic Variation …………. 57
Analytic (Laboratory) Variation …………………………………………………………….. 58
Limitations of Tests: Clinical Epidemiology …………………………………………….. 60
The Operating Characteristics of Tests ……………………………………………………. 61
Positive and Negative Predictive Values and Likelihoods ……………………….. 63
Deciding on the ‘‘Normality’’/‘‘Abnormality’’ of a Result …………………………… 65
The Single Isolated ‘‘Abnormal’’ Result ……………………………………………….. 65
The Single Isolated ‘‘Normal’’ Result …………………………………………………… 66
One ‘‘Abnormal’’ Result in a Set of Tests Done at (More or Less)
the Same Time …………………………………………………………………………………. 67
More Than One ‘‘Abnormal’’ Result in a Set of Tests ……………………………. 67
‘‘Normal’’ and ‘‘Abnormal’’ Results of Analytes at Different Times …………. 67
Algorithms ………………………………………………………………………………………….. 68
Discussion of Fig. 3.5 with Critical Comments ……………………………………… 69
The Logical Generation of the Provisional Diagnosis ………………………………… 70
Probability and Inference ………………………………………………………………………. 70
Case #2……………………………………………………………………………………………….. 71

Common Methods of Generating Pre-test Hypotheses ………………………………. 72
The Use of Heuristics in Generating Pre-test Hypotheses ……………………….. 72
The Final Diagnosis ……………………………………………………………………………… 74
Evidence-Based Medicine (EBM) ……………………………………………………………. 74
Summary …………………………………………………………………………………………….. 76
Exercise 2.1 ……………………………………………………………………………………… 78
Exercise 2.2 ……………………………………………………………………………………… 78
References …………………………………………………………………………………………… 79
Further Reading…………………………………………………………………………………… 79
4 Clinical Interactions Between the Blood and the Other Systems…………………….. 81
The Physiological Response to Acute Hemorrhage and the Effects
on the FBC………………………………………………………………………………………….. 81
Thrombocytosis ……………………………………………………………………………….. 82
Neutrophilia ……………………………………………………………………………………. 82
Anemia …………………………………………………………………………………………… 83
Reticulocytosis …………………………………………………………………………………. 83
The Physiological Response to Hypoxia and the Effects on the
Full Blood Count …………………………………………………………………………………. 83
The Raised Hematocrit …………………………………………………………………………. 84
Splenectomy and Hyposplenism……………………………………………………………… 85
Hyposplenism ………………………………………………………………………………….. 85
Clinical Interactions with Other Systems …………………………………………………. 86
The Immune System, Infections, and Blood Diseases ………………………………… 86
Immunohematology………………………………………………………………………….. 87
The Basis of the Antiglobulin Test (Coombs) ……………………………………….. 88
The Autoimmune Hemolytic Anemias (AIHA) …………………………………….. 88
Drug-Induced Hemolytic Disease ……………………………………………………….. 88
Autoimmune Diseases and the Blood: Other Aspects …………………………….. 88
HIV/AIDS, Primarily from the Hematological Perspective …………………….. 89
Other Infectious Diseases and the Blood ……………………………………………… 90
The Cardiovascular System and Blood Diseases ……………………………………….. 92
The Gastro-intestinal Tract (GIT) and Blood Disease ……………………………….. 92
Bleeding ………………………………………………………………………………………….. 93
Diverticular Disease ………………………………………………………………………….. 94
Gastro-intestinal Surgery and Its Complications ………………………………………. 94
Gastric Surgery ………………………………………………………………………………… 94
Intestinal Surgery ……………………………………………………………………………… 95
Functional Deficiencies……………………………………………………………………… 95
Liver and Biliary Disease …………………………………………………………………… 95
The Pancreas……………………………………………………………………………………. 97
Malabsorption and the Malabsorption Syndromes ……………………………….. 97
Miscellaneous Conditions ………………………………………………………………… 102
The Skin and Blood Diseases ……………………………………………………………….. 103
The Genito-urinary System and Blood Diseases ……………………………………… 107
Pregnancy and Changes in the Blood …………………………………………………….. 107
The Musculo-skeletal System and Blood Diseases …………………………………… 109
The Endocrine System and Blood Diseases …………………………………………….. 110
The Nervous System and Blood Diseases ……………………………………………….. 111
The Respiratory System and Blood Diseases ………………………………………….. 111
The Respiratory Gas Path at Rest and at Sea Level …………………………….. 112
The Nature of the Flow of Blood and Its Relevance to
Tissue Oxygenation…………………………………………………………………………. 114
The Diffusion of Oxygen from the Hemoglobin Molecule Through the
Endothelium ………………………………………………………………………………….. 116

Diffusion from the Endothelium Through the Interstitium to the
Tissue Cell……………………………………………………………………………………… 117
Oxygen Carriage and Transport ……………………………………………………….. 118
Other Lung Conditions of Relevance to Blood Disease ……………………………. 123
The Hematology of Malignant Disease ………………………………………………….. 123
Blood Loss in Malignant Disease ……………………………………………………… 123
Metastatic Spread to Bones ……………………………………………………………… 123
Microangiopathic Hemolysis ……………………………………………………………. 123
Disseminated Intravascular Coagulation (DIC) ………………………………….. 124
Hypercoagulable States……………………………………………………………………. 124
The Erythrocyte Sedimentation Rate (ESR) …………………………………………… 124
Other Activity Tests ……………………………………………………………………………. 125
Summary …………………………………………………………………………………………… 125
General Pathophysiological Processes ……………………………………………….. 125
Clinical Interactions of the Blood with Other Systems …………………………. 126
A Final Word! ……………………………………………………………………………………. 126
Exercise 4.1 ……………………………………………………………………………………. 127
Exercise 4.2 ……………………………………………………………………………………. 127
Answers ………………………………………………………………………………………… 127
Further Reading…………………………………………………………………………………. 128
References …………………………………………………………………………………………. 128
5 The Principles of Diagnosis and the Clinical Examination ………………………….. 129
The Nature of Traditional Clinical Diagnosis …………………………………………. 129
The Pathological Diagnosis in Blood Diseases ………………………………………… 132
The General Pathology Diagnosis …………………………………………………….. 133
The Special Pathology Diagnosis ………………………………………………………. 134
Statistical Methods of Diagnosis: Bayes’ Theorem ………………………………. 135
A Note About ‘‘Testing’’ in Hematology ……………………………………………. 137
How to Suspect that a Patient Has a Blood Disease ………………………………… 137
Symptoms Volunteered by or Elicited from the Patient that
Suggest a Blood Disease ………………………………………………………………….. 137
Signs Found on Inspection that Suggest a Blood Disease ……………………… 138
The Clinical History ……………………………………………………………………………. 138
Constitutional and General ……………………………………………………………… 139
Neurological, Mental, and Psychological Symptoms ……………………………. 139
Cardiovascular, Respiratory, and Performance Status …………………………. 140
Skin, Bone, Muscles, and Joints………………………………………………………… 141
Gastrointestinal and Nutritional History……………………………………………. 141
Previous Medical and Surgical History ………………………………………………. 143
Ethnic, Geographical, and Travel History ………………………………………….. 144
Family History……………………………………………………………………………….. 145
Drugs, Previous Therapies, Habits ……………………………………………………. 145
Occupational History………………………………………………………………………. 146
Bleeding and Thrombosis ………………………………………………………………… 146
The Clinical Examination…………………………………………………………………….. 147
The General Examination ……………………………………………………………………. 148
Hands and Wrists …………………………………………………………………………… 151
Upper Arm, Axilla ………………………………………………………………………….. 152
Head and Neck ………………………………………………………………………………. 152
Face, Mouth, and Eyes ……………………………………………………………………. 154
The Thorax ……………………………………………………………………………………. 155
The Abdomen and Pelvis …………………………………………………………………. 155
The Lower Limbs……………………………………………………………………………. 156
The Nervous System ……………………………………………………………………….. 156

The Assessment of Lymphadenopathy …………………………………………………… 157
Clinical Evaluation of Enlarged Lymph Nodes …………………………………… 157
The Clinical Examination in the Bleeding Disorders ………………………………… 158
What Features Can Suggest that Bleeding Is Pathological? …………………… 159
Hemarthrosis …………………………………………………………………………………. 160
The Acute, Very Painful Swollen Joint (Essentially a Monoarthritis) ……… 160
Acute on Chronic Hemarthrosis ……………………………………………………….. 161
Massive Bruising After Inappropriately Small Trauma ………………………… 161
Acute Muscle and Soft Tissue Bleeds…………………………………………………. 161
Raccoon Eyes (Periorbital Bleeding)………………………………………………….. 161
Laceration of the Frenum of the Tongue or Lower Lip ………………………… 161
Multiple Hemangiomata ………………………………………………………………….. 161
Liver Disease …………………………………………………………………………………. 161
Disseminated Intravascular Coagulation (DIC) ………………………………….. 162
Other Hematological Diseases with Bleeding………………………………………. 162
Miscellaneous Presentations …………………………………………………………….. 162
Other Characteristic Clinical Features ……………………………………………….. 163
Common Clinical Patterns in Blood Diseases ……………………………………… 163
An Application of the Epidemiological Approach …………………………………… 165
The Operating Characteristics of the Hb Test……………………………………… 166
Summary …………………………………………………………………………………………… 167
A Final Word …………………………………………………………………………………….. 167
Exercise 5.1 ……………………………………………………………………………………. 168
Exercise 5.2 ……………………………………………………………………………………. 168
Answers ………………………………………………………………………………………… 168
References …………………………………………………………………………………………. 168
Further Reading…………………………………………………………………………………. 169
6 A Practical Approach to the FBC and Hemostatic Screen ………………………….. 171
The Full Blood Count: Summary of the Approach ………………………………….. 171
How to Make the Anatomical Diagnosis ……………………………………………. 172
Making the General Pathology Diagnosis………………………………………………. 173
The Master-set of General Pathology Causes of Anatomical
Diagnoses Made from the FBC Findings …………………………………………… 174
Making the General Pathology Diagnosis: an Example………………………… 174
Clinical Input in Diagnosis (of the FBC) Summarized. …………………………….. 177
Making the Specific Diagnosis ………………………………………………………….. 178
The Final Diagnosis ………………………………………………………………………… 178
The Integrated Assessment …………………………………………………………………… 178
A Note on Morphology Comments ………………………………………………………. 182
The Report May Be a Semi-quantitative List of Certain Observations
Made Microscopically …………………………………………………………………………. 184
A Note on the Use of Elements of the FBC in Isolation ……………………….. 184
The Hemostatic Screen in Practice ………………………………………………………… 185
How to Make the First-Stage Diagnosis …………………………………………….. 185
The General Pathology Diagnosis …………………………………………………………. 186
The Master-set of General Pathology Causes of First-Stage Diagnoses
in the Bleeding Disorders …………………………………………………………………. 186
Deficient/Defective Procoagulant Production (Platelet Numbers) ………….. 186
Deficient/Defective Procoagulant Production (Platelet Defect) ……………… 187
Deficient/Defective Procoagulant Production (Vitamin K-Dependent
Coagulation Factors) ………………………………………………………………………. 187
Deficient/Defective Procoagulant Production (Other Coagulation
Factors) ………………………………………………………………………………………… 187
Deficient/Defective Procoagulant Production (Combinations) ………………. 187

Abnormal Consumption of Procoagulant Factors……………………………….. 187
Defects in Vascular Structure or Function ………………………………………….. 187
The Special Pathology (Specific) Diagnosis…………………………………………….. 187
Case #8 (Tables 6.5 and 6.6)…………………………………………………………………. 188
The Bone Marrow Aspiration and Report ……………………………………………… 190
The Peripheral Blood Concentration of Cells ……………………………………… 191
Case #10. …………………………………………………………………………………………… 193
Case #11. …………………………………………………………………………………………… 194
Case #12. …………………………………………………………………………………………… 194
A Summary of Indications and Contra-Indications to Marrow Studies………. 195
Indications for bone marrow aspiration and/or trephine biopsy.
(Adapted from EBMG database ebm00305/015.001.) ………………………….. 195
Exercise 6.1 ……………………………………………………………………………………. 197
Exercise 6.2 ……………………………………………………………………………………. 197
Answers ………………………………………………………………………………………… 197
Further Reading…………………………………………………………………………………. 197
7 Anemia: General Considerations ……………………………………………………………. 199
The Classification of the Anemias …………………………………………………………. 200
The Epidemiology of Anemia ………………………………………………………………. 201
Diagnostic Problems and Presentations in Anemia ………………………………….. 201
The Clinical Examination in Cases of Suspected Anemia or Obvious Pallor .. 201
Differentiating Clinical Features …………………………………………………………… 202
The Assessment of the Severity of Anemia ……………………………………………… 203
Anemia, Hypoxia, and Cyanosis …………………………………………………………… 203
Bone Marrow Failure and Anemia ……………………………………………………….. 203
Clinical Aspects of the Laboratory Diagnosis of Anemia …………………………. 204
Using the Average Cell Size (i.e., MCV) Diagnostically ……………………………. 205
Anisocytosis and the Raised RDW ……………………………………………………….. 205
The Effect of Developing Iron Deficiency on the RDW, MCV, and Hb …. 205
The Effect of Developing Folate Deficiency on the RDW, MCV,
and Hb ………………………………………………………………………………………….. 206
Other Causes of a Rise in RDW ……………………………………………………….. 206
Case #13. Examine Table 7.4 ……………………………………………………………….. 206
The Physiological Response to Anemia and the Effects on the Full Blood
Count ……………………………………………………………………………………………….. 206
The Response of the Micro-circulation to Anemia ………………………………. 207
The Response of the Heart to Anemia ……………………………………………….. 207
The Response of the Lungs to Anemia ………………………………………………. 208
The Response of the Bone Marrow to Anemia ……………………………………. 208
An Introduction to the Operating Characteristics of Tests in Patients
with Anemia or Pallor …………………………………………………………………………. 210
The Diagnosis of Anemia ………………………………………………………………… 211
The Characterization of the Type of Anemia………………………………………. 211
Screening for Certain Common Hereditary Blood Diseases ………………….. 212
Confirmatory Tests in Cases of Anemia …………………………………………….. 212
Exercise 7.1 ……………………………………………………………………………………. 213
Exercise 7.2 ……………………………………………………………………………………. 213
Answers ………………………………………………………………………………………… 213
Optional Advanced Reading ………………………………………………………………… 213
Further Notes on the MCV, MCH, MCHC, RDW, and Anisocytosis ……. 213
A Dynamic, Risk-Aware View of Blood Diseases, Primarily
the Anemias ………………………………………………………………………………….. 217
References …………………………………………………………………………………………. 218
Further Reading…………………………………………………………………………………. 218

8 Microcytosis: The Microcytic Anemias …………………………………………………… 219
Defining Microcytosis …………………………………………………………………………. 219
The General Pathology Causes of Microcytosis ………………………………………. 219
Deficient Uptake of Iron into the Developing Normoblasts
Required for the Formation of Heme ………………………………………………… 219
FBC Features of Hb-Deficient Red Cells……………………………………………. 220
Features in Other Laboratory Tests …………………………………………………… 220
Common Clinical Features ………………………………………………………………. 220
Specific Causes of Microcytosis ……………………………………………………………. 220
Iron Deficiency ………………………………………………………………………………. 221
Anemia of Chronic Disorders (ACD) ………………………………………………… 223
Thalassemia …………………………………………………………………………………… 224
Making the Diagnosis …………………………………………………………………………. 225
Clinically Obvious or Suggestive Cases ………………………………………………. 226
Clinically Undefined Cases ………………………………………………………………. 226
Combined Iron Deficiency and Anemia of Chronic Disorders ………………. 228
Combined Iron Deficiency and Thalassemia ………………………………………. 228
Combined Iron Deficiency and Folate or Vitamin B12 Deficiency ………….. 228
Teaching Cases …………………………………………………………………………………… 229
Case #14 (Tables 8.2 and 8.3) ……………………………………………………………….. 229
Case #15 (Examine Tables 8.4 and 8.5) ………………………………………………….. 230
Case #16 (Examine Table 8.6) ………………………………………………………………. 231
Case #17 (Examine Tables 8.7 and 8.8) ………………………………………………….. 232
Case #18 (Tables 8.9 and 8.10) ……………………………………………………………… 233
Case #19 (Tables 8.11 and 8.12) ……………………………………………………………. 233
Exercise Cases ……………………………………………………………………………………. 235
Case #20 (Table 8.14) ………………………………………………………………………….. 235
Questions ………………………………………………………………………………………. 235
Answers ………………………………………………………………………………………… 235
Case #21 (Table 8.17) ………………………………………………………………………….. 236
Questions ………………………………………………………………………………………. 236
Answers ………………………………………………………………………………………… 236
Case #22 (Examine Tables 8.18 and 8.19) ………………………………………………. 237
Questions ………………………………………………………………………………………. 237
Answers ………………………………………………………………………………………… 238
Further Questions …………………………………………………………………………… 238
Optional Advanced Reading ………………………………………………………………… 239
Rarer Causes of a Microcytic or Hypochromic Red Cell Picture ……………….. 239
Classification of the Sideroblastic Anemias ………………………………………… 239
The Anemia of Chronic Disorders Revisited ………………………………………. 240
Advanced Notes on the Thalassemias ………………………………………………… 240
The Pathophysiology of b-Thalassemia ……………………………………………… 241
Further Reading…………………………………………………………………………………. 244
References …………………………………………………………………………………………. 244
9 Macrocytosis: The Macrocytic Anemias………………………………………………….. 245
Defining Macrocytosis ………………………………………………………………………… 245
The General Pathology Causes of Macrocytosis ……………………………………… 245
Specific Causes of Macrocytosis……………………………………………………………. 245
Making the Diagnosis …………………………………………………………………………. 246
Clinically Obvious or Suggestive Cases ………………………………………………. 247
Clinically Undefined Cases ………………………………………………………………. 247
(Spurious) Macrocytosis Caused by Autoagglutination ……………………………. 247
The Megaloblastic Blood Picture ………………………………………………………….. 247
The Non-megaloblastic Macrocytic Blood Picture…………………………………… 248

The Blood Pictures of Aplasia and Reticulocytosis ………………………………….. 249
The Complete Brief Pseudoalgorithmic Approach to Macrocytosis …………… 249
Teaching Cases …………………………………………………………………………………… 250
Case #23 (Tables 9.1 and 9.2) ……………………………………………………………….. 250
Case #24 (Table 9.5) ……………………………………………………………………………. 252
Case #25 (Table 9.8) ……………………………………………………………………………. 253
Exercise Case……………………………………………………………………………………… 253
Case #26 (Table 9.9) ……………………………………………………………………………. 253
Questions ………………………………………………………………………………………….. 254
Answers …………………………………………………………………………………………….. 254
Questions ………………………………………………………………………………………….. 254
Answers …………………………………………………………………………………………….. 255
Further Reading…………………………………………………………………………………. 255
10 The Normocytic Anemias ……………………………………………………………………… 257
Defining Normocytosis ……………………………………………………………………….. 257
The General Pathology Causes of a Normocytic Anemia …………………………. 257
The Specific Causes of a Normocytic Anemia …………………………………………. 257
Endocrine Deficiencies …………………………………………………………………….. 257
Renal Anemia ………………………………………………………………………………… 258
Post-hemorrhagic Anemia ……………………………………………………………….. 258
Anemia of Chronic Disorders (ACD) ………………………………………………… 259
Combinations of Megaloblastic Anemia with Iron Deficiency or ACD ….. 259
Bone Marrow Infiltration or Replacement …………………………………………. 259
Hemolytic Anemias…………………………………………………………………………. 259
Hypersplenism ……………………………………………………………………………….. 260
The Distinction Between Hypersplenism and Hemolysis ………………………. 260
Making the Diagnosis …………………………………………………………………………. 260
Clinically Obvious or Suggestive Cases ………………………………………………. 261
Clinically Undefined Cases ………………………………………………………………. 261
Teaching Cases …………………………………………………………………………………… 262
Case #27 (Examine Table 10.1) …………………………………………………………….. 262
Case #28 (Tables 10.3 and 10.4) ……………………………………………………………. 263
Case #29 (Tables 10.5 and 10.6) ……………………………………………………………. 264
Case #30 (Examine Table 10.7) …………………………………………………………….. 265
Case #31 (Examine Table 10.9) …………………………………………………………….. 266
Exercise Case……………………………………………………………………………………… 268
Case #32 (Table 10.10) ………………………………………………………………………… 268
Questions ………………………………………………………………………………………. 268
Answers ………………………………………………………………………………………… 268
Further Questions …………………………………………………………………………… 268
Answers ………………………………………………………………………………………… 269
Case #33 (Table 10.13) ………………………………………………………………………… 270
Questions ………………………………………………………………………………………. 270
Answers ………………………………………………………………………………………… 270
Questions ………………………………………………………………………………………. 270
Answers ………………………………………………………………………………………… 270
Questions ………………………………………………………………………………………. 270
Answers ………………………………………………………………………………………… 271
Further Reading…………………………………………………………………………………. 271
11 Thrombocytopenia ………………………………………………………………………………. 273
Defining Thrombocytopenia ………………………………………………………………… 273
The General Pathology Causes of Thrombocytopenia ……………………………… 273
Specific Causes of Isolated Thrombocytopenia ……………………………………….. 273

Disseminated Intravascular Coagulation ……………………………………………. 274
Prosthetic Intravascular Devices ……………………………………………………….. 274
Extracorporeal Circulation ………………………………………………………………. 274
Micro-vascular Disease ……………………………………………………………………. 274
Drug-Induced Thrombocytopenia …………………………………………………….. 275
Thrombocytopenia Due to Infections ………………………………………………… 275
Alloimmune Thrombocytopenia ……………………………………………………….. 275
Autoimmune Thrombocytopenia ……………………………………………………… 275
Making the Diagnosis …………………………………………………………………………. 276
Platelet-Associated Antibody Testing ………………………………………………… 278
Diagnosis and Principles of Management of ITP…………………………………. 278
Teaching Cases …………………………………………………………………………………… 279
Case #34 (Examine Table 11.1) …………………………………………………………….. 279
Case #35 (Table 11.3) ………………………………………………………………………….. 280
Further Reading…………………………………………………………………………………. 282
12 Leukopenia ………………………………………………………………………………………… 283
Defining Leukopenia…………………………………………………………………………… 283
Generalized Leukopenia………………………………………………………………………. 283
Neutropenia ………………………………………………………………………………………. 283
General Pathology Causes of Neutropenia …………………………………………. 283
Specific Causes of Neutropenia ………………………………………………………… 285
Making the Diagnosis in a Case of Neutropenia ……………………………………… 287
The Clinical Examination ………………………………………………………………… 288
Lymphopenia …………………………………………………………………………………….. 290
Secondary Lymphopenia……………………………………………………………………… 291
Teaching Cases …………………………………………………………………………………… 291
Case #36 (Examine Table 12.1) …………………………………………………………….. 291
Case #37 (Examine Table 12.2) …………………………………………………………….. 291
Case #38 (Examine Table 12.3) …………………………………………………………….. 292
Exercise Case……………………………………………………………………………………… 294
Case #39 (Table 12.5) ………………………………………………………………………….. 294
Questions ………………………………………………………………………………………. 294
Answers ………………………………………………………………………………………… 294
Reference ………………………………………………………………………………………….. 295
Further Reading…………………………………………………………………………………. 295
13 Pancytopenia and Bicytopenia ……………………………………………………………….. 297
Defining Pancytopenia ………………………………………………………………………… 297
General Causes of Pancytopenia……………………………………………………….. 298
Specific Causes of Pancytopenia ……………………………………………………….. 298
Making the Diagnosis ……………………………………………………………………… 300
Clinically Suggestive Presentations ……………………………………………………. 300
Teaching Cases …………………………………………………………………………………… 300
Case #40 (Table 13.2) ………………………………………………………………………….. 300
Case #42. (Examine Table 13.8) ……………………………………………………………. 302
Case #42 (Examine Table 13.9) …………………………………………………………….. 303
Case #43 (Table 13.11) ………………………………………………………………………… 304
Exercise Cases ……………………………………………………………………………………. 305
Case #44 (Examine Table 13.12) …………………………………………………………… 305
Questions ………………………………………………………………………………………. 305
Answers ………………………………………………………………………………………… 305
Further Questions …………………………………………………………………………… 305
Answers ………………………………………………………………………………………… 306

Further Questions …………………………………………………………………………… 306
Answers ………………………………………………………………………………………… 306
Case #45 (Tables 13.15 and 13.16) ………………………………………………………… 306
Questions ………………………………………………………………………………………. 307
Answers ………………………………………………………………………………………… 307
Further Question ……………………………………………………………………………. 307
Answer ………………………………………………………………………………………….. 307
Further Reading…………………………………………………………………………………. 308
14 Thrombocytosis…………………………………………………………………………………… 309
Defining Thrombocytosis and Thrombocythemia……………………………………. 309
The Anatomical Diagnosis……………………………………………………………….. 309
The General Pathology Causes …………………………………………………………. 309
Specific Causes of Thrombocytosis ……………………………………………………….. 310
Acute Hemorrhage …………………………………………………………………………. 310
Acute Hemolysis …………………………………………………………………………….. 310
Splenectomy…………………………………………………………………………………… 310
Hyposplenism ………………………………………………………………………………… 311
Spurious Thrombocytosis ………………………………………………………………… 311
Making the Diagnosis …………………………………………………………………………. 311
Clinical Presentation ……………………………………………………………………….. 311
The Clinical Examination ………………………………………………………………… 312
Optional Advanced Reading ………………………………………………………………… 313
Teaching Cases …………………………………………………………………………………… 313
Case #46 ……………………………………………………………………………………………. 313
Case #47 (Examine Table 14.1) …………………………………………………………….. 313
Case #48 (Examine Table 14.2) …………………………………………………………….. 313
Case #49 (Examine Table 14.3) …………………………………………………………….. 314
Exercise Case……………………………………………………………………………………… 315
Case #50 (Table 14.4) ………………………………………………………………………….. 315
Questions ………………………………………………………………………………………. 315
Answers ………………………………………………………………………………………… 315
Further Readings ……………………………………………………………………………….. 316
15 The Leukocytoses………………………………………………………………………………… 317
Defining Leukocytosis…………………………………………………………………………. 317
Example #1 (Table 15.1) ……………………………………………………………………… 318
Example #2 (Table 15.2) ……………………………………………………………………… 319
Example #3 (Table 15.4) ……………………………………………………………………… 319
Example #4 (Examine Table 15.5)…………………………………………………………. 319
The Approach to a Raised White Cell Count ……………………………………… 320
General Investigations in the Leukocytoses ………………………………………… 321
General Leukocytosis ……………………………………………………………………… 322
Making the Diagnosis in a Case of General Leukocytosis ………………………… 322
Neutrophilia ………………………………………………………………………………………. 323
Associated Features in the FBC That May Occur with Neutrophilia ……… 324
The General Causes of Neutrophilia………………………………………………….. 324
The Reactive and Physiological Causes of Neutrophilia ……………………….. 324
Infective Causes of Neutrophilia……………………………………………………….. 325
Inflammatory Causes of Neutrophilia ……………………………………………….. 326
Malignancies as Causes of Neutrophilia …………………………………………….. 326
Making the Diagnosis in a Case of Neutrophilia …………………………………….. 326
To Summarize the Laboratory Investigations …………………………………………. 327
Representative Clinical Presentations ……………………………………………………. 327

Monocytosis ………………………………………………………………………………………. 328
Making the Diagnosis in Monocytosis……………………………………………….. 328
Lymphocytosis …………………………………………………………………………………… 328
Associated Features in the FBC That May Occur with Lymphocytosis ….. 329
The General Causes of Lymphocytosis ………………………………………………. 329
Making the Diagnosis in a Case of Lymphocytosis ……………………………… 330
Representative Clinical Presentations ………………………………………………… 331
Eosinophilia ………………………………………………………………………………………. 332
Mild Eosinophilia …………………………………………………………………………… 332
Moderate Eosinophilia ……………………………………………………………………. 333
Severe Eosinophilia …………………………………………………………………………. 333
Parasitoses and Eosinophilia ……………………………………………………………. 333
Making the Diagnosis in a Case of Eosinophilia …………………………………. 334
Mild and Moderate Eosinophilia ………………………………………………………. 335
Severe Eosinophilia …………………………………………………………………………. 335
Basophil Leukocytosis…………………………………………………………………………. 336
Unusual Causes of Leukocytosis ………………………………………………………. 336
The Acute Leukemias………………………………………………………………………….. 337
Lymphoblastic Leukemias ……………………………………………………………….. 337
Non-lymphoblastic Leukemias …………………………………………………………. 337
High-Grade Lymphomas in a Leukemic Phase……………………………………. 337
Features in Other Tests ……………………………………………………………………. 338
The Chronic Leukemias ………………………………………………………………………. 338
Chronic Lymphocytic Leukemia (CLL)……………………………………………… 338
Chronic Myelocytic Leukemia (CML) ……………………………………………….. 339
Making the Diagnosis ……………………………………………………………………… 340
Teaching Cases …………………………………………………………………………………… 340
Case #51 ……………………………………………………………………………………………. 340
Case #52 (Table 15.8) ………………………………………………………………………….. 340
Case #53 (Table 15.10) ………………………………………………………………………… 341
Case #54 (Table 15.11) ………………………………………………………………………… 342
Case #55 (Table 15.12) ………………………………………………………………………… 342
Case #56 (Table 15.13) ………………………………………………………………………… 343
Case #57 (Table 15.14) ………………………………………………………………………… 343
Case #58 (Table 15.16) ………………………………………………………………………… 344
Case #59 (Table 15.17) ………………………………………………………………………… 345
Case # 60 (Examine Table 15.18) ………………………………………………………….. 345
Case # 61 (Table 15.20) ……………………………………………………………………….. 347
Case #62 (Tables 15.22 and 15.23) ………………………………………………………… 348
Exercise Cases ……………………………………………………………………………………. 349
Case #63 (Tables 15.24 and 15.25) ………………………………………………………… 349
Questions ………………………………………………………………………………………. 349
Answers ………………………………………………………………………………………… 349
Further Developments …………………………………………………………………….. 349
Questions ………………………………………………………………………………………. 349
Answers ………………………………………………………………………………………… 350
Case #64 (Examine Table 15.27) …………………………………………………………… 350
Questions ………………………………………………………………………………………. 350
Answers ………………………………………………………………………………………… 351
Questions ………………………………………………………………………………………. 351
Answers ………………………………………………………………………………………… 352
Optional Advanced Reading ………………………………………………………………… 352
Neutrophilia ………………………………………………………………………………….. 352
Monocytosis ………………………………………………………………………………………. 353
The FAB Classification of the Acute Leukemias……………………………………… 353

Reference ………………………………………………………………………………………….. 354
Further Reading…………………………………………………………………………………. 354
16 Polycythemia ……………………………………………………………………………………… 355
Defining Polycythemia ………………………………………………………………………… 355
General Causes of Polycythemia …………………………………………………………… 355
Chronic Myeloproliferative Disease…………………………………………………… 355
FBC Features…………………………………………………………………………………. 355
Features in Other Laboratory Tests …………………………………………………… 355
Common Clinical Features ………………………………………………………………. 356
Specific Causes of Polycythemia …………………………………………………………… 356
Classical Polycythemia Vera (i.e., with All Three Cell Lines Increased)…… 356
Increased Circulating Cortisol or Cortisol-Like Hormones …………………… 357
Dehydration…………………………………………………………………………………… 357
Making the Diagnosis …………………………………………………………………………. 357
The Clinical Examination ………………………………………………………………… 357
Differentiating the Possible Causes ……………………………………………………….. 357
Atypical Presentations…………………………………………………………………………. 360
Teaching Cases …………………………………………………………………………………… 360
Case #65 (Table 16.1) ………………………………………………………………………….. 360
Treatment of Polycythemia Vera and Its Effects ……………………………………… 362
Case #66 (Tables 16.4, 16.5, and 16.6)……………………………………………………. 363
Case #67 (Examine Table 16.7) …………………………………………………………….. 364
Case #68 (Examine Table 16.9) …………………………………………………………….. 365
Optional Advanced Reading ………………………………………………………………… 366
The Formal Definition of Polycythemia Vera……………………………………… 366
Further Causes of Polycythemia ……………………………………………………….. 366
The Natural History of PV (in the Absence of Thrombosis)………………….. 366
Management Issues, Complications, and Their Effect on the FBC…………. 367
Exercise Cases ……………………………………………………………………………………. 369
Case #69 (Table 16.11) ………………………………………………………………………… 369
Questions ………………………………………………………………………………………. 369
Answers ………………………………………………………………………………………… 369
Subsequent Course …………………………………………………………………………. 369
Comments……………………………………………………………………………………… 370
Case #70 (Examine Table 16.12) …………………………………………………………… 370
Questions ………………………………………………………………………………………. 370
Answers ………………………………………………………………………………………… 371
Further Reading…………………………………………………………………………………. 371
17 Erythrocytosis…………………………………………………………………………………….. 373
Defining Erythrocytosis ………………………………………………………………………. 373
Dehydration ………………………………………………………………………………………. 373
Gaisbock Syndrome, Often Known as Apparent Erythrocytosis
(and Previously Called Stress Polycythemia) ………………………………………. 373
Hypoxia ……………………………………………………………………………………………. 374
Inappropriate Secretion of Erythropoietin ……………………………………………… 376
Early Polycythemia Vera ……………………………………………………………………… 376
Making the Diagnosis …………………………………………………………………………. 376
EPO Levels ……………………………………………………………………………………. 377
Teaching Cases …………………………………………………………………………………… 378
Case #71 (Examine Table 17.1) …………………………………………………………….. 378
Case #72 (Table 17.3) ………………………………………………………………………….. 379
Case #73 (Examine Table 17.4) …………………………………………………………….. 380
Case #74 (Examine Table 17.6) …………………………………………………………….. 380

Optional Advanced Reading ………………………………………………………………… 382
Notes in Regard to Erythrocytosis…………………………………………………….. 382
The Effect on Oxygen Transport of Treatment of Polycythemia (and
Erythrocytosis) ………………………………………………………………………………. 384
Erythrocytosis in Perspective ……………………………………………………………. 384
Advanced Teaching Cases ……………………………………………………………………. 384
Case #75 (Table 17.9) ………………………………………………………………………….. 384
Case #76 (Table 17.13) ………………………………………………………………………… 385
Exercise Case……………………………………………………………………………………… 388
Case #77 (Table 17.19) ………………………………………………………………………… 388
Questions ………………………………………………………………………………………. 388
Answers ………………………………………………………………………………………… 388
Further Reading…………………………………………………………………………………. 389
18 Bleeding Tendency ………………………………………………………………………………. 391
Defining ‘‘Bleeding Tendency’’ ……………………………………………………………… 391
The Anatomical Diagnosis …………………………………………………………………… 391
The General Pathology Diagnosis …………………………………………………………. 391
‘‘Coagulation Defect’’ ……………………………………………………………………… 392
‘‘Purpuric-Type’’ Defect …………………………………………………………………… 393
Mixed Presentation …………………………………………………………………………. 393
The Special Pathology Diagnosis ………………………………………………………….. 393
Making the Diagnosis …………………………………………………………………………. 394
Symptoms Suggesting Possible Pathological Bleeding ………………………….. 394
Signs Suggesting Possible Pathological Bleeding …………………………………. 394
The Clinical History………………………………………………………………………… 394
Miscellaneous Causes of or Comments Related to Bleeding Disorders ……….. 395
The Clinical Examination of Suspected Bleeding Disorders ………………………. 396
The Characteristic Laboratory Features of the Most Important
Coagulation-Type Bleeding Disorders …………………………………………………… 397
Teaching Cases …………………………………………………………………………………… 397
Case #78 ……………………………………………………………………………………………. 397
Case #79 (Table 18.9) ………………………………………………………………………….. 398
Case #80 (Table 18.10) ………………………………………………………………………… 398
Case #81 (Examine Tables 18.13 and 18.14)……………………………………………. 399
Case #82 (Examine Table 18.15) …………………………………………………………… 399
Case #83 (Examine Tables 18.18 and 18.19)……………………………………………. 400
Case #84 (Examine Tables 18.20 and 18.21)……………………………………………. 401
Case #85 (Tables 18.23 and 18.24) ………………………………………………………… 401
Exercise Case……………………………………………………………………………………… 403
Case #86 (Tables 18.26 and 18.27) ………………………………………………………… 403
Questions ………………………………………………………………………………………. 403
Answers ………………………………………………………………………………………… 403
Further Questions …………………………………………………………………………… 404
Answers ………………………………………………………………………………………… 404
Optional Advanced Reading ………………………………………………………………… 404
Hemophilia ……………………………………………………………………………………….. 404
Acute Hemarthrosis ………………………………………………………………………… 404
Muscle Bleeds ………………………………………………………………………………… 405
Disseminated Intravascular Coagulation (DIC) ………………………………….. 406
Further Reading…………………………………………………………………………………. 406
19 Transfusion-Related Problems……………………………………………………………….. 407
Complications of Transfusion of Blood Components ………………………………. 408
Acute or Early Complications ………………………………………………………….. 408

Long-Term Complications ……………………………………………………………….. 409
Transfusion Reactions…………………………………………………………………………. 409
Acute Transfusion Reactions ……………………………………………………………. 410
Delayed Transfusion Reactions ………………………………………………………… 411
Components, Their Indications, and Their Dangers ………………………………… 411
Whole Blood ………………………………………………………………………………….. 411
Red Cells……………………………………………………………………………………….. 411
Platelets…………………………………………………………………………………………. 413
Plasma Components ……………………………………………………………………….. 414
Patient Monitoring …………………………………………………………………………. 416
Blood Substitutes ……………………………………………………………………………….. 417
Red Cell Substitutes ………………………………………………………………………… 417
Teaching Cases …………………………………………………………………………………… 418
Case #87 (Examine Table 19.1) …………………………………………………………….. 418
Case #88 (Table 19.2) ………………………………………………………………………….. 418
Case #89 (Examine Tables 19.4, 19.5, 19.6, and 19.7) ………………………………. 419
Follow-up (Table 19.8) ……………………………………………………………………. 420
General Discussion …………………………………………………………………………. 421
Exercise Case……………………………………………………………………………………… 422
Case #90 (Table 19.12) ………………………………………………………………………… 422
Questions ………………………………………………………………………………………. 422
Answers ………………………………………………………………………………………… 422
Questions ………………………………………………………………………………………. 423
Answers ………………………………………………………………………………………… 423
Further Reading…………………………………………………………………………………. 423
20 Iron Overload …………………………………………………………………………………….. 425
Mechanisms of Iron Overload ………………………………………………………………. 425
Pathology and Resultant Clinical Features …………………………………………. 426
Hemochromatosis ………………………………………………………………………………. 426
Etiology ………………………………………………………………………………………… 426
Complications ………………………………………………………………………………… 426
Clinical Variability in Type I Hemochromatosis………………………………….. 426
Teaching Cases …………………………………………………………………………………… 427
Case #91 (Table 20.1) ………………………………………………………………………….. 427
Case #92 (Table 20.7) ………………………………………………………………………….. 428
Case #93 (Examine Table 20.8) …………………………………………………………….. 429
Case # 94 (Table 20.9) …………………………………………………………………………. 429
Further Reading…………………………………………………………………………………. 431
21 The Hypercoagulable States………………………………………………………………….. 433
The Primary Hypercoagulable States …………………………………………………….. 433
A Note About Proteins C and S ……………………………………………………….. 434
A Note About Antithrombin ……………………………………………………………. 434
Secondary Hypercoagulable States ……………………………………………………….. 434
The Antiphospholipid Syndrome (APS) …………………………………………….. 434
Venous Thromboembolic Disease (VTE) ……………………………………………….. 435
Arterial Thrombosis ……………………………………………………………………………. 435
Making the Diagnosis …………………………………………………………………………. 436
Making the Diagnosis of Antiphospholipid Syndrome …………………………. 436
A Suggested Approach to Suspected Hypercoagulability ……………………… 436
Making the Diagnosis of Deep Vein Thrombosis (DVT) and
Pulmonary Embolism (PE) ………………………………………………………………. 437
The FBC in the Hypercoagulable States …………………………………………….. 438
The Hemostatic Screen in the Hypercoagulable States …………………………. 438

Teaching Cases …………………………………………………………………………………… 439
Case #95 (Examine Table 21.1) …………………………………………………………….. 439
Case #96 (Examine Table 21.2) …………………………………………………………….. 439
Case #97 (Table 21.3) ………………………………………………………………………….. 440
Further Reading…………………………………………………………………………………. 440
22 The Immune Deficiencies and the Immuno-lympho-plasma Proliferative
Disorders …………………………………………………………………………………………… 441
Immune Deficiencies …………………………………………………………………………… 441
The Lymphomas ………………………………………………………………………………… 442
Myeloma and Related Conditions…………………………………………………………. 442
M Proteins Produced Regularly in the Course of a Disease …………………… 442
Making the Diagnosis …………………………………………………………………………. 444
The Clinical Examination…………………………………………………………………….. 444
Diagnosis in Practice …………………………………………………………………………… 444
Teaching Cases …………………………………………………………………………………… 445
Case #98 (Examine Table 22.1) …………………………………………………………….. 445
Case #99 (Examine Table 22.3) …………………………………………………………….. 446
Case #100 (Table 22.7) ………………………………………………………………………… 447
Case #101 (Table 22.8) ………………………………………………………………………… 448
Further Reading…………………………………………………………………………………. 448
23 Complex and Compound Disorders…………………………………………………………. 449
Case #102 (Examine Table 23.1) …………………………………………………………… 450
Case #103 (Table 23.3) ………………………………………………………………………… 450
Case #104 (Examine Table 23.8) …………………………………………………………… 452
Case #105 (Examine Table 23.11) …………………………………………………………. 452
Case #106 (Examine Table 23.12) …………………………………………………………. 453
The Iron Overload ………………………………………………………………………….. 454
The Blood Pressure …………………………………………………………………………. 455
The Possibility of a Chronic Intracellular Infection ……………………………… 455
Case #107 Examine Tables #23.17 and #23.18 ………………………………………… 456
24 Graded Exercises ………………………………………………………………………………… 457
General Hematological Problems………………………………………………………….. 457
Case #108 (Table 24.1) ………………………………………………………………………… 457
Questions ………………………………………………………………………………………. 457
Answers ………………………………………………………………………………………… 457
Further Questions …………………………………………………………………………… 458
Answers ………………………………………………………………………………………… 458
Further Questions …………………………………………………………………………… 458
Answers ………………………………………………………………………………………… 458
Case #109 (Table 24.5) ………………………………………………………………………… 459
Questions ………………………………………………………………………………………. 459
Answers ………………………………………………………………………………………… 459
Further Question ……………………………………………………………………………. 459
Answer ………………………………………………………………………………………….. 459
Case #110 (Examine Table 24.6) …………………………………………………………… 459
Questions ………………………………………………………………………………………. 459
Answers ………………………………………………………………………………………… 460
Question ……………………………………………………………………………………….. 460
Answer ………………………………………………………………………………………….. 460
Case # 111 (Table 24.8) ……………………………………………………………………….. 460
Questions ………………………………………………………………………………………. 461
Answers ………………………………………………………………………………………… 461

Further Questions …………………………………………………………………………… 461
Answer ………………………………………………………………………………………….. 461
Further Question ……………………………………………………………………………. 461
Answer ………………………………………………………………………………………….. 461
Case 112 (Examine Tables 24.9 and 24.10) ……………………………………………… 461
Questions ………………………………………………………………………………………. 461
Answers ………………………………………………………………………………………… 461
Further Question ……………………………………………………………………………. 462
Answer ………………………………………………………………………………………….. 462
Advanced Cases …………………………………………………………………………………. 462
Case #113 (Examine Tables 24.11 and 24.12) ………………………………………….. 462
Questions ………………………………………………………………………………………. 462
Answers ………………………………………………………………………………………… 463
Case #114 (Examine Table 24.13) …………………………………………………………. 464
Questions ………………………………………………………………………………………. 464
Answers ………………………………………………………………………………………… 465
Further Investigations……………………………………………………………………… 465
Questions ………………………………………………………………………………………. 465
Answers ………………………………………………………………………………………… 465
Case #115 (Table 24.16) ………………………………………………………………………. 465
Bone Marrow Examination ……………………………………………………………… 466
Questions ………………………………………………………………………………………. 466
Answers ………………………………………………………………………………………… 466
Further Questions …………………………………………………………………………… 466
Answers ………………………………………………………………………………………… 467
Further Questions …………………………………………………………………………… 467
Answers ………………………………………………………………………………………… 467
Case #116 (Table 24.19) ………………………………………………………………………. 468
Questions ………………………………………………………………………………………. 468
Answers ………………………………………………………………………………………… 468
Further Questions …………………………………………………………………………… 468
Answers ………………………………………………………………………………………… 468
Appendix A: Drugs, the First-Line Tests, and Blood Diseases ……………………………. 469
Aplastic Anemia …………………………………………………………………………………. 469
Neutropenia ………………………………………………………………………………………. 469
Thrombocytopenia ……………………………………………………………………………… 470
Hemolytic Anemia ……………………………………………………………………………… 470
Miscellaneous …………………………………………………………………………………….. 470
Appendix B: Likelihood Ratios and the Fagan Nomogram ………………………………… 471
Reference ………………………………………………………………………………………….. 472
Appendix C: Emergency Tests of Hemostasis …………………………………………………. 473
The Bleeding Time (Duke’s) …………………………………………………………………. 473
The Whole Blood Coagulation Time (Lee and White) ……………………………… 473
Reference ………………………………………………………………………………………….. 473
Index ……………………………………………………………………………………………………….. 475

……………………………………………………………………………………………………………………………………………………………………………………………………………………

 

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