Second Edition

Paul K Hamilton
BSc(Hons), MB BCh BAO(Hons)
MRCP(UK) MD
Consultant Physician
Belfast Health and Social Care Trust
Belfast
United Kingdom
Ian C Bickle
MB BCh BAO(Hons), FRCR
Consultant Radiologist
RIPAS Hospital
Brunei Darussalam

CASES

DATA INTERPRETATION
FOR MEDICAL
STUDENTS

CONTENTS

Contents

Preface to second edition

vi

Acknowledgements

vii

Normal values

viii

1.

Haematology

2.

Biochemistry

55

3.

Endocrinology

139

4.

Toxicology

167

5.

Pleural and peritoneal fluid analysis

189

6.

Microbiology

213

7.

Neurology

221

8.

Immunology

239

9.

Imaging

245

10.

Cardiology

341

11.

Pathology

395

12.

Genetics

401

13.

Respiratory medicine

419

14.

Interpreting bedside chart data

451

15.

Miscellaneous

493

16.

Complete clinical cases

509

Index

597

CASES

HAEMATOLOGY

HAEMATOLOGY
One of the most frequently requested tests in medicine is the full blood
picture (FBP). This contains a wealth of information about the components of
blood. The typical constituent parts of the FBP are as shown in the box.

FULL BLOOD PICTURE

A typical FBP comprises the following tests:
Haemoglobin concentration (Hb)
Mean cell volume (MCV)
Mean corpuscular haemoglobin (MCH)
Packed cell volume (PCV)
Red cell distribution width (RDW)
White cell count (WCC) incorporating a differential white cell count
Platelet count
Reticulocyte count

Abnormalities with red blood cells

Anaemia
Anaemia describes a low level of haemoglobin. It is usually defined by an
arbitrary cut-off haemoglobin concentration (eg 13 g/dl in men aged >15 years,
12 g/dl in non-pregnant women aged >15 years and 11 g/dl in pregnant women),
below which a patient is deemed to be anaemic.
Before deciding on the particular subtype of anaemia present in a patient, it is
worth looking at the other cell types described on the full blood picture. If
there are problems with red cells, white cells and platelets, then the major
problem is likely to be a disease of the bone marrow, and the test most likely
to give the diagnosis would be a bone marrow biopsy.

DATA INTERPRETATION FOR MEDICAL STUDENTS

Abnormal white blood cells

FOUND IN

ABNORMALITY
Hypersegmented neutrophils

Megaloblastic anaemias, chronic infections

Toxic granulation of neutrophils

Bacterial infection, poisoning, burns, chemotherapy

Auer rods

Acute myeloid leukaemia

Smear cells

Chronic lymphocytic leukaemia

Leukoerythroblastic blood film

This is a term used to describe the overall appearance of a blood film in which
immature red and white blood cells are seen in peripheral blood. There are
several causes.
CAUSES OF A LEUKOERYTHROBLASTIC BLOOD FILM

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Coagulation disorders
Haemostasis (the process of stopping bleeding) is a complex process. It
involves the interplay of blood vessel walls, platelets and clotting factors.
The common tests used to assess coagulation are as follows:

COMMON TESTS OF COAGULATION

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HAEMATOLOGY

Prothrombin time
The PT is dependent on clotting factors I, II, V, VII and X. In clinical practice, it
is most commonly measured to assess the synthetic function of the liver (eg in
liver failure), or to monitor the effects of warfarin therapy.

International normalised ratio

To allow comparison of coagulation results between laboratories, the PT is
often converted to the INR, by applying a correction factor. This takes into
account differences in laboratory methods, and means that the patients INR
should be the same regardless of the laboratory used to measure it.
The INR is the parameter most commonly used to monitor the effects of
warfarin. In a patient with normal coagulation, the INR will be close to 1.0
before warfarin is commenced. As warfarin is introduced, the INR rises. The
higher the INR, the less coagulable the blood becomes (ie the more difficult it
will be for the blood to clot). Target INRs are set, and warfarin dosing must be
adjusted to aim for these targets.

DISEASE

TARGET INR

Deep venous thrombosis (DVT)

2.5

Pulmonary embolism (PE)

2.5

Atrial fibrillation

2.5

Mechanical prosthetic heart valve

2.5

Recurrent DVT/PE in a patient with

a therapeutic INR

3.5

The essence of warfarin prescribing involves increasing the dose if the INR is
too low, reducing the dose if the INR is too high, and omitting it if the INR is
dangerously high or the patient is bleeding. An example of a warfarin
prescribing chart is shown on page 486.

Activated partial thromboplastin time

The APTT depends on all clotting factors except factor VII. In clinical practice,
the APTT is used most commonly in patients receiving an infusion of heparin.
The APTT is monitored frequently, and the rate of the heparin infusion adjusted
to achieve the desired level of anticoagulation. With the common prescribing of
low-molecular-weight heparin, in preference to unfractionated heparin, this
process is now performed infrequently. A frequent cause of concern relates to
elevated APTTs in patients with central venous catheters. The proximal end of

DATA INTERPRETATION FOR MEDICAL STUDENTS

such catheters are often filled with heparin to keep the lumina patent when they
are not being used. A spuriously high APTT will be obtained if blood is
withdrawn from one such lumen. If the APTT is tested on a sample of blood
tested peripherally, the true value will be obtained.

Coagulation correction testing

In cases of deranged coagulation, laboratories will often perform a coagulation
correction test. This is performed to detect problems in coagulation arising
because of a low level of a particular clotting factor. Essentially, normal plasma
(containing normal clotting factors) is mixed with the patients sample. If the
patient is deficient in clotting factors, a deranged coagulation profile would be
expected to normalise. There will be no change, however, if an inhibitor of
coagulation is present. Specialised assays for individual clotting factors are also
available.

Bleeding time
Bleeding time is measured directly at the bedside. A sphygmomanometer cuff
is inflated around the patients arm to 40 mmHg. A specially designed blade is
then used to make a small puncture in the arm. Blood is removed from the area
at fixed time intervals (eg 15 s) using a piece of filter paper to soak it up. The
time taken for bleeding to stop is recorded. Elevated bleeding times indicate
defective platelet function or low platelet numbers. This test should not be
performed if the patient is known to have severe thrombocytopenia.
Bear in mind that patients with abnormal numbers or deranged function of
platelets may also have abnormal bleeding. Patients with von Willebrand
disease may have normal coagulation profiles.

DONT FORGET
Patients with von Willebrand disease may have normal coagulation profiles.

Disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) is a disease of two apparently
conflicting problems. On the one hand, fibrin deposition in various organs
results in areas of micro-infarction. On the other hand, the bodys supplies of
clotting factors become used up because of all the clotting, leaving the
patient prone to bleeding.

HAEMATOLOGY

DISSEMINATED INTRAVASCULAR COAGULATION

A disease in which clotting and bleeding cause problems simultaneously.

Typical laboratory findings in DIC are as follows:

Raised PT and APTT

Since clotting factors are reduced

Reduced fibrinogen

Due to widespread fibrin formation

Raised D-dimer

Due to the bodys attempt to break

down the excess fibrin deposits

D-dimer
D-dimer is the most commonly measured fibrinogen/fibrin degeneration
product. It is detected following clot formation in the vasculature, as the
bodys fibrinolytic system attempts to break the clot down. D-dimer levels are
often tested in cases of suspected deep venous thrombosis and pulmonary
embolism, and in the majority of cases will be raised. However, D-dimer levels
are also raised in many other conditions, and a raised level should always be
interpreted in light of the clinical scenario.

Laboratory findings in bleeding disorders

PT

APTT

FIBRINOGEN

Warfarin treatment

Increased

Normal (or Increased)

Normal

Heparin
treatment

Normal (or
increased)

Increased

Normal

Haemophilia A or B

Normal

Increased

Normal

Liver disease

Increased

Increased

Normal

DIC

Increased

Increased

Reduced

DATA INTERPRETATION FOR MEDICAL STUDENTS

Plasma cell dyscrasias

Diseases of plasma cells are common, and their investigation is often a cause
for confusion. They represent a spectrum of disorders, with multiple myeloma
being the most important at the undergraduate level, and monoclonal
gammopathy of unknown significance (MGUS) being the most common. The
hallmark of these conditions is that plasma cells secrete M protein in excess.
The effects of multiple myeloma can be far-reaching, and can lead to the
following features:


x Anaemia

x Renal impairment

x Low levels of normal immunoglobulins with resultant infections

x Bone involvement, causing bony pain, hypercalcaemia, lytic lesions and

problems if bones collapse

x Hyperviscosity of the blood.

The conditions should be suspected if any of the following abnormalities are

present:


x Elevated ESR

x Hypercalcaemia

x Anaemia

x Renal impairment

x Abnormal M-protein detected on plasma protein electrophoresis

x Abnormal quantities of immunoglobulin light chains in the serum

(with an abnormal NO ratio)

x Low levels of immunoglobulins

x Lytic lesions on X-ray of bones

x Detection of Bence Jones protein in the urine (this represents

immunoglobulin light chains)

x Abnormal plasma cells seen on bone marrow biopsy

x Elevated E2-microglobulin.

HAEMATOLOGY

A 48-year-old retired civil servant is concerned with her pale colour and
feelings of faintness that have occurred over the past 4 weeks. She had felt well
before this and enjoyed regular trips to southern France. Brief clinical
examination reveals pallor. Her blood tests come to your attention.

Hb
MCV
Plt
WCC
Serum iron
Ferritin
TIBC
Vitamin B12
Folate

1.

8.7 g/dl
64.5 fl
556 109/l
7.7 109/l
6 mol/l
10 g/l
90 mol/l
221 ng/l
8.2 g/l

How would you interpret these results?

2. How would you proceed with investigation?

CASES

Case 1.1

DATA INTERPRETATION FOR MEDICAL STUDENTS

Answer 1.1

Low
Hb
MCV
Plt
WCC
Serum iron
Ferritin
TIBC
Vitamin B12
Folate

8.7 g/dl
64.5 fl
556 109/l
7.7 109/l
6 mol/l
10 g/l
90 mol/l
221 ng/l
8.2 g/l

Low
High
Low
Low
High

1. This patient has a microcytic anaemia. Her iron profile is in keeping with iron
deficiency with a low iron, low ferritin and high TIBC. There is a mild
thrombocytosis which may indicate active bleeding.
2. The most common cause for these findings in young women is menorrhagia.
In an older female or male of any age, investigations should be carried out
to exclude a sinister cause in particular an occult gastrointestinal tract
malignancy. Investigations should begin with a thorough history and clinical
examination which should include rectal examination. The next line of
investigation usually involves gastrointestinal tract endoscopy.

HAEMATOLOGY

A 57-year-old woman attends her GP complaining of tiredness. The GP knows

her medical history well as she also suffers from Graves disease. A full blood
count was analysed as well as haematinics.

1.

Hb
MCV
Plt
WCC

9.9 g/dl
104.5 fl
199 109/l
6.7 109/l

Serum iron
Ferritin
TIBC
Vitamin B12
Folate

21 mol/l
50 g/l
60 mol/l
22 ng/l
9.8 g/l

Interpret these blood results.

Following these results the GP also requests another test shown below.

Anti-parietal cell antibody

Anti-intrinsic factor antibody

2. What is the diagnosis?

Titre 1:220
Positive

CASES

Case 1.2

DATA INTERPRETATION FOR MEDICAL STUDENTS

Answer 1.2

Low
Hb
MCV
Plt
WCC

9.9 g/dl
104.5 fl
199 109/l
6.7 109/l

Serum iron
Ferritin
TIBC
Vitamin B12
Folate

21 mol/l
50 g/l
60 mol/l
22 ng/l
9.8 g/l

Anti-parietal cell antibody

Anti-intrinsic factor antibody

High

Low

Titre 1:220
Positive

Abnormal
Abnormal

1. The haemoglobin is low with an elevated mean cell volume. This patient has
a macrocytic anaemia. Haematinics show a low vitamin B12 level. Iron studies
and folate level are within normal limits.
2. The positive antibodies to gastric parietal cells and intrinsic factor indicate
that the likely underlying cause of the anaemia is pernicious anaemia. You
will note that the patient was already known to have an autoimmune
disease Graves disease. Always remember that patients with one
autoimmune disease are prone to developing another.
A Schilling test would have been useful in this case. The initial test would show
low levels of radiolabelled vitamin B12 in the urine. Once the patient was given
oral intrinsic factor, urine vitamin B12 excretion would be expected to return to
normal.

HAEMATOLOGY

A 49-year-old woman with systemic sclerosis complains of malaise and

palpitations. Her disease has been quiescent for 2 years and she is not on any
immunosuppressant medications. She has a balanced diet and has had no
previous surgery. Her rheumatologist requests the following tests:

Hb
MCV
Plt
WCC

8.2 g/dl
109.4 fl
169 109/l
6.2 109/l

Serum iron
Ferritin
TIBC
Vitamin B12
Folate

23 mol/l
49 g/l
62 mol/l
31 ng/l
>10 g/l

Anti-parietal cell antibody

Anti-intrinsic factor antibody

Titre < 1:120

Negative

Schilling test

Without oral intrinsic factor: 0.03 g radioactive vitamin

B12 in 24-h urine sample (3% of oral dose)
With oral intrinsic factor: 0.03 g radioactive vitamin B12
in 24-h urine sample (3% of oral dose)

Hydrogen breath test

Early peak in hydrogen excretion

1.

What would you infer from these results?

2. What is the reason for performing a hydrogen breath test?

CASES

Case 1.3

DATA INTERPRETATION FOR MEDICAL STUDENTS

Answer 1.3

Hb
MCV
Plt
WCC

8.2 g/dl
109.4 fl
169 109/l
6.2 109/l

Serum iron
Ferritin
TIBC
Vitamin B12
Folate

23 mol/l
49 g/l
62 mol/l
31 ng/l
>10 g/l

Anti-parietal cell antibody

Anti-intrinsic factor antibody
Schilling test
Less than 10% of
oral dose excreted
in urine
Hydrogen breath test

Low
High

Low

Titre < 1:120

Negative

Less than 10% of

oral dose excreted
in urine

Without oral intrinsic factor: 0.03 g radioactive vitamin

B12 in 24-h urine sample (3% of oral dose)
With oral intrinsic factor: 0.03 g radioactive vitamin B12
in 24-h urine sample (3% of oral dose)
Early peak in hydrogen excretion

Abnormal result

1. This patient has a macrocytic anaemia. Vitamin B12 is the only deficient
haematinic, but the autoantibodies for pernicious anaemia are negative. The
history states that the diet is balanced and no surgery has taken place on
the bowel to interfere with the absorption of vitamin B12. The Schilling test
is abnormal. Normally, at least 10% of the oral dose of radiolabelled vitamin
B12 is excreted in the urine. In this case, the excreted dose is low, and
supplementation with intrinsic factor makes no difference. The likely
pathology is therefore in the ileum.
2. The abnormal hydrogen breath test result points to the cause of anaemia
small bowel bacterial overgrowth. Patients with systemic sclerosis are prone
to developing this condition. Definitive testing for bacterial overgrowth
involves culturing small bowel contents. One would expect a normal
Schilling test after an adequate course of appropriate antibiotics.

HAEMATOLOGY

A 34-year-old accountant with a 15-year history of Crohns disease attends for

outpatient review. He feels reasonable, although has not yet been able to hold
down full employment after numerous hospital admissions and surgery over the
past 10 years. His last surgery involved small bowel resection and anastomosis
after further failure of medical therapy. The doctor in the clinic requests the
following tests.

Hb
MCV
Plt
WCC
RDW

8.9 g/dl
94.5 fl
399 109/l
9.7 109/l
20%

Serum iron
Ferritin
TIBC
Vitamin B12
Folate

9 mol/l
10 g/l
80 mol/l
12 ng/l
1.8 g/l

What is your interpretation of these tests?

CASES

Case 1.4

DATA INTERPRETATION FOR MEDICAL STUDENTS

Answer 1.4

Low
Hb
MCV
Plt
WCC
RDW

8.9 g/dl
94.5 fl
399 109/l
9.7 109/l
20%

Serum iron
Ferritin
TIBC
Vitamin B12
Folate

13 mol/l
10 g/l
80 mol/l
12 ng/l
1.8 g/l

Normal

Raised
Low
Low
High
Low
Low

This man has a normocytic anaemia. He is deficient in iron, vitamin B12 and
folate. The red cell distribution width (RDW) is raised, indicating a wide
variation in the size of circulating red cells. The patient is likely to have a
dimorphic blood picture, with small red cells resulting from iron deficiency, and
large cells resulting from deficiencies of vitamin B12 and folate. Crohns disease
is an inflammatory bowel disease involving the whole gastrointestinal tract so
has the potential to cause deficiencies in all three haematinics. In this case,
multiple operations have left him with a very short small bowel (short gut
syndrome).

HAEMATOLOGY

A 55-year-old woman with essential hypertension attends the medical clinic.

Her blood pressure remains elevated despite treatment with four drugs. Her
consultant commences her on methyldopa. Four weeks later she attends the
accident and emergency department feeling generally unwell. The A&E doctor
sends off a variety of blood tests, which are shown here.

Hb
MCV
Plt
WCC

9.2 g/dl
93.4 fl
376 109/l
7.2 109/l

Serum iron
Ferritin
TIBC
Vitamin B12
Folate

25 mol/l
154 g/l
65 mol/l
198 ng/l
6.5 g/l

Total bilirubin
AST
ALT
GGT
ALP

45 mol/l
25 IU/l
22 IU/l
15 IU/l
98 U/l

She is admitted to the medical unit, and several other tests are requested.

Urinary urobilinogen
Blood film
Direct antiglobulin test

1.

Positive
Large numbers of reticulocytes
Positive

Interpret the results above

2. What is the likely diagnosis?

CASES

Case 1.5