<TITLE: Haematology
ACADEMIC DOMAIN: medicine
DISCIPLINE: haematology
EVENT TYPE: seminar discussion
FILE ID: USEMD30B
NOTES: USEMD30A and USEMD30C are part of the same course, not transcribed

RECORDING DURATION: 51 min 49 sec

RECORDING DATE: 28.5.2007

NUMBER OF PARTICIPANTS: 4

NUMBER OF SPEAKERS: 4

S1: NATIVE-SPEAKER STATUS: Finnish; ACADEMIC ROLE: senior staff; GENDER: female; AGE: 51-over

S2: NATIVE-SPEAKER STATUS: Spanish; ACADEMIC ROLE: undergraduate; GENDER: female; AGE: 17-23

S3: NATIVE-SPEAKER STATUS: Spanish; ACADEMIC ROLE: undergraduate; GENDER: female; AGE: 17-23

S4: NATIVE-SPEAKER STATUS: Spanish; ACADEMIC ROLE: undergraduate; GENDER: male; AGE: 17-23

SU: unidentified speaker

SS: several simultaneous speakers>


<S1> okay let's go back to the haematology <S2> @@ </S2> so you have spent all your weekend studying that <COUGH> so <NAME S2> can you start with the first sentence or have you read it through <S2> [yeah] <S4> [mhm] </S4> </S2> you have okay so you know more or less what it's about <S4> (xx) </S4> and analyse the first sentence please </S1>
<S2> erm 76 old man er has been tired <S1> [mhm-hm] </S1> [erm] i don't remember </S2>
<S1> is there one word missing 76-year-old man <S2> mhm-hm </S2> so 76 <S2> yeah </S2> indicates what </S1>
<S2> mhm the age erm yeah , malignancies [(due to) age] </S2>
<S1> [mhm-hm and that could] yes . and that could maybe it's important what type of <S4> [(xx)] </S4> [malignancies] . what type of malignancies </S1>
<S2> mhm gastrointestinal [(xx)] </S2>
<S1> [mhm-hm so] solitary tumours , if you think about the haematological malignancies <S2> mhm </S2> can you think </S1>
<S2> anaemia well it is not a malignancy <S1> mhm-hm </S1> myeloma </S2>
<S1> myeloma what else </S1>
<S2> maybe lymphoma </S2>
<S1> lymphoma yes what else </S1>
<S2> mhm leukaemia </S2>
<S1> mhm-hm and leukaemias yeah how about the sex does it interfere with the haematological malignancies </S1>
<S2> yeah some of them maybe are more er frequent in men than in women </S2>
<S1> mhm-hm which one </S1>
<S2> i don't know maybe lymphomas mhm </S2>
<S1> i don't know <S3> erm </S3> what do they say </S1>
<S3> i'm not sure if it's more frequent with mhm some malignancies </S3>
<S1> mhm-hm </S1>
<S2> maybe some [types] </S2>
<S3> [yeah] </S3>
<S1> perhaps er find out for the for the wednesday if there's any predisposure related to the sex <P:07> and third key word was tired <S2> tired </S2> what does it indicate <S2> [er] </S2> [if a] old man is tired </S1>
<S2> it's very unspecific but also general so </S2>
<S1> mhm-hm so it's unspecific but general and usually , indicates that if a old if an old person is tired that indicates , that it is more </S1>
<S2> more he's more tired (and often so he is) </S2>
<S1> [mhm-hm] </S1>
<S3> [some] severe illness (is there) </S3>
<S1> yes it er indicates this severe thing of course er commonly any any other illness may cause tiredness but usually the cardio-vascular things are important be- because if you think about the tiredness what organ is affected , <S3> [oh yeah] </S3> [what make] you sleepy what organ is affected <S4> brain </S4> brain yes so you then think that er that something related to the circulation or metabolic things of course er drugs are included into those metabolic things yes or infections so on okay <NAME S3> next sentence please </S1>
<S3> he has lost his weight three four kilos during the last six months so in a short period he he lost weight and cou- could indicate also these malignancies or some </S3>
<S1> mhm-hm <S3> [disease] </S3> [malignancies] what else could it indicate </S1>
<S4> there's malnutrition </S4>
<S1> nutrition malnutrition mhm-hm important and common things among elderly people and er <NAME S4> , next one please </S1>
<S4> <READING ALOUD> moreover during the last months he has experienced pain in the back and sometimes (numbness) and shaking in his legs </READING ALOUD> </S4>
<S1> so what are the key words </S1>
<S4> er sorry during the last months <S1> mhm-hm [time] </S1> [and] yeah pain in the back <S1> [symptom] </S1> [and then] yeah and sometimes and (numbness) and shaking in his legs </S4>
<S1> okay so what do you see about the time <S4> subacute </S4> subacute <P:05> and about the symptom </S1>
<S4> erm pain in the back is quite un- unspecific could be tr- erm traumatology could be rheumatology could be malignancy [or] </S4>
<S1> [so] what is the com- most common reason for the pain </S1>
<S4> i guess traumatology mhm <S1> [rheumatology] </S1> [the trauma] trauma <S1> [mhm] </S1> [or osteoporosis] or </S4>
<S1> in in male <S4> trauma </S4> mhm no <S4> mhm </S4> of course it could be but quite seldom of course they can fall <S4> erm [yes] </S4> [but] what happens with the with the age [just] </S1>
<S4> [the] bones are weak weaker </S4>
<S3> mhm </S3>
<S1> and they become </S1>
<S4> [osteoporotic] </S4>
<S3> [brittle] </S3>
<S1> mhm not necessarily but but men have er quite a lot of body mass , [that] </S1>
<S4> [there] is the erm the <S3> [scoliosis] </S3> [her- herniation] of of of the intervertebral disc </S4>
<S1> er (xx) are more common what age </S1>
<S4> [middle age] </S4>
<S3> [50s] </S3>
<S1> uh-huh yeah 40s 50s pe- when people are actively doing something but what is common with the time your spine becomes </S1>
<S3> the scoliosis <S1> mhm </S1> the scoliosis [(xx)] </S3>
<S4> [(radi-) mhm] </S4>
<S1> no not or of course some stiffness but scoliosis is among who , among </S1>
<S4> [young people] </S4>
<S3> [children] </S3>
<S1> young people yes you check all the girls that they don't become so too curvy , so what happens with your spine already it starts to become </S1>
<S3> rigid and </S3>
<S1> uh-huh , not arthritis but <S4> arthrosis </S4> arthrosis yes so it's not a inflammatory process as such but it's more like related to <S4> yes </S4> arthrotic changes all of us when does start </S1>
<S4> i guess 50s maybe [and 30s] </S4>
<S1> [20s] 20s <S4> [20s] </S4> [20s] yes you are </S1>
<SS> [@@] </SS>
<S3> [25] </S3>
<S1> @@ you are already at the risk group that's why you have to keep good er care of your body , so that is like this arthrotic pain is quite common beca- why or why </S1>
<S4> why </S4>
<S1> why the elderly people have commonly pain in the back and they have </S1>
<S4> due to arthrosis </S4>
<S1> arthrosis and what happens there if you have the spinal </S1>
<S4> the erm the mhm the mhm </S4>
<S1> what can you see in the x-ray for example </S1>
<S4> er diminishing of the intervertebral disc <S1> yes [the] </S1> [and] the bones are touching each other and there's <S1> [mhm-hm] </S1> [sensibility] in the bone [so] </S4>
<S1> [mhm] and what are at the side like this this type of thing if this is the , disc area you have these small <S3> [mhm yeah] </S3> [bony (spik-)] what are they spikes these osteo- <S4> (osteophytes) </S4> osteophytes yes and they grow and then also when you move and you feel it and they erm can be annoying and they can com- do the compression pain , to the to the nerves because they compress them , and usually what happens with the weight with age </S1>
<S4> diminish [or] </S4>
<S1> [yes] when they are really old but before that </S1>
<S4> maybe they are sen- more (xx) they maybe tend to increase a bit </S4>
<S1> mhm-hm because they have </S1>
<S4> they eat and they don't move </S4>
<S1> mhm-hm yeah because of the back pain and then they become more obese and men drink beer and wine watch TV use car and so on so and then there's er lots of problems so that is more common than any other reason so what were the other osteoporosis of course in elderly ladies especially tho- wh- those who are thin there's er compression fractures even and then what was the third one you were thinking about </S1>
<S4> is there a third (xx) the second </S4>
<S3> @arthrosis arthrosis@ <S4> arthrosis </S4> yes [osteoporosis] </S3>
<S4> [okay] </S4>
<S1> mhm-hm osteoporosis [and then] </S1>
<S4> [maybe] muscular pain some stiffness in the muscles </S4>
<S1> yeah but usually it's always because of the bony changes . usually it's the secondary thing when you have the muscle contraction or spasticity usually you'll always look something and you said already this discus hernia herniation of the disc but that is one thing er of course it's more severe . mhm-hm and how do you interpret the (numbness) and sticking in his legs what is <S4> [ne-] </S4> [the] diagnosis <S4> neuropathy </S4> neuropathy yes . and it could be due to what </S1>
<S4> could be due to er mhm you may check if he is diabetic or not <S1> mhm-hm </S1> or malnutrition and deficiency B12 or [anything] <S1> [mhm-hm] mhm-hm </S1> or circulation just check the peripheric circulation if he's having like some er ischemia or <S1> mhm-hm </S1> maybe er some small degree <S1> [mhm-hm] </S1> [of] of arterial disease which affects er the sensitivity of the [legs and] </S4>
<S1> [mhm-hm can] it be associated with the pain in the back </S1>
<S3> mhm the nerves are compressed </S3>
<S4> [yeah yeah yeah that's right] </S4>
<S1> [mhm-hm yeah] yes if the roots are <S4> [mhm] </S4> [affected] , and you can then see what dermatoma dermatome is affected . so take <NAME S4> the last sentence </S1>
<S4> <READING ALOUD> otherwise he has been healthy and no regular medication </READING ALOUD> </S4>
<S1> what what what does it indicate </S1>
<S4> that no none of these previ- those symptoms we've been talking about have been (developed) </S4>
<S1> mhm-hm , so there was no diabetes there was no B12 deficiency at least known previously okay <NAME S2> what do you say what is your interpretation about the clinical examination the whole thing </S1>
<S2> mhm he's pale </S2>
<S1> mhm-hm <S2> [so] </S2> [pale] could indicate what </S1>
<S2> anaemia erm he has problems to move but he he doesn't have erm lymphnodes and nourishment the p- <S1> yeah </S1> the pulse is normal the lungs also the abdominal palpation also and there is then there's spots in the back especially in the lower back and then the prostate is hard but normal size , and the vibration sensation is diminished in the legs </S2>
<S1> let's er start with the paleness , so it's easy to see from you if you are pale or not but how about the people you a- also in spain you have people wh- who are a bit more coloured how do you see if they're pale </S1>
<S4> ask [family maybe or] </S4>
<S2> [(xx)] </S2>
<S3> [(xx) eyes] </S3>
<S1> mhm-hm so you can try to look from the from the eyes but it's quite unspecific and for here for example you see very pale people <S2> mhm </S2> . you see that they don't they don't look sick but they are pale compared to many other races yes so i- it's sometimes it's racial it's hard to er say who is pale and who is not you have to be really really pale mhm , okay so why did you <NAME S2> why is it important to palpate the lymphnodes </S1>
<S2> mhm because if you have for example lymphoma or infection </S2>
<S4> any cancer </S4>
<S1> [mhm-hm] </S1>
<S2> [yeah] you you wanna see </S2>
<S1> so where what regions <S2> mhm </S2> you should palpate </S1>
<S2> here in the neck <S1> uh-huh </S1> in subclavian area <S1> mhm-hm </S1> er in the axillary <S1> mhm-hm </S1> part the [the groin] </S2>
<S1> [mhm-hm yeah] and where other areas you might see , lymphnodes </S1>
<S2> in the mediastinum <S1> mhm-hm </S1> you see (xx) chest x-ray </S2>
<S1> mhm-hm and where else you see you look for en- enlarged lymphnodes you cannot palpate them but you can visualise them </S1>
<S2> yeah (xx) or something like that </S2>
<S1> where </S1>
<S4> abdomen </S4>
<S1> mhm-hm abdominal region </S1>
<S2> yeah <S1> yes </S1> around [the] </S2>
<S1> [where] are do they locate in abdomen </S1>
<S4> in </S4>
<S2> in the celiac trunk </S2>
<S4> yeah <S1> [mhm] </S1> [in the] (xx) celiac <S1> mhm-hm </S1> like in the (xx) or something like that </S4>
<S1> and para-aortic (gully) <SS> mhm </SS> yes close to the big vessels yes so usually always when you do the ultrasound the radiologists they talk about the lymphnodes and that's important to remember , okay so <NAME S2> what do you say about the cardiovascular status </S1>
<S2> erm it's apparently well <S1> mhm-hm </S1> no relevant findings </S2>
<S1> yes so circulation seems to be fine haemodynamics is compensated haemodynamics okay how about the er abdomen it was we palpate </S1>
<S2> er it was also normal </S2>
<MOBILE PHONE RINGING, P:10>
<S1> so if you palpate abdomen what </S1>
<S3> you can find masses abdominal <S1> mhm </S1> masses in the [abdomen] </S3>
<S1> [oh yes] abnormal masses what else you pay attention to </S1>
<S4> pain tenderness </S4>
<S1> tenderness if the abdomen is tender what else </S1>
<S3> hepatomegalia hepatomegalia </S3>
<S1> hepatomegaly so if liver is enlarged or spleen is enlarged so they should be written er in details so they shou- er they should be mentioned separately so the liver is normal because that's important information if they change in size that could indicate something , okay so er how do you interpret the finding of the back </S1>
<S2> erm tender spots erm he has pain in the back </S2>
<S1> mhm-hm where </S1>
<S2> in the lower part thoracic region </S2>
<S1> so which part can you show to <NAME S3> </S1>
<S2> mhm er here here [here] </S2>
<S1> [mhm-hm] so TH what , TH </S1>
<S2> one </S2>
<S4> mhm </S4>
<S3> mhm one </S3>
<S1> how many <S2> [(xx)] </S2> [(xx)] mhm-hm so if you have it like the lower thoracic region of the spine so which one was it which number </S1>
<S3> oh mhm </S3>
<S2> ten to 12 </S2>
<S1> ten to 12 yes so if you look at the x-ray picture you should see those and if we think about the these diagnoses which you mentioned <NAME S4> previously what diseases could affect that region , <S4> mhm </S4> the most common diagnosis which you mentioned </S1>
<S4> er prolapses are more common in the lumbar </S4>
<S1> mhm-hm lumbar area , what else <S4> (xx) </S4> mhm-hm so that is more unlikely , that this prolapsus what else arthrosis </S1>
<S4> why not <S1> mhm </S1> why not could be anywhere </S4>
<S1> mhm-hm yeah usually it's either lower or little bit upper part like six seven eight that area in the middle of thoracic </S1>
<S4> so osteoporosis maybe </S4>
<S1> osteoporosis could be yes that is something <P:06> and what else so it's a bit unusual area , so you should keep in mind </S1>
<S2> if you have a malignancy for example in this abdominal area [(xx) metastasises] <S1> [uh-huh] yeah </S1> so it's there </S2>
<S1> yes so osteolytic metastasises could be one reason , or of course you could have , not metastasis but </S1>
<S2> er leukaemia </S2>
<S3> if your pain from (xx) abdomen or something like <S1> mhm </S1> if you have pancreatitis or something the pain can be </S3>
<S1> can reflect <S4> [mhm] </S4> [yes] it may be a reflection but if we think about local changes what could affect locally </S1>
<S4> maybe a tu- bone tumour </S4>
<S1> bone tumour yes or , what is inside there </S1>
<S4> spinal cord </S4>
<S1> the spinal cord can you have tumours <S4> [yes] </S4> [there] yes you can have a er malignancy in that area and also , what is more common , like arthritis type of thing which could affect [thoracic] </S1>
<S4> [compression] like you said compression of roots yeah </S4>
<MOBILE PHONE RINGING>
<S1> mhm-hm , yeah but what is the inflammatory process which may affect </S1>
<S4> myelitis <S1> mhm </S1> myelitis </S4>
<S1> myelitis </S1>
<S4> spondylisis </S4>
<S1> spondylitis <P:07> so especially like erm your from your remember from the rheumatology have you studied rheumatology yet </S1>
<S4> not at all </S4>
<S1> yes so you have this er spondylarthritis deformans which is like a seroneg- negative rheumatoid arthritis type of thing which affects men and young men and can make them stiff and usually it affects and also this morbus scheuermann may give you some symptoms and later on is affecting (xx) okay but this is a bit uncommon area , mhm-hm so does it affect the er nerves <NAME S2> </S1>
<S2> mhm yeah because he has the vibration sensation diminished </S2>
<S1> mhm-hm so what does it indicate , why you lose vib- vibration </S1>
<S2> maybe he has some compression in the nerves and erm </S2>
<S1> mhm-hm , okay find out for the for the wednesday why the vi- vibration sensation is diminished what does it indicate </S1>
<S3> and the (xx) also you [could] </S3>
<S1> [yeah] we know that it's er it can be metabolic but can be can it be related to where do you sensate the vibration which fibres are involved <P:09> so <NAME S3> now your turn to analyse the the lab results </S1>
<S3> so mhm sedimentation (xx) improves </S3>
<S1> mhm-hm <S3> [so] </S3> [so] normal is what [is normal] </S1>
<S3> [it was] erm i can't remember it was like CRP (or something) [(or something is) normal] </S3>
<S1> [mhm-hm mhm-hm] depends little bit on the method but at least the (xx) they are up to ten <S3> mhm-hm </S3> you can read from there behind the back th- the pages so </S1>
<S3> from CRP (there is also a) big increase 13 <S1> mhm-hm </S1> and (xx) decrease and haematocrit and (xx) also <S1> mhm-hm </S1> MC8 and MCV er are normal so it's like chromo- (xx) chromo- (xx) <S1> mhm-hm </S1> and the leukocytes are er normal <S1> mhm-hm </S1> thrombocytes also are normal </S3>
<S1> mhm-hm so that indicates that what lines are </S1>
<S3> there's just one line affected [yeah] </S3>
<S1> [mhm-hm] yes so other myeloid lines are normal yes </S1>
<S3> from these albumin sticks is the the urine is positive but i'm not sure what does that [what does it mean] </S3>
<S4> [i guess albumin] proteins [maybe] </S4>
<S3> [ah albumin proteins] </S3>
<S1> [mhm-hm] mhm-hm <S3> okay </S3> like for example the diabetic patients the you can just study the albumin <S3> mhm-hm </S3> yeah </S1>
<S3> erm creatine is (xx) a bit increased </S3>
<S1> so what does it indicate </S1>
<S3> that the kidney isn't working [properly] </S3>
<S1> [mhm-hm] so [the problem is kidney] </S1>
<S3> [and there's there's albumin] also in the </S3>
<S1> and what is the most common reason to have slightly increased creatinine value in elderly people why the kidney starts to </S1>
<S4> atherosclerosis </S4>
<S1> atherosclerosis yes the because of the circulation but then of course usually you don't have proteinuria related to the vascular unless you have vasculitis where er where the vessels start to leak and then you have <NAME S2> what do you have then if you have vasculitis in urine you see </S1>
<S2> er haemoglobin </S2>
<S1> haemoglobin yes haematuria mhm-hm </S1>
<P:06>
<S4> so the the proteinuria is common with with erm with the atherosclerotic disease or [in] </S4>
<S1> [no] no usually they are n- usually it's a <COUGH> crea- function of the creatinine . but usually the glomerulus they start leaking <SOMEONE ENTERS THE ROOM> hello </S1>
<SU> hello <S2> hello </S2> don't want (xx) <S1> yeah yeah </S1> yeah just go ahead <S1> yes [we do] </S1> [go on] go on </SU>
<S4> so what kind of what does it mean the the this proteinuria </S4>
<S1> where does the protein come from </S1>
<S4> from blood </S4>
<S1> yes but if you think about the kidneys </S1>
<S4> from the glomeru- glomerulus </S4>
<S1> usually from the glomerulus because the filtration starts leaking and the protein goes through second area is what <S4> tubules </S4> tubules yes because y- that you see commonly when you have acute tubular necrosis or interstitial nephritis or (xx) nephritis so there will be like small amounts of of protein but if you have large amounts of protein it's usually always because of the glomerulus yes </S1>
<S3> mhm calcium is also increased </S3>
<S1> mhm-hm so now you have hyper- <S3> calcaemia </S3> hypercalcaemia and that rings a bell at least <NAME S4> should ring a bell what are are the different di- diagnostics of hypercalcaemia [the] </S1>
<S4> [para-] parathyroidism [hypoparathyroidism] </S4>
<S1> [parathyro-] hypoparathyroidism what else </S1>
<S4> mhm <P:06> [mhm] </S4>
<S3> [osteoporosis] also er </S3>
<S1> osteoporosis what do you say <NAME S4> </S1>
<S3> [er maybe (xx)] </S3>
<S4> [bone] mhm <S1> no </S1> bone destruction [mhm-hm] </S4>
<S1> [mhm-hm] bone destruction <P:08> because of the big fracture or </S1>
<S4> or metastasis [or osteolytic processes] </S4>
<S1> [mhm or metastasis] osteolytic pro- yes processes <P:07> okay so everybody should know different diagnostics of hypercalcaemia , important thing because that usually affects bones mhm-hm , but what do you say <NAME S3> about the alkaline phosphatase </S1>
<S3> it is normal </S3>
<S1> is normal <COUGH> . so what does it exclude </S1>
<P:08>
<S3> mhm problems in the pancreas or in the </S3>
<S1> yes alkaline phosphatase may also come from , bioducts <S3> mhm </S3> mhm-hm or <S4> bone </S4> bones or , also from intestine <SS> mhm </SS> but yeah the major fragment is is from the bone like er mass-wise </S1>
<S4> so apparently there's no bone destruction what does it mean then can you rule out bone destruction with a normal serum alkaline phosphatase </S4>
<S1> no but for example if you have osteoporosis do you have then increased alkaline phosphatase , you have studied that recently </S1>
<S4> mhm i think alkaline phosphatase is in er er regu- in regulation of bone <S1> [mhm-hm] </S1> [in osteo-] osteoclast and osteoclast is working <S1> mhm </S1> and osteoporosis is l- like a lack of bone mass <S1> [mhm mhm] </S1> [destruction so] maybe it's increasing <S1> [no] </S1> [no] normal </S4>
<S1> no it's normal yes so you can see the next line what does it indicate </S1>
<S3> mhm alright as where the osteoporosis is visible in the thoracic thoracic region (similar) vertebrae are always the same but non-destructive </S3>
<S1> so what was your diagnosis from there <P:07> so they took the x-ray thorax x-ray or especially thoracic spine . so what [did they see] </S1>
<S3> [(line 73)] </S3>
<P:06>
<S1> what did they see there </S1>
<S3> mhm , so there is like arthrosis th- there <S1> no [because] </S1> [or] osteoporosis [because there's (xx)] </S3>
<S1> [osteoporosis] so what does it indicate what was <NAME S4> osteoporosis </S1>
<S4> w- what do you mean </S4>
<S1> osteoporosis can you explain the girls what does it mean </S1>
<S4> bone destruction loss of bone mass </S4>
<S1> loss of bone mass it's not mineralisation of the bone but the bone mass decreases so if you see that in x-ray <NAME S4> what does it indicate </S1>
<S4> it's quite quite erm quite severe </S4>
<S1> quite severe yes because what is more sensitive where you s- can see the early phase of the osteoporosis </S1>
<S4> those the scans of the bone <S1> mhm-hm </S1> bone [densitometry] </S4>
<S3> [exactly] [yeah] </S3>
<S1> [yes] densitometry is more sensitive . so they are web-shaped they are like er compressed but they are not destructed . <COUGH> so there are changes and of course osteoporosis in male or in what does it is it a common thing </S1>
<S3> no it's not common at all </S3>
<S1> mhm-hm so you should find the reason for the osteoporosis and different diagnostics of the osteoporosis <NAME S4> in male <S4> mhm </S4> what are the risk factors </S1>
<S4> PDH high PDH <S1> mhm-hm </S1> may destruct the the bone <S1> mhm-hm </S1> hypoparathyroidism (of the bone) </S4>
<S1> yeah but that was <S4> mhm </S4> PDH yes what else <S4> mhm </S4> <COUGH> you remember the case two </S1>
<S4> erm yeah <S1> mhm-hm </S1> mhm , mhm . mhm </S4>
<S1> what did he do he was a [worker] </S1>
<S4> [carrying] carrying and carrying <S1> mhm </S1> he was ca- he was a worker a painter <S1> mhm-hm </S1> carrying hard and heavy er heavy weight </S4>
<S1> mhm-hm heavy loads in the in the [(xx)] </S1>
<S4> [er low-calcium] diet </S4>
<S1> low-calcium diet [because] </S1>
<S4> [family] osteoporosis </S4>
<S1> er family [history] </S1>
<S4> [because] there's a her- there can be a hereditary component </S4>
<S1> mhm-hm yes hereditary thing low-calcium diet what else did he do , what was hils- his lifestyle </S1>
<S4> mhm smoker </S4>
<S1> he was [a smoker] </S1>
<S4> [alcoholism] </S4>
<S1> he was drinking quite often what else <P:06> was he exercising </S1>
<S4> no so er lack of exercise lack of movement </S4>
<S1> but he was was working hard eight day- eight eight hours a day <SS> mhm </SS> so he was working , and what hormones affect bone [structure] </S1>
<S4> [it's mostly] estrogens <S1> mhm-hm so </S1> androgens </S4>
<S1> androgens testosterone </S1>
<S4> and corticoids also they may cause </S4>
<S1> yeah yeah so quite many things <ORGANISING PAPERS, P:10> okay that's to start with so you can find out then why some malignancies cause osteolytic processes </S1>
<S3> erm electrocytes are aggregating in growth </S3>
<S1> mhm-hm <P:07> what is causing the , <COUGH> aggregation <P:09> mhm you find out for the wednesday if you don't know <S3> mhm </S3> okay so one more there are some additional information . next page what er or how do you interpret these numbers or results </S1>
<S4> mhm <P:06> these are electropho- urine protein electrophoresis or </S4>
<S1> mhm-hm the first one <S4> so </S4> second one is zero </S1>
<S4> so we start with zero maybe <S1> okay </S1> , so albumin is quite high which is normal but then gammaglobulin are really high that's very a- abnormal </S4>
<S1> so what do you say what did you say about albumin </S1>
<S4> it's high er i don't know er the </S4>
<S3> no </S3>
<S1> [what is the normal rate] </S1>
<S4> [oh okay] </S4>
<S3> [this is] the normal level </S3>
<S4> (xx) the albumin somewhere <S3> mhm </S3> this is , this is normal rate or not </S4>
<S3> i think this is the normal level </S3>
<S1> [it says <FOREIGN> (xx) </FOREIGN> in finnish] </S1>
<S3> [it is re- reaching 35] [(er 55)] </S3>
<S4> [and so it was] it was a normal rate </S4>
<S3> [yeah] </S3>
<S1> [yeah] <S4> yeah </S4> so here you can see that the what is the major fraction of the proteins in the bloodstream </S1>
<S4> the albumin <S1> yes </S1> [and some] </S4>
<S1> [so you can] see there's this huge amount and also how d- how do these differences in size when you run the electrophoresis , what's the difference of their sizes the different proteins <S4> well the </S4> the electrophoresis [how you] </S1>
<S4> [yeah albumin] is the highest always <S1> highest </S1> the high peak and then the rest have a smaller </S4>
<S1> yeah but w- how about the size of the molecules </S1>
<S4> the size albumin is quite high molecule er quite big <S1> [no] </S1> [or not] small <S1> mhm-hm </S1> immo- immunoglobulins are the biggest maybe [i i think so] </S4>
<S1> [where do they go] where do they run globulins immunoglobulins <S4> where </S4> where which fragment </S1>
<S4> ah the gammaglobulin <S1> gammaglobulin </S1> er and also some in in beta some IGAs <S1> [mhm-hm] </S1> [or not] IGG IGM are in in the gammaglobulin <S1> [mhm-hm] </S1> [but] some one of them IGA maybe was in the other </S4>
<S1> IGA is [big] </S1>
<S4> [or] IGE [or] </S4>
<S3> [mhm] </S3>
<S1> it's a big molecule [actually] </S1>
<S4> [there was] one of them that wasn't there <S3> [yeah] </S3> [the] mhm , so ba- basically in the gammaglobulin </S4>
<S1> mhm-hm well find out which one is is running somewhere else so the smallest fragments like albumin comes first and then you have er alpha- beta- gammaglobulins and gammaglobulins include immunoglobulins they're big compounds but usually what do these alpha- and [betaglobulins] </S1>
<S4> [yeah in the] in the V2 it's the the IGA <S1> AGA </S1> IGA is in the V2 B- B- B- sorry beta-two </S4>
<S1> beta-two [yeah so close] </S1>
<S4> [and the rest of] the globulins are in the gamma [(xx)] </S4>
<S1> [mhm so close by] what is alpha usually alpha-fractions </S1>
<S4> they're (xx) </S4>
<S1> mhm-hm so they include <S4> (xx) or </S4> (xx) proteins yes so you may have monoclonal increase or . what type of increase in gammaglobulins you may have monoclonal or <S4> polyclonal </S4> polyclonal and a polyclonal increase you see where which diseases where you have [incre-] </S1>
<S4> [infections] <S1> mhm </S1> infections </S4>
<S1> yes that might but commonly in , liver diseases <S3> mhm </S3> do you remember , where you have a increase in immunoglobulin M </S1>
<S4> those liver (those cir- er) biliary [cirrhosis or] </S4>
<S1> [mhm-hm mhm-hm] and how where do you ha- where do you see IGG and IGA increased common disease </S1>
<P:05>
<S4> sorry </S4>
<S3> [IGG] </S3>
<S1> [where] IGG and IGA increase a big group of people we have seen at the ward many , who would be unemployed <S3> [alcoholics] </S3> [if they w-] yes alcoholics so who have liver disease usually those increase , okay but if you see this type of thing what is your impression <NAME S4> if you see this kind of zero protein fraction </S1>
<S4> er it's abnormal <S1> mhm </S1> it's abnormal </S4>
<S1> yeah yeah yeah but er </S1>
<S4> er i i may say haem- er i may (r- rule to) haematological malignancy </S4>
<S1> yeah but so w- what fragment is increased <S4> the gammaglobulin </S4> gammaglobulin and does it look like polyclonal or monoclonal </S1>
<S4> i don't know i've never seen the i don't know [was] </S4>
<S1> [in] the real life </S1>
<S4> yeah so i can't distinguish i don't know if i- there is [a difference] </S4>
<S1> [but] if the IGA is here in beta-two <S3> yeah </S3> so you should see it's like a pyramid like of thing if it's polyclonal because you have all kinds of everything but usually this type of peak indicates a monoclonal increase of the protein fraction and then what is the next step how do you want to , proceed </S1>
<S4> so it looks monoclonal yes </S4>
<S1> yes but how if you want to know which one is increased </S1>
<S4> mhm i don't know how do you measure the i know that electrophoresis is specific for globulins [mhm] </S4>
<S1> [how] do you how do you try to find out that how how do you like erm study them in , details </S1>
<S4> immunofluorescence <S1> mhm-hm </S1> (xx) [or] </S4>
<S1> [mhm-hm] immunofixation and study that because it's important for you to know because they're usually saying that in their results so so they presume they may ask you if you want to characterise that in details . usually they perform the immunoelectrophoresis let's see how it's done if you have forgotten that from the your course of immunology <COUGH> . so you can quantitate it and you can see it's ats- as much as or even more than er than albumin so . sometimes the amount of albumin then decreases dramatically and if we go to this urinary analysis , so what do you think about that , how do you interpret does it look normal <P:08> it says that is important that it says that the total amount of <P:06> total amount of protein in urine was </S1>
<S4> increased there was proteinuria </S4>
<S1> how much was it </S1>
<S4> 20 milligrams [per litre] </S4>
<S1> [20] milligrams per litre mhm-hm how much it's normally </S1>
<S4> three five from three to five or </S4>
<S3> (xx) </S3>
<S1> from three to five milligrams <P:06> this is er 24 hours , so it's point , so it's 40 milligrams how much is normal <NAME S2> do you remember less than </S1>
<S2> i don't know </S2>
<S1> less than , 200 300 depends w- [so not that] </S1>
<S4> [200] less than 200 milligrams <S1> mhm-hm </S1> is normal <S1> mhm-hm </S1> so this is normal </S4>
<S1> mhm-hm the total amount is normal but how does it look like </S1>
<S4> but there was er in the drug in the urinestick there wa- it was positive , ho- the albusticks </S4>
<S1> mhm-hm was positive </S1>
<S4> so how if it's normal the amount of proteins why is it positive </S4>
<S1> there is some albumin det- or detection rate of that sticks do you know , how much do you should have albumin in urine that it that <S2> the stick </S2> stick detects it </S1>
<S4> depends on the stick i think the normal ones like er quite high but (xx) that it could detect (the matter in the urea) </S4>
<S1> mhm so see what is the range that they can detect because that depends on the method but you can see that this is more sensitive because you you need to have (xx) because they are interested in what's coming out and what do you see . what is coming out , what is the main fracture </S1>
<S3> the gamma </S3>
<P:07>
<S1> mhm-hm gammaglobulins <S3> mhm </S3> <P:06> so those big big fragments are coming out so m- like it it's looks massive but of course er total amount is not so high <P:07> but it's not causing because if you have er a lot of protein coming out then you would expect that it it causes , nephrotic syndrome but then the patient didn't have it mhm so quite small amounts as such <P:10> okay [so are the] </S1>
<S4> [but he- he-] here in the in the book it's like </S4>
<S1> what do they say </S1>
<S4> proteins normal in urine from 60 to 80 gram per litre <S3> milligrams </S3> grams </S4>
<S3> (xx) three grams [or whatever] </S3>
<S1> [mhm-hm mhm] mhm what does it say </S1>
<S4> 60 er f- from 60 to 80 grams </S4>
<S1> 60 to 80 grams <S4> yeah </S4> per day <S4> per litre </S4> per litre but there er now it's like erm , per day <COUGH> or in this milligram per litre , mhm-hm </S1>
<S4> so i don't understand it </S4>
<S1> so it's a low amount total amount is low </S1>
<P:07>
<S4> so a no- a normal should in milligrams it's like 60,000 or </S4>
<S1> so milligrams or </S1>
<S3> [milligrams] </S3>
<S4> [f- from] from 60 to 80 grams per litre so [this is really really low] </S4>
<S3> [that is impossible] i think </S3>
<S4> this is really low </S4>
<S1> no no </S1>
<S3> @it's impossible@ </S3>
<S1> because if you think about it you have like th- if you think that you have many two litres maximum urine that would bring like hu- more than 100 grams and that is a lot because usually if you have more than three grams it's already causing nephrotic syndrome so it must be milligrams <P:07> because e- even less than sometimes it's less than 300 milligrams is still like a normal range because if you run or you have fever or many physiological things may cause slight proteinuria but of course here we are interested what's [coming out] </S1>
<S3> [(300)] milligrams per day is (xx) three [300 milligrams per day] </S3>
<S1> [300 mhm] yeah yeah </S1>
<S3> i don't know (xx) </S3>
<S1> so <NAME S2> can you think of anything else or can you give any conclusions <S2> mhm </S2> about the case what is <NAME S2> your conclusion what do you think this could be , tired old man lost some weight </S1>
<S2> and a lot of pro- er [proteins] </S2>
<S1> [and] high sedimentation rate high protein </S1>
<S2> some inflammatory process or malignancy </S2>
<S1> mhm-hm so do you remember that if you have high sedimentation rate too </S1>
<S2> yeah we have to exclude if it is about (xx) <S1> [mhm mhm] </S1> [myeloma or] temporal arthritis </S2>
<S1> mhm-hm which one would it be </S1>
<S2> myeloma </S2>
<S1> mhm-hm what is myeloma </S1>
<S2> i suppose it's a a cancer of the myeloma [in the spinal] </S2>
<S3> [(xx)] </S3>
<S4> the production of immunoglobulins is it the the is that the le- leukocytes or </S4>
<S1> mhm-hm <S2> lymphocytes </S2> so what happens with the lympho- lymphocytes when they activate they become </S1>
<S4> plasmatic cells </S4>
<S1> plasma cells yes and the plasma cells produce </S1>
<S4> immunoglobulins </S4>
<S1> immunoglobulins and sometimes of course they'd be immunoglobulins or just [fragments] <S4> [(xx)] yeah </S4> mhm <P:06> have you s- ever seen any myeloma patient </S1>
<S4> maybe but not like proper (xx) maybe we were watching some other patient and we saw a myeloma or some [but not] </S4>
<S1> [mhm-hm] mhm-hm . okay so <NAME S4> problems . what should you study </S1>
<S4> you mean that er all kinds of haemato- haematological malignancies </S4>
<SS> @@ </SS>
<S1> okay so leukaemias acute and chronic myeloma , lymphoma mhm-hm , er the basic thing that you should know the symptoms and signs , how to confirm the diagnosis and the main idea of the treatment , so you don't have to know all the cytostatics er -statics in details or classification of different kind of leukaemias but the main things about the procedure , okay because you definitely <COUGH> will see people who have this treatment and you should know about the side effects and interactions and so on with other drugs yes . mhm </S1>
<SOMEONE ENTERS THE ROOM, SU AND S1 CONVERSE IN FINNISH, P:17>
<S1> okay so what we will do today is that we are going to i try to find out if there are any of these sternal punctures or (xx) punctures we go and see those and then you have er you have gone through these cases for haematology on your own (xx) have you <S4> no </S4> studied them </S1>
<S4> which ones </S4>
<S1> cases of haematology they are here so you should know to explain me the <ORGANISING PAPERS> . case A B , C , D , E . have you done any of them </S1>
<S4> no i fo- i forgot </S4>
<S3> yeah @me too@ </S3>
<S4> er we can do it in the lunch time or [mhm] </S4>
<S1> [yeah] you try to <S3> @(xx)@ </S3> yes each of you (read) at least one okay and then we gather here <P:06> so these other cases did you go through with pia </S1>
<S4> yeah (xx) phases </S4>
<S1> er no these (xx) pictures <S4> yeah yeah </S4> okay so we we see the the cases with the anaemia in the afternoon and then i will pr- this is for tomorrow <PASSING HANDOUTS> give the </S1>
<S4> what's that </S4>
<S1> these are the blood pictures </S1>
<S3> the cases yeah </S3>
<S4> one two three four they are different </S4>
<S1> yeah and then if you put here the findings what type of anaemia <S2> [mhm-hm] </S2> [and] what is the diagnosis </S1>
<S4> what's <FOREIGN> sauva </FOREIGN> </S4>
<S1> ah yeah this is the finnish version okay so leukocytes you understand <FOREIGN> sauva </FOREIGN> is the , is it band cell </S1>
<S4> band ah yeah </S4>
<S1> yeah . and <FOREIGN> liuska </FOREIGN> is [neutrophils] </S1>
<S4> [(xx)] . eosinophils basophils monocytes lymphocytes thrombocytes </S4>
<S1> yeah yeah <S3> mhm-hm </S3> okay </S1>
<S4> and BL is like (xx) rate or </S4>
<S1> [blasts] </S1>
<S3> [BL] oh blasts </S3>
<S1> mhm , yeah </S1>
<S4> are blasts like fragments </S4>
<S1> no blasts are like these </S1>
<S3> [blastocytes] </S3>
<S4> [ah blast yeah] </S4>
<S1> [early yes] early phase [yeah] </S1>
<S3> [and] prom </S3>
<S4> prom [promelocytes] </S4>
<S1> [promelocytes] <S3> ah </S3> yeah melocytes these are like er these </S1>
<S4> [metamelocytes] </S4>
<S3> [mhm] </S3>
<S1> early (xx) <S3> yeah </S3> . mhm-hm okay so they are for tomorrow <SS> (xx) </SS> so don't even dream of resting </S1>
