Haematology

Question 1

1. Blood group
   A woman with BO positive blood and her partner with AB positive blood have a
   child together. Which of the following cannot be the child’s blood type?
   A. AB positive
   B. BB positive
   C. AO positive
   D. AA positive
   E. BB negative

Answer 1

D

Question 2

2. Blood transfusion
   A 24-year-old man is involved in a road traffic accident and rushed to accident and
   emergency accompanied by his mother who was unharmed. An examination shows
   severe abdominal injuries, peripheral cyanosis and cold extremities. The doctor on
   call decides a blood transfusion is necessary. The mother thinks the patient is blood
   group B negative but is unsure. The most appropriate blood group to give the
   patient is?
   A. Group O positive blood
   B. Group B positive blood
   C. Group B negative blood
   D. Group O negative blood
   E. Group A negative blood

Answer 2

D

Question 3

3. Epistaxis
   A 16-year-old boy presents to his GP complaining of nosebleeds and bleeding after
   brushing his teeth. He is unsure of how long this has been occurring but decided to
   seek advice after having to continually excuse himself from lessons. On examination
   you notice he has some skin bruises. A blood test shows a prolonged bleeding time
   and activated partial thromboplastin time (APTT), while platelet count and
   prothrombin times are all normal. The most likely diagnosis is:
   A. Von Willebrand disease
   B. Liver disease
   C. Disseminated intravascular coagulation
   D. Congenital afibrinogenaemia
   E. Glanzmann’s thrombasthenia

Answer 3

A

Question 4

4. Painful leg
   A 22-year-old Caucasian woman presents with a 1-day history of a painful right
   leg which is erythematous on appearance and tender on palpation. She states that
   she has had this problem many times in the last few years and her family has also
   suffered from similar problems. Her grandmother died of a pulmonary embolism.
   The most likely diagnosis is:
   A. Antithrombin deficiency
   B. Factor V Leiden mutation
   C. Protein S deficiency
   D. Lupus anticoagulant
   E. Protein C deficiency

Answer 4

B

Question 5

5. Shortness of breath
   A 44-year-old Asian female presents with a two-month history of shortness of
   breath and lethargy. She denies any intolerance to the cold or any changes in her
   weight and on examination appears slightly pale. She states that she has recently
   become a vegetarian. A blood film shows the presence of elliptocytes and blood
   results show the following:
   Haemoglobin 9.9 g/dL
   Mean cell volume (MCV) 75 fL
   Ferritin Low
   The most likely diagnosis is:
   A. Iron deficiency anaemia
   B. Sideroblastic anaemia
   C. Anaemia of chronic disease
   D. Thalassaemia trait
   E. Hereditary elliptocytosis

Answer 5

A

Question 6

6. Malaise (1)
   A 47-year-old teacher complains of difficulty maintaining her concentration at
   work teaching secondary school children. She states that over the last four months
   she has become increasingly tired and easily fatigued. She has noticed it has
   become more difficult for her to lift books, rise from her chair and she has also
   noticed a tingling sensation in her fingers. Examination shows a positive babinski
   sign and absent reflexes. A blood test reveals the following:
   Haemoglobin 10 g/dL
   MCV 103 fL
   The most likely diagnosis is:
   A. Hypothyroidism
   B. Vitamin B12 deficiency
   C. Folic acid deficiency
   D. Liver disease
   E. Alcohol toxicity

Answer 6

B

Question 7

7. Malaise (2)
   A 55-year-old man complains of a 4-week history of general malaise and fatigue,
   he has also noticed his trousers have become more loose fitting. A blood test shows
   the following results:
   Haemoglobin 12 g/dL
   MCV 90 fL
   Platelet count 250 × 109/L
   WBC 10 × 109/L
   Serum iron 10 μmol/L
   Total iron-binding capacity 40 μmol/L
   Serum ferritin 160 μg/L
   The most likely diagnosis is:
   A. Thalassaemia
   B. Iron deficiency anaemia
   C. Anaemia of chronic disease
   D. Macrocytic anaemia
   E. Aplastic anaemia

Answer 7

C

Question 8

8. Fatigue
   A 43-year-old woman suffers from Crohn’s disease. A blood test shows the
   following results:
   Haemoglobin 10.5 g/dL
   MCV 120 fL
   Platelet count 300× 109/L
   The most likely diagnosis is:
   A. Vitamin B12 deficiency
   B. Iron deficiency
   C. Hypothyroidism
   D. Folic acid deficiency
   E. Anaemia of chronic disease

Answer 8

A

Question 9

9. Collapse
   A 45-year-old man collapses at home and is brought to accident and emergency. He
   has a fever at 39.5°C and blood pressure is 90/60 mmHg, although he is in a lucid
   state. Bruises can be seen on his skin which he remembers being present before he
   fell. Blood tests show the patient to have a normocytic anaemia with a low platelet
   count and increased fibrin split products. The most likely diagnosis is:
   A. Warm autoimmune haemolytic anaemia
   B. Cold autoimmune haemolytic anaemia
   C. Paroxysmal nocturnal haemoglobinuria
   D. Disseminated intravascular coagulation
   E. Thalassaemia minor

Answer 9

D

Question 10

10. Microcytic anaemia
    A 23-year-old Asian man presents to his GP complaining of shortness of breath
    following exercise. He has always been a little unfit and decided to start going to
    the gym but noticed that even after 4 weeks he is still quite short of breath. He
    denies any coughing or wheezing and on examination you notice mild pallor but
    the patient says he has always been slightly pale in colour. Investigation results are
    given below:
    Haemoglobin 12 g/dL
    MCV 70 fL
    Serum iron 14 umol/L
    Ferritin 60 ug/L
    Transferrin saturation 35 per cent
    Mean cell haemoglobin 22 pg
    Haemoglobin electrophoresis HbA2 increased
    The most likely diagnosis is:
    A. α thalassaemia trait
    B. Anaemia of chronic disease
    C. β thalassaemia trait
    D. Haemoglobin H disease
    E. Iron deficiency anaemia

Answer 10

C

Question 11

11. Iron store
    A 29-year-old woman complains of a 1-week history of weakness and malaise, she
    has recently become a vegetarian and eats mostly green vegetables and drinks lots
    of tea during the day. She is apyrexial and has a C-reactive protein (CRP) <5. You
    suspect an abnormality of the patient’s iron stores. What is the most appropriate
    investigation to determine iron store levels?
    A. Bone marrow biopsy
    B. Serum ferritin
    C. Serum transferrin
    D. Total iron binding capacity
    E. Serum iron

Answer 11

B

Question 12

12. Peripheral blood smear
    A 60-year-old man presents with abdominal pain and a cupful of haematemesis.
    On examination he is noted to have ascites, hepatomegaly and a very enlarged
    spleen extending to the right iliac fossa. His initial blood tests reveal a
    leukoerythroblastic picture with a haemoglobin of 8, white cell count (WCC) of 3
    and platelets of 120. A diagnosis of myelofibrosis is made. What is most likely to
    be seen on the peripheral blood smear?
    A. Schistocytosis
    B. Sickle cells
    C. Spherocytes
    D. Dacrocytes
    E. Target cells

Answer 12

D

Question 13

13. Blood transfusion complications
    A 65-year-old woman suffers significant bleeding during a difficult bowel resection
    and is prescribed three units of blood after the operation is completed. It is the first
    time she has required a blood transfusion and her details are checked carefully.
    Approximately 4 hours after the transfusion the patient feels acutely unwell and
    complains of fever, chills and a dry cough. Blood pressure is 110/80 mmHg,
    temperature 38°C and oxygen saturation is 94 per cent. The most likely diagnosis is:
    A. Immediate haemolytic transfusion reaction
    B. Febrile non-haemolytic transfusion reaction
    C. Delayed haemolytic transfusion reaction
    D. IgA deficiency
    E. Transfusion-related lung injury

Answer 13

E

Question 14

14. Limb numbness
    A 52-year-old woman presents complaining of a two-month history of increasing
    fatigue and numbness in both of her arms and legs. She lives at home with her
    husband and has found it difficult coping with the daily activities of living. She
    suffers from hypothyroidism which is well controlled with thyroid replacement
    medication. A peripheral blood smear shows hypersegmented neutrophils. A blood
    test reveals the following:
    Haemoglobin 10 g/dL
    Mean corpuscular volume 110 fL
    Platelets 150 × 109/L
    Liver function tests:
    ALT 25 IU/L
    AST 27 IU/L
    GGT 22 IU/L
    ALP 100 IU/L
    Urea 5 mmol/L
    Creatinine 100 μmol/L
    The most likely diagnosis is:
    A. Thrombotic thrombocytopenic purpura
    B. Iron deficiency
    C. Folic acid deficiency
    D. Liver disease
    E. Pernicious anaemia

Answer 14

E

Question 15

15. Bleeding abnormality
    During a busy ward round you are asked to visit a patient the consultant has not
    had an opportunity to see. The only details you are given are that the patient is
    female and was admitted the previous day with bleeding abnormalities, you are
    given the results of her blood investigations:
    Prothrombin time Unaffected
    Partial thromboplastin time Prolonged
    Bleeding time Prolonged
    Platelet count Unaffected
    What is the most likely diagnosis?
    A. Factor V deficiency
    B. Warfarin therapy
    C. Glanzmann’s thrombasthenia
    D. Bernard Soulier syndrome
    E. Von Willbrand disease

Answer 15

E

Question 16

16. Fever
    A 14-year-old girl is brought to clinic by her parents who have been worried about a
    fever the patient has had for the last week. The patient looks pale and unwell. Blood
    tests reveal a neutropenia with normal red blood counts (RBCs) and platelets. A bone
    marrow exam reveals no abnormalities. The patient has been otherwise fit and well.
    There is no organomegaly or lymphadenopathy. The most likely diagnosis is:
    A. Acute myeloid leukaemia
    B. Aplastic anaemia
    C. Acute lymphoblastic leukaemia
    D. Bacterial infection
    E. Thrombotic thrombocytopenic purpura

Answer 16

D

Question 17

17. Pruritus
    A 65-year-old man presents with a chronic history of headaches and occasional
    dizziness. He hesitantly mentions that he experiences severe pruritus, especially
    after hot showers and baths. Blood pressure is 160/85 mmHg. A full blood count
    (FBC) reveals a haemoglobin of 20 g/dL, MCV of 94 fL, platelet count of 470 × 109/L
    and WBC count of 7.8 × 109/L
    The most likely diagnosis is:
    A. Polycythemia vera
    B. Idiopathic erythrocytosis
    C. Essential thrombocythaemia
    D. Myelofibrosis
    E. Chronic myeloid leukaemia

Answer 17

A

Question 18

18. Auer rods
    A 29-year-old woman complains of tiredness, especially during activity. On
    examination the patient appears pale. Auer rods and schistocytes can be seen on
    peripheral blood smear. The patient is referred for a bone marrow biopsy and the
    extracted cells are sent for cytogenetic analysis. The most likely results are:
    A. t(8:21)
    B. t(15;17)
    C. t(9:22)
    D. t(14;18)
    E. t(8;14)

Answer 18

B

Question 19

18. Auer rods
    A 29-year-old woman complains of tiredness, especially during activity. On
    examination the patient appears pale. Auer rods and schistocytes can be seen on
    peripheral blood smear. The patient is referred for a bone marrow biopsy and the
    extracted cells are sent for cytogenetic analysis. The most likely results are:
    A. t(8:21)
    B. t(15;17)
    C. t(9:22)
    D. t(14;18)
    E. t(8;14)

Answer 19

A

Question 20

20. Glucose-6-phosphate dehydrogenase deficiency
    A 27-year-old man presents with increasing tiredness and shortness of breath. A
    macrocytic anaemia with reticulocytes is discovered on blood tests and smear.
    Genetic analysis reveals the patient has glucose-6-phosphate dehydrogenase
    deficiency. What cell type is most likely to have been seen on the blood smear?
    A. Target cells
    B. Pencil cells
    C. Spherocytes
    D. Elliptocytes
    E. Schistocytes

Answer 20

E

Question 21

21. Heinz bodies
    A 33-year-old man travels to South Africa to take part in a safari. On arriving, the
    patient takes his antimalarial tablets. A few days into his course he becomes ill
    complaining of shortness of breath, pallor and bloody urine. Blood tests reveal
    anaemia and reduced haematocrit, while a blood smear shows the presence of
    Heinz bodies. The most likely diagnosis is:
    A. Hereditary elliptocytosis
    B. Glucose-6-phosphate dehydrogenase deficiency
    C. Hereditary spherocytosis
    D. Autoimmune haemolytic anaemia
    E. Microangiopathic haemolytic anaemia

Answer 21

B

Question 22

22. Sickle cell anaemia
    An 18-year-old African man presents with worries about his general health stating
    that hypertension and sickle cell anaemia are present in his family history. The patient
    denies any shortness of breath, chest pain, digit or limb changes. Blood pressure is
    124/77 mmHg. What test would be appropriate to investigate sickle cell anaemia?
    A. Ham’s test
    B. Coombs’ test
    C. Schilling test
    D. Metabisulfite test
    E. Osmotic fragility test

Answer 22

D

Question 23

23. AML and ALL differentiation
    A young patient presents with features of anaemia, neutropenia and
    thrombocytopenia. A large number of blasts are present on bone marrow biopsy.
    Which investigation would help differentiate between acute myeloid leukaemia
    (AML) and acute lymphoblastic leukaemia (ALL)?
    A. Myeloperoxidase stain
    B. Sudan black B
    C. Tartrate-resistant acid phosphatase stain
    D. Leukocyte alkaline phosphatase
    E. Auramine O stain

Answer 23

C

Question 24

24. Polycythaemia rubra vera
    A 47-year-old woman presents complaining of dark stools and painful fingers on
    both hands. She appears plethoric and complains of severe itching, often when she
    is washing. A large liver and spleen is palpable. You suspect features of
    polycythaemia rubra vera and measure red cell mass and erythropoietin levels
    among other tests. Which of the following is likely to be most accurate in this
    patient?
    A. Low erythropoietin and low red cell mass
    B. Normal erythropoietin and normal red cell mass
    C. Raised erythropoietin and low red cell mass
    D. Raised erythropoietin and raised red cell mass
    E. Low erythropoietin and raised red cell mass

Answer 24

E

Question 25

25. Vegetarian patient
    A 29-year-old woman presents complaining of shortness of breath, especially when
    walking up stairs. She is starting to struggle with yoga classes, which were never a
    problem before. She does not suffer from any medical conditions and takes no
    regular medication. On examination there is pallor, heart rate is 90 and blood
    pressure 119/79 mmHg. The patient mentions that she has recently become a
    vegetarian and in the morning only has time for tea before heading to work. Which
    of the following would you expect to be increased in this patient?
    A. Myoglobin
    B. Ferritin
    C. Haemoglobin
    D. Serum iron
    E. Transferrin

Answer 25

E

Question 26

26. Anaemia
    A 65-year-old man presents with a chronic history of malaise, shortness of breath
    and paraesthesia in his hands. He appears tired and pale while speaking and on
    examination his heart rate is 115, respiratory rate 16. A Schillings test is positive
    while blood tests reveal a macrocytic anaemia and a Coombs test is negative. The
    most likely diagnosis is:
    A. Iron deficiency anaemia
    B. Haemorrhage
    C. Anaemia of chronic disease
    D. Pernicious anaemia
    E. Autoimmune haemolytic anaemia

Answer 26

D

Question 27

27. Macrocytic anaemia
    A 47-year-old woman presents to clinic concerned about her recent ill health. She
    has noticed over the last three months that she has been suffering from headaches,
    fatigue and recurrent infections. She notes she has rarely been to the doctor before
    and otherwise leads a healthy lifestyle. She decided to see a doctor when she noticed
    petechial rashes appearing on her arms. On examination there is no organomegaly
    and blood tests reveal an MCV of 105, a pancytopenia with the bone marrow
    appearing hypocellular on biopsy.
    A. Chronic myeloid leukaemia
    B. Myeloproliferative disorder
    C. Aplastic anaemia
    D. Iron deficiency anaemia
    E. Acute lymphoblastic anaemia

Answer 27

C

Question 28

28. Auer rods
    A 65-year-old man presents to you reporting he has become increasingly worried
    about his lack of energy in the last 2 weeks. He mentions he has been increasingly
    tired, sleeping for long periods and has suffered from fevers unresponsive to
    paracetamol. He became increasingly worried when he noticed bleeding orginating
    from his gums. A blood film shows auer rods, hypogranular neutrophils and stains
    with Sudan black B. The most likely diagnosis is:
    A. Acute lymphoblastic leukaemia
    B. DiGeorge syndrome
    C. Disseminated intravascular coagulation
    D. Acute myeloid leukaemia
    E. Afibrinogenaemia

Answer 28

D

Question 29

29. Chronic myeloid leukaemia
    A 70-year-old woman complains of tiredness, fatigue and weight loss. Blood tests
    reveal an elevated WCC and on examination splenomegaly is palpated. Cytogenetics
    are positive for the Philadelphia chromosome and the patient is diagnosed with
    chronic myeloid leukaemia. The most appropriate treatment is:
    A. Hydroxycarbamide
    B. Imatinib
    C. Venesection
    D. Stem cell transplant
    E. Dasatinib

Answer 29

B

Question 30

30. Warfarin therapy
    A 27-year-old woman who suffers from rheumatic mitral stenosis develops atrial
    fibrillation. She is placed on warfarin therapy. What is the most appropriate target
    international normalized raio (INR) range?
    A. <1.0
    B. 1.0–2.0
    C. 2.0–3.0
    D. 3.0–4.0
    E. >5.0

Answer 30

C

Question 31

31. Multiple myeloma
    A 70-year-old woman complains of a dull pain in her lower back, especially when
    bending forwards to lift things. She presents after a severe episode in the last 2
    days. An x-ray reveals a lumbar compression fracture. Blood tests show a
    normocytic anaemia and urine electrophoresis reveals a monoclonal gammopathy.
    A diagnosis of multiple myeloma is made. Which of the following is not a recognized
    cause of multiple myeloma?
    A. High-dose radiation
    B. Human herpes virus-8 (HHV-8)
    C. HIV
    D. Herbecides and insecticides
    E. Hereditary

Answer 31

E

Question 32

32. Hypersplenism investigation
    A 44-year-old woman presents with recurrent fever, pallor, malaise and shortness
    of breath. She has noticed a petechial rash on her skin and small bruises on her
    arms. A blood test reveals a pancytopenia. During examination, you palpate a large
    spleen. Which investigation would differentiate between hypersplenism and aplastic
    anaemia?
    A. Reticulocyte test
    B. Direct Coombs test
    C. Metabisulfite test
    D. Ham’s test
    E. Osmotic fragility test

Answer 32

A

Question 33

33. Pernicious anaemia
    A 66-year-old man presents complaining of a three-month history of weakness,
    tingling in the limbs and a sore tongue. The patient notes an undesired 5 kg weight
    loss over 2 weeks. A peripheral blood smear shows a macrocytic anaemia, a
    Schilling test shows impaired vitamin B12 absorption and a diagnosis of pernicious
    anaemia is made. Which of the following antibodies is most closely associated with
    pernicious anaemia?
    A. Anti-mitochondrial antibodies
    B. Anti-intrinsic factor antibodies
    C. Anti-gliadin antibodies
    D. Anti-centromere antibodies
    E. Anti-smooth muscle antibodies

Answer 33

B

Question 34

34. Leukaemia investigation
    A 5-year-old girl presents with her parents who have become concerned about the
    small petechiae and ecchymoses on her skin. An abdominal examination reveals
    hepatosplenomegaly. You suspect an acute leukaemia. The most appropriate initial
    investigation for diagnosis is:
    A. Chromosomal analysis of bone marrow cells
    B. Cytochemical analysis of bone marrow cells
    C. Direct microscopy of bone marrow cells
    D. Electron microscopy
    E. Flow cytometry

Answer 34

C

Question 35

35. Bence–Jones protein
    A 51-year-old man complains of severe, diffuse back pain. An x-ray finds several
    lytic lesions in the vertebra alongside hypercalcaemia. Bence–Jones protein is
    detected in the urine. What is a Bence–Jones protein?
    A. IgG antibody
    B. IgA antibody
    C. IgE antibody
    D. Light chain
    E. IgM antibody

Answer 35

D