Hematology Practice Questions

Q: ESR is increased in

Multiple myeloma. ***Multiple myeloma*** [1] - **Erythrocyte sedimentation rate (ESR)** is commonly elevated due to inflammatory cytokines and the presence of abnormal proteins affecting blood viscosity [1]. - Patients often present with **bone pain** and can have **hypercalcemia**, which further contributes to an increased ESR [2]. *Thalassemia* - Typically presents with **microcytic anemia** but does not significantly elevate the ESR [3]. - The chronic hemolysis in thalassemia often results in a normal or slightly raised ESR, not markedly increased as seen in malignancies. *Polycythemia vera* - Characterized by excessive red blood cell production, leading to increased blood viscosity, but usually results in a **low or normal ESR**. - The inflammatory response is minimal, and the only changes in ESR are due to viscous blood rather than true inflammation. *Sickle cell anemia* - While patients may experience vasocclusive crises leading to inflammation, the overall ESR is generally normal or only mildly elevated. - The primary issue in sickle cell anemia is the **sickle-shaped red blood cells**, not significant changes in ESR levels [3].

Q: Which of the following is the MOST SIGNIFICANT modifiable predisposing factor for arterial thrombosis?

Cigarette smoking. ***Cigarette smoking*** - **Cigarette smoking** is a major modifiable risk factor for **atherosclerosis** and arterial thrombosis, primarily by promoting endothelial dysfunction, inflammation, and hypercoagulability. [1] - It damages the **endothelium**, leading to plaque formation and increasing the risk of **thrombotic events** such as myocardial infarction and stroke. [1] *Antiphospholipid syndrome* - This is an **autoimmune disorder** causing recurrent arterial and venous thromboses, but it is not a modifiable lifestyle factor. - While it dramatically increases thrombosis risk, therapeutic management focuses on anticoagulation rather than lifestyle modification. *Hyperlipidemia* - **Hyperlipidemia**, particularly elevated LDL cholesterol, is a significant risk factor for **atherosclerosis**, which can lead to thrombosis. [1] - However, while modifiable through diet and medication, its immediate thrombotic impact is often mediated through chronic plaque formation, whereas smoking has more direct prothrombotic effects on endothelium and platelet function. *Homocystinuria* - This is a rare, inherited **metabolic disorder** causing elevated homocysteine levels, leading to severe premature atherosclerosis and **thrombotic disease**. - It is a genetic condition and therefore not a modifiable risk factor in the same way as lifestyle choices.

Q: Which of the following is the most frequent site of thrombus?

Veins of lower extremities. The veins of the **lower extremities** are the most common site for thrombus formation, particularly due to **stasis** during prolonged immobility or conditions like **deep vein thrombosis (DVT)** [1]. These veins are often affected by a combination of factors including **venous stasis**, **endothelial injury**, and **hypercoagulability** (Virchow's triad). *Pulmonary vein* - While thrombosis can occur here, it is primarily associated with **pulmonary embolism** rather than being a primary site of thrombus formation. - Most thrombi in the pulmonary vein originate from **deep veins** in the legs during migration [1]. *Portal vein* - Thrombus formation in the **portal vein** is less common and often associated with specific conditions such as **cirrhosis**, **hypercoagulable states**, or **abdominal infections**. - The frequency of thrombus formation here is lower compared to the **lower extremity veins**. *Hepatic vein* - Hepatic vein thrombosis, also known as **Budd-Chiari syndrome**, is a rare condition and occurs under special circumstances like **liver disease** or **coagulopathy** [1]. - This is not a frequent site compared to the **lower extremities**, where thrombus formation happens much more commonly.

Q: A 40-year-old male presents with weakness, weight loss, and abdominal pain, accompanied by diffuse hyperpigmentation, a palpable liver edge, and polyarthritis of the wrist and hips. His fasting blood sugar level is 185 mg/dl. What is the most likely diagnosis?

Hemochromatosis. ***Hemochromatosis*** - The constellation of **hyperpigmentation**, diabetes (**fasting blood sugar 185 mg/dl**), **polyarthritis**, and **hepatomegaly** (palpable liver edge) is highly characteristic of **hemochromatosis** [1]. - **Iron overload** in hereditary hemochromatosis leads to deposition in various organs, causing organ damage and the classic triad of **bronze diabetes** (hyperpigmentation + diabetes) and **cirrhosis** [1]. *Type I Diabetes Mellitus* - While the patient has **elevated blood sugar**, Type I diabetes is typically an **autoimmune destruction of pancreatic beta cells** and does not cause **hyperpigmentation**, **hepatomegaly**, or widespread **polyarthritis** as primary features. - Onset is usually in childhood or early adulthood, and prominent symptoms often include **polydipsia, polyuria, and weight loss**, without the complex systemic manifestations described. *Pancreatic Carcinoma* - Pancreatic carcinoma can cause **weight loss**, **abdominal pain**, and sometimes **diabetes** due to pancreatic dysfunction. - However, it does not typically present with diffuse **hyperpigmentation**, **polyarthritis**, or significant **hepatomegaly** as described, unless there are widespread metastases to the liver, which would be a later stage phenomenon. *Addison's Disease* - **Addison's disease** (adrenal insufficiency) is characterized by **hyperpigmentation**, **weakness**, and **weight loss**, which align with some symptoms. - However, it does not cause **elevated blood sugar**, **hepatomegaly**, or **polyarthritis**, which are key findings in this patient.

Q: B-cell prolymphocytic leukemia patients differ from those with B-cell chronic lymphocytic leukemia in:

Having a shorter survival. Having a shorter survival - **B-cell prolymphocytic leukemia (B-PLL)** is characterized by a significantly more **aggressive** clinical course and **poorer prognosis** compared to B-cell chronic lymphocytic leukemia (B-CLL). - This aggressive nature leads to a **shorter overall survival** for patients with B-PLL. *Presenting at a younger age* - **B-CLL** typically presents in **older adults**, with a median age of diagnosis around 70 years [1]. - While B-PLL can occur at various ages, it is not consistently associated with a **younger presentation** compared to B-CLL. *Having a lower total leucocyte count* - **B-PLL** is classically associated with a **very high total leukocyte count**, often exceeding 100 x 10^9/L, due to the proliferation of prolymphocytes. - **B-CLL** can also have elevated leukocyte counts, but they are generally **not as dramatically high** as in B-PLL. *Having prominent lymphadenopathy* - **B-CLL** is characterized by prominent and widespread **lymphadenopathy** and **splenomegaly** [1]. - While B-PLL can involve lymph nodes and spleen, it often presents with **massive splenomegaly** and **less prominent lymphadenopathy** in comparison to B-CLL [1].

Q: Which of the following methods can be used to prevent graft-versus-host disease in bone marrow transplantation?

All of the options. ***All of the options*** - **T-cell removal** from the donor marrow significantly reduces the number of alloreactive T-cells that can cause GVHD. - **Prior immunosuppression** prepares the recipient's immune system to reduce graft rejection, while **post-procedure immunosuppression** helps manage any remaining alloreactive cells [1]. *T-cell removal* - This method directly targets the cells primarily responsible for initiating **graft-versus-host disease (GVHD)**. - While effective, it can also increase the risk of **graft failure** and **leukemic relapse** due to the loss of graft-versus-leukemia effects. *Post procedure immune suppression* - Administering **immunosuppressive drugs** after transplantation helps to suppress the recipient's immune response and prevent donor immune cells from attacking recipient tissues [1]. - Common regimens include **cyclosporine**, **methotrexate**, or **tacrolimus**, which are tapered over time to minimize side effects [2, 3]. *Prior immune suppression* - Suppressing the **recipient's immune system** before transplantation helps to create an environment where the donor cells are less likely to be rejected and reduces recipient T-cell mediated responses against the graft [1]. - This is typically part of the **conditioning regimen** given before the bone marrow infusion.

Q: Which of the following is least likely to cause iron deficiency anemia?

Excess of meat in the diet. ***Chronic blood loss*** - Chronic blood loss is a **significant cause** of iron deficiency anemia as it depletes iron stores over time [1]. - Conditions such as **peptic ulcers** or heavy menstrual bleeding can lead to significant blood loss, contributing to anemia [1], [2]. *Achlorhydria* - Achlorhydria refers to the **absence of stomach acid**, which can impair iron absorption, potentially leading to deficiency. - It is important but is **not a direct cause** of anemia, rather a contributing factor. *Excess of meat in the diet* - A diet high in meat actually provides **heme iron**, which is readily absorbed and can prevent deficiency rather than cause it [2]. - Iron deficiency is more likely in diets **low in meat** or in vegetarians unless iron supplements are included. *Extensive surgical removal of the proximal small bowel* - This can lead to **malabsorption** of nutrients, including iron, thus contributing to iron deficiency anemia indirectly [2]. - However, it can also cause deficiencies in other nutrients, not solely related to iron.

Q: Microcytic anemia is not typically associated with which of the following conditions?

Leukopenia. Leukopenia - **Leukopenia** is a decrease in white blood cell count and is not directly associated with the pathogenesis of microcytic anemia. - While both can occur in certain systemic conditions (e.g., bone marrow suppression), leukopenia itself does not cause or result from a microcytic anemia. *Osteomyelitis* - **Osteomyelitis**, a bone infection, can lead to **anemia of chronic disease**, which often manifests as a normocytic, normochromic anemia but can become microcytic over time due to impaired iron utilization [1]. - Inflammation in osteomyelitis can cause a functional iron deficiency, leading to smaller red blood cells [1]. *Papillary necrosis* - **Papillary necrosis** is a renal condition often associated with chronic analgesic abuse, sickle cell disease, or diabetes. - It can cause **renal failure** or chronic kidney disease, which is a common cause of **anemia of chronic disease**, sometimes presenting as microcytic initially or upon progression [1], [2]. *Rheumatoid arthritis* - **Rheumatoid arthritis** is a chronic inflammatory disorder that frequently causes **anemia of chronic disease** [3]. - This type of anemia is typically **normocytic**, but with prolonged severe inflammation, it can evolve into a **microcytic** and hypochromic anemia due to altered iron metabolism [1], [2].

Q: A 65-year-old retired accountant with a 60-pack-year smoking history presents for his annual physical examination, having been previously seen 3 years ago for acute bronchitis. He reports coughing for several months with productive green sputum, but denies dyspnea or daily activity limitation. On examination, his blood pressure is 126/62 mm Hg, pulse is 80/min, and respirations are 24/min, with diffuse bilateral expiratory rhonchi and a prolonged expiratory phase. Cardiac examination reveals a second heart sound that increases in intensity with inspiration, and the liver edge is 14 cm into the midclavicular line, being mildly tender to palpation. Bilateral lower extremity edema is present to the knees. Chest x-ray film shows hyperinflation of both lung fields, and pulmonary function tests reveal a diminished FEV1/FVC ratio. Routine laboratories are sent. Which of the following would most likely be expected?

A hemoglobin of 17 g/dL. ***A hemoglobin of 17 g/dL*** - Chronic **hypoxia** from chronic obstructive pulmonary disease (COPD) leads to increased **erythropoietin** production, stimulating the bone marrow to produce more red blood cells, resulting in a **compensatory polycythemia** (high hemoglobin/hematocrit) [1]. - The patient's presentation with a long history of smoking [2], productive cough, rhonchi, prolonged expiratory phase, hyperinflation, and diminished FEV1/FVC ratio is highly indicative of **COPD**, which often leads to chronic hypoxemia [1]. *A hemoglobin of 9 g/dL* - A hemoglobin of 9 g/dL indicates **anemia**, which is not a typical compensatory mechanism for chronic hypoxia in COPD; rather, the body attempts to increase oxygen-carrying capacity. - While patients with chronic diseases can develop anemia, in the context of chronic hypoxia from COPD, **polycythemia** is a more expected finding as a compensatory response [1]. *A platelet count of 84,000* - A platelet count of 84,000 indicates **thrombocytopenia**, a low platelet count, which is not directly associated with the pathophysiology of COPD or its compensatory mechanisms. - Thrombocytopenia can be caused by various underlying conditions, but there is no information in the vignette to suggest such a disorder. *A platelet count of 102,000* - Similar to the previous option, a platelet count of 102,000 also indicates **thrombocytopenia**, which is not a characteristic finding or expected complication related to COPD. - COPD primarily affects the respiratory system, and while it can have systemic effects, a low platelet count is not a typical presentation in this scenario.

Q: A 15-year-old female presented to the emergency department with a history of recurrent epistaxis, hematuria, and hematochezia. There was a history of profuse bleeding from the umbilical stump at birth. Previous investigations revealed normal prothrombin time, activated partial thromboplastin time, thrombin time, and fibrinogen levels. Her platelet counts as well as platelet function tests were normal, but the urea clot lysis test was positive. Which clotting factor is most likely to be deficient?

Factor XIII. ***Factor XIII*** - A positive **urea clot lysis test** indicates deficiency of factor XIII, which is responsible for stabilizing the **fibrin clot**. - **Recurrent bleeding** from various sites, including the umbilical stump, with normal standard coagulation tests (PT, aPTT, TT, fibrinogen, platelet count, and function) is characteristic of factor XIII deficiency. *Factor X* - Deficiency of factor X would lead to abnormal **PT and aPTT**, as it is involved in both the intrinsic and extrinsic pathways, which is not the case here [1]. - Patients typically present with **severe bleeding manifestations**, and routine coagulation tests would be prolonged. *Factor XI* - Factor XI deficiency primarily causes an abnormally **prolonged aPTT**, as it is part of the intrinsic pathway, which is normal in this patient [1]. - Bleeding symptoms can be variable, but it does not specifically present with a **positive urea clot lysis test**. *Factor XII* - Factor XII deficiency causes a markedly prolonged **aPTT** [1] but is usually **asymptomatic** and not associated with significant bleeding. - It would not result in a **positive urea clot lysis test** or the severe bleeding symptoms described.

Question 1

ESR is increased in

Accepted Answer

Multiple myeloma

Answer

Polycythemia

Answer

Thalassemia

Answer

Sickle cell disease

Question 2

Which of the following is the MOST SIGNIFICANT modifiable predisposing factor for arterial thrombosis?

Accepted Answer

Cigarette smoking

Answer

Antiphospholipid syndrome

Answer

Hyperlipidemia

Answer

Homocystinuria

Question 3

Which of the following is the most frequent site of thrombus?

Accepted Answer

Veins of lower extremities

Answer

Portal vein

Answer

Pulmonary vein

Answer

Hepatic vein

Question 4

A 40-year-old male presents with weakness, weight loss, and abdominal pain, accompanied by diffuse hyperpigmentation, a palpable liver edge, and polyarthritis of the wrist and hips. His fasting blood sugar level is 185 mg/dl. What is the most likely diagnosis?

Accepted Answer

Hemochromatosis

Answer

Type I Diabetes Mellitus

Answer

Pancreatic Carcinoma

Answer

Addison's Disease

Question 5

B-cell prolymphocytic leukemia patients differ from those with B-cell chronic lymphocytic leukemia in:

Accepted Answer

Having a shorter survival

Answer

Presenting at a younger age

Answer

Having a lower total leucocyte count

Answer

Having prominent lymphadenopathy

Question 6

Which of the following methods can be used to prevent graft-versus-host disease in bone marrow transplantation?

Accepted Answer

All of the options

Answer

T-cell removal

Answer

Post procedure immune suppression

Answer

Prior immune suppression

Question 7

Which of the following is least likely to cause iron deficiency anemia?

Accepted Answer

Excess of meat in the diet

Answer

Chronic blood loss

Answer

Achlorhydria

Answer

Extensive surgical removal of the proximal small bowel

Question 8

Microcytic anemia is not typically associated with which of the following conditions?

Accepted Answer

Leukopenia

Answer

Osteomyelitis

Answer

Papillary necrosis

Answer

Rheumatoid arthritis

Question 9

A 65-year-old retired accountant with a 60-pack-year smoking history presents for his annual physical examination, having been previously seen 3 years ago for acute bronchitis. He reports coughing for several months with productive green sputum, but denies dyspnea or daily activity limitation. On examination, his blood pressure is 126/62 mm Hg, pulse is 80/min, and respirations are 24/min, with diffuse bilateral expiratory rhonchi and a prolonged expiratory phase. Cardiac examination reveals a second heart sound that increases in intensity with inspiration, and the liver edge is 14 cm into the midclavicular line, being mildly tender to palpation. Bilateral lower extremity edema is present to the knees. Chest x-ray film shows hyperinflation of both lung fields, and pulmonary function tests reveal a diminished FEV1/FVC ratio. Routine laboratories are sent. Which of the following would most likely be expected?

Accepted Answer

A hemoglobin of 17 g/dL

Answer

A platelet count of 84,000

Answer

A platelet count of 102,000

Answer

A hemoglobin of 9 g/dL

Question 10

A 15-year-old female presented to the emergency department with a history of recurrent epistaxis, hematuria, and hematochezia. There was a history of profuse bleeding from the umbilical stump at birth. Previous investigations revealed normal prothrombin time, activated partial thromboplastin time, thrombin time, and fibrinogen levels. Her platelet counts as well as platelet function tests were normal, but the urea clot lysis test was positive. Which clotting factor is most likely to be deficient?

Accepted Answer

Factor XIII

Answer

Factor XII

Answer

Factor X

Answer

Factor XI

Hematology — MCQs

Hematology — MCQs

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