Hematology Practice Questions

Q: Which of the following is NOT part of the ABVD regimen for chemotherapeutic treatment of Non-Hodgkin's Lymphoma?

Vincristine. The **ABVD regimen** is the gold standard first-line chemotherapy for **Hodgkin Lymphoma (HL)** [1]. The question asks which drug is NOT part of this regimen in the context of Non-Hodgkin's Lymphoma (NHL). ### **Explanation of the Correct Answer** **D. Vincristine** is the correct answer because it is not a component of the ABVD regimen. Vincristine is, however, a key component of the **CHOP** or **R-CHOP** regimens, which are the standard treatments for **Non-Hodgkin Lymphoma (NHL)** [1]. It is also part of the older MOPP regimen for Hodgkin Lymphoma. ### **Analysis of Incorrect Options** The acronym **ABVD** stands for: * **A: Adriamycin (Doxorubicin):** An anthracycline that inhibits topoisomerase II. (Option A) * **B: Bleomycin:** A glycopeptide antibiotic that causes DNA strand breaks. (Option C) * **V: Vinblastine:** A microtubule inhibitor (vinca alkaloid). Note that while Vincristine and Vinblastine are in the same class, they are not interchangeable in this regimen. * **D: Dacarbazine:** An alkylating agent. (Option B) ### **Clinical Pearls for NEET-PG** * **Regimen Distinction:** Remember **ABVD for Hodgkin Lymphoma** and **CHOP for Non-Hodgkin Lymphoma**. * **Specific Toxicities (High Yield):** * **Doxorubicin:** Dilated Cardiomyopathy (monitor with ECHO/MUGA scan). * **Bleomycin:** Pulmonary Fibrosis (monitor with Pulmonary Function Tests/DLCO). * **Vinblastine:** Bone marrow suppression (unlike Vincristine, which is more neurotoxic). * **Vincristine:** Peripheral neuropathy and paralytic ileus. * **Historical Note:** ABVD replaced the MOPP regimen because it has a lower risk of causing secondary leukemia and sterility.

Q: Which of the following statements is true regarding oral therapy for iron deficiency anemia?

Absorption of iron decreases as symptoms improve.. The correct answer is **D: Absorption of iron decreases as symptoms improve.** **1. Why Option D is Correct:** Iron absorption is a tightly regulated physiological process. In iron deficiency anemia (IDA), the body’s iron stores are depleted, leading to a downregulation of **hepcidin** (the master regulator of iron). Low hepcidin levels allow for maximal absorption of iron through the ferroportin channels in the duodenum [1]. As oral therapy progresses and hemoglobin levels/iron stores normalize, hepcidin levels rise, which subsequently inhibits ferroportin and **decreases the efficiency of iron absorption** [3]. **2. Why the Other Options are Incorrect:** * **Option A:** In a state of iron deficiency, only about **10–20% (approx. 30–60 mg)** of a 300 mg dose of elemental iron is absorbed. The body cannot absorb 100 mg from a single dose due to the mucosal block and limited transport capacity [2]. * **Option B:** Reticulocytosis begins within 3–5 days, but it **peaks much earlier**, typically between **7 to 10 days**. It does not take 3–4 weeks to peak. * **Option C:** A response to therapy (indicated by a rise in hemoglobin) is seen much sooner. Hemoglobin typically begins to rise within **1 to 2 weeks**, and a significant increase (usually >2 g/dL) is expected by 3–4 weeks. **3. NEET-PG High-Yield Pearls:** * **Best Absorption:** Iron is best absorbed in the **ferrous (Fe2+) state** in an acidic environment (often prescribed with Vitamin C/Orange juice) [2]. * **Dose:** The standard therapeutic dose for IDA is **100–200 mg of elemental iron** daily. * **Duration:** Therapy must continue for **3–6 months** after hemoglobin normalizes to replenish bone marrow iron stores (monitored via Serum Ferritin). * **Side Effects:** Gastrointestinal upset (nausea, constipation, metallic taste) is the most common reason for non-compliance.

Q: A patient with rheumatic heart disease, mitral stenosis, and atrial fibrillation is on oral warfarin. On an OPD visit, his INR is found to be 6. What is the recommended action?

Stop warfarin, and review. **Explanation:** The management of supratherapeutic INR in patients on Warfarin is a high-yield topic governed by the **ACCP (American College of Chest Physicians) guidelines**. The primary factors determining management are the **INR value** and the **presence or absence of bleeding.** **1. Why Option A is Correct:** In this scenario, the patient has an INR of 6.0 but is **asymptomatic** (no mention of bleeding). According to guidelines, for patients with an **INR between 4.5 and 10.0 and NO clinically significant bleeding**, the recommended action is to **omit the next few doses of Warfarin** and monitor (review) the INR frequently [1]. Warfarin can be resumed at a lower dose once the INR returns to the therapeutic range. **2. Why Other Options are Incorrect:** * **Option B (FFP):** Fresh Frozen Plasma (or Prothrombin Complex Concentrate) is reserved for patients with **major or life-threatening bleeding**, regardless of the INR level. It is not indicated for asymptomatic elevation. * **Option C (Oral Vitamin K):** Oral Vitamin K (1–2.5 mg) is generally reserved for asymptomatic patients with an **INR > 10.0**. At an INR of 6.0 without bleeding, it is not routinely required. * **Option D (IM Vitamin K):** Intramuscular administration of Vitamin K should be **avoided** in patients on anticoagulants due to the high risk of hematoma formation at the injection site. **Clinical Pearls for NEET-PG:** * **INR 10.0 (No bleeding):** Hold Warfarin and give **Oral Vitamin K** (2.5–5 mg). * **Any INR with Serious/Life-threatening Bleeding:** Hold Warfarin + **IV Vitamin K** (10 mg) + **4-factor PCC** (preferred) or **FFP**. * **Target INR for Mitral Stenosis with AF:** 2.0 – 3.0 [2].

Q: Which of the following is a major criterion for the diagnosis of polycythemia vera?

Presence of JAK-2 mutation. Polycythemia Vera (PV) is a chronic myeloproliferative neoplasm characterized by the autonomous overproduction of red blood cells. The diagnosis is based on the **WHO 2016/Revised 4th Edition criteria**, which divides findings into Major and Minor categories. **1. Why Option A is Correct:** The **presence of a JAK2 mutation** (specifically *JAK2V617F* in ~95% of cases or *JAK2* exon 12 mutation in ~5%) is a **Major Criterion** [1]. This mutation leads to constitutive activation of the JAK-STAT signaling pathway, making erythroid progenitors hypersensitive to erythropoietin (EPO) and driving erythropoiesis independent of physiological control. **2. Analysis of Incorrect Options:** * **Option B (Low EPO levels):** While characteristic of PV, a subnormal serum EPO level is classified as a **Minor Criterion**, not a major one. It helps differentiate primary polycythemia (low EPO) from secondary causes like hypoxia (high EPO). * **Option C (High LAP score):** An elevated LAP score is often seen in PV, but it is a non-specific finding and is **not part of the formal WHO diagnostic criteria**. * **Option D (Thrombocytosis):** While PV is a panmyelosis (increase in all cell lines), thrombocytosis is a common clinical feature but **not a diagnostic criterion**. **3. NEET-PG High-Yield Pearls:** * **WHO Major Criteria for PV:** 1. Hemoglobin >16.5 g/dL (men) / >16.0 g/dL (women) OR Hematocrit >49% (men) / >48% (women) [1]. 2. Bone marrow biopsy showing hypercellularity for age with trilineage growth (panmyelosis) [1]. 3. Presence of *JAK2V617F* or *JAK2* exon 12 mutation [1]. * **Clinical Presentation:** Patients often present with **aquagenic pruritus** (itching after a hot bath), facial plethora, and splenomegaly [1]. * **Complications:** Increased risk of thrombotic events (Budd-Chiari syndrome) and transformation to myelofibrosis or AML [1].

Q: For which procedure is the following instrument used?

Bone marrow examination. ***Bone marrow examination*** - The instrument shown is a **Jamshidi needle** (bone marrow biopsy needle) with characteristic **trocar tip**, **outer cannula with stylet**, and **T-shaped handle** for optimal grip and control. - Specifically designed for **bone marrow aspiration** and **core biopsy** from sites like **posterior iliac crest**, allowing collection of both liquid marrow and solid tissue samples. *Liver biopsy* - Liver biopsies use **Menghini needles** or **Tru-cut needles** which are thinner, shorter, and lack the robust construction needed for penetrating bone. - These needles have **different tip designs** (cutting or suction) optimized for soft tissue sampling, not the thick cortical bone overlying marrow. *Pleural biopsy* - Pleural biopsies utilize **Abrams needles** or **Cope needles** which have **hooked or notched tips** specifically designed to scrape pleural tissue. - These instruments are **smaller gauge** and designed for accessing the **pleural space**, not for penetrating dense bone tissue. *Lumbar puncture* - Lumbar puncture uses **Quincke spinal needles** or **Whitacre needles** which are much **thinner (22-25 gauge)** and **longer** for reaching the subarachnoid space. - These needles have **pencil-point or cutting tips** designed for **CSF aspiration** only, without the robust construction needed for bone penetration.

Q: A 28-year-old man presents with a new onset rash on both legs for 1 week. He has no past medical history and is not taking any medications. He denies recent fever but reports occasional gum bleeding and one episode of epistaxis 4 days ago. He is a non-smoker, drinks alcohol socially, and denies recreational drug use. Physical examination reveals no lymphadenopathy or hepatosplenomegaly. Laboratory studies show hemoglobin 14.8 gm/dL, hematocrit 42%, MCV 86 fL, leukocyte count 6,000/mL, and platelet count 22,000/mL. Liver and renal function tests are normal. Peripheral smear shows decreased platelet count with no red cell abnormalities. What is the most probable diagnosis?

Immune thrombocytopenic purpura. **Explanation:** The patient presents with **isolated thrombocytopenia** (platelets 22,000/mL) in the absence of anemia, leukopenia, or systemic symptoms like fever, lymphadenopathy, or hepatosplenomegaly. This clinical picture is classic for **Immune Thrombocytopenic Purpura (ITP)**. **Why ITP is the correct answer:** ITP is an acquired autoimmune disorder characterized by the immune-mediated destruction of platelets [1]. In adults, it often presents as a diagnosis of exclusion. Key diagnostic features seen here include: * **Isolated thrombocytopenia:** Normal Hb and WBC counts. * **Normal peripheral smear:** No schistocytes (ruling out TTP/HUS) or blasts (ruling out leukemia). * **Clinical presentation:** Mucocutaneous bleeding (epistaxis, gum bleeding) and petechiae/purpura (the "rash" on the legs) without systemic illness [2], [3]. **Why the other options are incorrect:** * **Acute Lymphoblastic Leukemia (ALL):** Typically presents with "B-symptoms" (fever, weight loss), lymphadenopathy, hepatosplenomegaly, and significant abnormalities in other cell lines (anemia, high/low WBC) with blasts on the smear. * **Leukemoid Reaction:** This is an exaggerated WBC response (>50,000/mL) to infection or stress. This patient has a normal leukocyte count (6,000/mL). * **Chronic Lymphocytic Leukemia (CLL):** Usually seen in older adults (>60 years) and presents with significant lymphocytosis and lymphadenopathy. **High-Yield Pearls for NEET-PG:** * **ITP Treatment:** Start steroids if platelets <30,000/mL or if significant bleeding occurs. IVIG is used for rapid platelet elevation. * **Bone Marrow:** In ITP, bone marrow shows **increased megakaryocytes** (compensatory response). * **Secondary ITP:** Always screen for underlying HIV, Hepatitis C, or SLE in adults diagnosed with ITP [1].

Question 1

Which of the following is NOT part of the ABVD regimen for chemotherapeutic treatment of Non-Hodgkin's Lymphoma?

Accepted Answer

Vincristine

Answer

Doxorubicin

Answer

Dacarbazine

Answer

Bleomycin

Question 2

What is the recommended daily amount of elemental iron required for iron replacement therapy?

Accepted Answer

300 mg of elemental iron per day

Answer

60 mg of elemental iron per day

Answer

160 mg of elemental iron per day

Answer

360 mg of elemental iron per day

Question 3

While managing a febrile neutropenic patient, all of the following are essential EXCEPT:

Accepted Answer

White cell infusion

Answer

Repeated hand washing by hospital personnel

Answer

Prophylactic antibiotics

Answer

Colony-stimulating factor for macrophages

Question 4

Which of the following statements is true regarding oral therapy for iron deficiency anemia?

Accepted Answer

Absorption of iron decreases as symptoms improve.

Answer

Approximately 100 mg of elemental iron is absorbed from a 300 mg dose.

Answer

Reticulocytosis appears within one to two weeks and peaks in three to four weeks.

Answer

A response to therapy is typically seen within four weeks.

Question 5

All of the following statements about hereditary hemochromatosis are true EXCEPT?

Accepted Answer

Desferroxamine is the treatment of choice

Answer

Arthropathy involving small joints of hands may be seen

Answer

Skin pigmentation is a frequent presentation

Answer

Hypogonadism may be seen

Question 6

A patient with rheumatic heart disease, mitral stenosis, and atrial fibrillation is on oral warfarin. On an OPD visit, his INR is found to be 6. What is the recommended action?

Accepted Answer

Stop warfarin, and review

Answer

Stop warfarin, and administer fresh frozen plasma

Answer

Stop warfarin, and administer oral vitamin K

Answer

Stop warfarin, and administer intramuscular vitamin K

Question 7

Which of the following is a major criterion for the diagnosis of polycythemia vera?

Accepted Answer

Presence of JAK-2 mutation

Answer

Low erythropoietin levels

Answer

High leukocyte alkaline phosphatase (LAP) score

Answer

Thrombocytosis

Question 8

For which procedure is the following instrument used?

Accepted Answer

Bone marrow examination

Answer

Liver biopsy

Answer

Pleural biopsy

Answer

Lumbar puncture

Question 9

Which of the following is absent in hemolytic anemia?

Accepted Answer

Increased direct bilirubin

Answer

Increased indirect bilirubin

Answer

Increased reticulocyte count

Answer

Jaundice

Question 10

A 28-year-old man presents with a new onset rash on both legs for 1 week. He has no past medical history and is not taking any medications. He denies recent fever but reports occasional gum bleeding and one episode of epistaxis 4 days ago. He is a non-smoker, drinks alcohol socially, and denies recreational drug use. Physical examination reveals no lymphadenopathy or hepatosplenomegaly. Laboratory studies show hemoglobin 14.8 gm/dL, hematocrit 42%, MCV 86 fL, leukocyte count 6,000/mL, and platelet count 22,000/mL. Liver and renal function tests are normal. Peripheral smear shows decreased platelet count with no red cell abnormalities. What is the most probable diagnosis?

Accepted Answer

Immune thrombocytopenic purpura

Answer

Acute lymphoblastic leukemia

Answer

Leukemoid reaction

Answer

Chronic lymphocytic leukemia

Hematology — MCQs

Hematology — MCQs

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