Hematology Practice Questions

Q: All are predisposing factors of Deep Vein thrombosis, EXCEPT :

Subungual melanoma. ***Subungual melanoma*** - This is a rare form of melanoma that develops under the nail, and while serious, it is **not a recognized predisposing factor for deep vein thrombosis (DVT)**. Its primary concerns are local invasion and metastasis. - Unlike conditions affecting blood clotting or endothelium, **subungual melanoma does not directly promote hypercoagulability, venous stasis, or endothelial damage** that contribute to DVT. *Lower limb trauma* - **Trauma to the lower limb** can cause **endothelial damage** to blood vessels and **venous stasis** due to immobility or swelling, both key components of **Virchow's triad** for DVT [1]. - **Fractures or severe soft tissue injuries** often necessitate immobilization and can lead to inflammation, further increasing the risk of clot formation [1]. *Cushing's syndrome* - **Cushing's syndrome** is associated with **hypercoagulability** due to increased levels of clotting factors, such as **factor VIII** and **fibrinogen**, and decreased fibrinolytic activity. - The **elevated cortisol levels** seen in Cushing's syndrome [2] can directly contribute to a prothrombotic state, significantly increasing DVT risk. *Hip surgery* - **Major orthopedic surgeries**, especially hip surgery [1], are well-known to cause significant **venous stasis** and **endothelial damage**. - **Post-operative immobility** and a generalized **inflammatory response** following surgery contribute to a high risk of DVT formation [1].

Q: Which of the following is most Likely to be fatal?

Multiple myeloma. No changes made because no provided references reached the relevance threshold of 7. The provided text fragments discuss coagulation factor deficiency (Waldenström macroglobulinemia), physiology of taste, and Lambert-Eaton Myasthenic Syndrome, which do not directly support the clinical descriptions of Multiple Myeloma, Osteochondroma, Paget's disease, or Giant Cell Tumour as presented in the explanation.

Q: Most common cause of iron deficiency in elderly

Gastric bleeding/ hemorrhage. ***Gastric bleeding/ hemorrhage*** - In elderly patients, **chronic blood loss** from the gastrointestinal (GI) tract due to conditions like **peptic ulcers**, **gastritis**, or **GI malignancies** is the most common cause of iron deficiency [1], [3]. - This **slow, insidious blood loss** often goes unnoticed until significant iron stores are depleted, leading to anemia [1]. *Decreased absorption of iron* - While iron absorption can be reduced in the elderly due to conditions like **atrophic gastritis** or certain medications, it is less common than blood loss as a primary cause in symptomatic iron deficiency [1]. - Impaired absorption usually contributes to iron deficiency but is rarely the **sole and most significant cause** compared to chronic GI bleeding. *Achlorhydria* - **Achlorhydria**, or reduced gastric acid production, can impair the conversion of ferric iron (Fe3+) toferrous iron (Fe2+), which is more readily absorbed. - This condition is common in the elderly and can contribute to iron malabsorption but is generally not the **leading cause of significant iron deficiency** in this population without underlying blood loss [3]. *Nutritional deficiency* - While elderly individuals may have **poor dietary intake** and therefore decreased iron intake, it is typically less common than chronic blood loss as the primary cause of iron deficiency in resource-rich settings [2]. - Significant iron deficiency due solely to diet usually requires extremely **restricted diets** or severe malnutrition, which is not the most prevalent reason in general elderly populations presenting with iron deficiency.

Q: A 16-year-old adolescent boy with a history of severe hemophilia A is undergoing an elective inguinal hernia repair. Which of the following is the best option for preventing or treating a bleeding complication in the setting of this disease?

Combination of ε-aminocaproic acid and desmopressin. ***Combination of ε-aminocaproic acid and desmopressin*** - For **mild hemophilia A**, **desmopressin** can aid in increasing factor VIII levels temporarily [1]. **ε-aminocaproic acid (EACA)** is an **antifibrinolytic agent** which is useful for mucosal bleeding conditions or as an adjunct during dental procedures or minor surgeries to prevent clot breakdown. - While desmopressin alone may not fully prevent surgical bleeding in hemophilia A, the addition of EACA helps stabilize the clot, reducing the risk of bleeding for minor surgical procedures like inguinal hernia repair [1]. *Combination of desmopressin and fresh-frozen plasma* - **Desmopressin** is useful for **mild hemophilia A** as it releases stored factor VIII [1]. **Fresh-frozen plasma (FFP)** provides all clotting factors. - Using FFP carries a higher risk of **volume overload** and **transfusion-related acute lung injury (TRALI)** compared to factor concentrates or desmopressin alone. *Factor IX concentrate* - **Factor IX concentrate** is used to treat **hemophilia B**, which is a deficiency in factor IX, not factor VIII. - Administering factor IX concentrate to a patient with hemophilia A would not correct their coagulation defect or prevent bleeding [1]. *Fresh-frozen plasma* - While **fresh-frozen plasma (FFP)** contains factor VIII, it is in **non-concentrated amounts**, making it less effective for severe hemophilia A. - FFP also carries a risk of transfusion reactions and **volume overload**, especially when large quantities are needed.

Q: TRUE about arthropathy in hemochromatosis:

It usually occurs after age 50. ***It usually occurs after age 50*** - Hemochromatosis-related arthropathy typically manifests later in life, commonly **after the age of 50**, aligning with the progressive accumulation of iron. - The chronicity of iron overload is necessary for significant joint damage to occur, leading to symptoms in older individuals.*Acute brief attacks usually affects shoulder joints* - Arthropathy in hemochromatosis is generally a **chronic, progressive condition**, not characterized by acute, brief attacks. - While various joints can be affected, the **second and third metacarpophalangeal (MCP) joints** are characteristically the first and most commonly involved, not usually the shoulder.*Lower limb joints are first affected* - The **second and third metacarpophalangeal (MCP) joints** of the hands are classic initial sites of involvement in hemochromatosis arthropathy [1]. - Involvement of lower limb joints, such as the knees and hips, typically occurs later in the disease course.*Arthropathy improves with phlebotomy* - While phlebotomy is crucial for removing excess iron and preventing further organ damage in hemochromatosis, it generally **does not reverse or significantly improve existing arthropathy**. - Joint damage due to iron deposition and subsequent cartilage destruction is often irreversible once established, though phlebotomy can prevent worsening of joint symptoms.

Q: Which of the following types of leukemia is administered prophylactic methotrexate for CNS prophylaxis –

ALL. ***ALL*** - **Acute Lymphoblastic Leukemia (ALL)** has a high propensity for **central nervous system (CNS) involvement**, necessitating prophylactic intrathecal methotrexate to prevent CNS relapse [1]. - Prophylactic treatment of the CNS is a standard component of ALL treatment protocols due to the risk of leukemic cell infiltration into the brain and spinal cord [1]. *AML* - **Acute Myeloid Leukemia (AML)** has a lower incidence of CNS involvement compared to ALL, so prophylactic CNS treatment is generally not routine unless specific risk factors are present. - While CNS involvement can occur in AML, it is more commonly treated with systemic chemotherapy that has CNS penetration or intrathecal treatment only when CNS disease is confirmed. *CLL* - **Chronic Lymphocytic Leukemia (CLL)** rarely involves the CNS, and prophylactic CNS treatment is not part of standard management. - When CNS involvement does occur in CLL, it is an aggressive, late-stage complication and typically requires specific, targeted therapy rather than prophylaxis. *CML* - **Chronic Myeloid Leukemia (CML)** has an extremely low risk of CNS involvement, especially in the chronic phase, and therefore, prophylactic CNS treatment is not administered. - CNS involvement in CML is usually seen during a blast crisis and is rare, making prophylaxis unnecessary.

Q: 24 years old female patient presents with acute blood loss secondary to bilateral fracture femur. Reticulocytosis is evident on peripheral smear examination. Patient's anemia can be categorized into which of the following types?

Normocytic normochromic. ***Normocytic normochromic*** - **Acute blood loss** results in a loss of whole blood, meaning that the remaining red blood cells are still of normal size and hemoglobin content, hence **normocytic normochromic** [1]. - The presence of **reticulocytosis** is a physiological response, indicating that the bone marrow is actively producing new red blood cells to compensate for the acute loss, which also tend to be of normal size initially [1]. *Microcytic hypochromic* - This type of anemia is typically seen in conditions involving **chronic blood loss** or **iron deficiency**, where there is insufficient iron to produce normal hemoglobin, leading to small, pale red blood cells [3]. - While blood loss is present, it is acute, and there hasn't been sufficient time for iron stores to be depleted to this extent [2]. *Microcytic normochromic* - This is not a common classification of anemia; red blood cells that are **microcytic** (small) are almost always **hypochromic** (pale) due to reduced hemoglobin content. - This option does not accurately represent the physiological response to acute blood loss. *Normocytic Hypochromic* - This is also not a common classification; **normocytic** (normal size) red blood cells usually have normal hemoglobin content and thus appear **normochromic** [2]. - Hypochromia typically accompanies microcytosis due to the same underlying issues of impaired hemoglobin synthesis.

Q: A male child with gallbladder stone has Hb of 6 gm%, serum bilirubin 2.5 mg%, and high urobilinogen in urine. The diagnosis is:

Hemolytic jaundice. **Hemolytic jaundice** - The presence of **anemia** (Hb 6 gm/DL), **unconjugated hyperbilirubinemia** (total bilirubin 2.5 mg/dL suggests this given normal liver function, though direct bilirubin is not specified, indirect hyperbilirubinemia is typical), and **increased urinary urobilinogen** are classic signs of increased red blood cell destruction [1]. - **Gallbladder stones** (cholelithiasis) in a child with anemia and hemolytic features suggest conditions like **hereditary spherocytosis** or **sickle cell anemia** where chronic hemolysis leads to pigment gallstone formation. *Hepatocellular jaundice* - This would typically involve significantly elevated **liver enzymes** (ALT, AST) and often a mix of conjugated and unconjugated hyperbilirubinemia due to impaired hepatic uptake, conjugation, and excretion. - High urobilinogen in urine is not specific to hepatocellular damage; it reflects increased bilirubin load to the liver. *Secondary biliary cirrhosis* - This is a long-term complication of chronic **biliary obstruction**, leading to liver fibrosis and eventually cirrhosis. While gallbladder stones *can* lead to obstruction, the primary presentation here points to a hemolytic process, and **cirrhosis** would involve more pronounced liver dysfunction and portal hypertension, not just anemia and hyperbilirubinemia. - The symptoms described are acute and point towards hemolysis rather than chronic liver disease. *Obstructive jaundice* - Caused by a blockage in the bile ducts, leading to impaired bilirubin excretion. This would result in predominantly **conjugated hyperbilirubinemia** and **dark urine** with **pale stools**, and often **absent or low urinary urobilinogen** because bilirubin cannot reach the gut for conversion [1]. - The high urinary urobilinogen in this case explicitly rules out complete biliary obstruction, and unconjugated bilirubin is typically elevated in hemolytic jaundice.

Q: What is the threshold absolute neutrophil count that defines severe neutrophil depletion?

500. 500 - An absolute neutrophil count (ANC) of less than 500 cells/µL is defined as severe neutropenia. - At this level, the risk of serious bacterial and fungal infections significantly increases due to compromised immune defense. 100 - An ANC of less than 100 cells/µL is considered profound neutropenia, representing an even higher risk of severe infection. - While very low, it is not the general threshold for defining severe neutropenia, which is typically 500 cells/µL. 250 - An ANC of 250 cells/µL falls within the range of severe neutropenia, but the standard threshold for defining severe neutropenia is generally accepted as 500 cells/µL. - This count still indicates a very high risk of infection, but 500 cells/µL is the more common cutoff for "severe." 1000 - An ANC of 1000 cells/µL is considered mild neutropenia and does not meet the criteria for severe neutrophil depletion. - While it's lower than normal, the risk of serious infection is considerably lower compared to ANCs below 500 cells/µL.

Q: All are clinical manifestations of Felty's syndrome except:

Nephropathy. ***Nephropathy*** - **Nephropathy** is not a characteristic clinical manifestation of **Felty's syndrome**. While patients with **rheumatoid arthritis** can develop kidney involvement (e.g., secondary amyloidosis) [1], it is not considered part of the core diagnostic criteria or classic presentation of **Felty's syndrome**. - The syndrome specifically involves a triad of features linked to the immune system's overactivity, rather than direct kidney damage. *Neutropenia* - **Neutropenia** (low neutrophil count) is a hallmark feature of **Felty's syndrome**, leading to an increased risk of infections. - It results from the destruction of neutrophils and suppression of bone marrow granulopoiesis. *Rheumatoid arthritis* - **Felty's syndrome** is a severe extra-articular manifestation of **long-standing rheumatoid arthritis**, indicating that the presence of **RA** is a prerequisite [1]. - Patients typically have **seropositive, erosive rheumatoid arthritis** that has been active for many years [1]. *Splenomegaly* - **Splenomegaly** (enlarged spleen) is another key component of **Felty's syndrome**, contributing to the destruction of blood cells [1]. - The enlarged spleen can sequester and destroy neutrophils, further contributing to the neutropenia.

Question 1

All are predisposing factors of Deep Vein thrombosis, EXCEPT :

Accepted Answer

Subungual melanoma

Answer

Lower limb trauma

Answer

Cushing's syndrome

Answer

Hip surgery

Question 2

Which of the following is most Likely to be fatal?

Accepted Answer

Multiple myeloma

Answer

Osteochondroma

Answer

Paget's disease

Answer

Giant cell tumour

Question 3

Most common cause of iron deficiency in elderly

Accepted Answer

Gastric bleeding/ hemorrhage

Answer

Decreased absorption of iron

Answer

Achlorhydria

Answer

Nutritional deficiency

Question 4

A 16-year-old adolescent boy with a history of severe hemophilia A is undergoing an elective inguinal hernia repair. Which of the following is the best option for preventing or treating a bleeding complication in the setting of this disease?

Accepted Answer

Combination of ε-aminocaproic acid and desmopressin

Answer

Combination of desmopressin and fresh-frozen plasma

Answer

Factor IX concentrate

Answer

Fresh-frozen plasma

Question 5

TRUE about arthropathy in hemochromatosis:

Accepted Answer

It usually occurs after age 50

Answer

Acute brief attacks usually affects shoulder joints

Answer

Lower limb joints are first affected

Answer

Arthropathy improves with phlebotomy

Question 6

Which of the following types of leukemia is administered prophylactic methotrexate for CNS prophylaxis –

Accepted Answer

ALL

Answer

AML

Answer

CLL

Answer

CML

Question 7

24 years old female patient presents with acute blood loss secondary to bilateral fracture femur. Reticulocytosis is evident on peripheral smear examination. Patient's anemia can be categorized into which of the following types?

Accepted Answer

Normocytic normochromic

Answer

Microcytic hypochromic

Answer

Microcytic normochromic

Answer

Normocytic Hypochromic

Question 8

A male child with gallbladder stone has Hb of 6 gm%, serum bilirubin 2.5 mg%, and high urobilinogen in urine. The diagnosis is:

Accepted Answer

Hemolytic jaundice

Answer

Hepatocellular jaundice

Answer

Secondary biliary cirrhosis

Answer

Obstructive jaundice

Question 9

What is the threshold absolute neutrophil count that defines severe neutrophil depletion?

Accepted Answer

500

Answer

100

Answer

250

Answer

1000

Question 10

All are clinical manifestations of Felty's syndrome except:

Accepted Answer

Nephropathy

Answer

Neutropenia

Answer

Rheumatoid arthritis

Answer

Splenomegaly

Hematology — MCQs

Hematology — MCQs

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