Advance Institute of Medical

Science
Haematology Month End Exam
2014

A 36-year-old African-American woman with systemic lupus

erythematosus presents with the acute onset of lethargy
and jaundice. On initial evaluation, she is tachycardic,
hypotensive, appears pale, is dyspneic, and is somewhat
difficult to arouse. Physical examination reveals
splenomegaly. Her initial hemoglobin is 6 g/dL, white
blood cell count is 6300/L, and platelets are 2,94,000/L.
Her total bilirubin is 4 g/dL, reticulocyte count is 18%, and
haptoglobin is not detectable. Renal function is normal, as
is urinalysis.
What would you expect on her peripheral blood smear?
A. Macrocytosis and PMNs with hypersegmented nuclei
B. Microspherocytes
C. Schistocytes
D. Sickle cells
E. Target cells

An 89-year-old lady is an in-patient recovering from

community-acquired pneumonia. She is on
warfarin for atrial fibrillation, and has been put on
intravenous levofloxacin since admission forty-eight
hours ago. Dr. Iffa Mizan, the hematologist of AIMS
is contacted for advice regarding management of
her high international normalized ratio (INR). She is
currently well, with no symptoms or signs of
bleeding. INR > 10 (target 2.5).
What is the most appropriate management?
A. Observation alone
B. Intravenous vitamin K
C. 15 ml/kg fresh frozen plasma
D. 10 units of cryoprecipitate
E. Prothrombin complex concentrate containing
factors II, VII, IX and X

Dr Farhana Jakaria is reviewing a woman in AIMS GOPD who

is 34 weeks pregnant. Fetal growth has been normal so far.
She presents with epigastric pain, increasing ankle oedema.
Her midwife has noted her blood pressure to be 159/95.
She has proteinuria. Platelet count is reduced at 75. She has
raised transaminases and bilirubin.
What would be the most appropriate treatment for this
patient?
A. Observation
B. Urgent ultrasound scan of the liver
C. Hydralazine and admit for bed rest iv
D. Consider inducing the pregnancy
E. Oral nifedipine and discharge

Dr Ataullah is asked to see a 30-year-old man who is undergoing in-patient

treatment for acute myeloid leukaemia. He completed combination
chaemotherapy 6 days ago and was well until this morning when he noticed
increasing breathlessness. On examination he is pale and clammy, with a
high respiratory rate. Pulse is 130 bpm, blood pressure 110/70 mmHg and
skin is cool to the touch. He is slightly drowsy and disorientated.
Temperature is 35.6oC and he has several crops of black lesions over his
arms and legs. A chest X-ray is unremarkable.
Blood tests are shown:
haemoglobin (Hb) 7.3 g/dl
white cell count (WCC) 0.2 x 109/l
Platelets 13 x 109/l
Neutrophils 0 x 109/l
Urea 10.3 mmol/l (2.57.5)
How would Dr Ataullah manage this patient (pick three)?
1. Take a biopsy of skin lesions
2. Commence antifungal therapy with voriconcazole to cover Aspergillus
fumigatus
3. Commence antifungal therapy with caspofungin to cover Candida albicans
4. Take cultures from urine and all venous access and start antibiotics once
results are available
5. Commence broad-spectrum antibiotics with antipseudomonal activity

A 40-year-old man is admitted to AIMS Surgery unit with a

mild haematemesis and is awaiting endoscopy when he
suffers a massive haematemesis and loses
consciousness. On examination he is cool to the touch
and tachypnoeic pulse 140 beats per minute (bpm),
blood pressure 60/30 mmHg. He has already had blood
taken for group and save that day and his admission
haemoglobin was 10.5 g/dl. Dr Mushfiq Choose a
suitable fluid for the patient.
What is the most suitable fluid to give in the first instance?
1. Group O rhesus-negative packed red cells
2. Group specific packed red cells
3. Immediate spin cross-matched packed red cells
4. Fully cross-matched packed red cells
5. Crystalloid such as normal saline

A 40-year-old woman presents to AIMS hematology with a

twenty-four hour history of unilateral swelling of the left leg.
She has recently flown back to this country from Australia. She
is previously fit and well, does not smoke and is on no
medication. She has no family history of note. Other than the
swollen leg, examination is unremarkable. Ultrasound of the
deep veins of the leg confirms an above knee-deep vein
thrombosis, and she is commenced on enoxaparin 1.5 mg/kg
daily subcutaneously and started on 10 mg of warfarin. On the
second day after starting warfarin she has developed black
lesions over her buttocks.
What is the most likely diagnosis?
1. Heparin-induced skin necrosis
2. Protein C deficiency
3. Prothrombin gene 20210 mutation
4. Antithrombin III deficiency
5. Antiphospholipid deficiency

A 55-year-old gentleman presents to his GP with a six

month history of lethargy and left upper quadrant
abdominal discomfort. A blood count shows a white cell
count of 350 x 109/L, haemoglobin of 10.5 g/dL and a
platelet count of 223 x 109/L. A bone marrow aspirate
shows increased granulocytic precursors and less than
5% blasts. Molecular studies show the patient to be
BCR-ABL transcript positive. The most appropriate
therapy is:
A Chemotherapy
B Haemopoietic stem cell transplant
C Hydroxycarbamide
D Interferon
E Treatment with tyrosine kinase inhibitor, e.g. imatinib

A 45-year-old woman being treated for Acute

Myeloid Leukemia fails to get sufficient rises with
platelet transfusions. She is 14 days post
chemotherapy , afebrile and apart from minor
bruising is otherwise well. The next best step in
the management of platelet refractoriness would
be:
A avoid further platelet transfusions
B continue to monitor for platelet rises with random
platelets
C check for a 1 hr post platelet transfusion platelet
count
D prescribe HLA matched platelets
E request directed platelet donations

A 37-year-old nurse presents to the AIMS ENT with a flu-like illness. Dr

MUSHFIQ attend the patient. The patient gives a 10-year history of
tendency to have a blocked, stuffy nose and frequent recurrent
coughs and colds. The Occupational Health team has also noticed
that she failed to show a response to hepatitis B and tetanus
vaccinations. Dr MUSHFIQ suspect an IG deficiency.
Which immunoglobin is she likely to be deficient in?
1. IgA
2. IgE
3. IgD
4. IgM
5. IgG
Which organism is most likely to cause her infections?
A. Haemophilus influenzae
B. Klebsiella
C. Meningococcus
D. Haemolytic Streptococcus
E. Staphylococcus

All the following are associated with pure red

cell aplasia except
A. anterior mediastinal masses
B. connective tissue disorders
C. giant pronormoblasts
D. low erythropoietin levels
E. parvovirus B19 infection

A 49-year-old Caucasian woman presents to a local GP to find out the

results of some blood investigations performed by her own GP. She
was found to have splenomegaly on a routine examination after she
complained to her GP of feeling excessively tired and fatigued. Her
blood film had shown poikilocytes and normoblasts.

Her other results were:

Hb 11.0 g/dl
WCC 128 109/l
platelets 139 109/l
Which diagnosis would fit the above data?
1. Sideroblastic anaemia
2. Chronic myeloid leukaemia
3. Polycythaemia rubra vera
4. Essential thrombocythaemia
5. Thalassaemia

The blood product with the highest risk of

transmission of a bacterial infection related to
transfusion is:
A Cryoprecipitate
B fresh frozen plasma
C factor VIII concentrates
D packed red cells
E platelets

A 34-year-old female with a past medical history of sickle cell anemia presents
with a 5-day history of fatigue, lethargy, and shortness of breath. She denies
chest pain or
bone pain. She has had no recent travel. Of note, the patients 4-year-old
daughter had a cold 2 weeks before the presentation. On examination she
has pale conjunctiva, is anicteric, and is mildly tachycardic. Abdominal
examination is unremarkable. Laboratories show a hemoglobin of 3 g/dL;
her baseline is 8 g/dL. The white blood cell count and platelets are normal.
Reticulocyte count is undetectable. Total bilirubin is 1.4 mg/dL. Lactic
dehydrogenase is at the upper limits of the normal range.
Peripheral blood smear shows a few sickled cells but a total absence of
reticulocytes. The patient is given a transfusion of 2 units of packed red
blood cells and admitted to the hospital. A bone marrow biopsy shows a
normal myeloid series but an absence of erythroid precursors. Cytogenetics
are normal. What is the most appropriate next management step?
A. Make arrangements for exchange transfusion.
B. Tissue type her siblings for a possible bone marrow transplant.
C. Check parvovirus titers.
D. Start prednisone and cyclosporine.
E. Start broad-spectrum antibiotics.

Dr Sanaullah is asked to counsel a married couple expecting a baby. They are

both fit and well, with no previous medical history. They both originate
from South East Asia, and have no family history of birth abnormalities.
There are no abnormalities on examination.
Results are:
Male
Hb 11.7 g/dl Mean cell volume 70 fl Mean cell haemoglobin 19 pg Red
cell
count 5.6 x 1012/l Haemoglobin electrophoresis normal.
Female
Hb 10.1 g/dl Mean cell volume 68 fl Mean cell haemoglobin 18 pg Red
cell
count 6.0 x 1012/l Haemoglobin electrophoresis normal.
What condition is the fetus at risk from inheriting?
1. -Thalassaemia trait
2. Thalassaemia intermedia
3. Hydrops fetalis
4. Thalassaemia major
5. Homozygous haemoglobin E

A 17-year-old female is referred to AIMS hematology from her

GP complaining of menorrhagia and easy bruising. A
summary given by her GP of tests already performed shows
her prothrombin time (PT) to be within the normal range,
her APTT to be above the normal range, INR and platelet
levels were normal. A diagnosis of Von Willebrands disease
(vWD) is suspected.
Which of the following statements about the specific assays
available for this condition is TRUE?
1. Factor VIII activity is increased
2. A single level of von Willebrand factor (vWF) within the
normal range excludes this diagnosis
3. In the ristocetin cofactor assay, vWF activity is variably
increased
4. vWF antigen is variably increased
5. vWF antigen levels may be normal in vWD variants with
abnormal multimers

A 52-year-old woman is bought to AIMS OPD by her carer who has become
concerned after noticing that the patients gums have progressively become
more prominent over the last few months. She tried to take the patient to the
dentist but no NHS dental appointments were available. The patient lives in a
home since she has learning difficulties.
Her past medical history is unremarkable except for three infections in the last 6
weeks. The carer has also noticed that recently the patient has become
increasingly fatigued by even the lightest of activities and is commonly short
of breath on exertion. She is not currently on any medications but has taken
various courses of antibiotics recently.
On examination, she is noted to be anaemic and have multiple bruises over her
body. She has hypertrophic bleeding gums and on auscultation of the heart,
she is found to have a flow murmur. She has mild splenomegaly on palpation
of her abdomen. Routine blood tests were requested and confirmed the
presence of anaemia, a raised white cell count, low neutrophil count and
thrombocytopenia. A blood film shows increased numbers of blast cells and
the presence of Auer rods.
What is the most likely diagnosis?
1. Acute myeloid leukaemia (AML)
2. Chronic myeloid leukaemia (CML)
3. Acute lymphoblastic leukaemia (ALL)
4. Chronic lymphoid leukaemia (CML)
5. Chronic myelomonocytic leukaemia (CMML)

A 30-year-old woman admitted in DMCH with the history of Rat killer poison
intake 2hrs ago.
Her physical examination was unremarkable. Initial test reveals :Normal
After 3 days of conservative management her physical examination shows
ecchymoses on her arms. Her urine is bloody in appearance, but no clots
are present. After flushing the bladder with 100 mL of sterile saline, the
urine returns with a slight pink hue only. A urinalysis shows 35 white blood
cells per high power field and many red blood cells per high power field.
There are no bacteria present. The international normalized ratio (INR) is
7.0.
What is the best approach to treatment of this patients coagulopathy?

A. Administer vitamin K 10 mg IV. (Significant bleeding in the setting of an

elevated INR)
B. Administer vitamin K 2 mg SC. (SC route to be no better than placebo and
inferior to the oral and IV routes, which have similar efficacy)
C. Administer vitamin K 1 mg sublingually.
D. Administer tranexamic acid IV
E. Transfuse four units of fresh-frozen plasma.

A man aged 62 years is referred to the AIMS hematology

from Apollo Hospital for review. He received a routine
blood screen from his GP that revealed a raised ESR
(85mm/h), and an IgG paraprotein band (1.9 g/l). No
urinary light chain excretion was detected.
Three years later he is still well; however he still has an
increased ESR and IgG paraprotein band, though there
is still no urinary light chain excretion.
Which of the following diagnoses fit best?
1. Waldenstroms macroglobulinaemia
2. Monoclonal gammopathy of unknown significance
(MGUS)
3. Myeloma
4. B-cell lymphoma
5. Chronic myeloid leukaemia

A 70-year-old man presents to AIMS pulmonology with recurrent

chest infections and abdominal discomfort. He was well until a
year ago, but has required recurrent courses of antibiotics from
his general practitioner for chest infections. He has discomfort in
the left upper part of his abdomen, and finds that he feels full
despite eating only a few mouthfuls at each meal. On
examination he has a large spleen palpable 10 cm below the
costal margin. Investigations are shown below:
Hb 8.7 g/dl
What was Urmees suspected diagnosis?
WCC 23.2 x 109/l
Chronic lymphocytic leukaemia
Platelets 25 x 109/l
Pro-lymphocytic leukaemia
Neutrophils 0.3 x 109/l
Infectious mononucleosis
Splenic lymphoma with villous lymphocytes
Monocytes 0.0 x 109/l
Hairy cell leukaemia
Lymphocytes 21 x 109/l
Blood film shows large numbers of atypical monocytes with
abnormal villous projections. Dr Urmee suspect a diagnosis; but
to be become sure, he took an opinion from Dr Farhana, coordinator of CMS. Farhana confirms Urmee that, he was right

A 71-year-old woman presents to AIMS hematology with tiredness and

lethargy. Her GP had previously noted that she was anaemic and
commenced iron therapy. Examination reveals obvious splenic
enlargement. Blood results are shown below:
white cell count (WCC) 2.1 x 109 mmol/l
neutrophils 0.9 x 109 mmol/l (1.57.0)
lymphocytes 0.8 x 109 mmol/l (1.54.0)
monocytes 0.1 x 109 mmol/l (00.8)
eosinophils 0 x 109 mmol/l (0.040.4)
basophils 0 x 109 mmol/l (00.1)
haemoglobin (Hb) 9.1 g/dl
mean cell volume (MCV) 80 fl (7696)
platelets 90 x 109 mmol/l (150400)
Bone marrow biopsy reveals increased cellularity.
What diagnosis fits best with this clinical picture?
a) Myelofibrosis
b) Myelodysplasia
c) Myeloma
d) Chronic myeloid leukaemia
e) Acute myeloid leukaemia

A patient on a medical ward received a transfusion

48 hours ago for symptomatic anaemia on
background of chronic renal disease and
obstructive airways disease. He gives a history of
previous transfusions in the last year. The patient
has now actually dropped his Hb by 2g/L
compared to his pretansfusion level and reports a
dark coloured urine. The LDH and bilirubin are
elevated. The is most likely to represent:
A acute hepatitis as an infective complication
B acute haemolytic transfusion reaction
C delayed haemolytic transfusion reaction
D non haemolytic febrile transfusion reaction
E transfusion related graft versus host disease

A 20-year-old woman on the oral contraceptive pill presents to Dr Mithun, director

of AIMS Pulmonology with pleuritic chest pain of sudden onset. She has recently
flown back to this country from Australia. She has no family history of venous
thromboembolism. She is a full-time mother of two children aged 3 and 6. Her
only medication is the third generation oral contraceptive containing gestodene.
Examination shows her to be breathless, cyanosed and in distress. She is
tachycardic, blood pressure 110/70 mmHg with a loud pulmonary component of
the second heart sound. There is a pleural rub, a respiratory rate of 35/min. Chest
X-ray is clear. Results below:
p(O2) 7.9 kPa (11.312.6)
p(CO2) 3.5 kPa (4.76.0)
factor V Leiden mutation heterozygous
she responds promptly to high flow oxygen and intravenous heparin. A
ventilation/perfusion scan shows multiple mismatched perfusion defects.
What management would Dr Mithun now initiate?
1. Before discharge she should have a thrombophilia screen including protein C
and S quantification and antithrombin III measurement
2. She should change to a second-generation oral contraceptive pill containing
levonorgestrel
3. Her children should be tested for the presence of factor V Leiden
4. Cascade screening of family members for factor V Leiden is indicated and if
positive anticoagulation should be offered
5. The finding of factor V Leiden means that this patient is at a higher risk of
recurrence of venous thromboembolism

A 71-year-old man with a long history of rheumatoid arthritis

presents AIMS rheumatology to Dr Nigar, acting director of
AIMS rheumatology for review. He has recently complained
of loss of weight and a number of episodes of dark urine,
but normal stools. He admits to drinking 20 units of alcohol
per week and has previously lived in the tropics. On
examination he weighs 80 kg. There is a palpable spleen.
Urine analysis showed urobilinogen, urosiderin, no bilirubin
and no red blood cells. Haemoglobin was reduced at 10
g/dl, there was an increase in spherocytes, haptoglobins
were reduced and platelets were also reduced.
Which of the following is the next best investigation in this
case?
1. Hepatic ultrasound scan
2. ERCP
3. Direct antiglobulin test
4. Bone marrow
5. Thick and thin film

An 18-year-old girl presents AIMS neurology with sudden onset dysarthria and
right-sided weakness. You see her 12 hours after the event and her symptoms
have now resolved. She is on the oral contraceptive pill. She is in full time
education and smokes 510 cigarettes daily. Alcohol intake is minimal. She
lives with her parents. Family history is unremarkable other than a possible
deep vein thrombosis in an aunt. Examination is unremarkable other than a
lacy rash over her thighs and a grade II ejection systolic murmur.
Computed tomography of the brain performed 2 hours after admission is
unremarkable. Results of blood tests shown below:
haemoglobin (Hb) 12.3 g/dl
white cell count (WCC) 3.5 x 109/l
Platelets 135 x 109/l
activated partial thromboplastin time (APTT) 45 s (3040)
What is the most likely cause of the rash?
1. Erythaema ab igne
2. Erythaema chronicum migrans
3. Livedo reticularis
4. Erythroderma
5. Erythaema multiforme

A 24-year-old man is referred to AIMS hematology for investigation of anemia

by his GP. He is asymptomatic and has no physical complaints. Examination
is unremarkable.
Investigations:
Hb 12.5g/dl
WBC 6.8 x 109/l
PLT 340 x 109/l
MCV 65 fl
Haemoglobin electrophoresis:
HbA 91.7 % (> 95%)
HbA2 7.1 % (< 3.5%)
HbF 1.2 % (< 1.5%)
What is the most likely diagnosis?
A. Alpha thalassaemia trait
B. Haemoglobin H disease
C. Beta thalassaemia minor
D. Beta thalassaemia major
E. Sickle cell trait

Dr. Badhon is called to see a 40-year-old woman who has become acutely short of
breath. She had a total knee replacement the previous day, which was
uncomplicated. In the notes it is documented that she had a non-haemolytic
febrile reaction this morning during a single unit blood transfusion, which
responded rapidly to hydrocortisone and chlorpheniramine. She has received
no additional intravenous fluids. She has no previous medical history of note.
She works part time as an aerobics instructor and has four children. She does
not smoke.
On examination she is acutely short of breath, with a respiratory rate of 45
breaths per minute at rest. She is using accessory muscles and is clearly
exhausted. Auscultation of the chest reveals widespread crackles. She has
expectorated a small amount of frothy sputum. She is afebrile, blood pressure
150/90 mmHg, pulse 130 regular. Electrocardiogram is normal. Chest X-ray
shows widespread alveolar shadowing. Heart size is normal. FBC and RFT are
normal. Dr.Badhon thought its not his case & so he referred the case to Dr. Iffa,
dept of hematology, AIMS.
What Dr.Iffa should tell about the diagnosis?
A. Transfusion related acute lung injury
B. Acute pulmonary oedema due to fluid overload from too rapid blood
transfusion
C. Hospital acquired bronchopneumonia
D. Massive pulmonary embolism
E. Adult respiratory distress syndrome secondary to septicaemia

A 30-year-old woman presents to Dr. Sanaulla with a

3-day history of cramping abdominal pain and
vomiting. A week previously she had been absent
from her job as a paint factory worker, with flulike symptoms. She has now developed a rash (see
picture).
What complication might she be at most risk of
developing?
1. Epistaxis
2. Haemarteritis
3. Pulmonary haemorrhage
4. Acute blindness
5. Glomerulonephritis

A 65-year-old man is admitted to hematology dept of AIMS with

sudden onset left upper limb and lower limb weakness. Apart
from headaches, he was previously fit and well. He is a lifelong
smoker of four cigarettes per day and drinks two pints of beer
a day. Examination confirms left-sided motor and sensory
deficit. He has an ejection systolic murmur at the right second
inter costal space and prolonged expiratory polyphonic
wheeze at the lung bases. Abdominal examination reveals a
mass in the left upper quadrant that is dull to percussion and
moves downwards on inspiration.
BP 157/89 mmHg
Na+ 144 mmol/l
K+ 5.0 mmol/l
HR 70 bpm regular
Urea 7.4 mmol/l
Temperature 36.9o C
Creatinine 108 mol/l
O2 sats 92%
LAP score 210 (reference 25-180)
Initial investigations:
What is the most likely diagnosis?
Hb 18.9 g/dl
1. Chronic myeloid leukaemia
2. Polycythaemia rubra vera
WBC 12.2 x 109/l
3. Gaisbcks syndrome
PLT 462 x 109/l
4. Chuvash polycythaemia
Haematocrit 0.58
5. Renal cell carcinoma

Dr. Urmee was working in GOPD outdoor of AIMS. On routine

investigation she found paraprotein in a 45-year-old woman. She
instantly referred the patient to Dr. Ataullah, the director of
Hematology, AIMS. She is currently asymptomatic and working full
time as a teacher. She is on no medication and does not smoke. She
has three sisters who are all well. On examination pulse 90 beats
per minute, blood pressure 110/64 mmHg, heart sounds normal,
chest is clear. There is no palpable lymphadenopathy or
organomegaly. Neurological examination is unremarkable, with
normal funduscopy and intact sensation.
Results are shown below:
Hb 14.3 g/dl
What management will Dr
WCC 6.3 x 109/l
Ataullah give?
Platelets 355 x 109/l
1. Regular follow up with
blood tests only
Protein electrophoresis M band present
2. Melphalan and
Paraprotein quantification IgG kappa 12 g/dl
prednisolone
Serum corrected calcium 2.24 mM
3. Thalidomide and
Urine negative for Bence Jones protein
dexamethasone
4. Bortezomib
Skeletal survey unremarkable
Bone marrow aspirate shows 25% plasma cells 5. Vincristine, doxorubicin
and dexamethasone

A 53-year-old man presents to Dept of Gastro-enterology of AIMS with

tiredness of 3 months duration. He has had abdominal pains in the
past year that are fleeting in nature and has lost one stone in
weight. He is on antacids and has no significant previous medical
history. On examination he is slim, with pale conjunctivae but
otherwise there is nothing abnormal to find. Dr Imrul gave some
basic investigations
Results are shown below:
haemoglobin (Hb) 5.5 g/dl
white cell count (WCC) 4.3 x 109/l
Platelets 523 x 109/l
Ferritin 5 g/l 15300
colonoscopy and endoscopy are normal
Which investigation would be least suitable to make a diagnosis?
1. Repeat colonoscopy and endoscopy
2. Isotype-labelled red cell scan
3. Isotype-labelled white cell scan
4. Bone marrow aspirate and trephine
5. Tissue transglutaminase antibodies

A 30-year-old man presents to Dr Farhana, department of Hematology, AIMS

with breathlessness on exertion of three months duration. Usually fit and
relatively athletic, he now needs to stop for breath on climbing a single
flight of stairs. His general practitioner has arranged investigations for
possible renal stones, and he completed a six-month course for a deep vein
thrombosis in the last year, but otherwise he has no significant previous
medical history. Examination shows pale conjunctivae, pulse 100 beats per
minute, heart sounds normal and jugular venous pressure not raised. Dr
Farhana gives some more investigations which show Hb 6.3 g/dl
WCC 2.5 x 109/l
Neutrophils 1.1 x 109/l
Platelets 163 x 109/l
Mean Cell Volume 80 fl (8096)
Reticulocytes 63 x 109/l (2585)
Blood film marked anisocytosis, with polychromasia and hypochromatic cells
Ferritin 10(15300)
Urine dipstick positive for blood ++++
What is the most likely diagnosis?
Mid stream urinalysis no cells seen
A. Warm autoimmune haemolysis
B. Cold haemagglutinin disease
Culture negative
C. Paroxysmal cold haemoglobinuria
D. Blackwater fever
E. Paroxysmal nocturnal haemoglobinuria

The blood used for an exchange transfusion in a neonate

should fulfil these criteria:
A any blood less than 5 days old
B any Plasma reduced whole blood in CPD
C plasma reduced whole blood in CPD which is irradiated
D plasma reduced whole blood in CPD less than 5 days
old and irradiated
E plasma reduced whole blood in CPD less than 5 days old
, irradiated and Rh group should be same as the
neonate

A 70-year-old man is admitted to the cardiac care unit for complaints of chest
pressure occurring at rest radiating to his left arm with associated diaphoresis and
presyncope.
His admission electrocardiogram (ECG) showed ST depressions in V4V6. The chest
pain and ECG
changes resolve with sublingual nitroglycerin. He is treated with IV heparin, aspirin,
metoprolol, and lisinopril. His cardiac catheterization shows 90% occlusion of the
left anterior descending artery, 80% occlusion of the distal circumflex artery, and
99% occlusion of the right coronary artery. He remains in the cardiac care unit
awaiting coronary artery bypass. He has a history of rheumatic
heart disease and underwent mechanical mitral valve replacement at age 58. On
admission, his hemoglobin is 12.2 g/dL, hematocrit 37.1%, white blood cell (WBC)
count 9800/L, and platelet count 240,000/L. His creatinine is 1.7 mg/dL. On the
fourth hospital day, his hemoglobin is
10.0, hematocrit 31%, WBC count 7600/L, and platelet count 112,000/L. His
creatinine has risen to 2.9 mg/dL after the cardiac catheterization.
What is the most appropriate treatment of the patient at this time?
A. Continue heparin and give a platelet transfusion.
B. Discontinue heparin infusion and start argatroban.
C. Discontinue heparin and start lepirudin.
D. Discontinue heparin and start warfarin.
E. Send serum to assess for the presence of heparinplatelet factor 4 (PF4) IgG
antibody and continue heparin.

Dr Hasina is the chief consultant of Cardiology HDU. She is asked to see a 60-year-old
man on the High Dependency Unit. He underwent coronary artery bypass 7 days
ago and has developed some necrotic ulcers on his abdominal wall. He has had two
myocardial infarctions in the last year. He was otherwise recovering well postoperatively. He is on intravenous un-fractionated heparin, aspirin, atenolol and
lisinopril. Examination shows a breathless, cyanosed man, with tachycardia and a
clear chest. His left leg is swollen and mottled. Chest X-ray is clear. Blood tests
show:
haemoglobin (Hb) 10.3 g/dl
white cell count (WCC) 5.3 x 109/l
platelets 35 x 109/l
blood film confirms low platelet count
activated partial thromboplastin time (APTT) 42 s (3040s)
What decision Hasina should give?
1. Give a unit of platelets to attain a platelet count of > 50 x 109/l
2. Change to low molecular weight heparin
3. Stop all heparin including flushes to cannulae until the platelet count returns to
normal
4. Stop heparin and start anticoagulation with danaparoid until the platelet count
returns to normal
5. Stop heparin and start anticoagulation with warfarin, once a thrombophilia test
had ruled out protein C or S deficiency

A 70-year-old woman presents with fatigue and confusion that has come on
gradually over several weeks. She is a retired secondary school teacher who
was still tutoring on a part-time basis until 3 months ago, but has recently
become reliant on family and neighbours for basic self-care. She has no
previous medical history of note and is taking only antacids for occasional
dyspepsia. She was brought to Dr Kamrul, director of Neurology, AIMS. On
examination she is disorientated; tone power and reflexes are all within
normal limits. Plantar responses are down going. Funduscopy shows
prominent retinal veins but is otherwise normal. There are bi-basal crackles
at both bases. Blood tests are shown below:
haemoglobin (Hb) 9.5 g/dl
What test was given by Kamrul?
white cell count (WCC) 5.3 x 109/l
1. Plasma viscosity
Platelets 120 x 109/l
2. Skeletal survey
Urea 10.3 mmol/l (2.57.5)
3. Serum protein electrophoresis
4. Urine for BenceJones protein
Bilirubin 21 mol/l (122)
5. Bone marrow trephine
Albumin 29g/l (3749)
Protein 113 (6076) g/l
erythrocyte sedimentation rate 95 mm/1st hour
calcium 2.3 mmol/l (2.22.6)
Kamrul gave a single test that established the likely cause of confusion.

A 70yearold man presents to Pulmonology OPD of AIMS following a fall at home

with acute localized chest wall pain. On further questioning, he also complains of
chronic postural lower back pain and chronic fatigue.
On examination it was noted that he has a number of bruises over his arms and legs
although the patient denies previous trauma. Examination of his chest shows
marked tenderness over his left lower rib cage compatible with marked injury to
the ribs and he has tenderness to touch over this lower lumbar spine. He is mildly
anaemic and appears dehydrated. The remainder of his clinical examination is
normal.
Dr Al-amin, director of Pulmonology would like to exclude a diagnosis of myeloma as
an underlying cause of the patients symptomology.
Which of the following combinations of criteria is required to establish a diagnosis of
myeloma?
A. >30% plasma cells on bone marrow and radiography demonstrating lytic lesions
B. Hypercalcemia and a monoclonal band on serum electrophoresis
C. Increased acute leukaemia protocol (ALP) levels and Bence Jones protein in urine
D. Abnormal bone scintigram and Bence Jones protein in the urine
E. 1030% plasma cells on bone marrow, a monoclonal band on serum
electrophoresis

The evaluation in a newly diagnosed case of acute

lymphoid leukemia (ALL) should routinely include
all of the following except
A. bone marrow biopsy
B. cell-surface phenotyping
C. complete metabolic panel
D. cytogenetic testing
E. lumbar puncture
F. plasma viscosity

Which of the following patients would a gamma

irradiated blood product be recommended:
A a 37-year-old patient with Hodgkin's lymphoma
receiving chemotherapy
B a 16-year-old thalassemic receiving regular transfusions
C a 42-year-old lady receiving adjuvant hormonal therapy
for breast cancer post radical mastectomy
D 19-year-old nulliparous female after a road traffic
accident
E post operatively for carcinoma of the colon in a 50-yearold male

A 42-year-old man is admitted to neurology dept of AIMS

with headaches and visual disturbance. Dr Kamrul
diagnosed him Waldenstrms macroglobulinaemia. While
in the assessment unit, he has a nosebleed that is
continuing to ooze and is difficult to control. Fundoscopy
shows dilated retinal veins with a retinal haemorrhage in
the right eye. He has pale conjunctiva and appears
breathless. Observations:
BP 115/65 mmHg
HR 120 bpm
Temperature 37oC
What is the next best management step Kamrul needs to do?
1. Urgent ophthalmology referral
2. Carry out a CT brain scan
3. Give Haemodialysis
4. Haemoperfusion
5. Plasmapheresis

A 40-year-old man presents to cardiology dept of AIMS with breathlessness of

3 months duration. He is now moderately breathless on climbing a single
flight of stairs. He had been working as a gym instructor before the onset of
symptoms. He first noticed his symptoms after a heavy bout of indigestion
that occurred on the day of a close relatives funeral. He was treated with
chaemotherapy and mediastinal radiotherapy for Hodgkins disease 10
years previously and has been in complete remission ever since, although
he says his chest X-ray remains abnormal.
Dr Khaleda advices some investigations which was as follows:
His chest X-ray shows a widened mediastinum and borderline cardiomegaly
and an ECG shows poor R wave progression in the anterior chest leads with
Q waves in V2, 3 and 4. On examination he has a few crackles throughout
the chest, most prominent at the bases and an audible third heart sound.
He has prominent neck veins.
What is the most likely diagnosis?
1. Heart failure secondary to anterior myocardial infarction
2. Pericardial effusion from progressive Hodgkins disease
3. Progressive pulmonary fibrosis from bleomycin
4. Cardiac failure secondary to previous anthracycline administration
5. Cardiac amyloid infiltration

An 84-year old man presents to hematology dept of AIMS with easy bruising of three
months duration. He was previously fit and well, but has lost a stone in weight
recently. He is on no medication and has no allergies. Direct questioning is
unremarkable other than some symptoms of prostatism. Examination shows him to
be icteric, with multiple bruising.
Investigations are shown below:
Hb 8.0 g/dl
WCC 33.7 x 109/l
Platelets 56 x 109/l
Activated partial thromboplastin time 48 s (3040)
Fibrinogen 0.9 g/l (1.85.4)
Bilirubin 35 mol/l
Blood film shows schistocytes, nucleated red blood cells, metamyelocytes and
myelocytes.
What is the most likely diagnosis?
i.
Prostate cancer
ii.
Chronic myeloid leukaemia
iii. Myelofibrosis
iv. Thrombotic thrombocytopenic purpura
v.
Haemolytic uraemic syndrome

All but which of the following statements about the lupus

anticoagulant (LA) are true?
A. Lupus anticoagulants typically prolong the aPTT.
B. A 1:1 mixing study will not correct in the presence of
lupus anticoagulants.
C. Bleeding episodes in patients with lupus anticoagulants
may be severe and life-threatening.
D. Female patients may experience recurrent
midtrimester abortions.
E. Lupus anticoagulants may occur in the absence of
other signs of systemic lupus erythematosus (SLE).

A 50-year-old man with myelodysplasia came to hematology OPD of AIMS

complaining breathlessness on exertion. He was diagnosed with
myelodysplasia 3 years ago and since then has been on two units of blood
every 3 weeks to maintain his haemoglobin above 10g/dl. He has noticed
over the last 3 months increasing exertional breathlessness despite
adequate haemoglobin. Examination shows a slim gentleman with a greyish
skin colour. Pulse 90 beats per minute (bpm), sinus rhythm. Heart sounds
are normal. Jugular venous pressure is not raised. Cardiac apex is palpable
at the anterior axillary line. Chest is clear and abdominal examination is
normal. Results are shown below:
haemoglobin (Hb) 11.3 g/dl
white cell count (WCC) 1.3 x 109/l
platelets 23 x 109/l
neutrophils 0.3 x 109/l
glucose 12.4 mmol/l (3.06.0)
What is the best management?
1. Increase the transfusion program to maintain haemoglobin above 12 g/dl
2. Commence subcutaneous recombinant erythropoietin to raise the
haemoglobin to 12 g/dl
3. Start venesection program to reduce ferritin to less than 1000
4. Commence iron chelation with desferrioxamine subcutaneously
5. Commence hydroxyurea or similar cytotoxic to treat myelodysplasia

Which of the following infusion times would be

appropriate during the transfusion of a blood product
in a stable patient:
A A platelet transfusion should be given over 90 minutes
B A Packed cell transfusion should be given over 20
minutes
C A platelet transfusion should be given over 60 minutes
D A packed cell transfusion should be given over 90
minutes
E A Platelet transfusion over 120 minutes

A 30-year-old woman with known sickle-cell disease (SC phenotype) presents to Dr

Ershad with severe abdominal pain. She has had multiple admissions in the past for
abdominal pain, requiring large doses of parenteral opiates. She has not had any
chest crises or strokes in the past. She is on folic acid 5 mg daily, penicillin V 250 mg
twice daily, morphine sulphate slow release 200 mg twice daily with 80 mg
morphine sulphate for breakthrough pains. She works as a nurse in intensive care
and has two children aged 8 and 10 who are both well.

Her brother died from sickle-cell disease 1 year ago. Investigations have in the past
been unremarkable and the pain has been put down to painful vaso-occlusive
crises. On examination she is in extreme pain and distress with widespread
guarding over the abdomen.
haemoglobin (Hb) 5.4 g/dl
white cell count (WCC) 6.3 x 109/l
platelets 403 x 109/l
bilirubin 135 mol/l (122)
alkaline phosphatase 235 U/l
What do you think is the most likely cause of this patients abdominal pain?
1. Splenic sequestration crisis
2. Vaso-occlusive sickle-cell crisis
3. Gallstones
4. Mesenteric infarction
5. Splenic infarction

A 45-year-old man is referred to hematology dept of AIMS from his general

practitioner with an abnormal white cell count found on routine testing. On
examination he has several 12 cm lymph nodes and 3 cm splenomegaly. Blood
tests are shown below:
haemoglobin (Hb) 9.5g/dL
white cell count (WCC) 34.3 x 109/l
platelets 94 x 109/l
lymphocytes 31 x 109/l
blood film shows a proliferation of small, mature lymphocytes
immunophenotype positive for B-cell markers (CD19 and CD20) with aberrant
expression of the T-cell marker CD5.
How will Dr Afrina advise the patient?
A. He has CLL that is likely to run an indolent course and should not affect his overall
life expectancy
B. He has ALL, which has caused his normal bone marrow function to be severely
compromised
C. He has CLL that is in an advanced stage and it is likely to dramatically shorten his
life expectancy
D. He has CML that is at an advanced stage, but this can only be confirmed by
performing peripheral blood karyotyping for the Philadelphia chromosome
E. He has T pro-lymphocytic leukaemia that will dramatically shorten his life
expectancy

All the following match the anticoagulant with its

correct mechanism of action except
A. abciximabGpIIb/IIIa receptor inhibition
B. clopidogrelinhibition of thromboxane A2
release
C. fondaparinuxinhibition of factor Xa
D. argatrobanthrombin inhibition
E. warfarinvitamin Kdependent carboxylation
of coagulation factors

A 19-year-old female student presents with marked bruising and gum bleeding of 3
days duration. She has no previous medical history of note and is on no regular
medication. Examination shows wide spread bruising and marked gingival bleeding.
Temperature is 37.1oC, blood pressure 120/75 mmHg and pulse 93 beats per
minute (bpm). Chest is clear and abdominal examination is normal. Investigations
are shown below:
haemoglobin (Hb) 10.3 g/dl
white cell count (WCC) 2.3 x 109/l
platelets 7 x 109/l
fibrinogen 0.9 g/l (1.85.4)
prothrombin time 20.3 s (11.515.5)
activated partial thromboplastin time (APTT) 53 s (3040s )
D dimers 3.2 mg/l (< 0.5)
blood film shows occasional atypical pro-myelocytes packed with azurophilic granules
What is the best treatment?
1. All-trans-retinoic acid
2. Epsilon aminocaproic acid
3. Tranexamic acid
4. Aprotonin
5. Low-dose heparin

A 60-year-old lady with bruising is investigated and found to

have the following full blood count:
Haemoglobin
13 x10 g/dL
(11.5-16.5)
White cell count
6.3 x109/L
(4-11 x109)
Platelet count
15 x109/L
(150-400 x109)
She refuses to give consent to a bone marrow biopsy.
What is the most appropriate management plan?
A. Intravenous immunoglobulin
B. No treatment
C. Oral prednisolone
D. Platelet transfusion
E. Splenectomy