1-A 78-year-old lady is admitted to hospital for a right hemicolectomy for

carcinoma of
the caecum.
She has a history of osteoarthritis for which she takes non-steroidal anti-
inflammatory
agents intermittently. Two years previously she had a fibroma removed from her
right
breast. She is a non-smoker and drinks approximately 8 units of alcohol per week.
Investigations pre-operatively show:
Hb 105 g/L (115-165)
MCV 71 fL (80-96)
WCC 8.4 ×109/L (4-11)
Platelets 401 ×109/L (150-400)
The procedure was uncomplicated and she was given two units of packed red cells
postoperatively. Three days later she becomes jaundiced and complains of
lassitude.
Investigations post-operatively:
Hb 72 g/L (115-165)
MCV 110 fL (80-96)
WCC 9.5 ×109/L (4-11)
Platelets 395 ×109/L (150-400)

Which of the following is the best investigation to confirm the diagnosis?

A Antiglobulin test (indirect)

B- Direct Coombs' test
C- Haptoglobin level
D- Reticulocyte count
E- Serum iron level

2-A 32-year-old Afro-Caribbean lady is admitted to hospital with a three day

history of
increasing pain and swelling of her left leg. Over the past 24 hours she has also
developed a low-grade fever. There is no history of recent trauma, immobilisation
or
prolonged travel by land or air.
She was admitted two years previously with a similar episode of pain and swelling
in her
right calf; a deep vein thrombosis was confirmed on Doppler scanning. She is
otherwise
fit and well. She is married and lives with her husband and works on a production
line
for a company producing televisions. She is a non-smoker and does not drink
alcohol.
She had been taking the oral contraceptive pill when admitted two years ago with a
DVT, but this was then discontinued. Her only medication is an antidepressant,
prescribed by her GP after she had a miscarriage six months previously. Her
relationship with a previous partner ended after she miscarried his child.

Investigations showed:
Hb 105 g/L (115-165)
MCV 94 fL (80-96)
WCC 7.5 ×109/L (4-11)
Platelets 95 ×109/L (150-400)
Protein C Normal activity -
Protein S Normal activity -
VDRL Positive 1:8 –

What is the likely diagnosis?

A- Antiphospholipid syndrome
B- Factor V Leiden mutation
C- Hyperhomocysteinaemia
D- Pelvic inflammatory disease
E- Tertiary syphilis

3-A 25-year-old woman undergoing treatment for promyelocytic (M3) leukaemia

develops a high fever.
Sepsis is suspected and she rapidly develops widespread ecchymoses and starts
bleeding from venepuncture sites and mucous membranes.
Which is the most specific laboratory test to confirm the diagnosis of disseminated
intravascular coagulation (DIC)?

A- Activated partial thromoplastin time

B- D-dimer assay and fibrin degradation products (FDP)
C- INR
D- Plasma fibrinogen concentration
E- Platelet count

4-A 28-year-old lady presents with a three day history of a painful swollen right
calf.
Her coagulation screen shows:
Prothrombin time 13 s (11.5-15.5)
Thrombin time 13 s (13)
Activated partial thromboplastin time 78 s (30-40)
The APTT was not corrected when mixed with normal plasma.
What is the cause of the clotting abnormality?

A- Chronic liver disease

B- Disseminated intravascular coagulation
C- Haemophilia
D- Lupus anticoagulant
E- von Willebrand disease

5-A 72-year-old man is referred to clinic with a four month history of

breathlessness,
abdominal swelling and discomfort.
On examination, he appears pale and unwell. His liver is palpable 9 cm below the
right
costal margin and his spleen palpable 7 cm below the left costal margin. No
lymphadenopathy was detected.
Investigations show:
Hb 79 g/L (130-180)
RBC 2.1 ×1012/L -
PCV 0.17 -
MCH 30 pg (28-32)
MCV 82 fL (80-96)
Reticulocytes 1.4% (0.5-2.4)
Total WBC 23 ×109/L (4-11)
Normoblasts 8% -
Platelets 280 ×109/L (150-400)
Neutrophils 9.0 ×109/L (1.5-7)
Lymphocytes 5.2 ×109/L (1.5-4)
Monocytes 1.3 ×109/L (0-0.8)
Eosinophils 0.2 ×109/L (0.04-0.4)
Basophils 0.2 ×109/L (0-0.1)
Metamyelocytes 5.1 ×109/L -
Myelocytes 1.6 ×109/L -
Blast cells 0.4 ×109/L -
Blood film: Anisocytosis, poikilocytosis and occasional erythrocyte tear drop cells.
What is the first investigation of choice?
Bone marrow culture for mycobacteria
B- Bone marrow smear
C- Bone scan
D- Bone (trephine) biopsy
E- Leucocyte alkaline phosphatase

6- A 33-year-old female with a history of paranoid delusions of one month

duration was
treated with phenothiazine.
She presents with a 10 day history of fever, chills, and malaise, with increasing
weakness and fatigue over the last two days.
Examination reveals a temperature of 38.1°C, a pulse of 100 beats per minute
regular
and a blood pressure of 110/76 mmHg. She has a respiratory rate of 25/min and
chest
with dullness to percussion and decreased breath sounds at the left base. There is
no
splenomegaly.
Investigations reveal:
Haemoglobin 102 g/L (115-165)
Haematocrit 0.384 (0.36-0.47)
MCV 90 fL (80-96)
White cell count 0.9 ×109/L (4-11)
Neutrophils 0.3 ×109/L (1.5-7)
Lymphocytes 0.3 ×109/L (1.5-4)
Monocytes 0.01 ×109/L (0-0.8)
Eosinophils 0.01 ×109/L (0.04-0.4)
Platelets 210 ×109/L (150-400)
Serum sodium 131 mmol/L (137-144)
Serum potassium 3.3 mmol/L (3.5-4.9)
Serum urea 4.2 mmol/L (2.5-7.5)
Serum glucose 5.1 mmol/L (3.0-6.0)
The chest x ray shows evidence of left basal consolidation.
What is the most likely cause of her haematological indices?

A- Accelerated destruction of neutrophils

B- Aplastic anaemia
C- Drug induced
D- Ineffective erythropoiesis
E- Shift from circulating pool to marginal granulocyte pool
7- A 27-year-old Afro-Caribbean male attends for a routine insurance examination.
Questioning reveals that he has been frequently tired of late and sleeps in the
evenings.
He also gives a history of bleeding gums and several recent episodes of epitaxis.
He is
a non-smoker but drinks 22 units of alcohol weekly.
Examination reveals a pale appearance but no other abnormalities.
Investigations show:
Haemoglobin 80 g/L (130-180)
Haematocrit 0.24 (0.40-0.52)
MCV 88 fL (80-96)
White cell count 2 ×109/L (4-11)
Neutrophils 20% -
Lymphocytes 77% -
Platelets 40 ×109/L (150-400)
The peripheral blood film showed normocytic hypochromic erythrocytes.
What is the most likely diagnosis?

A- Accelerated destruction of neutrophils

B- Aplastic anaemia
C- Drug induced
D- Sepsis
E- Sickle cell crisis
8- A 55-year-old man was referred to the outpatient clinic with anaemia.
He had presented to his general practitioner with a three month history of fatigue
and
low back pain. There was no preceding history of trauma. A plain x ray of his
lumbar
spine showed a lytic lesion in the body of the fourth lumbar vertebra (L4).
Investigations revealed:
Haemoglobin 105 g/L (130-180)
WBC 4.0 ×109/L (4-11)
Platelets 175 ×109/L (150-400)
Serum sodium 137 mmol/L (137-144)
Serum potassium 3.5 mmol/L (3.5-4.9)
Serum urea 2.7 mmol/L (2.5-7.5)
Serum creatinine 110 µmol/L (60-110)
Serum corrected calcium 2.4 mmol/L (2.2-2.6)
Bence Jones proteins were detected in the urine.
A skeletal survey showed increased uptake in the L4.

Which of the following therapies will reduce the risk of pathological fracture?

A- Autologous stem cell transplantation

B- Melphalan
C- Pamidronate
D- Plasmapheresis
E- Steroids

9- A 32-year-old Nigerian lady with sickle cell anaemia (Hb SS) has a history of
recurrent back pain.
She presents to casualty with fever and a worsening of the back pain. There is no
history of weight loss or night sweats.
Investigations show:
Haemoglobin 78 g/L (115-165)
White cell count 10.1 ×109/L (4-11)
Platelets 475 ×109/L (150-400)
Reticulocytes 12%
Serum total bilirubin 88 µmol/L (1-22)
What is the most likely diagnosis?
A- Aplastic crisis
B- Haemolytic crisis
C- Malaria
D- Tuberculosis
E- Vasoocclusive event

10 - A 26-year-old man attends the dental hospital for a tooth extraction.

He reports prolonged bleeding after a tooth extraction two years previously. He has
had
no other surgical challenges and no other history of prolonged bleeding. He is
otherwise
fit and well.
On further questioning he said his mother had recently been referred to a local
hospital
for recurrent nose bleeds and menorrhagia. He was also aware that his sister had
been
seen in the past for menorrhagia.
The dental extraction cannot be delayed.
What should the dentist be advised to give the patient to reduce the risk of
significant
bleeding?
A-Cryoprecipitate
B- Factor VIII replacement
C- Fresh frozen plasma (FFP)
D- Tranexamic acid
E- von Willebrand factor concentrate

11- A 56-year-old man with chronic renal failure attended the renal clinic.
He was undergoing regular haemodialysis and had been treated for the past six
months
with oral ferrous sulphate (200 mg three times a day). His haemoglobin in clinic
measured at 76 g/L, compared with 106 g/L six months previously.
Which of the following is the most appropriate treatment?

A- Erythropoietin
B- Increase the dose of oral ferrous sulphate
C- Intravenous iron
D- Intravenous iron and subcutaneous erythropoietin
E- Transfusion of two units of packed red cells

12- A 64-year-old lady is reviewed in the outpatient clinic. She has been known to
have
chronic lymphocytic leukaemia (CLL) for six months.
Apart from three chest infections in the last year, she is otherwise well.
Investigations show:
Haemoglobin 134 g/L (115-165)
White cell count 30.2 ×109/L (4-11)
Lymphocytes 26.2 ×109/L (1.5-4)
Neutrophils 3.8 ×109/L (1.5-7)
Platelet count 350 ×109/L (150-400)
Serum electrophoresis:
IgG 2.5 g/L (6-13)
IgA 0.2 g/L (0.8-3.0)
IgM 0.1 g/L (0.4-2.5)
What is the most appropriate management option at this time?

A- Chlorambucil
B- Fludarabine
C- Intravenous immunoglobulin infusions
D- Observe
E- Stem cell transplant
13- A 15-year-old girl is referred urgently to clinic because of a two day history of
spontaneous bruising.
She has no past history of note and is not taking any regular prescribed medication.
She has noticed spontaneous appearance of bruises on her hips, thighs and upper
arms over the past three days. There is no history of trauma to account for their
appearance. The largest of these measures 15 cm in diameter. Otherwise she feels
well, though she reports having had a mild viral illness two weeks previously.
Investigations show:
Haemoglobin 141 g/L (115-165)
White blood cells 7.3 ×109/L (4-11)
Platelets 15 ×109/L (150-400)
What is the most important next step?
A- Blood film examination
B- Bone marrow biopsy
C- Check coagulation screen.
D- Reassure that this is likely to resolve and see again in five days
E- Start prednisolone treatment

14- A 34-year-old man presents with a swollen, painful right calf.

A Doppler ultrasound confirms the presence of a posterior knee occlusive deep
vein
thrombosis (DVT). Two weeks previously a below knee plaster cast had been
removed
on the right side. This had been in place for four weeks following a rugby injury.
He had
no other significant past medical history.
What is the best management plan for this man?

A- Low molecular weight heparin followed by warfarin for six months

B- Low molecular weight heparin followed by warfarin for three months.
C- No treatment necessary
D- TED support stockings and repeat Doppler in one week.
E- Warfarin only

15- An 18-year-old Zimbabwean man presented with a two week history of

massive
painless cervical lymphadenopathy.
Which of the following investigations should be performed to obtain the diagnosis?
A- Bone marrow aspiration and trephine biopsy
B- Chest x ray
C- CT scan chest
D- HIV antibody test
E- Lymph node biopsy

16- A 34-year-old man was admitted to hospital with a painful swollen left leg.
While in the admissions unit he also developed abdominal pain - which he said had
been recurring over several months. He had a past history of a right calf deep vein
thrombosis (DVT) six months previously that had been treated by anticoagulation
with
warfarin for three months. He had noticed that over the past two months his urine
had
been darker than usual in the morning.
Investigations showed:
Haemoglobin 85 g/L (130-180)
White cell count 2.5 ×109/L (4-11)
Platelets 75 ×109/L (150-400)
PT 12 seconds (11.5-15.5)
APTT 35 seconds (30-40)
Serum total bilirubin 29 µmol/L (1-22)
Serum AST 20 U/L (1-31)
Serum alkaline phosphatase 80 U/L (45-105)
What is the most likely diagnosis?
A- Acute intermittent porphyria
B- Autoimmune haemolytic anaemia
C- Factor V Leiden mutation
D- Paroxysmal nocturnal haemoglobinuria
E- Protein C deficiency

17- A 33-year-old male develops a rash and low grade fever (37.6°C) 21 days post
allogeneic bone marrow transplant for high risk acute myeloid leukaemia in first
complete remission.
The rash is initially maculopapular affecting palms and soles but 24 hours later
general
erythroderma is noted affecting the trunk and limbs. His total bilirubin was
previously
normal but is now noted to be 40 µmol/L (1-22). He remains very well in himself.
What would be your management of this patient at this stage?
A-Antibiotics after blood cultures
B- Antilymphocyte globulin
C- High dose methylprednisolone
D- Observation
E- Prednisolone

18- A 69-year-old lady is seen in the haematology clinic for the second time. Her
first
review was twelve months previously.
Her full blood count shows:
Haemoglobin 118 g/L (115 - 165)
White cell count 79 ×109/L (4 - 11)
Neutrophils 4 ×109/L (1.5 - 7)
Lymphocytes 74.5 ×109/L (1.5 - 4)
Monocytes 0.4 ×109/L (0 - 0.8)
Eosinophils 0.05 ×109/L (0.04 - 0.4)
Basophils 0.05 ×109/L (0 - 0.1)
Platelet count 385 ×109/L (150 - 400)
Her white cell count twelve months previously had been 50 ×109/L. She is very
well.
How do you manage her at this stage?
A- Chlorambucil
B- Fludarabine
C- Leucapharesis
D- Observation
E- Prednisolone

19- A 33-year-old lady is admitted to the gynaecology ward at 24 weeks gestation

in her
first pregnancy.
She had seen her midwife and complained of feeling generally not well. Her
husband
reported that she has become very vague and disorientated. The midwife found her
blood pressure to be 140/89 mmHg; her booking blood pressure was 120/80
mmHg.
On admission her blood tests are as follows:
Haemoglobin 79 g/L (115-165)
White cell count 11 ×109/L (4-11) Normal differential
Platelets 30 ×109/L (150-400)
MCV 103 fL (80-96)
Reticulocyte count 12.5% -
Blood film shows red cell fragmentation with thrombocytopenia and platelet
anisocytosis. There is polychromasia.
Serum lactate dehyrogenase 1112 U/L (10-250)
Serum sodium 140 mmol/L (137-144)
Serum potassium 3.7 mmol/L (3.5-4.9)
Serum urea 15.2 mmol/L (2.5-7.5)
Serum creatinine 200 µmol/L (60-110)
Serum total bilirubin 73 µmol/L (1-22)
Serum alanine aminotranseferase 40 U/L (5-35)
Serum alkaline phosphatase 160 U/L (45-105)
Coagulation screen Normal -
Fibrinogen 5.3 g/L (1.8-5.4)
What treatment would you advise the obstetric team to give to this lady?

A- Fresh frozen plasma transfusion

B- Haemodialysis
C- None
D- Plasma exchange
E- Platelet transfusion

20- An 18-year-old man was admitted to casualty at 3 am having collapsed at a

rave
party.
A friend, who accompanied him to hospital, said that the patient had been entirely
well
earlier in the evening and had been dancing most of the night. He reported that his
friend seldom drank alcohol, although there was alcohol available at the party
venue.
He did not know whether his friend had taken any drugs.
Investigations revealed:
Haemoglobin 89 g/L (130 - 180)
White cell count 25.0 ×109/L (4 - 11)
Neutrophils 21.7 ×109/L (1.5 - 7.0)
Lymphocytes 2.0 ×109/L (1.5 - 4.0)
Monocytes 0.8 ×109/L (0 - 0.8)
Eosinophils 0.4 ×109/L (0.04 - 0.4)
Basophils 0.1 ×109/L (0 - 0.1)
Platelets 27 ×109/L (150 - 400)
Reticulocyte count 10%
Prothrombin time 32 secs (11.5 - 15.5)
Activated partial thromboplastin time 82 secs (30 - 40)
Fibrinogen 0.3 g/L (1.8 - 5.4)
D-Dimer screen 2.6 mg/L (<0.5)
Serum sodium 137 mmol/L (137 - 144)
Serum potassium 6.3 mmol/L (3.5 - 4.9)
Serum urea 17.5 mmol/L (2.5 - 7.5)
Serum creatinine 200 µmol/L (60 - 110)
Lactate dehydrogenase 525 U/L (10 - 250)
A blood film showed red cell fragmentation with polychromasia, toxic granulation
of
neutrophils and platelet anisocytosis.
What is the diagnosis?

A- Autoimmune haemolysis
B- Autoimmune thrombocytopenia
C-Disseminated intravascular coagulation (DIC)
D- Drug-induced haemolysis
E- Thrombotic thrombocytopenic purpura (TTP)

21- A 53-year-old gentleman was admitted to hospital after presenting to his GP

complaining of feeling lethargic and generally unwell.
Despite having a normal appetite, he had lost two stones in weight in six weeks. He
also
reported sweating profusely at night and his wife said that she often had to change
the
sheets because they were drenched. He also has some upper abdominal discomfort.
On examination he looked thin and unwell. His pulse was 90 beats per minute in
sinus
rhythm with blood pressure 145/80 mmHg. A short systolic murmur was audible at
the
lower left sternal edge. His chest was clear. His abdomen was soft, with slight
tenderness in the epigastrium and central abdomen. The spleen was palpable 7 cm
below the left costal margin.
Investigations revealed:
Haemoglobin 97 g/L (130-180)
White cell count 17.4 ×109/L (4-11)
Neutrophils 14.0 ×109/L (1.5-7)
Lymphocytes 1.5 ×109/L (1.5-4)
Monocytes 0.8 ×109/L (0-0.8)
Basophils 0.7 ×109/L (0-0.1)
Eosinohils 0.4 ×109/L (0.04-0.4)
Platelets 550 ×109/L (150-400)
The blood film showed left-shifted neutrophils with numerous myelocytes present.
Occasional promyelocytes were seen, but no blasts. There were also a number of
nucleated red blood cells as well as a large number of tear drop red cells. There
was a
thrombocytosis with platelet anisocytosis.
What investigation should be performed next?
A- Cytogenetic analysis of the patient’s bone marrow
B- Immunophenotyping of peripheral blood
C- Lactate dehydrogenase
D- Neutrophil Alkaline Phosphatase score
E- Ultrasound scan of abdomen

22- A 62-year-old man attended the outpatient clinic for a follow up appointment.
He had
a history of two venous thromboembolic events and wanted advice regarding his
treatment with warfarin.
He had been diagnosed with an ilio-femoral deep vein thrombosis two years
previously
and had been treated with a six month course of warfarin. A thrombophilia screen,
performed two months after stopping the warfarin, was negative.
Six months after stopping warfarin he presented to hospital with left-sided pleuritic
chest
pain. His ECG was normal but a CT pulmonary angiogram showed a pulmonary
embolus. On this occasion there were no obvious risk factors, other than his
previous
event. He was recommenced on warfarin.
At the time of his follow up outpatient appointment he was approaching
completion of
six months of treatment. During his hospital admission, he had been advised that
he
should receive lifelong treatment with warfarin. However, he expressed concern
about
the risk of bleeding while on warfarin.
On further questioning, he reveals that he has had two admissions to hospital with
episodes of bleeding in the past three months. On the first occasion he had a
spontaneous epistaxis. The second admission was for bleeding from a scalp wound
after he hit his head accidentally on the bathroom cupboard. On both occasions his
INR
was over 8 and he had been admitted until the INR returned to normal.
What is the best course of action?
A- Continue warfarin and check compliance and monitoring of INR
B- Stop warfain
C-Stop warfarin and give long term low molecular weight heparin
D- Stop warfarin and implant an inferior vena caval filter
E- Stop warfarin and receive low molecular weight heparin for long journeys

23- A 33-year-old woman developed a fever (38.0°C) within 90 minutes of

starting a red
cell transfusion three days post allogeneic bone marrow transplant. Prior to the
transfusion her temperature had been 37.6°C.
On examination she appeared flushed, breathless and complained of dizziness and
a
tight chest. Her heart rate was 110 beats per minute and regular, blood pressure
was
90/60 mmHg and auscultation of the chest revealed widespread wheeze.
The staff nurse stopped the transfusion and checked a full blood count, the result of
which is shown below:
Haemoglobin 88 g/L (115-165)
White cell count 0.8 ×109/L (4-11)
Neutrophils 0.0 ×109/L (1.5-7)
Lymphocytes 0.5 ×109/L (1.5-4)
Monocytes 0.2 ×109/L (0-0.8)
Eosinophils 0.1 ×109/L (0.04-0.4)
Basophils 0.0 ×109/L (0-0.1)
Platelet count 12 ×109/L (150-400)
What other action should be taken?
A- Ask the blood bank for a further cross match of leucodepleted blood
B- Give paracetamol and keep close observation
C- Give paracetamol and restart transfusion at a slower rate
D- Give paracetamol, hydrocortisone and chlopheniramine
E-Start intravenous antibiotics to cover possible hospital acquired pneumonia

24- A 55-year-old gentleman presented to the outpatient clinic after being referred
by his
general practitioner.
He complained of feeling lethargic and had lost 15 kg in weight. He also
complained of
profuse sweating, especially at night and also had some upper abdominal
discomfort.
On examination, the spleen was palpable 12 cm below the left costal margin.
Investigations revealed:
Haemoglobin 97 g/L (130-180)
White cell count 17.4 ×109/L (4-11)
Neutrophils 14.0 ×109/L (1.5-7)
Lymphocytes 1.5 ×109/L (1.5-4)
Monocytes 0.8 ×109/L (0-0.8)
Basophils 0.7 ×109/L (0-0.1)
Eosinohils 0.4 ×109/L (0.04-0.4)
Platelets 550 ×109/L (150-400)
The blood film was reported as follows: The neutrophils are left shifted with
numerous
myelocytes present. There is an occasional promyelocyte but no blasts. There are
also
a number of nucleated red blood cells. There is a thrombocytosis with platelet
anisocytosis.
What investigation should be performed next?
A- Immunophenotyping of peripheral blood
B- Lactate dehydrogenase (LDH) measurement
C- Molecular analysis of peripheral blood
D- Neutrophil alkaline phosphatase (NAP) score
E- Ultra sound scan (USS) of abdomen
25- What is true about iron absorption and metabolism?
A- High levels of hepcidin are necessary for proper iron absorption
B- Heme iron is absorbed by the same intestinal receptor as nonheme iron
C- Dietary iron is present mostly in the ferrous form and must be oxidized for
absorbtion
D- Hepcidin's mechanism of action is by degradation of ferroportin, therefore
decreasing iron absorbtion
E- IL6 upregulates hepcidin production and high IL6 levels underlies the
refractory anemia in some cases of Castleman's disease.
26 - What is true about RBC exchange in sickle cell disease?
A- It has been proven to improve pregnancy outcome when used chronically
B- Should be performed prior to any surgical procedure instead of simple
transfusion
C- Is effective only when it raises Hb level to over 12
D- May be difficult or impossible to perform in patients with multiple
alloantibodies
E- Requires an apheresis machine as it can not be performed manually.

27- What is true about the sickling process?

A-It takes place in the post capillary venules which are too large to be
occluded by single cells
B- Cytokines have no role in acceleration of sickling
C- Thrombocytosis is universal in sickle cell disease but does not play a role in
sickling as the platelets are not activated.
D- Leukocytosis is common in sickle cell disease but does not play a role in
sickling as the neutrophils are not activated.
E- Since RBC adhesion involves plasma proteins, plasma exchange effectively
halts sickling.

28- What is true about coagulation in sickle cell disease?

A- Ischemic stroke is common and predominantly involves the microvessels
B- Loss of normal membrane phospholipids symmetry occurs due to a mutation in
the "flipase" enzyme, whose gene is present linked on chromosome 11.
C- Aspirin is effective in preventing thrombosis because the thrombocytosis is due
to functional asplenia
D- The pathophysiology of hypercoagulability involves the interaction of
coagulation proteins with hepatocytes.
E- Nitric oxide depletion by hemolysisn which releases free hemoglobinn
causes vasoconstriction and contributes to the tendency to clotting in many
hemolytic diseases (sickle cell, PNH etc).

29 - What is true about the anemia of beta-thalassemia major and intermedia?

A- It is caused by relative hypoplasia of the RBC series in the marrow, with low
retic counts.
B- The degree of anemia is generally well correlated with the severity of the
mutations carried by the patient, so accurate genetic counseling is possible.
C- Is exacerbated by concurrent alpha thalassemia and ameliorated by excess alpha
globin genes.
D- Is unaffected by mutations causing elevation of fetal hemoglobin
E- Can only be relieved by blood transfusions since no drugs (such as
erythropoietin, hydrea, and other agents) have ever been shown to be effective.

30- A 62-year-old gentleman was followed up every six months in the

haematology clinic.
During his most recent appointment he complained of a headache, blurred vision,
aching bones, and extreme lethargy. His wife reported that he has been very vague
at
times over the previous four weeks and drowsy when he was awake.
On examination he appeared pale with blood pressure 125/65 mmHg. He was
afebrile.
Respiratory rate was 12 breaths per minute. Cardiovascular, chest and abdominal
examination were unremarkable.
Further investigations showed:
Haemoglobin 82 g/L (130-180)
MCV 88 fL (80-96)
White cell count 9.0 ×109/L (4-11)
Neutrophils 6.2 ×109/L (1.5-7)
Lymphocytes 2.0 ×109/L (1.5-4)
Monocytes 0.6 ×109/L (0-0.8)
Eosinophils 0.1 ×109/L (0.04-0.4)
Basophils 0.1 ×109/L (0-0.1)
Platelet count 160 ×109/L (150-400)
Serum sodium 137 mmol/L (137-144)
Serum potassium 4.8 mmol/L (3.5-4.9)
Serum urea 9.0 mmol/L (2.5-7.5)
Serum creatinine 130 µmol/L (60-110)
Serum aspartate aminotransferase 30 U/L (1-31)
Serum alkaline phosphatase 90 U/L (45-105)
Serum total bilirubin 22 µmol/L (1-22)
Serum phosphate 1.2 mmol/L (0.8-1.4)
Serum corrected calcium 2.7 mmol/L (2.2-2.6)
Serum albumin 26 g/L (37-49)
Serum total protein 120 g/L (61-76)
Serum C-reactive protein 67 mg/L -
Serum immunoglobulins:
IgG 0.6 g/L (6.0-13.0)
IgA 78 g/L (0.8-3.0)
IgM 0.2 g/L (0.4-2.5)
Serum electrophoresis showed a monoclonal band (IgA kappa) with immune
paresis.
The IgA kappa level was 76 g/L.
Which of the following would be the best treatment option for this gentleman?
A- Blood transfusion
B- Chemotherapy
C- Intravenous fluids and furosemide
D- Plasma exchange
E- Plasma exchange and chemotherapy

31- A 55-year-old hotel manager was referred by her general practitioner with
abnormal
liver function tests.
She had routine blood investigations as part of a diabetes mellitus work up. She
had a
history of hypertension, type 2 diabetes, hypothyroidism and pernicious anaemia.
On
direct questioning she did complain of occasional right upper quadrant pain but
denied
any obvious features of obstructive jaundice. She did not drink alcohol.
She was taking aspirin, thiazide and metformin.
On examination she had a body mass index of 34, blood pressure 170/90 mmHg
and a
random glucose of 11.6 mmol/L (3.0-6.0). There were no other abnormal findings.
Haemoglobin 132 g/L (115-165)
White cells 9.0 ×109/L (4-11)
Platelets 350 ×109/L (150-400)
MCV 92 fL (80-96)
Albumin 40 g/L (37-49)
Bilirubin 20 μmol/L (1-22)
Alanine aminotransferase 105 U/L (5-35)
Aspartate aminotransferase 50 U/L (5-35)
Alkaline phosphatase 100 U/L (45-105)
Gamma gluteryltransferase 40 U/L (<50)
Smooth muscle antibody Not detected
Anti mitochondrial antibody Not detected
Serum IgG 10 g/L (6-13)
Serum IgA 1 g/L (0.8-3)
What is the likely cause of the liver abnormality?
A- Autoimmune hepatitis (AH)
B- Cholelithiasis
C- Drug induced hepatic dysfunction
D- Non-alcoholic fatty liver disease (NAFLD)
E- Viral hepatitis

32- A 50-year-old lady was seen in the clinic having been found by her general
practitioner to have deranged liver function.
She had been asymptomatic and felt very well. She had a past history Graves'
hyperthyroidism which had been treated with radio iodine and she was now
managed
with thyroxine.
On examination she had palmar erythema, and several spider naevi. The rest of the
examination was unremarkable.
Haemoglobin 132 g/L (115-165)
White cells 9.0 ×109/L (4-11)
Platelets 110 ×109/L (150-400)
MCV 92 fL (80-96)
Albumin 36 g/L (37-49)
Bilirubin 28 µmol/L (1-22)
Alanine aminotransferase 50 U/L (5-35)
Alkaline phosphatase 400 U/L (45-105)
Gamma gluteryltransferase 490 U/L (<50)
Smooth muscle antibody Not detected
Anti mitochondrial antibody Detected
What treatment option could you offer this lady?
A- Azathioprine
B- Cholestyramine
C- Interferon alpha
D- Prednisolone
E- Ursodeoxycholic acid

33- A 66-year-old lady presents to her GP with a two day history of intermittent
nose
bleeds. She is otherwise relatively fit and well with only hypertension as
significant in
her past medical history.
On examination her blood pressure is 135/86, cardiovascular and chest
examination
unremarkable. Her abdomen is soft and non-tender, with no masses or enlarged
organs. She has numerous bruises, mainly over her limbs but also over her trunk
and a
petechial rash over her shins.
The GP arranges some further investigations which are shown below:
Haemoglobin 110 g/L (115-165)
MCV 83 fL (80-96)
White cell count 26.9 ×109/L (4-11)
Platelets 15 ×109/L (150-400)
Blood film: Thrombocytopenia with platelet anisocytosis. There are numerous
lymphocytes on the film, they are mature with high nuclear: cytoplasmic ratio and
numerous smear cells present.
Manual differential:
Neutrophils 4.3 ×109/L (1.5-7)
Lymphocytes 22.0 ×109/L (1.5-4)
Monocytes 0.4 ×109/L (0-0.8)
Eosinophils 0.1 ×109/L (0.04-0.4)
Basophils 0.1 ×109/L (0-0.1)
What would you advise as the next step in her management?
A- Chemotherapy and intravenous immunoglobulin
B- Intravenous immunoglobulin only
C- Observation
D- Platelet transfusion
E- Prednisolone treatment only

34- A 26-year-old woman presented at 35 weeks of pregnancy with profuse

vaginal
bleeding. She had suffered two previous miscarriages.
She had a pulse of 95 beats per minute, blood pressure of 110/84 mmHg and no
fetal
heart sounds were audible.
Investigations revealed:
Haemoglobin 98 g/L (115 - 165)
Platelets 66 ×109/L (150 - 400)
Prothrombin time 21 sec (11.5-15.5)
APTT 52 sec (30-40)
Fibrinogen 0.5 g/L (2-4)
What is the most appropriate next step in management?
A- Antithrombin III infusion
B- Fibrinogen replacement infusion (cryoprecipitate)
C- Intravenous heparin
D- Platelet transfusion
E- Transfusion of two units group O rhesus D negative blood

35- A 76-year-old retired steel industry employee is diagnosed with renal cell
carcinoma.
It is noted that his full blood count is grossly abnormal:
Haemoglobin (Hb) 203 g/L (130-180)
Haematocrit (PCV) 0.60% (0.40-0.52)
Mean cell volume (MCV) 90 fL (84-96)
White cell count (WBC) 10 ×109/L (4.0-11.0)
Platelets 400 ×109/L (150-450)
Which of the following symptoms can be explained by the above blood test
results?
A- Onycholysis
B- Pruritus
C- Pyrexia
D- Torticollis
E- Vitiligo

36- A 34-year-old man with normal baseline cardiac and respiratory function
starts on the
ABVD (Adriamycin, Bleomycin, Vinblastine and Dacarbazine) chemotherapy
regimen
for his stage IIB Hodgkin's lymphoma. He tolerated the first three cycles of the
chemotherapy well.
After completion of the 4th cycle, he presents with exertional dyspnoea and a dry
cough. He is afebrile, a chest x ray and ECG are normal.
What is the most likely diagnostic possibility?
A- Adriamycin related cardiomyopathy
B- Bleomycin related pulmonary fibrosis
C- Hyperemesis and reflex cough related todacarbazine
D- Pneumocystis jirovecii pneumonia
E- Vinblastine related neurotoxicity

37- A mild lymphocytosis of 15 ×109/l is reported on a full blood count result in a

70-yearold asymptomatic man attending clinic for an annual review.
What would be the most essential investigation to establish a diagnosis of chronic
lymphocytic leukemia (CLL)?
A- CT scan of chest abdomen and pelvis
B- Lactic Dehydrogenase (LDH) levels
C- Peripheral blood flow cytometry
D- Presence of palpable cervical lymphadenopathy
E- Presence of smear cells on the blood film

38- A 64-year-old man presents with anaemia and blurring of vision with a
haemoglobin
level of 89 g/L. A total protein with a raised globulin fraction is noted.
A serum EPG shows an IgM paraprotein of 37 g/L. A bone marrow aspirate shows
a
lymphoplasmacytic infiltrate.
Which of the following would be the next most important investigation?
A- CT scan of head and orbits
B- Plasma viscosity
C- PET scan
D- Skeletal survey
E- Urine electrophoresis

39- A 23-year-old female presents with rapid distension of her abdomen. A biopsy
from a
abdominal mass shows a B cell lymphoblastic lymphoma with a high proliferative
index.
Which of the following is the cytogenetic abnormality seen in this lymphoma?
A- t(4;11)
B- t(8;14)
C- t(11;18)
D- t(11;14)
E- t(14;18)

40- A 42-year-old male is investigated for dyspepsia. An antral biopsy from an

irregular
area visualised in the gastroscopy is reported as mucosal associated lymphoid
tissue
lymphoma (MALT lymphoma).
He has no other sites of disease on staging and is systemically well.
Which of the following would be the first line treatment of choice for this man?
A- Chemotherapy in combination with monoclonal antibodies
B- Monoclonal antibody therapy
C- Radiotherapy
D- Surgery
E- Triple therapy
41- A 36-year-old man presents with stage IV diffuse large B cell lymphoma. On
the CT
scan he has bulky abdominal nodes. He receives combination chemotherapy along
with
rituximab.
About 24 hours later he reports feeling unwell and his investigations are shown
below:
Serum sodium 137 mmol/L (135-146)
Serum potassium 5.6 mmol/L (3.5-5.0)
Calcium 1.9 mmol/L (2.2-2.6)
Phosphate 1.42 mmol/L (0.8-1.4)
Urea 9.1 mmol/L (10-20)
Uric acid 1.2 mmol/L -
Creatinine 156 μmol/L (79-118)
Lactic acid dehydrogenase 1845 IU/L (105 - 333)

What is the diagnosis?

A- Cyclophosphamide related urothelial toxicity
B- Doxorubicin related renal toxicity
C- Infusional toxicity due to rituximab
D- Sepsis
E- Tumour lysis syndrome

42- A 14-month-old baby is admitted with an Hb of 58 g/L and a diagnosis of

Fanconi's
anaemia is suspected.
Which of the following observations would be consistent with the pathology in this
condition?
A- Haemoglobin synthesis disorder
B- Increased chromosomal fragility disorder
C- Increased extravascular red cell destruction
D- Increased intravascular red cell destruction
E- Iron metabolism disorder
43- A 52-year-old man develops a deep vein thrombosis after being admitted for a
fracture of his left femur following a car crash.

Which of the following is true about thrombophilia testing?

A- A thrombosis in an unusual vascular territory warrants thrombophilia
testing
B- All patients, irrespective of a family history of thrombosis, require to be tested
C- Patients with provoked DVT should always be tested for thrombophilia
D- The most common known heritable thrombophilia is prothrombin gene
mutation
E- This patient warrants testing as he is less than 60 years of age

44- A 32-year-old woman is admitted with acute cholecystitis. Imaging shows she
has
gallstones.
Full blood count shows an Haemoglobin 104 g/L, reticulocytosis and a blood film
showing numerous spherocytes. The direct Coombs' (DAT) test is negative.
On further enquiry the lady gives a history of her mother having a splenectomy for
her
anaemia.
What is the likely diagnosis?
A- Autoimmune haemolytic anaemia
B- Hereditary elliptocytosis
C- Hereditary spherocytosis
D- Sickle cell anaemia
E- Thalassaemia

45- A 24-year-old male is admitted with severe fatigue.

His full blood count shows:
Haemoglobin 45 g/L (130-180)
Neutrophils 0.7 ×109/L (1.5-7)
Platelets 14 ×109/L (150-400)
Reticulocyte count 1 ×109/L (25-85)
The bone marrow flow cytometry was reported as being non- diagnostic. The bone
marrow trephine was reported as being hypocellular with a few islands of
erythropoiesis.
What is the most likely diagnosis?
A- Acute lymphoblastic
B- Acute myeloid leukaemia
C- Aplastic anaemia
D- Haemolytic anaemia
E- Myelodysplastic syndrome