Hematology

1. A 30/F with profuse vaginal bleeding arrived

in the ER. She progressively became weaker
with shortness of breath. Initial assessment of
the patient revealed BP of 80/60 HR 120 RR
24 and T 37.3 deg C. She appeared
confused and diaphoretic. What is the
estimated blood loss for this patient? (HPIM
20th ed. C59 P386)

a. At least 10 percent
b. At least 20 percent
c. At least 30 percent
d. At least 40 percent
Blood Loss Manifestation
> 30% Patient prefers to lie supine, postural
hypotension and tachycardia
> 40% Confusion, dyspnea, diaphoresis,
hypotension and tachycardia
2. A 50/M presented in the OPD with anemia. A
peripheral blood smear done outside showed
the following:
2. (cont’d) Which of the following is the most
likely diagnosis?: (HPIM 20th ed. C59 P389 F59-
11)

a. Myelofibrosis
b. Liver disease
c. Chronic renal insufficiency
d. Presence of mechanical heart valves
PBS Findings Disease
Howell Jolly Bodies Asplenia

Dacryocytes/ Myelofibrosis
Teardrop cells

Target Cells Liver Disease

Thalassemia
PBS Findings Disease
Red Cell Mechanical heart valves
Fragmentation Thermal Injury

Burr Cells/ Uremia

Echinocytes

Spur Cells/ Abetalipoprotenemia

Acanthocytes Hemolytic anemia in
severe liver disease
3. A 50/M presented in the OPD due to
increased hemoglobin levels. On routine annual
check-up for employment, his CBC showed Hb
170 Hct 0.60 WBC 5 Plt 350. He was otherwise
asymptomatic. Past medical history is pertinent
for hypertension and a prolonged smoking
history. Serum EPO levels were elevated.
Subsequent ABG showed the following results:
pH 7.40 PCO2 39 PaO2 90 HCO3 24 at room
air. Which of the following is the most likely
cause of the patient’s elevated hemoglobin
levels? (HPIM 20th ed. C59 P393 F59-18)
a. Polycythemia vera
b. Smoker’s polycythemia
c. Chronic obstructive pulmonary disease
d. Intracardiac shunt
4. A 20/F who was being worked up for anemia
was computed to have a reticulocyte production
index of 3. Which of the following is the MOST
likely cause of the patient’s anemia? (HPIM 20th
ed. C59 P391 F59-17)

a. Blood loss
b. Thalassemia
c. Iron deficiency anemia
d. Sideroblastic anemia
5. Which of the following conditions is sufficient
to cause megaloblastic anemia? (HPIM 20th ed.
C95 P703 T95-3)

a. Partial gastrectomy
b. Zollinger-Ellison syndrome
c. Gastric bypass
d. Severe pancreatitis
Megaloblastic Anemia
• Megaloblastic anemia arises as a result of
deficiencies in folate (Vitamin B9) or cobalamin
(Vitamin B12)
• Intrinsic Factor (IF) vital to absorption of
cobalamin in ileum
• Gastrectomy (Total or Partial) can impede
production of IF
HPIM 20th Ed. C95 T95-3, T95-4 Page 703-704

HPIM 20th ed. C95 P703

6. What is the recommended daily dose of folic
acid supplementation in pregnant patients with
previous history of having children with neural
tube defects? (HPIM 20th ed. C95 P708)

a. 5 ug
b. 50 ug
c. 5 mg
d. 50 mg
6. What is the recommended daily dose of folic
acid supplementation in pregnant patients with
previous history of having children with neural
tube defects? (HPIM 20th ed. C95 P708)

a. 5 ug
b. 50 ug
c. 5 mg
d. 50 mg

*in normal pregnancies with no previous history

of NTDs: 400 ug
7. In the evolution of iron deficiency anemia, at
what phase does serum iron begin to decrease?
(HPIM 20th ed. C93 P685)
a. Normal iron stores
b. Negative iron balance
c. Iron deficient erythropoiesis
d. Iron deficient anemia
HPIM 20th ed. C93 P685
8. A 30/M presented to the OPD with progressive
generalized weakness over the past few weeks. He has
no known co-morbidities and vices. PE showed pale
conjunctiva and nail beds. Tests showed Hgb of 10.0
mg/dL, Hct of 0.30, WBC 8,000/uL, Platelet 400,000/uL.
Peripheral blood smear showed microcytic hypochromic
red blood cells, with no note of toxic granulations or
immature white blood cells. Further workup revealed
serum iron 100 ug/dL (N: 50-150 ug/dL), TIBC 320
ug/dL (N: 300-360 ug/dL), 40% saturation (N: 30-50%)
and Ferritin 280 ug/L (N 50-200 ug/L). What is the most
likely diagnosis? (HPIM 20th ed. C93 P687 T93-4)
a. Anemia of inflammation
b. Iron deficiency anemia
c. Sideroblastic anemia
d. Blood loss
HPIM 20th ed. C93 P687
9. Which of the following hemolytic anemias is
classified as acquired intra-corpuscular defects?
(HPIM 20th ed. C96 P709 T96-1)

a. Hemoglobinopathy
b. Paroxysmal nocturnal hemoglobinuria
c. Atypical hemolytic uremic syndrome
d. Microangiopathic hemolytic anemia
HPIM 20th ed. C96 P709
10. Which of the following diseases is associated
with warm autoimmune hemolytic anemia? (HPIM
20th ed. C96 P719 T96-7)

a. Lymphoma
b. Waldenstrom’s disease
c. Mycoplasma infection
d. Chronic lymphoblastic leukemia
HPIM 20th ed. C96 P719
11. A 25/F came to the OPD due gum bleeding
with associated generalized weakness. She
denied any comorbidities and claimed to have
lived a healthy lifestyle. Physical examination
revealed pallor and tachycardia. CBC showed
Hgb 8.0 mg/dl Hct 0.35 WBC 4,000/uL Plt
80,000/uL N 0.20 L 0.80. Bone marrow aspiration
biopsy showed the following:
11. (cont’d). What is the most likely diagnosis?
(HPIM 20th ed. C98 P726 F98-1)

a. Aplastic anemia
b. Myelophtisis
c. Myelodysplastic syndrome
d. Myeloproliferative neoplasm
11. (cont’d). What is the most likely diagnosis?
(HPIM 20th ed. C98 P726 F98-1)

a. Aplastic anemia
b. Myelophtisis – usually dry tap
c. Myelodysplastic syndrome – normal or
hypercellular marrow
d. Myeloproliferative neoplasm
• The diagnosis of aplastic anemia is usually straightforward,
based on the combination of pancytopenia with a fatty bone
marrow.

• Aplastic anemia is a disease of the young and should be a

leading diagnosis in the pancytopenic adolescent or young
adult.

• If pancytopenia is secondary the primary diagnosis is usually

obvious from either history or physical examination: the
massive spleen of alcoholic cirrhosis, the history of
metastatic cancer or SLE, or miliary tuberculosis on chest
radiograph.

• The most important differential diagnosis is between

acquired and constitutional aplastic anemia, and between
aplastic anemia and MDS.
HPIM 20th Ed. C98 T98-1 Page 724
12. Which of the following characteristics define
severe aplastic anemia? (HPIM 20th ed. C98 P727)

a. ANC < 500/uL

b. Platelet count < 50,000/uL
c. Corrected reticulocyte count < 2%
d. Hemoglobin < 8.0 mg/dL
Severe Aplastic Anemia
• ANC < 500/uL
• Plt < 20,000/uL
• Corrected reticulocyte count <1% OR
Absolute reticulocyte count < 60,000/uL

• Must have 2 out of 3

• Hemoglobin level not part of the criteria
13. What is the most common early symptom of
aplastic anemia? (HPIM 20th ed. C98 P726)

a. Easy fatigability
b. Bleeding
c. Fever
d. Weight loss
13. What is the most common early symptom of
aplastic anemia? (HPIM 20th ed. C98 P726)

a. Easy fatigability – most common early

symptom in MDS
b. Bleeding – most common early symptom in
aplastic anemia
c. Fever – points more towards
myeloproliferative neoplasms
d. Weight loss – points more towards
myeloproliferative neoplasms
14. A 65/F came to the OPD due to easy
fatigability over the past few weeks. Over the last
few days, she noted the onset of shortness of
breath. PE showed pallor and tachycardia. CBC
showed Hgb 8.0 mg/dl Hct 0.35 WBC 4,000/uL
Plt 80,000/uL N 0.20 L 0.80. Peripheral smear
showed hyposegmented neutrophils with Döhle
bodies. Bone marrow aspiration showed a
hypercellular marrow. Which of the following
treatment options can offer cure for this patient?
(HPIM 20th ed. C98 P732)
a. Imatinib
b. Lenaledomide
c. Stem cell transplantation
d. Antithymocyte globulin and cyclosporine
14. A 65/F came to the OPD due to easy fatigability
over the past few weeks. Over the last few days, she
noted the onset of shortness of breath. PE showed
pallor and tachycardia. CBC showed Hgb 8.0 mg/dl
Hct 0.35 WBC 4,000/uL Plt 80,000/uL N 0.20 L 0.80.
Peripheral smear showed hyposegmented
neutrophils with Döhle bodies. Bone marrow
aspiration was subsequently done which showed a
hypercellular marrow. Which of the following
treatment options can offer cure for this patient?
(HPIM 20th ed. C98 P732)
a. Imatinib – for CML
b. Lenaledomide – for reversing anemia
c. Stem cell transplantation – only one that offers
cure
d. Antithymocyte globulin and cyclosporine– for
aplastic anemia
15. A 19/M with hemophilia A came in due to
refractory gum bleeding. Vital signs were stable
and CBC parameters were still in the normal
range. Factor VIII was not available. Which of the
following blood products can be used for this
patient? (HPIM 20th ed. C112 P832)

a. FFP
b. Cryoprecipitate
c. Whole blood
d. Cryosupernate
HPIM 20th Ed. C109 T109-2 Page 811
Factor VIII therapy in Hemophilia A
Indication Target Levels Other Comments
Mild bleeding 30-50% For target joints provide
enough factor to
maintain 15-25% for 2-3
days
Large hematomas or >/=50% Factor replacement may
Deep muscle bleeding be required for a period
of 1 week or longer
Serious bleeds 50-100% Treatment may require
(including CNS, 7-10 days
oropharyngeal spaces,
retroperitoneal)
Prophylactic 100% Treatment may require
replacement for surgery 7-10 days

*Oral surgery May require

accompanying
antifibrinolytics
16. A 60/M patient on warfarin came in for
melena. INR was 6. What blood product is
appropriate for this patient? (HPIM 20th ed. C114
P854)

a. Four factor prothrombin complex concentrate

b. Cryoprecipitate
c. Fresh frozen plasma
d. Oral vitamin K
Treatment of Warfarin Toxicity
• Asymptomatic, INR between 3.5-10: hold
warfarin until INR returns to therapeutic range
• INR > 10: vitamin K 2.5-5mg
• Serious bleeding (GI/retroperitoneal bleed):
• 5-10 mg vitamin K SIVP until INR normal
• Four factor prothrombin complex concentrate
17. A 50/F was being treated for high-risk
community acquired pneumonia. She developed
bleeding per NGT and ET tube during the
admission. Labs showed the following results:
CBC Hb 7.1 mg/dl, Plt 83,000/uL, PT 17.9s, aPTT
42s, D-Dimer 2x elevated, Fibrinogen 75 mg/dL
(N 150-350 mg/dL). Which of the following
products is most appropriate for this patient?
(HPIM 20th ed. C112 P836)
a. Albumin
b. Cryoprecipitate
c. Platelets
d. Whole blood
Management of Bleeding in DIC
Clinical Setting Management
Active bleeding FFP and/or platelet
High risk for bleeding (preparation for concentrate transfusion
invasive procedure, after chemotherapy)
Low platelet (<10,000-20,000/uL) and low
levels of coagulation factors (PT > 1.5x)
Low levels of fibrinogen (<100mg/dL) Cryoprecipitate infusion
Brisk hyperfibrinolysis
Severe thrombocytopenia Platelet concentrate (1-2
U/10kg body weight
*replacement of single factors not recommended
18. A 45/F polycythemia vera patient came to the
OPD due to symptoms of hyperviscosity. Her
latest Hgb is 18.0 mg/dl and Hct is 0.50 despite
serial phlebotomy every 3 months. What is the
add-on treatment for this patient? (HPIM 20th ed.
C99 P735)

a. Aspirin
b. Folic Acid
c. Hydroxyurea
d. Methotrexate
18. A 45/F polycythemia vera patient came to the
OPD due to symptoms of hyperviscosity. Her
latest Hgb is 18.0 mg/dL and Hct is 0.50 despite
serial phlebotomy every 3 months. What is the
add-on treatment for this patient? (HPIM 20th ed.
C99 P735)
a. Aspirin – its use in prevention of thrombosis is
potentially harmful if red cell mass is not
controlled by phlebotomy
b. Folic Acid
c. Hydroxyurea
d. Methotrexate
19. The presence of these abnormal granules in
leukemic cells makes the involvement of the
myeloid lineage virtually certain: (C100, P743)

a. Auer rods
b. Heinz bodies
c. Howell-Jolly bodies
d. Pappenheimer bodies
20. Which of the following drug classes
revolutionized the treatment and prognosis in
CML? (C101, P753)

a. CD20 monoclonal antibodies

b. IFN inhibitors
c. JAK2 inhibitors
d. Tyrosine kinase inhibitors