National license Hematology

http://library.med.utah.edu/WebPath/EXAM/EXAMIDX.html
1. A 62-year-old man has had dull, constant back pain for 3 months. He recently developed a cough
productive of yellowish sputum. On physical examination there are crackles at the right lung
base. A plain film radiograph of the spine reveals several 1 to 2 cm lytic lesions of the vertebral
bodies. Laboratory studies show glucose 78 mg/dL, urea nitrogen 49 mg/dL, creatinine 5 mg/dL,
total protein 8.3 g/dL, albumin 3.7 g/dL, alkaline phosphatase 176 U/L, AST 45 U/L, ALT 22 U/L,
and total bilirubin 1.2 mg/dL. A sputum culture grows Streptococcus pneumoniae. Which of the
following pathologic findings is most likely to be seen in a bone marrow biopsy from this man?
a. Scattered small granulomas
b. Nodules of small mature lymphocytes
c. Occasional Reed-Sternberg cells
d. Numerous plasma cells
e. Hypercellularity with many blasts
2. A 33-year-old woman has experienced low grade fevers, night sweats, and generalized malaise
for the past 2 months. On physical examination she has non-tender cervical and supraclavicular
lymphadenopathy. A cervical lymph node biopsy is performed. On microscopic examination at
high magnification there are occasional CD15+ and CD30+ Reed-Sternberg cells along with large
and small lymphocytes and bands of fibrosis. Which of the following is the most likely diagnosis?
a. Burkitt lymphoma
b. Hodgkin lymphoma
c. Cat scratch disease
d. Mycosis fungoides
e. Multiple myeloma
3. A 42-year-old man has had fevers for the past 4 weeks. On physical examination his
temperature is 37.8C. Laboratory studies show a Hgb of 12.2 g/dL, Hct 37.1%, MCV 92 fL,
platelet count 243,000/uL, and WBC count 75,000/uL. The WBC differential count shows 82
segs, 8 bands, 3 metamyelocytes, 1 myelocyte, 4 lymphocytes, and 1 monocyte. The leukocyte
alkaline phosphatase (LAP) score is high at 130. Which of the following laboratory test findings is
most likely to be present in this man?
a. Bone marrow karyotype of 46, XY, t(9;22)
b. Serologic titer of 1:1024 for anti-double stranded DNA
c. Serum vitamin B12 level of 100 pg/mL
d. 4+ ketonuria and 4+ proteinuria
e. Blood culture positive for Streptococcus, viridans group
4. A clinical study is conducted involving adults from 18 to 80 years of age who underwent
splenectomy for blunt force abdominal trauma. An age-matched control group of patients
consists of patients who have congestive splenomegaly. The laboratory findings from these

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subjects are analyzed. Which of the following laboratory test findings is most likely to be
observed only in the study group following splenectomy?
a. Thrombocytopenia
b. RBC Howell-Jolly bodies
c. Decreased RBC distribution width
d. Leukopenia
e. Nucleated RBCs
A 30-year-old man has had a sore throat with fever for 5 days. On physical examination he has
mildly tender generalized cervical lymphadenopathy. Laboratory findings include Hgb 13 g/dL,
platelet count 277,000/microliter, and WBC count 12,670/microliter with differential count of
75 segs, 10 bands, and 15 lymphs which of the following is the most likely diagnosis?
a. Lymphocytic lymphoma
b. Hodgkin lymphoma
c. Group A Streptococcus infection
d. Human immunodeficiency virus infection
e. Brucellosis
A 30-year-old man has had a progressively worsening productive cough for one month. On
physical examination, a few small non-tender lymph nodes are palpable in the axillae, and the
tip of the spleen is palpable. Laboratory studies show Hgb 10.2 g/dL, Hct 31.1%, MCV 90 fL, WBC
count 67,000/microliter, and platelet count 36,000/microliter. Microscopic examination of his
peripheral blood smear shows many blasts with Auer rods. Which of the following is the most
likely diagnosis?
a. Leukemoid reaction
b. Acute myelogenous leukemia
c. Chronic lymphocytic leukemia
d. Lymphoblastic leukemia
e. Leukoerythroblastosis
A 40-year-old woman has had a week long course of fever and mental confusion. Physical
examination shows T 38.2C, P 100/minute, RR 22/minute, and BP 100/60 mm Hg. She has
widespread petechiae of skin and mucosal surfaces. Laboratory studies show her serum urea
nitrogen is 52 mg/dL with creatinine 5.3 mg/dL. She has a hemoglobin of 12.2 g/dL, hematocrit
36.8%, MCV 93 fL, platelet count 19,000/microliter, and WBC count 8180/microliter.
Schistocytes are seen on her peripheral blood smear. Her prothrombin time, partial
thromboplastin time, and D-dimer are not elevated. Which of the following is the most likely
diagnosis?
a. Disseminated intravascular coagulopathy
b. Idiopathic thrombocytopenic purpura
c. Thrombotic thrombocytopenic purpura
d. Trousseau syndrome
e. Warm autoimmune hemolytic anemia
For the past 4 months, a 62-year-old previously healthy man has noted increasing fatigue and
shortness of breath with minimal exercise. He has felt some abdominal discomfort over the past

month. On physical examination he has non-tender cervical lymphadenopathy. The liver span is
15 cm in the right mid-clavicular line; the edge is smooth and palpable just below right costal
margin. The spleen is palpated 3 cm below left costal margin on inspiration. A CBC shows WBC
count 23,100/microliter with 16 segs, 2 bands, 78 lymphs, and 4 monos, Hgb 11.9 g/dL, Hct 36%,
MCV 90, and platelet count 277,300/microliter. The direct Coombs test is positive. Which of the
following is the most likely diagnosis?
a. Leukemoid reaction
b. Chronic myelogenous leukemia
c. Acute myelogenous leukemia
d. Acute lymphocytic leukemia
e. Chronic lymphocytic leukemia
f. Systemic lupus erythematosus
9. An 83-year-old woman fell and broke her left wrist. She underwent open reduction with internal
fixation of the radial head fracture. Postoperatively she received heparin prophylaxis for
thromboembolism and diuretics to treat pulmonary edema. Laboratory studies showed:
On admission: Hgb 13.2 g/dL, Hct 39.1%, MCV 85 fL, platelet count 209,000/microliter, WBC count

5720/microliter, prothrombin time 13 seconds, partial thromboplastin time 28 seconds

1 week later: Hgb 13 g/dL, Hct 38.8%, MCV 86 fL, platelet count 101,000/microliter, WBC count
6310/microliter, prothrombin time 12 seconds, partial thromboplastin time 27 seconds
What is the most likely cause for her findings?
a. Hypersplenism
b. Idiopathic thrombocytopenic purpura
c. Disseminated intravascular coagulation
d. Drug-induced thrombocytopenia
e. Thrombotic-thrombocytopenic purpura
10. A 48-year-old man has experienced increasing malaise and difficulty concentrating at work for
the past 6 months. On physical examination he has splenomegaly but no lymphadenopathy. He
is afebrile. Laboratory studies show Hgb 12.0 g/dL, Hct 35.8%, MCV 92 fL, platelet count
390,000/uL, and WBC count 190,000/uL with differential count 73 segs, 12 bands, 6
metamyelocytes, 2 myelocytes, 2 myeloblasts, and 5 lymphs. The leukocyte alkaline
phosphatase (LAP) score is very low. A bone marrow biopsy is performed. Which of the
following microscopic findings is most likely to be found in this biopsy?
a. Sheets of plasma cells
b. Atypical cytokeratin positive glands
c. Numerous mature and immature myeloid cells
d. Predominance of adipocytes
e. Granulomas that have many acid fast bacilli

11. A clinical study is performed with subjects who are adults found to have anemia. Their clinical
histories and laboratory findings are reviewed. It is observed that ingestion of a drug preceded
development of the anemia in some of the subjects, but not in others. Which of the following
conditions is most likely to be found in persons without a history of drug ingestion?
a. G6PD deficiency
b.
c.
d.
e.

Autoimmune hemolytic anemia

Macrocytic anemia
Aplastic anemia
Microcytic anemia

12. A 25-year-old African-American man is given anti-malarial prophylaxis for a trip to West Africa.
Over the next week he develops increasing fatigue. On physical examination there are no
abnormal findings. Laboratory studies show a hematocrit of 30%. Examination of his peripheral
blood smear shows red blood cells with numerous Heinz bodies. There is a family history of this
disorder, with males, but not females, affected. Which of the following is the most likely
diagnosis?
a. Beta-thalassemia
b. Sickle cell anemia
c. Alpha-thalassemia
d. Hereditary spherocytosis
e. G6PD deficiency
13. A study is conducted to determine what changes in the size of the spleen take place with
hematologic disorders. The spleen sizes are estimated from CT scans for adult patients who
developed complications of their hematologic disease. For which of the following diseases is the
spleen most likely to remain normal in size?
a. Autoimmune hemolytic anemia
b. Chronic alcohol abuse
c. Myeloproliferative disorder
d. Idiopathic thrombocytopenic purpura
e. Sickle cell anemia
14. A 51-year-old man has become increasingly fatigued for the past 10 months. On physical
examination there are no abnormal findings. Laboratory studies show his Hgb is 9.2, Hct 27.9%,
MCV 132 fL, platelet count 242,000/microliter, and WBC count 7590/microliter. Which of the
following morphologic findings is most likely to be present on examination of his peripheral
blood smear?
a. Hypersegmented neutrophils
b. Nucleated red blood cells
c. Blasts with Auer rods
d. Hypochromic, microcytic RBC's
e. Schistocytes

15. A 19-year-old primigravida of Southeast Asian ancestry gives birth at 35 weeks gestation a male
infant. On physical examination the infant is markedly hydropic. Laboratory studies show his
hematocrit is 17% and the peripheral blood smear reveals numerous nucleated red blood cells
and even a few erythroblasts. The red blood cells display marked anisocytosis and poikilocytosis.
Which of the following diseases is most likely to be present in this infant?
a. Sickle cell anemia
b. Alpha-thalassemia
c. Hemoglobin E disease
d. G6PD deficiency
e. Hereditary elliptocytosis
16. A 46-year-old man has had worsening arthritis and swelling of his feet for the past year. On
physical examination he has rales audible in all lung fields. A chest radiograph shows
cardiomegaly and pulmonary edema. Laboratory studies show Hgb 13.0 g/dL, Hct 39.1%, MCV 86
fL, platelet count 255,500/uL, and WBC count 5920/uL. His serum iron is 406 microgram/mL with
iron binding capacity 440 microgram/mL and ferritin 830 ng/mL. Which of the following is the
most likely diagnosis?
a. Beta-thalassemia
b. Autoimmune hemolytic anemia
c. Anemia of chronic disease
d. Polycythemia vera
e. Pernicious anemia
f. Hereditary hemochromatosis
17. A 52-year-old man has had a fever with cough for a month. On physical examination his
temperature is 37.5C. There are crackles auscultated in upper lung fields. A chest radiograph
shows a reticulonodular pattern with upper lobe cavitary lesions. His sputum is positive for acid
fast bacilli. A CBC shows: Hgb 14.2 g/dL, Hct 42.5%, MCV 92 fL, platelet count 225,000/uL, and
WBC count 44,500/uL with differential count of 59 segs, 20 bands, 8 metas, 4 myelos, 2
promyelos, 5 lymphs, and 2 monos. Which of the following laboratory test findings is most likely
to be present in this man?
a. High leukocyte alkaline phosphatase
b. Karyotype with 46, XY, t(9;22)
c. Monoclonal gammopathy
d. Elevated D-dimer
e. Positive TdT assay
18. A 10-year-old girl has exhibited increasing sluggishness with poorer performance in school over
the past year. She has not had increased numbers of infections. The child now complains of
headaches. A physical examination shows no hepatosplenomegaly or lymphadenopathy. A CBC

shows: Hgb 11.8 g/dL, Hct 33.9%, MCV 71 fL, platelet count 293,000/microliter, and WBC count

8160/microliter. Examination of her peripheral blood smear shows basophilic stippling of

erythrocytes. The serum haptoglobin is 5 mg/dL. Which of the following laboratory test findings
is most likely to be present in this girl
a. Hemoglobin S on electrophoresis
b. Increased osmotic fragility
c. Positive direct Coombs test
d. Decreased serum iron
e. Elevated free erythrocyte protoporphyrin
19. A 28-year-old African-American woman has had worsening fatigue for the past 2 months. On
physical examination she has an erythematous macular rash on her upper chest, forearms, and
face. Laboratory studies show Hgb 9.2 g/dL, Hct 27.9%, MCV 101 fL, platelet count

179,000/microliter, and WBC count 5850/microliter. The red blood cell distribution width is
markedly increased. Her peripheral blood smear shows polychromasia. Her reticulocyte count is

4.2%. The serum haptoglobin is 3 mg/dL. Serum chemistries show total protein 7.9 g/dL, albumin
3.8 g/dL, alkaline phosphatase 49 U/L, AST 81 U/L, ALT 27 U/L, total bilirubin 3.3 mg/dL, and
direct bilirubin 0.8 mg/dL. Hemoglobinuria is detected on urinalysis. Which of the following
underlying conditions is she most likely to have?
a. Multiple myeloma
b. Systemic lupus erythematosus
c. Hepatitis C infection
d. Hereditary spherocytosis
e. Vitamin B12 deficiency
20. A 20-year-old healthy man incurs blunt force trauma to the abdomen in a motor vehicle
accident. On physical examination he has upper abdominal tenderness. An abdominal CT scan
reveals a splenic hematoma. At laparotomy a splenectomy is performed. Following
splenectomy, which of the following peripheral blood morphologic findings is most likely to be
present?
a. Tear drop cells
b. Elliptocytes
c. Target cells
d. Macro-ovalocytes
e. RBC inclusions
21. Two teenage siblings in the same family are noted to have frequent nosebleeds and easy
bruising from even minor trauma. Both have had menorrhagia since menarche. One girl's CBC
shows Hgb 14 g/dL, Hct 42.3%, MCV 90 fL, platelet count 242,000/microliter, and WBC count
7720/microliter. Her prothrombin time is 12 seconds and partial thromboplastin time 25

seconds. Platelet function studies show decreased aggregation in response to ADP, collagen,
epinephrine, and thrombin. Which of the following disorders are these siblings most likely to
have?
a. Hemophilia A
b. Antithrombin III deficiency
c. Glanzmann thrombasthenia
d. Systemic lupus erythematosus
e. Von Willebrand disease
22. A 47-year-old man has been chronically fatigued for the past year. A physical examination yields
no abnormal findings. A CBC shows: Hgb 10.8 g/dL, Hct 33.1%, MCV 104 fL, platelet count
239,000/microliter, and WBC count 7720/microliter. His peripheral blood smear shows normal
WBC morphology and RBCs with mild poikilocytosis and a few target cells. His serum vitamin
B12 is 512 pg/mL and folate 4.7 ng/mL. His serum haptoglobin is 151 mg/dL. Direct and indirect
Coombs tests are negative. Which of the following underlying conditions is most likely to explain
his findings?
a. Chronic lymphocytic leukemia
b. Peptic ulcer disease
c. Lead poisoning
d. Chronic alcohol abuse
e. Hereditary spherocytosis