Case 1:

A 23-year-old female comes in to your clinic complaining of heavy menses. You asked her about
what time it started, she replied: “I have always had heavy bleeding in my menstruation”. Her
current medications include some iron tablets as recommended by her Ob.Gyn specialist.
You ordered some labs to find:
Hemoglobin: 11.5 g/dl
Hematocrit value: 35 %
Red blood cell count: 3.5 million/microliter
Total leukocytic count: 6.1 x 109/L
Mean corpuscular volume: 80 fL
Platelet count: 172 x 109/L
Prothrombin Time: 11.5 seconds.
Partial thromboplastin time: 27 seconds.

Which of the following tests should be performed next?

a. Peripheral smear to detect fragmented cells.

b. Factor VII level
c. Factor IX level
d. Factor X level
e. Factor XI level
f. Factor XII level
g. Bleeding time, closure time, platelet aggregometry and RIPA
h. Mixing study
i. Serum lactate dehydrogenase level

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Case 2:

A lab technician was studying hemostasis, he was able to successfully isolate the alpha granules
from the platelet, then, he applied them to a medium containing some inactivated
thrombocytes...Next, he added Ristocetin, and observed that the granules were able to bind to
GPIb-IX-V receptor complex.

This receptor complex is responsible for which of the following steps in primary hemostasis?

a. Platelet activation
b. Platelet granule release
c. Platelet Fusion with fibrin meshwork.
d. Platelet adhesion
e. Platelet aggregation.

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Case 3:

A hematology research team were trying to study the mechanism of primary hemostasis, they
were focusing on platelet aggregation at the site of the injury. They isolated different types of
receptors until they were able to specify a receptor that plays a major role in aggregating the
platelets together with fibrinogen. This receptor complex interacts with fibrinogen, helps with
platelet aggregation. This complex can be activated by adenosine diphosphate and can be
inhibited by aggregin.

Which of the following receptors fit that description?

a. Glycoprotein Ib-IX-V
b. Glycoprotein VI
c. Glycoprotein Ia/IIa complex (integrin α2β1)
d. Glycoprotein IIb/IIIa complex (integrin αIIbβ3)
e. GPV / IIIa (integrin α5β1)

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Case 4:

A 47-year-old guy comes to your clinic because of weight loss and sleep problems…As he enters
the room, the patient had a very distinct odor. He appears jaundiced, unkempt and disheveled.
On asking, he admitted drinking 3 bottles of Bourbon every day for the past 15 years.
On physical exam, he was positive for hepatomegaly, splenomegaly, nail clubbing, Dupuytren’s
contracture, palmar erythema, spider nevi, caput medusae, generalized pitting edema, ascites,
bruising, flapping tremors, constructional apraxia, gynecomastia and testicular atrophy.
On palpation of the liver, it was hard, irregular and non-tender.

Aspiration of the ascites fluid yielded: a clear, straw-colored fluid with relatively few WBCs,
total protein concentration of 24 g/L and serum-ascites albumin gradient (SAAG) is 13 g/L.

Serum lab results were as follows:

Hgb: 11.1 g/dl
RBC count: 3.5 million/microliter
HCT: 34%
Total leukocytic count: 6.0 x 109/L
Platelet count: 58 x 109/L
Alkaline Phosphatase: normal
AST: elevated
ALT: elevated
GGT: elevated.

What’s the most important reason for his thrombocytopenia?

a. Increased BUN and Creatinine in the blood “uremia”

b. Splenomegaly
c. Hypoalbuminemia
d. Hypogammaglobulinemia
e. Autoantibodies against platelet’s GPIb
f. Autoantibodies against platelet’s GPIIb/IIIa
g. Bone marrow suppression
h. Megakaryocyte defect.
i. VonWillebrand factor deficiency.

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Case 5:

A 23-year-old lady scheduled a doctor’s appointment for “purple spots on the skin”…You
started taking her history and she complaint of: “I suffer from leg cramps, and I took some
tablets of an OTC medication for leg cramps, after which, I started seeing these several tiny
purple spots all over my body…I don’t like them since I am an avid athlete and my public
appearance matters”.
On physical exam, you discovered several small (1–2 mm), circular, non-raised, red-to-purple
spots on her skin.
On asking, she admits drinking tonic water as well as herbal tea.

You ordered some blood tests and here are the results:
Hgb: 13.1 g/dl
RBC count: 4 million/microliter
HCT: 40%
Total leukocytic count: 4.7 x 109/L
Platelet count: 49,000/microliter
Prothrombin Time: 12 seconds.
Activated Partial thromboplastin time: 27 seconds.
Peripheral smear: decreased number of platelets (normal sized), with no platelet
satellites or schistocytes.
HIV ELISA: negative.
HCV: negative.

What’s the most likely diagnosis?

a. Immune thrombocytopenic purpura (ITP)

b. Anabolic steroids abuse.
c. Thrombotic thrombocytopenic purpura (TTP)
d. Hemolytic uremic syndrome (HUS)
e. VonWillebrand disease (vWD)
f. Disseminated Intravascular coagulation (DIC)
g. Bernard-Soulier syndrome.
h. Quinine-induced thrombocytopenia
i. Glanzmann thromboasthenia.
j.

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Case 6:

The illustration below depicts the process of platelet aggregation.

S.E.C: subendothelial collagen, PLT: platelet.

Which of the following choices (A-D) matches the numbers in the illustration above (1-4)?

1 2 3 4

A GP Ib-IX-V GP IIb/IIIa vonWillebrand factor Fibrinogen

B vonWillebrand factor GP Ib-IX-V GP IIb/IIIa Fibrinogen

C GP Ib-IX-V vonWillebrand factor GP IIb/IIIa Fibrinogen

D GP Ib-IX-V Fibrinogen GP IIb/IIIa vonWillebrand factor

E GP Ib-IX-V Fibrinogen vonWillebrand factor GP IIb/IIIa

F GP Ib-IX-V GP IIb/IIIa Fibrinogen vonWillebrand factor

G GP IIb/IIIa vonWillebrand factor GP Ib-IX-V Fibrinogen

I GP IIb/IIIa Fibrinogen GP Ib-IX-V vonWillebrand factor

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END OF SAMPLE,

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