00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Secs)
  • Question 1 - A 14-year-old girl with known sickle-cell disease presents to the Emergency Department with...

    Incorrect

    • A 14-year-old girl with known sickle-cell disease presents to the Emergency Department with severe abdominal pain.
      On examination, she is found to have a tachycardia of 130 bpm, with generalised abdominal tenderness and 3 cm splenomegaly. Blood tests reveal marked anaemia, and a diagnosis of splenic sequestration crisis is considered.
      Which blood vessel in the spleen is most responsible for monitoring the quality of red blood cells and removing aged ones from circulation?

      Your Answer: Trabecular artery

      Correct Answer: Splenic sinusoid

      Explanation:

      The Anatomy of the Spleen: Splenic Sinusoids, Trabecular Veins, Arteries, and Sheathed Capillaries

      The spleen is an important organ in the immune system, responsible for filtering blood and removing old or damaged red blood cells. Its unique anatomy allows it to perform this function effectively.

      One key component of the spleen is the splenic sinusoid. These sinusoids are lined with elongated, cuboidal endothelial cells that are closely associated with macrophages. The gaps between the endothelial cells and incomplete basement membrane allow for the passage of red blood cells, with younger and more deformable cells passing through easily while older or abnormal cells are more readily destroyed by the macrophages.

      The trabecular veins receive blood from the splenic sinusoids, while the trabecular arteries are branches of the afferent splenic artery. These arteries pass deep into the spleen along connective tissue trabeculae and branch into central arteries that pass through the white pulp of the spleen.

      The central arteries then lead to sheathed capillaries, which are branches of the central arteries. These capillaries open directly into the red pulp of the spleen, allowing for further filtration and removal of old or damaged red blood cells.

      Overall, the anatomy of the spleen is complex and specialized, allowing it to perform its important functions in the immune system.

    • This question is part of the following fields:

      • Haematology
      17.2
      Seconds
  • Question 2 - A 67-year-old man presented with fever and body ache for 6 months. His...

    Correct

    • A 67-year-old man presented with fever and body ache for 6 months. His blood tests revealed a haemoglobin level of 110 g/l and erythrocyte sedimentation rate (ESR) of 121 mm in the first hour. Serum protein electrophoresis revealed an M band in the gamma globulin region with a total IgG level of 70 g/l. Bone marrow biopsy shows plasma cells in the marrow of 11%. A skeletal survey reveals no abnormalities. Other blood tests revealed:
      Test Parameter Normal range
      Calcium 2.60 mmol/l 2.20–2.60 mmol/l
      Creatinine 119 μmol/l 50–120 μmol/l
      Phosphate 1.30 mmol/l 0.70–1.40 mmol/l
      Potassium (K+) 4.6 mmol/l 3.5–5.0 mmol/l
      Lactate dehydrogenase 399 IU/l 100–190 IU/l
      His body weight was 80 kg.
      What is his condition better known as?

      Your Answer: Smouldering myeloma

      Explanation:

      Smouldering myeloma is a stage between monoclonal gammopathy of unknown significance (MGUS) and myeloma. To diagnose this condition, the patient must have a monoclonal protein in the serum of at least 30 g/l and monoclonal plasma cells of at least 10% in bone marrow or tissue biopsy, but no evidence of end-organ damage. Patients with smouldering myeloma should be closely monitored as they are at high risk of developing symptomatic myeloma.

      Multiple myeloma is a malignant neoplasm where there is clonal proliferation of plasma cells in the bone marrow, leading to the secretion of a monoclonal antibody and light immunoglobulin chains that cause organ damage. Patients with multiple myeloma present with various symptoms, including lethargy, bone pain, pathological fractures, renal impairment, amyloidosis, and pancytopenia due to marrow infiltration. To diagnose multiple myeloma, the patient must have a monoclonal antibody in serum and/or urine, clonal plasma cells of at least 10% on bone marrow biopsy, and evidence of end-organ damage.

      MGUS is a condition where low levels of paraprotein are detected in the blood, but they are not causing clinically significant symptoms or end-organ damage. To diagnose MGUS, the patient must have a monoclonal protein in the serum of less than or equal to 30 g/l, monoclonal plasma cells of less than or equal to 10% in bone marrow or tissue biopsy, and no evidence of end-organ damage.

      Non-secretory myeloma is a rare variant of multiple myeloma where the bone marrow findings and end-organ damage are similar to myeloma, but there is no detectable monoclonal protein in the serum or urine. This makes it difficult to diagnose.

      Plasma cell leukemia is a rare and aggressive form of multiple myeloma characterized by high levels of plasma cells circulating in the peripheral blood. It can occur as a primary condition or a secondary leukaemic transformation of multiple myeloma.

    • This question is part of the following fields:

      • Haematology
      47.2
      Seconds
  • Question 3 - The risk of contracting a viral infection through a blood transfusion can vary...

    Incorrect

    • The risk of contracting a viral infection through a blood transfusion can vary greatly. What is the estimated risk of hepatitis B transmission in the United Kingdom, for instance?

      Your Answer: 1 per 10 million donations

      Correct Answer: 1 per 1 million donations

      Explanation:

      Infective Risks of Blood Transfusion

      Blood transfusions carry the risk of transmitting viral infections such as hepatitis B, hepatitis C, and HIV. The likelihood of infection varies depending on the source of the donation and the type of testing used. In the UK, the risk of contracting hepatitis B from a blood transfusion is approximately 1 in 1.3 million donations. The risks for HIV and hepatitis C are even lower, at 1 in 6.5 million and 1 in 28 million donations, respectively. It is important for healthcare professionals to have a comprehensive of these risks when obtaining consent from patients for blood transfusions. Adequate knowledge and communication can help patients make informed decisions about their healthcare.

    • This question is part of the following fields:

      • Haematology
      10
      Seconds
  • Question 4 - A 65-year-old man comes to the clinic with complaints of haematuria. He has...

    Incorrect

    • A 65-year-old man comes to the clinic with complaints of haematuria. He has a history of chronic atrial fibrillation and is currently taking warfarin. His blood tests reveal a Hb level of 112g/L and an INR of 9, but he is stable hemodynamically. The consulting physician recommends reversing the effects of warfarin. What blood product/s would be the most appropriate choice for this patient?

      Your Answer: Cryoprecipitate

      Correct Answer: Prothrombin concentrate ('Octaplex')

      Explanation:

      Treatment Options for Warfarin Reversal

      Prothrombin concentrates are the preferred treatment for reversing the effects of warfarin in cases of active bleeding and a significantly elevated INR. While packed cells are important for managing severe bleeding, they are not the recommended treatment for warfarin reversal. Cryoprecipitate, recombinant factor VII, and platelets are also not indicated for reversing the effects of warfarin. It is important to choose the appropriate treatment option based on the patient’s individual needs and medical history. Proper management of warfarin reversal can help prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Haematology
      26.2
      Seconds
  • Question 5 - A 28-year-old woman who is 30 weeks pregnant arrives at the emergency assessment...

    Incorrect

    • A 28-year-old woman who is 30 weeks pregnant arrives at the emergency assessment unit with concerns of fluid leakage from her vagina. Upon examination, her pad is saturated with what appears to be amniotic fluid. What component of the fluid may indicate premature rupture of membranes (PROM)?

      Your Answer: Beta-HCG

      Correct Answer: Alpha fetoprotein

      Explanation:

      Using Biomarkers to Detect Premature Rupture of Membranes

      Premature rupture of membranes (PROM) can be difficult to diagnose in some cases. In 2006, a study was conducted to determine if measuring certain biomarkers in vaginal fluid could be used as an indicator of membrane rupture. The study found that alpha-fetoprotein (AFP) had the highest accuracy in predicting PROM, with a specificity and sensitivity of 94%. This suggests that AFP could be used as a marker in cases where diagnosis is uncertain.

      In addition to AFP, other biomarkers have been identified for different purposes. Carcinoembryonic antigen (CEA) is a tumor marker for colon cancer, while cancer antigen 125 (CA125) is a tumor marker for ovarian cancer. By measuring these biomarkers, doctors can detect the presence of cancer and monitor its progression. Overall, biomarkers have proven to be a valuable tool in diagnosing and monitoring various medical conditions.

    • This question is part of the following fields:

      • Haematology
      31.5
      Seconds
  • Question 6 - What is the diagnostic tool for beta thalassaemia? ...

    Correct

    • What is the diagnostic tool for beta thalassaemia?

      Your Answer: Haemoglobin electrophoresis

      Explanation:

      Diagnosis of Beta Thalassaemia

      Beta thalassaemia can be diagnosed through the presence of mild microcytic anaemia, target cells on the peripheral blood smear, and a normal red blood cell count. However, the diagnosis is confirmed through the elevation of Hb A2, which is demonstrated by electrophoresis. In beta thalassaemia patients, the Hb A2 level is typically around 4-6%.

      It is important to note that in rare cases where there is severe iron deficiency, the increased Hb A2 level may not be observed. However, it becomes evident with iron repletion. Additionally, patients with the rare delta-beta thalassaemia trait do not exhibit an increased Hb A2 level.

      In summary, the diagnosis of beta thalassaemia can be suggested through certain symptoms and blood tests, but it is confirmed through the measurement of Hb A2 levels.

    • This question is part of the following fields:

      • Haematology
      12.8
      Seconds
  • Question 7 - A 50-year-old patient presents to the general practitioner with a complaint of darkening...

    Incorrect

    • A 50-year-old patient presents to the general practitioner with a complaint of darkening of urine, particularly noticeable in the morning. The patient has no family history of bleeding disorders and was recently hospitalized for deep venous thrombosis in the right leg. Upon examination, the patient's heart and lungs appear normal. Blood tests reveal anemia, elevated levels of lactate dehydrogenase (LDH), high bilirubin levels, and a high reticulocyte count. What is the most likely cause of this patient's condition?

      Your Answer: Immunoglobulin M (IgM) antibody against red blood cells

      Correct Answer: Phosphatidylinositol glycan A defect in red blood cells

      Explanation:

      Understanding Different Causes of Haemolytic Anaemia

      Haemolytic anaemia is a condition where red blood cells are destroyed faster than they can be produced, leading to a shortage of oxygen-carrying cells in the body. There are various causes of haemolytic anaemia, including phosphatidylinositol glycan A defect, vitamin B12 deficiency, glucose-6-phosphate dehydrogenase deficiency, loss of spectrin in the red blood cell membrane, and immunoglobulin M (IgM) antibody against red blood cells.

      Phosphatidylinositol glycan A defect, also known as nocturnal haemoglobinuria, is an acquired condition caused by a mutation in the gene encoding for phosphatidylinositol glycan A. This leads to an increased susceptibility of red blood cells to complement proteins in an acidotic environment, resulting in haemolysis. Patients typically present with haematuria in the morning, and treatment involves managing symptoms and using medication such as eculizumab.

      Vitamin B12 deficiency causes megaloblastic anaemia and is not related to haemolysis. Glucose-6-phosphate dehydrogenase deficiency is an inherited X-linked recessive condition that results in red blood cell breakdown. Loss of spectrin in the red blood cell membrane is seen in hereditary spherocytosis, where red blood cells become spherical and are trapped in the spleen, leading to haemolysis. IgM antibody against red blood cells causes autoimmune haemolytic anaemia, where the antibody binds to the I antigen on the membrane of red blood cells, leading to haemolysis at low temperatures.

      Understanding the different causes of haemolytic anaemia is crucial for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Haematology
      42
      Seconds
  • Question 8 - A 72-year-old man experiences sudden paralysis on the right side of his body....

    Correct

    • A 72-year-old man experiences sudden paralysis on the right side of his body. He has been a smoker for 30 years, consuming 15 cigarettes a day. His vital signs are as follows: temperature 37.2°C, pulse 80/minute, respiratory rate 18/minute, and blood pressure 150/95 mm Hg. An angiogram of the brain shows blockage in a branch of the middle cerebral artery. Laboratory results indicate a haemoglobin A1c level of 80 mmol/mol (9.5%). Which component of blood lipids is the most significant factor in contributing to his condition?

      Your Answer: Oxidised low-density lipoprotein (LDL)

      Explanation:

      The patient had a stroke likely caused by cerebral atherosclerosis or embolic disease from the heart due to ischaemic heart disease from atherosclerosis. LDL brings cholesterol to arterial walls, and when there is increased LDL or hypertension, smoking, and diabetes, there is more degradation of LDL to oxidised LDL which is taken up into arterial walls via scavenger receptors in macrophages to help form atheromas. Chylomicrons transport exogenous products and are formed in intestinal epithelial cells. HDL particles remove cholesterol from the circulation and transport it back to the liver for excretion or re-utilisation. Lipoprotein lipase hydrolyses triglycerides in lipoproteins and promotes cellular uptake of chylomicron remnants, lipoproteins, and free fatty acids. VLDL transports endogenous triglycerides, phospholipids, and cholesterol and cholesteryl esters.

    • This question is part of the following fields:

      • Haematology
      26
      Seconds
  • Question 9 - A 55-year-old woman presents at the clinic for evaluation. She has not experienced...

    Correct

    • A 55-year-old woman presents at the clinic for evaluation. She has not experienced menstrual periods for the past six months and has taken two pregnancy tests, both of which were negative. Upon clinical examination, no abnormalities were found. The patient desires a blood test to determine if she has entered menopause. What is the most sensitive hormone to test for this purpose?

      Your Answer: FSH

      Explanation:

      Hormone Levels and Menopausal Status

      Follicle-stimulating hormone (FSH) levels that are greater than 30 IU/l, repeated over a period of four to eight weeks, are typically indicative of menopause. It is important to ensure that FSH is tested when the patient is not on contraception, although this is not relevant in the current scenario. While oestrogen and progesterone levels decrease after menopause, their assay is less reliable in determining menopausal status compared to FSH levels. Beta-HCG levels are elevated during pregnancy and trophoblastic disease, while prolactin levels increase in response to certain drug therapies and the presence of a pituitary tumour.

    • This question is part of the following fields:

      • Haematology
      12.4
      Seconds
  • Question 10 - A 75-year-old woman who is in hospital for pneumonia begins to deteriorate on...

    Incorrect

    • A 75-year-old woman who is in hospital for pneumonia begins to deteriorate on her third day of intravenous antibiotics. She develops purple bruises on her skin and on the inside of her mouth, and tells you that she feels short of breath and fatigued. Her platelet count has dropped from 165 × 109/l to 43 × 109/l over the last two days. She also complains of blurred vision in the last few hours.
      Which of the following will form part of her initial management?

      Your Answer: Platelet transfusions

      Correct Answer: Plasma exchange

      Explanation:

      Treatment Options for Thrombotic Thrombocytopenic Purpura

      Thrombotic thrombocytopenic purpura (TTP) is a medical emergency that requires prompt treatment. The most common initial management for TTP is plasma exchange, which aims to remove the antibodies that block the ADAMTS13 enzyme and replace the ADAMTS13 enzymes in the blood. Intravenous methylprednisone and rituximab may also be used in conjunction with plasma exchange.

      Aspirin should only be considered when the platelet count is above 50 × 109/l, and even then, it is not an essential part of initial management and will depend on the patient’s comorbidities. Cryoprecipitate is not recommended for TTP treatment, as it is indicated for disseminated intravascular coagulation or fibrinogen deficiency.

      Factor VIII infusion is used for haemophilia A, a C-linked-recessive disorder that presents with excessive bleeding and anaemia, and is less likely to be associated with thrombocytopenia and TTP. Platelet transfusions are relatively contraindicated in TTP and should only be considered in cases of catastrophic bleeding or urgent surgery that cannot wait until after plasma exchange. Platelet transfusions increase the risk of arterial thrombosis, which can lead to myocardial infarction and stroke.

      In summary, plasma exchange is the most common initial management for TTP, and other treatment options should be carefully considered based on the patient’s individual circumstances. Early diagnosis and prompt treatment are crucial for a successful outcome.

    • This question is part of the following fields:

      • Haematology
      23.2
      Seconds
  • Question 11 - A 33-year-old woman who gave birth three weeks ago is feeling very fatigued...

    Incorrect

    • A 33-year-old woman who gave birth three weeks ago is feeling very fatigued after walking to the park and back. The birth was via a caesarean section and she needed one unit of blood transfusion. She visits her family doctor and denies experiencing any chest pain, heart palpitations, shortness of breath, or further bleeding.

      During the examination, there are no indications of ongoing bleeding, and the caesarean section incision is healing properly. The blood test results are as follows:

      - Hb 95 g/L Female: (115 - 160)
      - Platelets 240 * 109/L (150 - 400)
      - WBC 7.0 * 109/L (4.0 - 11.0)
      - Ferritin 6 µg/L (15 - 300)

      What is the minimum haemoglobin level for this patient to be prescribed iron supplements?

      Your Answer: <100 g/L

      Correct Answer:

      Explanation:

      The appropriate cut-off for determining if iron supplementation is necessary in the postpartum period is <100 g/L. It is important to continue oral iron for three months after normalizing ferritin levels to ensure adequate stores for efficient oxygen delivery to the tissues. Cut-offs of <105 g/L, <110 g/L, and <120 g/L are incorrect for iron supplementation in the second or third trimester of pregnancy, first trimester of pregnancy, and postpartum period, respectively. However, the decision to administer iron for anaemia should be based on the doctor's discretion and the patient's symptoms. During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually around 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a pregnant woman requires oral iron therapy. These levels are less than 110 g/L in the first trimester, less than 105 g/L in the second and third trimesters, and less than 100 g/L postpartum. If a woman’s iron levels fall below these cut-offs, she will be prescribed oral ferrous sulfate or ferrous fumarate. It is important to continue this treatment for at least three months after the iron deficiency has been corrected to allow the body to replenish its iron stores. By following these guidelines, healthcare professionals can help ensure that pregnant women receive the appropriate care to prevent and manage anaemia during pregnancy.

    • This question is part of the following fields:

      • Haematology
      27.2
      Seconds
  • Question 12 - A 43-year-old woman was diagnosed with acute myeloid leukaemia (AML) with 71% of...

    Incorrect

    • A 43-year-old woman was diagnosed with acute myeloid leukaemia (AML) with 71% of bone marrow blasts. She declined bone marrow transplant and was started on appropriate chemotherapy. After 2 months, a repeat bone marrow revealed 8% of blasts. Peripheral blood was blast-free and blood tests revealed:
      Investigation Result Normal value
      Haemoglobin 106 g/l 115–155 g/l
      White cell count (WCC) 8.1 × 109/l 4–11 × 109/l
      Neutrophils 5.2 × 109/l 2.5–7.58 × 109/l
      Lymphocytes 1.8 × 109/l 1.5–3.5 × 109/l
      Platelets 131 × 109/l 150–400 × 109/l
      What is her clinical status?

      Your Answer: Complete remission with incomplete recovery

      Correct Answer: Partial remission

      Explanation:

      Partial remission occurs when a patient meets all the criteria for complete remission except for having more than 5% bone marrow blasts. To be diagnosed with partial remission, the blast cells can be between 5% and 25% and must have decreased by at least 50% from their levels before treatment.

      Complete remission is achieved when a patient meets specific criteria, including having a neutrophil count of over 1.0 × 109/l and a platelet count of over 100 × 109/l, not requiring red cell transfusions, having normal cellular components on bone marrow biopsy, having less than 5% blasts in the bone marrow without Auer rods present, and having no signs of leukemia anywhere else in the body.

      Complete remission with incomplete recovery is when a patient meets all the criteria for complete remission except for continuing to have neutropenia or thrombocytopenia.

      Resistant disease occurs when a patient fails to achieve complete or partial remission and still has leukemia cells in their peripheral blood or bone marrow seven days after completing initial therapy.

      A morphologic leukemia-free state is when a patient has less than 5% bone marrow blasts without blasts with Auer rods present and no extramedullary disease, but they do not meet the criteria for neutrophils, platelets, and blood transfusions.

    • This question is part of the following fields:

      • Haematology
      34.8
      Seconds
  • Question 13 - A 50-year-old woman presents with headaches and nosebleeds and is found to have...

    Incorrect

    • A 50-year-old woman presents with headaches and nosebleeds and is found to have a raised platelet count. She is diagnosed with essential thrombocytosis by the haematologist.
      Which of the following might be used to treat essential thrombocytosis?

      Your Answer: Interferon gamma

      Correct Answer: Hydroxyurea

      Explanation:

      Common Medications and Their Uses

      Thrombocytosis and Hydroxyurea
      Thrombocytosis is a condition characterized by an elevated platelet count, which can lead to bleeding or thrombosis. Primary or essential thrombocytosis is a myeloproliferative disorder that results in overproduction of platelets by the bone marrow. Hydroxyurea is the first-line treatment for essential thrombocytosis, as it inhibits an enzyme involved in DNA synthesis and reduces the rate of platelet production.

      Interferon Gamma for Immunomodulation
      Interferon gamma is an immunomodulatory medication used to reduce the frequency of infections in patients with chronic granulomatous disease and severe malignant osteopetrosis. It is administered by subcutaneous injection.

      Cromoglycate for Inflammation
      Sodium cromoglycate is a synthetic non-steroidal anti-inflammatory drug used in the treatment of asthma, allergic rhinitis, and various food allergies.

      Interferon β for Multiple Sclerosis
      Interferon β is a cytokine used in the treatment of relapsing-remitting multiple sclerosis. It is administered subcutaneously.

      Ranitidine for Acid Reduction
      Ranitidine is a H2 (histamine) receptor blocker that inhibits the production of acid in the stomach. It can be used in the treatment of gastro-oesophageal reflux disease, peptic ulcer disease, and gastritis.

    • This question is part of the following fields:

      • Haematology
      17.1
      Seconds
  • Question 14 - A 14-year-old girl presents with a history of easy bruising and excessive bleeding...

    Incorrect

    • A 14-year-old girl presents with a history of easy bruising and excessive bleeding after a dental procedure. She is diagnosed with von Willebrand's disease and is scheduled for additional dental extractions. The physician prescribes DDAVP. What is the mechanism of action of DDAVP in treating von Willebrand's disease?

      Your Answer:

      Correct Answer: Stimulates release of von Willebrand's factor from endothelial cells

      Explanation:

      DDAVP for Increasing von Willebrand Factor

      DDAVP is a medication that can be administered to increase the amount of von Willebrand factor in the body, which is necessary for surgical or dental procedures. This medication can increase plasma von Willebrand factor and factor VIII concentrations by two to five times. The mechanism of action involves the induction of cyclic adenosine monophosphate (cAMP)-mediated vWF secretion through a direct effect on endothelial cells. Overall, DDAVP is a useful tool for increasing von Willebrand factor levels in the body, allowing for safer and more successful surgical and dental procedures.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 15 - A 29-year-old female patient presents to the clinic with a complaint of missed...

    Incorrect

    • A 29-year-old female patient presents to the clinic with a complaint of missed periods for the past four months despite negative pregnancy tests. She is also distressed about the loss of her libido and has noticed milk leakage with minimal nipple stimulation during intercourse. On physical examination, her blood pressure is 122/70 mmHg, pulse is 70 and regular, and general physical examination is unremarkable. Which blood test is most likely to show elevated levels?

      Your Answer:

      Correct Answer: Prolactin

      Explanation:

      Symptoms and Diagnosis of Hyperprolactinaemia

      Hyperprolactinaemia is a condition characterized by elevated levels of prolactin in the body. This condition is typically associated with symptoms such as milk production, decreased libido, and absence of menstruation. However, visual disturbances are not always present, as many cases of hyperprolactinaemia are related to a microprolactinoma.

      When diagnosing hyperprolactinaemia, it is important to assess thyroid status as this condition is often associated with hypothyroidism. Thyroxine levels are usually low in individuals with hyperprolactinaemia. Additionally, beta-HCG levels are elevated in pregnancy, so it is important to rule out pregnancy as a potential cause of elevated prolactin levels.

      In summary, hyperprolactinaemia is a condition that can present with a variety of symptoms, but is typically characterized by elevated prolactin levels. Diagnosis involves assessing thyroid status and ruling out pregnancy as a potential cause.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 16 - A 67-year-old man was admitted with pain in the left groin. He had...

    Incorrect

    • A 67-year-old man was admitted with pain in the left groin. He had fallen from his chair, after which the pain started. He was unable to walk and his left leg was externally rotated. X-rays revealed a neck of femur fracture. He lives alone in a flat and is a vegetarian. His past medical history includes shortness of breath, body itching and occasional swelling of legs. His blood tests revealed:
      Investigation Result Normal range
      Haemoglobin 120 g/l 135–175 g/l
      Calcium 3.5 mmol/l 2.20–2.60 mmol/l
      Phosphate 1.52 mmol/l 0.70–1.40 mmol/l
      Erythrocyte sedimentation rate (ESR) 184 mm/h 0–15 mm/h
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Multiple myeloma

      Explanation:

      Diagnosis of Multiple Myeloma in a Patient with Pathological Fracture

      A man has sustained a pathological fracture after a minor trauma, which is likely due to lytic bone lesions. He also presents with anemia, raised calcium, and ESR, all of which are consistent with a diagnosis of multiple myeloma. This is further supported by his age group for presentation.

      Other possible diagnoses, such as osteoporosis, vitamin D deficiency, acute leukemia, and malignancy with metastasis, are less likely based on the absence of specific symptoms and laboratory findings. For example, in osteoporosis, vitamin D and phosphate levels are normal, and ESR and hemoglobin levels are not affected. In vitamin D deficiency, calcium and phosphate levels are usually normal or low-normal, and ESR is not raised. Acute leukemia typically presents with systemic symptoms and normal serum calcium levels. Malignancy with metastasis is possible but less likely without preceding symptoms suggestive of an underlying solid tumor malignancy.

      In summary, the patient’s clinical presentation and laboratory findings suggest a diagnosis of multiple myeloma.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 17 - A 32-year-old woman comes to Haematology complaining of fatigue, anaemia and splenomegaly. She...

    Incorrect

    • A 32-year-old woman comes to Haematology complaining of fatigue, anaemia and splenomegaly. She is diagnosed with a genetic disorder that causes abnormal blood cell shape due to a dysfunctional membrane protein. As a result, these cells are broken down by the spleen, leading to haemolytic anaemia and splenomegaly. What is the most probable abnormality observed in a blood film of individuals with this condition?

      Your Answer:

      Correct Answer: Sphere-shaped red blood cells

      Explanation:

      Understanding Abnormalities in Red Blood Cells: Hereditary Spherocytosis and Other Conditions

      Hereditary spherocytosis is an inherited condition that causes red blood cells to take on a sphere shape instead of their normal biconcave disc shape. This abnormality leads to increased rupture of red blood cells in capillaries and increased degradation by the spleen, resulting in hypersplenism, splenomegaly, and haemolytic anaemia. Patients with hereditary spherocytosis often present with jaundice, splenomegaly, anaemia, and fatigue.

      Schistocytes, irregular and jagged fragments of red blood cells, are not typically seen in hereditary spherocytosis. They are the result of mechanical destruction of red blood cells in conditions such as haemolytic anaemia.

      Acanthocytes or spur cells, which have a spiked, irregular surface due to deposition of lipids and/or proteins on the membrane, are not typically seen in hereditary spherocytosis. They are seen in several conditions, including cirrhosis, anorexia nervosa, and pancreatitis.

      Microcytic red blood cells, which are smaller than normal red blood cells but have a normal shape, are typically seen in iron deficiency anaemia, thalassaemia, and anaemia of chronic disease.

      Teardrop-shaped red blood cells are seen in conditions where there is an abnormality of bone marrow function, such as myelofibrosis. This is different from hereditary spherocytosis, which is a primary disorder of abnormal red blood cell shape.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 18 - A 35-year-old woman is brought to the Emergency Department after consuming 30 tablets...

    Incorrect

    • A 35-year-old woman is brought to the Emergency Department after consuming 30 tablets of warfarin which belonged to her mother. She has diarrhoea but has no mucosal bleeding. She admits to previously attending a psychiatric unit for self-harming behaviour. She has no remarkable medical history. Her mother has a history of recurrent venous thrombosis for which she is taking warfarin.
      What will the patient’s coagulation screen likely be?

      Your Answer:

      Correct Answer: Elevated prothrombin time, international normalised ratio, activated partial thromboplastin time and normal platelet counts

      Explanation:

      Warfarin poisoning is characterized by elevated prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (APTT), along with normal platelet counts. This is due to the drug’s ability to block the function of vitamin K epoxide reductase, leading to a depletion of the reduced form of vitamin K that serves as a cofactor for gamma carboxylation of vitamin-K-dependent coagulation factors. As a result, the vitamin-K-dependent factors cannot function properly, leading to elevated PT and INR, normal or elevated APTT, and normal platelet counts. Thrombocytopenia with normal PT, INR, and APTT can be caused by drugs like methotrexate and carboplatin isotretinoin, which induce direct myelosuppression. Decreased factor VIII levels are seen in haemophilia A, disseminated intravascular coagulation (DIC), and von Willebrand disease, but not in warfarin overdose. Isolated APTT elevation is seen in heparin overdose, while elevated fibrinogen levels can be seen in inflammation, acute coronary syndrome, and stroke, but not in warfarin overdose.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 19 - A 14-year-old girl presents to the clinic with her parents. She is worried...

    Incorrect

    • A 14-year-old girl presents to the clinic with her parents. She is worried about not having started her periods yet, while many of her peers have. Her medical history includes a lack of sense of smell, which she has had since childhood. On examination, she has normal height, early breast development, and minimal secondary sexual hair. Her BMI is 22. What blood test would be most helpful in determining the underlying cause of her amenorrhea?

      Your Answer:

      Correct Answer: FSH

      Explanation:

      Kallmann’s Syndrome and its Differential Diagnosis

      Anosmia and primary amenorrhoea are two symptoms that may indicate the presence of Kallmann’s syndrome. This condition is characterized by the underdevelopment of the olfactory bulb, which leads to a loss of the sense of smell, and the failure to produce gonadotrophin releasing hormone. As a result, low levels of follicle-stimulating hormone and luteinising hormone may cause a partial or complete failure to enter puberty in women.

      Congenital adrenal hyperplasia, on the other hand, may cause electrolyte imbalances, but it is typically associated with abnormal female virilization. Prolactinoma, a type of pituitary tumor, is usually linked to secondary amenorrhoea. Meanwhile, thyrotoxicosis, a condition characterized by an overactive thyroid gland, may cause menstrual cessation, but it is less likely to be the cause of primary amenorrhoea, especially in the absence of hyperthyroidism symptoms.

      In summary, Kallmann’s syndrome should be considered as a possible diagnosis in patients presenting with anosmia and primary amenorrhoea. However, other conditions such as congenital adrenal hyperplasia, prolactinoma, and thyrotoxicosis should also be ruled out through proper evaluation and testing.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 20 - A woman has some blood tests taken by her general practitioner (GP). The...

    Incorrect

    • A woman has some blood tests taken by her general practitioner (GP). The results show a Hb of 10.0, MCV of 69 and a ferritin of 9.
      Which is the most appropriate management plan for this patient?

      Your Answer:

      Correct Answer: Treat with ferrous sulphate 200 mg three times a day and repeat bloods in three months

      Explanation:

      Understanding Iron Deficiency Anaemia and Treatment Options

      Iron deficiency anaemia is a common condition that can present with symptoms such as lethargy, tiredness, and shortness of breath on exertion. It is often seen in women due to menstruation and blood loss associated with it, as well as in pregnant women. However, it is not a common finding in men and should be investigated further if present.

      Treatment for iron deficiency anaemia involves the use of ferrous sulfate, typically at a dose of 200 mg two to three times a day for at least three months. Blood tests should be repeated after this time to assess the effectiveness of therapy. Folic acid supplementation may also be necessary in cases of folate deficiency anaemia, which presents with a raised MCV.

      It is important to investigate persistent anaemia despite adequate iron supplementation, as it may indicate an underlying malignancy. Men with unexplained iron deficiency anaemia and a haemoglobin level of < 110 g/l should be referred urgently to the gastroenterology team for investigation of upper or lower gastrointestinal malignancy. Overall, understanding the causes and treatment options for iron deficiency anaemia can help improve patient outcomes and prevent complications.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 21 - A 28-year-old woman on vacation complained of a swollen left calf. She mentioned...

    Incorrect

    • A 28-year-old woman on vacation complained of a swollen left calf. She mentioned having the 'factor V Leiden mutation'. Can you explain the pathophysiology of this mutation?

      Your Answer:

      Correct Answer: Activated protein C resistance

      Explanation:

      Factor V Leiden: A Genetic Condition Affecting Blood Clotting

      Factor V is a protein that acts as a cofactor to allow the generation of an enzyme called thrombin, which is responsible for cleaving fibrinogen to fibrin. This process leads to the formation of a dense meshwork that makes up the majority of a clot. Activated protein C (aPC) is a natural anticoagulant that limits clotting by degrading factor V. However, in individuals with Factor V Leiden, a genetic condition that is inherited in an autosomal dominant manner, the coagulation factor cannot be destroyed by aPC.

      Factor V Leiden is caused by a single nucleotide substitution of adenine for guanine in the gene encoding factor V. This mutation changes the protein’s 506th amino acid from arginine to glutamine, which prevents efficient inactivation of factor V. As a result, factor V remains active, leading to overproduction of thrombin and excess fibrin generation, which in turn causes excess clotting.

      In summary, Factor V Leiden is a genetic condition that affects blood clotting by preventing the efficient inactivation of factor V. This leads to excess clotting, which can increase the risk of developing blood clots and related complications.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 22 - Which autoantibody is correctly matched with its associated disease in the following list?...

    Incorrect

    • Which autoantibody is correctly matched with its associated disease in the following list?

      Your Answer:

      Correct Answer: Pernicious anaemia and anti-intrinsic factor antibodies

      Explanation:

      Autoimmune Disorders and Associated Antibodies

      Autoimmune disorders occur when the immune system mistakenly attacks healthy cells and tissues in the body. These disorders are often associated with the presence of specific antibodies that can help diagnose and monitor the disease. Here are some examples:

      Pernicious Anaemia and Anti-Intrinsic Factor Antibodies
      Pernicious anaemia is a type of anaemia caused by a deficiency in vitamin B12. It is associated with the presence of anti-intrinsic factor antibodies, which bind to intrinsic factor and prevent the absorption of vitamin B12 in the gut.

      Primary Biliary Cholangitis and Anti-Jo-1 Antibodies
      Primary biliary cholangitis is an autoimmune disorder that affects the liver. It is associated with the presence of anti-mitochondrial antibodies, but not anti-Jo-1 antibodies, which are associated with other autoimmune disorders like polymyositis and dermatomyositis.

      Myasthenia Gravis and Voltage-Gated Calcium Channel Antibodies
      Myasthenia gravis is a neuromuscular disorder that causes muscle weakness and fatigue. It is associated with the presence of anti-acetylcholine receptor antibodies, but not anti-striated muscle antibodies, which are found in other autoimmune disorders.

      Granulomatosis with Polyangiitis (GPA) and Anti-Myeloperoxidase (p-ANCA) Antibody
      GPA is a type of vasculitis that affects small and medium-sized blood vessels. It is associated with the presence of cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA), but not p-ANCA, which are found in other types of vasculitis.

      Hashimoto’s Thyroiditis and Thyroid-Stimulating Antibodies
      Hashimoto’s thyroiditis is an autoimmune disorder that affects the thyroid gland. It is associated with the presence of anti-thyroglobulin and anti-thyroperoxidase antibodies, which attack the thyroid gland and cause inflammation.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 23 - A 50-year-old male has a history of severe rheumatoid arthritis for the past...

    Incorrect

    • A 50-year-old male has a history of severe rheumatoid arthritis for the past four years. Despite being compliant with therapy (NSAIDs and methotrexate), the disease remains poorly controlled. Recently, he has been experiencing extreme fatigue. Upon conducting an FBC, the following results were obtained:
      - Haemoglobin 70 g/L (120-160)
      - White cell count 1.5 ×109/L (4-11)
      - Platelet count 40 ×109/L (150-400)

      What could be the possible cause of his pancytopenia?

      Your Answer:

      Correct Answer: Methotrexate

      Explanation:

      Pancytopenia in a Patient with Erosive Rheumatoid Arthritis

      This patient is showing signs of pancytopenia, a condition where there is a decrease in all three blood cell types (red blood cells, white blood cells, and platelets). Given her history of erosive rheumatoid arthritis for the past three years, it is likely that she has been on immunosuppressive therapy, which can lead to this type of blood disorder.

      Immunosuppressive drugs such as methotrexate, sulfasalazine, penicillamine, and gold can all have an impact on blood cell production and lead to pancytopenia. It is important to monitor patients on these medications for any signs of blood disorders and adjust treatment accordingly. Early detection and management can prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 24 - A 70-year-old man presents to the clinic with a four-month history of abdominal...

    Incorrect

    • A 70-year-old man presents to the clinic with a four-month history of abdominal swelling and discomfort along with breathlessness. Upon examination, he appears unwell and pale. The liver is palpable 12 cm below the right costal margin, and the spleen is palpable 15 cm below the left costal margin. No lymphadenopathy is detected. The following investigations were conducted:

      Hb 59 g/L (130-180)
      RBC 2.1 ×1012/L -
      PCV 0.17 l/l -
      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 -

      The blood film shows anisocytosis, poikilocytosis, and occasional erythrocyte tear drop cells. What is the correct term for this blood picture?

      Your Answer:

      Correct Answer: Leukoerythroblastic anaemia

      Explanation:

      Leukoerythroblastic Reactions and Myelofibrosis

      Leukoerythroblastic reactions refer to a condition where the peripheral blood contains immature white cells and nucleated red cells, regardless of the total white cell count. This means that even if the overall white cell count is normal, the presence of immature white cells and nucleated red cells can indicate a leukoerythroblastic reaction. Additionally, circulating blasts may also be seen in this condition.

      On the other hand, myelofibrosis is characterized by the presence of tear drop cells. These cells are not typically seen in other conditions and are therefore considered a hallmark of myelofibrosis. Tear drop cells are red blood cells that have been distorted due to the presence of fibrous tissue in the bone marrow. This condition can lead to anemia, fatigue, and other symptoms.

      Overall, both leukoerythroblastic reactions and myelofibrosis are conditions that can be identified through specific characteristics in the peripheral blood. It is important for healthcare professionals to be aware of these findings in order to properly diagnose and treat patients.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 25 - Which structure, containing both white and red pulp, is responsible for trapping foreign...

    Incorrect

    • Which structure, containing both white and red pulp, is responsible for trapping foreign substances present in the blood?

      Your Answer:

      Correct Answer: Spleen

      Explanation:

      Comparison of Lymphoid Organs and Non-Lymphoid Organs

      The human body contains various organs that serve different functions. Among these are the lymphoid organs, which play a crucial role in the immune system. In this article, we will compare the characteristics of three lymphoid organs (spleen, lymph node, and thymus) with two non-lymphoid organs (heart and thyroid gland).

      Spleen
      The spleen is the largest secondary lymphoid organ. It is located in the left upper quadrant of the abdomen and contains both white pulp (lymphatic tissue and macrophages) and red pulp (sinusoids and red blood cells). One of its functions is to filter foreign substances from the blood.

      Lymph Node
      Lymph nodes are secondary lymphoid organs that contain structures where mature lymphocytes are stimulated by antigens to undergo further division and differentiation. They do not contain white and red pulp.

      Thymus
      The thymus is a primary lymphoid organ where T lymphocytes mature, differentiate, and proliferate. It does not contain white and red pulp.

      Heart
      The heart is the main organ of the circulatory system and does not contain white and red pulp.

      Thyroid Gland
      The thyroid gland is located in the anterior neck and is part of the endocrine system. It does not contain white and red pulp.

      In summary, lymphoid organs play a crucial role in the immune system, while non-lymphoid organs serve other functions. Understanding the characteristics of these organs can help us appreciate the complexity and diversity of the human body.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 26 - This is the full blood count result of a 72-year-old male who presents...

    Incorrect

    • This is the full blood count result of a 72-year-old male who presents with fatigue following his retirement 6 months ago:

      Hb 130 g/L (120-160)
      RBC 4.5 ×1012/L -
      Haematocrit 0.39 (0.36-0.46)
      MCV 86.5 fL (80-100)
      MCH 28.1 pg (27-32)
      Platelets 180 ×109/L (150-400)
      WBC 6.5 ×109/L (4-11)
      Neutrophils 3.8 ×109/L (2-7)
      Lymphocytes 1.9 ×109/L (1-4)
      Monocytes 0.5 ×109/L (0.2-1)
      Eosinophils 0.2 ×109/L (0-0.5)
      Basophils 0.1 ×109/L (0-0.1)

      He is brought into the clinic by his wife who is concerned that her husband is constantly tired, has lost interest in his hobbies and has trouble sleeping.

      Examination is pretty much normal except that he appears fatigued. There are no abnormalities on chest, abdominal or respiratory examination. Neurological examination is normal.

      What is the most likely cause of this blood picture?

      Your Answer:

      Correct Answer: Alcohol excess

      Explanation:

      Delayed Grief Reaction and Elevated MCV in a Patient

      Explanation:
      The patient in question is displaying a delayed grief reaction following the recent death of her husband. Her FBC shows a normal picture except for an elevated MCV, which suggests alcohol excess. If the cause of macrocytosis were folate or B12 deficiency, it would be expected to cause anemia in association with the macrocytosis. Hypothyroidism may also cause macrocytosis, but the patient’s weight loss argues against this diagnosis. For further information on macrocytosis, refer to the BMJ Practice article Macrocytosis: pitfalls in testing and summary of guidance, the BMJ Endgames case report A woman with macrocytic anemia and confusion, and the BMJ Best Practice article Assessment of anemia.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 27 - A 65-year-old woman is two days postoperative, following a Hartmann’s procedure for bowel...

    Incorrect

    • A 65-year-old woman is two days postoperative, following a Hartmann’s procedure for bowel cancer. Her haemoglobin levels had dropped to 70 g/l, and as a result, she was started on a blood transfusion 12 hours ago. You are asked to review the patient, as she has suddenly become very agitated, pyrexial and hypotensive, with chest pain.
      Which of the following transfusion reactions is most likely to be occurring in this patient?

      Your Answer:

      Correct Answer: Acute haemolytic reaction

      Explanation:

      An acute haemolytic reaction is a transfusion complication that can occur within 24 hours of receiving blood. It is often caused by ABO/Rh incompatibility and can result in symptoms such as agitation, fever, low blood pressure, flushing, pain in the abdomen or chest, bleeding from the site of the venepuncture, and disseminated intravascular coagulation (DIC). Treatment involves stopping the transfusion immediately. Iron overload, hepatitis B infection, graft-versus-host disease (GvHD), and human immunodeficiency virus (HIV) infection are all delayed transfusion reactions that may present after 24 hours.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 28 - A 35-year-old woman comes to the clinic for follow-up three months after undergoing...

    Incorrect

    • A 35-year-old woman comes to the clinic for follow-up three months after undergoing evacuation of a hydatidiform mole. She reports feeling well and has not experienced any significant issues since the procedure.

      What blood test is the most effective in monitoring for the recurrence of trophoblastic disease?

      Your Answer:

      Correct Answer: Beta-HCG

      Explanation:

      Hydatidiform Mole and Trophoblastic Disease

      A hydatidiform mole is a type of abnormal pregnancy that only generates placental tissue. However, approximately 10% of cases of hydatidiform mole can transform into malignant trophoblastic disease. To assess if there is any retained tissue or recurrence/malignant transformation, the best way is to measure the levels of HCG, which is primarily produced by the placenta. On the other hand, alpha-fetoprotein, CEA, and CA-125 are tumour markers associated with hepatocellular carcinoma, colonic carcinoma, and ovarian carcinoma, respectively. It is important to note that progesterone levels are not useful in determining the prognosis of trophoblastic disease. the characteristics and markers of hydatidiform mole and trophoblastic disease is crucial in the diagnosis and management of these conditions.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 29 - A patient who is seen in the Renal Outpatient Department for glomerulonephritis presents...

    Incorrect

    • A patient who is seen in the Renal Outpatient Department for glomerulonephritis presents to the Emergency Department with a swollen, erythematosus right leg with a 4-cm difference in circumference between the right and left leg. Routine blood tests show:
      Investigation Result Normal value
      Sodium (Na+) 143 mmol 135–145 mmol/l
      Potassium (K+) 4.2 mmol 3.5–5.0 mmol/l
      Urea 10.1 mmol 2.5–6.5 mmol/l
      Creatinine 120 μmol 50–120 µmol/l
      eGFR 60ml/min/1.73m2
      Corrected calcium (Ca2+) 2.25 mmol 2.20–2.60 mmol/l
      Bilirubin 7 μmol 2–17 µmol/l
      Albumin 32 g/l 35–55 g/l
      Alkaline phosphatase 32 IU/l 30–130 IU/l
      Aspartate transaminase (AST) 15 IU/l 10–40 IU/l
      Gamma-Glutamyl transferase (γGT) 32 IU/l 5–30 IU/l
      C-reactive protein (CRP) 15 mg/l 0–10 mg/l
      Haemoglobin 78 g/l
      Males: 135–175 g/l
      Females: 115–155 g/l
      Mean corpuscular volume (MCV) 92 fl 76–98 fl
      Platelets 302 x 109/l 150–400 × 109/l
      White cell count (WCC) 8.5 x 109/l 4–11 × 109/l
      Which of the following should be commenced after confirmation of the diagnosis?

      Your Answer:

      Correct Answer: Apixaban

      Explanation:

      According to NICE guidance, the first-line treatment for a confirmed proximal deep vein thrombosis is a direct oral anticoagulant such as apixaban or rivaroxaban. When warfarin is used, an initial pro-coagulant state occurs, so heparin is needed for cover until the INR reaches the target therapeutic range and until day 5. Low-molecular-weight heparin is typically used with warfarin in the initial anticoagulation phase, but it can accumulate in patients with renal dysfunction. Unfractionated heparin infusion is used in these cases. For patients with normal or slightly deranged renal function, low-molecular-weight heparin can be given once per day as a subcutaneous preparation. However, warfarin is not the first-line treatment according to NICE guidance.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 30 - A 32-year-old male patient complained of frequent nosebleeds and was diagnosed with iron...

    Incorrect

    • A 32-year-old male patient complained of frequent nosebleeds and was diagnosed with iron deficiency anemia. During a chest x-ray, a shadow was detected over the right lung base, and a bruit was heard upon auscultation in the same area. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Hereditary haemorrhagic telangiectasia

      Explanation:

      Hereditary Haemorrhagic Telangiectasia

      Hereditary haemorrhagic telangiectasia is a genetic disorder that causes bleeding from small blood vessels called telangiectasia on mucous membranes such as the nose, mouth, and gastrointestinal tract. This condition is characterised by the presence of telangiectasia on the skin, which can be seen during clinical examination. In some cases, arteriovenous malformations may also be present in the lung or brain.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Haematology (4/13) 31%
Passmed