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Question 1
Correct
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Detection of urinary Bence-Jones protein would be most suggestive of which of the following malignancies:
Your Answer: Multiple myeloma
Explanation:Bence Jones proteins are monoclonal immunoglobulin light chains found in urine (and plasma) of some patients with myeloma. Because of their relatively small size, light chains are readily excreted into the urine. The presence of significant amounts of Bence Jones proteins in urine is indicative of malignant B cell proliferation.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 2
Correct
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Which of the following is the most abundant immunoglobulin in plasma:
Your Answer: IgG
Explanation:IgA is the major Ig in secretions, particularly from the gastrointestinal tract (but also in saliva, tears, sweat and breast milk).IgE is important for mast cell degranulation in allergic and antiparasitic response. In the allergic response, the plasma cell produces IgE-antibodies, which, like antibodies of other immunoglobulin isotypes, are capable of binding a specific allergen via its Fab portion.IgG is the most abundant in plasma (comprising 80% of normal serum immunoglobulin) and the main circulatory Ig for the secondary immune response.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 3
Correct
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Regarding T helper cells, which of the following statements is CORRECT:
Your Answer: They form the vast majority (about 75%) of the total circulating T-cell population.
Explanation:CD4+ T-cells (Helper T cells)Recognise antigen only in association with HLA class II molecules (found on antigen presenting cells (APCs) e.g. dendritic cells, B-cells; present exogenous antigens that have been phagocytosed/endocytosed into intracellular vesicles)Form most of the circulating T-cell population (about 75%)Secrete cytokines (e.g. IFN-gamma) which are required for recruitment and activation of other immune cells such as macrophages, T cytotoxic cells and NK cells and for the activation of and production of immunoglobulin from B-cells
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 4
Correct
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A 13-year-old male presents to the Emergency Department with a heavy nosebleed. His medical record shows that he was diagnosed with Haemophilia B as a child. What is the mode of inheritance of this disease?
Your Answer: X-linked recessive
Explanation:Deficiency of Factor IX causes Haemophilia B, and like the other Haemophilia’s, it has an X-linked recessive pattern of inheritance, affecting males born to carrier mothers.Haemophilia B is the second commonest form of haemophilia and is rarer than haemophilia A. Haemophilia B is similar to haemophilia A but is less severe. You can distinguish the two disorders by specific coagulation factor assays. The incidence of Haemophilia B is one-fifth of that of haemophilia A. In laboratory findings, you get prolonged APTT, normal PT and low factor IX for Haemophilia B. There is also a variation called Leyden, in which factor IX levels are below 1% until puberty, when they rise, potentially reaching as high as 40-60% of normal. This is thought to be due to the effects of testosterone at puberty.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 5
Correct
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Which of the following is the most common cause of megaloblastic anaemia:
Your Answer: Vitamin B12 deficiency
Explanation:Megaloblastic anemia results from inhibition of DNA synthesis during red blood cell production. When DNA synthesis is impaired, the cell cycle cannot progress from the growth stage to the mitosis stage. This leads to continuing cell growth without division, which presents as macrocytosis, with an increase in mean corpuscular volume (MCV). The defect in red cell DNA synthesis is most often due to hypovitaminosis, specifically vitamin B12 deficiency or folate deficiency.Folate is an essential vitamin found in most foods, especially liver, green vegetables and yeast. The normal daily diet contains 200 – 250 μg, of which about 50% is absorbed. Daily adult requirements are about 100 μg. Absorption of folate is principally from the duodenum and jejunum. Stores of folate are normally only adequate for 4 months and so features of deficiency may be apparent after this time.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 6
Correct
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A 24-year-old female visits her family physician to complain of painless lumps in her neck. Her physician notes several enlarged, rubbery, non-tender cervical lymph nodes on examination. He immediately refers the patient for a lymph node biopsy, the results of which show the presence of Reed-Sternberg cells. What is the diagnosis in this case based on the above scenario?
Your Answer: Hodgkin’s lymphoma
Explanation:The presence of Reed-Sternberg cells is pathognomonic for Hodgkin’s Lymphoma, which is a disease-causing neoplastic transformation of lymphocytes. There is a bimodal age distribution with peaks in the 20s and 60s. Patients typically present with enlarged, rubbery, non-tender lymph nodes. Symptoms such as fever, night sweats and weight loss may be present. Pain after alcohol consumption is a pathognomonic sign of Hodgkin’s lymphoma, it is, however, not a ‘B’ symptom. It is rare though, only occurring in 2-3% of patients with Hodgkin’s lymphoma.The Ann Arbour clinical staging is as follows:Stage I: one involved lymph node groupStage II two involved lymph node groups on one side of the diaphragmStage III: lymph node groups involved on both sides of the diaphragmStage IV: Involvement of extra-nodal tissues, such as the liver or bone marrowDiagnosis is made by lymph node biopsy, which should be taken from a sufficiently large specimen or excisional biopsy, as opposed to a fine needle biopsy. Multiple myeloma most commonly presents with bone pain, especially in the back and ribs. In non-Hodgkin’s lymphoma, Reed-Sternberg cells are not present. Acute lymphoblastic leukaemia will present with features of anaemia, thrombocytopenia and leukopenia. The most common symptoms of chronic lymphocytic leukaemia are fatigue, night sweats and low-grade fever.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 7
Incorrect
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Which of the following clotting factors is NOT vitamin K-dependent:
Your Answer: X
Correct Answer: V
Explanation:Fat-soluble vitamin K is obtained from green vegetables and bacterial synthesis in the gut. Deficiency may present in the newborn (haemorrhagic disease of the newborn) or in later life. Deficiency may be caused by an inadequate diet, malabsorption or inhibition of vitamin K by drugs such as warfarin. The activity of factors II, VII, IX and X are vitamin K dependent as well as that of protein C and protein S. Both PT and APTT are prolonged.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 8
Correct
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Question 9
Correct
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The qSOFA score is a bedside prompt designed to identify patients with suspected infection who are at greater risk for a poor outcome outside of the intensive care unit.Which of the following is one of the criteria used in the qSOFA score? Select ONE answer only.
Your Answer: Respiratory rate >22
Explanation:In February 2016 the Society of Critical Care Medicine published a JAMA article reformatting the definitions of sepsis in an attempt to overcome the shortcomings of the old definitions.The main changes are a new definition of sepsis, the replacement of the SIRS criteria with the quick Sepsis-related Organ Failure Assessment (qSOFA), and the complete removal of “severe sepsis” as an entity.The new definition of sepsis is that it is “life-threatening organ dysfunction caused by a dysregulated host response to infection.”Septic shock is “a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to increase mortality.”In essence this means that septic shock is sepsis plus the following, despite adequate fluid resuscitation:Vasopressors required to maintain a MAP > 65 mmHgSerum lactate > 2 mmol/lThe qSOFA score is a bedside prompt designed to identify patients with suspected infection who are at greater risk for a poor outcome outside of the intensive care unit. It uses the following three criteria:Hypotension (SBP < 100 mmHg)Tachypnoea (RR > 22)Altered mental status (GCS < 15)The presence of 2 or more of the qSOFA criteria near the onset of infection is associated with greater risk of death or a prolonged intensive care unit stay.
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This question is part of the following fields:
- Pathology
- Pathology Of Infections
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Question 10
Correct
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Which of the following immunoglobulin molecules is the most abundant in secretions (such as saliva and breast milk):
Your Answer: IgA
Explanation:IgA is the predominant antibody class in secretions and tremendous quantities are secreted into various body spaces and onto mucosal surfaces (the gut lumen, the pharynx and sinuses, the larger airways, although not the alveoli). Because of its size, the majority of IgM is found in the circulation.Along with IgM, IgD is predominant among the surface receptors of mature B cells, where it plays a key role in B cells activation.IgE has the lowest concentration in normal human serum. It plays a prominent role in immune responses to helminth parasites, and in allergic reactions.IgG is the most abundant immunoglobulin and constitutes 75 percent of serum immunoglobulin in an adult human
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 11
Correct
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A 30-year-old woman is transfused following a diagnosis of anaemia secondary to heavy vaginal bleeding. She complains of feeling hot and cold during transfusion of the second unit and her temperature is 38.5ºC. Prior to the transfusion, her temperature was 37ºC. She has no other symptoms.Which of these transfusions reactions most likely occurred?
Your Answer: Febrile transfusion reaction
Explanation:Febrile transfusion reactions presents with an unexpected temperature rise (≥ 38ºC or ≥ 1ºC above baseline, if baseline ≥ 37ºC) during or shortly after transfusion. It is usually an isolated finding and the fever is accompanied by chills and malaise occasionally.Allergic reaction is commonly caused by foreign plasma proteins but may be due to anti-IgA. Allergic type reactions usually present with urticaria, pruritus, hives. Associations include laryngeal oedema or bronchospasm.Acute haemolytic reaction aka immediate haemolytic transfusion reaction presents with fever, chills, pain at transfusion site, nausea, vomiting, dark urine and feeling of ‘impending doom’. Often, it occurs due to ABO incompatibility.Transfusion-associated circulatory overload (TACO) presents as acute or worsening respiratory distress within 6 hours of transfusion of a large volume of blood. It is common in patients with diminished cardiac reserve or chronic anaemia. Elderly patients, infants and severely anaemic patients are particularly susceptible. Clinical features of TACO include: Acute respiratory distress, Tachycardia, Hypertension, Acute/worsening pulmonary oedema on chest X-ray. The BNP is usually raised to at least 1.5 times the pre-transfusion baseline.Transfusion-related lung injury (TRALI) is a form of acute respiratory distress caused by the donor plasma containing antibodies against the patient’s leukocytes. It is defined as hypoxia and bilateral pulmonary oedema that occurs within 6 hours of a transfusion in the absence of other causes of acute lung injury. Clinical features include Breathlessness, cough, frothy sputum, hypertension or hypotension, hypoxia and fever. Chest X-ray shows multiple perihilar nodules with infiltration of the lower lung fields.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 12
Incorrect
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Haemophilia B results from a deficiency in:
Your Answer: Factor VIII
Correct Answer: Factor IX
Explanation:Haemophilia B is a bleeding disorder caused by a deficiency of clotting factor IX. It is the second commonest form of haemophilia, and is rarer than haemophilia A. Haemophilia B tends to be similar to haemophilia A but less severe. The two disorders can only be distinguished by specific coagulation factor assays.The incidence is one-fifth of that of haemophilia A. Laboratory findings demonstrate prolonged APTT, normal PT and low factor IX.Haemophilia B inherited in an X-linked recessive fashion, affecting males born to carrier mothers.There is also a variation called Leyden, in which factor IX levels are below 1% until puberty, when they rise, potentially reaching as high as 40-60% of normal. This is thought to be due to the effects of testosterone at puberty.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 13
Incorrect
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Chronic myeloid leukaemia is most common in middle-aged and elderly people. It is responsible for 20% of all leukemias.Which of the following statements about CML is NOT TRUE?
Your Answer: There is typically a low neutrophil alkaline phosphatase score
Correct Answer: Serum B12 is typically low
Explanation:Chronic myeloid leukaemia is most common in middle-aged and elderly people. It is responsible for 20% of all leukemias. The majority of CML patients experience fatigue, weight loss, and excessive sweating.The Philadelphia chromosome is found in over 90% of CML cases. A balanced translocation between chromosomes 9 and 22 is known as the Philadelphia chromosome.Because white cells produce a B12 binding protein, serum B12 levels in CML are typically high.In CML, the neutrophil alkaline phosphatase score is usually low.Almost all patients with CML eventually progress to blast crisis, though this can take up to ten years. If any of the following features are present in a CML patient, a blast crisis is diagnosed:In the blood or bone marrow, there are more than 20% myeloblasts or lymphoblasts.On a bone marrow biopsy, large clusters of blasts were discovered.CML can be treated with tyrosine kinase inhibitors like imatinib and dasatinib if a chloroma (a solid tumour made up of myeloblasts that grows outside of the bone marrow) is present.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 14
Correct
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Which of the following laboratory findings is NOT typical of von Willebrand disease (VWD):
Your Answer: Thrombocytopaenia
Explanation:Laboratory findings typically show (although this varies depending on VWD type):Abnormal PFA-100 testLow factor VIII levels (if low a factor VIII/VWF binding assay is performed)Prolonged APTT (or normal)Normal PTLow VWF levelsDefective platelet aggregationNormal platelet count
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This question is part of the following fields:
- Haematology
- Pathology
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Question 15
Correct
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A patient noticed ankle swelling and has passed very little urine over the past 24 hours. He also has nausea and vomiting, reduced urine output and his blood results reveal a sudden rise in his creatinine levels over the past 48 hours. You make a diagnosis of acute kidney injury (AKI).Which one of these is a prerenal cause of AKI?
Your Answer: Cardiac failure
Explanation:The causes of AKI can be divided into pre-renal, intrinsic renal and post-renal causes. Majority of AKI developing in the community is due to a pre-renal causes (90% of cases).Pre-renal causes: Haemorrhage, severe vomiting or diarrhoea, burns, cardiac failure, liver cirrhosis, nephrotic syndrome, hypotension, severe cardiac failure, NSAIDs, COX-2 inhibitors, ACE inhibitors or ARBs, Abdominal aortic aneurysm, renal artery stenosis, hepatorenal syndrome, Intrinsic (renal) causes:Eclampsia, glomerulonephritis, thrombosis, haemolytic-uraemic syndrome, acute tubular necrosis (ATN), acute interstitial nephritis, drugs ( NSAIDs), infection or autoimmune diseases, vasculitis, polyarteritis nodosa, thrombotic microangiopathy, cholesterol emboli, renal vein thrombosis, malignant hypertensionPost-renal causes: Renal stones, Blood clot, Papillary necrosis, Urethral stricture, Prostatic hypertrophy or malignancy, Bladder tumour, Radiation fibrosis, Pelvic malignancy, Retroperitoneal fibrosis
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 16
Incorrect
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Eosinophils comprise what percentage of circulating white cells:
Your Answer: 0.2
Correct Answer: 1 - 3%
Explanation:Eosinophils comprise 1 – 3% of circulating white cells. Eosinophils are similar to neutrophils, except that the cytoplasmic granules are coarser and more deeply red staining, and there are rarely more than three nuclear lobes. They are less motile, but longer lived. They enter inflammatory exudates and have a special role in allergic responses, defence against parasites and removal of fibrin formed during inflammation. Thus they play a role in local immunity and tissue repair.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 17
Correct
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Regarding Hodgkin lymphoma, which of the following statements is CORRECT:
Your Answer: Some patients may complain alcohol-induced nodal pain and pruritus
Explanation:Lymphomas are a group of diseases caused by malignant lymphocytes that accumulate in lymph nodes and other lymphoid tissue and cause the characteristic clinical feature of lymphadenopathy. The major subdivision of lymphomas is into Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) and this is based on the histological presence of Reed-Sternberg cells present in HL. Hodgkin lymphoma can present at any age but is rare in children and has a peak incidence in young adults. There is an almost 2 : 1 male predominance. Most patients present with painless, asymmetrical, firm and discrete enlargement of superficial lymph nodes. Cervical nodes are involved in 60-70% of cases, axillary nodes in 10-15% and inguinal nodes in 6-12%. Modest splenomegaly occurs during the course of the disease in 50% of patients; the liver may also be enlarged. Bone marrow failure involvement is unusual in early disease. The prognosis depends on age, stage and histology, but overall approximately 85% of patients are cured. Alcohol‐induced pain and pruritus are two well‐known but rare symptoms in HL.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 18
Correct
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Regarding the factor V Leiden gene mutation, which of the following best describes the clinical effect:
Your Answer: It results in increased levels of activated factor V.
Explanation:Factor V Leiden gene mutation is the most common inherited cause of an increased risk of venous thrombosis. Activated protein C normally breaks down activated factor V and so should slow the clotting reaction and prolong the APTT, but a mutation in the factor V gene makes factor V less susceptible to cleavage by activated protein C, resulting in increased levels of activated factor V.Heterozygotes for factor V Leiden are at an approximately five- to eight- fold increased risk of venous thrombosis compared to the general population (but only 10% of carriers will develop thrombosis in their lifetime). Homozygotes have a 30 – 140-fold increased risk. The incidence of factor V Leiden in patients with venous thrombosis is approximately 20 – 40%. It does not increase the risk of arterial thrombosis.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 19
Correct
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Which of the following is NOT mainly characterised by intravascular haemolysis:
Your Answer: Beta-Thalassaemia
Explanation:Causes of intravascular haemolysis:Haemolytic transfusion reactionsG6PD deficiencyRed cell fragmentation syndromesSome severe autoimmune haemolytic anaemiasSome drug-and infection-induced haemolytic anaemiasParoxysmal nocturnal haemoglobinuria
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This question is part of the following fields:
- Haematology
- Pathology
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Question 20
Incorrect
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A blood transfusion is given to a 52-year-old woman. She develops chills and rigours shortly after the transfusion begins. The following are her observations: Temperature 40°C, HR 116 bpm, BP 80/48, SaO 2 97 percent on air.Which of the following treatments is the most appropriate?
Your Answer: Stop the transfusion and administer corticosteroids
Correct Answer: Stop the transfusion and administer antibiotics
Explanation:Bacterial infections are common in the following situations:Platelet transfusions are associated with a higher risk of bacterial infection (as platelets are stored at room temperature)Immersion in a water bath thawed previously frozen components.Components of red blood cells that have been stored for several weeksGram-positive and Gram-negative bacteria have both been linked to transfusion-transmitted bacterial infection, but Gram-negative bacteria are linked to a higher rate of morbidity and mortality.Yersinia enterocolitica is the most common bacterial organism linked to transfusion-transmitted bacterial infection. This organism can multiply at low temperatures while also utilising iron as a nutrient. As a result, it’s well-suited to proliferating in blood banks.The following are some of the most common clinical signs and symptoms of a bacterial infection transmitted through a blood transfusion. These symptoms usually appear shortly after the transfusion begins:Fever is very high.Rigours and chillsVomiting and nauseaTachycardiaHypotensionCollapse of the circulatory systemIf a bacterial infection from a transfusion is suspected, the transfusion should be stopped right away. Blood cultures and a Gram stain should be requested, as well as broad-spectrum antibiotics. In addition, the blood pack should be returned to the blood bank for an urgent culture and Gram-stain.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 21
Correct
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Regarding acute lymphoblastic leukaemia (ALL), which of the following statements is CORRECT:
Your Answer: 75% of cases occur before the age of 6 years.
Explanation:Acute lymphoblastic leukaemia (ALL) is caused by an accumulation of lymphoblasts in the bone marrow and is the most common malignancy of childhood. The incidence of ALL is highest at 3 – 7 years, with 75% of cases occurring before the age of 6. 85% of cases are of B-cell lineage. Haematological investigations reveal a normochromic normocytic anaemia with thrombocytopenia in most cases. There is great variation in the chance of individual patients achieving a long-term cure based on a number of biological variables. Approximately 25% of children relapse after first-line therapy and need further treatment but overall 90% of children can expect to be cured. The cure rate in adults drops significantly to less than 5% over the age of 70 years.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 22
Correct
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Mast cells play a significant part in which of the following?
Your Answer: Allergic disease
Explanation:Mast cells play a central role in the response to allergen challenges. The activation of mast cells results in both an early and a delayed phase of inflammation. Mast cells have been implicated in both physiologic and pathogenic processes. Mast cells are important in defence against some bacteria and viruses and contribute to defence against parasites. They are key effector cells in both innate and acquired immunity and are capable of inducing and amplifying both types of responses. Specifically, mast cells are capable of detecting microbial products through surface pattern recognition receptors, and they are involved in the recruitment of other leukocytes, containment of bacterial infections, and tissue repair.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 23
Correct
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You are asked to review the blood results on a 56-year-old man who appears to be acutely unwell. His results show that he is neutropenic.Which ONE of the following is NOT a recognized cause of a neutropenia?
Your Answer: Hyposplenism
Explanation:Neutropenia is defined as a total neutrophil count of < 2.0 x 109/l.It can be caused by:Viral infectionsCollagen disease e.g. SLE and RAChemotherapy and radiotherapyHypersplenismMarrow infiltrationVitamin and folate deficiencyDrug reactionsDrugs that cause neutropenia include flecainide, phenytoin, carbimazole, indomethacin and co-trimoxazole.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 24
Correct
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Tiredness, night sweats, and easy bruising are symptoms of a 58-year-old woman. Splenomegaly is observed during the examination.Which of the following diagnoses is the SINGLE MOST LIKELY?
Your Answer: Chronic myeloid leukaemia (CML)
Explanation:CML is a myeloproliferative disorder characterised by an abnormal pluripotent haemopoietic stem cell. A cytogenetic abnormality known as the Philadelphia chromosome, which results from a reciprocal translocation between the long arms of chromosomes 9 and 22, causes more than 80% of cases of CML.CML is a disease that develops slowly over several years. This is known as the ‘chronic stage.’ This stage is usually asymptomatic, and 90 percent of patients are diagnosed at this point, with the disease being discovered frequently as a result of a routine blood test. During this stage, the bone marrow contains less than 10% immature white cells (blasts).When CML cells expand, symptoms typically begin to appear. The ‘accelerated stage’ is what it’s called. Approximately 10% of people are diagnosed at this point. During this stage, between 10% and 30% of blood cells in the bone marrow are blasts. During this stage, common clinical features include:Fatigue and exhaustionNight sweats and feverDistension of the abdomenPain in the left upper quadrant (splenic infarction)Splenomegaly (commonest examination finding)HepatomegalyBruising is simple.Gout is a type of arthritis that affects (rapid cell turnover)Hyperviscosity is a condition in which the viscosity of (CVA, priapism)A small percentage of patients experience a ‘blast crisis’ (blast stage). More than 30% of the blood cells in the bone marrow are immature blast cells at this stage. Patients with severe constitutional symptoms (fever, weight loss, bone pain), infections, and bleeding diathesis typically present at this stage.In CML, laboratory findings include:White cell count is abnormally high (often greater than 100 x 109/l).Increased number of immature leukocytes causes a left shift.Anaemia that is mild to moderately normochromic and normocytic.Platelets can be low, normal, or elevated, and the Philadelphia chromosome can be found in > 80% of patients. Serum uric acid and ALP levels are frequently elevated. Tyrosine kinase inhibitors (TKIs), such as imatinib and dasatinib, are the current mainstay of CML treatment. Allogenic bone marrow transplantation is now only used in cases where TKIs have failed to work.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 25
Incorrect
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A 17-year-old male presenting in the department has a history of C3 deficiency.C3 deficiency is associated with all of the following EXCEPT?
Your Answer: Systemic lupus erythematosus
Correct Answer: Hereditary angioedema
Explanation:C1-inhibitor deficiency is the cause of hereditary angioedema not C3 deficiency,All the other statements are correct
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 26
Incorrect
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A 66-year-old male is brought to your clinic by his wife with the complaint of increasing confusion and disorientation over the past three days, along with decreased urination. She reports that he has been complaining of increasing pain in his back and ribs over the past three months. On examination, the patient looks anaemic, is not oriented in time, place and person and has tenderness on palpation of the lumbar spine and the 10th, 11th and 12th ribs. Blood tests show anaemia which is normocytic, normochromic, raised urea and creatinine and hypercalcemia. Which one of the following diagnoses is most likely in this case?
Your Answer: Metastatic prostate cancer
Correct Answer: Multiple myeloma
Explanation:Multiple myeloma is a clonal abnormality affecting plasma cells in which there is an overproduction of functionless immunoglobulins. The most common patient complaint is bone pain, especially in the back and ribs. Anaemia and renal failure are common, along with hypercalcemia. Hypercalcemia may lead to an altered mental status, as in this case. Chronic lymphocytic leukaemia occurs due to the overproduction of lymphocytes, usually B cells. CLL may present with an asymptomatic elevation of B cells. Patients are generally more than 50 years old and present with non-specific fatigue and weight loss symptoms.There is no history of alcohol abuse in this case. Furthermore, patients with a history of alcohol abuse may have signs of liver failure, which are not present here. Metastatic prostate cancer would most often cause lower backache as it metastasises first to the lumbar spine via the vertebral venous plexus. A patient with Vitamin B12 deficiency would have anaemia, megaloblastic, hypersegmented neutrophils, and signs of peripheral neuropathy.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 27
Correct
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How does abciximab mediate its antiplatelet effect:
Your Answer: It is a GPIIb/IIIa inhibitor.
Explanation:Abciximab, eptifibatide and tirofiban are GPIIb/IIIa inhibitors, inhibiting platelet aggregation by preventing the binding of fibrinogen, von Willebrand factor and other adhesive molecules.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 28
Correct
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One of the benefits of wound healing through first intention is:
Your Answer: Minimisation of scar tissue formation
Explanation:Primary wound healing, or healing by first intention, occurs within hours of repairing a full-thickness surgical incision. This surgical insult results in the mortality of a minimal number of cellular constituents. Healing by first intention can occur when the wound edges are opposed, the wound is clean and uninfected and there is minimal loss of cells and tissue i.e. surgical incision wound. The wound margins are joined by fibrin deposition, which is subsequently replaced by collagen and covered by epidermal growth.
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This question is part of the following fields:
- Pathology
- Wound Healing
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Question 29
Correct
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Which of the following laboratory findings are suggestive of functional hyposplenism:
Your Answer: Howell-Jolly bodies
Explanation:Functional hyposplenism is characterised by the blood film findings of Howell-Jolly bodies or siderotic granules on iron staining. The most frequent cause is surgical removal of the spleen e.g. after traumatic rupture, but hyposplenism can also occur in sickle cell anaemia, gluten-induced enteropathy, amyloidosis and other conditions.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 30
Correct
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The most important Complement protein for antigen opsonization is:
Your Answer: C3b
Explanation:Phagocytosis is largely responsible for depletion of cells coated with antibodies. Cells opsonized by IgG antibodies are recognized by phagocyte Fc receptors, which are specific for the Fc portions of some IgG subclasses. In addition, when IgM or IgG antibodies are deposited on the surfaces of cells, they may activate the complement system by the classical pathway. Complement activation generates by-products, mainly C3b and C4b, which are deposited on the surfaces of the cells and recognized by phagocytes that express receptors for these proteins. The net result is phagocytosis of the opsonized cells and their destruction.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 31
Correct
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A 40-year-old woman was rushed to the Emergency Department due to an anaphylactic reaction after being stung by a bee. She responded well to initial treatment but developed anaphylactic symptoms after 6 hours. Her symptoms were resolved after a further dose of adrenaline. Her family threatened legal action as they thought she had not received adequate treatment but withdrew their accusation after the attending physician explained that the woman had suffered a biphasic reaction. What is the approximate percentage of people who suffer this type of reaction?
Your Answer: 20%
Explanation:Anaphylactic reactions are Type 1 hypersensitivity reactions IgE-mediated and can be potentially life-threatening if not treated promptly. There are four well-recognized patterns of anaphylaxis:1) Uniphasic2) Biphasic3) Protracted4) RefractoryBiphasic reactions occur in 20% of the population, although their mechanism is poorly understood. The symptoms of anaphylaxis recur within 4-6 hours, although they may also recur up to 72 hours later. All patients discharged from the hospital after an anaphylactic shock must:1) Be warned to return to the hospital immediately if symptoms recur2) Have a treatment plan in place3) Have a follow-up appointment4) Be considered for an adrenaline auto-injector5) Referred to an allergy clinic
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This question is part of the following fields:
- General Pathology
- Pathology
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Question 32
Incorrect
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A 22-year-old man arrives at the emergency department with a sore throat, low-grade fever, and malaise. His partner has infectious mononucleosis, which was recently diagnosed. In this situation, which of the following cells is the most proliferative:
Your Answer: Monocytes
Correct Answer: Lymphocytes
Explanation:Histologic findings in EBV infectious mononucleosis: Oropharyngeal epithelium demonstrates an intense lymphoproliferative response in the cells of the oropharynx. The lymph nodes and spleen show lymphocytic infiltration primarily in the periphery of a lymph node.Relative lymphocytosis (≥ 60%) plus atypical lymphocytosis (≥ 10%) are the characteristic findings of Epstein Barr virus (EBV) infectious mononucleosis.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 33
Correct
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Which of the following immunoglobulins is most important for mast cell degranulation:
Your Answer: IgE
Explanation:IgA is the major Ig in secretions, particularly from the gastrointestinal tract (but also in saliva, tears, sweat and breast milk).IgE is important for mast cell degranulation in allergic and antiparasitic response. In the allergic response, the plasma cell produces IgE-antibodies, which, like antibodies of other immunoglobulin isotypes, are capable of binding a specific allergen via its Fab portion.IgG is the most abundant in plasma (comprising 80% of normal serum immunoglobulin) and the main circulatory Ig for the secondary immune response.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 34
Incorrect
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A 23-year-old male presents to his family physician with the complaint of repeated episodes of abdominal pain and the passage of dark coloured urine every morning. He also reports increasing fatigue over the past several months. On examination, there are raised, painful red nodules over the skin of the back. Laboratory workup shows haemolytic anaemia, leukopenia and thrombocytopenia. Which one of the following disorders is this patient most likely to have?
Your Answer: Paroxysmal cold haemoglobinuria
Correct Answer: Paroxysmal nocturnal haemoglobinuria
Explanation:Paroxysmal nocturnal haemoglobinuria is an acquired genetic disorder that causes a decrease in red blood cells due to a membrane defect that allows increased complement binding to RBCs, causing haemolysis. Patients complain of dark-coloured urine first in the morning due to haemoglobinuria secondary to lysis of red blood cells overnight. Thrombosis occurs, which affects hepatic, abdominal, cerebral and subdermal veins. Thrombosis of hepatic veins can lead to Budd-Chiari syndrome, thrombosis of subdermal veins can lead to painful nodules on the skin, and thrombosis of cerebral vessels can lead to stroke. The presence of dark urine in the morning only and at no other time differentiates this condition from other conditions.Multiple myeloma would present with bone pain, signs of radiculopathy if there were nerve root compression and a history of repeated infections. Patients with Non-Hodgkin Lymphoma would complain of enlarged lymph nodes, fatigue, fever, weight loss and a history of repeated infections. Acute lymphoblastic leukaemia presents more commonly in children than in adults. The patient would complain of bone pain, and on examination, there would be hepatosplenomegaly.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 35
Correct
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The blood test reports of a 56-year-old female are sent for your review. She seems acutely sick and has had multiple infections over the past few months. Her complete blood count report shows neutropenia. Which one of the following options is true with regards to neutropenia?
Your Answer: It can be caused by both radiotherapy and chemotherapy
Explanation:A total neutrophil count of less than 2 x 109/L is defined as neutropenia. It can be caused by the following:1. viral infections2. SLE3. RA4. hypersplenism5. chemo- and radiotherapy6. vitamin B12 and folate deficiency7. drug reactions
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This question is part of the following fields:
- Haematology
- Pathology
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Question 36
Correct
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Which of the following laboratory findings are indicative of von Willebrand disease (VWD):
Your Answer: Prolonged APTT
Explanation:Laboratory results often show that:PFA-100 test results are abnormal.Low levels of factor VIII (if a factor VIII/VWF binding assay is conducted)APTT is Prolonged (or normal)PT is normalVWF values are low.Defective Platelet aggregationThe platelet count is normal.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 37
Incorrect
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A 40-year-old male visits his family physician with the complaint of a high-grade fever for the past five days. A complete blood count report shows the presence of neutrophilia. Which one of the following facts regarding neutrophilia is accurate?
Your Answer: It is typically caused by typhoid fever
Correct Answer: It can be caused by eclampsia
Explanation:A total neutrophil count of greater than 7.5 x 109/L is called neutrophilia. Typhoid fever usually causes leukopenia or neutropenia. Both localised and generalised bacterial infections can cause neutrophilia. Metabolic disorders such as – gout- eclampsia- uraemia can also cause neutrophilia. Acute neutrophilia, in which immature neutrophils can be seen, is referred to as a left shift and can be seen in conditions such as appendicitis.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 38
Correct
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The most common cause of anaemia worldwide is which of the following?
Your Answer: Iron deficiency anaemia
Explanation:The most common cause of microcytic anaemia and of any anaemia worldwide is iron deficiency anaemia.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 39
Correct
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Which of the following is NOT a typical clinical feature of sickle cell disease:
Your Answer: Neutropaenia
Explanation:Features of sickle cell disease include:Anaemia (symptoms are usually mild because the O2 dissociation curve of Hb S is shifted to the right)Vaso-occlusive crisisVisceral sequestration crisisAplastic crisisIncreased susceptibility to infectionOther clinical features: Pigment gallstones with cholecystitisChronic leg ulcersAvascular necrosis of the femoral and humeral heads or other bonesCardiomyopathyPulmonary hypertensionProliferative retinopathyPriapismRenal papillary necrosisStroke
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This question is part of the following fields:
- Haematology
- Pathology
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Question 40
Correct
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Which of the following is NOT a common myeloma laboratory finding:
Your Answer: Elevated serum Bence-Jones protein
Explanation:Myeloma laboratory findings include:- The presence of a paraprotein in serum or urine (the paraprotein is IgG in 60 percent of cases, IgA in 20 percent, and light chain only in almost all the rest),- Increased serum immunoglobulin-free light chain proteins generated by plasma cells but not coupled with heavy chains – Reduced IgG, IgA, and IgM levels in the blood (immune paresis)- Anaemia, whether normochromic, normocytic, or macrocytic. – On a blood film, a Rouleaux formation has been marked. – In advanced illness, neutropenia and thrombocytopenia are common. – ESR is high. – Plasma cells in the bone marrow are overabundant, typically in aberrant forms. – Hypercalcemia- Creatinine levels are high. – Serum albumin levels are low in advanced illness. 60 percent of patients have osteolytic lesions, osteoporosis, or pathological fractures.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 41
Incorrect
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A 42-year-old woman with a history of hyposplenism arrives at the Emergency Department sick and feverish. A complete set of bloods, including a peripheral blood film, is organised.On a hyposplenic blood film, which of the following features is LEAST likely to be seen?
Your Answer: Heinz bodies
Correct Answer: Teardrop cells
Explanation:The collection of abnormalities found in these patients is referred to as a hyposplenic film.The following features can be seen on hyposplenic blood films:Howell-Jolly bodiesHeinz’s bodiesTarget cellsRBCs with nuclei on occasionLymphocytosisMacrocytosisAcanthocytesTeardrop cells, also known as dacrocytes, are named for their teardrop-shaped shape. Dacrocytosis is a condition in which a large number of these cells are present. Myelofibrosis and beta thalassemia major both have dacrocytes, but hyposplenism does not.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 42
Correct
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A 29-year-old female with chronic anaemia secondary to sickle cell disease is being transfused. A few minutes after starting the blood transfusion, she develops widespread itching with urticarial rash, wheezing, nausea and chest pain. Her BP reduces to 60/40 mmHg.What is the most appropriate treatment?
Your Answer: Stop the transfusion and administer adrenaline
Explanation:Anaphylaxis transfusion reaction occurs when an individual has previously been sensitized to an allergen present in the blood and, on re-exposure, releases IgE or IgG antibodies. Patients with anaphylaxis usually develop laryngospasm, bronchospasm, abdominal pain, nausea, vomiting, hypotension, shock, and loss of consciousness. The transfusion should be stopped immediately and the patient should be treated with adrenaline, oxygen, corticosteroids, and antihistamines.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 43
Incorrect
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By the third day of wound healing, which sort of inflammatory cell has predominated:
Your Answer: Lymphocytes
Correct Answer: Macrophages
Explanation:The inflammatory phase of healing is sometimes called the lag phase because wound strength does not begin to return immediately. The inflammatory phase is completed within three days except in the presence of infection or other factors associated with impaired wound healing. Mononuclear leukocytes accumulate and are transformed into macrophages. The maturation of blood-derived monocytes into macrophages is heralded by several events, including secretion of vimentin, which is a structural filament protein involved in wound healing.
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This question is part of the following fields:
- Pathology
- Wound Healing
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Question 44
Correct
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Which of the following statements about neutrophils is TRUE:
Your Answer: Neutrophils are typically the first immune cell to arrive to a site of injury.
Explanation:Neutrophils are the most numerous peripheral blood leukocytes, accounting for 50-70 percent of all circulating white cells. Neutrophils have a compact nucleus with two to five lobes and a pale cytoplasm with an irregular shape containing numerous fine pink-blue or grey-blue granules. The granules are classified as primary, which emerges during the promyelocyte stage, and secondary, which develop at the myelocyte stage and predominate in the mature nucleus.The lifespan of neutrophils in the blood is only 6 – 10 hours. In response to tissue damage, cytokines and complement proteins, neutrophils migrate from the bloodstream to the site of insult within minutes, where they destroy pathogens by phagocytosis.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 45
Correct
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The following are all examples of type I hypersensitivity EXCEPT for:
Your Answer: Contact dermatitis
Explanation:Examples of type I reactions include:Allergic rhinitisAllergic conjunctivitisAllergic asthmaSystemic anaphylaxisAngioedemaUrticariaPenicillin allergy
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 46
Correct
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Regarding folate requirements, which of the following statements is CORRECT:
Your Answer: Dietary folate is found particularly in leafy green vegetables and liver.
Explanation:Megaloblastic anemia results from inhibition of DNA synthesis during red blood cell production. When DNA synthesis is impaired, the cell cycle cannot progress from the growth stage to the mitosis stage. This leads to continuing cell growth without division, which presents as macrocytosis, with an increase in mean corpuscular volume (MCV). The defect in red cell DNA synthesis is most often due to hypovitaminosis, specifically vitamin B12 deficiency or folate deficiency.Folate is an essential vitamin found in most foods, especially liver, green vegetables and yeast. The normal daily diet contains 200 – 250 μg, of which about 50% is absorbed. Daily adult requirements are about 100 μg. Absorption of folate is principally from the duodenum and jejunum. Stores of folate are normally only adequate for 4 months and so features of deficiency may be apparent after this time.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 47
Correct
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Regarding basophils, which of the following statements is INCORRECT:
Your Answer: They are the second most common type of granulocyte.
Explanation:Basophils are only occasionally seen in normal peripheral blood comprising < 1% of circulating white cells. However, they are the largest type of granulocyte. They have many dark cytoplasmic granules which overlie the nucleus and contain heparin and histamine. They have immunoglobulin E (IgE) attachment sites and their degranulation is associated with histamine release. Basophils are very similar in both appearance and function to mast cells.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 48
Correct
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The most common type of adult leukaemia is chronic lymphocytic leukaemia (CLL). It develops as a result of lymphocyte clonal proliferation.Which of the following statements about CLL is CORRECT?
Your Answer: It is most commonly discovered as an incidental finding
Explanation:CLL (chronic lymphocytic leukaemia) is the most common type of chronic lymphoid leukaemia, with a peak incidence between the ages of 60 and 80. It is the most common type of leukaemia in Europe and the United States, but it is less common elsewhere. The CLL tumour cell is a mature B-cell with low immunoglobulin surface expression (IgM or IgD). The average age at diagnosis is 72 years, with only 15% of cases occurring before the age of 50. The male-to-female ratio is about 2:1. Over 80% of cases are identified by the results of a routine blood test, which is usually performed for another reason. Lymphocytic anaemia, thrombocytopenia, and normochromic normocytic anaemia are common laboratory findings. Aspiration of bone marrow reveals up to 95% lymphocytic replacement of normal marrow elements.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 49
Correct
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Approximately what proportion of lymphocytes are B-cells:
Your Answer: 0.2
Explanation:B-cells (20% of lymphocytes) mature in the bone marrow and circulate in the peripheral blood until they undergo recognition of antigen. B-cell immunoglobulin molecules synthesised in the cell are exported and bound to the surface membrane to become the B-cell receptor (BCR) which can recognise and bind to a specific antigen (either free or presented by APCs). The BCR is also important for antigen internalisation, processing and presentation to T helper cells. Most antibody responses require help from antigen-specific T helper cells (although some antigens such as polysaccharide can lead to T-cell independent B-cell antibody production). When the B-cell is activated, the receptor itself is secreted as free soluble immunoglobulin and the B-cell matures into a memory B-cell or a plasma cell (a B-cell in its high-rate immunoglobulin secreting state). Plasma cells are non-motile and are found predominantly in the bone marrow or spleen. Most plasma cells are short-lived (1 – 2 weeks) but some may survive much longer. A proportion of B-cells persist as memory cells, whose increased number and rapid response underlies the augmented secondary response of the adaptive immune system.
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This question is part of the following fields:
- Immune Responses
- Pathology
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Question 50
Incorrect
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The Philadelphia chromosome is a genetic abnormality associated primarily with which of the following malignancies:
Your Answer: Chronic lymphocytic leukaemia
Correct Answer: Chronic myeloid leukaemia
Explanation:Chronic myeloid leukaemia (CML) is a clonal disorder of a pluripotent stem cell. The disease accounts for around 15% of leukaemias and may occur at any age. The diagnosis of CML is rarely difficult and is assisted by the characteristic presence of the Philadelphia (ph) chromosome. This disease occurs in either sex, most frequently between the ages of 40 and 60 years. In up to 50% of cases the diagnosis is made incidentally from a routine blood count. Leucocytosis is the main feature, with a complete spectrum of myeloid cells seen in the peripheral blood. The levels of neutrophils and myelocytes exceed those of blast cells and promyelocytes.Increased circulating basophils are a characteristic feature. Normochromic normocytic anaemia is usual. Platelet count may be increased (most frequently), normal or decreased. The clinical outlook is very good and 90% of patients can expect long-term control of disease.
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This question is part of the following fields:
- Haematology
- Pathology
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SESSION STATS - PERFORMANCE PER SPECIALTY
