History:- A 40 years old lady presented with history of

bleeding per vagina in between regular menstrual

periods, post coital bleed. She reports to have multiple
sexual partners and history of cancer in her family

Fig A
Fig B
Questions:

1. What is your approach?

2. What is exfoliative cytology? How is cervical cancer

screening practiced?

3. What does the hyperchromatic crowded cell group in pic

(A)represents?

4. What are the most common types of high risk HPV

associated with cervical cancer?

5. Describe the microscopic features in the above Pic (b).

6. Name the system used for reporting cervical cytology and

what are the indications and importance of pap smear?
1.What is your approach?
cervical cancer screening by Pap smear test

2.What is exfoliative cytology?

It is a microscopic study of cells that are shed or
obtained from the body especially for diagnostic purpose
(as in determining the presence or absence of a
cancerous condition).
A pap smear test is the screening test for cervical
cancer.

3. What does the hyperchromatic crowded cell group in

Pic A represent?
The hyperchromatic crowded cell group in Pic A
represents Endocervical cells / transformation zone
component

4 What are the most common types of high risk HPV

associated with cervical cancer?

The most common types of high risk HPV associated with

cervical cancer are HPV -16 and HPV -18

5.Describe the microscopic features in the above Pic C .

The cells show squamous cells with hyperchromatic

nucleus with reduced cytoplasm , increased in nucleus
to cytoplasm ratio

6.Name the system used for reporting cervical cytology

and what are the indications and importance of pap
History 1: 70 year old male, chronic smoker with
history of breathlessness, cough, dyspnoea. (A)

History 2: 60 year old male, chronic alcoholic

developed gradual weakness, anorexia, weight loss
,clinical findings of ascites, jaundice(B) was noted

A. Pleural fluid B. Ascitic fluid

Questions:

1. Write differences between Transudate and Exudate

2. Write the Microscopic finding of Pleural(fig 1) A

fluid cytology

3. Describe the Malignant cell in Ascitic fluid (fig 2)

1.Write differences between Transudate and Exudate

2. Write the Microscopic finding of Pleural(A)fluid cytology

Reactive proliferation of mesothelial cells ,
Polymorphonuclear neutrophils are seen in acute
inflammation and lymphocytes in chronic inflammation, If
lymphocytes are predominant in the effusion fluid in a
fibrin rich background , rule out tuberculosis .

3. What are the types of cells in Malignant effusions ? (B )

Malignant cells may be from primary –eg mesothelioma or

secondary /metastatic tumors .
Mesothelioma – epithelial type
Adenocarcinoma
Squamous cell carcinoma
Small cell carcinoma .
Lymphoma .
35 year old male presented with severe headache, neck
stiffness, nausea and vomiting since 4 days.

CSF findings-
Cell count- 280 cells/cumm
Protein- 60 mg/dl
Glucose- 70 mg/dl

Questions:
1.What is the diagnosis?

2.What is CSF pleocytosis?

3.Identify the cells in the CSF smear

4.What are the sites of CSF collection?

5.Differentiate between traumatic tap and CSF in

subarachnoid hemorrhage

6.Comment on the gross appearance of CSF in fig 2

Fig 01 Fig 02
 1) Viral meningitis

2) Pleocytosis is increase in the cell count of

CSF.

3) Presence of lymphocytes

4) Techniques of obtaining CSF-

• Lumbar puncture (LP)-between L3 & L4.
• Cisternal puncture.
• Ventricular cannulas/shunt
• Lateral cervical puncture.

5)

6) It is the gross appearance of CSF in traumatic tap,

in initial tubes blood is more than the following
tubes.
5 year old male child presented with fever, severe headache
and vomiting since 1 day. On examination neck stiffness
present, positive kerning's sign.

Lumbar puncture was done

CSF pressure - 280 mm/H2O
Appearance – Slight turbid.
Cell count- 8000 cells/cumm
Protein- 110mg/dl
Glucose- 30 mg/dl

Questions:

1.Identify the cells in CSF.

2.what is the diagnosis?

Mention the etiology

3. What are the other investigations that can be done?

4. What are the complications of lumbar puncture?

5. Comment on the gross appearance of CSF.

1) Neutrophils

2) Bacterial meningitis
Streptococcus pumonia, Neisseria
meningitides, H. Influenza, Staphylococcus
aureus.

3) Grams staining, Culture, Latex

agglutination test.

4) Headache
Herniation of cerebellum through foramen
magnum.
Hematoma.
Introduction of infection

5) Turbid appearance
30yr old male presented with fever, head ache for 5
weeks . H/o weight loss, fatigue since 3months. Past
history of being treated for similar complaints. Lumbar
puncture was done.
CSF analysis
Cell count-566cells/cumm
Lymphocytes-94%
Neutrophils-06%
Proteins-400mg/dl
Glucose-35mg/dl
Questions:
1. What is the diagnosis based on clinical and
laboratory findings?
2. Identify the gross characteristic feature of CSF in fig
01.
3. Comment on the cell type and cell count.
4. Mention the types of meningitis that can occur in
Acquired immuno-deficiency syndrome.
5. Interpret India ink preparation in fig 02.
6. What are the complications of lumbar puncture?

Fig 01 Fig
02
1) Tuberculous meningitis.

2) Cob web appearance, forms fibrin coagulum

on standing.

3) In the smear, lymphocytes will be increased,

count being 100-1000 lymphocytes/cumm.

4) Fungal meningitis caused by candida,

Cryptococci, histoplasma, Blastomyces, and
Aspergillus.

5) India ink preparation is a negative stain

done for identification of capsule of
Cryptococci.

4) Complications of lumbar puncture:

Headache
Herniation of cerebellum through foramen
magnum.
Hematoma.
Introduction of infection
Clinical history : A 45yrs old male presented with anorexia,
malaise, nausea/ vomiting and pruritis. O/E: yellowish
discolouration of sclera, tender hepatomegaly.

Laboratory findings: dark coloured urine, clay coloured

stools.

Liver function tests: Total bilirubin: 4mg/dl, Direct

(conjugated): 1mg/dl, Indirect bilirubin : 2 mg/dl, ALT/ SGPT :
95 U/L, AST/ SGOT: 86 U/L, serum alkaline phosphatase
(ALP): 155U/L. Total serum proteins: 10gm/dl, serum
albumin: 3 gm/dl, serum globulins: 6.6 gm/dl, albumin/
globulin (A/G) ratio: 0.45, prothrombin time: 45 seconds.

Questions :
1. What are the phases of Acute hepatitis.
2. Describe the gross and microscopic features of liver in
acute viral hepatitis.
1. Clinically acute hepatitis is categorized into 4 phases:
Incubation period, pre- icteric phase, icteric phase and
post icteric phase

2.
Gross:
Liver is slightly enlarged, soft and greenish.

Microscopy:
1. Hepatocellular injury most marked in
centrilobular zone (zone 3): ballooning
degeneration of hepatocytes, acidophil body or
councilman body formed by the process of
apoptosis, bridging necrosis.
2. Mononuclear inflammatory cells in the portal
tract and also within hepatic lobules.
3. Kupfer cell hyperplasia,
4. Cholestasis,
5. Regeneration following hepatocyte necrosis
results in lobular disarray.
 Clinical history: 50 yrs old male presented with history
of multiple transfusions, anorexia, fatigue, nausea/
vomiting, pain right hypochondrium.
O/E: Yellowish discolouration of sclera, tender
hepatomegaly.

Lab findings: high coloured urine, pale stools.

Liver function tests: Total bilirubin: 4.5mg/dl, Direct
(conjugated): 1.8mg/dl, Indirect bilirubin : 2.3 mg/dl,
ALT/ SGPT : 86 U/L, AST/ SGOT: 92 U/L, serum alkaline
phosphatase (ALP): 165U/L. Total serum proteins:
11gm/dl, serum albumin: 3.2 gm/dl, serum globulins:
6.2 gm/dl, albumin/globulin (A/G) ratio: 0.5,
prothrombin time: 66 seconds.

• Questions

1. Name the hepatotropic viruses associated with

chronic hepatitis.
2. Describe the morphological features of chronic
hepatitis.
3. Discuss the histological grading of chronic hepatitis
as a prognostic indicator.
 1. Hepatitis C and Hepatitis B

2. Microscopy
1.Piecemeal necrosis
2. Portal tract lesions
3. Intralobular lesions
4. Bridging fibrosis.

3. As prognostic indicator of chronic hepatitis, a

histologic grading of chronic hepatitis (ranging from
none to minimal/mild to moderate and severe) was
originally described by Knodell and Ishak. A combined
histologic grade leads to hepatitis activity index( HAI)
and takes the following features into consideration:
• A. Necroinflammatory activity:
• Periportal necrosis i.e. piecemeal necrosis and/or bridging
necrosis (ranging from score 0 as ‘no necrosis’ to score 4 as
‘multilobular necrosis’).
• Intralobular necrosis, focal or confluent (ranging from score
0 as ‘none’ to score 4 for’ >10 foci’ for focal necrosis and
score 6 as ‘panacinar/multiacinar’ for confluent necrosis).
• Extent and depth of portal inflammation (ranging from grade
0 as ‘no inflammation’ to grade 4 having ‘marked portal
inflammation’).
• B. Stage of fibrosis:
• Extent and density of fibrosis (ranging from score 0 as ‘no
fibrosis’ to score 6 as ‘cirrhosis’).
A 30 year old male patient presents with
nausea, vomiting, malaise, pruritis & right
upper quadrant pain.

O/E: Liver enlargement is present, Icterus is

seen.

Laboratory findings:
Total serum bilirubin:- 3.0 mg/dl
SGPT:- 160 U/L SGOT:- 70 U/L

Serology:- HBsAg positive

Questions:

1. What is your diagnosis?

2. List the conditions causing hepatic

jaundice.

3. List the serological markers used for

diagnosis of above condition.
1) Viral hepatitis (Hepatitis B)

2) Gilberts syndrome,

Physiological jaundice of newborn

Viral hepatitis

Alcoholic hepatitis

Drugs

Primary biliary cirrhosis

3) Hepatitis surface antigen(HBsAg)

Antibody to HBsAg(Anti-HBS)

HBeAg

Anti-HBeAg

Anti-HBc

Hepatitis B Virus DNA(HBV-DNA

 A 35 year old female patient comes with history
of weight gain, lethargy, constipation, cold
intolerance and irregular menstruation.

On examination: Swelling in the midline of

neck +

Laboratory investigations:

• TSH: - 20mU/L
• T4: - 3µg/dl
• T3: - 90ng/dl

Questions:
1) What is your diagnosis?
2) What are the causes for above condition?
3) What is cretinism?
1) What is your diagnosis?
Hypothyroidism

2) What are the causes for above condition?

Hashimoto’s thyroiditis
Iodine deficiency
Exogenous goitrogens
Iatrogenic cause: drugs, surgery & radiation.

3) What is cretinism?
It is hypothyroidism present at birth or
developing within first two years of postnatal life.
• A 34 years old male presented with complaints of shortness
of breath on lying down and during exercise(exertional).
Initially it was mild but gradually increasing over a period of 1
week.He has observed swelling of the both feet since 5 days.
Patient met with a road traffic accident one month back and
underwent surgery and continued with painkillers until now.
There is no history of chest pain.
• On examination BP - 150 /90 mmhg, pulse rate-110 bpm,
Pallor and edema present, no icterus On auscultation-
bilateral basal crepitation present . Per-abdomen
examination- normal.
• INVESTIGATIONS:
• URINE MICROSCOPY: Plenty of WBC with casts(refer Fig2)
• RFT:BUN 197 mg/dl,(normal range7-20 mg/dl) Creatinine
48.8 mg/dl( normal range 0.6-1.2 mg/dl) urea -55mg/dl,
(normal range-20-40mg/dl) Uric Acid 8.7 mg/d(normal
range-3.1-7mg/dl) Potassium 6.1 mmol/L3(normal
range-3.5-5.0 meq/l)
• Renal biopsy was done(refer Fig1)

1) What is your diagnosis?

2) What are the causes?
3) Name two complications?
1) Acute renal failure

2) Prerenal- hypovolemia, decreased cardiac

output, NSAIDs
Post renal- extrarenal obstruction(bladder
outlet obstruction)
Renal- acute glomerulonephritis, rapidly
prograssive glomerulonephritis, vasculitis,
malignant hypertension, nephrotoxins

3) Metabolic- Hyperkalemia, hypocalcemia

cardiovascular- cardiac arrhythmias, pulmonary
odema
gastrointestinal- hemorrhage
Hematological- Anaemia, bleeding
• A 50 years male complains of swelling of both the limbs
upto shin for 6 months, shortness of breath on doing
minimal activity.There was no history of chest pain. Since 1
week, his appetite is reduced and is associated with
nausea.He is a known case of diabetes since 15 years and
hypertensive since 8 years but not taking medications
regularly.
On examination
BP 180/90mm hg, pulse 96 beats per minute,Pallor and
pedal edema present, no icterus. On auscultation bilateral
crepitations present,Per abdomen examination mild
ascites present.
INVESTIGATIONS:
CBC:Hb- 7.2g/dl RBC -5.56,Hct -22.0MCV63.6,MCH
21.1,MCHC32.2,WBC-13.8, with rise in neutrophils(N 81%),
Platelet 1.6 lakh cells/cumm
RFT:
BUN 157 mg/dl(normal range-7-20mg/dl) Creatinine 48.8
mg/dl(normal range -0.6-1.2 mg/dl) urea- 78mg/dl,(normal
range-20-40mg/dl) Potassium 7.9 mmol/L(normal
range-3.5-5.0meq/l)
Renal biopsy was done(refer picture)

1) What is your diagnosis?

2) What are the causes?
3) What is morphological changes expected/
seen?
1) Chronic renal failure

2) Glomerulopathies- proliferativeGN, crescentic

GN, membranoproliferative GN,
mesangiocapillary GN
systemic- diabetes, Systemic lupus
erythematosus, amyloidosis gout
Interstitial- chronic interstitsl nephritis, chronic
pyelonephritis, tuberculosis

3) Kimmelstiel-Wilson (KW) lesion

A 45 yr old male presented with fatigue,
chills, dark colored urine and yellow
discoloration of skin.
Hb- 6 g/dl
Total bilirubin-5.2g/dl

Leishman Stain,40XA B

Questions:
a) What is the probable diagnosis?
b) Describe the above peripheral smear(a).
c) What is Coomb’s test ?
d) What are warm antibodies?
e) What are cold antibodies?
a) What is the probable diagnosis?
Hemolytic anemia

b) Describe the above peripheral smear.

Shows poly chromatophils, nucleated rbc’s
and microspherocytes

c) What is Coomb’s test ?

It is a test done to detect the presence of IgG
antibodies on the red cell surface.

d) What are warm antibodies?

IgG antibodies which bind to the red cells at
37 degree Celsius

e) What are cold antibodies?

IgM/ IgG antibodies which demonstrate
affinity to red cells at zero to 10 degree
Celsius and it diminishes gradually with rise
in temperature.
 6 year old girl Presented with abdominal pain and joint pain.
O/E- Hepatomegaly +

Investigations done:
Hb% 8gm/dl
Reticulocyte count 6%

Peripheral blood smear:

Questions

1. What is your diagnosis? Mention the hemoglobin defect.

2. What are the relevant investigations done to confirm

your diagnosis?

3. What are the complications?

1. What is your diagnosis? Mention the hemoglobin defect

Sickle cell anemia.

Hemoglobin defect- substitution of valine for glutamic

acid at position 6 of β polypeptide chain in hemoglobin
resulting in formation of HBS.

2. What are the relevant investigations done to confirm

your diagnosis?

a. Peripheral blood examination

b. Identification of HbS by slide test using 2% sodium

metabisulphite, solubility test, haemoglobin
electrophoresis, and high performance liquid
chromatography (HPLC).

3. What are the complications?

a)Infections

b)Vaso-occlusive crises:

c)Hematologicic crisis: i)Aplastic crisis

ii) Megaloblastic crisis

iii)Haemolytic (“Hyperhaemolytic”)
crisis

iv)Splenic sequestration crisis

Two year old boy presents with failure to
thrive, intercurrent infections, pallor and mild
jaundice. On examination, there is enlargement
of liver, spleen, frontal bossing. X ray showed
hair on end appearance.
Lab findings :
Hemoglobin: 4gm/dl
MCV: decreased
MCH: decreased
Retic count: 5%
Fetal hemoglobin is increased.
X ray skull

Nestroft test Peripheral blood smear

Questions:
1. What is your diagnosis?
2. What is the basic defect in this condition?
3. How do you classify this disease?
1. Beta thallasaemia Major

2. Thallassemia are a group of disorders which

result from an inherited abnormality of globin
production. Thallasemia syndrome result from
defects in the rate of synthesis of α or β globin
chains.

3. Thallasemia syndromes are classified into

three types :
a. beta thallasemia: further classified into
Thallasemia major, intermedia and minor
b. Alpha thallasemia and
c. Miscellaneous syndromes
30 year old male presented with abdominal pain
and yellowish disolouration of the eyes and
passing of pale stools. Abdominal palpation
revealed splenomegaly. Ultrasonography showed
presence of gall stones.
Peripheral blood smear findings:

Questions:

1. What is your diagnosis?

2. What are polychromatophilic cells?
3. What is the basic defect in this condition?
4. What complication is caused by parvovirus
B19
infection in this condition?
1. Hereditary Spherocytosis
2. Polychromatophilic cells are slightly immature, non nucleated,
multicoloured red cells (shades of greyish blue) in a blood smear.
It is an indication of red blood cells being released prematurely from
the bone marrow during formation. They are larger in size than RBCs.
Under normal circumstances, the young red cells remain in the
bone marrow one or two days before release into the blood stream.
However, when the bone marrow is stressed due to bloos loss or
otherconditions, these cells are prematurely released into the blood.
They are identified as reticulocytes, if stained with a supravital stains.

3. The basic defect in this condition lies in the red cell membrane
skeleton, and qualitative and quantitative abnormalities of spectrin,
major protein of the membrane: there is either reduction in the amount
of spectrin or spectrin lacks the ability to attach to protein 4.1

4. Parvovirus B19 infection causes Aplastic crisis in

Hereditary spherocytosis
60 years male with history of fatigue, fever and
bleeding gums since 1 week. On examination
hepatosplenomagaly present.
Investigations -
Hb- 4.2 g/dl,TC- 1,60,000 cells, Platelets-90,000 cells.

SUDAN BLACK

Leishman Stain, 100X MPO

Questions:
1. What is your diagnosis?
2. Describe the peripheral smear picture
3. Describe the bone marrow picture
4. What are auer rods?
5. Classify the disease according to WHO
classification.
6. Name the cytochemical stains done for
confirmation.
1. What is your diagnosis?
Acute myeloid leukaemia.
2. Describe the peripheral smear picture.
RBC: Normocytic and Normochromic (Hb% is
reduced)
WBC: markedly increased in number with more
than 20% myeloblasts with few myeloblasts
showing auer rods
Platelets: decreased in number and normal in
morphology.

3. Describe the bone marrow picture.

Bone marrow is hyper cellular with increase in
myeloid
series of cells showing more than 20%
myeloblasts , auer
rods seen,erythroid series are dercreased with
normoblastic
maturation,megakaryocyte are decreased in
number.
4. What are auer rods?
Azurophillic needle like peroxidase positive
structures in
cytoplasm of myeloblasts especially M3 and M4.

5. Classify the disease according to WHO

classification.
1.AML with recurrent genetic abnormalities
2.AML with myelodysplasia related changes.
3.Therapy related myeloid neoplasms
4.AML-Not otherwise specified
5 Years boy presented with complaints of fever fatigue.
On examination he has generalized Lymphadenopathy
& splenomegaly.
Investigation-
Hb 5.6 gm / dl,WBC- 80,000 cells,Platelet- 50,000 cells

Leishman Stain, 100X PAS

Questions:
1. What is your diagnosis?
2. Describe the Peripheral smear picture.
3. State the differences between myeloblast &
lymphoblast
4. Classify the disease according to WHO
classification.
5. Name the cytochemical stains done for
confirmation.
 1. What is your diagnosis?
Acute Lymphoblastic Leukemia
2. Describe the Peripheral smear picture.
RBC: Normocytic and Normochromic (Hb% is reduced).
WBC: markedly increased in number with more than 20%
lymphoblasts.
Platelets: decreased in number and normal in morphology.

3. State Myeloblast
the differences between myeloblast & lymphoblast
Lymphoblast

5 times the size of lymphoblast 3 times the size of lymphoblast

Moderate amount of cytoplasm(> Scant amount of cytoplasm (<

lymphoblast) myeloblast)
Cytoplasmic granules present Cytoplasmic granules present

Auer rods present Auer rods absent

Fine chromatin with 3-5 Coarse chromatin with

prominent nucleoli inconspicuous nucleoli
Cytochemistry

MPO and SUDAN BLACK B positive MPO and SUDAN BLACK B negative

PAS negative PAS block/coarse positivity

NSE positive in M4 and M5 NSE negative

4. Classify the disease according to WHO classification.

B lymphoblastic leukemia/lymphoma
1. B lymphoblastic leukemia/lymphoma, NOS
2. B lymphoblastic leukemia/lymphoma with recurrent genetic
abnormalities
T lymphoblastic leukemia/lymphoma

5. Name the cytochemical stains done for confirmation.

Periodic acid schiff(PAS)- Block/Coarse positivity
Myeloperoxidase(MPO)- Negative
Sudan Black B- Negative
A 60 year old male presented with complaints
of low backache, fatigue and weight loss.
Hb-7g/dl
ESR-120mm/hr
Bone marrow picture X ray skull

Questions:

a) What is the diagnosis?

b) What is the characteristic X ray finding in
this condition?
c) What is the characteristic finding in urine?
a. What is the diagnosis?
Multiple myeloma

b. What is the characteristic X ray finding in

this condition?
X ray shows osteolytic lesions (punched out
lesions in the skull)

c. What is the characteristic finding in urine?

Urine shows presence of Bence Jones
proteins
A 60 year old male presented to the casualty with
complaints of chest pain, breathlessness, sweating and
vomiting .

ECG findings –

Questions:

a) What is the finding in the above ECG and probable

diagnosis?
b) What are the serum markers that help in the diagnosis
of this condition?
c) Which is the most specific marker?
d) What are the risk factors for this condition?
a) What is the finding in the above ECG and
probable diagnosis?

ST segment elevation , The condition is

Myocardial Infarction

b) What are the serum markers that help in the

diagnosis of this condition?

CK MB, Cardiac troponins, LDH, Myoglobin

c) Which is the most specific marker?

Cardiac troponins

d) What are the risk factors for this condition?

Smoking, Alcoholism, Obesity, Family history,

Co morbidities like diabetes, hypertension.