UNIVERSITY OF THE PHILIPPINES MANILA

PHILIPPINE GENERAL HOSPITAL

DEPARTMENT OF MEDICINE

HEMATOLOGY
MONTHLY RESIDENTS’ EXAM
August 23, 2017

MULTIPLE CHOICE. Choose the BEST answer. On the scantron, shade the corresponding letter. Good luck!

1. A 58-year-old male was referred to you for persistent anemia. He is a known diabetic for 20 years, and has
shifted from metformin to insulin 5 years ago with poor compliance. He shares that he has been increasingly
fatigued over the past few months. On PE, BP 160/80, HR 78, RR 18, with slightly pale conjunctivae, no neck
vein distention, decreased breath sounds on the bases, and bipedal edema. Laboratories reveal Hemoglobin of
75 g/L, Hematocrit 23%, and Reticulocyte Production Index of 2.25, Creatinine 500 umol/L. Which of the
following should be expected in the peripheral blood smear? (HPIM 19, c77, p398)
A. Normocytic, normochromic red cells
B. Microcytic red cells
C. Macrocytic red cells
D. Sideroblastic anemia

2. A 35-year-old female is in your clinic for a second opinion after her CBC revealed abnormal findings. She was
hospitalized briefly when she was born for “butas sa puso”. She occasionally has headaches, more prominently
during her regular monthly period, but apart from that has no other symptoms. PE shows normal vital signs,
no murmurs are apparent. She weighs Labs reveals Hemoglobin of 175 g/L, Hematocrit of 58%, Which of the
following is the next step in achieving a diagnosis? (HPIM 19, c77, p400)
A. Measure serum EPO levels
B. Measure arterial O2 saturation
C. Measure RBC mass
D. Measure carboxyhemoglobin levels

3. A 60-year-old male in in the OPD for “bukol sa katawan.” He has been feeling feverish and fatigued over the
past 4 weeks and notices lumps on his neck. He has lost about 5kg over the past month. He has no other
illnesses. On PE, VS are normal. On bimanual palpation at the left lower rib cage, the tip of the spleen is felt on
inspiration. What is the likely mechanism responsible for the physical examination finding in this patient?
(HPIM 19, c79, p411)
A. Reticuloendothelial hyperplasia
B. Passive congestion due to decreased blood flow
C. Infiltrative disease
D. Normal variant

4. A 45-year-old male is in the OPD for “bukol sa katawan.” He has been feeling several lumps in his neck over
the past month, which he attributed to his cough initially but has since persisted. He has no fever, weight loss,
or other symptoms. He is a 30-pack-year smoker, of good functional capacity. On PE, VS are normal; there are
multiple lymphadenopathies measuring about 2.5-3.0 cm on the bilateral submandibular and occipital areas of
his neck. Which of the following is the next step in management? (HPIM 19, c79, p409)
A. Glucocorticoids
B. Antibiotics
C. Observation for 2 weeks
D. Lymph node excision biopsy

5. What is the hallmark of moderate and severe factor VIII and IX deficiency? (HPIM 19, c78, p403)
A. Easy bruising
B. Spontaneous hemarthroses
C. Mucosal bleeding
D. Epistaxis

6. A 30-year-old female in the OBAS was referred to you due to abnormal blood results. She has a 2-week history
of menorrhagia and comes in weak and pale. VS are BP 90/65, HR 110, RR 18. Labs reveal Hemoglobin of 85
g/L, WBC 10,000/uL, Platelet 180,000/uL, Bleeding time prolonged, Normal PT, Prolonged PTT. What is the
likely diagnosis? (HPIM 19, c78, p403; Similar PSBIM 2017 Question)
A. Factor VIII deficiency
B. Factor IX deficiency
C. Von Willebrand Disease
D. Drug-induced platelet defect

7. Mixing studies are used to evaluate a prolonged aPTT to distinguish between a factor deficiency and an
HEMATOLOGY EXAM | JACL 2017 1
 inhibitor. What is the expected result for isolated factor deficiencies? (HPIM 19, c78, p406)
A. Corrects with mixing; Stays corrected with incubation
B. Corrects with mixing; Remains prolonged with incubation
C. No correction with mixing or incubation
D. Variable depending on factor deficiency

8. A 30-year-old female is in the Dermatology OPD due to persistent wounds around her mouth. She always
seems to have fissures at the corners of her mouth even if she judiciously applies lip balm and drinks a lot of
water. She does not have any other symptoms and has not had any acute illnesses recently. Labs reveal
hypochromic microcytic anemia. Which of the following diagnostic tests is the most convenient laboratory test
to evaluate her anemia? (HPIM 19, c126, p627)
A. Serum iron
B. Total iron-binding capacity
C. Red cell protoporphyrin levels
D. Serum ferritin

9. Which of the following is not included in the differential diagnosis of hypochromic, microcytic anemia? (HPIM
19, c126, p628)
A. Inherited defects in globin chain synthesis
B. Anemia of inflammation
C. Myelodysplastic syndromes
D. Hemophilias

10. In the asymptomatic patient with established iron-deficiency, treatment with oral iron is usually adequate.
How many mg of elemental iron per day is usually needed? (HPIM 19, c126, p629)
A. 50 mg
B. 200 mg
C. 600 mg
D. 1000 mg

11. The goal of therapy in individuals with iron-deficiency anemia is to repair the anemia and provide adequate
stors. How many months of sustained treatment will be needed? (HPIM 19, c126, p629)
A. 1-6 months
B. 3-6 months
C. 6-12 months
D. > 1 year

12. A 19-year-old male is in the ER for chest pain, tachypnea, fever, cough, and desaturation. His older brother
says that as a child, he was very sickly, with intermittent bouts of abdominal pain and muscle pain lasting the
entire afternoon – usually after excessive exercise. This is the third time this year that he has been brought to
the ER for difficulty of breathing. He has no other symptoms. On PE, BP 140/80, HR 110, RR 24, O2Sat 88% on
room air, breath sounds reveal occasional crackles. Laboratories reveal Hemoglobin of 80 g/L, MCV 85 fL.
What long term complications may be expected in his case? (HPIM 19, c127, p635)
A. Coronary artery disease
B. Pulmonary hypertension
C. Renal papillary necrosis
D. Retinal hemorrhages

13. A 20-year-old male is in the OPD for a second opinion on an abnormal blood result. He is asymptomatic.
Laboratories for pre-employment reveal Hemoglobin of 110 g/L, Hematocrit 33%, MCV of 72 fL. You order a
Hemoglobin electrophoresis revealing elevated HbA2. What is the likely diagnosis? (HPIM 19, c127, p638)
A. Silent thalassemia
B. Alpha Thalassemia-2 trait
C. Beta Thalassemia minor
D. Beta Thalassemia intermedia

14. Which of the following is NOT a general tissue effect of cobalamin and folate deficiencies? (HPIM 19, c128,
p642-643)
A. Premature birth
B. Psychiatric disturbances
C. Breast cancer
D. Asthma

15. How much folic acid must be given as a supplement to pregnant women? (HPIM 19, c129, p648)
A. Unnecessary since food is fortified with enough folic acid needed.
B. 200 ug
C. 400 ug
D. 5mg
16. A 28-year-old female is referred to the Hema OPD for an incidental finding on her CBC. Laboratories reveal a
HEMATOLOGY EXAM | JACL 2017 2
 Hgb of 100 g/L, Hematocrit of 32%, MCV of 110 fL. The only prominent symptom is anorexia which has been
present for about 4 weeks. Pregnancy test is negative. Personal social history reveals that she is a vegetarian
for the past 8 years. You join your fellow to read the peripheral blood smear afterwards revealing the
following. What is the likely diagnosis? (HPIM 19, c128, p643)

A. Iron-deficiency anemia
B. Cobalamin deficiency
C. Folate deficiency
D. Anemia of inflammation

17. A 35-year-old male intentionally ingested muriatic acid and was admitted at the ER. He was referred to you as
SAPOD due to his moderately persistent asthma. A gastrectomy was performed. Which of the following factors
will influence you to start prophylactic cobalamin therapy? (HPIM 19, c128, p645)
A. Serum vitamin B12 levels 4 weeks postoperatively
B. Extent of surgery (Total vs Partial)
C. Involvement of the ileum
D. Level of anemia

18. A 26-year-old PLHIV has been started on PJP prophylaxis due to his low CD4+ count. The week after, he comes
to your clinic saying he discontinued his medications because he felt very weak after taking it. He looks pale.
You order a CBC with PBS. What typical feature should you expect? (HPIM 19, c129, p655)
A. Bite cells
B. Rouleaux formation
C. Macrocytosis
D. Dohle bodies

19. What constitutes the triad to suspect autoimmune hemolytic anemia? (HPIM 19, c129, p658)
A. Anemia, jaundice, splenomegaly
B. Anemia, jaundice, mucosal bleeding
C. Anemia, jaundice, neurologic symptoms
D. Anemia, jaundice, co-morbidity (i.e. lupus, leukemia)

20. The definitive diagnosis of PNH is based on the demonstration of that a substantial proportion of the patient’s
red cells have increased susceptibility to complement due to a deficiency in surface proteins that normally
protect the RBCs from activated C. Which surface proteins would be negative on flow cytometry in PNH
patients? (HPIM 19, c129, p660)
A. CD34 and CD56
B. CD4 and CD34
C. CD8 and CD55
D. CD55 and CD59

21. A 30-year-old male is in the OPD due to his elevated Hemoglobin on CBC. He has no other illnesses and does
not engage in any vices. On ROS, he complains that he has frequent headaches and has increasingly been itchy
and it seems to be worse after taking a shower. Physical examination findings reveal splenomegaly.
Laboratories reveal Hemoglobin of 180 g/L and Hematocrit of 55%. You consider performing phlebotomy.
What level of hemoglobin will avoid thrombotic complications? (HPIM 19, c131, p674)
A. 150 g/L
B. 140 g/L
C. 130 g/L
D. 120 g/L

HEMATOLOGY EXAM | JACL 2017 3

22. A 24-year-old male is evaluated for a 2-month history of frequent URTI, easy bruising, and worsening
endurance. Past medical and family histories are unremarkable. He takes no medications. On PE, the patient
appears fatigued, but not acutely ill. BP 100/60, HR 108, RR 14, T 36.7. Pallor and several 3- to 4-cm
ecchymoses on the lower extremities are noted. He has no hepatosplenomegaly. Laboratories as follows:
Haptoglobin 40 mg/dL (400 mg/L)
Hemoglobin 72 g/L
Leukocyte count 1000/uL with 5%
neutrophils
Platelet count 7000/uL
Lactate 150 U/L
dehydrogenase
Bone marrow aspirate Less than 5% blasts and
no dysplastic changes

What is the most likely diagnosis? (HPIM 19, c130, p665)

A. Acute lymphoblastic leukemia
B. Aplastic anemia
C. Myelodysplastic syndrome
D. Paroxysmal nocturnal hemoglobinuria

23. A 54-year-old male is evaluated during follow-up consultation regarding laboratory studies completed for a life
insurance policy. He reports no symptoms. On PE, BP 130/70, HR 88, RR 15, T 37.2. No splenomegaly noted.
Laboratories as follows.
Hemoglobin 89 g/L
Leukocyte count 3000/uL with 30% neutrophils, 10% monocytes, and 60%
lymphocytes
MCV 105 fL
Platelet count 75,000/uL
Folate Normal
Vitamin B12 Normal
Bone marrow biopsy Trilineage dysplasia with 1% blasts
Findings are compatible with low-risk disease by the International Prognostic Scoring System – Revised
Criteria.
Which of the following treatments offer cure? (HPIM 19, c130, p671)
A. 5-Azacytidine
B. Allogeneic hematopoietic stem cell transplantation
C. Erythropoietin
D. Alemtuzumab

24. A 27-year-old female is in the OPD for a follow-up visit. She was evaluated 3 months previously for symptoms
of fatigue of 9 months' duration and a craving for ice. She experiences heavy, irregular menstrual cycles, but
has no history of other bleeding. Medications are oral contraceptive pills and daily iron, which were initiated 3
months ago. Vital signs are normal; no splenomegaly is noted. Labs are as follows:
3 months ago 2 months ago Current
Ferritin 6 ng/mL 16 ng/mL 45 ng/mL
Hemoglobin 87 g/L 101 g/L 130 g/L
MCV 71 fL 77 fL 88 fL
Platelet count 800,000/uL 790,000/uL 775,000/uL
Which of the following is the most appropriate diagnostic test to perform next? (HPIM 19, c131, p677)
A. BCR-ABL genetic analysis
B. JAK2 V617F analysis
C. PT and APTT
D. von Willebrand factor antigen

25. A 43-year-old female is admitted to the hospital for fatigue of 4 weeks duration, easy bruising and bleeding
gums of 1 week's duration, and a 1-day fever of 38.9. On PE, patient appears ill; BP 100/60, HR 115, RR 22, T
39.4. She has gingival bleeding, bleeding around her intravenous insertion site, and multiple ecchymoses and
petechiae. Hepatomegaly is also noted. Labs show APTT 65 secs, Hgb 76 g/L, WBC 32,000/uL, Platelet
25,000/uL, PT 24 secs, Fibrinogen 97 mg/dL. A peripheral blood smear shows 80% immature blasts with
prominent Auer rods phenotypically consistent with promyelocytes. What is the mechanism of action of the
drug of choice? (HPIM 19, c132, p686; Similar PSBIM Question)
A. Cellular differentiation
B. Topoisomerase II inhibitor
C. Inhibitor of DNA and RNA replication
D. Nonspecific cytocidal activity

HEMATOLOGY EXAM | JACL 2017 4

26. A 20-year-old female is in the OPD for fatigue and easy bruisability of 1-month duration. On PE, she has
normal VS, with note of multiple dental caries, multiple lymphadenopathy on the neck and sternal tenderness.
The rest of the PE is unremarkable. You suspect AML; apart from laboratory studies, what should be included
in her initial evaluation? (HPIM 19, c132, p683)
A. Dental evaluation
B. Lumbar puncture
C. Screening spine MRI
D. Brain MRI

27. What is the most important independent prognostic factor in AML? (HPIM 19, c132, p679)
A. Chromosome findings at diagnosis
B. Molecular markers
C. Performance status
D. Percent of circulating blasts at diagnosis

28. A 34-year-old male is evaluated for a 3-month history of fatigue, early satiety, and a 10-kg (22 lb) weight loss.
Past medical history is notable for hypertension, which is controlled with hydrochlorothiazide. On PE, BP
130/80, HR 114, RR 13, T 36.7. Heart and lung exams are normal; there is no lymphadenopathy. Spleen is
palpable 10 cm below the costal margin. Laboratories show Hemoglobin of 84 g/L, leukocyte count of
314,000/uL, and platelet count of 622,000/uL. Peripheral blood smear is shown below.

Which of the following is the most sensitive test to determine disease burden in patients on TKI therapy?
(HPIM 19, c133, p689; Actual PSBIM 2017 Question)
A. FISH for BCR-ABL
B. JAK2 V617F mutation testing
C. Flow cytometry
D. Chromosomal analysis

29. A 48-year-old female is evaluated for a 6-week history of fatigue and an enlarged right cervical lymph node.
She has no significant past medical history and takes no medications. On PE, vital signs are normal. A 4-cm
firm, enlarged right cervical lymph node is palpated. There is no other lymphadenopathy and no
splenomegaly. The remainder of the examination is unremarkable. Labs including CBC, ESR, LDH, and serum
β2-microglobulin level, are normal. Lymph node biopsy reveals effacement of the normal architecture by
sheets of atypical lymphoid cells. Flow cytometry results are positive for B antigens CD19, CD20, CD22, and
CD79a, consistent with diffuse large B-cell lymphoma. CT scans of the chest, abdomen, and pelvis show an
isolated enlarged right cervical lymph node but are otherwise normal. Which of the following is the most
appropriate treatment? (HPIM 19, c134, p705)
A. Allogeneic hematopoietic stem cell transplantation
B. Autologous hematopoietic stem cell transplantation
C. Involved-field radiation therapy
D. Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP)

30. A 63-year-old male is evaluated for severe mid-upper back pain following a minor fall 1 day ago. He also notes
progressive fatigue of 6 months' duration and a 6.8-kg weight loss. He is an 80-pack-year previous smoker. On
PE, BP 110/80, HR 98, RR 18, T 37.3, BMI 22. Point tenderness to palpation is noted over the mid thoracic
spine. Rest of the PE is unremarkable. Labs as follows: Hgb 110 g/L, WBC 4800/uL, Platelt 155,000/uL, Albumin
28 g/L, Calcium 3.0 mmol/L, Creatinine 274 umol/L, Total Protein 63 g/L, Urinalysis trce protein, Urine Protein-
Creatinine Ratio 2300 mg/g. A chest radiograph shows no infiltrates and a normal cardiac silhouette.
Radiographs of the thoracic spine reveal osteopenia with a compression fracture of T6. Which of the following
is the most appropriate diagnostic test to perform next? (HPIM 19, c136, p715)
A. 1,25-Dihydroxyvitamin D measurement
B. Intact parathyroid hormone measurement
C. Parathyroid hormone-related protein measurement
D. Serum protein electrophoresis and free light chain test

31. A 72-year-old female is evaluated in follow-up for a recent diagnosis of multiple myeloma. She presented with
HEMATOLOGY EXAM | JACL 2017 5
 an 8-month history of progressive fatigue and dyspnea with exertion, but has had no other symptoms. Medical
history is unremarkable, and she takes no medications. PE is normal. Initial labs showed Hemoglobin of 92 g/L,
Calcium of 2.6 mmol/L, and Creatinine of 115 umol/L. A skeletal survey demonstrates diffuse osteopenia and a
T12 compression fracture with 50% height loss. No lytic lesions are seen. In addition to starting chemotherapy,
which of the following is the most appropriate treatment? (HPIM 19, c136, p717)
A. Balloon kyphoplasty to the T12 vertebra
B. Radiation therapy to the thoracic spine
C. Zoledronic acid
D. No additional treatment

32. A 60-year-old female is in the ambulatory care clinic presenting with a 6-month history of fatigue. PE is
normal. Initial laboratories reveal Hemoglobin of 85 g/L. She is referred for further work-up to the Hematology
clinic in the OPD where work-up was done. Additional laboratories showed lytic bone lesions, and an M
protein in serum protein electrophoresis. What is the diagnosis? (HPIM 19, c136, p715; Actual PSBIM 2017
Question)
A. Smoldering multiple myeloma
B. Symptomatic multiple myeloma
C. Nonsecretory myeloma
D. Solitary plasmacytoma

33. A 28-year-old female is evaluated for a 1-week history of progressive dyspnea and fatigue. She was diagnosed
with Hodgkin lymphoma 2 months ago and is receiving chemotherapy with doxorubicin, bleomycin,
vinblastine, and dacarbazine (ABVD). She takes no other medications. On PE, BP 130/80, HR 105, RR 16, T 36.8,
O2Sat 98% on room air. She has pale conjunctivae, clear breath sounds, and the rest of the PE is
unremarkable. Laboratories reveal Hemoglobin of 68 g/L, WBC 1300/uL, Platelet 83,000/uL, CMV IgG antibody
positive, and a PBS showing pancytopenia. Which of the following is the most appropriate erythrocyte
transfusion product for this patient? (HPIM 19, c138-5)
A. Leukoreduced, washed
B. Leukoreduced, irradiated
C. Leukoreduced, CMV-negative
D. Leukoreduced

34. A 73-year-old male develops acute respiratory distress near the completion of a transfusion of 1 unit of prBC
following a total hip arthroplasty. Past medical history is significant for hypertension, type 2 DM complicated
by nephropathy, and dyslipidemia. Medications are amlodipine, insulin, atorvastatin, and subcutaneous UFH.
On PE, BP 180/70, HR 115, RR 24, T 36.8, O2Sat 86% on room air, JVP 8 cm H20. Crackles on mid to upper lung
fields. Cardiac PE shows tachycardia but no murmurs. Minimal bilateral pedal edema is noted. Labs are as
follows:
Hemoglobin 77 g/L [68 g/L before transfusion]
Total bilirubin 20.5 umol/L
Creatiine 248 umol/L [239 umol/L before transfusion]
LDH 90 U/L
Urinalysis Negative for protein or blood
ECG Sinus tachycardia
Chest x-ray Bibasilar airspace opacities
Which of the following is the most likely diagnosis? (HPIM 19, c138e-5)
A. Acute hemolytic transfusion reaction
B. Transfusion-associated circulatory overload
C. Transfusion-related acute lung injury
D. Transfusion-transmitted sepsis

35. A 45-year-old female is evaluated in the ER for a 1-day history of abdominal pain and fever. She also reports
unexpected, heavy menstrual bleeding of 1 day duration and easy bruising of 2 days duration. Past medical
and family histories are unremarkable, and she takes no medications. On PE, she is not oriented to time
however the rest of the neuro PE is normal; BP 170/100, HR 110, RR 20, T 38.1. There is subconjunctival
hemorrhage; abdominal examination reveals tenderness to palpation without guarding or rebound. Pelvic
examination shows blood in the vaginal vault with no cervical motion tenderness. Labs as follows: Hematocrit
26%, WBC 10,300/uL, Platelet 24,000/uL, Reticulocyte count 8.3% of erythrocytes, Total Bilirubin 39.3 umol/L,
Creatinine 283 umol/L, LDH 1500 U/L. Which of the following is the most appropriate diagnostic test to
perform next? (HPIM 19, c140, p729)
A. ADAMTS-13 activity level
B. Osmotic fragility test
C. Peripheral blood smear
D. Stool Shiga toxin assay

HEMATOLOGY EXAM | JACL 2017 6

36. You order a repeat CBC for your 75-year-old male patient with VAP and CVD bleed after 7 days of IV
antibiotics. CBC reveals Hemoglobin of 105 g/L, WBC 8,000/uL, and Platelet of 35,000/uL. Medication list of
the patient includes Meropenem, Amikacin, Enoxaparin, Amlodipine, and Omeprazole. Which of the following
is TRUE of the management of his thrombocytopenia? (HPIM 19, c140, p728)
A. Hold enoxaparin.
B. Shift enoxaparin to fondaparinux or lepirudin.
C. Anticoagulation should no longer be given.
D. An increased risk of bleeding is present for at least 1 month after diagnosis.

37. A 24-year-old male is evaluated in the ER for prolonged and severe bleeding 3 days after undergoing
hemorrhoidectomy. He reports continually bleeding and soaking through four bath towels. Past medical
history is significant for prolonged bleeding following wisdom tooth removal. His brother also experienced
heavy bleeding with tooth extraction and he has a maternal grandfather who died of an intracerebral
hemorrhage at age 32 years. He takes no medications. On PE, he is pale, BP 90/55, HR 110, RR 20, T 36.7;
there is continued rectal bleeding with no clear source on anoscopy. Labs are as follows: Hct 17%, WBC
12,000/uL, Platelet 380,000/uL, aPTT 45 secs, PT 12.2 secs, aPTT with mixing 32 secs. Which of the following is
the most appropriate diagnostic test to perform next? (HPIM 19, c141, p733)
A. Bleeding time
B. Factor VIII level
C. Factor XI level
D. Lupus anticoagulant

38. A 25-year-old male about to undergo internal fixation for a fractured femur is referred to you for evaluation.
On preoperative work-up, he has a prolonged aPTT that is not corrected by Factor VIII deficient plasma but is
corrected by Factor IX deficient plasma. What is the diagnosis? (Actual PSBIM 2017 Question)
A. Factor VIII deficiency
B. Factor IX deficiency
C. Factor X deficiency
D. Von Willebrand disease

39. In a patient with previous venous thrombosis, what is an independent predictor for recurrence? (HPIM 19,
c142, p744)
A. Pregnancy
B. Hormone replacement therapy
C. Air travel
D. Increasing age

40. Which of the following tests can be used to monitor low molecular heparin therapy? (HPIM 19, c143, p751)
A. Protime
B. International Normalized Ratio
C. Anti-factor Xa levels
D. Monitoring is not required

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HEMATOLOGY EXAM | JACL 2017 7