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Hematology-Oncology Self-Assessment Exam #1

Choose the one best answer. The answers are following the exam. 1. A 21 year old man with diffuse large B-cell non-Hodgkin’s lymphoma had Cytoxan, Adriamycin, Vincristine and Prednisone (CHOP) chemotherapy 7 days ago. Now he has fever, light-headedness, rigors, weakness, and decreased urine output. On work-up what else could you find? A- Blood culture positive for E. coli B- Disseminated intravascular coagulation (DIC). C- Neutropenia D- Hypotension E- All of the Above 2. Immediate treatment for this patient must includeA- IV normal saline B- Empiric IV antibiotics C- Steroids such as prednisone D- A and B E- All of the above. 3. A 48 year old man who had squamous cell carcinoma of the lung one year ago treated with surgery now presents to you with shortness of breath, facial swelling, headaches, and vomiting. A chest x-ray finding that explains his symptoms would most likely showA- Right lower lobe pneumococcal pneumonia B- Cytomegalovirus interstitial pneumonitis C- 10 cm upper mediastinal mass D- Right pleural adenocarcinoma of the lung 4. Potential problems this patient could have that would need your immediate care includeA- Increased intracranial pressure B- Airway compression C- Superior vena cava syndrome D- All of the above

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5. The most sensitive way to detect asymptomatic breast cancer isA- Monthly self-exam B- Yearly mammogram C- Yearly exam by an MD that lasts longer than 5 minutes D- Blind bilateral breast biopsies 6. A 30 year old woman is found to have an enlarged right ovary on her routine pelvic exam. Your work-up would includeA- CA125 B- vaginal ultrasound C- physical exam to assess GI obstruction D- Alpha-feto protein and b-human chorionic gonadotropin levels. E- All of the above 7. Factors that increase a woman’s risk of breast cancer includeA- not having children B- BRCA-1 and 2 negative C- Step-mother with breast cancer D- Late menarche E- All of the above 8. You arranged for a lumpectomy and axillary node dissection for a pre-menopausal woman with a 2 cm ductal carcinoma of the breast. Which of the following is true? A- Radiation is not needed for local control B- If there are 4 or more nodes positive for malignancy, then the patient has a much higher 5 year survival chance C- Adjuvant chemotherapy should be performed D- If the tumor has Estrogen and Progesterone receptors present then the patient has a much lower chance of surviving 5 years. 9. A 48 year old chain smoking day trader comes into your office for a worsening bloody cough. He has been on albuterol inhaler for bronchitis for 4 years. Prior to day trading he worked for the NRC cleaning up radioactive waste sites. Prior to that he worked as an asbestos remover in older medical school buildings. Which of the following increases his risk of lung cancerA- Smoking B- family history of lung cancer C- Sclerodema D- A, B, and C E- A and C
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10. A chest x-ray finds a left upper lobe 3 cm mass. A bronchoscopic biopsy shows small cell carcinoma. The patient develops several bizarre problems. You know that several of these are paraneoplastic syndromes due to the tumor, but which ones? A- Imbalance in gait due to cerebellar degeneration B- Extraordinary muscle strength due to Eaton-Lambert myasthenia C- Profound fluid retention due to inappropriate ADH secretion D- A, B, and C E- A and C 11. A 56 year old Viet Nam veteran with a long smoking history presents with a 3 cm lung mass. The mass was resected, but 3 surrounding lymph nodes were positive for adenocarcinoma. Work-up found no distant metastasis. What stage is the patient? A- I B- II C- III D- IV E- V 12. You are planning this patient’s future care. The best chance at cure for this patient is fromA- Adjuvant chemotherapy. B- Interferon- alpha therapy. C- Surgical resection of the mass and surrounding lymph nodes. D- Local intensive radiation therapy. 13. A 14 year old African-American girl comes to your clinic with a 6 month history of weakness, light-headedness, and pallor. He hemoglobin (Hb) is low at 7.2 mg/dl, and her mean corpuscalar volume (MCV) is high at 101. Her reticulocyte count is high at 6.5%. You know that she could haveA- Autoimmune hemolytic anemia B- Sickle Cell anemia C- G6PDH deficiency D- Iron deficiency anemia E- A, B, and C

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14. You find that a 78 year old Caucasian woman in a nursing home has vitamin B12 deficiency anemia. Which could you also find? A- Reticulocyte count high at 12% B- Marrow erythrocyte precursors have small nuclei and a large amount of cytoplasm typical of a globin synthetic defect C- Neurologic deficits such as gait imbalance, or cognition loss. D- MCV would be low 15. A 17 year old Italian high school exchange student comes into to your clinic with jaundice, splenomegaly, and weakness. On taking a careful history you find that his only medications are Trimethoprin-Sulfamethoxazole for a Strep pharyngitis. An initial Hb is low at 5.4. Before the reticulocyte count comes back, what further work-up to pin down your diagnosis do you order? A- A Coomb’s test (direct anti-globulin) test to indicate an auto-immune hemolytic anemia B- Haptoglobin, lactate dehydrogenase (LDH), and total bilirubin (TB) levels to indicate acute hemolysis C- Hemoglobin electrophoresis D- G6PDH level E- All of the above 16. A 51 year old African-American attorney long time patient of yours has a history of sickle cell anemia. He presents today with abdominal pain, shortness of breath, weakness, and fever beginning 3 days ago when a stressful court case started. He put off coming to you until he was doubled over with pain. This is his 5th such episode in the last 3 months. Your thoughts areA- His Hb F levels must be low B- Treatment includes oxygen, IV fluids, IV narcotic analgesics, RBC exchange transfusions, and antibiotics. C- His reticulocyte count must be low D- He will need an allogeneic stem cell transplant E- A and B 17. On a lonely snowing night a patient comes in to see you in the Wishard ER. She is a 39 year old homemaker finally convinced by her husband to seek medical care. She has a vague 6 month history of early satiety, abdominal fullness, and mild nausea. Just before you are about to dismiss her from the ER, you take a few more minutes on the abdominal exam and find an enlarged spleen. Then you walk to the lab to see the peripheral blood smear. Her total leukocyte count is 27,900/ul, and she has promyelocytes, myelocytes, and bands prominent on the smear. You obtain a marrow aspirate with cytogenetics. A week later you are told by cytogenetics that she has a t(9;22). A- A PML-RAR fusion oncogene stimulates her marrow cells to divide without stopping B- The only cure for this type of leukemia is an allogeneic bone marrow transplant
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C- This type of leukemia is often inherited D- These patients often present with DIC. E- All of the above 18. An 8 year old girl comes to your clinic with fever, weakness, petechiae, and splenomegaly. She has a platelet count that is low at 8,000/ul, a Hb that is low at 7.4, and a total leukocyte count that is high at 36,000/ul. A marrow aspirate could findA- Myeloperoxidase positive lymphoblasts B- PAS positive lymphoblasts C- Esterase positive lymphoblasts D- The t(8;21) AML1-ABL translocation E- The t(8;14) ETO-Ig translocation 19. A 28 year old Down’s patient works in a machine shop cleaning grease off lathes with organic solvents. His boss calls him into the office for working slower and slower. In the office the employer notices that the patient has bruises and red spots. Just then the patient’s right pupil dilates and he has a seizure. At first the boss thinks he is faking to get off work, but unable to arouse the patient, he becomes anxious, and calls you. Upon hearing the situation, you immediately hypothesize thatA- He has hypercalcemia from Hodgkin’s lymphoma B- He developed Down’s syndrome skin disorder C- He had a cerebral hemorrhage from thrombocytopenia secondary to acute myeloid leukemia (AML) D- He is faking it to obtain disability E- He has airway obstruction from lung cancer 20. Treatment that you immediately arrange for this patient includeA- Platelet transfusions B- Ara-C and daunorubicin C- 3 year maintenance chemotherapy with thiogaunine and mercaptopurine D- local radiation E- A and B

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21. A 52 year old male auto mechanic presents to you with urinary frequency, difficulty starting his stream, and dribbling after urination. Upon exam you find that he has point tenderness along his thoracic spine and nodules on his prostate during rectal exam. He has a prostate specific antigen (PSA) that is high at 29. You ask forA- A lumbar puncture to rule out meningeal cancer B- A brain CT scan C- A trans-rectal prostate biopsy D- A carcinoembryonic antigen (CEA) level E- A and C 22. Pathology of this patient’s prostate probably showsA- Acinar adenocarcinoma B- A Gleason’s score that is less than 7 indicating aggressive disease C- Lymphomatous involvement of the prostate D- Ductal squamous cell carcinoma E- All of the above 23. Multiple bone metastasis are found in this patient indicating to you thatA- This is Stage IV disease B- Prostatectomy will not improve the patient’s survival C- Treatment will include orichiectomy and LHRH agonists such as leuprolide D- Radiation to local bone mets can relieve pain or prevent fracture E- All of the above 24. Adverse prognostic features in prostate cancer includeA- Low Gleason’s score B- Urinary difficulty at presentation C- Bone metastasis D- The tumor shrinks after orchiectomy E- A and C 25. A 49 year old male comes to your clinic with back and rib pain, decreased urine output, roaring in his ears, and a headache. Laboratory exam finds a creatinine that is high at 6.2, Hb low at 8.9, and a total protein that is high at 11.8. Spine and rib x-rays show multiple punched out lesions in his bones. You ask forA- Quanitative immunoglobulins B- Marrow aspirate C- Calcium level D- Skeletal X-ray survey E- All of the above
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26. Treatment that you plan for this patient would beA- Vincristine/Adriamycin/Dexamethasone (VAD) B- Splenectomy and Prednisone C- Autologous stem cell transplant D- Ara-C and Daunorubicin E- Both A and C 27. A 61 year old male living alone presents to you with a 11 cm right neck mass. He has had this for several years, and it is slowly enlarging. On history the patient describes weight loss, fever, and night sweats. On exam you find hepatomegaly and splenomegaly and adenopathy in the axilla and inguinal (groin) region. Biopsy reveals low grade nonHodgkin’s lymphoma. You know thatA- Local radiation can cure this patient B- This is Stage II disease C- The marrow is almost always free of disease at this stage D- The patient has a worse prognosis because of the B symptoms E- Chemotherapy is reserved for patients with high grade disease 28. A 19 year old male college student complains to you that his skin itches when he has a drink of alcohol. On taking a careful history and physical you also notice that he has enlarged cervical and inguinal nodes . A chest x-ray finds a 5 cm mediastinal mass. A mediastinoscopy and biopsy find Reed-Sternberg cells surrounded by many lymphocytes on microscopic analysis. You know thatA- This is lymphocyte-depleted Hodgkin’s lymphoma B- Initial treatment would be with Adriamycin/Bleomycin/Vinblastine/Dacarbzine (ABVD) C- Initial treatment would be with an autologous stem cell transplant D- Salvage therapy with Anti-CD40 antibody (Rituxan) is effective E- All of the above 29. A 48 year old man presents to your office with a Hb low at 8.1 and an MCV low at 62. You find that his serum ferritin is low and his serum iron is low while his iron binding capacity is high. You next Guiac test his stool. It is positive. From these lab tests you ask the patientA- If he has had any new constipation B- To undergo a colonscopy C- If he has polyps that run in his family D- If he has ulcerative colitis E- All of the above 30. This patient develops vomiting and severe abdominal pain. He develops a fever and leukocytosis (high white blood cell count). What do you do next?
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A- Decrease his gastrointestinal pressure by placing a rectal tube. B- Discontinue his fluids and antibiotics C- Call a surgeon to relieve his bowel obstruction D- Perform a rigid sigmoidoscopy E- All of the above 31. The patient is found to have a colonic mass. Resection of this mass takes place. Pathology finds that the margins are clear, but that there are 3 subserosal lymph nodes positive for tumor. Which is true? A- A CT scan of the liver is not important. B- If this is the only extent of disease, then this would be considered Duke’s stage A (or TNM Stage I) C- Adjuvant Fluorouracil and Irenotecan increase survival D- This patient has a less than 5% chance of 5 year survival. E- All of the above 32. In carcinoma located primarily in the rectum, which is true about treatment? A- Radiation therapy prevents local re-occurrence. B- A colostomy is rarely needed C- Such cancer is rarely cured. D- Fluorouracil based chemotherapy is rarely used. E- All are true 33. A 12 year old boy is brought to the ER by his friend’s parents where he was at a sleep-over while his parents were out of town. He was injured in a pillow fight. He has a warm, tender and enlarging swollen area around her right knee. He also has a warm, tender knot in her right bicep. He says that he has hemophilia A. A- The swollen knee is called a pseudotumor, and may lead to total knee replacement in this type of hemophilia. B- Prednisone may decrease the hemolysis C- Factor VIII intravenously will decrease the bleeding. D- Coumadin would help stop the bleeding into the joint.

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34. You are called to consult on a 48 year old man prior to an elective cholecystectomy the next day. He has a history of bleeding the day after a wisdom toot extraction. His bleeding time is long at 19 minutes, but his Von Willibrand’s antigen and activity are normal. You check the peripheral blood smear. It shows giant hypogranular platelets. A- You need to transfuse Factor VIII before surgery B- The long bleeding time has no significance for the patient’s surgery. Do nothing. C- Transfuse cryoprecipitate D- Transfuse platelets 35. A 28 year old woman presents to your clinic with a swollen, red, painful left leg. Venogram finds a femoral vein clot. You start her on heparin. She has a history of 3 miscarriages. She had a transient ischemic attack her physician said was secondary to oral contraceptives. You are not so sure. You find that her prothrombin (PT) time is normal, her partial thromboplastin (PTT) time is elevated, and a bleeding time is normal. Which of the following tests do you do to help assess this patient? A- Attempt to correct the PTT with normal plasma B- ATIII levels C- Resistance of Factor V to activated Protein C D- VDRL syphilis test E- All of the above 36. Her PTT did not correct with normal plasma added. You tell the patient with her husband present that she has a positive VDRL syphilis test. This causes an angry marital argument before you have the chance to break in and explain. A year later, after treatment, when she successfully delivers her first born child, she sends you a 1000 shares of her husband’s software start-up as a small token of her esteem. When that develops into a small fortune, you endow the Robert A. Hromas, Chair in Hematology because you knew that she hadA- ATIII deficiency B- Lupus anti-coagulant C- VWF deficiency D- Factor V Leiden E- Protein S deficiency 37. In AML the t(8;21) in M2 and the t(15;17) in M3A- Both produce fusion oncogenes that function as tyrosine kinases B- Both produce fusion oncogenes that function as both transcription repressors C- Both cause leukemia by mutating regulators of cell division D- Both increase differentiation of marrow granulocyte precursors E- Both B and D

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38. A 29 year old woman comes to you to check a mole on her back. She is worried that her tanning bed use prior to a trip to Cancun has given her melanoma. Which of the following characteristics of the mole worry you the most? A- The flatness of its surface. B- The round regularity of its border C- The 2 cm diameter D- The smooth brown color E- All of the above 39. While you recommend removal, the patient would rather not worry about the problem, so she does not return to you. One year later, she is brought in by her room-mate because the mole has now ulcerated. Which is true? A- This is a good prognostic sign as it indicates infection rather than malignancy. B- Besides a wide resection she will likely need a regional lymph node dissection. C- Adjuvant chemotherapy would increase her chance at cure. D- There is little likelihood of wide-spread metastasis. E- If the mole is more than 2 mm, then an abdominal ultrasound is necessary for work-up. 40. Which tumors are immunolgically responsive and can be treated with immune stimulators such as Interferon-α? A- Chronic myeloid leukemia B- Renal cell carcinoma C- Melanoma D- A and C E- A, B, and C 41. A 65 year pathologist who has been teaching you marrow histology tells you that he has just had painless hematuria. A cystogram shows a filling defect in the bladder. Which is true? A- Methotrexate/Vinblastine/Adriamycin/Cyclophosphamide chemotherapy is effective at both increasing the quality and quantity of life. B- Bone mets rarely occur, but brain mets are common. C- Surgical resection is the only effective therapy. D- A mass can be palpated in Stage II disease, and is an adverse prognostic sign.

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42. A 28 year old pediatric nurse comes to see you for cervical adenopathy that has persisted for several months despite multiple antibiotic courses. Her node biopsy shows Reed-Sternberg cells. She has no other adenopathy or marrow involvement. Which is true? A- Weight loss would be a good prognostic sign. B- CHOP chemotherapy should be initiated. C- Surgical resection can be curative. D- Local radiation therapy can be curative. E- All of the above 43. A 43 year old woman presents with pelvic pain and what she describes as “irregular periods.” On pelvic exam there is a fungating mass extending from her cervix. Which is true? A- Epstein-Barr virus type 16 or 18 could be cultured from this lesion. B- This cell type is most likely adenocarcinoma. C- This tumor is very sensitive to chemotherapy. D- This woman will become infertile from the surgical resection required for treatment. E- All of the above. 44. An impoverished 36 year old woman with 6 children comes to your free clinic because of her insatiable desire to eat clay. Although pale and light-headed on standing, she has no adenopathy, or hepatosplenomegaly. You are about to swear to never again volunteer in free clinics because the problems are too difficult when you notice that her fingernails are flat and scaling. Which is true? A- She can be easily treated with oral iron replacement. B- She likely has a high MCV and a low reticulocyte count, indicating B12 deficiency. C- She likely has β- thalassemia. D- She has a low haptoglobin and a high LDH from auto-immune hemolysis. E- All of the above.

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Answers 1- E 2- D 3- C 4- D 5- B 6- E 7- A 8- C 9- E 10- E 11- B 12- C 13- E 14- C 15- E 16- E 17- B 18- B 19- C 20- E 21- C 22- A 23- E 24- C 25- E 26- E 27- D 28- B 29- E 30- C 31- C 32- A 33- C 34- D 35- E 36- B 37- E 38- C 39- B 40- E 41- A 42- D 43- A 44- A
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