Hemato Onology

HEMATO-ONCOLOGY CLASS AUG 26
DR. MOHAMMED DWAIMA 1

Question 1
A 26-year-old woman comes to your clinic because of a constant dry cough, low grade
fevers, and night sweats for the last 4 weeks.
She denies shortness of breath or chest pain. Furthermore, she has lost 2.3 kg over the
past 4 weeks.
She denies any other medical problems and takes no medications except for over-the-
counter cough syrup.
She denies recent travel or sick contacts. She does not use tobacco, alcohol, or illicit
drugs.
Her temp 38.0 C, BP is 110/80 mm Hg, and PR 90/min.
Physical examination shows multiple, bilateral, firm, rubbery, 2 to 3 cm-sized lymph nodes
in the cervical, supraclavicular, and axillary region.
There is no hepatosplenomegaly.
Chest imaging shows a widened mediastinum, hilar fullness, and clear lungs. HIV and
heterophile antibody testing are negative.
Which of the following is the most appropriate next step in management?

A. Core Needle biopsy of axillary LN
B. Excisional biopsy of supraclavicular LN
C. FNA of the cervical LNs
D. BAL, AFB Stain, and culture.
E. Mediastinoscopy and Biopsy.

Q1 Answer ( …….….)
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Question 2
A previously healthy 38-year-old woman is brought to the emergency department
because of left-sided weakness for the past 4 hours.
Her husband noticed that she was confused.
She has a 3-year history of diabetes mellitus, for which she takes metformin.
She had a knee operation 1 month ago.

Her temperature is 38.9°C, pulse is 98/min, respirations are 17/min, and blood pressure
is 138/85 mm Hg.
She is confused and oriented only to person. Neurologic examination shows diminished
muscle strength on the left side. There are scattered petechiae over the chest, arms, and
legs. Laboratory studies show:
Haemoglobin 7.5 g/dL

Leukocyte count 10,500/mm3
Platelet count 40,000/mm3
Prothrombin time 15 seconds
Partial 36 seconds
thromboplastin time
Serum
Bilirubin
Total 3.5 mg/dL
Direct 0.3 mg/dL
Urea nitrogen 35 mg/dL
Creatinine 2.5 mg/dL
Lactate 1074 U/L
dehydrogenase
The Best Next Step in Management is?
A. Platelets Transfusion
B. ASA 81 mg PO OD
C. Septic workup and empiric antibiotics
D. Plasma Exchange
E. Rituximab 375 mg/m2 weekly x 4 weeks
Q2 Answer ( …….….)
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Question 3
Match:
1. DIC-like presentation, Vitamin-A derivative is a life-saving drug.
2. Huge Splenomegaly, weight loss with a good appetite.
3. ADAMT13 deficiency
4. Auto-splenectomy.
5. AIHA IgG autoantibody, Positive Coomb's test.
6. A complication of Mycoplasma pneumonia

Q3 Answer ( …….….)
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Question 4
A 24-year-old man with sickle cell disease (Hb SS) comes to the emergency department
with chest pain and shortness of breath. He has felt unwell for the last several days with
increasing extremity, abdominal, and chest pain. The patient took extra doses of oral
morphine with little relief. He stopped taking hydroxyurea 4 months ago due to stomach
upset.
BP 122/72 mm Hg, PR 108/min, RR 22/min, and oxygen saturation is 84% on room air.
Bilateral crackles are heard on chest auscultation. A 2/6 mid-systolic murmur is heard at
the left upper sternal border.
Leukocytes 14,000/µL
Platelets 435,000/µL
The best next step in management is?

A. Glucocorticoids
B. Hydroxyurea STAT
C. Folic acid 5 mg PO STAT
D. Exchange Transfusion
E. NIPPV

Q4 Answer ( …….….)
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Question 5
32-year-old male underwent an elective right knee surgery 1 day ago.
He initially sustained an injury to right knee 5 years ago while playing tennis.
Recently, his right knee was bothering him to a point where he underwent surgery. After
this surgery, his right leg starts to swell, and an ultrasound reveals an acute venous
thrombosis.
The patient is started on Rivaroxaban.
Hematology team is consulted regarding thrombophilia work up.

He has a normal BMI, has no medical issues and never smoker.
He has no family history of venous thrombotic events.
What test should be ordered at this time?

A. Factor V Leiden mutation
B. Prothrombin gene mutation 20210A
C. Lupus anticoagulant
D. No work up is needed
E. Protein C activity

Q5 Answer ( …….….)
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Question 6
A 37-year-old woman with known SLE is evaluated for generalized weakness and dyspnea
on exertion. Her current medications include HCQ, naproxen, and low-dose
prednisone. She stopped taking azathioprine 4 weeks ago due to side effects.
Her BP is 142/90 mm Hg and Pulse is 82/min. The oropharynx is moist with no visible
lesions.
Small, mobile lymph nodes are palpable in the submandibular area.
Skin examination shows a scaly erythematous rash over the face, scalp, and upper trunk.
Cardiopulmonary examination is within normal limits. There is no splenomegaly.
Laboratory results are as follows:
Liver function studies
Total protein 8.0 g/dL
Albumin 3.7 g/dL
Total bilirubin 2.3
mg/dL
Direct bilirubin 0.4
mg/dL
ALP 20 U/L
AST 12 U/L
ALT 24 U/L
Complete blood count:

MCV 102 fL
Reticulocytes 6.0%
Platelets 180,000/µL
Leukocytes 3,800/µL
Which of the following is most likely responsible for this patient's symptoms?
A. Anemia of chronic disease
B. Autoimmune hemolytic anemia
C. Folic acid deficiency
D. Microangiopathic hemolytic anemia
E. Red cell aplasia
Q6 Answer ( …….….)
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Question 7
A 35-year-old woman is hospitalized with severe SOB. She also has Right calf pain and
swelling.
US Doppler showed R popliteal DVT.
CTPA showed PE as well.
Anticoagulation was started.

On the sixth day of hospitalization, she developed R arm pain and coldness on
examination, with no palpable radial pulse.
LAB:
Hb 13.5 WBC 8.5 PLT 75000 (254 at presentation), PT 12, INR 1.0, PTT 68 s.
Which of the following drugs was initially used to treat this patient leg DVT?
A. Enoxaparin
B. Apixaban
C. Dabigatran
D. UFH
E. Fondaparinux

Q7 Answer ( …….….)
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Question 8
35-year-old lady presented with a 4-wk history of progressive weakness and feet
paranesthesia.
She is known to have Crohn’s disease that required bowel resection 3 years ago.
LE: Normal tone, power5/5, reflexes and all sensation modalities are normal.
CBC:
WBC 3.5, Hb 8.0, MCV 98, PLT 140.
U/E:
BUN 12.0, Cr 1.0, Ca 8.8, Gluc 98 mg.
What is the most likely seen abnormality in this patient?

A. Positive HIV serology.
B. Low Serum iron level.
C. Elevated MMA and Homocysteine
D. Elevated Homocysteine but normal MMA
E. Hyposegmented Neutrophils on blood film

Q8 Answer ( …….….)
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Question 9
A 33 y/o pregnant woman at 28 weeks, presented with sudden onset R chest pain and
SOB. She has no hemoptysis, syncope or a preceding reparatory symptom.
Temp 36.5 C, BP 110/70 mmHg, HR 110, RR 26.
She is diaphoretic and appears to be in distress.
CVS: NAD, Chest: EBSB, VB,

LL: Equal in size and no tenderness.
ABG: PH 7.45, PCO2 30, HCO3 24, PO2 64 mmHg.
CXR: Normal.
What is the best next test modality to confirm the diagnosis?

A. CTPA
B. D-Dimer
C. Start Warfarin
D. V/Q Scan
E. Enoxaparin 1 mg/kg SC bd.

Q9 Answer ( …….….)
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Question 10
A 30-year-old man was leading a healthy life before he experienced L Leg DVT with no
discernible provoking factor. No personal history of previous VTE. However, his younger
sister has had and unprovoked DVT 3 years back.
PT 13 s, APTT 30 s, D-Dimer 1200 ng, Hb 14 HCT 42%, WBC 6.5, PLT 250
What is the most likely contributor to this current condition?

A. Antiphospholipid Syndrome
B. Protein C deficiency
C. FVL ‘Activated PCR’
D. Anti-thrombin deficiency.

Q10 Answer ( …….….)

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Question 11
A 22-year-old woman comes to the emergency department due to heavy vaginal
bleeding.
The patient has always had heavy menses, but this time the bleeding has not stopped
since it started 5 days ago.
Her medications include ibuprofen for headaches and iron supplementation for iron
deficiency anemia. She has no other significant medical history.
Her mother had heavy menstrual periods and frequent nosebleeds.
Vital signs are within normal limits.

Bimanual examination reveals no palpable abnormalities. Laboratory results are as
follows:
CBC
Hb 9.0 g/dL
MCV 76 fL
Platelets 210,000/mm3
Coagulation studies
INR 0.8
Activated PTT 23 sec
Which of the following is the best next step in management of this patient?
A. Factor IX levels
B. Fibrinogen levels
C. Mixing study
D. No further testing
E. Plasma von Willebrand factor antigen and activity

Q11 Answer ( …….….)

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Question 12
A 77-year-old man with AF on dabigatran presents with new right sided weakness.
Labs are notable for normal creatinine and a normal INR.
A head CT is shown.
Last Dabigatran dose was taken 3 hours back.
Which of the following agents is most appropriate to administer?

A. Prothrombin Complex Concentrate PCC
B. FFP
C. Andexanet alfa
D. Idarucizumab

Q12 Answer ( …….….)

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Question 13
A 70-year-old woman is brought to the ED after she tripped and fell at home while getting
out of a bathtub. She did not lose consciousness but does have headache and mild right
arm pain.
Her medical history is significant for advanced breast cancer treated with radical
mastectomy and chemotherapy a year ago.
CT of the head is unremarkable. Radiographs of the upper extremities show bone lesions
consistent with metastases, but no evidence of fracture. Her serum creatinine level is 1.4
mg/dL (creatinine clearance 30 mL/min), serum calcium level is 9.6 mg/dL, and alkaline
phosphatase level is 220 U/L.
The patient is most likely to benefit from which of the following?

A. Zolendronic Acid
B. Alendronate
C. Denosumab
D. Calcitonin
E. Calcium and Vitamin D supplementations

Q13 Answer ( …….….)

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Question 14
A 56-year-old male patient presents to ED with worsening SOBOE and increased redness
of his face with difficulty laying down flat over the last 4- 5 days. He had a CXR done and
showed a new mass occupying the right side of the chest and appears to be compressing
on the mediastinal structures.
Physical Exam: See picture.
What is the name of the clinical sign in this setting?

A. Courvoisier's sign
B. Pemberton’s sign
C. Kussmaul’s sign
D. gallavardin phenomenon
E. Frog sign
The patient was admitted, and he was started on dexamethasone with elevation of the
head of the bed. On further evaluation he states that he had weight loss of 8 kg, night
sweats, decreased appetite.
What is the best next approach in his case?
A. Staging CT C/A/P
B. PET-CT scan
C. Biopsy of the lesion
D. Percutaneous intravascular stent placement
E. Dexamethasone

Q14 Answer ( …….….)

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Question 15
This is a 59-year-old male patient who has a known hx of high-grade lymphoma (DLBCL)
who is receiving his 1st cycle of R-CHOP. He has a massive mediastinal mass which was Bx
proven to be DLBCL.
The ROD has called you because he noticed a metabolic derangement as following:
K 5.6 Ca 7.2 mg PO4 3.2 mg Cr 1.5 mg HCO3 20.0
What other electrolytes you want to ask ROD bout?

A. Magnesium
B. Chloride
C. Uric ACID
D. Sodium
E. That’s enough I made a diagnosis!
Uric acid level is 11.0 mg/dl

You made a diagnosis of laboratory TLS.
How would you have prevented TLS in the first place?
A. Allopurinol prophylaxis + IV fluids
B. Encouraged IV hydration + Lasix
C. Encouraged IV hydration + HCTZ
D. Allopurinol and 6-MP
E. IV Sodium HCO3

Q15 Answer ( …….….)

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Question 16
In the previous question, given that, TLS is established, you decided to proceed with
aggressive hydration and Rasburicase along continuous cardiac & electrolytes monitoring.
30 minutes later, the patient became icteric and having SOB.
What is the best next step in management?

A. Administer Rituximab
B. Administer Prednisolone
C. Stop Rasburicase and maintain supportive measures
D. Measure G6PD level
E. Measure ADAMTD-13 activity and inhibitor assay

Q16 Answer ( …….….)

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Question 17
A 65-year-old man known to have Chronic Lymphocytic Leukemia Stage I, with baseline
Lymphocytes count 30,000.
He was entirely symptomatic until 3 days ago when he starts to experience shortness of
breath and marked fatigue.
He looks tired, No palpable LNs, No Hepatosplenomegaly.
Hb 8.0 ‘baseline 13.0 2 weeks back ‘MCV 95 PLT 400 WBC 35000 ‘Lymphocytes 95% ‘,
Reticulocytes count: 12%
LDH 600, Total Bilirubin 5.0 g, DB: 1.0 AST 40 ALT 25, Folate Normal, B12 Normal,
Ferritin 200 ng
Blood film is shown
What is the next step in CLL treatment?
A. Prednisolone
B. Ibrutinib
C. Venetoclax
D. Rituximab
E. Imatinib

Q17 Answer ( …….….)

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Question 18
A 75-year-old man with a history of CAD presents for follow-up after a recent diagnosis of
anemia. In addition to fatigue related to his anemia, he complains of a tingling sensation
and burning pain in the feet, extending up to the midcalf. He reports consistent headache,
occasional epistaxis, and on/off blurry vision!
This discomfort limits his mobility, and he has difficulty sleeping because of the pain.
Laboratory workup for his anemia is shown below:
Laboratory studies
SPEP with immunofixation IgM monoclonal spike 7 g/dL
UPEP Negative
IgM 4895 mg/dL (normal 40-230 mg/dL)

Hgb 10.2 g/dL
Platelets 105 000/L
Viscosity 1.7 cP (normal 1.4-1.8 cP)
A bone marrow biopsy is performed and demonstrates 65% bone marrow involvement
with monoclonal plasmacytoid lymphocytes.
What is the diagnosis?
A. MM
B. WM
C. HCL
D. AL Amyloidosis
E. Polycythemia Vera.

The best next step in management?

A. Rituximab based therapy
B. Ibrutinib
C. Plasmapheresis
D. Bortezomib based therapy
E. Watch and Wait
Sub-Q18
56 Y/O Man with recurrent sinusitis due to H. influenza. Incidental lab abnormalities
show:
Hb 9.0 g/dl MCV 88 fl WBC 6700 PLT 250
Cr 1.5 mg Ca 11.0 mg/dl PO4 N Protein 90 Albumin 35

Skull X ray for sinuses has revealed scattered bone lytic lesions. Which of the following
tests is not helpful in working him up?
A. Bone scan
B. Serum protein Electrophoresis
C. Bone marrow examination
D. B2 macroglobulin
E. LDH

Q18 Answer ( …….….)

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Question 19
A 24-year-old woman has a low platelet count on routine blood work.
She denies bleeding, fever, chills, weight loss, bone pain, or abdominal pain.
Her past medical history is unremarkable, and she does not take any medications.
She does not use tobacco, alcohol, or illicit drugs.

She is sexually active.
Complete physical examination is within normal limits.
Laboratory results are as follows:
Blood smear shows a true thrombocytopenia. Otherwise, is unremarkable! Pregnancy

test is Negative.
Which of the following is the best next step in managing this patient?
A. ANA
B. HIV
C. Bone Marrow examination
D. H. Pylori
E. No further workup is required.
What do you recommend at this time?

A. Observation
B. Steroid
C. Splenectomy
D. Rituximab
E. Eltrombopag

Q19 Answer ( …….….)

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Question 20
55 y/o M, lifelong non-smoker, comes to the office with headache, non-restorative sleep
and daytime fatigue and sleepiness. Alcohol 2-3 drinks/day.
Hx of HTN and hypercholesterolemia.
O/E;
BMI 45 %, BP 160/90, chest NAD, remaining exam is unremarkable.

WBC 4.3, Hb 19 mg/dl, HCT 57 %, PLT 240 K, BUN 12, Cr 0.7 mg.
What abnormal test do you expect to see?

A. High testosterone level.
B. High EPO level.
C. JAK2 mutation.
D. Plasma volume contraction.
Sub-Q20
62-year-old woman with moderate fatigue, routine CBC:
Hb 12.5 WBC 5.5 PLTs 900 K
ESR 25 Ferritin 60 ‘Normal ‘
No identifiable reactive etiology!
Likely Diagnosis is ………………………………………………..
Molecular test of choice is ………………………………………………..
Bone marrow findings: ………………………………………………..
How would you treat this patient? ……………………………………………….. and ………………………………………………..

Sub-Q20
The patient in previous question refused to be treated with ASA and HU.
She came in 2 years later with massive splenomegaly!
WBC 25 K ‘See blood film’
Hb 8.0 g/dl PLT 1.5 million.

LDH 1200 Bilirubin Normal, Retics low
What happened? ………………………………………………..
What do you expect to find in bone marrow?

Aspirate: ………………………………………………..
Trephine Bx: ………………………………………………..
Rx: ………………………………………………..

Q20 Answer ( …….….)

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Question 21
A 26-year-old woman is hospitalized with a temperature of 38.5 °C 10 days after her first
cycle of chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine and
prednisone (R-CHOP) for diffuse large B-cell lymphoma. Other than fever, she has no
symptoms of infection.
On physical examination, temperature is 38.5, BP 110/80 mm Hg.
The remainder of the vital signs and physical examination are normal.
LAB: CBC: WBC 0.7, 50% Neutrophils, Hb 11.0 g/dl PLT 144,000 Urine/Blood cultures
Pending.
CXR PA normal.
What is the best next?

A. Vancomycin IV
B. Meropenem
C. Linezolid
D. Piperacillin-Tazobactam.
E. Tazocin PLUS Amikacin.
A junior resident asks you on G-CSF use in this patient, what shall you answer him?
A. Instead of G-CSF, we will reduce the doses of cyclophosphamide and doxorubicin

next cycle
B. You are perfectly right! we must start right now a 300 mcg of Filgrastim.
C. Will consider G-CSF for next cycle from Day 2 as s secondary prophylaxis.
D. Give it now and with every cycle in the future.
E. Although G-CSF improves the mortality in FN patients, it has no effect on
neutropenia duration.

Q21 Answer ( …….….)

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Question 22
42-year-old female is currently undergoing a pRBC transfusion for her known thalassemia
major. She develops marked onset SOB and tachycardia. She has hypoxemia and requires
a high FiO2 requirement.
BP 105/70 PR 120 RR 22 Spo2 88 % Temp 37.8 C
A CXR is done urgently and she has whiteout of her lungs.
The BNP is WNL.
What is the etiology of this event?

A. Transfusion overload
B. Graft versus host disease
C. Allergic reaction to proteins in the donor red blood cells
D. Acute hemolytic transfusion reaction
E. Antibodies in donor plasma against the patient’s white blood cells.

Q22 Answer ( …….….)

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Question 23
A 57-year-old man is scheduled to undergo a laparoscopic left inguinal hernia repair. He
known to have NVAF for years, with no previous embolic or hemorrhagic events.
He takes Apixaban 5 mg bid.
His basic lab including renal functions is within normal.
Which of the following is the most appropriate recommendation?

A. Last dose 1 day prior to the operation.
B. Last dose 2 days prior to the operation.
C. Last dose 3 days prior to the operation.
D. Last dose 5 days prior to the operation.
E. No interruption of anticoagulant.

Q23 Answer ( …….….)

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Question 24
Two weeks after undergoing allogeneic stem cell transplant for multiple myeloma, a 55-
year-old man develops a severely pruritic rash, abdominal cramps, and profuse diarrhea.
He appears lethargic.
Physical examination shows yellow sclerae.
There is a generalized maculopapular rash on his face, trunk, and lower extremities,
and desquamation of both soles.
His serum ALT is 115 U/L, serum AST is 97 U/L, and TB is 2.7 mg/dL.
Which of the following is the most likely underlying cause of this patient's
condition?
A. Donor T cells in the graft

B. Recipient Bformed anti-HLA antibodies
C. Preformed cytotoxic cells in bone marrow.
D. Newly anti-HLA antibodies
E. Activated recipient T cells.

Q24 Answer ( …….….)

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Question 25
A 67-year-old very active and healthy man has a PSA checked, which returns at 6. On
repeat testing 3 months later, the PSA is 6.1. He meets with a urologist to discuss these
results.
On rectal examination, he has a smooth but enlarged prostate without any nodules or
abnormalities.
The patient is quite hesitant to have invasive testing.
What is the best next step in management?

A. Likely secondary to benign prostatic hyperplasia (BPH). No further testing
B. Proceed with ultrasound-guided transrectal 12-core prostate biopsy
C. Prostate MRI
D. Repeat PSA in 6 months
E. Radical Prostatectomy

Q25 Answer ( …….….)

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Question 26
A 46-year-old woman comes to the physician with complaints of exertional dyspnoea over
the last 6 months. She can barely walk a block without having to stop and catch her
breath. She was diagnosed with Hodgkin’s lymphoma 2 years ago and was treated with
doxorubicin, bleomycin, vinblastine, and dacarbazine. She does not use tobacco, alcohol,
or illicit drugs.
CXR as shown.
Which of the following conditions is the most likely cause of this patient’s presentation?
A. Anthracycline toxicity
B. Bleomycin Toxicity.
C. Pleural disease.
D. Disease recurrence.
E. COVID-19

Q26 Answer ( …….….)

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HEMATO-ONCOLOGY CLASS AUG 26

DR. MOHAMMED DWAIMA 1

Which of the following is the most appropriate next step in management?

DR. MOHAMMED DWAIMA 2

DR. MOHAMMED DWAIMA 3

She had a knee operation 1 month ago.

Haemoglobin 7.5 g/dL

DR. MOHAMMED DWAIMA 5

DR. MOHAMMED DWAIMA 6

DR. MOHAMMED DWAIMA 7

The best next step in management is?

DR. MOHAMMED DWAIMA 8

DR. MOHAMMED DWAIMA 9

Hematology team is consulted regarding thrombophilia work up.

What test should be ordered at this time?

DR. MOHAMMED DWAIMA 10

DR. MOHAMMED DWAIMA 11

Complete blood count:

DR. MOHAMMED DWAIMA 13

Anticoagulation was started.

DR. MOHAMMED DWAIMA 14

DR. MOHAMMED DWAIMA 15

What is the most likely seen abnormality in this patient?

DR. MOHAMMED DWAIMA 16

DR. MOHAMMED DWAIMA 17

CVS: NAD, Chest: EBSB, VB,

What is the best next test modality to confirm the diagnosis?

DR. MOHAMMED DWAIMA 18

DR. MOHAMMED DWAIMA 19

What is the most likely contributor to this current condition?

DR. MOHAMMED DWAIMA 20

Q10 Answer ( …….….)

DR. MOHAMMED DWAIMA 21

Vital signs are within normal limits.

DR. MOHAMMED DWAIMA 22

Q11 Answer ( …….….)

DR. MOHAMMED DWAIMA 23

Last Dabigatran dose was taken 3 hours back.

Which of the following agents is most appropriate to administer?

DR. MOHAMMED DWAIMA 24

Q12 Answer ( …….….)

DR. MOHAMMED DWAIMA 25

The patient is most likely to benefit from which of the following?

DR. MOHAMMED DWAIMA 26

Q13 Answer ( …….….)

DR. MOHAMMED DWAIMA 27

DR. MOHAMMED DWAIMA 28

DR. MOHAMMED DWAIMA 29

What is the name of the clinical sign in this setting?

DR. MOHAMMED DWAIMA 30

Q14 Answer ( …….….)

DR. MOHAMMED DWAIMA 31

What other electrolytes you want to ask ROD bout?

Uric acid level is 11.0 mg/dl

DR. MOHAMMED DWAIMA 32

Q15 Answer ( …….….)

DR. MOHAMMED DWAIMA 33

What is the best next step in management?

DR. MOHAMMED DWAIMA 34

Q16 Answer ( …….….)

DR. MOHAMMED DWAIMA 35

What is the next step in CLL treatment?

DR. MOHAMMED DWAIMA 36