Anaemia, leukaemia and coagulation in practice

22 NEET-PG practice questions on Anaemia, leukaemia and coagulation in practice, part of General Medicine. The first 22 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Easy

   A 60-year-old man had a mechanical aortic valve replacement and is discharged on warfarin. Which test is used to adjust his warfarin dose?

   1. AAnti-factor Xa level
   2. BBleeding time
   3. CActivated partial thromboplastin time
   4. DProthrombin time with INR

   Show answerHide answer

   Answer: D · Prothrombin time with INR

   Warfarin blocks vitamin K epoxide reductase, lowering the vitamin K-dependent factors II, VII, IX and X. The prothrombin time is most sensitive to factor VII, which has the shortest half-life, and the INR standardises PT between laboratories and reagents. The dose is adjusted to the target INR for his valve, and he is warned about interacting drugs and keeping vitamin K intake steady.

   • A: Anti-Xa levels are used for low molecular weight heparin in special cases.
   • B: Bleeding time tests platelet function, not warfarin effect.
   • C: aPTT is used to monitor unfractionated heparin.

2. Question 2 · Easy

   A 34-year-old woman with heavy periods for a year has fatigue and breathlessness on climbing stairs. Hb 8.4 g/dL, MCV 68 fL, MCH 21 pg, RDW raised, and the smear shows microcytic hypochromic cells with pencil cells. Which single test best confirms iron deficiency?

   1. ASerum iron
   2. BHaemoglobin HPLC
   3. CBone marrow iron stain
   4. DSerum ferritin

   Show answerHide answer

   Answer: D · Serum ferritin

   Serum ferritin reflects body iron stores, and a low ferritin is diagnostic of iron deficiency. Serum iron falls in both iron deficiency and inflammation and varies through the day, so it is less useful alone. Ferritin is an acute-phase reactant, so a normal value with inflammation does not fully exclude deficiency. She needs oral iron and evaluation of the menorrhagia.

   • A: Serum iron varies diurnally and is also low in inflammation.
   • B: HPLC detects thalassaemia and haemoglobin variants, not iron deficiency.
   • C: Marrow iron is the old gold standard but is invasive and not needed.

3. Question 3 · Medium

   A 40-year-old man with newly diagnosed acute myeloid leukaemia becomes breathless and confused, with blurred vision. WBC 2,10,000/µL (mostly blasts), Hb 7.4 g/dL, platelets 40,000/µL. SpO2 is 89% on room air and the chest X-ray shows diffuse bilateral infiltrates. Hydroxyurea and IV fluids are started. Until the count falls, which should be avoided if possible?

   1. ARed cell transfusion
   2. BIV crystalloids
   3. CPlatelet transfusion
   4. DAllopurinol

   Show answerHide answer

   Answer: A · Red cell transfusion

   Very high blast counts in AML can cause leukostasis: large, rigid blasts plug small vessels in the lungs and brain, giving hypoxia, infiltrates, confusion and visual change. It is an emergency treated with rapid cytoreduction (hydroxyurea, then induction chemotherapy, with leukapheresis in selected cases), hydration and tumour lysis prophylaxis. Red cell transfusion raises blood viscosity further and is withheld unless clearly needed, whereas platelets can be given because they add little to viscosity.

   • B: Hydration is part of the treatment, lowering viscosity and protecting the kidneys.
   • C: Platelets add little to viscosity and are given to prevent bleeding at this count.
   • D: Allopurinol is needed to prevent tumour lysis during cytoreduction.

4. Question 4 · Medium

   A 70-year-old man on warfarin for atrial fibrillation vomits blood and is brought to casualty. BP 90/60 mmHg, pulse 118/min, INR 7.8. Fluids are running and an endoscopy is being arranged. Which is the best way to reverse the warfarin?

   1. AIdarucizumab
   2. BProtamine sulfate
   3. COral vitamin K alone
   4. DFour-factor PCC with IV vitamin K

   Show answerHide answer

   Answer: D · Four-factor PCC with IV vitamin K

   Major bleeding on warfarin needs rapid reversal: four-factor prothrombin complex concentrate replaces factors II, VII, IX and X within minutes, and IV vitamin K keeps the INR down once the PCC wears off. Fresh frozen plasma is used where PCC is not available, but it needs large volumes and works more slowly. The decision to restart anticoagulation is taken after the bleeding source is treated.

   • A: Idarucizumab reverses dabigatran only.
   • B: Protamine reverses heparin, not warfarin.
   • C: Oral vitamin K takes about a day and is used for a high INR without serious bleeding.

5. Question 5 · Medium

   A 52-year-old woman with active rheumatoid arthritis has fatigue. Hb 9.6 g/dL, MCV 80 fL, serum iron 35 µg/dL (60-170), TIBC 210 µg/dL (250-400), ferritin 280 ng/mL, CRP raised. What is the main mechanism of her anaemia?

   1. AChronic blood loss from NSAIDs
   2. BAutoimmune destruction of red cells
   3. CRaised hepcidin trapping iron in macrophages
   4. DFolate deficiency from methotrexate

   Show answerHide answer

   Answer: C · Raised hepcidin trapping iron in macrophages

   Low serum iron with low TIBC and a normal or high ferritin is the pattern of anaemia of inflammation. IL-6 drives hepatic hepcidin, which degrades ferroportin, so iron is trapped in macrophages and absorption from the gut falls. Erythropoietin response is also blunted. Treatment is control of the underlying disease; oral iron is poorly absorbed.

   • A: Blood loss would give iron deficiency, with low ferritin and high TIBC.
   • B: Haemolysis would raise the reticulocytes, LDH and bilirubin.
   • D: Folate deficiency causes macrocytosis, not this iron pattern.

6. Question 6 · Medium

   A 30-year-old woman with SLE has fatigue and yellow eyes for 2 weeks. Hb 7.0 g/dL, reticulocytes 9%, LDH and indirect bilirubin raised, haptoglobin low, spherocytes on smear, direct antiglobulin test positive for IgG. What is the first-line treatment?

   1. AFolic acid alone
   2. BSplenectomy
   3. CRituximab
   4. DOral prednisolone

   Answer and explanation in LearnFree account

7. Question 7 · Medium

   A 22-year-old man from Gujarat comes for premarital screening. Hb 11.6 g/dL, RBC count 6.2 million/µL, MCV 62 fL, MCH 19 pg, RDW normal, serum ferritin 85 ng/mL. He is well. Which investigation is most useful next?

   1. ADirect Coombs test
   2. BHaemoglobin HPLC for HbA2
   3. COsmotic fragility test
   4. DBone marrow iron stain

   Answer and explanation in LearnFree account

8. Question 8 · Medium

   A 21-year-old man with T-cell ALL and a WBC of 1,50,000/µL started induction chemotherapy 2 days ago. He now has muscle cramps, palpitations and falling urine output. Four biochemical changes are listed: 1. Hyperkalaemia. 2. Hypercalcaemia. 3. Hyperphosphataemia. 4. Hyperuricaemia. Which of these are expected in tumour lysis syndrome?

   1. A1, 2, 3 and 4
   2. B1, 2 and 4 only
   3. C1, 3 and 4 only
   4. D2, 3 and 4 only

   Answer and explanation in LearnFree account

9. Question 9 · Medium

   A 48-year-old woman is on day 10 after docetaxel-based chemotherapy for breast cancer. She has a temperature of 38.6°C, BP 118/72 mmHg and no localising signs. Absolute neutrophil count 300/µL. Four statements are made: 1. She meets the definition of febrile neutropenia. 2. Empirical IV antibiotics should start within about an hour. 3. Piperacillin-tazobactam or cefepime alone is an acceptable first choice. 4. Blood cultures should be taken before the first dose without delaying it. Which statements are correct?

   1. A1, 2, 3 and 4
   2. B1, 2 and 4 only
   3. C2, 3 and 4 only
   4. D1 and 2 only

   Answer and explanation in LearnFree account

10. Question 10 · Medium

    A 24-year-old man with bulky Burkitt lymphoma is about to start chemotherapy. Serum uric acid is 12 mg/dL and creatinine 1.4 mg/dL. Rasburicase is given before the first cycle. How does rasburicase lower uric acid?

    1. AIncreases renal tubular secretion of urate
    2. BAlkalinises the urine
    3. CInhibits xanthine oxidase
    4. DOxidises uric acid to soluble allantoin

    Answer and explanation in LearnFree account

11. Question 11 · Medium

    A 66-year-old man with prostate cancer has had back pain for 3 weeks that is worse lying down. For 2 days his legs have been weak, he has a sensory level at T10, and he has not passed urine since morning. What is the next best step?

    1. AX-ray of the spine and analgesics
    2. BStart bicalutamide and review in clinic in a week
    3. CIV dexamethasone and urgent whole-spine MRI
    4. DBone scan at the next clinic visit

    Answer and explanation in LearnFree account

12. Question 12 · Hard

    A 64-year-old woman with rheumatic heart disease has a mechanical mitral valve and atrial fibrillation. Four statements are made about her anticoagulation: 1. Warfarin is the oral anticoagulant of choice. 2. Dabigatran is contraindicated. 3. Her usual target INR is about 2.5-3.5. 4. She must stop eating green leafy vegetables completely. Which statements are correct?

    1. A1 and 2 only
    2. B1, 2, 3 and 4
    3. C1, 2 and 4 only
    4. D1, 2 and 3 only

    Answer and explanation in LearnFree account

13. Question 13 · Easy

    A 28-year-old man has bleeding gums and bruises for a week. Hb 8.2 g/dL, WBC 3,000/µL, platelets 20,000/µL, PT prolonged, fibrinogen 90 mg/dL. Bone marrow shows abnormal promyelocytes, some with bundles of Auer rods. Which drug should be started at once?

    1. ARituximab
    2. BHydroxyurea
    3. CImatinib
    4. DAll-trans retinoic acid

    Answer and explanation in LearnFree account

14. Question 14 · Hard

    A 30-year-old woman with postpartum haemorrhage is transfused red cells and fresh frozen plasma. Two hours after the plasma, she becomes breathless with SpO2 84%, temperature 38.2°C and BP 88/56 mmHg. JVP is not raised and she is not in positive fluid balance. Chest X-ray shows new bilateral infiltrates, and echocardiography shows normal ventricular function. What is the most likely diagnosis?

    1. ATransfusion-related acute lung injury
    2. BTransfusion-associated circulatory overload
    3. CAcute haemolytic transfusion reaction
    4. DAnaphylactic transfusion reaction

    Answer and explanation in LearnFree account

15. Question 15 · Medium

    A 45-year-old woman in the surgical ward receives a unit of packed red cells after surgery. Ten minutes into it she has fever with chills, pain in the loins, a feeling of doom and BP 84/50 mmHg, and her urine turns red. What should be done first?

    1. AComplete the unit, then send samples
    2. BGive IV chlorpheniramine and continue the unit
    3. CStop the transfusion; keep the line open
    4. DSlow the rate and give paracetamol

    Answer and explanation in LearnFree account

16. Question 16 · Hard

    A 52-year-old man with a bulky lymphoma is due to start chemotherapy. Uric acid 11 mg/dL, creatinine 1.8 mg/dL, and rasburicase is planned. His brother once became jaundiced with dark urine after taking primaquine for vivax malaria. Which test should be done before rasburicase is given?

    1. AHaemoglobin HPLC
    2. BSerum ferritin
    3. CG6PD screening
    4. DDirect antiglobulin test

    Answer and explanation in LearnFree account

17. Question 17 · Medium

    A 36-year-old man, a lifelong strict vegetarian, has tingling in both feet and unsteadiness in the dark. Vibration and joint position sense are reduced in the legs. Hb 7.9 g/dL, MCV 118 fL, smear shows macro-ovalocytes and hypersegmented neutrophils. Serum B12 is low and folate is normal. What is the most appropriate treatment?

    1. AIntramuscular vitamin B12 injections
    2. BPacked red cell transfusion
    3. COral folic acid alone
    4. DOral iron with vitamin C

    Answer and explanation in LearnFree account

18. Question 18 · Medium

    A 19-year-old man has had recurrent painful swelling of the knees since childhood, and his maternal uncle had a similar problem. Platelets 2,40,000/µL, PT normal, aPTT 68 s (control 30 s), and the aPTT corrects fully on mixing with normal plasma. What is the next investigation?

    1. APlatelet aggregation studies
    2. BLupus anticoagulant tests
    3. CPlasma fibrinogen level
    4. DFactor VIII and IX assays

    Answer and explanation in LearnFree account

19. Question 19 · Medium

    A 45-year-old man has dragging pain in the left upper abdomen. The spleen is 10 cm below the costal margin. WBC 1,80,000/µL with neutrophils, myelocytes, metamyelocytes and basophils, few blasts; platelets 5,20,000/µL. Cytogenetics shows t(9;22). Which drug is the first-line treatment?

    1. ARituximab
    2. BIbrutinib
    3. CAll-trans retinoic acid
    4. DImatinib

    Answer and explanation in LearnFree account

20. Question 20 · Medium

    A 66-year-old woman is on day 7 after knee replacement and has received IV unfractionated heparin since day 1. Her platelet count has fallen from 2,40,000 to 85,000/µL, and she now has a painful swollen left calf with a DVT on Doppler. There is no bleeding. What is the next best step?

    1. ASwitch from heparin to enoxaparin
    2. BTransfuse platelets and continue heparin
    3. CStop heparin and start warfarin alone
    4. DStop heparin; start argatroban

    Answer and explanation in LearnFree account

21. Question 21 · Hard

    A 24-year-old woman has had gum bleeding and blood-filled blisters in her mouth for 2 days, and bruises on her legs. She is otherwise well, with no fever and no splenomegaly. Hb 12.6 g/dL, WBC 7,200/µL, platelets 6,000/µL; the smear shows few, large platelets and no schistocytes or blasts. PT and aPTT are normal, and HIV and hepatitis C tests are negative. What is the most appropriate treatment?

    1. AObserve and repeat the count in a week
    2. BGlucocorticoids with IV immunoglobulin
    3. CPlatelet transfusion alone
    4. DEmergency splenectomy

    Answer and explanation in LearnFree account

22. Question 22 · Easy

    A 58-year-old man is on day 4 in the medical ICU with pneumonia. He is haemodynamically stable, has no bleeding and no history of heart disease. His Hb has fallen to 7.8 g/dL from haemodilution and repeated sampling. What is the most appropriate step?

    1. ANo transfusion; continue to monitor
    2. BGive IV erythropoietin
    3. CTransfuse two units of whole blood
    4. DTransfuse one unit of packed red cells

    Answer and explanation in LearnFree account