10 USMLE Hematology and Oncology Questions with Answers and Explanations (Set 2)

These 10 USMLE hematology and oncology practice questions (Set 2) cover hemolytic anemias, nutritional anemias, thalassemia, venous thrombosis, anticoagulation in atrial fibrillation, metastatic endometrial cancer and melanoma prognosis. Each question includes the correct answer and an explanation.

Written by Dr. Ray Makar, MD, author of the Repeated USMLE Questions eBook series.

Prefer video? Watch daily USMLE case questions on MedFocus by Dr. Ray on YouTube.

How to use this page: read the question, pick your answer, then tap Show Answer and Explanation.

Questions

Question 1. A 20-year-old exchange male student from Greece presents to the office for evaluation. Two days ago, he noticed yellow discoloration of his conjunctiva. His family history is significant for hemolytic anemia due to glucose-6-phosphate dehydrogenase deficiency. Which one of these findings is most likely revealed in this patient’s workup?

A- Increased plasma unconjugated bilirubin
B- Increased bilirubin in urine
C- Increased urobilinogen in urine
D- Clay colored stool
E- Dark brown urine

Hemolysis of RBCs results in a large amount of bilirubin delivered to the liver. The ability of the liver to conjugate all the bilirubin to glucuronic acid fails and unconjugated bilirubin increases in the plasma causing jaundice. Unconjugated bilirubin is unlikely to pass into the urine because it is bound to albumin and has low solubility in plasma. Clay colored stool occurs due to absence of bile pigments in the colon, which is not associated with hemolytic anemia.
The correct answer is A

 

Question 2. A 45-year-old man who was diagnosed with malaria and treated with antimalarial medications presents to the office with progressive fatigue and loss of appetite. He has noticed that his urine has become dark. Urinalysis is positive for urobilinogen and negative for bilirubin. Blood studies show serum total bilirubin of 4.3 mg/dL (mostly unconjugated), hemoglobin of 8.5 g/dL and hematocrit of 30%. Which of the following antimalarial drugs most likely caused this condition?

A- Atovaquone
B- Chloroquine
C- Doxycycline
D- Primaquine

This is a case of hemolytic anemia due to glucose-6-phosphate dehydrogenase (G6PD) deficiency. This anemia is caused by lack of reduced glutathione secondary to decreased production of NADPH. Accumulation of oxidizing metabolites such as peroxides and other free radicals in the red blood cells leads to their lysis and resulting in hemolytic anemia. G6PD deficiency is induced by some drugs such as primaquine, sulfonamides, nitrofurans, phenacetin, vitamin K derivatives, dapsone, phenazopyridine and methylene blue. Atovaquone is used in combination with proguanil in prophylaxis of malaria. It is not associated with G6PD deficiency. Chloroquine is effective in eradication of blood schizonts and is not associated with hemolytic anemia and so is doxycycline.
The correct answer is D

 

Question 3. A 21-year-old pregnant woman visits her physician for a prenatal visit. Ultrasonography shows neural tube defects. The patient was not compliant with her medications. Assuming that the condition is caused by deficiency of a certain nutrient, which one of these abnormalities would be seen as well?

A- Coagulation disorder
B- Microcytic anemia
C- Macrocytic anemia
D- Macrocytic anemia with neurological signs
E- Normochromic normocytic anemia

This is most likely a case of folic acid deficiency. Folic acid is routinely administered during pregnancy to avoid complications of its deficiency which result in neural tube defects. Folic acid deficiency also leads to macrocytic anemia which is differentiated from Vitamin B deficiency macrocytic anemia in lack of neurological signs. Microcytic anemia is mainly caused by iron-deficiency and some congenital diseases while normocytic anemia occurs in general diseases and some types of hemolytic anemias.
The correct answer is C

 

Question 4. A 1-year-old girl is brought to the pediatrician by her parents due to poor growth and skeletal abnormalities. Laboratory investigations show microcytic anemia and higher concentration of hemoglobin A2. Which is the most likely diagnosis?

A- Sickle cell anemia
B- β-thalassemia
C- Lead poisoning
D- Iron deficiency

β-thalassemia is an inherited blood disorder that has defective production of hemoglobin. Beta thalassemia indicates decreased production of hemoglobin and confirmed by the high level of hemoglobin A2. Children suffering from β-thalassemia tend to present poor growth, skeletal abnormalities and severe anemia particularly during the first two years of life.
The correct answer is B

 

Question 5. A 1-week-old girl presents for her first checkup. Examination reveals jaundice and splenomegaly. Laboratory investigations show: Total bilirubin level: 27 mg/dL Direct bilirubin: 0.6 mg/dL Hgb: 10.1 g/dL Reticulocytes: 6% A blood smear shows burr cells and spherocytosis. Which of these tests will be positive in this patient?

A- Acid hemolysis test
B- Coombs test
C- Osmotic fragility test
D- Metabisulfite test
E- Schilling test

This is a case of hereditary spherocytosis. Osmotic fragility test is diagnostic in this patient. Spherocytes lyse at a higher concentration of salt than normal red blood cells which causes an increased osmotic fragility. Acid hemolysis test is used to diagnose cases of paroxysmal nocturnal hemoglobinuria while Coombs test is used in diagnosis of autoimmune hemolytic anemia. Metabisulfite test is used in sickle cell anemia and Schilling test is used in cases of pernicious anemia.
The correct answer is C

 

Question 6. A 62-year-old man complains of fatigue, progressive weakness and numbness of his arms and legs. Complete blood count shows decreased numbers of erythrocytes and increase in the mean cell volume. Removal of which of these structures requires lifelong administration of the vitamin involved in this case?

A- Ascending colon
B- Gall bladder
C- Ileum
D- Left kidney
E- Tonsils

This is a case of megaloblastic anemia due to vitamin B12 deficiency. Vitamin B12 is absorbed in the ileum after combining with intrinsic factor secreted in the stomach. Removal of the stomach or the ileum results in lifelong administration of vitamin B12 to protect the patient against megaloblastic anemia.
The correct answer is C

 

Question 7. A 48 year-old man, who visited his daughter in London last week, complains of sudden severe pain and swelling in his right leg during his flight back to the USA. He is taken to the hospital and ultrasound is performed. It reveals femoral vein thrombosis. What most likely contributed to this finding?

A- Hypertension
B- Immobilization
C- Alcohol abuse
D- Hypothyroidism
E- Daily aspirin

Immobilization during long flights predisposes to deep venous thrombosis. Immobilization for long hours as in this case and in prolonged bed restrictions such as cases of paralysis or following major surgeries is the most common cause of deep venous thrombosis. Hypertension contributes to thrombosis in arteries due to atherosclerosis. Alcohol abuse may lead to liver disease which contributes to coagulopathy and hemorrhage. Hypothyroidism and aspirin do not have any relation to DVT.
The correct answer is B

 

Question 8. A 75-year-old man presents to his physician for a routine examination. He has a history of hypertension, hypercholesterolemia, and osteoarthritis. He takes atenolol, simvastatin, and ibuprofen as needed. His pulse is 76/min and irregular. Blood pressure is 130/74. Physical examination and imaging studies are normal except for asymptomatic atrial fibrillation. What is the next step in managing this patient?

A- Reassurance and follow-up in 3 months
B- Start aspirin
C- Start heparin
D- Start long-term oral anticoagulation (warfarin or a direct oral anticoagulant)
E- Start low molecular weight heparin and warfarin

This patient has nonvalvular atrial fibrillation with a CHA2DS2-VASc score of 3 (age 75 or older = 2 points, hypertension = 1 point). A score of 2 or more in men calls for long-term oral anticoagulation to prevent stroke. Direct oral anticoagulants such as apixaban are now generally preferred over warfarin, but warfarin is also correct. Aspirin is not enough for stroke prevention in AF, heparin is only for acute anticoagulation, and bridging is not needed in stable nonvalvular AF.
The correct answer is D

 

Question 9. A 79-year-old woman complaining of persistent cough presents to the clinic for chest x-ray. A small nodule is detected on the x-ray. Biopsy of the nodule reveals adenocarcinoma containing progesterone receptors. Her past history is significant for endometrial carcinoma treated 2 years ago. What is the most effective treatment for this patient?

A- Cytotoxic agents
B- Lobectomy
C- Progestin therapy
D- Radiotherapy

This patient has metastases to her lung secondary to recurrent endometrial carcinoma. Recurrence of endometrial cancer occurs in 90% of cases within 5 years. Hormone-containing endometrial adenocarcinoma is effectively treated with progestin therapy. Lung is the most common site for extra-pelvic metastases. Non-hormonal endometrial cancer is usually treated with cytotoxic drugs such as doxorubicin and cisplatin. Lobectomy and radiotherapy are not indicated in this case as hormonal treatment is more effective.
The correct answer is C

 

Question 10. A 62-year-old farmer visits his physician at his wife’s request who noticed that he had an irregular dark pigmented lesion on his back. According to his wife, he has had this lesion since their wedding 35 years ago but lately it became darker and irregular. What is the most important prognostic factor in this case?

A- Age of the patient
B- Color of the lesion
C- Depth of the lesion
D- Diameter of the lesion

This lesion is most likely at risk to convert to malignant melanoma which is characterized by ABCDE, Asymmetric, Border irregular, Color darker, Diameter greater and Evolving over time. Melanoma is confirmed by skin biopsy. The most important prognostic factor is the depth of the lesion.
The correct answer is D

 

High-yield points from this set

  • Hemolysis raises unconjugated bilirubin; it does not appear in the urine.
  • Primaquine, sulfonamides and dapsone trigger hemolysis in G6PD deficiency.
  • Neural tube defects point to folate deficiency, which causes macrocytic anemia without neurologic signs.
  • Microcytic anemia with high HbA2 = beta-thalassemia trait or major.
  • Spherocytes with a negative Coombs test = hereditary spherocytosis; osmotic fragility (or EMA binding) test.
  • Removal of the terminal ileum requires lifelong vitamin B12.
  • Long flights and immobility cause DVT.
  • AF with CHA2DS2-VASc of 2 or more (men): long-term oral anticoagulation.
  • Progesterone-receptor-positive metastatic endometrial cancer responds to progestin therapy.
  • Depth of invasion (Breslow thickness) is the most important prognostic factor in melanoma.

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