A 43 year old man presents with a 3 month history of tiredness, night sweats and weight loss of 4kg. He has recently noticed bruises over his legs especially and prolonged bleeding from minor cuts or superficial wounds.
On examination:
Lean man, alert, afebrile, pale conjunctivae. Numerous bruises over arms and legs and fine pinpoint skin haemorrhages (purpura) over lower legs near ankles. Remainder of physical examination normal.
Question 5.
List this man’s problems.
(3 minutes)
Question 6.
Suggest two hypotheses to account for his problems, explaining how each hypothesis relates to the
(12 minutes)
Question 7.
On the basis of the above information, suggest the two investigations which are most likely to help define this man’s problem of bruising. Give reasons for your choices.
(5 minutes)


Result Reference Range
Haemoglobin 90g/L (130-180)
MCV 86 fL (80-99)
White Cell Count 30 x109/L (4.0-11.0)
Neutrophils 1.2 x109/L (1.8-7.5)

2.8 x109/L

Monocytes 0.8 x109/L (0.2-0.8)
Eosinophils 0.4 x109/L (0.0-0.4)
Blasts 24.8 x109/L

Platlets 10 x 109/L (150-450)

The film shows many immature white cells with the appearance of myeloblasts International Normalised Ratio (INR) 1.0 (0.8-1.2) Activated Partial Thromboplastin Time (APTT) 28 seconds (26-40)
Question 8.
Comment on the test results above. Briefly analyse them and make a diagnosis if possible.
(10 minutes)
Question 9.
Outline why the patient has a problem with bruising and prolonged bleeding from cuts. Include in your answer a description of events in normal haemostasis after a cut.
(15 minutes)

The patient is diagnosed as having acute myeloid leukaemia and is informed that chemotherapy offers a 80% chance of remission of his disease. After considering his options, he decides to proceed with drug treatment aimed at killing his malignant cells (chemotherapy) Two weeks after initial high dose chemotherapy his neutrophil count is 0.2x109/L (1.8-7.5) and he presents with fever, rigors and hypotension. He is transferred to the Intensive Care Unit.
Question 10.
What are the normal functions of neutrophils? (5 minutes)
Question 11.
What are the pathophysiological mechanisms leading to fever, rigors and hypotension? What clinical condition/s could have initiated these processes?
(25 minutes)


A 35-year-old woman has noted spontaneous bruising for one week.
a) Describe briefly the normal haemostatic mechanism
(12 minutes)
b) List three diseases that might cause spontaneous bruising and indicate the haemostatic defect in each.
(6 minutes)

A 68 year old man who is receiving warfarin therapy for atrial fibrillation and who has a long history of chronic bronchitis (ex smoker, presents to his GP with fever and worsening cough. He has been brining up large amount of green sputum for three days.

Examination reveals a febrile elderly man in moderate respiratory distress. He has scattered wheezes through his chest, which is hyper-expanded in keeping with chronic obstructive airway disease. Pulse is 92/min irregularly irregular. BP is 140/80.

Question 6:
What routine microbiological tests would help identify and characterise the pathogens responsible for this mans signs and symptoms. In your answer, give examples of likely pathogens and how they might be identified.
(12 minutes)
The patient is treated with 2 week course of amoxicillin, bronchodilator therapy and chest physiotherapy. He presents one week after completing his antibiotic course stating that he has not improved. He has lost 4kg in weight over the past month.

Question 7:
Suggest reasons why his symptoms might be persisting despite several weeks of treatment.
(6 minutes)
Question 8:
In what way might smoking have interfered with his hose defences?

The doctor is surprised amoxicillin has not helped, as sputum culture grew haemophilus influenza sensitive to amoxicillin and the patient has taken his medication regularly. She orders a chest x ray:

Chest X ray report:
There is collapse of the right middle lobe. Prominent hilar(central) lymph nodes noted. Peripheral lung mass 2cm x3cm.

Question 9:
• Select two disease which might presnt an combination of “peripheral mass, right middle lobe collapse and prominent hilar lymph nodes” and for each, describe how these features might be produced. (15 minutes)

• Select one of thse disease and describe the cellular changes that you expect to be present in the peripheral mass. Outline their pathogenesis.

The treating physician wants to biopsy the mass bt the patient is at an increased risk of bleeding from the procedure.

Question 10:
• Briefly explain how wafarin affects the coagulation pathway. (4 minutes
• Suggest ways in which the introduction of an antiobiotic might have affected the anticoagulation regime
• What test is routinely used to monitor warfarin therapy?
• Suggest approaches to normalising the coagulation pathway in this patient

As part of the diagnostic workshop a blood picture is done and shows the following.
Hb 85g/L (130=175)
MCV 92fL (82-98)
WCC 2.0x109 (4-11)
Neutrophils 0.5x109/L (1.8-7.5)
Lymphocytes 1.5x109/L (1.5-4.5)
Pl. 35,000 (150,000-450-000)

Question 11:
Analyse the blood findings and discuss possible underlying mechanisms. (15 minutes)

Question 1:
Describe the role of platelets in haemostatic response. (10 minutes)
Question 2:
Describe theimmediate and long-term haematological consequences of the loss of 1 litre of blood. Do not discuss the homeostatic reflex responses of the circulatory or respiratory system. (15 minutes)


A patient arrives in the emergency department, pale and hypotensive. You discover a history of
significant blood loss over the last 3 hours. The patient has had a recent pulmonary embolus and is
presently anticoagulated on warfarin. Resuscitation is commenced with intravenous saline.

a) In addition to the saline, what is the most appropriate transfusion product? Explain your answer.
(6 marks)
b) What strategies may be used to reverse a warfarin overdose? What properties of warfarin and coagulation factors must be taken into account in the management of warfarin overdose?
(6 marks)

Question 5 (14 marks in total)
An 80-year-old indigenous woman who has diabetes has a 3cm cut in her right leg. The wound fails to heal for three months. On physical examination, the area is swollen and pus is noted. On pathological examination, the area is an abscess with granulomatous inflammation. After treatment, the wound heals by secondary intention.

• Name 3 processes that can delay the healing of wound in this patient(3 marks)
• Describe the histological features of an abscess(2 marks)
• Explain the term ‘granulomatous inflammation(1 mark)
• Name 3 cells that characterise granulomatous inflammation(3 marks)
• Name any 2 causes of granulomatous inflammation(2 marks)
• Name 3 differences between healing by first and second intention(3 marks)
Question 7
List three principle factors that contribute to thrombosis and for each give a predisposing clinical condition. (6 marks)


Question 1.
“Thrombosis is the result of more than just poor circulation”
Discuss the mechanisms which give rise to thrombosis in a deep vein.
(12 marks)


A 60 year old man presents to his local doctor with a three day history of progressive shortness of breath and chest pain. He also says on questioning that he has coughed blood stained sputum this morning. He has a 60 pack year smoking history, has poorly controlled type II diabetes and has been off work for the last 10 days with a painful ankle.
On clinical examination, he has a temperature of 37.5C, he is tachycardic (heart rate 90 beats per minute), a high respiratory rate of 24 breaths per minute, with clinical signs of poor air entry into the right lung base.
Question 6.
List three hypotheses to explain the clinical symptoms and signs of this man’s presentation.
(3 marks)
Suggested Answer:
1. Acute chest infection such as bronchitis or pneumonia
2. Venous thromboembolism – pulmonary embolus
3. Lung malignancy – first presentation

Question 7.
Explain how the clinical features of his presentation have led you to suggest these hypotheses. (12marks)
A chest X-ray reveals a mass involving the right lung. Sputum cytology demonstrates malignant cells consistent with lung cancer. Additionally, a complete blood picture is taken and the results are as follows:
Hb 102 (reference range 130-175)
MCV 77 (reference range 80-100)
WCC 12.2 (reference range 4-11)
Platlets 500 (reference range 150-450)
Reticulocyte count 28 (reference range 20-100)
Erythrocyte sedimentation rate 45mm/hour (reference range <20)

You have previous complete blood pictures for this man, which were normal.
Question 8.
Name two broad possible causes of microcytic anaemia in this man.
(2 marks)

Question 9.
What laboratory test(s) would be most helpful to distinguish between the two possible causes of his microcytic anaemia? Explain the qualitative differences you would expect to see to distinguish between these causes.
Question 10.
Explain why the reticulocyte count is low despite the fact that he is anaemic. What mechanisms act to increase the reticulocyte count normally?
(4 marks)

A CT scan is performed which shows a lung mass and a right hilar mass (lymph nodes). It also reveals pulmonary emboli, a pleural effusion and abnormalities within the bones.
Question 11.
Using this new information, describe the main routes of spread which may give rise to metastasis. What are the cellular mechanisms that facilitate metastasis?
Question 12.
In the treatment of pulmonary emboli, the patient is first commenced on heparin followed by warfarin.
• Write short notes on the mechanism of action of warfarin. What factors relevant to coagulation are affected by warfarin?
• With reference to the case, what are the particular risks of anticoagulation?
• How may the effects of warfarin be reversed?
• What test is used to monitor warfarin?

Question 8.
“Bone marrow failure is due to the failure of production of myeloid cells within the bone marrow, leading to low peripheral blood counts.”
a) Explain the concept of “stem cells and differentiation” specifically referring to the myeloid
cells within the normal bone marrow. Briefly list the relevant stimuli for production of the differentiated cells.
(6 marks)
b) Briefly explain the clinical consequences of bone marrow failure linked to each of the major myeloid cell lines:
• Erythroid
• Granulocytic, and
• Megakaryocytic
(6 marks)
c) Describe the mechanism of action of platelets in their role as the primary component of the coagulation pathway.
(4 marks)