Setting questions

I have spent an interesting day learning to set multiple choice questions at the Royal College of Pathologists. The principle is to put more detail in the question stem. Make the question sound more like real life, rather than a contrived examination of trivia designed to make the examiner feel one-up on the student. Here are some of the questions I designed.

A 53 year old woman had suffered from systemic lupus erythematosus since the age of 30. It manifested mainly as malar rash, arthralgia, hair loss, and five years ago with acute nephritis. Initial treatment was with steroids and then plasma exchange was introduced. Arthralgia was well controlled with chloroquine, but with the onset of the renal disease she was treated and brought under control with six courses of cyclophosphamide, vincristine and prednisolone. Over the past two months she has developed mild pancytopenia. Her FBC showed Hb 10.2 g/dL, MCV 99fl, WBC 2.3 x 109/L, (neutrophils 53%, lymphocytes 44%), platelets 103 x 109/L

From the following options select the most likely cause of the pancytopenia?

Option A Acute lymphoblastic leukaemia
Option B Aplastic anaemia
Option C Megaloblastic anaemia
Option D Myelodysplastic syndrome
Option E Systemic lupus erythematosus

Correct answer Myelodysplastic syndrome

A 73 year old widower is brought into accident and emergency confused and disoriented which had been coming on over the past 2 weeks. He had been coping well at home until recently, cooking his own meals and doing his own washing. It is impossible to obtain a full history form him, but you learn from his daughter that he had recently won a pub quiz competition. On examination he does not have a fever. He has some raised red lumps 0.5 cm in diameter on both forearms. His chest is dull at the left base with limited air entry and his spleen is palpable. FBC shows Hb 12.2 g/dL, MCV 101 fl, WBC 73.3 x 109/L (neutrophils 37%, lymphocytes 4%, monocytes 58%, blasts 1%), platelets 74 x 109/L.

From the following options select most likely cause of the confusion?

Option A Alcoholism
Option B Cerebrovascular haemorrhage
Option C Cerebral leucostasis
Option D Cerebral secondaries
Option E Pneumonia

Correct answer Pneumonia

A 68 year old lifelong smoker is admitted with an unrelenting cough. He has recently brought up some green sputum with flecks of blood. Since he is seeing a chest physician he is sent immediately for a chest X-ray which shows a mass in the right hilum. Bronchoscopy reveals this to be a non-small cell carcinoma of the bronchus. A stickler for detail, the chest physician orders a blood count, and this is found to show Hb 11.9 g/dL. WBC 9.8 x 109/L (neutrophils 79%, lymphocytes 8%, monocytes 13%), platelets 97 x 109/L. Blood film shows a few Pelger cells and hypogranular neutrophils with some basophilic stippling. The chest physician insists on a bone marrow aspirate which shows no cancer cells, but erythroid hypoplasia with irregularly shaped normoblasts and dyskaryorrhexis, 10% ringed sideroblasts, myeloid hyperplasia, with myelocytes lacking secondary granulation, increased promyelocytes and 4% myeloblasts, and increased megakaryocytes, many with dispersed multiple nuclei.

From the following options selct the correct haematological diagnosis.

Option A Chronic myelomonocytic leukaemia
Option B Myelodysplastic syndrome (unclassified)
Option C Refractory anaemia with excess of blasts
Option D Refractory anaemia with multilineage dysplasia
Option E Refractory anaemia with ringed sideroblasts

Correct answer Chronic myelomonocytic leukaemia

A 37 year old Turkish immigrant presented with bruises on her forearms. She had come to the UK three years ago having previously worked on a farm in central Turkey. She was living in a squat in Camden Town. She denied having been subject to trauma. Clinical examination was unremarkable apart from the bruises. Her FBC showed Hb 12.7 g/dL, WBC 6.4 x 109/L, (neutrophils 69%, lymphocytes 26%, and monocytes 4%), platelets 37 x 109/L. A bone marrow aspirate is performed, but the only abnormality seen is a reduction in megakaryocytes.

Select from the following options your next investigation.

Option A
Antinuclear factor
Option B
Blood test for drugs and toxins
Option C
Cytogenetics
Option D
Electron microscopy of the bone marrow
Option E
Platelet associated IgG

Correct answer
Cytogenetics

A 47 year old writer of crime fiction had been complaining of pain in her left side. Her GP felt she could feel a mass there and referred her to the hospital for investigation. There was much argument amongst the junior doctor over whether the spleen could be felt. A bone marrow aspirate was a dry tap. A marrow trephine and a CT barium were ordered.The bone marrow showed general hyperplasia with trilineage dysplasia with no increased myelobalsts but with greatly increased reticulin staining. The CT barium showed a constricting carcinoma of the descending colon which was successfully removed under platelet cover. The writer named her next murderer after the haematologist who performed the bone marrow trephine.

Select from the following options the most likely bone marrow diagnosis.

Option A
Aplastic anaemia with a 'hot spot'
Option B
Myelodysplastic syndrome (unclassifiable)
Option C
Myelofibrosis
Option D
Refractory anaemia
Optiion E
Refractory anaemia with multilineage dysplasia

Correct answer
Myelodysplastic syndrome (unclassifiable)