Practice questions Anemia I
Practice questions
Anemia I
© Jun Wang, MD, PhD
Abbreviations:
|
Hb: hemoglobin |
HCT: hematocrit |
|
MCV: Mean Corpuscular Volume |
MCHC: Mean Corpuscular Hemoglobin |
|
RDW: Red Cell Distribution Width |
TIBC: total iron binding capacity |
1. Use this case for the next three questions. A 25-year-old woman is brought to the emergency department 2 hours after being involved in a motor vehicle accident. She is conscious but feels dizziness and weakness. Her blood pressure is 90/60 mmHg, and her heart rate is 120 beats per minute. Physical examination reveals pale skin and mucosa and a 15 cm laceration on her left thigh with significant bleeding. What are most likely the CBC and TIBC results?
B. Low Hb, low HCT, slightly low MCV, normal RDW, normal TIBC
C. Low Hb, low HCT, slightly high MCV, normal RDW, normal TIBC
D. Normal Hb, normal HCT, normal MCV, normal TIBC
E. Normal Hb, normal HCT, low MCV, high TIBC
2. A 25-year-old woman is brought to the emergency department 2 hours after being involved in a motor vehicle accident. She is conscious but feels dizziness and weakness. Her blood pressure is 90/60 mmHg, and her heart rate is 120 beats per minute. Physical examination reveals pale skin and mucosa and a 15 cm laceration on her left thigh with significant bleeding.
Laboratory results reveal a Hb of 8 g/dL (normal: 12-16 g/dL) and HCT of 24% (normal: 36-46%). Her WBC and platelet counts, as well as TIBC are within normal range. What additional test result is likely to be found?
B. High indirect bilirubin
C. High reticulocyte count
D. Low haptoglobin
E. Target cells
3. A 25-year-old woman is brought to the emergency department 2 hours after being involved in a motor vehicle accident. She is conscious but feels dizziness and weakness. Her blood pressure is 90/60 mmHg, and her heart rate is 120 beats per minute. Physical examination reveals pale skin and mucosa and a 15 cm laceration on her left thigh with significant bleeding. Laboratory results reveal a Hb of 8 g/dL (normal: 12-16 g/dL) and HCT of 24% (normal: 36-46%). Her WBC and platelet counts, as well as TIBC are within normal range.
She has a reticulocyte count of 5% (0.5%-2.5%). Serum bilirubin, haptoglobin, liver and renal function tests are within normal range. Peripheral blood smear reveals no evidence of morphological abnormalities. What is most likely the cause of her CBC results?
B. Autoimmune reaction
C. Hemoglobin abnormalities
D. Iron deficiency
E. Lead poisoning
F. Vitamin B12 deficiency
4. Use this case for the next three questions. A 32-year-old man presents to the clinic with recurrent fever, chills, and sweating, occurring in cycles every 48 hours for a month. He recently returned from a business trip to a tropical area. He also reports fatigue, headache, and muscle aches. His temperature is 39°C (102.2°F), blood pressure is 110/70 mmHg, heart rate is 100 beats per minute. Physical examination reveals pale skin and mucosa with a yellowish hue. His CBC results are as follows:
Hemoglobin: 7 g/dL (normal: 13.5-17.5 g/dL)Hematocrit: 21% (normal: 41-53%)
White blood cell count: 4,500/mm³ (normal: 4,000-11,000/mm³)
Platelet count: 90,000/mm³ (normal: 150,000-450,000/mm³)
An image of his peripheral blood smear is shown. What additional lab test result would likely be decreased?
A. Bilirubin
B. Erythropoietin
C. Haptoglobin
D. Lactate dehydrogenase (LDH)
E. Reticulocytes count
5. A 32-year-old man presents to the clinic with recurrent fever, chills, and sweating, occurring in cycles every 48 hours for a month. He recently returned from a business trip to a tropical area. He also reports fatigue, headache, and muscle aches. His temperature is 39°C (102.2°F), blood pressure is 110/70 mmHg, heart rate is 100 beats per minute. Physical examination reveals pale skin and mucosa with a yellowish hue. His CBC results are as follows:
Hemoglobin: 7 g/dL (normal: 13.5-17.5 g/dL)Hematocrit: 21% (normal: 41-53%)
White blood cell count: 4,500/mm³ (normal: 4,000-11,000/mm³)
Platelet count: 90,000/mm³ (normal: 150,000-450,000/mm³)
An image of his peripheral blood smear is shown. Additional lab test results include a haptoglobin of 12 mg/dL (50-220 mg/dL), indirect bilirubin of 2.5 mg/dL (normal: 0.2-0.8 mg/dL) and LDH of 450 U/L (normal: 140-280 U/L). His TIBC is within normal range. What is most likely the cause of his reduced Hb?
(Image credit: public domain)
B. Chronic blood loss
C. Hemoglobin synthesis abnormalities
D. Increased red cell destruction
E. Nutritional deficiency
6. A 32-year-old man presents to the clinic with recurrent fever, chills, and sweating, occurring in cycles every 48 hours for a month. He recently returned from a business trip to a tropical area. He also reports fatigue, headache, and muscle aches. His temperature is 39°C (102.2°F), blood pressure is 110/70 mmHg, heart rate is 100 beats per minute. Physical examination reveals pale skin and mucosa with a yellowish hue. His CBC results are as follows:
Hemoglobin: 7 g/dL (normal: 13.5-17.5 g/dL)Hematocrit: 21% (normal: 41-53%)
White blood cell count: 4,500/mm³ (normal: 4,000-11,000/mm³)
Platelet count: 90,000/mm³ (normal: 150,000-450,000/mm³)
An image of his peripheral blood smear is shown. Additional lab test results include a haptoglobin of 12 mg/dL (50-220 mg/dL), indirect bilirubin of 2.5 mg/dL (normal: 0.2-0.8 mg/dL) and LDH of 450 U/L (normal: 140-280 U/L). His TIBC is within normal range. What is most likely the cause of increased red cell destruction?
(Image credit: public domain)
B. Cytoskeletal defects
C. Mechanical shear-force
D. Oxidative stress
E. Parasitic infection
F. Renal failure
7. Use this case for the next three questions. A 61-year-old man presents with worsening fatigue for 1 month. His past medical history is unremarkable. He does not drink alcohol nor smoke cigarettes. Physical examination reveals pallor of skin and mucosa. There is no evidence of jaundice. CBC results are listed below.
Reticulocyte count: 2.5% (normal: 0.5-2.5%)
MCV: 74 fL (normal: 80-100 fL)
MCHC: 29 g/dL (32-36 g/dL)
RDW: 20% (11.5%-14.5%)
White blood cell count: 6,500/µL (normal: 4,500-11,000/µL)
Platelet count: 250,000/µL (normal: 150,000-450,000/µL)
What type of anemia this should be
classified?
C. Microcytic hypochromic anemia
D. Microcytic normochromic anemia
E. Normocytic hyperchromic anemia
F. Normocytic normochromic anemia
8. A 61-year-old man presents with worsening fatigue for 1 month. His past medical history is unremarkable. He does not drink alcohol nor smoke cigarettes. Physical examination reveals pallor of skin and mucosa. There is no evidence of jaundice. CBC results are listed below.
Hemoglobin: 7.5 g/dL (normal: 13.8-17.2 g/dL)Reticulocyte count: 2.5% (normal: 0.5-2.5%)
MCV: 74 fL (normal: 80-100 fL)
MCHC: 29 g/dL (32-36 g/dL)
RDW: 20% (11.5%-14.5%)
White blood cell count: 6,500/µL (normal: 4,500-11,000/µL)
Platelet count: 250,000/µL (normal: 150,000-450,000/µL)
What is most likely the cause of his presentation?
C. Hemoglobin b gene deletion
D. Hematopoietic stem cell defect
E. Oxidative stress
F. Red cell cytoskeleton abnormalities
9. A 61-year-old man presents with worsening fatigue for 1 month. His past medical history is unremarkable. He does not drink alcohol nor smoke cigarettes. Physical examination reveals pallor of skin and mucosa. There is no evidence of jaundice. CBC results are listed below.
Hemoglobin: 7.5 g/dL (normal: 13.8-17.2 g/dL)Reticulocyte count: 2.5% (normal: 0.5-2.5%)
MCV: 74 fL (normal: 80-100 fL)
MCHC: 29 g/dL (32-36 g/dL)
RDW: 20% (11.5%-14.5%)
White blood cell count: 6,500/µL (normal: 4,500-11,000/µL)
Platelet count: 250,000/µL (normal: 150,000-450,000/µL)
B. Eosin-5-maleimide (EMA) binding
C. Enzymatic activity of G6PD
D. Fecal blood test
E. Hemoglobin electrophoresis
F. Molecular studies for FA mutations
10. Use this case for the next two questions. A 65-year-old woman presents to her primary care physician with worsening fatigue over the past six months. She has a history of rheumatoid arthritis, which has been managed with methotrexate and nonsteroidal anti-inflammatory drugs (NSAIDs). She has morning stiffness lasting for about an hour and joint pain as well. Physical examination reveals pallor but no signs of bleeding or petechiae. Her rheumatoid arthritis is active with swollen and tender joints in her hands. Her laboratory test results are listed below:
MCV: 82 fL (normal: 80-100 fL)
MCHC: 34 g/dL (32-36 g/dL)
RDW: 13% (11.5%-14.5%)
White blood cell count: 7,000/µL (normal: 4,500-11,000/µL)
Platelet count: 400,000/µL (normal: 150,000-450,000/µL)
Serum iron: 30 µg/dL (normal: 60-170 µg/dL)
Total iron-binding capacity (TIBC): 200 µg/dL (normal: 240-450 µg/dL)
Ferritin: 500 ng/mL (normal: 12-300 ng/mL)
Her bilirubin, haptoglobin and renal function tests are within normal ranges. What type of anemia this should be classified?
B. Macrocytic normochromic anemia
C. Microcytic hypochromic anemia
D. Microcytic normochromic anemia
E. Normocytic hyperchromic anemia
F. Normocytic normochromic anemia
11. A 65-year-old woman presents to her primary care physician with worsening fatigue over the past six months. She has a history of rheumatoid arthritis, which has been managed with methotrexate and nonsteroidal anti-inflammatory drugs (NSAIDs). She has morning stiffness lasting for about an hour and joint pain as well. Physical examination reveals pallor but no signs of bleeding or petechiae. Her rheumatoid arthritis is active with swollen and tender joints in her hands. Her laboratory test results are listed below:
Hemoglobin: 9.5 g/dL (normal: 12.0-15.5 g/dL)MCV: 82 fL (normal: 80-100 fL)
MCHC: 34 g/dL (32-36 g/dL)
RDW: 13% (11.5%-14.5%)
White blood cell count: 7,000/µL (normal: 4,500-11,000/µL)
Platelet count: 400,000/µL (normal: 150,000-450,000/µL)
Serum iron: 30 µg/dL (normal: 60-170 µg/dL)
Total iron-binding capacity (TIBC): 200 µg/dL (normal: 240-450 µg/dL)
Ferritin: 500 ng/mL (normal: 12-300 ng/mL)
Her bilirubin, haptoglobin and renal function tests are within normal ranges. What is most likely associated with her CBC results?
B. Chronic blood loss
C. Erythroid maturation arrest
D. Iron deficiency
E. Rheumatoid arthritis
F. Vitamin B12 deficiency
12. Use this case for the next two questions. A 42-year-old woman presents to her primary care physician with fatigue, shortness of breath on exertion, and a tingling sensation in her hands and feet for two months. Her past medical history is unremarkable. She does not have any recent illnesses or changes in diet, though she mentions being a vegetarian for the past 10 years. Physical examination reveals a pale, thin woman with glossitis and decreased vibratory sensation in the lower extremities. Her laboratory tests are listed below.
MCV: 115 fL (normal: 80-100 fL)
MCHC: 34 g/dL (32-36 g/dL)
RDW: 19% (11.5%-14.5%)
Reticulocyte count: 0.5% (normal: 0.5-2.5%)
White blood cell count: 4,000/µL (normal: 4,500-11,000/µL)
Platelet count: 150,000/µL (normal: 150,000-450,000/µL)
Homocysteine: 25 mcmol/L (normal: <15 mcmol/L)
Methylmalonic acid: 525 nmol/L (55-335 nmol/L)
What type of anemia this should be
classified?
C. Microcytic hypochromic anemia
D. Microcytic normochromic anemia
E. Normocytic hyperchromic anemia
F. Normocytic normochromic anemia
13. A 42-year-old woman presents to her primary care physician with fatigue, shortness of breath on exertion, and a tingling sensation in her hands and feet for two months. Her past medical history is unremarkable. She does not have any recent illnesses or changes in diet, though she mentions being a vegetarian for the past 10 years. Physical examination reveals a pale, thin woman with glossitis and decreased vibratory sensation in the lower extremities. Her laboratory tests are listed below.
MCV: 115 fL (normal: 80-100 fL)
MCHC: 34 g/dL (32-36 g/dL)
RDW: 19% (11.5%-14.5%)
Reticulocyte count: 0.5% (normal: 0.5-2.5%)
White blood cell count: 4,000/µL (normal: 4,500-11,000/µL)
Platelet count: 150,000/µL (normal: 150,000-450,000/µL)
Homocysteine: 25 mcmol/L (normal: <15 mcmol/L)
Methylmalonic acid: 525 nmol/L (55-335 nmol/L)
What is most likely associated with these
findings?
C. Erythroid maturation arrest
D. Iron deficiency
E. Rheumatoid arthritis
F. Vitamin B12 deficiency
14. Use this case for the next three questions. A 30-year-old man presents to the clinic with complaints of fatigue, frequent infections, and easy bruising over the past three months. He reports no significant past medical history and denies any recent travel or exposure to toxins. His physical examination is notable for pallor, petechiae on his lower extremities, and mild hepatosplenomegaly. Laboratory tests show the following:
White blood cell count: 1,500/µL (normal: 4,500-11,000/µL)
Platelet count: 20,000/µL (normal: 150,000-450,000/µL)
Reticulocyte count: 0.2% (normal: 0.5-2.5%)
MCV: 85 fL (normal: 80-100 fL)
MCHC: 34 g/dL (32-36 g/dL)
What type of anemia this should be
classified?
C. Microcytic hypochromic anemia
D. Microcytic normochromic anemia
E. Normocytic hyperchromic anemia
F. Normocytic normochromic anemia
15. A 30-year-old man presents to the clinic with complaints of fatigue, frequent infections, and easy bruising over the past three months. He reports no significant past medical history and denies any recent travel or exposure to toxins. His physical examination is notable for pallor, petechiae on his lower extremities, and mild hepatosplenomegaly. Laboratory tests show the following:
Hemoglobin: 7.5 g/dL (normal: 13.8-17.2 g/dL)White blood cell count: 1,500/µL (normal: 4,500-11,000/µL)
Platelet count: 20,000/µL (normal: 150,000-450,000/µL)
Reticulocyte count: 0.2% (normal: 0.5-2.5%)
MCV: 85 fL (normal: 80-100 fL)
MCHC: 34 g/dL (32-36 g/dL)
What test should be done next?
B. Direct Coombs antiglobulin test
C. Hemoglobin electrophoresis
D. Iron studies
E. Serum folate and VB12 levels
16. A 30-year-old man presents to the clinic with complaints of fatigue, frequent infections, and easy bruising over the past three months. He reports no significant past medical history and denies any recent travel or exposure to toxins. His physical examination is notable for pallor, petechiae on his lower extremities, and mild hepatosplenomegaly. Laboratory tests show the following:
Hemoglobin: 7.5 g/dL (normal: 13.8-17.2 g/dL)White blood cell count: 1,500/µL (normal: 4,500-11,000/µL)
Platelet count: 20,000/µL (normal: 150,000-450,000/µL)
Reticulocyte count: 0.2% (normal: 0.5-2.5%)
MCV: 85 fL (normal: 80-100 fL)
MCHC: 34 g/dL (32-36 g/dL)
A bone marrow biopsy reveals hypocellular marrow with a marked reduction in hematopoietic cells and an increase in fat spaces. There is no evidence of malignancy, fibrosis, or infiltration. What is the diagnosis?
B. Aplastic anemia
C. Hemolytic anemia
D. Iron deficiency anemia
E. Megaloblastic anemia
17. Use this case for the next four questions. A 7-year-old boy presents to the office with fatigue, frequent nosebleeds, and increased bruising over the past few months. His past medical history is significant for recurrent infections and short stature. Physical examination reveals pallor and petechiae involving his skin and mucosa. A few irregular light brown macules are seen on his back. Laboratory tests show the following:
White blood cell count: 2,300/µL (normal: 4,500-11,000/µL)
Platelet count: 55,000/µL (normal: 150,000-450,000/µL)
Reticulocyte count: 0.2% (normal: 0.5-2.5%)
MCV: 103 fL (normal: 80-100 fL)
Serum iron: 90 µg/dL (normal: 60-170 µg/dL)
Total iron-binding capacity (TIBC): 280 µg/dL (normal: 240-450 µg/dL)
Ferritin: 250 ng/mL (normal: 12-300 ng/mL)
What test should be done next?
B. Direct Coombs antiglobulin test
C. Hemoglobin electrophoresis
D. Parvovirus B19 test
E. Serum folate and VB12 levels
18. A 7-year-old boy presents to the office with fatigue, frequent nosebleeds, and increased bruising over the past few months. His past medical history is significant for recurrent infections and short stature. Physical examination reveals pallor and petechiae involving his skin and mucosa. A few irregular light brown macules are seen on his back. Laboratory tests show the following:
Hemoglobin: 7.5 g/dL (normal: 13.8-17.2 g/dL)White blood cell count: 2,300/µL (normal: 4,500-11,000/µL)
Platelet count: 55,000/µL (normal: 150,000-450,000/µL)
Reticulocyte count: 0.2% (normal: 0.5-2.5%)
MCV: 103 fL (normal: 80-100 fL)
Serum iron: 90 µg/dL (normal: 60-170 µg/dL)
Total iron-binding capacity (TIBC): 280 µg/dL (normal: 240-450 µg/dL)
Ferritin: 250 ng/mL (normal: 12-300 ng/mL)
Bone marrow biopsy demonstrates hypocellularity with a predominance of fat cells. Maturation is seen in all three lineages.
What test should be done next?
B. Flowcytometry for myeloblasts
C. Hemoglobin electrophoresis
D. Parvovirus B19 test
E. Serum folate and VB12 levels
19. A 7-year-old boy presents to the office with fatigue, frequent nosebleeds, and increased bruising over the past few months. His past medical history is significant for recurrent infections and short stature. Physical examination reveals pallor and petechiae involving his skin and mucosa. A few irregular light brown macules are seen on his back. Laboratory tests show the following:
Hemoglobin: 7.5 g/dL (normal: 13.8-17.2 g/dL)White blood cell count: 2,300/µL (normal: 4,500-11,000/µL)
Platelet count: 55,000/µL (normal: 150,000-450,000/µL)
Reticulocyte count: 0.2% (normal: 0.5-2.5%)
MCV: 103 fL (normal: 80-100 fL)
Serum iron: 90 µg/dL (normal: 60-170 µg/dL)
Total iron-binding capacity (TIBC): 280 µg/dL (normal: 240-450 µg/dL)
Ferritin: 250 ng/mL (normal: 12-300 ng/mL)
Bone marrow biopsy demonstrates hypocellularity with a
predominance of fat cells. Maturation is seen in all three lineages. Chromosomal
breakage tests on peripheral blood lymphocytes show increased chromosomal
fragility. What genetic mutation is most likely associated with this
patient's condition?
B. Hemoglobin b
C. PIGA
D. SPTA1
E. RPS19
20. A 7-year-old boy presents to the office with fatigue, frequent nosebleeds, and increased bruising over the past few months. His past medical history is significant for recurrent infections and short stature. Physical examination reveals pallor and petechiae involving his skin and mucosa. A few irregular light brown macules are seen on his back. Laboratory tests show the following:
Hemoglobin: 7.5 g/dL (normal: 13.8-17.2 g/dL)White blood cell count: 2,300/µL (normal: 4,500-11,000/µL)
Platelet count: 55,000/µL (normal: 150,000-450,000/µL)
Reticulocyte count: 0.2% (normal: 0.5-2.5%)
MCV: 103 fL (normal: 80-100 fL)
Serum iron: 90 µg/dL (normal: 60-170 µg/dL)
Total iron-binding capacity (TIBC): 280 µg/dL (normal: 240-450 µg/dL)
Ferritin: 250 ng/mL (normal: 12-300 ng/mL)
Bone marrow biopsy demonstrates hypocellularity with a predominance of fat cells. Maturation is seen in all three lineages. Chromosomal breakage tests on peripheral blood lymphocytes show increased chromosomal fragility. What is the diagnosis?
B. Fanconi anemia
C. Hemolytic anemia
D. Paroxysmal nocturnal hemoglobinuria
E. Pure red cell aplasia
21. Use this case for the next three questions. A 15-year-old girl presents to the clinic with progressive fatigue and weakness over the past two months. Her past medical history is unremarkable. She does not have recent infections or significant weight changes. Physical examination reveals pale skin and mucosa. No lymphadenopathy or hepatosplenomegaly are noted. Laboratory tests results are listed below:
White blood cell count: 5,800/µL (normal: 4,500-11,000/µL)
Platelet count: 230,000/µL (normal: 150,000-450,000/µL)
Reticulocyte count: 0.1% (normal: 0.5-2.5%)
Mean corpuscular volume (MCV): 89 fL (normal: 80-100 fL)
Peripheral blood smear reveals normal morphology for RBCs and WBCs. Her iron tests, folate and VB12 are within normal ranges.
What test should be done next?
B. Chromosomal breakage tests
C. Direct Coombs antiglobulin test
D. Hemoglobin electrophoresis
E. Peripheral blood flowcytometry for myeloblasts
22. A 15-year-old girl presents to the clinic with progressive fatigue and weakness over the past two months. Her past medical history is unremarkable. She does not have recent infections or significant weight changes. Physical examination reveals pale skin and mucosa. No lymphadenopathy or hepatosplenomegaly are noted. Laboratory tests results are listed below:
Hemoglobin: 6.8 g/dL (normal: 12-16 g/dL)White blood cell count: 5,800/µL (normal: 4,500-11,000/µL)
Platelet count: 230,000/µL (normal: 150,000-450,000/µL)
Reticulocyte count: 0.1% (normal: 0.5-2.5%)
Mean corpuscular volume (MCV): 89 fL (normal: 80-100 fL)
Peripheral blood smear reveals normal morphology for RBCs and WBCs.
Her iron tests, folate and VB12 are within normal ranges.
Bone marrow biopsy shows a marked decrease in erythroid precursors, with normal granulopoiesis and thrombopoiesis. What test should be done next?
B. Hepatitis B
C. Hepatitis C
D. HIV
E. Parvovirus B19
23. A 15-year-old girl presents to the clinic with progressive fatigue and weakness over the past two months. Her past medical history is unremarkable. She does not have recent infections or significant weight changes. Physical examination reveals pale skin and mucosa. No lymphadenopathy or hepatosplenomegaly are noted. Laboratory tests results are listed below:
Hemoglobin: 6.8 g/dL (normal: 12-16 g/dL)White blood cell count: 5,800/µL (normal: 4,500-11,000/µL)
Platelet count: 230,000/µL (normal: 150,000-450,000/µL)
Reticulocyte count: 0.1% (normal: 0.5-2.5%)
Mean corpuscular volume (MCV): 89 fL (normal: 80-100 fL)
Peripheral blood smear reveals normal morphology for RBCs and WBCs. Her iron tests, folate and VB12 are within normal ranges.
Bone marrow biopsy shows a marked decrease in erythroid precursors, with normal granulopoiesis and thrombopoiesis. Viral serologies for hepatitis B, hepatitis C, and HIV are negative. Parvovirus B19 IgM and IgG antibodies are positive. What is the most likely diagnosis?
B. Fanconi anemia
C. Iron deficiency anemia
D. Myelodysplastic syndrome
E. Pure red cell aplasia
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