Hematology

One of the earliest laboratory markers in iron deficiency anemia is: A. An increase in RBC distribution width (RDW) B. A reduced hemoglobin C. A low MCH D. An increased platelet count

A - RDW reflects the degree of variant in RBC size. RDW measurement is elevated when RBCs are of varying sizes implying that cells were synthesized under varying conditions. In iron deficiency anemia normal sized cells produced before iron depletion continue to circulate for 90 to 100 days meanwhile the microcytic, hypochromic containing less hemoglobin are being produced. The RDW reflects the large variation in cell size (over 15%)

In anemia of chronic illness you would expect to see: A. Low TICB and High serum ferretin B. High TICB and low serum ferretin C. Low TICB and low serum ferretin D. High TICB and high serum ferretin

A- total binding capacity would be low and serum ferretin which is the storage of iron would be high.

In iron deficiency anemia you would expect to see: A. High TIBC and low serum ferretin B. Low TICB and high serum ferretin C. Low TICB and low serum ferretin D. High TICB and high serum ferretin

A. High TIBC and low serum ferretin

A 68 year old man is usually healthy, but presents with new onset of huffing and puffing with exercise. Physical exam reveals conjunctiva pallor and a hemic murmur. Hgb 7.6 g; MCV is 71 fl. The most likely clinical problem is: A. Poor nutrition B. Occult blood loss C. malabsorption D. microcytosis

B - A common cause of iron deficiency anemia is GI bleed. This man has a low Hgb (normal is 12-14 g) and we know from his MCV his anemia is microcytic.

Which of the following illnesses is unlikely to result in anemia of chronic disease? A. Rheumatoid arthritis B. Peripheral vascular disease C. Chronic renal insufficiency D. Chronic osteomyelitis

B - Anemia of chronic diseases such as cancer, HIV/AIDS, acute and chronic inflammatory conditions (rheumatoid arthritis, Crohn's disease, osteomyelitis), hypothyroidism, and renal failure are among the most common causes of anemia of chronic illness.

In the first week of pernicious anemia therapy with parenteral B12 in a 68 year old woman the patient should be carefully monitored for: A. hypernatremia B. dehydration C. hypokalemia D. acidemia

C - Hypokalemia caused by serum to intracellular potassium shifts is common if the anemia was particularly severe and is most likely seen with the peak of reticulocytosis. Monitoring serum potassium levels daily during the first week of therapy is important especially in patients receiving diuretic therapy, at other risks for hypokalemia, or taking digoxin.

Pernicious anemia causes which of the following changes in RBC indices? A. Microcytic, normochromic B. Normocytic, normochromic C. Microcytic, hypochromic D. Macrocytic, normochromic

D - Both Vit B12 and folate are macrocytic, normochromic anemias. They are both megablastic anemias.

Folate deficiency anemia causes which of the following changes in the RBC indices? A. Microcytic, normochromic B. Normocytic, normochromic C. Microcytic, hypochromic D. Macrocytic, Normochromic

D - Both Vit B12 and folate deficiency are macrocytic, normochromic anemias. Folate deficiency is related to diet where as Vit. B12 is intrinsic.

Worldwide which of the following is the most common type of anemia? A. Pernicious anemia B. Folate deficiency anemia C. Anemia of chronic disease D. Iron deficiency anemia

D - Iron deficiency anemia is the most common worldwide anemia. The only exception is in the elderly population where anemia of chronic illness is the most common.

You examine a 27 year old woman with menorrhagia and note the following hemogram results: Hgb: 10.1 g; HCT 33%; MCV 72 Fl. On your physical exam you may see: A. Conjunctiva pallor B. Hemic murmur C. Tachycardia D. No specific anemia related findings

D- Although this patient is suffering from iron deficiency anemia there are often few symptoms present with a hematocrit above 30%. As the Hct falls you may see pica, dyspnea and mild fatigue with exercise, headache, palpitations, weakness, tachycardia, postural hypotension, and pallor.

When prescribing erythropoietin supplementation, the NP considers that: A. The adrenal glands are its endogenous source B. The addition of iron and other micronutrient supplementation is advisable C. Its use is an adjunct in treating thrombocytopenia D. With its use, the RBC life span is prolonged

B - Anemia of chronic illness is caused by reduced erythropoetin response in the marrow resultng in RBC hypoproliferation. Recombinant human erythropoietin is used in the treatment of anemias associated with end stage renal disease, HIV, and cancer chemotherapy and other forms of anemia of chronic illness. The drug can be administered parenterally three times per week with an expected increase in Hct of 4% over two weeks. Iron therapy is also needed unless iron overload is present.

A 40 year old woman with polynephritis who is taking ciprofloxacin and is being treated for iron deficiency anemia with ferrous sulfate asks about taking both medications. You respond: A. She should take the medications with a large glass of water B. An inactive drug compound is potentially formed when the two drugs are taken together C. She can take the medications together to enhance adherence to therapy D. The ferrous sulfate potentially slows gatrointestinal motility and results in enhanced ciprofloxacin absorption.

B - Fluoroquinolones used with iron can decrease the effect of the fluoroquinolone. ACE inhibitors and methyldopa will have decreased effect when taking iron as well. Thyroid hormones can be decreased with the utilization of iron. Levodopa, tetracylcines including doxycyline, and histamine 2 receptor antagonists decrease iron absorption. Levodopa and tetracycline will also be decreased in effect when taking iron. Taking iron with juice that has vitamin C increases absorption rates.

Which of the following is the most consistent with iron deficiency anemia? A. Low mean corpuscular volume (MCV) and normal mean corpuscular hemoglobin (MCH) B. Low MCV and Low MCH C. Low MCV and elevated MCH D. Normal MCV and normal MCH

B - Iron deficiency anemia is a microcytic (MCV) - meaning the average size of erythrocytes is small <80; and hypochromic (MCH) meaning the the portion of each RBC occupied by Hgb is <32%.

You examine a 57 year old woman with rheumatoid arthritis and find the following on her hemogram: Hgb: 10.5 g; HCT 33%; and MCV of 88 fl. These laboratory findings are most consistent with: A. Pernicious anemia B. Anemia of chronic disease C. Beta thalassemia minor D. Folate deficiency anemia

B - MCV of 88 is normocytic (80-100 fl). Anemia of chronic illness is the only anemia that is normocytic.

Most of the body's iron is obtained from: A. Animal based food sources B. Recycled iron content from aged red blood cells C. Endoplasmic reticulum production D. Vegetable food sources

B - Recycled iron content from aged red blood cells

One month into therapy of pernicious anemia you wish to check the efficacy of the intervention. The best laboratory test to order at this point is a: A. Schilling test B. Hemoglobin measurement C. Reticulocyte count D. Serum ferritin

B - Vit. B12 deficiency is an intrinsic issue. Vitamin B12 plays an essential role in RBC DNA synthesis. The hematologic response is generally rapid and reticulocytosis peaks at about 5 to 7 days after therapy has begun and will take about 2 months to reach full recovery. The schilling test is used to determine if the body absorbs Vit. B12 correctly. Ferritin represents the stores of iron in the body.

Pernicious anemia is usually caused by: A. Dietary deficiency of vitamin B12 B. Lack of production of intrinsic factor by the gastric mucosa C. RBC enzyme deficiency D. A combination of micronutrient deficiency caused by malabsorption.

B - Vitamin B12 a member of the cobalmin family is found in abundance in foods of animal origin and is essential for the development of RBC's. When Vitamin B12 is ingested orally it binds with intrinsic factor, a glycoprotein produced by the gastric parietal cells, and is transported systematically, within the portal blood flow, the vitamin is attached to transcobalmin II, a polypeptide synthesized in the liver and ileum. Intrinsic factor is not absorbed and the new compound is transported to the bone marrow and other sites where it is available for use in RBC formation.

Common physical exam findings in a patient with pernicious anemia include: A. Hypoactive bowel sounds B. Stocking glove neuropathy C. Thin, spoon shaped nails D. Retinal hemorrhages

B - Vitamin B12 deficiency is associated with neurological dysfunction. Neurological changes if present for less than six months reverse quickly. Neurologic reversal is likely impossible however, if these changes have been present for a protracted period.

Folate deficiency anemia causes which of the following changes in the RBC indices? A. Menorrhagia B. Chronic ingestion of overcooked foods C. Use of nonsteroidal anti-inflammatory drugs D. Gastric atrophy

B. Chronic ingestion of overcooked food. Folic acid is a water soluble B complex vitamin found in abundance in peanuts, fruits, and vegetables.

A healthy 34 year old man asks whether he should take an iron supplement. You respond that: A. This is a prudent measure to ensure health B. Iron deficiency anemia is a common problem for a man of his age C. Use of an iron supplement in the absence of a documented deficiency can lead to iatrogenic iron overload. D. Excess iron is easily excreted

C - Iron use without distinct clinical indication including the use of iron fortified multivitamins is not recommended because this can lead to an iatrogenic iron overload. Antacids and Caffeine can both decrease iron absorption.

A woman is planning a pregnancy should increase her intake of which of the following to minimize the risk of neural tube defect in the fetus: A. Iron B. Niacin C. Folic Acid D. Vitamin C

C - Maternal folic acid deficiency is a teratogenic state, particularly during neural tube formation. To reduce the rate of neural tube defects in the fetus a woman planning a pregnancy should be advised to take additional amounts of folic acid, 0.4mg/day for 3 months before conception and continued at least through the first 12 weeks of pregnancy.

In health the ratio of hemoglobin to hematocrit is: A. 1:1 B. 1:2 C. 1:3 D. 1:4

C - Normally the Hgb to Hct ratio is 1:3, so that in health, 1 g of hemoglobin is equivalent to 3% points of hematocrit. The hematocrit value reflects the percentage of RBCs in a given volume of blood; the value influences the body's hydration status. Hct will be elevated in dehydration and low in overhydration.

A 48 year old woman developed iron deficiency anemia after excessive perimenopausal bleeding, successfully treated with endometrial ablation. Her Hematocrit level is 25% and she is taking iron therapy. At 5 days into therapy you expect to find: A. A correction in mean cell volume B. A 10% increase in hematocrit C. Brisk reticulocytosis D. A normal ferritin level.

C - The body's normal response to anemia is to increase reticulocyte formation production to increase the hemoglobin level. An increased reticulocyte count known as reticulocytosis is an expected normal response to a decrease in hemoglobin. If reticulocytosis is absent you should suspect impaired bone marrow function or lack of erythropoietin stimulus.

Which of the following is the best advise on taking ferrous sulfate to enhance iron absorption: A. Take with other medication B. Take on a full stomach C. Take on an empty stomach D. Do not take with vitamin C

C- Food can decrease the absorption of iron by up to 50% however many people find it very rough on the stomach and may experience nausea with the absence of food. For these people they may need to obtain extra iron from food sources.

Results of hemogram in anemia of chronic disease include: A. Microcytosis B. anisocytosis C. Reticulocytopenia D. Macrocytosis

C- Reticulocytopenia or aplastic crisis defines an abnormal decrease in the immature red blood cells known as reticulocytes in the body. This is sometimes seen in sickle cell anemia where 2 anemia induced mechanisms are induced: decrease RBC production and hemolysis. This results in aplastic crisis which may require a blood transfusion. Anisoctosis: means RBCs of different size