HEME CLASS QUESTONS

1. Q: A 48 y/o alcoholic male presents to your primary care office c/o diarrhea that began 1 week ago. Patient admits to eating fast food 3 times day. During the exam you note yellow sclera and glossitis, lab findings show MCV>100. What are you suspecting to be the cause of his symptoms?

a) folate deficiency
b) B12 deficiency
c) hereditary spherocytosis
d) thalassemia
e) lipid deficiency

A

2. 67 yo homeless, white male patient was brought to ED by local EMTs. Pts stuporous, HR: 120, regular BP: 160/90 and RR: 10 non-labored. While inspecting the patient, you notice upper extremity peripheral jaundice, rosacea, finger clubbing and rhinophyma. On futher exam, JVD and LE edema is visible with palpable splenomegaly and hepatomegaly. As a part of your work up, you order a CBC with diff, which reveals normocytic, hypochromic red cells and a decreased reticulocyte count. Your CBC work up reveals the patient's likely cause of anemia.

ANSWER: alcoholic with anemia of chronic disease.

3. Pregnant 28 year old female brought into the ER by her husband because she was exhibiting neuro symptoms of stupor, bloody diarrhea, and abdominal pain. On further observation patient is in renal failure, has microangiopathic hemolytic anemia, and severe HTN. You ran labs on your patient and discovered she has low thrombocytes, low haptoglobin, high reticulocyte count, high LDH and creatinine, schistocytes on peripheral smear. What would you diagnose the patient with?

Answer: thrombotic thrombocytopenic purpura

4. 20 year old male presents to his pcp with a HB level of 17g. after 2 weeks later the patient follows up with his pcp with a HB level is 14g. upon running lab tests his reticulocyte count is increased, unconjugated bilirubin is increased, lactate dehydrogenase is increased, haptoglobin is decreased, and urine hemoglobin and urin hemosiderin are both present... the pcp does a coombs test and it comes back negetive. which of the following is a possible cause for this hemolytic anemia?
a) hypersplenism
b) drug induced
c) infectious
d) cold autoantibody IgM
e) A and C the answer is E

5. A 15 year old boy comes to the ER complain of fever, headaches, dizziness and fatigue. On completing your history you discover his parents are from a small town in Africa. When you observe the patient you notice jaundice of the sclera. You order labs and get back that elevated reticulocyte of 3%, Hematocrit is 25, MCV 95, WBC 15,000 and Howell- jolly bodies. What would you order next to diagnosis your patient?

A. Hemoglobin electrophoresis B. Duplex ultra sound C. WBC differential
d. Urine analysis

answer: A

6. 3 year old boy is brought to ER by mother for uncontrolled bleeding from his mouth for past 6 hours after a fall. Patient is alert and in no distress. On examination, you identify two small lacerations on inside of his lower lip, profusely bleeding. Rest of exam is negative with no petechia, bruising or joint swelling. Mother states child has a history of bleeding for long time after any cut or after receiving an immunization, but no known family history of bleeding disorder.

Coagulation study reveals:
Prolonged bleeding time
Prolonged aPTT
Decreased Factor VIII
Normal platelets
Low ristocetin cofactor

What is the next best step in management of this patient?

a. Give the child aspirin, weight based and send him home
b. Administer Factor VIII
c. Platelet infusion
d. Administer Desmopressin(DDAVP)
e. Fresh frozen plasma transfusion

(Answer: d)

7. 32 y.o. male construction worker with a C/C of numbness and tingling in the distal extremities, weakness, light-headedness, pallor, easy bruising, stomach upset with and MCV>100, which of the follow best fits the description?

A) Iron deficiency
B) B12 deficiency
C) Thalassemia
D) Sideroblastic Anemia
E) None of the Above

- answer- B12 def-

8. You are working in the ED when a pt comes in c/o of an uncontrollable nose bleed. The pt has a history of afib, for which the family states he takes some pill for. While waiting for the labs to come back, you are talking with the family and his wife tells you that lately he has been getting depressed and has stoppped his vegeterian diet. You suspect the cause of the bleeding is:
A. less Vit K in his diet, so less warfarin action
B. less Vit K in his diet , so more warfarin action
C. too much Vit K in his diet, so more warfarin action
D. too much vit K in his diet, so less warfarin action

Correct answer :B green leafy vegetables has Vit K which will decrease the action of warfarin. His primary care physician accounted for that and gave him a higher dose, now that he has stopped eating alot of vegatables his dose of warfarin is too high.-

9. Patient reports to your office with suspected inherited Von Willebrand's disease. Which of the following would you NOT find upon examination of this patient?

a) deficiency of VWF
b) deep bleeding of soft tissue
c) decreased clotting time
d) joint destruction and muscle atrophy

Answer: C
Because: if you have a deficieny of VWF....this increases the clotting time...its an inherited coagulation disorder.

10. Patient presents to the ER bleeding from the skin and mucous membranes with small to large ecchymoses. Your lab tests show increased PT, PPT, thrombotime, and bleeding time with thrombocytopenia, and elevated fibrin degrading products. Your D dimer comes back elevated. you suspect which disease?

A) Disseminated intravascular coagulation
B) hemophilia A
C) Von willebrand disease
D) sever liver disease

Answer is A ,

11. A 28 yo women presents to her primary care physician for her annual physical examination reporting that when she took her normal dose of two aspirin for her menstrual cramps she subsequently experienced a small amount of nose bleeding. She tells you she is concerned because she had been told that her family had "problems with bleeding." She was found to have prolonged bleeding time and a reduced level of VIII antigen. The most appropriate initial tests would include"
(A) plasma von Willebrand factor (vWF) concentration
(B) factor VIII:C level
(C) factor IX coagulant activity
(D) vitamin K level
(E) None of the above

Answer: (A) plasma von Willebrand factor (vWF) concentration.

12. Which of the following is NOT a cause of Folate deficiency?
a. alcoholism
b. pregnancy
c. hyperthyroidism
d. hyperglycemia
e. neoplasm Answer -- d. hyperglycemia

13. A 30 year old white male patient presents to the office complaining of heart palpitations with a sore throat. Patient states that he also feels fatigued. In taking the history, the patient states a significant past medical history of Fifth's Disease. Patient's occupation is a farmer with frequent exposure to insecticides. The patient's lab work is the following: MCV is 98, MCH is 29, WBC is 2,000, platelet count is 50,000, RBC is 3.5. Serum iron is 150 with increased ferritin. Based on this history and lab results, which of the following is the most likely diagnosis for this patient?

(a) Vitamin B 12 deficiency
(b) Sideroblastic Anemia
(c) Fanconi Anemia
(d) Acquired Aplastic Anemia
(e) None of the Above

Answer: (D) Acquired Aplastic Anemia

Why (D) the best choice:
(a) No: Vit B-12 Deficiency is Macrocytic, MCV > 110.
(b) No: Sideroblastic Anemia is microcytic, WBC and platelets are normal.
C and D: This is an Aplastic Anemia: Peak incidence is 30 years, more common in males, presents with heart palpitations, fatigue, and sore throat. Lab results including normocytic, normochromic anemia with pancytopenia, increased iron and ferritin. Which of these is the best choice?
(c) Possibly: Lab work is consistent with Aplastic Anemia. Not the best choice because this is Inherited Aplastic Anemia and it would have the clinical manifestations of growth retardation and skeletal abnormalities.
(d) This is the best choice. Lab work is consistent with Aplastic Anemia. Clinical manifestations are consistent. History of Fifth's Disease: Fifth's disease is most commonly caused by Parvovirus B19, which is an indication for acquired aplastic anemia along with exposure to chemicals including insecticide.

14. A 24y.o. pregnant(first trimester) Caucasian female who is previously healthy present into outpatient clinic with complains of weakness, dizziness and rapid heartbeat. During history taking patient revealed that she is also more irritable that usual and has trouble with concentration. Physical exam revealed pale fingernails and pale lips. CBC revealed a WBC of 7.2, HGb 10.3,HCT 30 and ferritin 10.What diagnosis is most likely causing pt. symptoms?
A. Pernicious anemia
B. Aplastic anemia
C. Iron deficiency anemia
D. Hemolytic anemia
E. Sickle cell anemia

Answer C-

15. New Patient presents to the office complaining of malaise and small reddish purple clusters on his skin and lips. In taking his history he stated that other than severe recurrent epistaxis he was otherwise relatively healthy. At his last office visit, his previous doctor told him he was anemic and that he should take an iron supplement with a follow up in 3 months. The presentation of these new spots and his recurrent nose bleeds brings him to your office. What would you suspect the diagnosis to be?

Answer- Osler Weber Rendu

16. which of the following are not associated with Howell jolly bodies?
A hemolytic anemia
B megaloblastic anemia
C iron deficiency anemia
D absence of a spleen
E all of the above are associated with Howell jolly body

Correct answer c- Sara

17. A young girl present to the office for a recent infection of tapeworms. She mentions in passing that she has recently become a vegetarian. Which of the following would you expect to see on the CBC?
A high mcv
B low mcv
C high rdw
D a and c
E b and c
Correct answer d:

18. 34 y.o. Caucasian male comes to the office complaining of weakness and numbness of his hands and feet for about a month now and his symptoms have been getting progressively worse. Prior to the exam, pt mentioned that hes been on a vegan diet for over 2 years. On the PE he has paresthesia of the UE and LE bilateral. What's the problem?

Ans: He has vitamin b12 deficiency.

19. > 27 yo male pt comes in to your office complaining of headache, n/v throbbing on his temporal region dizzyness and fatigue. pt states he just went with his friends and climbed mt. everest and had a little too much to drink and had a bad hangover the next morning. pt appears pale, irritable and weary has had some altered consciousness and altered coordination. pt is confused, disoriented and has impaired judgement. after diagnosing the pt. with mountain sickness what positive lab values would you see?
>
> a. inrease reticulocyte
> b. increase neutrophills
> c. basophillic stiplings
> d.. a and c
> e. all of the above

answer-Increase Reticulocytes-

21. 1. Which of the following is NOT a cause of Microcytic Anemia?
A. Thalassemia
B. Anaemia of chronic disease
C. Iron Deficiency Anemia
D. Pancytopaenia
E. Lead Poisoning

22. The Most Common cause of microcytic anemia is
A. B12 Deficiency
B. Iron Deficiency
C. Folate Deficiency
D. B6 Deficiency
E. Vitamin A Deficiency

23. A 65 year old male has signs of of Microcytic anemia on his CBC. What could be causing the abnormal lab results?
A. Kidney Failure
B. Hepatitis
C. Bleeding GI Malignancy
D. Hyperthyroidism

24. Which of the following laboratory results indicate the presence of a microcytic anemia?
a) Hemoglobin result of 13 g/dL; MCV value of 92 fL
b) Hemoglobin result of 9 g/dL; MCV value of 88 fL
c) Hemoglobin result of 10 g/dL; MCV value of 108 fL
d) Hemoglobin result of 8 g/dL; MCV value of 75 fL

25. A patient is found with a microcytic anemia. Further laboratory findings include a serum iron value of 26 mcg/dl (50 to 175 mcg/dl), a total iron binding capacity of 376 mcg/dl (250 to 370 mcg/dl), a lactic dehydrogenas of 143 U/L (100 to 190 U/L) and a creatinine level of 0.8 mg/dl (0.1 to 1.5 mg/dl). Which of the following is the best recommendation for therapy? 1. Ascorbic acid 250 mg PO daily 2. Ferrous sulfate 325 mg PO TID 3. Glucophage 500 mg PO BID 4. Sodium Ferric gluconate1.5 GM IM Monthly 5. Vitamin B12 100 mcg PO daily

26. A 59-year-old female patient with no complaints is undergoing routine physical examination in your family practice office and has a hypochromic, microcytic anemia that was not present on her physical examination last year. Which of the following is the most important cause to rule out in this patient?
A. acute pathology secondary to aplastic anemia
B. chronic anemia secondary to colon cancer
C. falconi’ anemia
D. Iron deficiency anemia
E. Medication induced anemia

Answers 21.D 22.B 23.C 24.D 25. B 26. B
21-26

27. 23 y/o female presents to ER 4 hours after MVA complaining of profuse bleeding from an injury on her knee. Pt states she went home after MVA because she felt fine and had "only scraped her knee upon hitting the dashboard." States bleeding began 30 min ago and does not stop. She states a few years ago her and her mother were involved in a MVA and they both had to be hospitalized a few hours later for profuse bleeding. You order STAT labs. Upon receiving the results, which of the following lab results would you most likely find?
A. PTT 30, Bleeding time 9 min, high VWF, Factor VII deficiency
B. PTT 32, Bleeding time 7 min, high VWF, Factor I deficiency
C. PTT 39, Bleeding time 10 min, low VWF, Factor VIII deficiency
D. PTT 37, Bleeding time 6 min, low VWF, Factor I deficiency

Answer is C-

28. 16. a 30 year old man presents to the office with a chief complaint of an acute infection on his lower leg. He was diagnosed at an early age with a CT disorder known as Marfans syndrome, that gave his appearance to have extremely tall with long bones, and thin spider like fingers and toes. These clinical manifestations can be presented with which of the following:

1. Antiphospholipid Antibody Syndrome 2. Inherited thrombophilia 3. Factor V leiden 4. Protein C defiency 5. B and C

ANSWER A-