تصفح
دخول
تسجيل
نسيتها؟

Anemia Quiz


Anemia Quiz

Enjoy

(والمؤمنون والمؤمنات بعضهم أولياء بعض يأمرون بالمعروف وينهون عن المنكر ويقيمون الصلاة ويؤتون الزكاة ويطيعون الله و رسوله أولئك سيرحمهم الله إن الله عزيز حكيم)

Al Durra's picture
by
بعد التخرج


1) You are reviewing blood work on patients cared for by a vacationing physician, and note a complete blood count showing a hematocrit of 32% with an MCV 76 fl. The WBC and platelet counts are normal, and the reticulocyte count is 1.2%. Iron studies reveal a serum iron of 100 mcg/dL (normal 40-80), TIBC 200 mg/dL (normal 250-450), and transferrin saturation of 78% (normal 20-55). Her ferritin is 598 ng/mL (normal 10-300). Which ONE of the following diagnoses is the most likely?
a). Anemia of chronic disease
b). Iron deficiency anemia
c). Hypothyroidism
d). Sideroblastic anemia

2) A 42-year-old woman with no significant past medical history presents to your office for a physical. She has not seen a physician in over 10 years. Her only complaint is fatigue. Her family history is notable for colon cancer in her mother. Her review of systems is negative for menorrhagia but she continues to have her normal monthly periods that are not heavy. Findings on examination are unremarkable. Lab values are as follows:
Hemoglobin 11.8 g/dL
Hematocrit 34.3%
RBC count 5.9 million/mm3
MCV 70 fL
RDW 12.5%
Platelets 188 K/mm3
Serum iron 100 µg/dL (normal 40-80 µg/dL)
TIBC 275 mg/dL (normal 250-450)
Saturation 40% (normal 20-55%)
Ferritin 200 ng/mL (normal 10-300 ng/mL)

Which of the following tests is most likely to aid in the diagnosis of this patient’s anemia?

a). Serum soluble transferrin receptor level

b). Prescribe iron tablets for 6 weeks and repeat the blood count

c). Colonoscopy

d). Upper endoscopy

e). Hemoglobin electrophoresis

3) A 25-year-old man with no significant past medical history presents to your office complaining of fatigue and lassitude. He denies significant alcohol or drug use. His review of systems is otherwise negative. His laboratory studies reveal the following:
WBC 2900
RBC 3.2 million
Hemoglobin 10 g/dL
Hematocrit 29%
MCV 92fl
Platelets 79,000
Reticulocyte count 32,000
BUN 20mg/dL
Creatinine 1.2mg/dl

The most likely diagnosis is:

a). Folic acid deficiency

b). Aplastic anemia

c). Autoimmune hemolytic anemia

d). Glucose 6-phosphate dehydrogenase deficiency

4) A 68-year-old woman presents with vague abdominal pain and bloating. She is found to have a hematocrit of 31%. Her MCV is 92 fl. Her RDW is high at 17%. Her WBC and platelet count are normal. Her creatinine is 1.1 mg/dL. Iron studies are done which reveal a low iron, high TIBC, and low saturation. Her ferritin is 9 ng/ml (normal 10-300). Her peripheral smear reveals significant anisocytosis with microcytes and macrocytes. Which of the following tests is most likely to reveal the etiology of this patient's anemia.

a). Soluble serum tranferrin receptor level

b). Tissue transglutaminase and anti-endomysial antibodies

c). Serum protein electrophoresis

d). Bone marrow biopsy
5) A 66-year-old man with a history of diabetes presents to your office complaining of fatigue and left foot pain over the past four weeks. He reports that he has been taking his glyburide regularly. He drinks about two beers per night. His review of systems is positive for occasional night sweats. On physical examination his temperature is 38.0° C and his pulse is 96 bpm. Examination of his left foot reveals a 3-cm diameter ulcer on the dorsal surface of the first metatarsal with some surrounding erythema. Rectal examination reveals heme-positive stool. An x-ray of the left foot reveals mild periosteal elevation of the first metatarsal. Laboratory studies are as follows:
WBC 12,200/L, with 85% neutrophils and 15% lymphocytes
Hgb 11 g/dL
Hct 33%
MCV 79 fl
RDW 14%
Platelets 500,000/L
BUN 20 mg/dL
Creatinine 1.2 mg/dL
Serum iron 25 mg/dL (normal: 50–170 mg/dL)
TIBC 180 mg/dL (normal: 250–450 mg/dL)
Saturation 12% (normal: 20%–50%)
Ferritin 200 ng/mL (normal 10–300 ng/mL).

Which of teh following is the most appropriate treatment for this patient's anemia.
a). Oral iron after performing a colonoscopy
b). Parenteral iron after performing a colonoscopy
c). Ciprofloxacin and metronidazole
d). Erythropoietin 20,000 units SC per week
e). Blood transfusion

6) A 36-year-old man presents with fatigue and pallor. He is found to have a hematocrit of 23%. His corrected reticulocyte count is 6. You suspect a hemolytic anemia. Which of the following lab abnormalities are notassociated with hemolytic anemia?
a). An elevated haptoglobin level
b). An elevated LDH
c). An elevated indirect bilirubin
d). An elevated reticulocyte count
e). The presence of hemosiderin in the urine
7) A 26-year-old man presents with fatigue and a hematocrit of 24%. Her corrected reticulocyte count is 5.2%. Her peripheral smear reveals numerous spherocytes. What test should be ordered next?
a). Urine hemosiderin
b). Direct antiglobulin (Coombs'’) test
c). Indirect antiglobulin (Coombs'’) test
d). Haptoglobin
-END-

Al Durra's picture
Al Durra
بعد التخرج


1) You are reviewing blood work on patients cared for by a vacationing physician, and note a complete blood count showing a hematocrit of 32% with an MCV 76 fl. The WBC and platelet counts are normal, and the reticulocyte count is 1.2%. Iron studies reveal a serum iron of 100 mcg/dL (normal 40-80), TIBC 200 mg/dL (normal 250-450), and transferrin saturation of 78% (normal 20-55). Her ferritin is 598 ng/mL (normal 10-300). Which ONE of the following diagnoses is the most likely?
a). Anemia of chronic disease
b). Iron deficiency anemia
c). Hypothyroidism
d). Sideroblastic anemia

2) A 42-year-old woman with no significant past medical history presents to your office for a physical. She has not seen a physician in over 10 years. Her only complaint is fatigue. Her family history is notable for colon cancer in her mother. Her review of systems is negative for menorrhagia but she continues to have her normal monthly periods that are not heavy. Findings on examination are unremarkable. Lab values are as follows:
Hemoglobin 11.8 g/dL
Hematocrit 34.3%
RBC count 5.9 million/mm3
MCV 70 fL
RDW 12.5%
Platelets 188 K/mm3
Serum iron 100 µg/dL (normal 40-80 µg/dL)
TIBC 275 mg/dL (normal 250-450)
Saturation 40% (normal 20-55%)
Ferritin 200 ng/mL (normal 10-300 ng/mL)

Which of the following tests is most likely to aid in the diagnosis of this patient’s anemia?

a). Serum soluble transferrin receptor level

b). Prescribe iron tablets for 6 weeks and repeat the blood count

c). Colonoscopy

d). Upper endoscopy

e). Hemoglobin electrophoresis

3) A 25-year-old man with no significant past medical history presents to your office complaining of fatigue and lassitude. He denies significant alcohol or drug use. His review of systems is otherwise negative. His laboratory studies reveal the following:
WBC 2900
RBC 3.2 million
Hemoglobin 10 g/dL
Hematocrit 29%
MCV 92fl
Platelets 79,000
Reticulocyte count 32,000
BUN 20mg/dL
Creatinine 1.2mg/dl

The most likely diagnosis is:

a). Folic acid deficiency

b). Aplastic anemia

c). Autoimmune hemolytic anemia

d). Glucose 6-phosphate dehydrogenase deficiency

4) A 68-year-old woman presents with vague abdominal pain and bloating. She is found to have a hematocrit of 31%. Her MCV is 92 fl. Her RDW is high at 17%. Her WBC and platelet count are normal. Her creatinine is 1.1 mg/dL. Iron studies are done which reveal a low iron, high TIBC, and low saturation. Her ferritin is 9 ng/ml (normal 10-300). Her peripheral smear reveals significant anisocytosis with microcytes and macrocytes. Which of the following tests is most likely to reveal the etiology of this patient's anemia.

a). Soluble serum tranferrin receptor level

b). Tissue transglutaminase and anti-endomysial antibodies

c). Serum protein electrophoresis

d). Bone marrow biopsy
5) A 66-year-old man with a history of diabetes presents to your office complaining of fatigue and left foot pain over the past four weeks. He reports that he has been taking his glyburide regularly. He drinks about two beers per night. His review of systems is positive for occasional night sweats. On physical examination his temperature is 38.0° C and his pulse is 96 bpm. Examination of his left foot reveals a 3-cm diameter ulcer on the dorsal surface of the first metatarsal with some surrounding erythema. Rectal examination reveals heme-positive stool. An x-ray of the left foot reveals mild periosteal elevation of the first metatarsal. Laboratory studies are as follows:
WBC 12,200/L, with 85% neutrophils and 15% lymphocytes
Hgb 11 g/dL
Hct 33%
MCV 79 fl
RDW 14%
Platelets 500,000/L
BUN 20 mg/dL
Creatinine 1.2 mg/dL
Serum iron 25 mg/dL (normal: 50–170 mg/dL)
TIBC 180 mg/dL (normal: 250–450 mg/dL)
Saturation 12% (normal: 20%–50%)
Ferritin 200 ng/mL (normal 10–300 ng/mL).

Which of teh following is the most appropriate treatment for this patient's anemia.
a). Oral iron after performing a colonoscopy
b). Parenteral iron after performing a colonoscopy
c). Ciprofloxacin and metronidazole
d). Erythropoietin 20,000 units SC per week
e). Blood transfusion

6) A 36-year-old man presents with fatigue and pallor. He is found to have a hematocrit of 23%. His corrected reticulocyte count is 6. You suspect a hemolytic anemia. Which of the following lab abnormalities are notassociated with hemolytic anemia?
a). An elevated haptoglobin level
b). An elevated LDH
c). An elevated indirect bilirubin
d). An elevated reticulocyte count
e). The presence of hemosiderin in the urine
7) A 26-year-old man presents with fatigue and a hematocrit of 24%. Her corrected reticulocyte count is 5.2%. Her peripheral smear reveals numerous spherocytes. What test should be ordered next?
a). Urine hemosiderin
b). Direct antiglobulin (Coombs'’) test
c). Indirect antiglobulin (Coombs'’) test
d). Haptoglobin

Green Wave's picture
Green Wave


Green, 4/7

Al Durra's picture
Al Durra
بعد التخرج


1 d
c 2
b 3
c 4
c 5
b 6
b 7

lonely
طبيب مقيم

lonely, back again to 4/7
did u read q6 carefully?
Al Durra's picture
Al Durra
بعد التخرج


1- d
c-2
b-3
b-4
c-5
a-6
-7? im very eager to know

Tariq1987's picture
Tariq1987
بعد التخرج


tariq 5/7

Al Durra's picture
Al Durra
بعد التخرج

hmmm,interesting cases; I'll try Surprised :

1-d

2-c

3-b

4-c

5-c

6-a

7-b
According to the history; I think this pt has either an autoimmune hemolytic anemia or hereditary spherocytosis..So, if we order DAT this test will be helpful to distinguish between them..
A positive result indicates an immune cause of the hemolysis --->AHA

prettyflower's picture
prettyflower
بعد التخرج


pretty 5/7

Al Durra's picture
Al Durra
بعد التخرج

Quote:
did u read q6 carefully

فعلا ما انتبهت إنه notassociated
و احترت لأنه أربع احتمالات صح
باهالحالة
a 6

lonely
طبيب مقيم


Answers:
d
e
b
b
c
a
b

Discussion for Question 1
This patient has a hypoproliferative anemia (as shown by the low reticulocyte count) and microcytosis. Her iron studies show high levels of iron in the serum and in storage (i.e. ferritin was elevated). This is most consistent with a sideroblastic anemia that causes impaired heme production and utilization and causes a feedback enhancement of iron absorption from the GI tract. The iron level, saturation, and ferritin would be low in iron deficiency anemia. In anemia of chronic disease the ferritin may be elevated but the serum iron and transferrin saturation are typically low. Hypothyroidism usually causes a macrocytic or normocytic anemia.

Discussion for Question 2
This patient has typical findings for thalassemia trait. She has a mild microcytic anemia with significant microcytosis (very low MCV) but a normal RDW and high-normal red blood cell count. Her iron studies are normal. Hemoglobin electrophoresis can be helpful by revealing elevated levels of Hgb A2 and Hgb F in beta-thalassemia. The electrophoresis will, however, usually be normal in alpha-thalassemia. Serum transferrin receptor level assays can be helpful to distinguish iron deficiency anemia with inflammation from pure anemia of chronic disease. A high transferrin receptor level is usually seen patients with iron deficiency anemia (with or without inflammation). The level should be normal in patients with anemia of chronic disease. In this patient the indices are not suggestive of either iron deficiency or anemia of chronic disease. Because iron deficiency is not evident in this case, endoscopy would not be indicated. A trial of iron pills would, likewise, not be indicated.

Discussion for Question 3
This gentleman has a hypoproliferative normocytic anemia. His reticulocyte percentage is 1% (retic count ÷ RBC count). Corrected for the degree of anemia it is even lower. The differential diagnosis of hypoproliferative normocytic anemia is:
Anemia of chronic disease
Aplastic anemia
RBC aplasia
Thyroid disease (may be macrocytic)
Myelofibrosis or myelophthisic process
Multiple myeloma
Autoimmune hemolytic anemia and G6PD deficiency are hemolytic processes that would result in an elevation of the reticulocyte count. The patient also has thrombocytopenia and leukopenia, suggesting a bone marrow process. Only aplastic anemia fits this picture. Folate deficiency can cause a deficiency of production of all 3 cell lines in the bone marrow but it typically causes a macrocytic anemia.

Discussion for Question 4
This patient has a normocytic anemia with an elevated RDW, suggestive of 2 populations of cells. Iron deficiency is present, but another cause of anemia is also likely to be present (such as vitamin B12 deficiency), to account for the population of macrocytes also present. Celiac disease should be considered in this patient with normocytic indices and can be investigated by checking tissue transglutaminase and anti-endomysial antibodies.

Discussion for Question 5
This patient has evidence of anemia of chronic disease (ACD) caused by osteomyelitis. The iron, TIBC, and saturation are low, but the ferritin is normal. The most effective treatment is aimed at the underlying disorder. In this case, antibiotic therapy would be the treatment of choice. A and B are incorrect because ferritin levels above 100 ng/mL are rarely seen in iron deficiency anemia even with associated inflammation. Iron therapy is not appropriate for treatment of ACD because it is not an iron-deficient state. E is incorrect because there is no evidence of hemodynamic compromise. Transfusion is rarely indicated in cases of ACD. D is incorrect as well; although erythropoietin has been shown to increase the Hgb and quality of life in anemic patients with cancer and rheumatoid arthritis, it is certainly not indicated in patients with infections who would improve more readily with antibiotic therapy. Additionally, a hematocrit of 33% would not be an indication for transfusion or erythrocyte stimulating agents.

Discussion for Question 6
Patients with hemolytic anemia typically present with an elevated reticulocyte count, LDH, and indirect bilirubin. Hemosiderin may be present in patients with intravascular hemolysis. Haptoglobin is a protein that binds free hemoglobin for uptake by the reticuloendothelial system. During hemolyis the amount of free hemoglobin rapidly exceeds the production of haptoglobin, so levels are typically low.

Discussion for Question 7
The direct antiglobulin test (Coombs' test) is a test that measures whether there is antibody coating the patient's red blood cells. The test is done by mixing the patient's erythrocytes with anti-human globulin (which contains antibody to IgG and C3). In patients with immune hemolytic anemia, spherocytes will usually be seen on peripheral smear. A positive direct antiglobulin test (DAT) would then confirm the immune mediated hemolysis. If the DAT were negative, hereditary spherocytosis should be considered.

في نهاية المجموعة العاشرة أرجو أن تكون سلسلة الحالات السريرية مفيدة و أضافت شيئاً إلى حصيلة المعلومات لديكم.
أشكر جميع من شاركوا و أتمنى إعطائي feedback أو اقتراحات لتحسين مستوى المشاركات المستقبلية-إن شاء الله-.

Al Durra's picture
Al Durra
بعد التخرج


There is a problem with question 5.
Whenever there is heme positive stools espicially in age > 50 it is a must to do colonoscopy. You have to know also that with infection (anemia of chronic disease) ferritin can be an acute phase reactant and fasley elevated. So in this case we have not rule out FE defeciency (particularly with low Fe saturation which is still a sign of FE deficiency) and we may be ignoring colon cancer.
I would be interested how the person who put this question would respond to my comment?

ABIM's picture
ABIM

Quote:
أتمنى إعطائي feedback أو اقتراحات لتحسين مستوى المشاركات المستقبلية-إن شاء الله-
Al Durra's picture
Al Durra
بعد التخرج


الله يعطيك العافية ويجزيك الخير .

They were very interesting cases w precious infos inside.

We are in ,if u have time to put more cases.BTW,it's very unusual that Hakeem members participated in that numbers of times in ur previous threads.Lucky u ,rather lucky us .
I have a little point that I want to put the light on ,it's that I really appreciate if u can discuss some ideas that might sometimes look vague or ambiguous .I mean ,may be we can push those threads a little bit further in a way that they will be more discussion-based rather "pick the right answer and go"-based .
For ex,in the previous threads ,I had may be ,one or two questions that I asked regarding the cases and were not answered or even responded to .

That was my feedback.

Thanks Again .
Very Happy

mbs2380's picture
mbs2380
بعد التخرج

Thank you Bassam for the nice words. Your feedback is appreciated. You are right in regard to the lack of discussion about what appeared to be vague or unclear info during the previous quizzes. One reason is that I really did not have answers to what appeared to be a conflict between two different resources we relied on, one of them is obviously the cases bank I made my quizzes from, especially as you may noticed that the discussions usually do not mention the reference which I think is a weak point. For example, ABIM was not satisfied with a couple of answers for which he provided us with website links that carry a different explanation to what was written in my cases bank. Another reason is that you can not be that fast in providing quizzes that cover multiple common topics in such a short time if you will be discussing every detail, especially that I may not have time later to continue what I started on. So I wanted to provide you with many cases as much as I can before I got busy again.

Thank you again and look forward to reading more feedbacks.

Al Durra's picture
Al Durra
بعد التخرج


شكراً كتير والله يعطيك العافية
حالات كتير حلوة وممتعة اضافت كتير لمعلوماتنا وحتى كان فيا نوع من التشويق ...
وهون بدي اعتزر على شغلة .. بتزكر مرة قلت اني مو مهتم ازا اجوبتي صح (بالكويز الأول) Embarrased بس لما طلع عندي اغلب الاجوبة خطأ تشوقت وتحمست لأعرف الاجابات الصحيحة
كانت هالحالات اضافة مهمة كانت ناقصتنا بحكيم بتمنى او تستمر بشكل دائم Very Happy لأنو اكيد رح تضيف شي للطلاب
بالنسبة للفيدباك .. ماعندي شي غير قول انو لو نناقش الأسئلة الصعبة بشكل مناقشة بدل من اجابة سريعة أو متل ما طلبت حضرتك من الشخص اللي حل الاسئلة كلها صح بالكويز الاول .. طلبت يومها منو شرح سريع عن كل حالة .. بصراحة كان كتير مفيد واضاف شي جديد كمان ممكن ماكان خاطرلنا.
وبدي اعتزر اني عم اكتب بالعربي .. بصراحة هيك اسرعلي Rolling Eyes
شكراً جزيلاً مرة تانية Very Happy

Tariq1987's picture
Tariq1987
بعد التخرج


العفو طارق, ما عملنا إلا واجبنا. بالنسبة لعرض الحالات السريرية في عدة طرق; الطريقة الشائعة على حكيم و هي عرض حالة سريرية مفصلة و من ثم اجراء نقاش موسع حولها. هذه الطريقة تحتاج انسان متفرغ لإدارة النقاش و الاجابة على الاسئلة و هذا للأسف ما افتقده شخصياً في الوقت الحالي. الطريقة الاخرى الأقل شيوعاً و التي لجأت لها هي عرض عدة حالات مختصرة و سريعة على شكل مسايقة يتنافس فيها المشاركون لتجميع اكبر عدد ممكن من النقاط. هذه الطريقة من سلبياتها كما ذكرت عدم النقاش الموسع في كل حالة على حدة و لكنها تحمل ايجابية ايصال عد كبير من المعلومات و الافكار بوقت قصير نسبيا كما أنه يحمل نوع من الإثارة من خلال خلق الجو التنافسي.

انا كنت اتمنى بصراحة الطلب من كل من حل جميع الاسئلة القيام بشرح عنها و لكن ربما قلة عدد المشاركين و معرفتي بانشغالهم هو ما منعني من الإثقال عليهم بمزيد من الطلبات. يعني بيكفي الله يجزيهم الخير تبرعوا و شاركوا من بين عشرات الأخرين ممن اكتفوا بالمشاهدة فقط للأسف.

الواحد لازم يعتزر اذا كتب بغير لغته مو بلغتهEye-wink

بالتوفيق

Al Durra's picture
Al Durra
بعد التخرج


فقط كلمتان..نرجو منك الاستمرار
و بصراحة كنت انتظر cardiology Eye-wink

شكرا لك دكتور..

lonely
طبيب مقيم

Quote:
و بصراحة كنت انتظر cardiology

كنت قد بحثت سابقاً و لكن لا يوجد للأسف حالات cardiology في مصدر الأسئلة.

Al Durra's picture
Al Durra
بعد التخرج


شكرا الدرة على الكويزات الجميلة، كنتُ دائما أستفيد منها و بأوجه عديدة: المعلومات الجديدة، بالذات بالعظمية Very Happy، تطوير طريقة التفكير بحل الأسئلة، كجزء من التدريب لخوض هكذا امتحانات ستواجهنا كثيرا في المستقبل القريب و البعيد.

الحقيقة كانت الكويزات غزيرة جدا،و هذا شيء إيجابي، يعني نحن تعودنا متل ما ذكرت إنو نناقش حالة وحدة بمشاركة كانت تاخدلها يومين تلاتة، أما هيك فكنا نناقش بمشاركة واحدة، و أحيانا بأقل من يوم سبع حالات.

أكثر شي بحبه بهيك أسئلة هو Patient presentation ..
something like, the pt is coming with bla bla, what is the most likely Dx ??
I believe in most common thinking Cool

شكرا كثيرا الدرة، على وقتك و جهدك..
و نحن و كما ذكر بسام جاهزون للتفاعل مع أي فعالية علمية تقومون بها حضراتكم Eye-wink Very Happy

Green Wave's picture
Green Wave


كلامك أسعدني Green. شكراً جزيلاً لك.

بالمناسبة أنا تفاجأت بقدرتكم على حل مجموعة من الأسئلة لم أتوقع أن يحلها أحد. المستوى العلمي لمن شاركوا بشكل عام ممتاز و يدعو للتفاؤل.

Al Durra's picture
Al Durra
بعد التخرج


عفواً في شغلة كانت ببالي بس نسيت قولها وبظن هامة
انو ياريت لو صارت مستقبلاً هالفعاليات الحلوة انو يكون في وقت معين تنزل فيه الكويزات .. لأنو احياناً منتفاجأ اول ما منجي منلاقي الكويز انتهى!
و

Quote:
شكرا كثيرا الدرة، على وقتك و جهدك..
و نحن و كما ذكر بسام جاهزون للتفاعل مع أي فعالية علمية تقومون بها حضراتكم
Tariq1987's picture
Tariq1987
بعد التخرج

Quote:
انو ياريت لو صارت مستقبلاً هالفعاليات الحلوة انو يكون في وقت معين تنزل فيه الكويزات .. لأنو احياناً منتفاجأ اول ما منجي منلاقي الكويز انتهى!

ملاحظة ذكية و قد خطرت ببالي و ما منعني من القيام بها سببان. الأول فارق التوقيت فما يناسبني قد لا يناسبكم و العكس صحيح. الثاني هو عدم معرفتي بالأصل ما سيناسبني لذلك كان تنزيل المشاركات يتم عند سنوح الفرصة ( ماني متأكد من صحة كلمة"سنوح" ).

Al Durra's picture
Al Durra
بعد التخرج


صراحة أرجو أن يستمر عرض الحالات لأنها أفادتني جداً

بارك الله فيك دكتور ياسر

prettyflower's picture
prettyflower
بعد التخرج
ابق على تواصل مع حكيم!
Google+