Anemia

Chapter 63 Anemia




Clinical Case Problem 1 A 35-Year-Old Woman with Fatigue


A 35-year-old woman comes to your office with a 4-month history of fatigue. Her history is unremarkable; she has had no major medical illnesses. She has noticed that during the past 12   months, her menstrual periods have become heavier and longer; instead of lasting for only 4   days with bleeding that was “light to moderate,” she now has a 7- to 9-day period with “very heavy flow.” She is the mother of three healthy children.


On examination, the patient appears pale. Her lower eyelids are pale and so is her skin. Her blood pressure is 100/70   mm Hg. Her pulse is 86 beats/minute. Physical examination, including a pelvic examination, is otherwise normal. Her blood smear reads as follows: red blood cells (RBCs) are microcytic and appear to be hypochromic. Her platelet count is 175,000/mm3. Her hemoglobin level is 9.5   g/dL.



Select the best answer to the following questions




1. What is the most likely cause of this patient’s anemia?


a. iron deficiency anemia

b. hemolytic anemia

c. folic acid deficiency anemia

d. pernicious anemia

e. anemia of chronic disease

2. What treatment(s) is (are) therapeutic in this patient’s condition?


a. naproxen 375   mg twice a day (or a similar nonsteroidal antiinflammatory drug [NSAID]) during the last 2   weeks of the menstrual cycle

b. a low-dose oral contraceptive pill (OCP) given either continuously or in a cyclic manner

c. ferrous sulfate 325   mg once a day to 300   mg two times a day

d. all of the above

e. none of the above

3. The patient comes to the emergency department later during the week. Now her hemoglobin level is 6   g/dL. She is tachycardic and hypotensive. Of the treatments listed, which will be most beneficial?


a. intramuscular (IM) medroxyprogesterone acetate

b. intravenous (IV) conjugated estrogen

c. cryoprecipitate

d. fresh frozen plasma

e. high-dose OCPs given every hour

4. The patient follows up in your office a week after hospitalization. Her hemoglobin level is now 9.6   g/dL. She says she has black stools, constipation, and nausea with the Fem-Iron (ferrous fumarate) medication. Your next step is to


a. prescribe Slow Fe (ferrous sulfate)

b. prescribe an enteric-coated iron preparation

c. prescribe weekly IM injections of iron

d. advise her to continue her current medication with concomitant antacid use

e. admit to the same-day unit for IV iron administration

5. Which statement about the treatment of iron deficiency anemia is false?


a. treatment goals should be for 150 to 200   mg of elemental iron per day

b. tea drinkers may show decreased iron absorption

c. concurrent vitamin C administration may decrease iron absorption

d. reticulocyte count should increase in 1 week

e. iron therapy should continue for 6   months after hemoglobin level goal is reached

6. Which of the following investigations should be performed in this patient to rule out a secondary cause?


a. pelvic ultrasound plus or minus pelvic laparoscopy

b. coagulation profile

c. computed tomography (CT) scan of the abdomen/pelvis

d. a and b

e. a, b, and c

f. none of the above

7. What is the most sensitive test for the detection of the anemia described here?


a. serum iron

b. serum iron-binding capacity

c. serum ferritin

d. serum transferrin

e. reticulocyte count

8. Based on a complete blood count (CBC) and peripheral smear only, how can iron deficiency anemia be differentiated from thalassemia?


a. thalassemia is normochromic, normocytic, and iron deficiency is microcytic, hypochromic

b. previous CBCs are normal in patients with thalassemia

c. thalassemia shows a normal to high RBC count, whereas iron deficiency shows a low RBC count

d. b and c

e. a, b, and c


Clinical Case Problem 2 A Pregnant Woman with a Hemoglobin Level of 10.8   g/dL


A pregnant woman at 22   weeks of gestation comes to your office for her regular checkup. Her hemoglobin level is 10.8   g/dL.



9. Which of the following statements regarding anemia and pregnancy is false?


a. iron supplementation is necessary in pregnancy to prevent microcytic anemia

b. a “false” anemia is seen as a result of the relative expansion of the plasma volume relative to the RBC mass

c. folic acid supplementation is necessary in pregnancy to prevent macrocytic anemia

d. hemoglobinopathies are often first diagnosed when a woman comes for prenatal care

e. iron deficiency is the most common anemia in pregnancy


Clinical Case Problem 3 A Fatigued 55-Year-Old Man


A 55-year-old man comes to your office for a periodic health assessment. His only complaint is that he has been feeling quite fatigued during the past 3   months. He does not smoke and rarely drinks.


On physical examination, the patient appears pale. His blood pressure is 100/80   mm Hg. His pulse is 96 and regular. No other abnormalities are found. A CBC reveals a hemoglobin value of 10   g/dL. His blood smear also shows a decreased mean corpuscular hemoglobin count and a decreased mean corpuscular volume (MCV).



10. Until it is proved otherwise, what is the most likely cause of his low hemoglobin level?


a. lymphoma

b. gastrointestinal malignant neoplasm

c. lack of intrinsic factor

d. dietary deficiency of folic acid

e. dietary lack of iron


Clinical Case Problem 4 A 78-Year-Old Woman Complaining of a “Lack of Energy”


A 78-year-old woman with osteoarthritis comes to your office complaining of a “lack of energy” that began 8   months ago. On examination, the patient has marked pallor. Her hemoglobin level is 7.5   g/dL. A peripheral blood smear reveals hypochromasia and microcytosis. One year ago, her hemoglobin level was 13   g/dL.



11. What is the most likely cause of this patient’s anemia?


a. malnutrition

b. pernicious anemia

c. folic acid deficiency

d. gastrointestinal bleeding

e. hypothyroidism

12. The anemia of chronic disease is most often which of the following?


a. hypochromic and normocytic

b. hypochromic and microcytic

c. normochromic and macrocytic

d. normochromic and normocytic

e. hyperchromic and macrocytic

13. What is the most common cause of anemia of chronic disease?


a. chronic hepatic failure

b. chronic renal failure

c. congestive cardiac failure

d. autoimmune disease

e. chronic neurologic disease

14. What is (are) an acceptable treatment(s) for anemia of chronic disease?


a. iron therapy

b. erythropoietin

c. treatment of the underlying condition

d. b and c

e. a, b, and c

15. Which of the following disorders is (are) associated with the anemia of chronic disease?


a. rheumatoid arthritis

b. non-Hodgkin lymphoma

c. chronic renal failure

d. chronic hepatic failure

e. all of the above

16. Which of the following is the most common type of anemia in the U.S. population?


a. anemia of chronic disease

b. iron deficiency anemia

c. macrocytic anemia

d. autoimmune hemolytic anemia

e. iatrogenic anemia


Clinical Case Problem 5 A 75-Year-Old Woman with Fatigue, Paresthesias, Weakness, and an Unsteady Gait


A 75-year-old woman comes to your office with an 8-month history of increasing fatigue, paresthesias, weakness, and an unsteady gait. These are new symptoms. Her past medical history is significant for hemicolectomy for colon cancer of the terminal ileum 3   years ago.


On examination, her skin is pale, as are her lower conjunctival lids. She has a number of interesting neurologic findings on physical examination, including patchy impairment of the sensations of touch and temperature, loss of vibration and position sense, presence of Romberg sign, hyperreflexia, and bilateral upgoing Babinski signs. Her hemoglobin level is 6.8   g/dL.



17. Which of the following statements regarding this patient’s condition is (are) true?


a. this patient has a hemolytic anemia

b. a CT scan of the brain should be performed

c. hyposegmented neutrophils will be seen on the blood smear

d. the MCV value will be above 100 mm3

e. all of the above

18. If you could choose only one investigation to do next, what would it be?


a. reticulocyte count

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Anemia

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