Anemias
Hemolytic Anemias
Transfusion Reactions
Thrombotic Disorders
Bleeding Disorders
Myeloproliferative Disorders and Leukemias
Abnormal Morphology
100
A 74 y.o. woman on protonix and metformin presents with symptoms of forgetfulness. Exam reveals positive Romberg sign. MCV is 103. Further Testing reveals elevated methylmalonate and homocysteine levels. What does this patient have?
Vitamin B12/Colbalamin Deficiency
100
A 35 y.o. woman had a recent URI treated with PCN now presents with fatigue and pallor. Blood indices were normal a year ago. Hb is now 9 g/dL. MCV 92, MCHC 39, Retic 12%. Polychromasia+, Spherocytes+. What does this patient most likely have?
Autoimmue hemolytic anemia
100
A patient is getting a blood transfusion. Within one hour, he becomes restless, dyspneic, complains of low back pain, fever and chills. Temp is 101.5, HR increases from 80 to 110/min. Urine is dark red. H Drops from 9g/dL to 7g/dL. The patient is suffering from a Major hemolytic Reaction due to ________
ABO incompatibility (This is and early reaction)
100
A patient with unstable angina is started on heparin. Admission platelets were 200,000. 2 weeks later, platelet count is 125,000. What do you do next?
No additional workup needed, continue heparin
100
You prescribe Warfarin for a patient with AFib and mitral stenosis. Patient does an internet search and finds out that it’s a rat poison. What do you do next?
Continue warfarin and check PT/INR
100
A 45 y.o. man presents for follow up. He takes testerone and current testosterone is 690 (300-800), EPO is increased, hepcidin is decreased. HCT is 54%. What do you do next?
Discontinue or Decrease dose of testosterone
100
These can be seen in Asplenia, myelofibrosis, thalassemia, Sickle cell, Hb C, Hb E, and alcohol use
Target Cells
200
A patient from Asia (India/Vietnam/Laos/Cambodia) presents with Hb 12 g and MCV 70. His blood was refused while trying to donate blood for his friend’s surgery. Smear shows target cells. What is the most likely diagnosis?
What is alpha thalassemia trait?
(The next best step in diagnosis would be DNA PCR analysis)
200
A 25 y.o. had a normal labor, 7 days postpartum presents with fatigue. She has petechiae over her arms. Hb 8 g/dL, Plt. 20,000, Retic 7%, LDH 850, PT/PTT normal, BUN 30 mg/dL, creatinine 1.6 mg/dL, AST/ALT 120/250, peripheral smear shows anisocytes with polychromasia, and + schistocytes. What is the diagnosis?
HELLP Syndrome
200
A 45 y.o. pt with acute GI bleed and orthostatic hypotension receives vigorous hydration and about 8 units of PRBC. Pt remained stabilized for several hours and now bleeds again. PT/PTT prolonged. What should you give?
Give FFP for the plasma Washout
200
A patient with breast cancer develops a DVT. She is on anti-seizure medication secondary to brain mets. What is the best management?
Place on long-term DOAC (Apixaban) or LMWH
200
A 35 y.o. woman with usually heavy menses is complaining that her menses has not stopped in the past 10 days. She started ASA a month ago. PT/PTT are normal. What is the most likely diagnosis?
Von Willebrand disease
200
A 20 y.o. woman presents with fatigue and pallor. Her menses have been heavy. Hb is 9.0 g/dL, WBC is 8,000, Platelets are 800,000, MCV is 74. What is the most likely cause of her thrombocytosis?
Reactive Thrombocytosis secondary to iron deficiency anemia
200
This can be seen in anemia of uremia
Burr cell/Echinocyte
300
A 60 y.o. woman with diabetes and renal insufficiency presents with fatigue. Hb is 9g/dL. Stool for occult blood is negative. Serum ferritin is 300 mg/dL (nl>500) and transferrin saturation <30%. Pt is started on erythropoietin therapy. 4 weeks later, Hb is 9.2 g/dL. What do you do next?
Start supplemental IV ferrous sulfate
300
In a patient with a platelet count of 30,000 with pneumonia, what will guide your treatment of TTP?
PLASMIC SCORE
300
A 67 y.o. patient recieving PRBCs; about 1-3 hrs later she has a cough and SOB. Temp is 99, BP 150/90, HR 110/min, RR 24/min, Pulse ox 85%. JVP is 10 cm, Rale + on PE and CXR shows infiltrates. What is the Diagnosis?
Transfusion associated circulatory overload (TACO)
300
A 25 y.o. woman presents with weakness of her left hand and aphasia. Past history is significant for three sponaneous abortions. P.E. reveals left sided hemiparesis. CBC including platelet count are normal. PTT is 62 secs. on mixing with normal plasma, the PTT does NOT correct. CT head is normal. What is the next best test?
Antiphospholipid antibodies (Beta-2-glycoprotein I (Beta2GPI) antibodies)
300
A patient is on warfarin for AFib with an INR of 2.4 needs to go in for urgent surgery tomorrow. What is the next best stop?
Give vitamin K 2.5mg PO 1 dose
300
A patient with CLL presents with Hb <10 and platelets <100,000. What is the next best management?
Chemotherapy
300
These can be seen in TTP, HUS, HELLP/Preeclampsia, DIC, and prosthetic heart valves
Schistocytes
400
An elderly man presents with nausea, abdominal pain and diarrhea. Exam reveals slight confusion and an abnormal gait, along with decreased vibration sensation. hb 9g/dL, MCV 78. What do you do next?
Obtain a Urine for heavy metal screen
400
An 18 y.o. presets with abdominal pain and bloody diarrhea. NO fever or mental status change. Hb 10g/dL, Platelets 60,000, Retic 8%, LDH 650, PT/PTT normal, BUN 30 mg/dL, creatinine 2.2 mg/dL, Peripheral smear shows reticulocytes with polychromasia and + schistocytes. What is the most likely diagnosis?
Hemolytic uremic syndrome
400
After a massive blood transfusion a patient has a seizure, what is the most likely cause?
Citrate Toxicity
400
A patient with a platelet count of 250,000 on admission. Next day, platelet count 5,000. No symptoms, no bleed. No drop in Hb. PT/PTT nl, LDH nl. What do you do next?
Repeat Manual platelet count
(Why? Because EDTA in blood tubes may cause a clumping artifact)
400
A patient with mild hemophilia A with 10% factor VIII is scheduled for dental extraction. What do you do next?
Demsopressin spray +/- Tranexamic acid (anti-fibrinolytic agent)
400
A 65 y.o. man presents with complaints of dyspnea and headaches. He is a chronic smoker. HB is 22, MCV 78, WBC 14,000, Platelets 550,000, Alk phos normal, SaO2 on room air is 96%. What is the most appropriate treatment for this patient?
Phlebotomy + LOW does ASA
400
These can be seen in liver disease and alcoholic disease anemia
Acanthocyte/Spur Cells
500
Patient with sickle cell Trait with left upper quadrant pain, enlarging spleen and dropping Hb/Ht. BP 100/80 supine and 80 systolic sitting up. HR 96 supine and 114 sitting up. What is the diagnosis?
Splenic Sequestration Crisis
(Treatment is IV fluids then PRBCs)
500
A patient develops anemia after taking hydroxychloroquine (or sulfonamides, or dapsone, or fava beans, or rasburicase, or after an infection or an episode of DKA). How would you establish the diagnosis?
Obtain G6PD level in 2-3 months
(when hemolysis occurs, older cells are destroyed leading to increased reticulocytes, blister/bite cells. younger cells are normal meaning the immediate G6PD level would be normal)
500
Patient gets fever and chills every time he gets transfused. Hb/Ht doesn’t drop. What is the diagnosis and what would prevent this in the future?
Dx is Febrile Nonhemolytic Reaction
w.t.d. Leukocyte poor RBAC transfusions in the future
500
A 55 y.o. man is scheduled for elective coronary bypass surgery. The surgeon consults you for intraoperative anticoagulation and postoperative prophyaxis. He had a DVT 2 years ago with HIT for which he was treated. ELISA for heparin-platelet factor 4 antibodies is negative. What is the best management?
IV heparin during surgery followed by subcutaneous Fondaparinux postoperatively
500
A patient has a laceration with delayed bleeding. He has been taking INH for 8 months for a + PPD. He has a cut wich has not healed in 10 days. PT, PTT, BT, and platelets are normal. Platelet aggregation studies are normal. Clot retraction test is abnormal. What is the diagnosis?
Factor XIII deficiency
(INH causes an acquired inhibitor to factor XIII, resulting in an immune-mediated deficiency)
500
A 62 y.o. man presents with a lower respiratory tract infection. WBC 18,000, predominatly lhymphocytes. Smear shows mature lymphocytes, smudge cells. What do you do next?
Obtain flow cytometry of peripheral blood to diagnose CLL
500
This can be seen in hemolysis, blood loss, and recovery phase of vitamin B12 or folate
Polychromatophila (Reticulocytes)