MEQ

Case 1
Soraya Mahfouz is a 73 year old woman, widowed one year ago. She has
been brought to you, her GP, by her son who is concerned that she is not
coping. Mrs Mahfouz reports that she doesnt feel up to much, and while
insisting that she is managing at home, is clearly avoiding activity due to
fatigue and breathlessness on exertion that has become more of a problem
in the last three months. She has lost 4-5 kg in the last year but has no
specific symptoms on system review other than features of moderate
depression. On examination she has pallor of mucous membranes and
nailbeds and you suspect that she is significantly anaemic. She has no
evidence of bruising or splenomegaly, but her liver edge is palpable 2 cm
below the costal margin.
Question 1.1
Identify two features from this womans history and/or examination suggestive of
anaemia. For each of these features state why they are suggestive.

Her haemoglobin is 93 g/L, (normal range 115 - 165 g/L), mean

corpuscular volume is 72 fL (normal range 80 - 100 fL) and mean
corpuscular haemoglobin concentration is 295 g/L (normal range 310 - 350
g/L). Platelet and white cell measures are normal, as is the blood film.
Question 1.2
Describe the physiology of red blood cell production. Pay particular attention to key
nutritional components and any other relevant stimulatory factors.

Question 1.3
What is the most likely micronutrient deficiency underlying this womans anaemia
and why?

Question 1.4
List 3 additional blood parameters you would test which would confirm a diagnosis of
iron deficiency. Specify whether you would expect each to be high, low or normal.

Question 1.5
Describe the mechanisms by which the biochemical environment in the tissues
mediates oxygen delivery to active cells from haemoglobin in red cells.

You confirm that she has a significant iron deficiency, with depleted iron
stores.
Question 1.6
a) What is the most likely cause of iron deficiency anaemia in a woman of this age?
b) What tests would you recommend to confirm the most likely cause?

Question 1.7
Soraya is likely to need some services to help her live in the community. A referral is
made to the Aged Care Assessment Team (ACAT).
a) Write a short paragraph describing, for Soraya and her son, the role of the ACAT
team.
b) Write another short paragraph explaining what they should know about
Community Aged Care Packages (CACPs).

Case 2
Cynthia Salakas is a 78-year old widow who presents with dyspnoea,
palpitations on exertion and "pounding in the ears". She also describes
unsteadiness on standing with occasional falls. Mrs Salakas lives alone with
no family support and prepares her own meals. On examination, she is pale
and anxious, with a tachycardia of 100 beats/min and BP of 130/80. The
spleen is just palpable but there is no lymphadenopathy.
A full blood count shows the following:
Indices

Mrs Salakas' Results

Normal Range

Hb

68 g/L

115 - 165 g/L

MCV

124 fl

76 - 96 fl

WBC

3.5 x 109/L

4.0 - 11.0 x 109/L

Platelets

89 x 109/L

150 - 500 x 109/L

Question 2.1
List at least THREE common causes of a macrocytic anaemia.

She has had difficulty preparing her own meals over the past few months as
she feels very unsteady and has resorted to toasted cheese or tomato
sandwiches several evenings per week as her main meal. She often
consumes only half to three-quarters of her usual intake and she has
noticed some weight loss which she is becoming concerned about.
Question 2.2
What nutritional assessment methods could you use to decide if Mrs Salakas is
malnourished? (Give THREE)

Further testing shows a serum B12 level of 60 pmol/L (normal range 130600 pmol/L) with normal red cell folate level.
Question 2.3
Describe the typical blood film of B12/folate deficiency.

You perform a neurological examination on Mrs Salakas. Her perception of

position, sense and vibration is impaired in the feet and hands. Tendon
reflexes are generally brisk with upgoing plantars. Her gait is abnormal,
with unsteadiness on walking.

Question 2.4
a) Describe the location and nature of the pathological effects of B12 deficiency on
the nervous system.
b) Describe at least TWO of the main neurological signs associated with B12
deficiency.

Mrs Salakas is transfused initially and commenced on a course of parenteral

B12 replacement. After two weeks in hospital she feels much improved and
is anxious to return home.
Question 2.5
You are about to discuss handing over her care with her local GP. List at least TWO
community services or agencies that could provide support following her assessment
as fit to go home. Give a brief explanation of each agency's role and why she might
require their involvement.

Case 3
Brian Murphy is a 77 year old man who presents to your surgery
complaining of tiredness and dyspnoea. You note that he is pale and has
signs of heart failure. His haemoglobin measures 87 g/L (normal range
125-165 g/L).
Question 3.1
Name at least three laboratory test results that would suggest the anaemia is due to
haemolysis rather than reduced red cell production.

The direct antiglobulin (Coombs) test is requested and is positive.

Question 3.2
a) Which components of the red cell are responsible for blood groups?
b) What does the direct antiglobulin test detect?

Question 3.3
Describe the physiology of red blood cell production. Pay particular attention to key
nutritional components and any other relevant stimulatory factors.

Question 3.4
Describe two possible mechanisms of destruction of circulating red cells which
become coated with immunoglobulin/antibody.

Question 3.5
The patient is treated with oral prednisone. Name at least two short term and at
least two long term complications of oral corticosteroid administration.

Case 4
Sarah Weiss is a 15 year-old girl who comes to the GP with her mother who
is concerned that Sarah has lost weight, seems tired all the time and
appears pale. Up until 10 months ago, Sarah was a good eater and was a
normal and active girl. Her weight is now 58 kg (was previously 68 kg) and
her height is 165 cm.
The GP orders a full blood count (FBC) and blood film which show:
FBC

Sarahs results

Reference range

Blood film

WCC

8.1 x 10 /L

4.513.0 x 10 /L

Hypochromia +

Platelets

598 x 109/L

150600 x 109/L

Microcytosis +

Haemoglobin

*81 g/L

120160 g/L

Poikilocytes +

MCV

*71 f

7895 fl

Pencil cells occasional (thin

elongated cells)

MCHC

*295 g/L

320360 g/L

Question 4.1
Regarding Sarahs blood film and red cell indices, which 2 features are most helpful
in suggesting the cause of her anaemia is iron deficiency?

Question 4.2
You plan to do additional tests to confirm the diagnosis. List 3 additional blood
parameters you would test which would confirm a diagnosis of iron deficiency.
Specify whether you would expect each to be high, low or normal.

For the past year Sarah has not eaten meat, fish, chicken, eggs, or milk
products. She changed to a vegan diet consisting of green vegetables,
legumes and cereals because of concerns about killing animals and eating
animal products.

Question 4.3
a) Give 2 foods or food types which would have been the major sources of iron in
her diet during the past year.
b) How might the bioavailability of iron be increased in her diet?

Question 4.4
You consider the possibility that Sarah may have an eating disorder. What are the
psychological issues which need to be addressed in relation to eating disorders? In
your answer refer to individual, family and social factors.

Case 4
Brian Murphy is a 77 year old man who presents to your surgery
complaining of tiredness and dyspnoea. You note that he is pale and has
signs of heart failure. His haemoglobin measures 87g/L (normal range 125165 g/L).
Question 4.1
Name 3 laboratory test results that would suggest the anaemia is due to haemolysis
rather than reduced red cell production.

Question 4.2
a) Which components of the red cell are responsible for blood groups?
b) The direct antiglobulin (Coombs) test is requested and is positive. What does the
direct antiglobulin test detect?

Question 4.3
Describe two possible mechanisms of destruction of circulating red cells which
become coated with immunoglobulin/antibody.

Question 4.4
The patient is treated with oral prednisone. Name two short term and two long term
complications of oral corticosteroid administration.

SBA
Case 1
Miriam Liebling, a 37 year old woman, presents to the GP complaining of
tiredness and lethargy. She has 3 children aged 9, 5 and 4 years. She is not
vegetarian and eats a normal Western diet. She has had menorrhagia for
the last year but has been too busy to seek medical help. Her haemoglobin
is measured and the lab phones to say the Hb measures 64 g/L (NR 125160g/L).
Question 1.1
Erythropoiesis is stimulated principally by which one of the following?
A) Reduced pulmonary venous oxygen tension
B) Reduced oxygen tension in renal arterial blood
C) Reduced firing of a chemoreceptor in the carotid arteries
D) Reduced secretion of an inhibitory adrenocortical hormone

Question 1.2
With respect to erythropoiesis, cellular iron is acquired from circulating:
A) Cytochromes
B) Erythropoietin
C) Ferritin
D) Transferrin

Question 1.3
Which one of the following would be the best screening test for patients with iron
deficiency?
A) Serum iron
B) Transferrin concentration
C) Percentage transferrin saturation with iron
D) Serum ferritin

Question 1.4
Which one of the following is most helpful in indicating a likely cause for the reduced
haemoglobin in a patient with anaemia?
A) The severity of the anaemia
B) The mean corpuscular volume (MCV)
C) The presence of a normal platelet count
D) The patients age

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Case 2
Mrs Christina Nuvoli is an elderly woman from Malta who is obese. She has
become progressively fatigued but has no other symptoms. She has no
clinical signs except a mild resting tachycardia of 104/min.
Question 2.1
What is the most appropriate initial investigation?
A) ECG
B) Echocardiogram
C) Full blood count
D) Hb electropheresis

Question 2.2
The differential diagnosis of microcytic anaemia includes:
A) Beta thalassaemia trait
B) Aplastic anaemia
C) Liver disease
D) Hereditary spherocytosis

Question 2.3
The presence of anaemia and unconjugated hyperbilirubinaemia would suggest:
A) Gallstones
B) Haemolysis
C) Non-Hodgkins lymphoma
D) Thalassaemia trait

Question 2.4
The presence of pallor, fever, mouth ulcers and petechiae would suggest:
A) Megaloblastic anaemia
B) HIV infection
C) Malaria
D) Aplastic anaemia

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Question 2.5
Reticulocytes are:
A) Immature red cells seen in the circulation
B) White cell precursors
C) Readily identified on a blood film
D) Red cells damaged by phagocytosis

Question 2.6
Reticulocytes are increased in:
A) Iron deficiency
B) Chronic renal failure
C) Auto-immune haemolytic anaemia
D) Vitamin B12 deficiency

Question 2.7
Features of pernicious anaemia include:
A) A normal gastric biopsy
B) Anti-myelin antibodies
C) Intrinsic factor antibodies
D) Association with vegetarianism

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Case 3
Ron Porter is a 53 year old solicitor who presents to his GP in Mosman with
mild dyspnoea on exertion and a history suggestive of angina. There is no
history of blood loss. Results of a full blood count are given in the table
below.
An occult blood test was performed on a stool specimen and reported to be
negative. He is considered for a blood transfusion.
Indices

Mr Porters Results

Normal Range

Haemoglobin

75 g/L

130 - 180 g/L

MCV

65.3 fL

80 - 100 fL

MCHC

31.7 g/dl

300 - 350 g/L

White Cell Count

4.7 x 10 /L

4.0 - 11.0 x 109/L

Platelets

426 x 109/L

150 - 400 x 109/L

Question 3.1
The most likely finding on this mans blood film is:
A) Macrocytic erythrocytes
B) Hypochromic erythrocytes
C) Hypersegmented neutrophils
D) Spherocytic erythrocytes

Question 3.2
Erythrocytes in a person with iron deficiency are microcytic i.e., smaller than
normal because of:
A) Loss of intracellular water
B) Reduced intracellular haemoglobin concentration
C) An additional mitotic division during erythropoiesis
D) Impaired oxygen carrying ability

Question 3.3
Which one of the following characteristics of circulating blood is consistent with
accelerated red cell production?
A) An increase in the packed cell volume
B) The presence of normoblasts in circulating blood
C) An increase in the reticulocyte count in circulating blood
D) An increase in the myelocyte count in circulating blood

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Question 3.4
Adult haemoglobin is:
A) An extracellular protein
B) Composed of two distinct subunits
C) A copper/iron binding protein
D) Localised to the nucleus

Question 3.5
In the management of Mr Porter Which one of the following actions is most
appropriate?
A) Therapy should be commenced using intramuscular iron
B) Colonoscopy is indicated to exclude gastrointestinal malignancy
C) Investigations should exclude haemolysis
D) Transfusion is indicated as the main therapy to prevent further angina

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Case 4
Mrs Mehar Singh is a 45 year old woman who complained of increasing
lethargy over the past month and was found to have pale mucosa on
examination. Her blood count shows a haemoglobin of 90 g/L (115-165
g/L) with mean cell volume of 60 fL (75-100 fL), white cell count of 6 x
109/L (4-11 x 109/L) and platelets of 510 x 109/L (150-400 x 109/L). Her GP
notes that a previous haemoglobin result at the time of her hysterectomy
twelve months ago was normal. Investigations demonstrate that she is iron
deficient.
Question 4.1
Further investigations should include:
A) Isotope tests of vitamin B12 absorption
B) Bone marrow examination
C) Upper endoscopy and colonoscopy
D) Duodenal biopsy for adult coeliac disease

Question 4.2
The best immediate marker of a response to iron therapy would be:
A) Normalisation of the platelet count
B) Increasing reticulocyte count
C) Increase in haemoglobin
D) Reduction in pallor

Question 4.3
Which of the following is most correct regarding dietary iron absorption?
A) The major site of absorption is the lower small intestine
B) Iron in eggs and vegetables is as well absorbed as iron in meat
C) Ferrous iron is more readily absorbed than ferric iron
D) Increased body iron stores result in increased dietary iron absorption

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Question 4.4
Which one of the following proteins is the major carrier of iron in blood?
A) Albumin
B) Ferritin
C) Transcobalamin
D) Transferrin

Question 4.5
Iron plays a key functional role for all of the following proteins EXCEPT:
A) Cytochrome oxidase
B) Hemoglobin
C) Insulin receptor
D) Myoglobin

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Case 5

Question 5.1

Question 5.2

Question 5.3

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Question 5.4

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Question 5.5

Question 5.6

Question 5.7

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Case 6

Question 6.1

Question 6.2

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Case 7

Question 7.1

Question 7.2

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Question 7.3

Question 7.4

Question 7.5

Question 7.6

Question 7.7

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Question 7.8

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Case 8

Question 8.1

Question 8.2

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Question 8.3

Question 8.4

Question 8.5

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Question 8.6

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Case 9
Ron Porter is a 53 year old solicitor who presents to his GP in Mosman with
mild dyspnoea on exertion and a history suggestive of angina. There is no
history of blood loss. Results of a full blood count are given in the table
below. An occult blood test was performed on a stool specimen and
reported to be negative. He is considered for a blood transfusion.
Indices

Mr Porters Results

Normal Range

Haemoglobin

75 g/L

130 180 g/L

MCV

65.3 fL

80 100 fL

MCHC

317 g/L

White Cell Count

4.7 x 10 /L

4.0 11.0 x 109/L

Platelets

426 x 109/L

150 400 x 109/L

300 350 g/L

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Question 9.1
Which of the following disorders may manifest as hypochromic microcytic anaemia?
A) Haemolytic anaemia
B) Thalassaemia trait
C) Liver disease
D) Acute blood loss

Question 9.2
Which one of the following series of results would be consistent with iron deficiency?
A) Increased iron saturation, elevated serum ferritin, and normal serum transferrin
B) Normal serum ferritin, reduced serum iron, and reduced total iron binding
capacity
C) Reduced serum ferritin, reduced iron saturation, and increased total iron binding
capacity
D) Reduced serum transferrin and reduced serum transferrin receptor

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Question 9.3
Which of the following is correct about iron?
A) Iron is more readily absorbed in the ferric (Fe3+) form
B) Iron absorption is enhanced in the presence of ascorbate
C) Transferrin is the main reservoir of iron in the liver
D) Ferritin represents the major circulating form of iron

Question 9.4
The transfer of oxygen from haemoglobin to the tissues is:
A) Decreased by 2,3-diphosphoglycerate (2,3-DPG)
B) Increased at low pH
C) Not affected by the storage of red cells at 4oC
D) Enhanced by fetal haemoglobin

Question 9.5
Which one of the following is the most likely cause of anaemia in Mr Porter?
A) Dietary iron deficiency
B) Malabsorption
C) Diverticulitis
D) Gastrointestinal malignancy

Question 9.6
Which of the following red cell concentrate transfusions would be incompatible and
cause a serious haemolytic transfusion reaction?
A) Donor Group O RhD Negative to Patient Group A RhD Positive
B) Donor Group A RhD Positive to Patient Group A RhD Negative
C) Donor Group AB RhD Positive to Patient Group B RhD Positive
D) Donor Group O RhD Positive to Patient Group AB RhD Positive

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