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ЗмістII. Learning Objectives
IV. Theory Topics on the Subject
Teaching Guidelines for Practice Activities on Anemias
Complaints and on examination
Differential diagnosis by a diagnostic algorithm
elimination of anemia cause
3. Hemolytic anemias
Normal parameters of a blood
Parameters of iron metabolism
Final Test Questions
I. Importance of the Subject:
Anemia is the clinic and hematological syndrome described by decrease of haemoglobin level and erythrocytes in unit of blood volume. The prevalence of anemia in population studies of healthy nonpregnant people depends on the Hb concentration chosen for the lower limit of normal values. By World Health Organization criteria in the United States, approximately 4% of men and 8% of women have values lower than those cited. The prevalence of anemia in Canada and northern Europe is believed to be similar to that in the United States. In underprivileged countries, limited studies of purportedly healthy subjects show the prevalence of anemia to be 2-5 times greater than that in the United States. Although geographic diseases, such as sickle cell anemia, thalassemia, malaria, hookworm, and chronic infections, are responsible for a portion of the increase, nutritional factors with iron deficiency and, to a lesser extent, folic acid deficiency play major roles in the increased prevalence of anemia. Populations with little meat in the diet have a high incidence of iron deficiency anemia because heme iron is better absorbed from food than inorganic iron. The anemic syndrome could be a sign of many other diseases: lymphoproliferative, endocrine, rheumatological, chronic renal failure, pneumonias, chronic active hepatitises etc. Process of diagnostics is difficult and demands attraction of specialist in various fields of medicine.
If the importance of the subject has been understood, proceed to studying the learning objectives.
Key objective: to develop skills in making a differential diagnosis of diseases with anemia, and planning a patient management.
The information necessary for reviewing and revising the basic knowledge and skills can be found in the following references:
Pre-Practice Knowledge and Skills Test Questions
Q1. In complete blood count was found the cells having spherical or slightly oval biconcave form without nucleus. Average diameter of cells was 7,5-8,3 microns, average volume cells 80-100 microns, an osmotic resistance of cells - the beginning 0,44 %, the end - 0,32 %. What cells have been found?
А) normal erythrocytes;
Д) target cells.
Q2. In the complete blood count: erythrocytes 2,5x1012/l, haemoglobin - 81 g/l, color index of blood- 0,8, reticulocytes - 0 %, mean corpuscular volume 65 microns. Which anemia is it?
А) microcytic, hypochromatic, aregenerative;
B) macrocytic, hyperchromatic, aregenerative;
C) macrocytic, hypochromatic, hyperregenerative;
D) microcytic, hyperchromatic, normoregenerative;
E) normocytic, hypochromatic, hyporegenerative.
Q3. Results of analysis of patient D., 38 years old: in complete blood count: erythrocytes-1,2x1012/l, haemoglobin - 58 g/l, color index of blood - 0,9 reticulocytes-10 %, white blood cells -4,0x109/l, basophilocytes -1, eosinophils - 1 %, bond neutrophils - 6 %, segmentonuclear leukocytes - 54 %, lymphocytes-36 %, monocytes-2 %, thrombocytes-25x109/l, ESR-15 mm/hour; in biochemical blood analysis: total bilirubin-98,6 mkmol/l, indirect - 86,6 mkmol/l, direct-12 mkmol/l. What changes are found?
А) anemia, reticulocytosis, hyperbilirubinemia;
B) anemia, leukopenia, normal bilirubin level;
C) hyporegenerative anemia, lymphocytosis, hyperbilirubinemia;
D) anemia, leukocytosis, hyperbilirubinemia;
E) all parameters are normal.
Q4. On examination of patient С., 66 years old, hospitalized because of serious anemia, were found icteritiousness of scleras, atrophy of lingual papillas; symmetric paresthesias, gait disorder; splenomegaly. On gastroscopy: atrophic gastritis with achlorhydria. In the complete blood count macrocytosis was revealed. Which of the following is necessary for diagnosis?
А) a sternal puncture;
B) ultrasound of abdomen;
C) lumbar puncture;
D) upper gastrointestinal endoscopy;
E) chest roentgenography.
Q5. Patient К., 35 years old, was admitted to the hospital with complaints of weakness, palpitation and a short wind at exertion. She marked inverted gustatory sensation: wish for eating a chalk, clay. On examination: paleness, xeroderma, koilonychia, systolic murmur on the heart apex. The liver and spleen are not palpated. In complete blood count: erythrocytes-2,2x1012/l, haemoglobin - 65 g/l, color index of blood - 0,7 reticulocytes-0,5 %, white blood cells -5,4x109/l, basophilocytes -0, eosinophils - 1 %, bond neutrophils - 5%, segmentonuclear leukocytes - 52%, lymphocytes-38%, monocytes-5%, ESR-18 mm/hour, anisocytosis, poikilocytosis of erythrocytes. serum level of Fе - 7 mkmol/l, total bilirubin-17,3 mkmol/l. Which of the following is necessary for treatment of this patient?
А) iron preparations;
B) vitamin B12;
C) fresh frozen plasma;
D) red cells;
Key Answer 1
Correct answer is А) - in this question the form, the sizes, and parameters of an osmotic resistance of cells is typical for normal erythrocytes of a peripheric blood.
Key Answer 1
Correct answer is А) - this anemia is microcytic because mean corpuscular volume <80 microns, hypochromatic because color index of blood <0,82, aregeneratiry ecause of reticulocytes level=0.
To reach the learning objectives it is essential to master the following theory issues:
The information necessary for mastering the theory issues may be found in the following references:
Then, proceed to solving some test questions and checking test question 5 with the key answers.
Q1. In complete blood count of patient D.: erythrocytes-2,9x1012/l, haemoglobin - 75 g/l, color index of blood - 1,1, white blood cells -3,4x109/l, basophilocytes -0, eosinophils - 1 %, bond neutrophils - 4%, segmentonuclear leukocytes - 58%, lymphocytes-32%, monocytes-5%, thrombocytes-200x109/l, ESR-10 mm/hour, Howell-Jolly bodies, Cabot rings. On examination – symptoms of funicular myelosis. What complaints are typical for this syndrome?
А) short wind, palpitation, weakness;
B) shedding of hair, fragility of nails, xeroderma;
C) jaundice, heaviness in left and right hypochondrium;
D) nausea, diarrhea, burning sensation in tongue;
E) symmetric paresthesia, gait disorder.
Q2. The patient was admitted to hematological department with complaints of shedding of hair, fragility of nails, koilonychias, desire hunger for chalk, inhale odor nuisance. Symptoms of what syndrome are this complaints?
C) funicular myelosis;
Q3. Patient B., 50 years old, was admitted to hematological department with complaints of weakness, short wind, palpitation. On examination: skin and mucous were pale, with an icteric shade. The spleen was + 3 sm. In complete blood count: erythrocytes-2,9x1012/l, haemoglobin - 75 g/l, color index of blood - 1,0, reticulocytes-30%o, white blood cells -5,4x109/l, basophilocytes -0, eosinophils - 1 %, bond neutrophils - 4%, segmentonuclear leukocytes - 58%, lymphocytes-32%, monocytes-5%, thrombocytes-200x109/l, ESR-10 mm/hour, positive direct Cumbs’ test. Serum level of Fе - 20 mkmol/l, total bilirubin-42,0 mkmol/l, indirect - 30 mkmol/l, direct - 12 mkmol/l. Which of the following is the most probable diagnosis?
А) iron deficiency anemia;
B) aplastic anemia;
C) chronic myelosis;
D) chronic lymphoid leucosis;
E) autoimmune hemolytic anemia;
Q4. In complete blood count of patient N., 29 years old: erythrocytes-1,9x1012/l, haemoglobin - 53 g/l, color index of blood - 0,9, reticulocytes-0%o, white blood cells -2,0x109/l, basophilocytes -0, eosinophils - 1 %, bond neutrophils - 0%, segmentonuclear leukocytes - 15%, lymphocytes-80%, monocytes-4%, thrombocytes-25x109/l, ESR-45 mm/hour. In resulrs of trephine biopsy - replacement of red bone marrow by yellow bone marrow. Which of the following is the most probable diagnosis?
А)chronic lymphoid leucosis;
B) hemolytic anemia;
C) iron deficiency anemia;
D) pernicious anemia;
E) aplastic anemia.
Q5. For patient D., suffering from autoimmune hemolytic anemia, therapy by glucocorticoids wasn’t effective. What is you tactic for this case?
А) transplantation of bone marrow;
B) treatment by erythropoietin;
C) treatment by iron supplementations;
D) treatment by anabolic steroids;
Key Answer 5
The correct answer is E) - splenectomy is recommended to the patients suffering from autoimmune hemolytic anemia for whom treatment by glucocorticoids was noneffective or in case of relapse of a hemolysis after a end of treatment.
At the beginning of the class, the instructor gives a test to check and correct the pre-practice level of knowledge. Then, the students start to see patients under the instructor’s supervision after which the students give an analysis of the practice patients and the instructor checks the mastering of the practice topics. A final test is provided to strengthen the knowledge gained. At the end of the class, the instructor reviews the students’ self-learning activity, considers and corrects the students’ typical mistakes with a subsequent improvement of knowledge and skills.
Flow Chart of «Аnemias»
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