CR1 (Three Tired Ladies)

Question 1

Name this symptom [1]

Answer 1

Angular stomatitis

Question 2

State 5 reasons why may have microcytic anaemia

Answer 2

i. Thalassemia
ii. Anaemia of chronic disease
iii. Iron deficiency
iv. Lead poisoning
v. Sideroblastic (disorder where the body produces enough iron but is unable to put it into the haemoglobin)

Question 3

Name 5 signs of microcytic anaemia

Answer 3

• atrophic glossitis
• Angular stomatitis
• Tiredness
• Blood loss in vagina, urine or rectum: flecks of blood mixed with her stool.
• Black / tarry / maroon stools: indicates blood loss is higher up in GI tract
• Koilonychia
• Pica syndrome: craving for substances not normally eaten like clay
• Cold hands and feet

Italics: mentioned in the PBL

Question 4

What can be given as a treament for microcytic anaemia? [1]
What alternative can be given if first line treatment causes bad side effects? [1]

Answer 4

Oral iron: Ferrous sulphate.
Can give ferrous gluconate if side effects are bad

Question 5

Name a disease that commonly causes Anaemia of chronic inflammatory disease [1]

Answer 5

rheumatoid arthritis

Question 6

What are the two types of macrocytic anaemia? [2]
State what can cause each type of macrocytic anaemia [3 & 2]

Answer 6

1. Macronormocytic:
   a. Alcoholism
   b. Liver disease
   c. Reticulocytosis
2. Megaloblastic
   a. B12 deficiency
   b. Folate deficiency

Question 7

Describe causes of B12 deficiency causing megaloblastic anaemia [4]

Answer 7

Autoimmune pernicious anaemia:
* Parietal cells of the stomach are attacked resulting in atrophic gastritis and the loss of intrinsic factor production and thus vitamin B12 malabsorption

Diet
Bacterial / parasitic infection
Surgery after effects from ileum

Question 8

Explain why a lack of B12 / folate causes megaloblastic anaemia [2]

Answer 8

Lack of B12 or folate interferes with the synthesis of DNA in bone marrow cells.

Vitamin B12 (and folate) are coenzymes for cellular metabolism, particularly haemopoesis.

Question 9

How would you ID if have megaloblastic anaemia from B12 / folate deficiency on a blood film? [1]

Answer 9

Hypersegmented neutrophils

Question 10

Which signs are specific to B12 deficiency [1]

Answer 10

glossitis

Question 11

How would you treat Vitamin B12 deficiency caused anaemia:

Due to ii. If a low B12 is due to malabsorption then injections are required:? [1]
Diet? [1]

Answer 11

Malabsorption:
* six injections of hydroxocobalamin (1 mg) at intervals of about 3-4 days followed by four such injections a year for life.

Diet:
* Oral cyanocobalamin

Question 12

If B12 is left too long, which disease can it lead to? [2]

Answer 12

i. Focal demyelination of CNS: can lead to subacute combined degeneration of the cord
1. Degeneration of the lateral and posterior columns of spinal cord

Question 13

State causes of normocytic anaemia

Answer 13

i. Acute blood loss
ii. Anaemia of chronic disease – main:
1. Infections
2. Cancer
3. CKD
4. Obesity
5. RA
6. Lupus
7. IBD

iii. Renal failure: Anaemia of chronic kidney disease:
1. Decreased renal production of EPO – which stimulates erythrocytes
a. Decreased EPO causes a downregulation of hypoxia induced factor (HIF): which regulates EPO

iv. Pregnancy
v. Malnurition
vi. Endocrine disorders like hypothyroidism

Question 14

State two drugs that can cause B12 deficiency [2]

Name two autoimmune conditions that can cause B12 deficiency [2]

Answer 14

Drugs:
* Nitrous oxide
* Metformin

Autoimmune conditions:
* Crohns diease
* Pernicious anaemia

Question 15

Describe the process of normal metabolism of B12 [7]

Answer 15

i. B12 broken down from protein
ii. Binds to haptocorrin in stomach
iii. Dissociates from haptocorrin
iv. Binds to stomach intrinsic factor
v. Absorbed in terminal ileum into blood
vi. In blood, binds with transcobalamin
vii. Stored in liver

Question 16

Explain why assessing serum B12 levels may be deceptive [1]

Answer 16

B12 is either active or inactive in blood. Therefore may say have normal levels even though patient is deficient as they only have inactive B12

Question 17

How do you calculate MCV? [1]
What is the unit [1]

Answer 17

MCV = Haematocrit / (Hb X RBC). It is expressed in femtolitres (fl) (1015 fl = litre)

Question 18

Following haemorrhage there will be a what type of anaema in the short term? [1]
Explain your answer [1]

Answer 18

Following haemorrhage there will be a normocytic anaemia due to haemodilution, in the short term.

Question 19

What serum markers would indicate someone is suffering from pernicious anaemia? [2]

Answer 19

• Antibodies to intrinsic factor
• Antibodies to gastric parietal cells occur in serum.

Question 20

Which cell in the bone marrow differentiates into a common myeloid progenitor? (1 mark)

Answer 20

Haematopoietic stem cells

Question 21

Which cells secrete intrinsic factor and where are they located? (1 mark)

Answer 21

Parietal cells [0.5] gastric mucosa [0.5]

Question 22

How can reticulocytes be differentiated from erythrocytes on a blood film (1 mark).

Each point is worth half a mark

Answer 22

Reticulocytes are stained blue [0.5]
Reticulocytes bigger [0.5]
Ribosomes present [0.5]

Question 23

Where is ferritin found and what is its function? (2 marks)

Answer 23

Ferritin found intracellularly storage of iron in all cells [2]

Question 24

How will the blood count of someone suffering from acute blood loss differ from someone suffering from chronic blood loss? (2 marks)

Answer 24

Acute: normocytic anaemia [1]

Chronic: IDA -> hypochromic microcytic anaemia [1]

Question 25

Calculate a patient’s mean corpuscular volume, if their haematocrit = 0.45, Hb = 120 g/l, red cell count = 5 x 1012 /l (2 marks)

Answer 25

MCV = 0.45 / 5 x1012
= 90 fL