MEDICINE I

Anemia
Samplex Rationale

2019 - 2nd Term - 3rd Shift - Quiz #3

Questions Answers Rationale
TEST TYPE (MULTIPLE CHOICE)
1. Skin physical examination finding associated D Petechiae and Ecchymoses
with thrombocytopenia? ○ Petechiae - small (1-2mm) round, red, or brown
A. Pallor lesions from hemorrhage into the skin present in areas of high venous
B. Cyanosis pressure
C. Bronze/ Grayish pigmentation ■ Dengue fever - petechiae in lower extremities
D. Petichiae ○ Ecchymoses - may be of various size and shapes (flat, elevated, painful
and tender)
○ Signs of platelet disorders
2. A pure vegan may present with anemia due to B Pernicious anemia is a condition caused by too little vitamin B12 in the
absence of this vitamin: body. It is one form of vitamin B12 deficiency anemia.
A. Zinc
B. B12 Eating food high in vitamin B12 and folic acid can help prevent vitamin B12
C. Selenium deficiency caused by a poor diet.
D. Vit E

3. A 24 year old female consulted in the clinic due C Petechiae and Ecchymoses
to petechiae in the lower extremities and ○ Petechiae - small (1-2mm) round, red, or brown
episodes of gum bleeding. There was no fever lesions from hemorrhage into the skin present in areas of high venous
noted nor anorexia. No melena nor pressure
hematochezia. Above findings are associated ■ Dengue fever - petechiae in lower extremities
with which of the following? ○ Ecchymoses - may be of various size and shapes (flat, elevated, painful
A. An elevated WBC count and tender)
B. Elevated hemoglobin levels ○ Signs of platelet disorders
C. Decreased platelet counts
D. Elevated factor VIII

4. Physical examination finding that may be D Heart murmurs are sounds during heartbeat cycle (whooshing or swishing),
demonstrated in chronically anemic patient: made by turbulent blood flow in the heart. There are two kinds of murmurs:
A. Weak peripheral pulses Innocent (with normal heart) and Abnormal (most often due to acquired heart
B. Hypertension valve problems)
C. Muffled heart sounds
D. Mid-holosystolic murmurs Patients with anemia would present with an innocent murmur since the
patient has a normal heart. Conditions that may cause rapid blood flow
through the heart, resulting in an innocent murmur, include:

- Physical activity or exercise

- Pregnancy
- Fever
- Not having enough healthy RBCs to carry adequate oxygen to the tissues
(e.g Anemia)
- hyperthyroidism
- phases of rapid growth such as adolescence
A. Should be tachycardia as compensatory response
B. Instead, anemic patient could be possibly have HYPOtension.
C. Muffled heart sounds can be seen in patients with cardiac tamponade as
part of Beck’s Triad (Hypotension, distended neck vein, and distant,
Muffled heart sounds)
5. Gastrointestinal manifestation frequently seen in C Focused PE would include the checking of:
neutropenic patients resulting from chemotherapy • Presence of wet purpura
A. Splenomegaly • gingival hyperplasia
B. Hepatomegaly • gum bleeding
C. Oral ulcers • oral ulcers
D. Gingival hyperplasia • thrush

6. RX is 45 year old male with myelofibrosis, B An enlarged spleen may cause early satiety, or feeling full without eating or
presenting with massive splenomegaly. Which after eating only a small amount, due to the its pressing on one’s stomach
of the following is a prominent symptom
associated with splenomegaly?
A. Ascites
B. Early satiety
C. Pallor
D. Abdominal enlargement

A.Santos, J. Santos, K. Sebollena, K. Sia (PPS)| Page 1 of 8

7. SY 35 year old female who presented in the C Amongst the choices, only Choice C is possible but rare. OCULAR findings
clinics with multiple pinpoint rashes on the lower are RARELY encountered. Thrombocytopenia alone, even severe (PC of
extremities and episodes of epistaxis. CBC showed <50,000), rarely sufficient to cause significant retinal hemorrhage.
low platelets. Which of the following eye finding However, thrombocytopenia combined with anemia is a known risk factor.
can be expected in this case?
A. Dilated veins
B. Icteresia
C. Retinal hemorrhage
D. Copper wiring

8. Which of the following statement is TRUE D Pallor (<8 - 10 mg/dL Hemoglobin)

regarding pallor? Affected by:
A. It is unaffected by the degree and nature of - State of Vasoconstriction/Vasodilation
pigmentation - Degree and nature of pigmentation
B. The skeletal muscles affects the degree of pallor - Nature and fluid content of the subcutaneous tissues
C. Pallor is constantly detected in areas far from
the skin surfaces Most constantly detected in:
D. It is affected by the state of vasoconstriction and - Mucous membranes of the mouth, pharynx, conjunctivae, lips, nailbeds
vasodilation (areas where vessels are close to the skin surface)

9. The relevance of taking the drug history and A Drug History

intake of herbal/dietary supplements in patients ○ Antiplatelet, anticoagulants, herbal medication
presenting with bleeding/coagulopathy ■ Can cause coagulopathy
A. Many herbal supplements can impair hemostatic
functions B. Ginseng INHIBITS platelet aggregation
B. Ginseng promotes platelet aggregation C. Fish oil INHIBITS platelet aggregation also
C. Fish oil enhances platelet function D. Clopidogrel is an ADP inhibitor thus INHIBITING platelet aggregation
D. Clopidogrel acting on GP IIb/IIIa causing platelet
migration

10. PH 24 year old male presented in the ER with C

right sided weakness and diagnosed with Patient with a family history of DVT is at risk of having a DVT also, hence
cerebrovascular accident. What additional predisposing the patient to have a dislodged embolus from DVT that could
information should be sought to further aid in the lodged in the brain blood vessels resulting to CVA.
diagnosis and work up of the patient?
A. History of gallstones
B. Family history of hemophilia
C. Family history of venous thromboembolism
D. History of jaundice

11. In the work up of anemic patients which of the C Past Medical History
following statements is true? ○ Past illnesses, previous surgical procedures, previous
A. History should provide an evaluation of hematologic problem that may suggest bleeding diathesis or associated with
cardiovascular involvement hematologic sequelae (e.g., splenectomy)
B. History and PE should seek involvement of the
endocrine system only as a source of anemia Transfusion History
C. History should include prior therapy and ○ Ask about blood products transfused like PRBC, blood
response plasma, etc.
D. History should include recent onset of joint ○ Ask about year of transfusion (Related to infectious
pains process)

12. Indoy came to the clinic complaining of C Pancytopenia is a hematological condition wherein there is a decrease in
hematuria. CBC shows pancytopenia. Which of the ALL cellular components of blood (RBCs, WBCs, Platelets).
following will contribute to the diagnosis of
pancytopenia? Causes:
A. History of paracetamol use Iatrogenic causes include chemotherapy for malignancies if the drugs used
B. History of increased intake of vegetables cause bone marrow suppression.
C. History of exposure to benzenes
organophosphates or herbicides Occupational exposure
D. History of 12 pack years smoking history ○ Chemical exposure (benzene)
■ Can cause malignancies
○ High dose radiation
■ Can cause malignancies
○ Environmental hazards

13. Borders of the Traube’s space: A Traube’s Semilunar Space

A. 6th superiorly, Left anterior axillary line laterally, o area should be resonant
left costal margin inferior o dullness when percussed = (+)
B. 4th superior, Left anterior axillary left, left costal splenomegaly
margin inferior - Boundaries:
C. 6th superior, left posterior axillary line,left costal - Superior: 6th rib
margin inferior - Inferior: Left Costal margin
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 D. 6th rib superiorly, left anterior axillary line, left - Lateral: Anterior Axillary Line
costal margin laterally

14. Folic acid deficiency is an example of: C Refer to the Diagram regarding “Approach to Anemia” on the last page of the
A. Microchtic anemia trans. MEMORIZE and UNDERSTAND!!! VERY IMPORTANT
B. Normochromic, normocytic anemia
C. Megaloblastic anemi
D. Aplastic anemia

15. Which of the following findings represent C/D Refer to # 1 for the rationale.
bleeding due to platelet pathology? According to trans, Choice C could be a possible answer also, BUT the Best
A. Absence of splenomegaly answer still is Choice D. Hematuria can be present in severe platelet
B. Presence of lymphadenopathy deficiency showing spontaneous bleeding. Hematuria is also present in
C. Presence of hematuria coagulation deficiency.
D. Findings of multiple petechiae

16. Which laboratory exam would be deranged with B Hemophilia B is clotting factor deficiency specifically Factor IX.
a patient with hemophilia B?
A. Elevated PT and platelet Remember!!!
B. Elevated APTT - Clotting factor deficiency- check Coagulation studies: PT and aPTT (should
C. Decreased platelet count be PROLONGED or ELEVATED)
D. Decreased RBC - Platelet Disorder- check Platelet Count or Bleeding Time
- Anemia- Check RBC and Hgb

17. 35 year old female presented with multiple B

petechiae on the lower extremities and episodes of
epistaxis. CBC showed low platelets which of the ff
eye findings is seen in thrombocytopenic patient
A. Icterisia
B. Retinal Hemorrhage
C. Copper Wiring
D. Conjunctival injection

18. Enlarged supraclavicular lymph node infiltrated B A. Sister Mary Joseph Nodule refers to a palpable nodule bulging into the
with metastatic cancer from a gastrointestinal umbilicus as a result of metastasis of a malignant cancer in the pelvis or
primary: abdomen.
A. Sister Mary Joseph C. Chloroma is an extramedullary manifestation of AML. In other words, it is
B. Virchow a collection of leukemic cells occurring outside of the bone marrow.
C. Choloroma D. Scrofula is the term used for lymphadenopathy of the neck, usually as a
D. Scrofula result of an infection in the lymph nodes, know as lymphadenitis. Can be
caused by tuberculous or nontuberculous mycobacteria.

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19. Percussion maneuver to evaluate the spleen C Nixon’s Method
done by placing the patient on supine position and 1. Place the patient in Right lateral decubitus.
percussing the 8th intercostal space in the anterior 2. Begin percussion midway along the Left costal margin.
axillary line and noting for resonance if the spleen 3. Proceed in a line perpendicular to the Left costal margin
is normal 4. If the upper limit of dullness extends > 8 cm above the Left costal margin,
A. Middleton’s maneuver this indicates possible splenomegaly
B. Traube’s space maneuver
C. Castell’s maneuver Castell’s Method
D. Nixon’s maneuver 1. Percuss in the lowest Left intercostal space in the
anterior axillary line (usually the 8th or 9th IC space)
2. This space should remain resonant during full inspiration
3. Dullness on full inspiration indicates splenomegaly (positive Castell’s sign)

Bimanual palpation
• Palpation from above (Middleton maneuver)
• The patient is supine with flexed knees. The examiner's left hand
is placed on the lower rib cage and pulls the skin toward the costal
margin， allowing the fingertips of the right hand to feel the tip of
the spleen as it descends while the patient inspires slowly,
smoothly, and deeply. Palpation is begun with the right hand in the
left lower quadrant with gradual movement toward the left costal
margin, thereby identifying the lower edge of a massively enlarged
spleen.
• Ballottement

Traube’s Semilunar Space

• area should be resonant
• dullness when percussed = (+) splenomegaly
• Boundaries:
Superior: 6th rib
Inferior: Left Costal margin
Lateral: Anterior Axillary Line
20. A 25 year old male is complaining of fever B P. malariae with a 72 hours cycle, manifests with fever every fourth day
which he describes as intermittent and occurs (previous paroxysm being day 1) with two days of afebrile interval and is
every 4th day The most likely cause is called quartan malaria.
Plasmodium? P. vivax and P. ovale with 48 hours cycles have the paroxysms every third
A. Falciparum day, termed as tertian malaria.
B. Malariae P. knowlesi, with a 24 hour cycle, manifests with fever every day
C. Ovale (Quotidian).
D. Vivax P. falciparum, fever can occur every third day, or more frequently, even in a
daily paroxysmal pattern, depending on the synchronization and size of the
broods (tertian or subtertian or quotidian).
Mixed infections of P. malariae with the other parasites can result in
double quartan fever, with paroxysms for 2 consecutive days followed by
one day of remission.

21. According to WHO anemia is defined as hgb C Normal Values:

levels of < __ in men Male 13.5-18 g/dL
A. 11 Female 12.5-15 g/dL
B. 12
C. 13 REMEMBER!!!
D. 14 Patient is ANEMIC
If there is a <10% drop in the Hgb level even if it is within normal, consider
the patient as anemic
Always ask for patient’s previous CBCs to investigate further
22. Which of the ff is not consistent with a B Iron Deficiency Anemia is a Microcytic, Hypochromic type of Anemia
diagnosis of Iron deficiency Anemia
A. MCV<80 Normal MCV: 80-100
B. Ataxia Microcytic: <80
C. Microcytic anemia Macrocytic: >100
D. Atrophied papilae of tounge
*refer to the diagram on the last page for the possible causes of these
laboratory results

Iron Deficiency Anemia:

Microcytic, Hypochromic (MCV <80, low hemoglobin (it depends on the age)
Plummer Vinson Syndrome (PVS): “CASE ni IDA”
Cheilosis
Atrophic Glossitis (atrophied papilla of the tongue)
Swallowing difficulty (Dysphagia)
Esophageal webs
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 IDA: Iron Deficieny Anemia

B. Ataxia usually manifest in patients with Pernicious Anemia (B12

deficiency), a type of Megaloblastic Anemia (hence, MCV >80) due to
nerve damage and degeneration of spinal cord.

23. Which of the following is compatible with Iron B *refer to the diagram on the last page for the possible causes of these
Deficiency Anemia laboratory results and its interpretation
A. High ferritin
B. High transferrin REMEMBER!!!
C. High iron saturation
D. High mean cell volume Transferrin is a plasma protein that transport iron through the blood to the
liver, spleen and bone marrow.

LOW transferrin: Liver disease and Hemolytic Anemia

HIGH transferrin: IDA

IDA: Low Iron and Ferritin, HIGH TIBC

Anemia of Chronic Disease: LOW iron and Ferritin, LOW TIBC
24. A patient is complaining of easy fatigability loss FALSE Chest and Heart
of stamina breathlessness his hemoglobin is 70 FALSE • Dyspnea & palpitation
mg/dl the ff PE findings are expected in this patient FALSE • Chest pain (associated with chest infiltration or metastatic diseases to the
PR 60/ min TRUE/FALSE bones)
Pink palpebral conjunctiva TRUE/FALSE • Angina
Diastolic murmur TRUE/FALSE
25. The ff are true about anemia TRUE Acute Hemorrhage
Acute anemia is due to blood loss TRUE/FALSE TRUE • Bleeding from Trauma
Anemia is most often recognized by abnormal blood TRUE • Acute GI Bleeding (PUD, Diverticulosis, Neoplastic Disease, Ulcerative
tests TRUE/FALSE Colitis)
Most of the cases of anemia are hypoproliferative in • Vascular Aneurysm
nature TRUE/FALSE • The likely hematological diagnosis may be apparent from tests carried out
before the patient has been referred, it is nevertheless essential to assess
the clinical background fully
26. A 33 y/o female was diagnosed with Acute D
Lymphoblastic Leukemia by immunophenotyping.
She was not taking aspirin warfarin nor clopidogrel
but she was taking herbal supplements with gingko
bloba and ginseng. Lab showed Hgb of 131 g/l wbc
of 15000 U/L plt of 165000 U/L PT of 14 secs
APTT of 66 secs. Which of the following is
contributory to establish her etiology of
hematoma?
A. The abscence of trauma
B. Taking gingko biloba
C. Plt of 165000
D. Prolonged APTT

27. A 40 year old female consulted because of early C Palpation:

satiety and you suspect that the cause of this is Bimanual palpation
obliteration of the traube’s space which of the Ballottement
following PE techniques will you use to check if the Middleton maneuver
Traube’s space is obliterated Percussion:
A. Auscultation Nixon’s Method
B. Inspection Castell’s Method
C. Percussion Traube’s semilunar space
D. Palpation e

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28. A 60 y/o male presenting with hematuria had B
CBC done which revealed hgb 75 hct of 0.25 wbc of
12000 and plt of 15,000 U/L there was no
splenomegaly no lymphadenopathies however
there were multiple petechiae on examination of the
lower extremities. Which of the ff is the most likely
diagnosis?
A. Iron Deficiency Anemia
B. Aplastic Anemia
C. Immune Mediated thrombocytopenia
D. Pancytopenia due to liver cirrhosis

29. Which of the following findings represents D A - Normal result

bleeding due to platelet pathology? B - platelets are unrelated to Lymphadenopathy
A. Absence of splenomegaly C - Presence of RBC in the urine is not due to platelet pathologies alone
B. Presence of lymphadenopathy D - Multiple petechiae is a hallmark sign of DENGUE, wherein the platelets
C. Presence of hematuria are mainly affected
D. Presence of multiple petechiae
30. EJ was scheduled for elective thyroidectomy. C Hemophilia is suspected in patients with recurrent bleeding, unexplained
However on family history his father has moderate hemarthroses, or a prolongation of the PTT. If hemophilia is suspected,
hemophilia B. PTT, PT, platelet count, and factor VIII and IX assays are obtained. In
hemophilia, the PTT is prolonged, but the PT and platelet count are
EJ’s OR was postponed because of derangement in normal.
this laboratory parameter
A. Elevated PT and Platelet
B. Elevated APTT
C. Decreased Platelet Count
D. Decreased RBC
31. EJ’s procedure was rescheduled until factor IX A Since the patient is undergoing surgery, it follows that for patients with
concentrates are available. EJ’s coagulation Hemophilia B, there is increased risk of bleeding, ergo coagulation
function should be optimal prior to OR because function must be optimal to prevent complications.
A. There is increased risk of bleeding in all
hemophilia patients
B. There is increased risk of thromboembolic
episodes in all hemophilia patients
C. There is increased risk of clotting in all
hemophilia patients
D. AOTA
32. EF, a 30 year old female presenting with D Iron Deficiency Anemia
menorrhagia. PE revealed pallor, absence of Lab Findings:
splenomegaly, absence of lymphadenopathies. o Microcytic hypochromic RBC
CBC was done which revealed hgb 75 hct 0.25 wbc o Increased RDW
10.2x10^9/L plt 250,000 U/L. Peripheral smear o Free Erythrocyte Protoporphyrin (FEP) is increased (no iron to
showed microcytic, hypochromic anemia. Which of bind with protoporphyrin)
the following parameters is the most likely elevated
in this case?
A. Ferritin o Iron Studies:
B. Mean cell volume Ferritin ⬇
C. Iron saturation TIBC ⬆
D. Transferrin % Sat ⬇
Serum iron ⬇

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33. FB, 67 year old male resented with easy C
fatigability and pallor. CBC was done. The RBC
value for indices done on a patient were: MCV 70
femtoliters (NV 84 +-4) MCH 22 picograms (26+-2).
What would be the most likely description of the
red cells appearance in the stained blood film?
A. Macrocytic, hypochromic
B. Macrocytic, normochromic
C. Microcytic, hypochromic
D. Microcytic, normochromic

34. Pernicious anemia and folic acid deficiencies B MEGALOBLASTIC ANEMIA

are examples of _______ anemia: ● Impaired synthesis of DNA precursors → impaired division and
A. Microcytic enlargement of RBC precursors
B. Megaloblastic o Folate and Vit. B12 are needed for synthesis of DNA precursors
C. Normochromic, normocytic ▪ Lack of of nuclear material → “one less division” of RBC → larger RBCs
D. Aplastic and presence of hypersegmented neutrophils
Hence “MEGALOBLASTIC”

Pernicious Anemia - Vit. B12 deficiency

Folic Acid Deficiency also causes megaloblastic anemia
35. In anemia, the reduction of haemoglobin from B If there is a <10% drop in the Hgb level even if it is within normal, consider
previous value is considered significant if the the patient as anemic
current level is reduced by ______%
A. 5 From Doc Julian’s lecture
B. 10
C. 20
D. 50
36. A patient is complaining of easy fatigability, D Dullness in the 9th LICS, AAL = (+) Castell’s Maneuver denoting
loss of stamina, and breathlessness. His presence of SPLENOMEGALY
hemoglobin is 70 mg/dL. Which of the following PE
findings is most likely to be present in this patient? Presence of splenomegaly: Suggestive of
A. Cardiac rate of 55/min Acute or chronic leukemia
B. Pink lips Lymphoma
C. Diastolic murmur Infectious mononucleosis
D. Dullness in the 9th LICS, AAL
A & C - not enough to cause loss of stamina and breathlessness and a low
hemoglobin lvl
B - normal
37. Which of the ff statement/s is/are true of anemia? D A - anemia is diagnosed through abnormal lab findings:
A. Anemia is most often recognized by abnormal Lab Findings:
laboratory tests o Microcytic hypochromic RBC
B. Most of the cases of anemia are o Increased RDW
hypoproliferative in nature o Free Erythrocyte Protoporphyrin (FEP) is increased (no iron to
C. Acute anemia is due to blood loss or hemolysis bind with protoporphyrin)
D. AOTA o Iron Studies:
Ferritin ⬇
TIBC ⬆
% Sat ⬇
Serum iron ⬇

B - Anemia is a HYPOPROLIFERATIVE disorder. Blood components are not

elevated, and hemoglobin is markedly low

C - ACUTE ANEMIA can be brought about by the ff:

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Acute Hemorrhage
o Bleeding from Trauma
o Acute GI Bleeding (PUD, Diverticulosis, Neoplastic
Disease, Ulcerative Colitis)
o Vascular Aneurysm

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