MCQs on Anemia – AMC Wise

Written by Dr. Daniel Fraser (MBBS, FRACP) – Physician

Question 1

A 70-year-old woman presents to your practice with complaints of weakness and easy fatigability for the past 5 months. She is a recent immigrant from Algeria landing in Australia almost 8 months ago. She has been a vegetarian most of her adult life. Past medical history is insignificant for any chronic condition otherwise. Based on the history and physical findings, you suspect anemia and order a full blood examination (FBE) which is significant for a red cell count (RCC) of 2.9×10¹²/L (4.5–6.5×10¹²/L), hemoglobin of 90 g/L (120–160 g/L), MCV of 62 fL (80–100 fL). Which one of the following could be the most likely cause of this presentation?

A) Cecal cancer
B) Thalassemia minor
C) Hookworm infestation
D) The vegetarian diet
E) Vitamin B12 deficiency

Correct Answer: C) Hookworm infestation.

Explanation:

The decreased RCC, low hemoglobin, and low MCV indicate a microcytic anemia. The most common causes of microcytic anemia include iron deficiency anemia and thalassemia.

Thalassemia minor (option B) is unlikely because it typically shows normal or elevated RBC count, and patients are usually asymptomatic.

Vitamin B12 deficiency (option E), which vegetarians are prone to, causes macrocytic anemia, not microcytic, and therefore does not explain the MCV of 62 fL.

A vegetarian diet (option D) usually includes adequate iron from green leafy vegetables, and any anemia related to it would more likely be macrocytic, due to vitamin B12 deficiency.

Cecal cancer (option A) and other right-sided colon cancers can cause iron deficiency anemia, especially in older patients. However, vegetarians have a lower risk of colorectal cancers, and there are no GI symptoms in this case to support this option.

Hookworm infestation (option C) is the most likely cause. Hookworm is endemic in regions like Africa, South Asia, and the Mediterranean, which includes Algeria. Infection is acquired through skin contact with contaminated soil, and chronic infestation can lead to iron deficiency anemia due to intestinal blood loss.

Only about 10% of infected individuals show symptoms, typically iron deficiency anemia in moderate to severe infestations. The parasite’s lifecycle involves skin penetration, pulmonary migration, and eventual residence in the small intestine, where blood loss occurs.

Question 2

A 22-year-old man presents with complaints of weakness and lethargy for the past few months. He denies any abdominal pain, rectal bleeding, or bowel symptoms. His past medical history is not remarkable. A full blood exam (FBE) and iron studies are ordered with the following results:
• RBC: 3.5×10¹²/L (4.5–6.5×10¹²/L)
• WBC: 6.3×10⁹/L (4.0–11×10⁹/L)
• PLT: 210×10⁹/L (150–400×10⁹/L)
• Hemoglobin: 70 g/L (130–180 g/L)
• MCV: 66 fL (76–96 fL)
• Ferritin: 15 µg/L (30–200 µg/L)
• Serum iron: 7 µmol/L (10.74–30.43 µmol/L)

Which one of the following options is most likely to help reach a diagnosis?

A) Bone marrow biopsy
B) Small bowel biopsy
C) Hemoglobin electrophoresis
D) Colonoscopy
E) Sigmoidoscopy

Correct Answer: D) Colonoscopy.

Explanation:

This young male has iron deficiency anemia, evidenced by low hemoglobin, microcytosis (MCV 66 fL), and low ferritin (15 µg/L). According to the Royal College of Pathologists of Australasia, ferritin <30 µg/L confirms iron deficiency. Iron deficiency is not a final diagnosis—it always requires identification of an underlying cause.

In males with unexplained iron deficiency anemia, the most common and important source of blood loss is the gastrointestinal (GI) tract. Therefore, GI investigations are mandatory to evaluate for possible occult bleeding or malignancy. Colonoscopy is the best first step to assess for sources of bleeding, especially in the right colon, which may not present with overt symptoms.

Sigmoidoscopy (option E) is not sufficient, as it only examines the distal colon and may miss proximal lesions.
Small bowel biopsy (option B) is used only after positive celiac screening tests or when small bowel pathology is suspected.
Hemoglobin electrophoresis (option C) would be relevant if thalassemia were suspected. However, in this case, low ferritin and iron levels rule out thalassemia.
Bone marrow biopsy (option A) is reserved for pancytopenia or unexplained anemia not attributable to nutritional deficiency.

Thus, colonoscopy is the most appropriate and likely to yield a diagnosis.

Question 3

A 25-year-old man develops shortness of breath shortly after landing in Port Vila after a flight from Sydney. He has a known history of sickle cell trait, and his father died of myocardial infarction at the age of 36. He denies chest pain and joint or muscle pain but reports mild shortness of breath. On examination, he has central cyanosis, a blood pressure of 130/85 mmHg, pulse of 110 bpm, respiratory rate of 24 breaths per minute, and is afebrile. Pulse oximetry reveals an oxygen saturation of 86% on room air. A full neurological examination is inconclusive. Which one of the following is the next best step in management?

A) Start intravenous heparin immediately
B) Do a chest X-ray to confirm pulmonary embolism
C) Do an ECG
D) Do CTPA to confirm pulmonary embolism
E) Give oxygen and review

Correct Answer: E) Give oxygen and review.

Explanation:

This patient has sickle cell trait, which is usually benign, but complications can arise in situations like hypoxia from high altitude or prolonged air travel. In rare cases, individuals may develop shortness of breath and central cyanosis due to impaired oxygen delivery.

The immediate priority in any hypoxic patient is to correct the oxygen saturation. Giving supplemental oxygen is the safest and most urgent step, which will help determine if the symptoms resolve or persist.

If the hypoxia resolves, other serious causes like pulmonary embolism or acute chest syndrome become less likely. If symptoms persist despite oxygen, further work-up with a chest X-ray, ECG, and CTPA may be warranted.

CTPA (option D) is useful if PE is strongly suspected, but it’s not the first step.
ECG (option C) may support PE diagnosis but is nonspecific.
Chest X-ray (option B) can rule out other causes but doesn’t confirm PE.
Heparin (option A) should not be started empirically without a diagnosis.

Thus, the first and most appropriate step is to administer oxygen and monitor the patient’s response.

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6. Hematology Module

6.1 Anemia

6.2 Thrombocytopenia

6.3 Thromboembolism

6.4 Anti-Coagulation

6.5 Lymphomas

6.6 Other Hematological Disorders