Correctly: Incorrectly

You answered the question correctly.
Aplastic anemia may be caused by all of the following except:
The correct answer is highlighted below
Infections
Chemical agent
Enzyme deficiencies
Ionizing radiation
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Enzyme deficiencies are usually associated with hemolytic anemias.
Question Difficulty: Level 6

You answered the question incorrectly.
Identify the cell in this illustration:
Myeloblast
Myelocyte
Monocyte
Metamyelocyte
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The cell in the image is a myeloblast. The myeloblast typically has a high nuclear to
cytoplasm ratio, meaning that the nucleus size is increased compared to the amount of
cytoplasm present. This cell can be defined as a myeloblast and not another type of
blast, due to the presence of the auer rod in the cytoplasm. This is a key feature only
found in myeloblasts.

A patient suffering from typical leukemic symptoms presents in the emergency room.
Physicians order a spinal tap after noticing possible central nervous system
involvement. What are the cells seen in his spinal fluid cytospin preparation? (choose
all that apply)
The correct answers are highlighted below
Reactive mesothelial cells

Monocytes
Atypical lymphocytes
Blasts
Tumor cells other than leukemic basts
Lymphocytes
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In this cerebrospinal fluid cytospin, the predominant cell type appears as large cells
with irregularly shaped nuclei and scant cytoplasm. These cells are L2 Lymphoblasts
and would be reported as blasts. Examples are indicated by the red arrows. There are
also a few normal lymphocytes in this field as well. Examples are indicated by the
blue arrows.

Why might serum ferritin (SF) alone be considered a less than optimal screening test
for hereditary hemochromatosis (HH)?
It is an acute phase reactant that is frequently elevated in a variety of clinical

conditions.
It does not assess an individual's iron status.
It is an expensive test to perform.
It is only performed in laboratories doing molecular assays.
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SF is an acute phase reactant that is frequently elevated in a variety of clinical

conditions, therefore it lacks the specificity needed for a good screening test.


Match the red cell morphologies shown in the images to the right with their most
likely corresponding clinical condition.
Your answers are on the left. The correct answers are on the right and highlighted.
Myelofibrosis Frame A
Uremia Frame B
Disseminated intravascular coagulation Frame C
Abetalipoproteineimia Frame D
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In Frame A are tear drop cells, a red blood cell morphology highly associated with
myelofibrosis. In Frame B, burr cells are present, representing artifacts of smear
preparation or true burr cell presentation accompanying uremia. In Frame C,
schistocytes are present, which is a common marker in disseminated intravascular
coagulation. Finally, in Frame D, acanthocytes are present, which accompany lipid
disorders, including abetalipoproteinemia.

The cell diameter of a normal RBC is slightly smaller than the nucleus of a small
lymphocyte.

True
False
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Normal red blood cells are round, biconcave, and measure about 6-8 µm in diameter.
Their size can be compared to the nucleus of a small lymphocyte. This is a good way
to estimate RBC shape on a peripheral smear if the MCV is not available.

All of the following statements describe an eosinophil EXCEPT:
Cytoplasm contains large purple/blue-staining granules.

May be called an "eo"
Is a member of the granulocyte series
Cytoplasm contains large reddish-orange granules.
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'Eosinophils do not have cytoplasm containing large purple/blue-staining granules.

Instead, their granules are large but are orange/red in color. These granules are very
distinctive for this type of cell, typically making their identification simple.

Using an automated cell counter analyzer, an increased Red Cell Distribution Width
(RDW) should correlate with:

Leukocytosis
Anisocytosis
Spherocytosis
Platelet satellitosis
macrocytosis
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Anisocytosis, or the increased variation in red cell size, would be expected if the red
cell distribution width (RDW) was elevated.
Leukocytosis defines an increase in white blood cell counts.
Spherocytosis could cause a lowered MCV, but would not affect the RDW as much as
anisocytosis would.
Platelet satellitosis would affect white cell and platelet counts, but not have an impact
on the RDW.
Finally, if macrocytosis is present, the MCV would be increased, but unless there is
anisocytosis present also (meaning microcytes and normocytes) the RDW would not
be greatly affected.

The gel electrophoresis pattern for hemoglobin S shows which of the following
migration patterns?
Hb S migrates alone in alkaline and D in acid electrophoresis.

Hb S migrates with D in alkaline and A in acid electrophoresis.
Hb S migrates with D in alkaline and alone in acid electrophoresis.
Hb S migrates with A in alkaline and D in acid electrophoresis.
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Hb S migrates with D in alkaline and alone in acid electrophoresis.

The abnormal RBC shape seen in this illustration is:
Burr cell
Target cell
Helmet
Stomatocyte cell
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Helmet cells appear as if a section had been bitten out of them.


The predominant cells seen in this CSF are suggestive of:
Normal cytocentrifuged smear

Viral meningitis
Bacterial meningitis
Alzheimer's disease
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Almost exclusively mononuclear cells are seen, suggestive of viral meningitis.

The M:E ratio represents the ratio of:
monocytes to erythrocytes
myeloid cells to erythroid cells
myelocytes to erythrocytes
megakaryocytes to erythrocytes
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The M:E ratio stands for the Myeloid:Erythroid ratio. This represents the relationship
of myeloid cells and erythroid cells.

Cells that stain positive with acid phosphatase, and are NOT inhibited with tartrate,
are characteristically seen in:
Infectious mononucleosis
Infectious lymphocytosis
Hairy cell leukemia
T-cell ALL
Leukomoid reactions
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Tartrate resistant acid phosphatase (TRAP) is a test performed on blood cells or bone
marrow to confirm a diagnosis of hairy cell leukemia. Hairy cells characteristically
display red staining granulation with the TRAP stain, while other leukocytes will not.
Hairy cells will also stain positive, like other types of leukocytes with regular acid
phosphatase stain.

Select each marker listed below that is expressed by a normal mature B cell.
CD19
CD20
Kappa or Lambda
CD2
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Normal mature B cells express CD19, CD20, and Kappa or Lambda.
CD2 is expressed by mature T cells.

Which of the following erythrocyte inclusions is indicated by the arrow in the image
on this page?
Pappenheimer bodies
Siderotic granules
Basophilic stippling
Howell-Jolly bodies
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The cell indicated by the arrow is demostrating basophilic stippling. Basophilic

stippling is a condition where the red blood cells have cytoplasmic remnants of RNA
which give the cells their speckled appearance. This condition is associated with
various types of anemia as well as lead poisoning.

Identify the large, foamy cells in the joint fluid image shown to the right.
Macrophage
Bronchial lining cells
Tumor clump
Synovial lining cells
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The large foamy cells in the joint fluid are synovial lining cells.

Conditions suggested by the macrocytes and the neutrophil in the photograph to the
right include which of the following?
Thalassemia
Vitamin B12 deficiency
Pelger-Huet anomaly
Folate deficiency
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The intended response is Vitamin B12 and folate deficiencies. Each of these
conditions lead to a megaloblastic production of the red blood cells in the bone
marrow. Since vitamin B12 and folate are needed in order to produce a synchronous
development of the nucleus with the cytoplasm in hematologic cells, oval-
macrocytosis often occurs if these nutrients are not in adequate supply within the
body. This can also affect neutrophils, allowing for the characteristic hypersegmented
nucleus.
The photographic field contains several oval-macrocytes and a hypersegmented

neutrophil with greater than 5 nuclear segments. Oval macrocytes are most commonly
associated with pernicious anemia and malabsorption syndromes leading to vitamin
B12 and folic acid deficiencies.
Clinical information relating to chronic infection, aplastic anemia, and other
hematologic maligancies provide the context for the presence of the oval macrocyte.
Macrocytic erythrocytes and hypersegmented neutrophils are not present in

thalassemias or in Pelger-Huet anomaly (hyposegmented neutrophils).

Which of these factors may be deficient if both the PT and aPTT are prolonged?
Factor II
Factor VII
Factor VIII
Factor XI
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If both the PT and aPTT are prolonged, one or more factors in the common pathway
may be deficient. Factor II is in the common pathway along with factors I, V, and X.
Factors VIII and XI are intrinsic pathway factors. If either of these factors were
deficient, the aPTT would be prolonged, but the PT would be normal. Factor VII is
monitored by the PT test. If factor VII were deficient, the PT would be prolonged, but
the aPTT would be normal.


Identify the cell in this illustration indicated by the arrow:
Eosinophil
Monocyte
Basophil
Neutrophil
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Eosinophils have characteristic large prominent orange granules.


The hemoglobin electrophoresis patterns that are shown on the right include controls
for A and F and A, S, and C above and below the patient results on the alkaline
electrophoresis (on the left) and above the patient results on the acid electrophoresis
(on the right). (NOTE: AF and ASC are simply labels for the controls and do not
indicate order of migration.) The patient was tested in duplicate and the results are
in lanes 4 and 6.
The patient lanes displayed in these hemoglobin electrophoresis patterns are

consistent with what diagnosis?
HbSA
HbSC
HbSD
HbS/HPFH
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The patient lanes show equal bands of hemoglobin in the "S" position and the "A"
position on both alkaline and acid electrophoresis.

With which of these conditions or procedures may there be an increased number of

megakaryocytes in the bone marrow, but a decreased number of circulating platelets?
Folic acid deficiency

Aplastic anemia
Radiation therapy
Massive blood transfusion
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Pancytopenia is often seen with megaloblastic anemias that are caused by folic acid or
vitamin B12 deficiency. Thrombopoiesis (as well as erythropoiesis and granulopoiesis)
is ineffective. The bone marrow will contain normal, or even increased
megakaryocytes, but the number of platelets entering the peripheral circulation is
decreased.
In aplastic anemia, megakaryocytes are decreased in number in the bone marrow,

leading to a decreased number of circulating platelets.
Radiation therapy causes bone marrow hypoplasia. Platelets as well as all other cell
lines are depressed. The effect is transient; once the therapy has ended, the marrow
will regenerate.
Massive blood transfusion may also cause a transient thrombocytopenia, but

megakaryocytes will not be increased in the bone marrow.


A monoclonal B-cell population (Kappa or Lambda predominant) with expression of
CD19, CD20, CD23, and co-expression of CD5 is consistent with which of the
following?
A normal B cell
Chronic lymphocytic leukemia
Mantle cell lymphoma
A mature T cell
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If Kappa or Lambda is predominant and CD5 is co-expressed with CD19 (CD19/CD5

dual positive lymphocyte population), and CD23 is expressed, chronic lymphocytic
leukemia is a probable diagnosis. CD19 is normally found on normal B cell
populations and CD5 is normally found on mature T cell populations. However, CD5
is present on B cells in B-chronic lymphocytic leukemia or Mantle Cell Lymphoma,
both abnormal B cell malignant processes.
CD23 expression is not consistent with Mantel cells as shown on the decision tree on
the right.

The scatterplot that is pictured below represents results from a normal peripheral
blood sample that analyzed using flow cytometery.
The cell that is indicated by the arrow on the right would fall into which of the circled
areas?
Population A
Population B
Population C
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The arrowed cell would display with the population of cells included in the circled
area that is labeled "C."
The cell that is indicated by the arrow is a segmented neutrophil. Segmented

neutrophils are the most granular of the white blood cells in a sample of normal
peripheral blood. Therefore, segmented neutrophils would display furthest to the right
on a scatterplot where the x axis is side scatter, representing granularity.

Continue to the next page »
Report a problem with this question.
Which of the following is currently considered to be a good test for screening persons
for hereditary hemochromatosis (HH) due to its sensitivity and specificity for iron
overload. ?
Transferrin saturation
Liver biopsy
Quantitative phlebotomy
Serum iron alone
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The most widely used test for screening for HH is the transferrin saturation due to its
sensitivity and specificity for iron overload.

What is the identification of the red blood cell inclusions indicated by the arrows on
this peripheral blood smear image?
Howell-Jolly bodies
Pappenheimer bodies
Heinz bodies
Basophilic stippling
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The small, spherical, dark blue-staining, non-refractile inclusions are known as

Howell-Jolly bodies. They may represent chromosomal remnants, and may be found
in pernicious anemia, hemolytic anemias, and often after splenectomy.

Observe the bone marrow sample in the image to the right. Out of the descriptors
below, please select all that apply.
Myeloid precursors predominant

Erythroid precursors predominant
Normal myeloid to erythroid (M:E) ratio present
Inverted M:E ratio - around 1:3
Megakaryocyte absent
Megakaryocyte present
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This is a trilinear bone marrow with an erythroid predominance. This causes an

inverted M:E ratio; meaning there are more erythroid precursors then myeloid
precursors present.

What abnormaility is present in the white blood cell indicated by the arrow?
Döhle bodies
Pelger-Huet anomaly
Toxic granulation
Auer rods
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The cell is exhibiting toxic granulation. Toxic granulation can be seen in infections
and inflammations.

Which of the following types of lymphocytes express CD4?

Only T-helper cells

Only T-suppressor (cytotoxic) cells
All T cells
B cells
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T- helper cells express CD4.
Neither T-suppressor cells nor B cells express CD4.
CD3 is expressed by all mature T cells (helper and suppressor), but is not expressed
by B cells.

This drawing depicts which alpha chain genotype?
Alpha thalassemia major (Hydrops fetalis)

Alpha thalassemia intermedia (Hemoglobin H Disease)
Normal Adult
Silent Carrier
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The genotype pictured, --/-α, is known as Alpha thalassemia intermedia or

Hemoglobin H disease.
When three gene loci of alpha chains are deleted (--/-α) or inactive, only 70-90% of
Hemoglobin A is made.
The excess beta chains that remain unpaired form the tetramers of Hemoglobin H.

Which of the following laboratory tests of hemostatic function is a screening test used
to assess the functionality of both the intrinsic and common pathways?
Bleeding time
Activated partial thromboplastin time (aPTT)
Prothrombin time (PT)
Factor assays
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The intrinsic and common pathways can be analyzed by utilizing the aPTT test.

In which disorder may a mild anemia be present even with an increased red blood cell
(RBC) count and normal adult hemoglobin electrophoresis?
Alpha thalassemia silent carrier

Alpha thalassemia minor
Alpha thalassemia intermedia
Alpha thalassemia major
Feedback
Alpha thalassemia minor may show an increased RBC count and normal adult
hemoglobin electrophoresis, even though the hemoglobin is decreased and anemia is
present.

Identify the white blood cell seen in this illustration:
Myelocyte
Neutrophil
Eosiniphil
Basophil
Feedback
Basophils have characteristic large prominent dark granules.

The large number of these cells seen in the CSF cytocentrifuged smear in this
illustration is suggestive of:
Fungal infection
Viral infection
Malarial infection
Bacterial infection
Feedback
Almost exclusively segmented neutrophils are seen, suggestive of bacterial infection.

Match the following cells with their corresponding characteristics:
May live 20 years or more T-cell

Transform into fixed or free macrophages Neither T-Cell nor B-Cell
Type of lymphocyte T-Cell and B-Cell

All of the following statements describe a method by which platelets aid coagulation
EXCEPT:
Lower blood pressure by releasing heparin

Catalyze coagulation by releasing Platelet Factor 3
Cause blood vessels to constrict by releasing serotonin
Form a plug to stop the flow of blood
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Platelets do not lower blood pressure by releasing heparin. However, they do form a
plug to stop the flow of blood, cause blood vessels to constrict by releasing serotonin,
and catalyze coagulation by releasing platelet factor 3. Each of these functions aids in
the process of coagulation.

Please identify the illustrated leukocyte.
Neutrophil
Monocyte
Lymphocyte
Basophil
Eosinophil
Platelet
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The cell illustrated in the image on the right is a lymphocyte. Lymphocytes typically
have a round, darkly staining nucleus with a scant amount of blue cytoplasm
surrounding the nucleus.

Which of the following smear techniques can be utilized when processing bone
marrow aspirate samples? (Choose all that apply)
Differential smear
Touch prep
Coverslip smear
Pull prep
T-prep
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Coverslips, differential smears, pull preps and t-preps are all techniques used when
making bone marrow aspirate smears. Touch preps are made from bone marrow
biopsy samples.

Traditional coagulation assays are based almost solely on this technique:
Chromogenic assays
Clot-based assays
RIA assays
ELISA assays
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Traditional coagulation assays were all based on the detection of clot formation.

Hypersegmentation of granulocytes is most commonly associated with:
Inherited trait or lipid storage disease

Iron deficiency
Viral infection
Vitamin B12 or Folate deficiency
Feedback
Hypersegmentation can be the result of B12 or folate deficiency.

Which HFE genotype is most common in patients with hereditary hemochromatosis

(HH)?
homozygous for C282Y

heterozygous for C282Y
homozygous for H63D
heterozygous for H63D
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The majority of patients with HH are homozygous for the C282Y mutation of the
HFE gene.

The light blue-gray inclusions observed in the cytoplasm of many of the bands and
segmented neutrophils of a burn patient are MOST likely?
Auer rods
Dohle bodies
Toxic granules
May- Hegglin bodies
Feedback
Dohle bodies are associated with the peripheral smears of burn patients. Auer rods
are found in myeloblasts, toxic granules can be found in many conditions, especially
infections. May-Hegglin bodies are found in May-Hegglin anomaly- a white cell
disorder.

Identify the nucleated blood cell:
Lymphocyte
Neutrophil
Band form
Monocyte
Eosinophil
Basophil

Which of the following statements is FALSE?

White blood cell counts increase more in bacterial septicemia than in viral
meningitis.
Nucleated red blood cells can cause a falsely decreased white blood count.
An acceptable blood smear (i.e., peripheral smear) will have a feathered edge.
Normal cell count values often differ among age groups.
Feedback
Nucleated red blood cells actually cause a falsely elevated WBC count as they are
often counted as white cells during automated CBC analysis.

A patient admitted to the hospital for ongoing fever produces the following laboratory
results:
RBC count: 3.56 x 1012/L
WBC count: 57.5 x 109/L
Platelet count: 375,000/uL
Differential count: 3 blasts, 10 myelocytes, 6 metamyelocytes, 12 bands, 64 segs, 4

lymphocytes, and 1 monocyte
LAP score = 155.
Which of the following conditions correlates closely with this patient's results?
Leukemoid Reaction
Chronic Myelogenous Leukemia
Genetic translocation (9;22)(q34;q11)
Paroxysmal Nocturnal Hemoglobinuria
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A high white blood cell count, usually 50-100 x 109/L with a left shift is a common
finding in leukemoid reactions. In addition, a key feature of a leukemoid reaction is a
high LAP score.
Chronic Myelogenous Leukemia (CML) is highly associated with the Philadelphia

chromosome, or translocation (9;22)(q34;q11). CML typically shows a low LAP
score, in contrast to the findings in this case.
Finally, Paroxysmal Nocturnal Hemoglobinuria (PNH) is also associated with a low

LAP score, which excludes this as the correct answer.

The most immature neutrophil found in normal peripheral blood is:
Segmented neutrophil
Neutrophil band
Eosinophil
Basophil
Feedback
The band neutrophil is the earliest neutrophil precursor that is found in normal
peripheral blood. Other precursor cells such as blasts, promyelocytes, myelocytes, and
metamyelocytes should not be found in nornal peripheral blood.

What is one of the main characteristics of secondary granules in the neutrophilic

granulocyte cytoplasm?

Appear first at the myelocyte stage
Dissolve in mature granulocytes
Are formed on the mitochondria
Are derived from azurophil (primary) granules
Feedback
Secondary granules, also known as specific granules first appear in the myelocyte
stage next to the nucleus. In neutrophils this is termed the "dawn of neutrophilia".

Spherocytes are associated with which two of the following conditions:
Hereditary spherocytosis
Autoimmune hemolytic anemia
Thalassemia
Iron deficiency
Feedback
Spherocytes result from removal of small amounts of erythrocyte membrane, with

resultant reduction in surface to volume ratio. This may occur in the
reticuloendothelial system, as in hereditary spherocytosis and autoimmune hemolytic
anemia, or may be due to direct injury of red cells, as in patients with severe burns.


Spherocytes are associated with which two of the following conditions:
Hereditary spherocytosis
Autoimmune hemolytic anemia
Thalassemia
Iron deficiency
Feedback
Spherocytes result from removal of small amounts of erythrocyte membrane, with

resultant reduction in surface to volume ratio. This may occur in the
reticuloendothelial system, as in hereditary spherocytosis and autoimmune hemolytic
anemia, or may be due to direct injury of red cells, as in patients with severe burns.

Which form of hemoglobin cannot be measured using the cyanmethemoglobin

method:
Sulfhemoglobin
Carboxyhemoglobin
Oxyhemoglobin
Hemoglobin
Feedback
Sulfhemoglobin cannot be oxidized by potassium cyanide.

The diagnostic value of the reticulocyte count in the evaluation of anemia is that it
determines the:
response and potential of the bone marrow

nutritional status of the patient
corrected RBC count after calculation
potential sampling error for RBC count
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Reticulocytes counts can help determine how well the bone marrow is responding and
its potential to make new RBCs. For example, an increased retic count could show the
physician that the medication given to a patient to treat his/her anemia is working
since the bone marrow is releasing new, young RBCs (reticulocytes).

A bone marrow biopsy from a 50-year-old patient that has an overall cellularity of
20% (i.e., 80% fat and 20% hematopoietic cells) is considered:
normocellular
hypocellular
hypercellular
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A general estimate of the expected normal cellularity range in an adult can be

determined by first subtracting the age of the patient from 100%. The range is then +/-
10 of that number. Therefore, a normal, healthy 50-year-old should have an overall
cellularity between 40% and 60%.
At age 50, cellular elements to fat cells in the bone marrow is about 1:1; meaning that
adults should have approximately 50% fat and 50% hematopoietic cells in the bone
marrow. If there is an increased amount of fat with a decreased percentage of cells,
this is considered to be HYPOcellular.

An abnormality of which of the following assays would be least likely to be

associated with thrombotic tendency:
AT III
Protein C
APTT
Protein S
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APTT is used to evaluate the intrinsic pathway. Deficiencies of Protein C, Protein S,

and Antithrombin III all cause hypercoagulability.


Match the letter representing the cell type with the condition in which increased
numbers of the cell may be found in the peripheral smear.
Infectious lymphocytosis Frame A

Multiple myeloma Frame B
Metastatic carcinoma Frame C
Pulmonary tuberculosis Frame D
Feedback
In Frame A is shown a small atypical lymphocyte found on the peripheral smear in

infectious lymphocytosis; in Frame B, a plasmaytoid lymphocyte is found on the
peripheral smear of a patient with multiple myeloma; in Frame C, a circulating
nucleated red blood cell on a smear from a male with prostate cancer and metastasis
to the bone marrow; in Frame D, a monocyte. Increased numbers of these cells may
circulate in the peripheral blood of patients with tuberculosis.


Select the choices below that would need to be resulted when reporting this cytospin
from a pleural fluid.
Macrophages
Mesothelial cells
Tumor cells
Histocytes
Neutrophils
Bacteria
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This is a mesothelial clump in a patient with pneumonia and there are RBCs and
neutrophils in the background.


Select the choices below that would need to be resulted when reporting this cytospin
from a pleural fluid.
Macrophages
Mesothelial cells
Tumor cells
Histocytes
Neutrophils
Bacteria
Feedback
This is a mesothelial clump in a patient with pneumonia and there are RBCs and
neutrophils in the background.

New Methylene Blue works by what mechanism?

reflecting ultra-violet light

inhibit lipids and proteins
staining hemoglobin components
staining cytoplasmic RNA, mitochondria, and ribosomes
Feedback
New methylene blue actually stains cytoplasmic RNA, mitochondria, and ribosomes.
It does not stain hemoglobin components, does not inhibit lipids and proteins, and
does not reflect ultra-violet light.

A patient with a Platelet count of 230 x 109/L, and a Bleeding time of 15 minutes,
could be suffering from which condition?
Defective platelet function

Decreased platelet production
Increased platelet production
Increased platelet destruction
Feedback
The normal platelet count combined with an abnormal bleeding time points to a
qualitative platelet problem, also known as defective platelet function. It could not be
increased or decreased platelet production nor increased platelet destruction since the
platelet count is within normal range.

The hematology analyzer reported an elevated white blood cell count and flagged for
manual review due to the suspected presence of immature cells. What is the arrowed
cell's identity, and what name is given to its inclusion?
Lymphoma cell with ingested bacteria

Promyelocyte with overlying platelet
Blast with Auer rod
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The arrowed cell is a blast containing an Auer rod. Auer rods are red-purple in color
and 0.2 to 0.5 µm in length. One or more may be observed in the cytoplasm of blasts.

Which of the following is least likely to stimulate the production of reactive

lymphocytes:

HIV
Cytomegalovirus
Infectious mononucleosis
Toxoplasmosis
Feedback
The HIV virus suppresses lymphocyte production.

The Red cell distribution width (RDW) in alpha thalassemia is
within normal limits

usually increased
usually decreased
Feedback
The red blood cell distribution width (RDW) increases as the severity of alpha
thalassemia increases because of changing MCV as the bone marrow produces
smaller cells. In addition, if Hemoglobin H bodies are present, they result in the
formation of schistocytes (RBC fragments) that can have an effect on the MCV and
RDW.


Which hormone is produced by the kidney and influences erythrocyte production?
Growth hormone
erythropoietin
hemoglobin synthetase
ALA synthetase
Feedback
Erythropoietin, or EPO, is created in the kidney and signals the bone marrow to
produce more red blood cell precursors. EPO is simulated during anemia and
conditions that lead to low blood oxygen levels.

A patient with multiple myeloma is admitted to the hospital due to a flare up of

symptoms. Her physician orders a complete blood count with differential. The
peripheral blood smear is shown below. Which morphology is consistent with the
findings in this case?
Rouleaux
Agglutination
Polychromasia
Hypochromia
Feedback
The red blood cells present in this image have "stacked coins" formation. This is
known as rouleaux formation, which is highly associated with conditions where
increased serum proteins, particularly fibrinogen and globulins., are present. This
stacking is also the mechanism for increased sedimentation rates, as associated with
multiple myeloma and other inflammatory conditions. Plasma cell disorders such as
multiple myeloma are characterized by a clonal population of plasma cells that
produce a monoclonal protein (M protein, or paraprotein), causing the red blood cells
to stick together and form rouleaux.

==
A college student is treated in the hospital for suspected meningitis. Which cells
should be identified in the cerebrospinal fluid report for the cytospin field that is
shown?

Monocytes
Blast cells
Lymphocytes
Tumor cells
Atypical lymphocytes
Feedback
The cell types which should be included in this report are lymphocytes and atypical
lymphocytes.

Which of the following observations would best explain why a peripheral blood smear
is exhibiting polychromasia:
Lower RBC count

Increased reticulocyte count
Decreased hematocrit
Increased hemoglobin concentration
Feedback
Reticulocytes contain residual RNA which gives a bluish hue to RBCs when they are
stained.

In which of the following conditions is Hgb D elevated?
Hemoglobin D disease
Hemoglobin SD disease
Hb D/beta-thalassemia
Hemoglobin CD disease
Alpha thalassemia
Feedback
Hemoglobin D is an inherited autosomal recessive variation of Hb A that occurs in the

β-globin protein chain of Hb A. The formation of Hb D occurs by substitution of
glutamic acid for glutamin at codon 121 of the β-chain. Hemoglobin D disease, also
known as Hb DD, occurs when two copies of the Hb D variant gene are inherited. It is
also possible to inherit a condition known as Hb D/beta-thalassemia (Hb D/β-thal).
Hemoglobin CD disease does not exist and alpha thalassemia would not show an
increase in hemoglobin D.

Warfarin-based (coumarin derivative) oral anti-coagulant therapy is commonly

monitored with :
APTT
PT/INR
APTT and PT
Thrombin time
Feedback
Coumarin derivatives inhibit the vitamin K dependent Factors (II, VII, X) which can
be measured with the PT and monitored frequently with the INR assay.

Match the following blood cell types to the respective body fluids where they may
reside.
Choriod Plexus Cluster Cerebrospinal Fluid

Mesothelial Cells Pleural and Peritoneal Fluids
Synovial Lining Cells Joint Fluids
Bronchial Lining Cells Bronchoaveolar Lavages (BALs)
Feedback
Bronchoaveolar Lavages = Bronchial lining cells
Joint Fluids = Synovial lining cells
Cerebrospinal Fluid = Choriod Plexus Clusters
Pleural + Peritoneal Fluids = Mesothelial cells

A yellow coloration found in fresh cerebrospinal fluid supernatant is termed:
Xanthochromia
Hemolysis
Jaundice
Hyperlipidemia
Feedback
Xanthochromia usually implies subarachnoid hemorrhage of at least several hours

duration, if in vitro lysis of red cells can be excluded.

A white blood cell stained with Wright’s stain has the following characteristics:
 Round eccentric nucleus with clumped chromatin pattern

 1:1 nucleus to cytoplasm ratio
 Basophilic cytoplasm
 Crescent-shaped clear area next to nucleus
What is the MOST likely identification of this cell?
myeloblast
plasma cell
reactive lymphocyte
polychromatic normoblast
rotunda blast
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Plasma cells, which produce immunoglobulin, characteristically show a "halo" next to

the nucleus, which is a cresent shaped lighter colored region of the cytoplasm. The
eccentric nucleus and the 1:1 nucleus to cytoplasm ratio with basophilic cytoplasm are
also typical characteristics of plasma cells. Plasma cells are seen in most commonly in
patients with conditions such as multiple myeloma, plasmacytoma, plasma cell
leukemia, Waldenström macroglobulinemia, and malignant neoplasms.

A defect in which of the following factors causes impaired platelet adhesion and
aggregation?
Stuart-Prower factor
Von Willebrand factor
Hageman factor
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In hemostasis, the adhesion of platelets to the collagen exposed on subendothelial cell

surfaces is mediated by von Willebrand factor (vWF). vWF acts as a bridge between a
specific glycoprotein complex on the surface of platelets and collagen on the
subendothelial surface.


What is the identification of this cellular clump found in CSF? Note the presence of
many similar-appearing nuclei without distinct lines of demarcation between cells.
Choroid Plexus Clump

Mesothelial Clump
Ependymal Clump
Macrophage Clump
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A key feature in identifying ependymal clumps is the presence of many similar-

appearing nuclei without distinct lines of demarcation between cells. Basically, this
cellular clump appears as one large cell, instead of many individual cells. Choroid
plexus clumps, mesothelial clumps, and macrophages do not display this "fused"
morphology between cells. These types of cell clumps appear as individual cells
gathered into a grouping.


This autosomal recessive disorder is associated with recurrent bacterial infections and
cells consistent with the cell in the image.
Alder-Reilly anomaly
May-Hegglin anomaly
Chediak-Higashi syndrome
Pelger-Huet anomaly
Chronic granulomatous disease
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The cell in the image as well as the clinical picture are consistent with Chediak-
Higashi syndrome. Chediak-Higashi cells appear to have giant lysosomes and fused
granules in the cytoplasm. This cell is not consistent with the morphologic
appearances of Alder-Reilly anomaly, May-Hegglin anomaly, Pelger-Huet anomaly,
or Chronic granulomatous disease.


On this alkaline electrophoresis gel, which patient most likely has an alpha
thalassemia syndrome ?
1
2
3
4
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Lane six in this alkaline electrophoresis demonstrates the typical control pattern of
hemoglobins C, S, and A from left to right; and Lane five is the hemoglobin F, A
control. The patient lanes show the following patterns from left to right:
Lane 1- normal (nearly undetectable) amounts of hemoglobin A2, and normal

hemoglobin A
Lane 2- equal amounts of hemoglobin C, and hemoglobin A
Lane 3- decreased amount of hemoglobin A, and a clearly visible band of hemoglobin
H
Lane 4- a visible band of hemoglobin A2, and near equal amounts of hemoglobin S,
and hemoglobin A


Match clotting factor with its commonly associated name:
Factor XII Hageman factor

Fletcher factor Prekallikrein
Factor XIII Fibrin stabilizing factor
Fitzgerald factor High-molecular-weight kininogen
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Factor XII- Hageman factor
Factor XIII- Fibrin stabilizing factor
Fletcher factor- Prekallikrein
Fitzgerald factor- High-molecular-weight kininogen

What characteristics are often associated with alpha thalassemia intermedia?
Nothing abnormal
Polycythemia, hepatomegaly,
Anemia, splenomegaly
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Infants born with alpha thalassemia intermedia appear normal at birth but often
develop anemia and splenomegaly by the end of their first year.
Hepatomegaly is not a common finding.

The red blood cells pictured here are morphologically normal.
True
False
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The red blood cells depicted in this image display both normal size and hemoglobin
content. These cells would be described as normocytic, normochromic.


A manual white blood cell count was performed by the hematology technologist. The
cell counts for both sides were 99 and 164 respectively. All nine large squares were
counted on each side. The dilution for this kit was pre-measured at 1:100. What
should the technologist report as the white cell count?

14.61 x 10^9/L
1.46 x 10^9/L
4.61 x 10^9/L
cannot report
Feedback
The white cell counts from one side of the hemacytometer to the other are too
discrepant to report.

When performing controls for the morning run in coagulation, the normal control is
within acceptable limits for both PT and APTT, but the abnormal control is out of
range for both procedures. Appropriate action would be to:
document the out of range QC and continue with morning run while reporting
out only those results that are in normal range
continue with morning run and report out only those results that fall within
normal range
document QC, then repeat controls at the end of the morning run and report if
both controls are acceptable
document the out of range QC, repeat the abnormal control, troubleshoot if
necessary; report patient results only when both controls are within acceptable
ranges.
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When coagulation controls are out of range, the technologist must document the
situation first. Then the problem must be resolved by repeating, opening a new lot,
calibration, etc. Only when the issue has been resolved and the coagulation controls
are BOTH within range, can the patient samples be analyzed and resulted.

The image on the right is a cytospin preparation of cerebrospinal fluid viewed at

1000X magnification. What is the identity of the primary blood cell type observed in
this microscopic field?
Monocytes
Macrophages
Mesothelial cells
Lymphocytes
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This is the normal range of variation for lymphocytes in a cytospin. There are no
monocytes, macrophages, or mesothelial cells present in this image.


This smear shows Pappenheimer bodies.
True
False
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The correct answer for this question is true. Pappenheimer bodies appear as dark
purple-violet granules usually found along the periphery of the red cells, often in
clusters. In order to confirm the presence of Pappenheimer bodies, an iron stain must
also be performed. Pappenheimer bodies are found in following splenectomy, in
sideroblastic and megaloblastic anemias, alcoholism, and in some
hemoglobinopathies.

The MAIN function of the hexose monophosphate shunt in the RBC is to:

Regulate the level of 2,3-DPG
Prevent the reduction of heme iron
Provide energy for membrane integrity
Provide reduced glutathione to prevent oxidation of hemoglobin
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The NADPH produced by the hexose monophosphate shunt converts the oxidized

form of glutathione(GSSG) to glutathione(GSH) in order to maintain hemoglobin in
the reduced functional state. Often when the HMS is not functioning properly,
hemoglobin is denatured and Heinz bodies may result.

What substance is measured in a Drabkin’s solution for hemoglobin determination?
hemoglobin
methemoglobin
cyanmethemoglobin
acid hematin
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Drabkin's solution oxidizes hemoglobin to methemoglobin which reacts with

potassium cyanide to create cyanmethemoglobin. Cyanmethemoglobin can be
measured spectrophotometrically at 540 nm. The color intensity measured at 540 nm
is proportional to the total hemoglobin concentration.

The cell indicated by the arrow in this illustration is called:
Hair cell
Smudge cell
Megakaryocyte
Blast
Feedback
Smudge Cells (bare nuclei) are commonly seen in blood smears from patients with
chronic lymphocytic leukemia.

What is a typical finding for determining the endpoint for the initial or iron-depletion
phase of treatment for hereditary hemochromatosis (HH)?
The serum ferritin decreases to between 20 and 50 ng/mL

The hepatic iron index returns to normal
The transferrin saturation drops below 20%
The serum iron falls to below 35 g/dL.
Feedback
The end of the initial phase of HH treatment is considered when the serum ferritin
decreases to between 20 and 50 ng/mL.

Which of the following is responsible for humoral response:
Neutrophils
Basophils
B lymphocytes
Monocytes
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In the humoral response, B-lymphocytes are stimulated to when an antigen binds to its
surface receptors. This sensitizes or primes the B cell and it undergoes clonal
selection, where it reproduces asexually by mitosis. Most of the family of clones
become plasma cells. These cells produce antibodies while other B cells become long-
lived memory cells.

Adult (normal) Hemoglobin is made up of the following composition:
>90% HbA, 5%HbF, 1% HbA2

>95% HbA, <3.5% HbA2, <1-2% HbF
<90% HbA, 10% HbA2, 5% HbF
>90% HbA, 1% HbA2, 5-10% HbF
Feedback
Adult Hemoglobin is made up predominantly of HbA with only small amounts (< 1-2
%) of HbF (fetal hemoglobin).

You have just performed stat PT and aPTT tests on your coagulation instrument. Your
results are as follows:
PT = 12 seconds (normal range 10-13 seconds)
aPTT = 24 seconds (normal range 21-34 seconds)
What would be your next step?
Perform a mixing study

Report the results
Request a redraw of the specimen
Feedback
The results of this PT and aPTT are in normal range. These results can be reported
and are not indicative of the need to: order a mixing study or request a redraw.

Choose the term that describes the most prominent finding in this peripheral smear:
Rouleaux
Normal RBCs
Anisocytosis
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Anisocytosis is a variation in the size of the red blood cells. This slide shows
poikilocytosis, but anisocytosis is more prominent here.

What other hemoglobin gene loci occur on the same chromosome as the beta chain
loci?

alpha
delta
gamma
zeta
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Globin chain loci are found on:
 chromosome 11 (beta, delta, epsilon, and gamma)

 chromosome 16 (alpha, and zeta)

What cellular characteristic of red blood cells is described by the term poikilocytosis?
Size
Shape
Presence of nuclear material
Concentration of hemoglobin
Feedback
poikilocytosis = variation in red blood cell shapes
anisocytosis = variation red blood cell size


Match the images of erythrocyte inclusions from Wright-stained peripheral blood
smears that are shown below with the correct identifications from the drop-down box.
Artifact Image A
Howell-Jolly body(or bodies) Image B
Cabot ring(s) Image C

Pappenheimer body(or bodies) Image D
Basophilic stippling Image E

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Image A is an artifact caused by water drying.
Image B is a Howell-Jolly body.
Image C is a Cabot ring.
Image D is Pappenheimer bodies.
Image E is basophilic stippling.

Which factors offer a protective effect, delaying symptoms in persons with hereditary
hemochromatosis (HH)?
regular blood donation

pregnancy and menstruation
regular use of multivitamins with iron
eating a balanced diet
Feedback
Pregnancy, menstruation, and regular blood donation are thought to offer a protective
effect, delaying symptoms in persons with HH.

Which factors offer a protective effect, delaying symptoms in persons with hereditary
hemochromatosis (HH)?
regular blood donation

pregnancy and menstruation
regular use of multivitamins with iron
eating a balanced diet
Feedback
Pregnancy, menstruation, and regular blood donation are thought to offer a protective
effect, delaying symptoms in persons with HH.


Identify the nucleated blood cell:
Lymphocyte
Neutrophil
Band form
Monocyte
Eosinophil
Basophil

A 27-year-old man with Down syndrome has the following CBC results which are
MOST suggestive of which condition?
WBC: 27 x 103/µL
HGB: 8.5 g/dl
HCT: 25.0%
PLT: 30 x 109/L
Differential blood smear results:

8% segmented neutrophils
25% lymphocytes
67% TdT-positive blasts
Acute Myelogenous leukemia

Myeloproliferative disorder
Leukemoid reaction
Acute lymphocytic leukemia
Feedback
The increased white cell count along with the presence of TdT (Terminal
Deoxynucleotidyl Transferase) positive blasts indicate ALL. TdT will stain
lymphoblasts positive and myeloblasts negative.

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You answered the question correctly.

Aplastic anemia may be caused by all of the following except:

The correct answer is highlighted below

Enzyme deficiencies are usually associated with hemolytic anemias.

Question Difficulty: Level 6

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Identify the cell in this illustration:

The correct answer is highlighted below

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Reactive mesothelial cells

Question Difficulty: Level 9

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It is an acute phase reactant that is frequently elevated in a variety of clinical

SF is an acute phase reactant that is frequently elevated in a variety of clinical

Question Difficulty: Level 5

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Question Difficulty: Level 8

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The correct answer is highlighted below

Question Difficulty: Level 4

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All of the following statements describe an eosinophil EXCEPT:

The correct answer is highlighted below

Cytoplasm contains large purple/blue-staining granules.

'Eosinophils do not have cytoplasm containing large purple/blue-staining granules.

Question Difficulty: Level 4

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Leukocytosis defines an increase in white blood cell counts.

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Hb S migrates alone in alkaline and D in acid electrophoresis.

Hb S migrates with D in alkaline and alone in acid electrophoresis.

Question Difficulty: Level 7

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The abnormal RBC shape seen in this illustration is:

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Helmet cells appear as if a section had been bitten out of them.

Question Difficulty: Level 3

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Normal cytocentrifuged smear

Almost exclusively mononuclear cells are seen, suggestive of viral meningitis.

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The M:E ratio represents the ratio of:

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Question Difficulty: Level 6

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Normal mature B cells express CD19, CD20, and Kappa or Lambda.

CD2 is expressed by mature T cells.

Question Difficulty: Level 9

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The correct answer is highlighted below

The cell indicated by the arrow is demostrating basophilic stippling. Basophilic