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Chapter 7: Megaloblastic Anemias
2. A patient with pernicious anemia has the following indices: mean corpuscular volume
(MCV) >100 fL, mean corpuscular hemoglobin (MCH) = 31 pg, mean corpuscular
hemoglobin concentration (MCHC) = 33% What might be seen on the peripheral smear?
A) Codocytes
B) Macrocytes
C) Microcytes
D) Schistocytes
E) None of the above
Page 1
Chapter 7: Megaloblastic Anemias
8. What protein is responsible for vitamin B12 transport to the bone marrow?
A) Transcobalamin II
B) Intrinsic factor
C) Interleukin-3
D) Thymidine triphosphate
E) None of the above
12. What findings distinguishes megaloblastic anemia due to vitamin B12 deficiency from that
due to folate deficiency?
A) Severe neurologic manifestation
B) Jaundice
C) Abnormal epithelial cells
D) High reticulocyte count
E) None of the above
Page 2
Chapter 7: Megaloblastic Anemias
13. The presence of polychromatophilic macrocytes in a treated megaloblastic anemia is due to:
A) RBC degeneration
B) Reticulocytosis
C) Macrocytosis
D) Megaloblastoid dyspoiesis
E) None of the above
14. What is most striking when viewing the peripheral smear of a severely anemic patient with
megaloblastic anemia?
A) Anisocytosis
B) Poikilocytosis
C) Macro-ovalocytes
D) Hypersegmented neutrophils
E) All of the above
16. What is the most common red cell inclusion body seen in megaloblastic anemia?
A) Cabot ring
B) Howell–Jolly body
C) Basophilic stippling
D) Hemoglobin H bodies
E) None of the above
17. In megaloblastic anemia, the absolute reticulocyte count is decreased as a result of:
A) Effective erythropoiesis
B) Ineffective erythropoiesis
C) Medullary hematopoiesis
D) Extramedullary hematopoiesis
E) None of the above
18. An elderly white male of Scandinavian descent presents with the following hematopoietic
studies: MCV = 115 fL, 3+ oval macrocytes, 20% hypersegmented neutrophils. What
hematologic condition is suspected?
A) Iron-deficiency anemia
B) Megaloblastic anemia
C) Thalassemia
D) Anemia of chronic disorders
E) None of the above
Page 3
Chapter 7: Megaloblastic Anemias
21. What other hematologic condition would present a similar peripheral blood picture as
megaloblastic anemia?
A) Hemoglobinopathies
B) Myelodysplastic syndromes
C) Chronic leukemia
D) Anemia of chronic disorders
E) None of the above
24. The reversed myeloid–erythroid ratio in the bone marrow of a person with megaloblastic
anemia is defined as:
A) Myeloid hyperplasia
B) Erythroid hypoplasia
C) Erythroid hyperplasia
D) Hypocellularity
E) None of the above
Page 4
Chapter 7: Megaloblastic Anemias
25. Which hematologic condition is indicated with a macrocytosis and a reticulocyte count of
>5%?
A) Iron-deficiency anemia
B) Hemolytic anemia
C) Megaloblastic anemia
D) Thalassemia
E) None of the above
26. All of the following are initial diagnostic tests performed simultaneously in determining the
cause of macrocytosis except:
A) Reticulocyte count
B) Serum and red cell folate
C) Schilling test
D) Serum vitamin B12
E) None of the above
27. What percentage of megaloblastic anemia is due to vitamin B12 or folic acid deficiency?
A) 50%
B) 90%
C) 40%
D) 60%
E) 20%
Page 5
Chapter 7: Megaloblastic Anemias
Answer Key
1. D
2. B
3. C
4. A
5. B
6. C
7. B
8. A
9. C
10. D
11. B
12. A
13. B
14. E
15. C
16. B
17. B
18. B
19. D
20. D
21. B
22. B
23. C
24. C
25. B
26. C
27. B
28. C
29. C
Page 6
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Figure 79. De Konick’s Apparatus.
Figure. 83.
This indicates that 109.9 cubic centimeters of air would occupy a volume of 100 cubic
centimeters when subjected to standard conditions.
The tubes A, B, and C are filled with mercury of which about two and a half kilograms will
be required. By means of the leveling tube B, the stopper in C being opened, the mercury in C
is brought exactly to 109.9 cubic centimeters. The stopper in C is then closed, mercury
poured into D, which is then closed with a rubber stopper, carrying a small glass tube as
indicated in the figure.
The leveling tube B serves to regulate the pressure on the gas in A and this is secured by
depressing or elevating it as the case may require.
The tube for reducing the volume to standard conditions of temperature and pressure, viz.,
0° and 760 millimeters of mercury, is shown in C. In its narrow part which has the same
internal diameter as A it is graduated into tenths of a cubic centimeter. The upper end of C is
furnished with a heavy glass neck D surmounted by a glass cup. In the neck is placed a
ground-glass stopper, carrying a groove below, which corresponds to a similar groove above
in the side of the neck whereby communication can be established at will between the interior
of C and the exterior. The joint is also sealed by pouring mercury into D as is shown in the
figure. When the stopper is well ground and greased the reduction tube may be raised or
lowered as much as may be necessary without any danger of escape or entrance of gas. To
determine the position of the reduction tube C the reading of the barometer and
thermometer at room temperature is taken. From the reading of the barometer subtract one
millimeter if the temperature be below 12°, two millimeters at a temperature from 12° to 19°,
three from 20° to 25°, and four above 25°.
When a gas has been introduced into the measuring tube A it is brought to the volume
which it would assume under standard conditions by adjusting the tube C in such a way as to
bring the level of mercury in C and A to the same point and the level of the mercury in C is
exactly at 100 cubic centimeters. The gas in A is then at the volume which it would occupy
under standard conditions and this volume can be directly read. This adjustment is secured
by moving the tubes B and C up or down. If gases are to be measured wet, a drop of water
should be put on the side of the upper part of C, and, if dry, of sulfuric acid, before the
adjustment for temperature and pressure.
475. Method of Manipulation.—By the action of mercury in the presence of sulfuric
acid, the nitrogen in nitrates, nitrites, nitrosulfates, nitroses, nitrocellulose, nitroglycerol, and
the greater number of explosives, may be obtained and measured as nitric oxid. The nitrogen
compounds are decomposed in the apparatus shown in Fig. 84.
To make an analysis, the apparatus is filled with mercury, through F, until the two
openings in the cock and i are entirely occupied with that liquid. The cock h is then closed,
and the nitrogen compound, in solution, introduced through g, care being taken that no air
enters g when F is depressed and h opened to admit the sample. The funnel g is washed
several times with a few drops of sulfuric acid, which are successively introduced into G. The
total liquid introduced should not exceed ten to fifteen cubic centimeters, of which the
greater part should be sulfuric acid. The rubber tube connecting G and F is carefully closed
with a clamp and G violently shaken for a few minutes until no further evolution of nitric oxid
takes place. In shaking, the apparatus should be so held as to prevent the escape of the
mercury from the small tube i by keeping it closed with the finger or drawing over it a rubber
cap.
After the evolution of the gas has ceased, the tube e, Fig. 83, is brought into contact with i,
Fig. 84, and the two are joined by a tight-fitting piece of rubber tubing in such a way as to
exclude any particle of air. The tube F, Fig. 84, is lifted and B and C, Fig. 83, depressed. On
carefully opening the cocks h and b and bringing i and e into union, the gas is passed from G
into A. When all the gas has entered A and the acid mixture from G has reached b the latter is
closed, and also h. The apparatus G is disconnected and removed. The gas in A is then
reduced to normal conditions by manipulating the reduction tube C in the manner already
described.
The gas in A is measured dry by reason of having been generated in presence of rather
strong sulfuric acid. Consequently, for this operation the adjustment of the volume of gas in C
should be made in contact with a drop of strong sulfuric acid. In order to make the readings,
a quantity of material must be taken which will give less than thirty or from 100 to 140 cubic
centimeters of nitric oxid.
The quantities of the different compounds of nitric acid corresponding
to the number of cubic centimeters of nitric oxid, measured under
standard conditions, are shown in the following table:
Figure 84.
Lunge’s Analytic
Apparatus.
CORRESPONDING TO
———————————— ———————————— ————————————
Cubic Weight in N₂O₃ in milligrams. HNO₃ in milligrams. NaNO₃ in milligrams.
centimeters milligrams.
of NO.
1 1.343 1.701 2.820 3.805
2 2.682 3.402 5.640 7.610
3 4.029 5.103 8.460 11.415
4 5.372 6.804 11.280 15.220
5 6.715 8.506 14.100 19.025
6 8.058 10.206 16.920 22.830
7 9.401 11.907 19.740 26.635
8 10.744 13.608 22.560 30.440
9 12.087 15.309 25.380 34.245
476. Utility of the Method.—Where it is desirable that the nitric oxid method be used,
and at the same time heating be avoided, the decomposition of a nitrate by means of metallic
mercury and sulfuric acid affords a convenient and accurate procedure. But, as a rule, there is
no objection to the application of the lamp, and in such cases the mercury method appears to
have no advantage over the ferrous chlorid process. Nevertheless, in the hands of a skilled
worker the results are reliable, and the process is a quicker one, on the whole, than by
distillation with ferrous chlorid and hydrochloric acid. This method, however, can not be
recommended as in any way superior to the reduction methods to be hereinafter described.
ESTIMATION OF NITRIC ACID BY OXIDATION OF A
COLORED SOLUTION.
477. Method of Boussingault.—The process for the estimation of nitric acid by the
decoloration of a solution of indigo is due originally to Boussingault.[305] In this method the
extract, obtained by washing slowly 200 grams of soil until the filtrate amounts to 300 cubic
centimeters, is evaporated until its volume is no greater than two or three cubic centimeters,
and it is transferred to a test-tube, with washings, and again evaporated in the tube until the
volume is not greater than that last mentioned. A few drops of solution of indigo are added,
and then two cubic centimeters of pure hydrochloric acid; the whole is then heated. As the
color of the indigo disappears more is added. When the color ceases to fade, the liquid in the
test-tube is concentrated by boiling. If concentration fail to destroy the blue or green color,
another one-half cubic centimeter of hydrochloric acid is introduced. The reaction is
completed when neither concentration nor fresh addition of hydrochloric acid destroys the
excess of indigo present. The color produced by a small excess of indigo is a bright sap-green;
this tint is the final reaction sought. The small excess of indigo necessary to produce a green
color is deducted in every experiment.
When more than mere traces of organic matter are present, Boussingault advises that the
nitric acid be first separated by distillation and then reduced by the indigo solution. For this
purpose the concentrated solution of the nitrate, two or three cubic centimeters, is placed in a
small tubulated retort with two grams of manganese dioxid in fine powder. The retort is next
half filled with fragments of broken glass, over which is poured one cubic centimeter of
concentrated sulfuric acid. The retort is heated carefully by means of a small flame, which is
kept in motion so as to successively come in contact with all parts of the bottom of the retort.
The distillate is received in a graduated test-tube which is kept cool. The distillation is
continued until the vapors of sulfuric acid begin to appear. The apparatus is allowed to cool,
the stopper of the retort removed, two cubic centimeters of water introduced, and the
distillation again made until fumes of sulfuric acid are again seen. The distillation with water
is made twice in order to remove every trace of nitric acid from the retort. The distillate is
neutralized with a solution of potassium hydroxid and concentrated to two cubic centimeters,
and the nitric acid estimated in the manner already described. The manganese dioxid used
should be previously well washed and the sulfuric must be free of nitric acid.
Preparation of the Indigo Solution.—Fifty grams of indigo in fine powder are digested for
twenty-four hours, at 40°, in a liter of distilled water. The water is then poured off and
replaced with a fresh supply. After the second decantation the residue is treated with 750
cubic centimeters of equal parts of water and pure concentrated hydrochloric acid and boiled
for an hour. After cooling, the undissolved portion is collected on a filter and washed at first
with hot, and afterwards with cold water, until the filtrate is no longer colored and is free of
acid. The dried residue is treated with ether under a bell-jar, or in a continuous extraction
apparatus, until the ether is only of a faint blue tint. The fifty grams of indigo at first taken
will give about twenty-five grams of the purified article, which, however, will still leave a little
ash on combustion.
Solution in Sulfuric Acid.—Five grams of the purified indigo are placed in a flask having a
ground-glass stopper, treated with twenty-five grams of fuming sulfuric acid, and allowed to
digest two or three days at a temperature of from 50° to 60°. From seventy to 200 drops of
the solution thus made are placed in 100 cubic centimeters of water for use in the process.
Standardization of the Indigo Solution.—The solution as prepared above is standardized
by a solution of one gram of pure potassium nitrate in 1,000 cubic centimeters of distilled
water. The oxidation of the indigo solution is accomplished as described above. For this
strength of standard nitrate solution two cubic centimeters are taken corresponding to two
milligrams of potassium nitrate. The indigo solution for this strength should have only
twenty drops of the sulfuric acid solution of indigo to 100 cubic centimeters of water. If
twenty grams of potassium nitrate are taken for 1,000 cubic centimeters of the standard
solution then 200 drops of the sulfindigotic acid should be used to 100 cubic centimeters of
water.
478. Method of Marx.—As usually practiced, the indigo method is conducted according
to the variation described by Marx.[306] There are required for the process the following
reagents and apparatus:
a. A solution of pure potassium nitrate containing 1.8724 grams per liter. One cubic
centimeter of the solution is equivalent to one milligram of nitric anhydrid (N₂O₅).
b. A solution of the best indigo carmine in water which should be approximately
standardized by solution in the manner described hereafter, and then diluted so that six to
eight cubic centimeters equal one milligram of nitric acid.
c. Chemically pure sulfuric acid of specific gravity 1.842, perfectly free from sulfurous and
arsenious acids and nitrogen oxids.
d. Several thin flasks of about 200 cubic centimeters capacity.
e. A small cylindrical measure holding fifty cubic centimeters and divided into cubic
centimeters.
f. A Mohr’s burette divided into tenths of a cubic centimeter.
g. A twenty-five cubic centimeter pipette or another burette.
h. A five cubic centimeter pipette divided into cubic centimeters or half cubic centimeters.
i. A measuring flask of 250 cubic centimeters capacity.
Preliminary Trial.—Twenty-five cubic centimeters of the sample are transferred to a flask;
the fifty cubic centimeter measure is filled with sulfuric acid and the burette with indigo
solution. The sulfuric acid is added to the sample all at once, shaken for a moment, and the
indigo run in as quickly as possible with shaking until a permanent greenish tint is produced.
If the sample do not require more than twenty cubic centimeters of indigo solution of the
above strength, it can be titrated directly, otherwise it must be diluted with a proper quantity
of pure water, and subjected again to the preliminary trial.
The Actual Titration.—(1) Twenty-five cubic centimeters of the sample properly diluted if
necessary, are measured and poured into a flask, and as much indigo as was used in the
preliminary trial, is added; a quantity of sulfuric acid, equal in volume to the liquid in the
flask, is added all at once, the mixture shaken, and indigo solution run in quickly out of the
burette until the liquid remains permanently of a greenish tint.
(2) The last experiment is repeated as often as may be necessary adding to the water at first
half a cubic centimeter less indigo than the total quantity used previously, afterwards
proceeding as in (1) until the final test shows too little indigo used.
(3) From the rough titration of the indigo, calculate the amount of potassium nitrate
solution corresponding with the indigo solution used in (2), multiply the result by ten,
transfer this quantity of the standard nitrate solution to a 250 cubic centimeter flask, fill with
pure water to the mark, and titrate twenty-five cubic centimeters of this fluid with indigo as
in (2). If the quantity of indigo solution used is nearly the same as that required in (2), its
exact value may be calculated, but if it is not, another nitrate solution may be made up in the
250 cubic centimeter flask, more closely resembling the sample in strength, and the titration
with the indigo solution must be repeated.
(4) If the water contain any considerable amount of organic matter, it must first be
destroyed by potassium permanganate. In this case, the estimation of the organic matter and
nitric acid may be conveniently combined.
The use of permanganate in the above case is likely to introduce an error as has been
shown by Warington. The method therefore can not be recommended in the presence of
organic matter.
479. Method of Warington.—The modification of the indigo method as used by
Warington, applicable only in absence of organic matter, is the one chiefly employed in
England.[307]
Instead of the ordinary indigo of commerce, indigotin is used. The normal solution of the
coloring matter is made of such a strength as to be equivalent to a solution of potassium
nitrate containing 0.14 gram of nitrogen per liter. Where large quantities of the coloring
matter are to be used it is advisable to prepare it about four times the strength given above
and then dilute it as required. Four grams of sublimed indigotin will furnish more than two
liters of the color solution.
The solution is prepared as follows:
Four grams of indigotin are digested for a few hours with five times that weight of
Nordhausen sulfuric acid, diluted with water, filtered, and made up to a volume of two liters.
The strength of the indigotin solution is determined with a solution of potassium nitrate of
the strength mentioned above. The process is performed as follows:
From ten to twenty cubic centimeters of the standard nitrate solution are placed in a wide-
mouthed flask of about 150 cubic centimeters capacity. A portion of the indigotin solution is
next added, such as will be deemed sufficient for the process, and the whole is well mixed.
Strong sulfuric acid is next measured out from a burette into a test-tube, in volume equal to
the united volumes of the nitrate solution and indigotin. The whole of the sulfuric acid is then
poured as quickly as possible, into the solution in the flask and rapidly mixed, and the flask
transferred to a calcium chlorid bath, the temperature of which should be maintained at 140°.
It is essential to the success of the operation that the sulfuric acid should be mixed with the
greatest rapidity. It should be poured in at once and the whole well shaken without waiting
for the test-tube containing the acid, to drain. The flask should be covered by a watch-glass
while it is held in the bath. As soon as the larger part of the indigotin is oxidized the flask in
the bath should be gently rotated. With very weak solutions of nitrate it may be necessary
sometimes to keep the flask in the bath for five minutes. When the indigo color is quickly
discharged it shows the presence of nitric acid in considerable excess and a considerably
larger quantity of indigo must be taken in the next experiment. The experiments are
continued until just the quantity of indigo necessary to consume the nitric acid is taken, the
amount of indigo being in very slight excess, not exceeding one-tenth cubic centimeter of the
indigo solution used. The tint produced by the small excess of indigo remaining is best seen
by filling the flask with water. On substances of approximately known strength about four
experiments are usually necessary to determine the amount of indigo to be taken, but with
unknown substances a larger number may be necessary.
Usually in determinations of this kind it is directed to use double the volume of sulfuric
acid mentioned above. In this case not only is the quantity of indigo oxidized much greater
than with a smaller portion of acid, but the prejudicial effect of organic matter is also greater
than when the smaller quantity of acid is employed.
An indigo solution standardized as above is strictly to be used for a solution of nitrate of
the strength employed during the standardization. The quantity of indigo oxidized in
proportion to the nitric acid present diminishes as the nitrate solution becomes more dilute.
Instead of determining this during each series of experiments it may be estimated once for all
and a table of corrections used.
The following table is based upon experimental determinations:
Strength of Indigo Difference Nitrogen Difference Difference in the
niter solution required, between corresponding between the nitrogen values for a
used. cubic amounts of to one cubic nitrogen difference of one cubic
centimeters. indigo, cubic centimeter of values, gram. centimeter in the
centimeters. indigo, gram. amount of indigo, gram.
⁸⁄₆₄ Normal 10.00 0.000035000
⁷⁄₆₄ „ 8.71 1.29 0.000035161 0.000000161 0.000000125
⁶⁄₆₄ „ 7.43 1.28 0.000035330 0.000000169 0.000000132
⁵⁄₆₄ „ 6.14 1.29 0.000035627 0.000000298 0.000000231
⁴⁄₆₄ „ 4.86 1.28 0.000036008 0.000000381 0.000000298
³⁄₆₄ „ 3.57 1.29 0.000036763 0.000000756 0.000000586
²⁄₆₄ „ 2.29 1.28 0.000038209 0.000001445 0.000001129
¹⁄₆₄ „ 1.00 1.29 0.000043750 0.000005541 0.000004295