REPUBLIQUE DU CAMEROON REPUBLIC OF CAMEROON

Peace-Work-Fatherland
MINISTERE DE L’ENSEIGNEMENT SUPERIEUR
MINISTRY OF HIGHER EDUCATION
COMMISSION NATIONALE D’ORGANISATIION DE
L’EXAMEN
DU HIGHER NATIONAL DIPLOMA (HND) NATIONAL COMMISSION FOR THE
ORGANIZATION OF THE HIGHER NATIONAL
DIPLOMA EXAM (HND)
HIGHERNATIONAL DIPLOMA EXAMINATIONS 2020
Specialty/Option: Haematology; Paper: Haematology/blood transfusion
blood transfusion Hemostasis science

Code Nature of Paper Duration Credit value Total

MLS 20 written 03hrs 4 100

Instructions: Answer All Questions

PART A: MCQ: CIRCLE THE CORRECT ANSWER (S) [30 marks, 1mks each]
1. An acute leukemia can be describe as:
a) Of short duration with many mature leukocytes forms in the peripheral blood
b) Of short duration with many immature leukocyte forms in the peripheral blood.
c) Of short duration with little alteration of the leukocytes in the peripheral blood.
d) Of long duration with many mature leukocyte forms in the peripheral blood.

2. In acute leukemic anemia usually present and caused by:

a) Bleeding
b) Possible secondary anemia
c) The replacement of normal of replacement of normal marrow element by leukemic
blast cells
d) A + b + c

3. The clinical signs and symptoms of acute leukemia include:

a) Hepatomegaly
b) Splenomegaly
c) Easy bruising
d) All of the above

4. Macrocytic anemia can be due to:

a) Tape worm infestation
b) Gastric resection
c) Celiac disease
d) Nutritional deficiency
e) All of the above are correct

5. Hemolytic disruption of the erythrocytes always involves:

a) An alteration in the erythrocyte membrane
b) A defect of haemoglobin molecule
 c) Antibody coating the erythrocyte.
d) Physical trauma

6. A hemolytic crisis may be precipitated in G6PD deficiency

a) Fava beans
b) Quinine
c) Only a
d) A + B

7. The height of the column of blood in the Wintrobe ESR tube is :

a) 10mm
b) 50mm
c) 100mm
d) 200mm

8. What laboratory procedures would reflect a shorter – than normal life span:
a) Increased osmotic fragility
b) Decreased serum haptoglobin level
c) Increased total bilirubin level
d) Increased reticulocyte count
e) All of the above

9. The common denominator in the haemoglobinopathies is that all are:

a) Structural defects in the erythrocytic membrane
b) Metabolic defects in the erythrocytic physiology
c) Inherited or genetic defects related to haemoglobin
d) Acquired defects related to haemoglobin

10. Thalassemia major is equivalent to:

a) Cooley’s anemia
b) Mediterranean fever
c) Beta thalassemia major
d) All of the above.

11. Alpha thalassemia is caused by deletion of:

a) All four alpha globin genes
b) 3 alpha globin genes
c) 2 alpha globin genes
d) 1 alpha globin genes

12. The synthesis of globin is under the control of genes on chromosome:

a) 16 for the alpha family of globin
b) 12 for the beta family of globin
c) 22 and 9 chromosomes
 d) A + b only
13. Iron found in the bone marrow stores is in the form of:
a) Ferritin
b) Hemosiderin
c) Transferrin
d) Histiosiderin
14. The protein needed far vitamin B12 to be adsorbed from food into the intestinal
mucosa
a) Transcobalamin II
b) Pteroylgutamine
c) Albumin
d) Intrinsic factor (IF)
15. The primary cause of folic acid deficiency is:
a) Malabsorption
b) Increased utilization
c) Increased loss
d) Decreased dietary in take

16. The primary cause of vitamin B12 deficiency

a) Malabsorption
b) Increased utilization
c) Increased loss
d) Decreased dietary intake

17. The system most commonly associated with HDN is

a) Rh
b) ABO
c) Kidd
d) Lewis
18. When red cell inclusion originate as a result of denatured haemoglobin
a) Howell – Jolly body
b) Heinz body
c) Pappenheimer bodies
d) Malarial parasites
19. Macrocytosis can be caused by:
a) Decreased erythorpoesis
b) Dietary iron deficiency
c) Abnormal DNA production
d) Acute haemorrhage
20. Microcytosis can be caused by:
a) Decreased erythropoiesis
b) Dietary iron deficiency
c) Abnormal DNA production
d) Acuehaemorrhage
21 Blood transfusion is intended to :-a)increase blood volume only b) increase the number of
WBCs only c) increase RBCs and other blood components as the need arises.
 22. Quality control in blood banking involves:-a)control of reagents b)control of equipments c)
control of personnel d) none of the above are involved e) all of the above are involve.
23. Blood is composed of:- a) cells and water only b) cells, water, mineral salts and hormones
only . c) Cells, water, dissolved mineral salts, clotting factors and hormones.
24. A typical immunoglobulin molecule is made of a) two light chains and two heavy chains.
B)two light chains and one heavy chain c)two heavy chains and one light chains
25. The anti-human globulin test is use to detect:-a)both antigens and antibodies b)antigens
only c)immune antibodies and compliments d)compliments only in the recipient’s blood.
26. The light chains exist as:- a)alpha , lambda and kappa. B) Lambda, Alpha, delta and
kappac) lambda and kappa only d)all of the above are very correct.
27. The chains are held together by a:-a)a hydrogen bond b)bisulphate bond c) disulphate bond
d)disulphide bond e)disulphide and a hydrogen bonding.
28. Antigen- antibody complexes are held together by:-a)hydrogen and ionic bonds only
b)hydrogen, ionic and van der wall’s forces c) van der Wall’s forces , hydrogen, ionic and
hydrogen bonds.
29. Compliment is a complex protein made up of :-a) 8 b)9 c)10 d)11e) 12 components.
30. Fresh frozen plasma is used to:-a)increase blood volume b)increase blood plasma c)to treat
multiple clotting factor deficiency d)all of the above answers are correct.

PART B Structural [30 marks]

1) Write short notes on the following:

a) Factors affecting the measurement of erythrocyte sedimentation rate (ESR) (3pts)
b) Haemoglobin cyanide reagent (2pts)
c) The Stuart-Prower factor (2pts)
d) Direct Coomb’s test (3pts)
e) Bovine albumin Rhesus grouping technique (2pts)
2) Define, draw and label:
a) Macropolyte (3pts)
b) “Mexican Hat cell “(3pts)
c) Rieder cell (3pts)
d) Pelger-Huet anomaly (3pts)
e) Non-secretor (2pts)
3) Contrast ABO and Rhesus hemolytic disease of the new born (HDN) (5pts)

SPART C :ESSAY [40 marks ]

1. What role does each of the following play in the formation of blood clot? (12mks)
a) Fibrinogen (3)
b) Calcium (3)
c) Thrombin (4)
2. Soon after obstetric manipulations, the blood of a patient is notices to be incoagulable.
This patient was later transfused with packed red blood cells to later avail but die.
a) Nome of the condition and synonyms. (3pts)
b) Name three diverse stimuli that are capable of triggering the coagulation in this
manner. (3pts)
c) Name 6 causes of this condition of which 3 must be as a result of obstetric
manipulation plus any other (5pts)
d) Name 3 clinical presentation of this case (3pt)
e) Give the laboratory findings and expected results. (5pts)
f) How would you manage this case? (3pts)
3. a) List the 4 main causes of microcytic, hypochromic anemias (9pts)
b) Where is iron absorbed in the body and what factors influence the absorption of
iron.
c) Give the laboratory features of iron deficiency anemia (IDA).
 MARKING GIUDE

SECTION A: [30 marks, 1mk each]

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

B D D E A D C E C D A D B D D A B B C B

21 22 23 24 25 26 27 28 29 30

B D C D C C E D B D

PART B Structural [30 marks, ]

1. a) Factors that affect the ESR measurement.

The speed at which RBCs settle in the column of plasma is influenced by two general
factors.
- Red blood cell factors
- Plasma factors
Red blood cell factors
- Red blood are more dense than plasma
- The rate at which the RBC settles is directly proportional to their density.
- Rouleaux formation tends to influence the red cell to settle faster.
- The concentration of the RBCs also affects the rate at which the cells settle.
Decreased as in anemia increases the rate at which the RBCs fall and in polycythemia
the rate is reduced.

Plasma factors
- 3 plasma proteins (fibrinogen, albumin and globulin) affect the rate at which RBCs
settle.
- Increases in the level of fibrinogen and globulin decrease the negative charge on the
surface of the RBCs.
- Increases in the level of albumin, retard the rate of sedimentation of the RBCs.
b. Haemoglobincyanide reagent or Drabkin’s solution.
- Composed fo potassium cyanide potassium ferricyanide
- Potassium dihydrogen phosphate, nonidet P40 and distilled water.
- Used for the measurement of haemoglobin by the cyanmethaemobglobin method.
 - pH of 7.0 to 7.4. Pale yellow. Stored in dark brown bottles. Should read zero at a
wavelength of 540nm with water as blank.
c. The Stuart-Prower factor
- Also known as factor x
- Vitamin K dependent and synthesized in the liver
- Initiates the clotting of blood form either the intrinsic or extrinsic pathway.
- Responsible for the conversion of prothrombin into thrombin.
- Stable on storage and found in serum.
- MW – 59000 dalton with half-life of 24 – 65hrs.
- Also involved in the common pathway.
d. Direct Coomb’s test
- Also known as the antihuman globulin test.
- Performed directly on patient’s washed RBC to establish if the RBCs have been
coated with 1g G antibodies in vivo.
- Positive in HDN, drug induced haemolytic anemia incompatible blood
transfusion, autoimmune.
- Haemolytic anemia
e. Bovine Albumin Rhesus grouping technique.
This alters the electrostatic field charge between the RBCs and allows the shorter 1g G
chains of the incomplete antibodies to bridge the RBCs and cause agglutination.
Rhesus antibodies are enhanced at 37oC.
2. a. Macropolycyte
- also known as hypersegmented neutrophil or shift to the right
- the cell has 6 or more nuclear lobes
- enlarged and are found in megaloblastic anemia and sometimes in sepsis.
b. “Mexican Hat cell”
- Also known as target cell, leptocyte.
- The cell has haemoglobin at the centre and at the periphery making the cell have
the appearance of the “bull’s eye” or a shooting target.
- Cells are thinner than the normal cells.
- Cell associated with haemoglobinopathies (HbS, HbCC, Sickle cell –thalassemia,
liver disease in iron deficiency and post Splenectomy.
c. Rieder cell: Cells similar to lymphocytes except that the nucleus is notched, lobulated
and cloverleaf-like. They are seen in CLL.
d. Pelger – Heut anomaly.
An autosomal dominant genetic disorder that produces hyposegmentation of
neutrophils (failure of the nucleus to segment). The nuclear shape may resemble a
 dumbbell or a pair of eyeglasses. The function of the cell is considered to be normal
despite the morphological abnormality.
e. Non – Secretors
There are individuals whose saliva does not contain haptens. The secretion of
allelemorhphic gene Se, and se. Non-secretors have the sese and make up 20% of the
population. They do not secrete the A, B and H substances at all.
3. ABO and Rhesus HDN

ABO incompatibility Rhesus incompatibility

1. The antigen concerned as usually A and
sometimes B
2. The antibody concerned is the iso-immune
anti A or anti B in group O.
3. First borns frequently affected.
4. The DCT is negative or weakly positive.
5. Jaundice is mild.
6. Anemia is mild or moderate
7. Spherocytes are present.
8. Nucleated RBCs few or moderate.
- The Ag usually concerned is the D but
other Ags of the Rhesus system may be
involved.
- The Ab concerned in anti-D
- First borns rarely affected
- The DCT is positive.
- Jaundice is severe
- Anemia moderate or severe
- Spherocytes are absent.
- NRBC moderate or marked.

Part C: ESSAY QUESTIONS.(40marks)

1.
a) Role of fibrinogen in coagulation.
This is one of the coagulation proteins produced by the liver and belongs to the
fibrinogen group. It is present in plasma but absent in serum. It is the precursor of
fibrinogen molecule, leaving a fibrin monomer. These monomersaggregatge together to
form the final polymerized fibrin clot product.
Thrombin
Fibrinogen Fibrin monomer Fibrin clot
b) Calcium (factor IV)
Ionized calcium is necessary for the activation of thromboplastin and for the conversion
of prothrombin to thrombin. Calcium ions take in several steps of the blood coagulation
in both the intrinsic and extrinsic and the common pathways but do not take part in the
first two steps in the intrinsic pathway. i.e. the conversion of factor XII to XIIa and XI to
XIa.
c) Thrombin (Factor IIa): This is the activated form of prothrombin, which is normally
found as an inert precursor in the circulation. Thrombin has the following actions in the
coagulation mechanism.
- It converts fibrinogen into fibrin
- It activates plasminogen into plasmin
- It activates Factor XIII to Factor XIIIa
 - It amplifies factors V, VII and VIII
- It also stimulates the pits to prostaglandins important for vessel dilation.
2.
a. This disseminated intravascular coagulation (DIC) or consumptive coagulation or
consumptive coagulopathy or Defibrination Syndrome This is the excessive activation of
the coagulation factors and platelets and the generation of fibrin. DIC may be acute or
chronic.
b. The diverse stimuli trigger DIC are:
1. Intravascular platelets aggregation: Platelet aggregation activation of the intrinsic
pathway with factor XIIa formation leads to the activation of coagulation and the
generation of microthrombin and the thrombin causes pHs to release ADP and
aggregate e.g sepsis viremia and haemolytic anemia.
2. Activation of the extrinsic pathway by the release of tissue thromboplastin. DIC
can be caused by direct activation of F VII as seen in certain obstetrical
complications, results from the release of tissue. Thromboplastin from injured tissue
or from amniotic fluid entering the circulation examples are abruption placentae,
septicemia, liver disease, renal disease, trauma including shock, hypothermia,
eclampsia, extensive burns, crush injuries.
3. Direct activation of factors II and X: This can be seen to occur in the presence of
proteolytic enzymes venoms of certain snakes act through this mechanism Russel’s
Viper venom activates factor X whereas venom from sand rattlesnake causes direct
conversion of prothrombin to thrombin fat emboli syndrome e.g.
- snake venoms
- liver disease cancers
- spider bite
- acute pancreatitis
c. obstetrical complication causes of DIC
- Placentae abruption
- Retained dead foetus syndrome.
- Amniotic fluid embolism
- Septic abortion
Non-obstetrical complication:
- Crush injuries
- Septicemia
- Snake bites e.g. carpet viper
- Intravascular hemolysis
- Shock
- Heel stroke
- Extensive burns
- Promyelocyticlevkemia
- Prostatic cancer.
d. Hemorrhaging from: unrelated sites, melena hematemesis, epistaxis, hemoptysis, fever
hypotension, ypoxia proteinuria, haemoturiapurpura, petechiae gangrene.
e. Lab DX
 The lab findings in patients with DIC reflect the direct or indirect effects of excess
thrombin and plasmin generation.
Expected result prolonged

Test Expected result

- PT Prolonged
- KCCT -
- Thrombin time -
- Fibrinogen titre Decreased
- D-Dimer Decreased
- Anti thrombin III Increased
- pH count Decreased
- Euglobulin Increased
- lysis test -
- FDP -
- Factor assay Decreased

f. Therapy for DIC is essentially two fold.

1. Removal of the underlying pathological stimuli
2. Maintenance of blood volume and hemostatic function.
- Removal of dead foetus
- Giving antibiotic to control bacterial or endotoxin (induces vascular damage).

Blood component replacement therapy with transfusion of packed red cells, GGP and
PLTs to maintain blood volume and to support hemostatic function.

- Fresh frozen plasma, cryprecipitate.

- Stop or slow coagulation process e.g. with AT-III concentration, heparin, antiplatelet
drugs.

3. a) Mirocytic hypochromic anemia is caused by a defective haemoglobin synthesis,

either in the heme or the globin components and is caused principally by the
following IDA ,sideroblastic anemia, Anemia and thalassemia.
b) iron is absorbed by the intestinal mucosal cells in the duodenum in the inorganic
form and the factors that influence the absorption are.
- Serum iron concentration.
- The amount in the diet
- The pH of the intestine-achlorhydria enhances absorption.
- Presence of vitamin C and alcohol.
c) Lab features of IDA
1. RBC count, Hb, Hct – all reduced
2. MCV, MCHC, MCH – all reduced
3. a. PB – Anisocytosis, poikilocytosis and Target cells – present
 b. Basophilic stippling – present.
c. RDW –increased
4. Serum Fe – decreased
Serum Ferritin – decreased
TIBC – Normal to increase
Free Erythrocyte proporphyrin (FEP) – increased
% iron saturation – severely decreased
5. Stainable BM iron – absent.