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Blood films for NEET PG: six worked fields, from fragments to a crowded marrow

PathologyPublished 23 October 2026 · Recallab

A blood film is solved by asking what the red cells have been through. Cells that were sheared, trimmed, starved or squeezed out each carry a different shape, and the shape tells you where to look next.

These six illustrated Recallab questions each put a film at the centre: three where red cells are being destroyed, and three where the film points to what is missing or what is crowding the marrow. Whether you are learning haematology in MBBS or revising for NEET PG or INI-CET, try each question before opening its worked answer.

Before you read a blood film: three questions

What shape are the red cells? Fragments, small round dense cells, large oval cells and teardrops each point somewhere different.
What else is in the field? Count the platelets, and look for immature cells, young blue-grey red cells and inclusions.
What result goes with it? An antiglobulin test, the clotting times or one blood level usually separates two films that look alike.

Red cells being destroyed: sheared, coated or trimmed

Recallab example 1 · fragments and few platelets

A woman has fever, confusion and falling platelets, with normal clotting times. Her blood film is drawn in the figure as panel 1, beside three other films. What are the cells in panel 1, and what process do they indicate? Four peripheral blood films, the first from a woman with fever and falling platelets.

Look first: name the shape in panel 1 first, then let the clotting times choose between the two causes of that shape.

Four peripheral blood film panels at high power: panel 1 with fragmented red cells shaped like helmets, triangles and crescents and very few platelets; panel 2 with small round dense red cells; panel 3 with target cells; panel 4 with teardrop cells. — Recallab question 55459. Four blood films, the first from a woman with fever, confusion and falling platelets.

ASchistocytes, from microangiopathic haemolysis
BSchistocytes, from disseminated intravascular coagulation
CTarget cells, from thalassaemia
DSpherocytes, from warm autoimmune haemolysis

Show the answer and explanation

Answer: A. Schistocytes, from microangiopathic haemolysis

A. Schistocytes, from microangiopathic haemolysis. Helmet cells, triangles and crescents are fragments of red cells, sheared as they pass platelet thrombi in small vessels. Fragments with a falling platelet count mean a thrombotic microangiopathy, and fever, confusion and normal clotting times point to thrombotic thrombocytopenic purpura. It is treated urgently with plasma exchange, a very low ADAMTS13 activity confirms it, and platelet transfusion is generally avoided.

Why the other options lose: Disseminated intravascular coagulation (B) also makes schistocytes, but it prolongs the clotting times, and here they are normal. Target cells (C) are panel 3. Spherocytes (D) are panel 2, small round dense cells with no pale centre. Fragments, low platelets, normal clotting: think of TTP.

Recallab question 55459 · Pathology › Blood RBC · reference: Robbins and Cotran Pathologic Basis of Disease

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Recallab example 2 · spherocytes, a positive test and no platelets

A woman of 26 has bruising, tiredness and yellow eyes. Her blood film and her results are drawn in the figure. What is the diagnosis? A peripheral blood film at high power beside four result tags.

Look first: name the small dense round cells, then count the platelets and read the antiglobulin test.

A blood film at high power with many small dense round red cells without a pale centre, several larger blue-grey red cells, a single platelet and no fragments, beside four result tags: direct antiglobulin test positive for IgG, platelets 18, reticulocytes 12 per cent and normal clotting times. — Recallab question 56857. Her blood film beside four results.

AEvans syndrome
BImmune thrombocytopenic purpura
CThrombotic thrombocytopenic purpura
DHereditary spherocytosis

Show the answer and explanation

Answer: A. Evans syndrome

A. Evans syndrome. The small dense round cells are spherocytes, trimmed by the spleen, and the larger blue-grey cells are reticulocytes, the marrow answering the haemolysis. A positive antiglobulin test for IgG shows that the red cells are coated with antibody, and the platelets are very low as well. Two antibody-mediated cytopenias together make Evans syndrome, and in a young woman lupus is the first underlying disease to look for.

Why the other options lose: Immune thrombocytopenic purpura (B) on its own gives no spherocytes, no jaundice and no positive antiglobulin test. Thrombotic thrombocytopenic purpura (C) gives fragments and a negative antiglobulin test, and this film has no fragments. Hereditary spherocytosis (D) looks the same on the film, but its antiglobulin test is negative and its platelets are normal. Spherocytes, a positive antiglobulin test and no platelets: Evans.

Recallab question 56857 · Medicine › Blood · reference: Harrison's Principles of Internal Medicine

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Recallab example 3 · a leukaemia film that changed

A man of 68 was found at a routine check to have a very high lymphocyte count and was left on observation. Three months later he is tired and pale. His two films, his antiglobulin card and his new results are drawn in the figure. What is the first treatment? Two blood films three months apart, an antiglobulin card and a panel of results.

Look first: compare the red cells, not the lymphocytes, between the two films, then read the card.

Two blood films from one man three months apart, both crowded with small alike lymphocytes and smudge cells; the second also shows small dense red cells without a pale centre and larger blue-grey red cells. Beside them a gel card with agglutinated cells at the top of the anti-human immunoglobulin lane, and results: haemoglobin low, reticulocytes high, unconjugated bilirubin high, LDH high, haptoglobin undetectable. — Recallab question 57520. His two films three months apart, his antiglobulin card and his new results.

ASplenectomy
BOral iron
CCorticosteroids
DCombination chemotherapy

Show the answer and explanation

Answer: C. Corticosteroids

C. Corticosteroids. The lymphocytes are unchanged; what is new is in the red cells. The second film adds spherocytes and young blue-grey cells, the reticulocytes are high, the bilirubin and LDH are raised and the haptoglobin has gone, so the marrow is working hard against haemolysis rather than failing. The card shows immunoglobulin on the red cells, so the haemolysis is autoimmune, a recognised complication of chronic lymphocytic leukaemia, and it is treated first with steroids.

Why the other options lose: Splenectomy (A) is kept for haemolysis that fails steroids and later treatments. Oral iron (B) is for iron lack, which gives small pale cells, not spherocytes with a positive card. Combination chemotherapy (D) answers marrow replacement, which gives a low reticulocyte count and a negative antiglobulin test. An anaemia in chronic lymphocytic leukaemia is not automatically progression.

Recallab question 57520 · Pathology › Blood WBC & Lymphoma · reference: Robbins and Cotran Pathologic Basis of Disease

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What is missing, and what is crowding the marrow

Recallab example 4 · a megaloblastic film after surgery

A woman of 34 has had two operations on her small bowel for Crohn disease and is tired and breathless on exertion. Her operative diagram, her blood film and her results are drawn together in the figure. Which single result separates the deficiency behind her film from its alternative? A small bowel diagram after two resections, the blood film, and a panel of results with their reference ranges.

Look first: see which length of bowel has gone, then find the one result that only one of the two vitamins can raise.

Three panels: the small bowel with two resected lengths, one taking the last sixty centimetres before the caecum; a blood film with large oval red cells, teardrop cells and a six-lobed neutrophil beside a normal film; and a results table with mean cell volume 118, ferritin 96, red cell folate 402, methylmalonic acid 1.9, homocysteine 34 and reticulocytes 0.4, each beside its reference range. — Recallab question 57349. Her bowel after two resections, her blood film and her results.

ARaised homocysteine
BHypersegmented neutrophils
CRaised methylmalonic acid
DRaised mean cell volume

Show the answer and explanation

Answer: C. Raised methylmalonic acid

C. Raised methylmalonic acid. Large oval red cells with a six-lobed neutrophil make a megaloblastic film, and the folate and ferritin are normal. The terminal ileum is the only place where vitamin B12 bound to intrinsic factor is absorbed, and that segment has been removed. Methylmalonyl-CoA mutase needs vitamin B12, so its substrate builds up only when vitamin B12 is lacking, which separates it from folate deficiency.

Why the other options lose: Raised homocysteine (A), hypersegmented neutrophils (B) and a raised mean cell volume (D) all appear in either deficiency, so none of them can separate the two. Methylmalonic acid is the tie-breaker: homocysteine rises in both, and only vitamin B12 deficiency raises the acid. After an ileal resection the replacement has to be by injection, for life.

Recallab question 57349 · Medicine › Blood · reference: Harrison's Principles of Internal Medicine

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Recallab example 5 · golf-ball stippling

A blood film stained with brilliant cresyl blue is drawn in the figure in three panels. A man of Southeast Asian descent has a lifelong moderate microcytic haemolytic anaemia and splenomegaly. Which inclusion will his film show? A supravitally stained blood film drawn in three panels showing different red cell inclusions.

Look first: decide whether each inclusion is spread evenly through the cell or sits as one or two lumps at the edge.

Three panels of supravitally stained red cells: panel 1 evenly stippled all over with fine blue-green dots like a golf ball; panel 2 with one or two large dense inclusions at the membrane; panel 3 with a fine blue mesh through the cytoplasm. — Recallab question 55324. Three panels from a film stained with brilliant cresyl blue.

AHeinz bodies
BReticulocytes
CPappenheimer bodies
DHaemoglobin H inclusions

Show the answer and explanation

Answer: D. Haemoglobin H inclusions

D. Haemoglobin H inclusions. Losing three of the four alpha-globin genes leaves unpaired beta chains, which form beta-4 tetramers, haemoglobin H, and precipitate inside the red cell. Supravital staining shows the precipitate as fine, even golf-ball stippling, as in panel 1. A lifelong microcytic haemolytic anaemia with splenomegaly in a man of Southeast Asian descent fits this alpha thalassaemia. Losing all four genes causes haemoglobin Bart's hydrops fetalis instead.

Why the other options lose: Heinz bodies (A) are the few large eccentric inclusions of panel 2, seen in G6PD deficiency after an oxidant trigger rather than lifelong. Reticulocytes (B) are panel 3, the normal RNA mesh of a young red cell. Pappenheimer bodies (C) are iron granules shown by Perls stain, not fine even stippling. Fine even stippling: haemoglobin H; eccentric lumps: Heinz bodies.

Recallab question 55324 · Pathology › Haematology: RBC · reference: Robbins and Cotran Pathologic Basis of Disease

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Recallab example 6 · two immature lines at once

Four anaemic patients each had a blood film made, and the four fields are drawn in the figure. Which field says that the marrow space itself is being taken over? Four blood film fields from four anaemic patients.

Look first: look for cells that should still be in the marrow, and count how many cell lines they come from.

Four blood film fields at one magnification: field 1 with small pale red cells and pencil forms; field 2 with large oval red cells and a six-lobed neutrophil; field 3 with nucleated red cells, two immature granulocytes and teardrop cells; field 4 with red cell fragments, a helmet cell and sparse platelets. — Recallab question 56221. Four blood film fields from four anaemic patients.

AField 4
BField 1
CField 2
DField 3

Show the answer and explanation

Answer: D. Field 3

D. Field 3. Nucleated red cells and immature granulocytes in the blood together, with teardrop cells, make a leucoerythroblastic film. Immature cells of two lines at once are being pushed out of a marrow that is being crowded, by fibrosis, secondary deposits or a marrow tumour, and teardrops form as cells squeeze through the distorted marrow. The next step is to examine the marrow, and an aspirate may yield nothing.

Why the other options lose: Field 4 (A) shows fragments and a helmet cell with few platelets: red cells sheared in the circulation, not a crowded marrow. Field 1 (B) is the iron-lack film of small pale cells and pencil forms. Field 2 (C) is the megaloblastic film of large oval cells and a six-lobed neutrophil. Two immature lines at once: look in the marrow, not in the diet.

Recallab question 56221 · Pathology › Blood RBC · reference: Robbins and Cotran Pathologic Basis of Disease

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The one-minute routine

If the film shows	Ask first	It settles
Fragments with few platelets	Are the clotting times normal?	Normal: thrombotic microangiopathy such as TTP; prolonged: DIC
Spherocytes with few platelets	Is the antiglobulin test positive?	Positive: Evans syndrome; then look for lupus
Spherocytes appearing in a known leukaemia	Are the reticulocytes up and the card positive?	Autoimmune haemolysis: steroids first, not chemotherapy
Large oval cells and a six-lobed neutrophil	Is the methylmalonic acid raised?	Raised: vitamin B12 deficiency, not folate
Inclusions on a supravital stain	Fine and even, or one or two lumps at the edge?	Even stippling: haemoglobin H; eccentric lumps: Heinz bodies
Nucleated red cells and immature white cells	Are two immature lines out at once, with teardrops?	A crowded marrow: examine the marrow next

Practise red cell questions, white cell and lymphoma questions and platelets and coagulation, and see more stained cells in microbiology and pathology spotters.

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Drawn from questions #55459, #56857, #57520, #57349, #55324, #56221 in the Recallab bank, each with its own verified answer and current-edition reference. Last reviewed 22 October 2026.