Question of the week # 444

444) A 25 year old woman is seen by you today due to an abnormal blood count. Three weeks ago, she volunteered for blood donation and a complete blood count that was drawn at that time showed abnormal values. She has regular menstrual periods with normal flow. Her last menstrual period was one week ago.  Her previous blood count was done several years ago and she is unaware of being told they were abnormal. A complete blood count is as follows :

WBC 5.5k/µl

HGB: 12.1 gm%

MCV 84 fl

Platelets : 800k/µl ( Normal 140k to 340k/ul)

Differential count : Neutrophils : 64% Lymphocytes 30% Monocytes 4%

Which of the following is the most important next step?

A) Obtain Bone Marrow Biopsy

B) Order Transferrin Saturation

C) Obtain Jak-2 Mutation Analysis

D) Obtain Arterial Blood Gases

E) Start her on Aspirin

48 Responses

  1. ans:obtain BBM

  2. E..start on aspirin.

  3. start aspirin

  4. E

  5. A

  6. i like this.

  7. Order Jak-2 Mutation Analysis

  8. jak 2 mutation.

  9. Answer: C
    The reason is not “A” is this pt is ASYMPTOMATIC, thus you need to go for the SIMPLE blood TEST and NOT the PAINFUL PROCEDURE.
    If the simple TEST does not answer your question then you can go for the next step which is a PROCEDURE.

    • she has essential thrombocythemia, she may be asymptomatic but the BEST INitial step sure would be prophylactic aspirin to reduce risk of thrombosis and thromboembolism, genetic analysis surely cannot be the next best step before medical management which this patient needs

  10. E. start her on Aspirin low dose for the diagnosis of essential thrombocythemia

  11. obtain bone marrow biopsy

  12. ans.: A she has low WBC along with abnormal platelet count… need to rule out leukemia

  13. A

  14. a

  15. A..bone marrow biopsy to differentiate whether the high platelet count is reactive or essential?

    • never the first step with bone marrow, you need to medically manage the thrombocythaemia first, then determine whether reactive or essential but the intial medical management will be the same..ASPIRIN prophylaxis

  16. start her on asprin n then go for BMB

  17. Start her on Asa

  18. Obtain bonemarrow biopsy.

  19. Obtaine bonemarrow biopsy.

  20. Ans: A low WBC count along with abnormally high platelets

  21. suggest leukemia high in the differentials… we should get Bone morrow biopsy first to exclude that

  22. E start asprin… answer a is not likely becasue such a large platelet count during an intervention may lead to some vasoocclusive disease.

  23. a

  24. C

  25. Hi,why don’t some of your questions have answers provided on your blog and why is it that I could only see 190 questions on your blog? How do I see the rest up till this recent number. Thanks

    Sent from my iPad

  26. E.

  27. It is between Band E, I would go with E because look like she is not anemic.

  28. e

  29. ~E. Aspirin
    This pt is at risk for thrombosis – next best step is start aspirin.

  30. I am modifying my answer from “C” to “E”.
    That is b/c in the same office visit that you are ordering jak-2 mutation analysis you need to start her on aspirin prophylactically until you have a definitive answer by blood test or bone marrow.

  31. Its c, high plts ansd wbc, pt is young

  32. WBC: 3.3-8.7 K/uL


  33. The hallmark of essential thrombocytosis (primary thrombocythemia) is a sustained, unexplained thrombocytosis.
    Leukocytosis, erythrocytosis, and mild anemia may be found.

  34. What is the best answer?

  35. Anyone pls post answer

  36. E)

  37. Oooops … confused …
    D/Dx for thrombocytosis with leucocytosis

    1st step in Management
    Peripheral blood smear, Acute phase reactants, iron studies
    then : repeat blood count to confirm persistent thrombocytosis. If persistent, investigate for clonal.
    reactive causes are by far the most common etiology of thrombocytosis. iron deficiency anemia can also associated with reactive thrombocytosis with leucocytosis. Although this patient does not have history of menorrhagia, and Hb and pcv in normal, I dont want to skip the steps. Because it is easier to treat underlying cause.
    She has thrombocytosis but low risk for thrombosis because <40 years, no history of thrombosis, platelet counts <1500,000.

    my answer will be B)
    please correct me if I did wrong.

    • not sure if i agree she is low risk for thrombosis, she has platelet count of 850, 000 which is high, what is the clinical evidence to suggest that only platelet counts of 1,500,000 are cut off point for aspirin prophylaxis?? and iron studies with transferrin saturation would not indicate to me the best initial step, prophylaxis with aspirin is initial medical treatment for thrombocythaemia, determining whether reactive or essential is next step.

  38. C. Hydroxyurea > aspirin for essential thrombocytosis.

  39. can someone please give the answer, because bone marrow biopsy seems the best answer, can you ignore a low WBC and high platelet and Hg borderline/low

  40. wbc is normal , there is leukocytosis, correction of error

  41. c

  42. All patients with ET should undergo an initial evaluation that confirms the diagnosis, evaluates factors that influence outcomes, and informs treatment options. Calculate the risk of complications with the IPSET-thrombosis model, which evaluates age, history of thrombosis, presence of JAK2 V617F mutation, and we also evaluate cardiovascular risk factors. This risk score is then used to recommend cytoreductive (platelet-lowering) therapy, anticoagulation, and/or aspirin.

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