Question of the Week # 268

268 )  A 62 year old man with history of chronic alcohol abuse, Hepatitis C and gout is admitted for nausea, vomiting and diarrhea.  His medications include colchicine for gout prophylaxis and multivitamins. The patient admits that he has increased his alcohol intake to about 4 pints vodka per day over the past two weeks. He has not been drinking or eating adequately. On physical examination, his vitals reveal a heart rate of 110 and blood pressure of 90/60. Oral mucosa are dry with poor skin turgor. Abdominal examination is benign. Laboratory investigations reveal acute renal insufficiency with a creatinine of 4mg% and BUN of 90mg%. His liver functuion tests are elevated with an AST of 160U/L, ALT  70U/L and ALP 240U/L. Total bilirubin is 2.0mg%. Complete blood count shows hemoglobin of 8.6gm%, WBC count of 1.6k/µl with absolute neutrophil count of 500/µl and Platelets 56k/μl. His laboratory investigations three months ago were with in normal limits. CT scan of the abdomen does not show any evidence of liver cirrhosis or Splenomegaly. The patient is started on intravenous hydration, thiamine and folic acid. Which of the following is the most appropriate next step in managing this patient”s pancytopenia?

A) Renal biopsy

B) Liver Biopsy

C) Stop colchicine

D) Bone marrow biopsy

E) Parvo virus RNA

Question of the Week # 266

266 )  A 70 year old man is evaluated in the emergency room for severe fatigue and exertional shortness of breath. He was diagnosed with pulmonary embolism 4 months ago and is on Coumadin. He denies any melena or hematochezia. There is no other history of gross bleeding.  On examination, his blood pressure is 100/70 mm Hg and he is afebrile.  Physical examination is normal. Stool for occult blood is negative.  His hemoglobin one month ago was 12gm/dl. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 6.2 g/dL,

Mean cell volume (MCV)  102  fL

Platelet count 170k/µl

Lactic Dehydrogenase 140U/L

Haptoglobin 100U/L

Reticulocyte count 12%

INR : 8.0

Which of the following is the most appropriate next step in managing this patient?

a) Direct Coombs Test

b) Vitamin B12 and Folate levels

c)  Bonemarrow biopsy

d) Start Corticosteroids

e) CT scan of the Abdomen

Question of the Week # 189

189) A 38 year old woman presents for follow up visit of right leg weakness. Her history is significant for episodes of diplopia and right sided weakness that recurred thrice in the last 3 months. These presentations were also associated with concomitant urinary incontinence and ataxia. Her most recent hospitalization for such an episode was three weeks ago. She was discharged after her symptoms improved upon using intravenous steroids. An MRI brain taken during the initial episode revealed multiple white matter lesions in the peri-ventricular area. Today, she feels well except for minimal weakness in her right leg. Most appropriate drug that should be administered to this patient to reduce the frequency and severity of these recurrences?

A) Methyl dopa

B) Interferon Beta

C) Methyl Prednisolone

D) Interferon Alpha

E) Intravenos Immunoglobulin ( IVIG)

Question of the Week # 188

188) A 24 year old woman is evaluated for a history of chronic anemia. Her history is significant for anemia for the past 7 years. She has been treated with oral iron supplements in the past with out any response. She denies any  gastrointestinal bleeding. Her menstrual cycle is 3 days in duration and her menses have been scant for the past 5 years. There is no family history of anemia or bleeding disorder or cancer. Physical examination is unremarkable. Laboratory investigations reveal :

Hemoglobin : 10.6gm%

MCV: 68fl ( normal 80 to 100)

WBC : 8.8K/μl

Platelets: 230k/μl

Red Cell Distribution Width : 12.8% ( 10.2 to 14.5%)

Reticulocyte count : 6% ( normal 0.5% to 1.5%)

Which of the following are most helpful in diagnosing this patient’s anemia?

A) Serum ferritin

B) Bone marrow biopsy

C) Direct Coombs’ test

D) Hemoglobin Electrophoresis

E)  Anti-endomysial antibodies

Question of the Week # 89

A 61-year-old man is admitted because of altered mental status. On physical examination, he is afebrile. Laboratory studies show sodium 136 mmol/L, potassium 4.4 mmol/L, chloride 108 mmol/L, CO2 30 mmol/L, glucose 78 mg/dL, urea nitrogen 49 mg/dL, calcium 13.8gm%, creatinine 5 mg/dL, hemoglobin 8.9gm%, total protein 8.3 g/dL, albumin 3.7 g/dL, alkaline phosphatase 116 U/L, AST 45 U/L, ALT 22 U/L, and total bilirubin 1.2 mg/dL.  The patient is started on aggressive Intravenos hydration. Which of the following may be typically seen with this patient’s disease?

A) Hypercellular Bone marrow with many blasts

B) Serum protein electrophoresis with polyclonal hypergammaglobulinemia

C) An increase in all immunoglobulins ( IgA, IgG and IgM)

D) A negative anion gap

E) Increased Alkaline Phosphatase

F) A positive bonescan

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