Question of the Week # 446

446) A 64 year old woman presents to your office with productive cough and fever for the past three days. About two months ago, she was admitted for pneumonia. Past medical history is significant for Rheumatoid arthritis. Her medications include hydroxychloroquine and prednisone. Previously, she was treated with Azathiprine for about 6 years.

On examination, temperature is 101F, blood pressure 120/80 and heart rate of 106/min.  Chest examination reveals decreased breath sounds at left lower lobe. No hepatomegaly, spleen tip is palpable. Chest X-Ray reveals left lower lobe consolidation  Labs reveal WBC 1000/µl with differential count showing neutrophils of 30% and Hemoglobin 9.9 gm%

Which of the following is the most likely explanation for the patient’s presentation?

A) Hypogammaglobulinemia from Rheumatoid arthritis

B) Marrow suppression by Hydroxychloroquine

C) Marrow toxicity by Azathiprine

D) Myeloproliferative disorder

E) Felty Syndrome

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

Question of the Week # 443

443 ) A 38 year old man is evaluated in your office for a chronic rash on his elbows. He reports this has been worsening over the last 6 months and is intensely itchy. He lost about 8lbs weight in the past 6 months. Review of systems is normal except for 4 to 5 episodes of loose stools every day. Laboratory investigations reveal moderate microcytic anemia. On examination, he is afebrile. There is a vesicular rash on the extensor aspects of his bilateral elbows as shown below:

elbows

Which of the following is most helpful in diagnosing this condition?

A) Fecal occult blood testing and Sigmoidoscopy

B) Anti-nuclear antibodies

C) Anti-Endomysial antibodies

D) Small bowel follow through

E) Anti-Sacharomyces Cerviseae antibodies ( ASCA)

Question of the Week # 435

435) A 29 year old woman is seen in your office for fatigue and exertional shortness of breath of 2 week duration. Past medical history is significant for hospitalization for splenic vein thrombosis 1 year ago. She received heparin 1 year ago and therafter, coumadin for 6 months. She is off anticoagulation now. Physical examination is unremarkable. Laboratory Studies reveal

WBC 2400/µl

HGB: 6.8 gm%

MCV 84 fl

Platelets : 80k/µl

Reticulocyte count 4.5%

Haptoglobin : Undetectable

Lactic Dehydrogenase (LDH) 800U/L

Direct Coombs Test : Negative

Which of the following is the best step in diagnosing this condition?

A) Hemoglobin Electrophoresis

B) Flow cytometry

C) Osmotic Fragility Test

D) Urine Hemosiderin

E) Heparin Antibody Testing

Question of the Week # 434

434) A 44 year old woman is evaluated in your office for one month history of worsening fatigue. She also reports tingling and numbness in bilateral lower extremities. Her past medical history is significant for morbid obesity for which she underwent gastric bypass surgery four years ago. She has lost about 80lbs weight since her surgery. Her medications include oral ferrous sulfate, folic acid and vitamin b-complex. Physical examination reveals absent ankle jerks. Laboratory Studies reveal WBC 5400/µl HGB: 9.8 gm%, MCV 74 fl, Platelets : 300k/µl, Serum ferritin 280ng/ml, Transferrin saturation 26% . A bone marrow aspirate smear is shown below :

Archer USMLE

Which of the following is the most likely cause of patient’s presentation?

A) Iron deficiency

B) Copper deficiency

C) Vitamin B12 deficiency

D) Zinc deficiency

E) Pure red cell aplasia

Question of the Week # 433

433) A 27 year old woman with no significant past medical history presents to your office after she sustained an accidental cut from a clean, new kitchen knife. She has no significant family history. She does not smoke or drink. She enjoys hanging out in beaches over the weekends and sun tanning. She however, noticed that she tans very quickly when compared to her friends. She received Tetanus immunization as a child and her last tetanus booster was 1 year ago. She also reports she recently visited her gynecologist office at which time some routine labs were done. She has the copies of her lab reports with her which reveal:
WBC : 10k/µl

HGB: 15gm%

Platelets : 300k/µl

Iron : 150 mcg/dL

TIBC: 200 mcg/dl

Transferrin saturation : 75%

Serum Ferritin : 220 ( N= 12 to 200 ng/ml)

Further investigations revealed homozygos state for C282Y mutation. On examination, her skin is golden tan in color. She has a  1cm cut on her palm which is clean. The wound is cleaned with soap and water.

Which of the following is the most appropriate management?

A) Instruct her to increase Vitamin C intake to promote wound healing

B) Administer Tetanus Immunoglobulin

C) Administer Tetanus Toxoid

D) Instruct her to avoid contact with sea water until the wound is healed

E) Instruct her to increase Red Meat Intake

 

 

Question of the Week # 431

431) A 25 year old G2P1L1 at 32 weeks gestation presents with right leg swelling and pain progressively increasing over the past two days. Her previous pregnancy was uneventful except for uncomplicated C-section and she has a 2 year old healthy male child. Past medical history is negative for any significant health issues. There is no family history of clots or cancer.  Physical examination is consistent with 32 week gestation. Right lower extremity is swollen about 3cm more in calf-circumference when compared to the left. There is tenderness in right calf. A Doppler ultrasound reveals thrombosis in superficial femoral vein. Factor V leiden mutation, Lupus anticoagulant, anti-cardioloipin antibodies, prothrombin gene mutation are negative. Anti-thombin III is within normal limits. She is scheduled for C-section in 6 weeks. Which of the following is the most appropriate Statement concerning her management?

A)     Since this is not deep vein thrombosis, start her on LMWH ( Low Molecular Weight Heparin) at prophylactic doses

B)      Start warfarin and continue for total 6 months

C)      Start LMWH, discontinue 2 days prior to C-section, start unfractionated heparin followed by discontinuation 4 hrs prior to C-section and then start LMWH 12 hrs after surgery followed by Warfarin for 6 months.

D)     Start LMWH, discontinue 2 days prior to C-section, start unfractionated heparin followed by discontinuation 4 hrs prior to C-section and then start LMWH 12 hrs after surgery followed by Warfarin for 6 weeks post-partum

E)      Start LMWH now through delivery followed by warfarin for 6 months post-partum.

Question of the Week # 349

349)  A 46 year old man presents to your office with generalized itching. The itching is severe during shower and for past few weeks, it has become intolerable. He denies any headache, chest pain or shortness of breath.  He does not smoke and consumes alcohol only occasionally. He works as a public health officer in New York City. He reports no sleep related problems, denies snoring at night or day-time drowsiness. He denies any past medical problems . On examination, he is overweight, afebrile,  Blood pressure 110/60 mm Hg,  Heart Rate 88/min, Respiratory rate is 16/minute. Physical examination is benign. There is no splenomegaly. A CT Scan of the chest, abdomen and pelvis does not reveal any neoplasm. Laboratory investigations reveal :

WBC : 9.0k/µl

Hemoglobin 20gm% ( N = 13.5 to 16.5gm%

Hematocrit 62%

Mean Corpuscular Volume ( MCV) 65µl

Platelet count 280k/µl

Serum Creatinine 0.8mg%

Serum Calcium 9.8mg%

Erythropoetin Level 3U/L ( Normal 5 to 25U/L)

Which of the following is features can be seen with this condition?

A) Low serum uric acid

B) Iron deficiency

C) Elevated HGBA2 fraction on HGB electrophoresis

D) Reduced Leucocyte Alkaline Phosphatase

E) Elevated Reticulocyte Count

Question of the Week # 318

318)  A 55 year old woman underwent a debulking surgery with total abdominal hysterectomy, Salpingo-oophorectomy, omentectomy and appendicectomy for a recently diagnosed Stage IIIC  Epithelial Ovarian Cancer. Her intra-operative course was complicated by severe blood loss and she received about 15 units of Packed Red Blood Cells. She is currently in the intensive care unit. Six hours after surgery, her blood pressure drops to 80/50 mm Hg. On examination, she is afebrile. She is drowsy but can be awakened. She denies any chest pain or shortness of breath. She has muscle tremors. Chest is clear to auscultation. Abdominal sutures are intact with no clinical evidence of Hematoma. An electrocardiogram is shown below:

Which of the following is the most likely explanation of the patient’s acute findings?

A) Hyperkalemia

B) Acute Myocardial Infarction

C) Circulatory Overload

D) Transfusion Associated Acute Lung injury

E) Citrate Toxicity

Question of the week # 310

310) A 28 year old man is admitted with abdominal pain and diarrhea of one day duration. Abdominal pain is diffuse in nature, mild to moderate and is associated with cramps and vomiting. He reports having had recurrent attacks of abdominal pain and diarrhea for several months. His past medical history is significant for Vitiligo and Hypothyroidism. He denies any allergies, atopy or Asthma. Family history is unremarkable. On examination, his mucous membranes and dry and he appears moderately dehydrated. He is afebrile, Blood pressure is 90/60 mm HG, heart rate 120/min, Respiratory rate 18/min. There is no peripheral lymphadenopathy. Skin examination reveals hypopigmented patches consistent with Vitiligo on his chest and the extremities. Abdominal examination is benign , Spleen is not palpable. CT scan of the chest, abdomen and pelvis are normal. Stool anlaysis performed several times during his previous episodes did not reveal any evidence of parasitic infection or leukocytes or blood. Laboratory investigations and peripheral smear are shown below:

WBC 6.0k/µl

Differential: Neutrophils 45%, Lymphocytes 34% ( N = 20 to 40%), Monocytes 6%, Eosinophils 15% ( normal range 1 to 4%)

Hemoglobin 14.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Stool Ova and Parasites negative

TSH 4 μIU/ml ( 0.3 – 5.0 uIU/ml)

Which of the following diagnoses is most likely explanation for the patient’s clinical presenation?

A) Giardiasis

B) Addison’s disease

C) Vitiligo

D) Chronic Myeloid Leukemia

E) Lymphoma

Question of the week # 297

297) A 64 year old man is seen in the office for pre-operative evaluation of right inguinal hernia repair. His past medical history is significant for diabetes and recurrent right foot cellulitis. His most recent episode of right foot cellulitis was 2 weeks ago for which he received a 2 week course of oral antibiotics. His surgery is scheduled within one week. On examination, he is afebrile. He has reducible right inguinal hernia and bilateral lower extremity stasis dermatitis. His laboratory investigations reveal:

Platelet Count 240k/μl ( Normal 150–400k/μl)

Prothrombin time 22 seconds ( Normal 10 to 13 secs)

Partial Thromboplastin time : 34 sec ( Normal 22 to 37 secs)

Which of the following is the most appropriate action at this time?

A) Obtain PTT mixing studies

B) Administer Oral Vitamin K

C) Intravenous Fresh Frozen Plasma

D) Intravenous Factor VIII

E) Von Willebrand Factor Assay

Question of the week # 286

286) A 55 year old woman with history of diabetes mellitus and hypertension is admitted with chest pain. Chest pain started about 30 minutes ago but now resolved after she received sublingual nitroglycerin. An electrocardiogram obtained by EMS showed ST segment depressions but a repeat electrocardiogram in the Emergency room is normal. She is placed on Aspirin, low molecular weight heparin, atorvastatin and metoprolol. She denies any easy bruising, nose bleeding or any other gross bleeding. She denies smoking , alcohol or drug abuse She has not been admitted to any hospital and has never received anticoagulants in the past. Physical examination  is benign . Laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 15 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 8k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. Three sets of cardiac enzymes are negative. Cardiology team held aspirin and low molecular weight heparin immediately. A peripheral blood smear is shown below:

 

Which of the following is the most appropriate next step in management?

A) Platelet transfusion

B) Heparin induced platelet antibodies

C) Start Lepirudin

D) Send CBC in a citrate tube

E) IV Gamma Globulin

Question of the week # 285

285) A 26 year old man is seen in the office because he was found to have abnormal blood counts during a health check up prior to his life insurance application. He says he was told to see his physicians because his platelet count was very low. He denies any easy bruising, nose bleeding or any other gross bleeding. He has no other medical problems. He denies smoking , alcohol or drug abuse. He denies any recent infections. He leads a very active lifestyle and is a professional soccer player. He proudly states that he won his team the state level championship a year ago and likes to aggressively pursue this career. Physical examination  is benign. There is no splenomegaly. Repeat aboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 15 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 45k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative.

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

A) Intavenous Immunoglobulin

B) Recommend against soccer for life

C) Splenectomy

D) Observation

E) Prednisone

Question of the week # 284

284) A 32 year old pregnant woman is evaluated in the emergency room for new onset abdominal pain. She has mild nausea and vomited once prior to arrival in the emergency room. She denies any bleeding . This is her first pregnancy and she is at 34 weeks gestation.  Physical examination reveals normal blood pressure. There is mild tenderness in epigastric region. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 7 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 50k/µl

Lactic Dehydrogenase  1200U/L

AST 120U/L

ALT 180U/L

Serum Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. Amylase and lipase are normal. A peripheral blood smear shows reduced number of platelets and some fragmented red blood cells. Antinuclear antibodies, Anti-phospholipid antibodies, Lupus anticoagulant profile, HIV testing and Hepatitis C are negative.

Which of the following is the most appropriate next step in management?

A) Platelet transfusion

B) Intravenous Methyl Prednisolone

C) Induction of labor

D) Observation

E) Plasmapheresis

Question of the week # 283

283) A 26 year old man is seen in the office during a pre-employment health check-up. He has no medical problems. He denies smoking , alcohol or drug abuse. Physical examination  is benign. Laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 15 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 45k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative.Upon further questioning, he denies any easy bruising, nose bleeds or gross bleeding. There is no family history of thrombocytopenia or bleeding disorder.

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

A) Intavenous Immunoglobulin

B) Prednisone

C) Observation

D) Bone marrow biopsy

E) Platelet transfusion

Question of the week # 282

282) A 32 year old woman is seen in the antenatal clinic during her regular antenatal visit. This is her first pregnancy and she is at 32 weeks gestation. She takes prenatal vitamins. She currently has no complaints. Physical examination  is benign. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 14 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 70k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative. The patient is concerned about her abnormal platelet counts. She denies any easy bruising or nose bleeds or gross bleeding. Her complete blood count 3 months ago was completely normal.

Which of the following is the most appropriate response?

A) “You will require treatment with steroids”

B) “Urgent delivery with cesarean section is required.”

C) “Your platelet count will normalize within 2 to 12 weeks after delivery”

D) “You will require Bone marrow biopsy”

E) “No treatment needed since it is immune thrombocytopenia”

Question of the week # 281

281) A 22 year old woman is seen in the office for a rash on legs. She had an upper respiratory tract infection one week ago which resolved spontaneously. She is not on any medications. She has no other significant mast medical history. She has easy bruising which started 5 days ago but denies any nose bleeds or gross bleeding. Her last menstrual period was one week ago and she has regular cycles with no history of menorrhagia. Family history is negative for any bleeding disorders or thrombocytopenia. She denies any smoking , alcohol or drug abuse. Physical examination  is benign except for  petechiae on her bilateral lower extremities. There is no splenomegaly on examination. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 14 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 18k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative.

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

A) Ristocetin cofactor assay

B) Prednisone

C) Observation

D) Bone marrow biopsy

E) Plasmapheresis

F) Platelet transfusion

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 # 140

140) A 15 year old boy with history of Cystic Fibrosis presents to the Emergency room with complaints of severe right lower quadrant abdominal pain. He also gives a history of nausea and vomiting for the past 8 hours. On examination, his temperature is 102F and he has right lower quadrant tenderness at McBurney’s Point.  CT scan of the abdomen revealed calcified appendicolith within the dilated, fluid-filled appendix and infiltration of the surrounding retroperitoneal fat. The patient is scheduled for Appendicectomy. However, pre-operative labs reveal an abnormal result that would put the patient at an increased risk of bleeding from surgery. The patient is referred for medical clearance. Which of the following is most likely to be abnormal in this patient?

A)     Platelet count

B)      Prothrombin time

C)      Partial Thromboplastin Time

D)     Both Prothrombin time and Partial Thromboplastin time

E)      Bleeding time

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