A
B
C
D
100
A 28-year-old woman undergoes evaluation for easy bruising, epistaxis, and bleeding gums. She is pregnant at 16 weeks' gestation. Medications include only prenatal vitamins.
On physical examination, vital signs are normal. Dried blood is noted around the nares. She has a gravid uterus.
Laboratory studies:
Hemoglobin
12.2 g/dL (122 g/L)
Leukocyte count
4500/μL (4.5 × 109/L)
Platelet count
66,000/μL (66 × 109/L)
Creatinine
0.7 mg/dL (61.9 μmol/L)
Peripheral blood smear shows normal erythrocytes and granulocytes without platelet clumping.
Which of the following is the most likely diagnosis for her thrombocytopenia?
Gestational thrombocytopenia
HELLP syndrome
Immune thrombocytopenic purpura
Thrombotic thrombocytopenic purpura
100
A 51-year-old woman is evaluated before hospital discharge. She was diagnosed with high-risk acute myeloid leukemia and completed induction chemotherapy. Her leukemia is believed to be secondary to breast cancer therapy, which included surgery and chemotherapy following diagnosis 2 years ago.
On physical examination, vital signs and other findings are normal. A peripherally inserted central catheter is located in the left upper extremity.
Complete blood count and bone marrow aspirate and biopsy indicate complete remission.
Which of the following is the most appropriate management?
Allogeneic hematopoietic stem cell transplantation
Consolidation chemotherapy
Intrathecal chemotherapy plus whole brain irradiation
Maintenance chemotherapy
No additional treatment
100
A 65-year-old man is diagnosed with multiple segmental pulmonary emboli in the right lung. He has no other medical problems, and he takes no medications.
On physical examination, blood pressure is 132/76 mm Hg, pulse rate is 100/min, and respiration rate is 18/min. Oxygen saturation is 98% at rest breathing ambient air.
The patient is alert and quickly comprehends the diagnostic implications and required therapy. He does not require pain medication. The patient is engaged in a shared decision-making process regarding treatment.
Which of the following is the most appropriate recommendation?
Discharge home and treat with dabigatran
Discharge home and treat with rivaroxaban
Hospitalize and treat with thrombolytic therapy
Hospitalize and treat with unfractionated heparin and warfarin
100
A 74-year-old man is evaluated in the hospital for new-onset thrombocytopenia. He was hospitalized 48 hours ago for management of CT angiography–confirmed pulmonary embolism. Medical history is significant for coronary artery bypass graft surgery 3 weeks ago. Medications are aspirin, clopidogrel, metoprolol, lisinopril, furosemide, and atorvastatin; low-molecular-weight heparin (LMWH) was initiated on admission to the hospital.
On physical examination, vital signs are normal. Other than a well-healing sternotomy scar, the physical examination is unremarkable.
Laboratory studies:
Hemoglobin
12 g/dL (120 g/L)
Leukocyte count
11,500/μL (11.5 × 109/L)
Platelet count
90,000/μL (90 × 109/L) (at admission: 250,000/μL [250 × 109/L])
Estimated glomerular filtration rate
>60 mL/min/1.73 m2
Peripheral blood smear is normal.
The 4T score is 5, corresponding to an intermediate risk of heparin-inducted thrombocytopenia. LMWH is discontinued, and a test for heparin-induced antibody is ordered.
Which of the following is the most appropriate management?
Discontinue aspirin and clopidogrel
Insert an inferior vena cava filter
Start rivaroxaban
Start warfarin
200
A 49-year-old man is evaluated for progressive fatigue and a 13.6-kg (30-lb) weight loss in 4 months. Medical history is unremarkable, and he takes no medications.
On physical examination, vital signs are normal. On abdominal palpation, the spleen is enlarged to 17 cm.
Laboratory studies:
Hemoglobin
11 g/dL (110 g/L)
Leukocyte count
87,500/μL (87.5 × 109/L) (87% neutrophils, 2% bands, 2% metamyelocytes, 3% myeloblasts, 2% basophils, 2% lymphocytes)
Platelet count
465,000/μL (465 × 109/L)
Bone marrow biopsy shows hypercellular marrow with granulocytic hyperplasia and 6% myeloblasts. Chromosomal analysis and fluorescence in-situ hybridization studies show t(9;22).
Which of the following is the most appropriate treatment?
Hydroxyurea
Imatinib
Induction chemotherapy
Stem cell transplantation
200
75-year-old woman is evaluated for fatigue and a 3-month history of pain in her neck, shoulders, and hips and low-grade fevers. She reports no headaches, vision changes, or jaw claudication. Her last colonoscopy was 5 years ago. She has no other medical problems and takes no medications.
On physical examination, vital signs are normal. No temporal or jaw tenderness is noted. Proximal girdle muscles are tender to palpation, with restricted range of motion owing to stiffness and pain. Muscle strength is symmetric and normal. No joint effusions or synovitis is evident.
Laboratory studies:
Erythrocyte sedimentation rate
90 mm/h
Hemoglobin
8.5 g/dL (85 g/L)
Leukocyte count
8000/μL (8 × 109/L) with normal differential
Platelet count
450,000/μL (450 × 109/L)
Mean corpuscular volume
84 fL
Reticulocyte count
1% of erythrocytes
Iron studies
Ferritin
800 ng/mL (800 μg/L)
Iron
10 μg/dL (2 μmol/L)
Total iron-binding capacity
200 μg/dL (36 μmol/L)
Which of the following is the most appropriate management of this patient's anemia?
Bone marrow biopsy
Colonoscopy
Erythropoiesis-stimulating agent
Low-dose prednisone
Oral iron replacement
200
A 58-year-old man is evaluated in the emergency department for fever, headache, and stiff neck. The fever began 2 days ago; the headache and stiff neck were present on awakening today and have become severe. Two weeks ago, he was diagnosed with trigeminal neuralgia, and carbamazepine therapy was initiated.
On physical examination, temperature is 38.7 °C (101.7 °F), blood pressure is 110/70 mm Hg, pulse rate is 110/min, and respiration rate is 18/min. Nuchal rigidity is present, but the remainder of the neurologic examination is otherwise normal. He has no papilledema. Petechiae and ecchymoses are noted over the lower extremities.
Laboratory studies:
Activated partial thromboplastin time
36 s
Haptoglobin
Normal
Hemoglobin
12.5 g/dL (125 g/L)
Leukocyte count
18,100/μL (18.1 × 109/L)
Platelet count
30,000/μL (30 × 109/L)
Prothrombin time
11.5 s
Lactate dehydrogenase
Normal
A peripheral blood smear reveals decreased platelets and normal erythrocyte morphology. A direct antiglobulin test is negative.
Carbamazepine is discontinued. Blood cultures are obtained. Dexamethasone and empiric antibiotics are initiated for presumed bacterial meningitis.
Which of the following is the most appropriate next step in management?
Lumbar puncture
Plasma exchange
Platelet transfusion
No additional interventions
200
A 63-year-old man is evaluated for easy bruising, worsening edema, and dizziness on standing over the past 9 months. Medical history is otherwise noncontributory; he takes no medications.
On physical examination, blood pressure is 105/60 mm Hg sitting and 80/50 mm Hg standing; pulse rate is 105/min both sitting and standing. Periorbital ecchymoses, macroglossia, and jugular venous distention are present.
Laboratory studies show a normal hemoglobin level, serum albumin level of 2 g/dL (20 g/L), and serum creatinine level of 1.5 mg/dL (133 μmol/L). 24-Hour urine albumin excretion is 3500 mg. Serum protein electrophoresis shows an IgG λ spike of 1.2 mg/dL.
Echocardiogram shows biventricular myocardial hypertrophy with nondilated ventricles and diastolic dysfunction. Left ventricular ejection fraction is 51%.
Which of the following is the most appropriate diagnostic test to perform next?
Abdominal fat pad biopsy
Endomyocardial biopsy
Kidney biopsy
Tilt-table test
300
A 68-year-old man is evaluated for a transfusion reaction. He was hospitalized for acute upper gastrointestinal bleeding. While receiving his first unit of packed red blood cells, he developed fever, dyspnea, and flank pain 15 minutes into the transfusion. The transfusion was stopped by the nursing staff. His only medication is omeprazole.
On physical examination, temperature is 38.3 °C (100.9 °F), blood pressure is 80/40 mm Hg, pulse rate is 120/min, and respiration rate is 18/min. Oxygen saturation is 96% breathing ambient air. Cardiopulmonary examination reveals clear lungs, normal heart sounds, and low central venous pressure.
Inspection of a collected urine specimen reveals a pink coloration.
Which of the following is the most likely diagnosis?
Acute hemolytic transfusion reaction
Allergic reaction
Transfusion-associated circulatory overload
Transfusion-related acute lung injury
300
A 19-year-old woman is evaluated for easy bruising of 2 weeks' duration. She has no other symptoms, and medical history is unremarkable. She takes no medications.
On physical examination, vital signs are normal. Examination findings are limited to petechiae on the lower extremities and small, scattered ecchymoses.
Laboratory studies show a platelet count of 15,000/μL (15 × 109/L); the remainder of the complete blood count is normal.
The peripheral blood smear is shown.
HIV and hepatitis C testing is pending.
Which of the following is the most appropriate management?
Glucocorticoids
Plasma exchange
Platelet transfusion
Observation
300
A 28-year-old woman is evaluated for a 3-day history of fever and pharyngitis. Medical history is significant for hyperthyroidism diagnosed 3 months ago. She consumes a vegetarian diet. Her only medication is methimazole.
On physical examination, temperature is 38.2 °C (100.8 °F); other vital signs are normal. Posterior pharyngeal erythema is noted.
Laboratory studies:
Hemoglobin
13.9 g/dL (139 g/L)
Leukocyte count
2300/μL (2.3 × 109/L) (20% neutrophils, 72% lymphocytes, 8% monocytes)
Absolute neutrophil count
460/μL (0.46 × 109/L)
Mean corpuscular volume
92 fL
Platelet count
302,000/μL (302 × 109/L)
Which of the following is the most likely diagnosis?
Duffy-null associated neutrophil count
Cyclic neutropenia
Drug-induced neutropenia
Vitamin B12 deficiency
300
A 30-year-old man is evaluated for progressive fatigue of several months' duration. Medical history is otherwise unremarkable. He indicates having a sibling. He takes no medications.
On physical examination, pulse rate is 114/min; other vital signs are normal. Oxygen saturation is 98% breathing ambient air. Conjunctival rim pallor and scattered petechiae are noted.
Laboratory studies:
Hemoglobin
7.1 g/dL (71 g/L)
Leukocyte count
1200/μL (1.2 × 109/L) (65% neutrophils, 35% lymphocytes)
Mean corpuscular volume
90 fL
Platelet count
22,000/μL (22 × 109/L)
Reticulocyte count
1% of erythrocytes
Peripheral blood smear shows erythrocytes with normal morphology and decreased platelets. A bone marrow biopsy shows marked hypocellularity and increased fat content without dysplastic cells. Testing for viral hepatitis is negative.
The sibling's test results show an HLA match.
Which of the following is the most effective therapy?
Allogeneic hematopoietic stem cell transplantation
Antithymocyte globulin
Azacytidine
Intravenous immune globulin
400
A 48-year-old woman is evaluated for easy bruising. She has no history of gingival bleeding, menorrhagia, or bleeding following procedures. Medical history is notable only for systemic lupus erythematosus. Medications are prednisone, hydroxychloroquine, and NSAIDs as needed.
On physical examination, vital signs and examination findings are normal.
Laboratory studies show an activated partial thromboplastin time of 38 seconds, platelet count of 190,000/μL (190 × 109/L), and prothrombin time of 12.5 seconds.
Which of the following is the most appropriate diagnostic test?
Factor VIII inhibitor titer
Factor XI level
Factor XII level
Mixing study
400
A 32-year-old man is evaluated in the emergency department for a 1-week history of fatigue, low-grade fever, bruising, and epistaxis. He has no other medical problems, and he takes no medications.
On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 120/65 mm Hg, pulse rate is 108/min, and respiration rate is 22/min. Pallor is noted. Dried blood is present in the nares. Multiple bruises are seen on his extremities, and he has petechiae at his ankles.
Laboratory studies:
Activated partial thromboplastin time
38 s
D-dimer
2.5 μg/mL (2.5 mg/L)
Hematocrit
22%
Leukocyte count
2300/μL (2.3 × 109/L)
Platelet count
22,000/μL (22 × 109/L)
Prothrombin time
25 s
Albumin
3.5 g/dL (35 g/L)
Alanine aminotransferase
30 U/L
Aspartate aminotransferase
35 U/L
Bilirubin, total
0.9 mg/dL (15.4 μmol/L)
Fibrinogen
60 mg/dL (0.6 g/L)
Which of the following is the most likely diagnosis?
Aplastic anemia
Coagulopathy of liver disease
Disseminated intravascular coagulation
Thrombotic thrombocytopenic purpura
400
A 70-year-old man is hospitalized with a 3-day history of acute abdominal pain and nausea and vomiting. Medical and family histories are noncontributory, and he takes no medications.
On physical examination, vital signs are normal. Palpation elicits mild tenderness in the upper abdomen, without hepatosplenomegaly or abdominal mass.
Laboratory studies show a hemoglobin level of 14.5 g/dL (145 g/L), leukocyte count of 5000/μL (5 × 109/L), and platelet count of 250,000/μL (250 × 109/L).
CT of the abdomen with contrast demonstrates an acute portal vein thrombosis.
Which of the following is the most appropriate additional diagnostic test?
Antithrombin measurement
JAK2 tyrosine kinase mutation
Protein C measurement
Protein S measurement
400
A 75-year-old man is evaluated for an elevated INR found on routine monitoring. He is otherwise well and has no evidence of bleeding. Medical history is significant for atrial fibrillation. His only medication is warfarin.
Laboratory studies show a normal hemoglobin level and INR of 8.5.
The patient is instructed not to take his warfarin until further INR evaluation.
Which of the following is the most appropriate additional management?
Observation
4-Factor prothrombin complex concentrate
BFactor VIIa
Fresh frozen plasma
Vitamin K