HEME-ONCOLOGY-3
A 68-year-old woman is brought to the emergency department because of a 3-day history of progressive fatigue, confusion, and easy bruising. She has type 2 diabetes mellitus, hypertension, and chronic kidney disease that requires hemodialysis. She missed her last dialysis appointment. On examination, she appears lethargic and is oriented only to person. She has a 3+ pitting edema of both ankles and several ecchymoses across both lower extremities. Further evaluation of this patient is most likely
A on the diagram
A 78-year-old man is brought to the emergency department by ambulance 30 minutes after the sudden onset of speech difficulties and right-sided arm and leg weakness. Examination shows paralysis and hypoesthesia on the right side, positive Babinski sign on the right, and slurred speech. A CT scan of the head shows a hyperdensity in the left middle cerebral artery and no evidence of intracranial bleeding. The patient's symptoms improve rapidly after pharmacotherapy is initiated and his weakness com
Alteplase
A 54-year-old woman comes to the emergency department because of sharp chest pain and shortness of breath for 1 day. Her temperature is 37.8°C (100.0°F), pulse is 110/min, respirations are 30/min, and blood pressure is 86/70 mm Hg. CT angiography of the chest shows a large embolus at the right pulmonary artery. Pharmacotherapy with a tissue plasminogen activator is administered. Six hours later, she develops right-sided weakness and slurred speech. Laboratory studies show elevated prothrombin
Aminocaproic acid
A 59-year-old woman comes to the physician because of left leg swelling that started after a transcontinental flight. A duplex ultrasound of the left leg shows a noncompressible popliteal vein. A drug is prescribed that inhibits the coagulation cascade. Two weeks later, laboratory studies show: Platelet count210,000/mm3 Partial thromboplastin time53 secondsProthrombin time20 secondsThrombin time15 seconds (control: 15 seconds) Which of the following drugs was most likely prescribed?
Apixaban
A 4-year-old boy is brought to the physician by his mother because of generalized weakness and difficulty walking for the past month. Laboratory studies show a hemoglobin concentration of 6.6 g/dL, mean corpuscular volume of 70 μm3, platelet count of 150,000/mm3, and serum total bilirubin concentration of 2 mg/dl. An MRI of the spine shows low signal intensity in all vertebral bodies and a small epidural mass compressing the spinal canal at the level of L1. A CT scan of the head shows osteopeni
Beta thalassemia
A 19-year-old woman comes to the physician because of a 1-month history of mild fatigue and weakness. Physical examination shows no abnormalities. Her hemoglobin concentration is 11 g/dL and mean corpuscular volume is 74 μm3. Hemoglobin electrophoresis shows 10% HbA2 (N < 3.5). Which of the following is the most likely diagnosis?
Beta thalassemia minor
Four days after admission to the hospital for acute pancreatitis, a 41-year-old man develops hypotension and fever. His temperature is 39.1°C (102.3°F), pulse is 115/min, and blood pressure is 80/60 mm Hg. Physical examination shows warm extremities, asymmetric calf size, and blood oozing around his IV sites. There are numerous small, red, nonblanching macules and patches covering the extremities, as well as several large ecchymoses. His hemoglobin concentration is 9.0 g/dL. A peripheral blood
C on the diagram
Three days after undergoing laparoscopic colectomy, a 67-year-old man reports swelling and pain in his right leg. He was diagnosed with colon cancer 1 month ago. His temperature is 38.5°C (101.3°F). Physical examination shows swelling of the right leg from the ankle to the thigh. There is no erythema or rash. Which of the following is likely to be most helpful in establishing the diagnosis?
Compression ultrasonography
A 9-year-old boy is brought to the emergency department by his mother because of painful swelling in his right knee that started after he collided with another player during a soccer game. He has no history of serious illness except for an episode of prolonged bleeding following a tooth extraction a few months ago. Physical examination shows marked tenderness and swelling of the right knee joint. There are multiple bruises on the lower extremities in various stages of healing. Laboratory studies
Conversion of factor X
A 54-year-old man is brought to the emergency department 1 hour after the sudden onset of shortness of breath, severe chest pain, and sweating. He has hypertension and type 2 diabetes mellitus. He has smoked one pack and a half of cigarettes daily for 20 years. An ECG shows ST-segment elevations in leads II, III, and aVF. The next hospital with a cardiac catheterization unit is more than 2 hours away. Reperfusion pharmacotherapy is initiated. Which of the following is the primary mechanism of ac
Conversion of plasminogen to plasmin
An otherwise healthy 23-year-old man comes to the physician because of a 3-day history of mild persistent bleeding from the site of a tooth extraction. He has no prior history of medical procedures or surgeries and no history of easy bruising. He appears well. Vital signs are within normal limits. Laboratory studies show: Hemoglobin12.4 g/dLPlatelets200,000/mm3SerumProthrombin time25 secondsPartial thromboplastin time (activated)35 seconds Deficiency of which of the following coagulation factors
Factor VII
A 48-year-old man comes to the emergency department because of a 1-hour history of heavy nasal bleeding. He drinks half a bottle of wine daily. His pulse is 112/min and blood pressure is 92/54 mm Hg. Physical examination shows scattered ecchymoses across the extremities and oozing from a venipuncture site. Laboratory studies show a prothrombin time of 28 seconds and a partial thromboplastin time of 36 seconds. Impaired function of which of the following proteins is the most likely cause of this
Gamma-glutamyl carboxylase
A 7-year-old girl is brought to the physician for evaluation of recurrent epistaxis. Her mother reports that she bruises easily while playing. Her pulse is 89/min and blood pressure is 117/92 mm Hg. Examination shows multiple bruises in the upper and lower extremities. Laboratory studies show: Platelet count100,000/mm3Prothrombin time12 secondsPartial thromboplastin time33 secondsBleeding time13 minutes (N = 2-7) A peripheral blood smear shows enlarged platelets. Ristocetin cofactor assay show
Glycoprotein Ib deficiency
A 26-year-old woman, gravida 2, para 1, at 26 weeks' gestation, comes to the emergency department because of pain and swelling in her right calf. Physical examination shows an increased circumference of the right calf. The leg is warm and tender on palpation. Dorsiflexion of the right foot elicits calf pain. An ultrasound of the right leg shows a noncompressible popliteal vein. Which of the following is the most appropriate pharmacotherapy for this patient's condition?
Heparin
A 58-year-old woman is brought to the emergency department for shortness of breath and chest pain. Pulmonary angiography shows a large saddle embolus in the pulmonary arteries. Emergency drug therapy is administered and she is admitted to the hospital for observation. A follow-up CT scan of the chest shortly after admission shows that the thrombus has disappeared. Five hours later, the patient is found to be lethargic with slurred speech. Physical examination shows decreased consciousness, dysar
Intracerebral hemorrhage
A 45-year-old woman with β-thalassemia major comes to the physician with a 1-week history of fatigue. She receives approximately 8 blood transfusions per year; her last transfusion was 1 month ago. Examination shows conjunctival pallor. Her hemoglobin level is 6.5 mg/dL. Microscopic evaluation of a liver biopsy specimen in this patient would most likely show which of the following?
Macrophages with cytoplasmic granules that stain golden-yellow with hematoxylin
An investigator is studying the role of different factors in inflammation and hemostasis. Alpha-granules from activated platelets are isolated and applied to a medium containing inactive platelets. When ristocetin is applied, the granules bind to GpIb receptors, inducing a conformational change in the platelets. Binding of the active component of these granules to GpIb receptors is most likely responsible for which of the following steps of hemostasis?
Platelet adhesion
A previously healthy 4-year-old boy is brought to the emergency department because of a 1-day history of pain and swelling of his left knee joint. He has not had any trauma to the knee. His family history is unremarkable except for a bleeding disorder in his maternal uncle. His temperature is 36.9°C (98.4°F). The left knee is erythematous, swollen, and tender; range of motion is limited. No other joints are affected. An x-ray of the knee shows an effusion but no structural abnormalities of the
Prolonged partial thromboplastin time
A 21-year-old woman comes to the physician for an annual health maintenance examination. She has no particular health concerns. Laboratory studies show: Hemoglobin11.2 g/dLMean corpuscular volume74 μm3Mean corpuscular hemoglobin concentration30% Hb/cellRed cell distribution width14% (N = 13-15) Genetic analysis shows a point mutation in intron 1 of a gene on the short arm of chromosome 11. A process involving which of the following components is most likely affected in this patient?
Small nuclear ribonucleoprotein
A 29-year-old woman, gravida 1, para 0 at 11 weeks' gestation comes to the physician because of a 2-day history of left lower extremity pain and swelling. Her temperature is 37.9°C (100.2°F). Physical examination shows a tender, palpable cord on the lateral aspect of the left lower leg. The overlying skin is erythematous and indurated. Duplex ultrasound shows vascular wall thickening and subcutaneous edema. Which of the following is the most likely diagnosis?
Superficial thrombophlebitis
A 54-year-old woman comes to the emergency department because of sharp chest pain and shortness of breath for 1 day. She has been coughing intermittently, which worsens the pain. She has osteoporosis, for which she takes raloxifene. Arterial blood gas analysis on room air shows: pH7.52PCO225 mm HgPO265 mm HgO2 saturation92% Physical examination is most likely to show which of the following findings?
Unilateral swelling of the leg
