B3E2 - Practice Exam

Which laboratory test result is most indicative of cobalamin deficiency? A. Elevated serum methylmalonate B. Elevated serum homocysteine C. The presence in serum of antibodies against gastric parietal cells D. Neutral pH of gastric fluid (achlorhydria) E. Hypersegmented neutrophils

A

Which of the following conditions should be considered if both the PT and PTT are prolonged in a patient noted to be oozing from a surgical incision? A. Severe liver disease, DIC, factor X deficiency B. Heparin effect, VWD, factor XII deficiency C. Warfarin effect, factor VII deficiency, vitamin K deficiency D. All of the above

A

Which of the following disorders is not associated with small red cells (microcytosis)? A. Liver disease B. Lead poisoning C. Thalassemia D. Iron deficiency E. X-linked sideroblastic anemia

A

Which of the following lab values is most commonly found in vWD? A. Normal PT, normal PTT, and normal platelet count B. Normal PT, abnormal PTT, and normal platelet count C. Abnormal PT, normal PTT, and normal platelet count D. Abnormal PT, abnormal PTT, and normal platelet count

A

You decide to transfuse your patient with one unit of packed red blood cells (PRBCs). After 30 minutes, the patient complains of dyspnea and back pain. Repeat examination of this patient reveals a diaphoretic man with a pulse of 130 bpm and BP of 88/50 mm Hg. His lung fields are clear. Initial vitals before the transfusion were a pulse of 110 bpm and BP of 94/52 mm Hg. What is your next step? A. Stop the blood transfusion and begin normal saline through the IV B. Increase the rate of transfusion C. Administer acetaminophen 650 mg PO D. Administer furosemide 40 mg IV E. Place a nasogastric tube for lavage

A

A 6-month-old boy presents to your office after his mother notices swelling and ecchymosis over his anterior right thigh. She does not recall any trauma to the area. The mother denies any history of bleeding problems, including during his circumcision. On physical examination the child has a large hematoma over his thigh. There are no obvious bony deformities and the child otherwise looks well. You suspect the child may have an inherited coagulation disorder. Which of the following statements is NOT correct? A. Child abuse should be included in the differential diagnosis B. The child did not bleed during circumcision, so the possibility of hemophilia need not be considered C. A careful family history is important in the workup D. Coagulation studies (PT, PTT) and CBC should be obtained

B

Which of the following statements about β-thalassemia major is correct? A. Patients with β-thalassemia major rely on hemoglobin A2 (α2δ2) for oxygen-carrying capacity after birth because synthesis of β-globin is impaired. B. Adequate transfusion therapy suppresses ineffective erythropoiesis. C. Transferrin-bound iron causes heart disease. D. Although hematopoietic stem cell transplantation is effective therapy, it is much more costly than standard treatment with transfusions and iron chelation. E. Newborns with β-thalassemia major are severely anemic

B

You start iron supplementation therapy in your patient w/ IDA. Which of the following tests will be the first to indicate that you have instituted appropriate therapy and that the patient is responding? A. Increase in hematocrit B. Increase in reticulocyte count C. Increase in serum-free hemoglobin D. Decrease in ferritin E. Decrease in transferrin saturation

B

A 20-year-old woman comes to establish care with you. She is sexually active and reports inconsistent use of condoms or other methods of contraception. She has had 3 sexual partners in the last year. Regarding cervical cancer screening, which of the following statements is true? A. Given her age of greater than 18, a Pap smear is recommended. B. Given her risky sexual behavior, a Pap smear is recommended. C. Given her age of less than 21, a Pap smear is not recommended. D. Her sexual history does not put her at greater risk for cervical cancer; therefore, a Pap smear is not indicated.

C

A 22-year-old female college student presents to your office with complaints of an enlarged cervical lymph node and sore throat. She has felt feverish on and off for several weeks, but never measured her temperature. She is afebrile today, a rapid strep test is negative, and there is no evidence of lymphadenitis; you treat her symptomatically. You ask her to return if her symptoms do not resolve within 2 to 4 weeks. She returns 4 weeks later. The sore throat has resolved; however, she now complains of intense pruritus and sweats at night. The cervical lymph node now measures 3 cm. The remainder of her physical examination is negative. What is the most appropriate next step? A. Direct laryngoscopy B. Empiric antibiotic trial C. Lymph node biopsy D. MRI of the neck E. Observation for another 4 weeks

C

Which of the following combinations of laboratory test values best supports the presence of hemolysis? A. Low lactate dehydrogenase, high unconjugated bilirubin, low haptoglobin B. Low lactate dehydrogenase, high unconjugated bilirubin, high haptoglobin C. High lactate dehydrogenase, high unconjugated bilirubin, low haptoglobin D. High lactate dehydrogenase, high conjugated bilirubin, low haptoglobin E. High lactate dehydrogenase, high conjugated bilirubin, high haptoglobin

C

Which of the following is MOST LIKELY to help a patient with tumor lysis syndrome and a creatinine of 8? A. Allopurinol 300 mg orally B. Calcium carbonate 500 mg orally C. Emergent hemodialysis D. IV D5W with 2 amps bicarbonate E. IV normal saline 200 mL/hr

C

Which of the following is NOT TRUE about hemophilia A? A. It is an X-linked disorder B. It is the result of factor VIII deficiency C. It generally leads to mucosal bleeding D. It occurs most often in males E. It can be treated with factor VIIa

C

Which of the following is NOT likely to lead to a sustained (let's say at least 2 days) increase in the patient's platelet count? A. IVIG B. Steroids (e.g., prednisone) C. Platelet transfusion D. Splenectomy

C

Which of the following situations increases risk of iron-deficiency anemia in children? A. Introduction of cow's milk after 12 months old B. Breastfeeding with introduction of iron-fortified cereal at 4 to 6 months C. Premature birth D. Feeding with iron-fortified formula

C

You can reassure your patient that an adequate platelet count for clotting is typically as low as: A. Minimum of 150,000/mm3 B. Minimum of 100,000-110,000/mm3 C. Minimum of 20,000-50,000/mm3 D. Minimum of 5,000/mm3 E. Minimum of 1. One platelet—that's it. It's just gotta be a big one.

C

You diagnose this patient with hemophilia A, and he grows up under your excellent tutelage (along with some guidance from your friendly neighborhood hemophilia treatment center, since overall outcomes are better with multidisciplinary care through a hemophilia center). As a junior high school student, he attends summer camp for hemophiliacs in Transylvania. For some bizarre reason, the counselors decide to have the kids play tackle football (crazy, but a true story that happened to one of your authors). The patient presents to the ED with bleeding into his right knee and left elbow. What is the initial step in the management of this patient's hemarthroses? A. Joint aspiration B. Desmopressin C. Factor VIII infusion D. Heparin infusion E. Leeches

C

You obtain a lymph node biopsy that is consistent with nodular sclerosing Hodgkin lymphoma. Which of the following statements is INCORRECT? A. The patient has B symptoms B. Further staging is necessary C. Chemotherapy is palliative only in this patient D. Treatment includes both radiation and chemotherapy

C

Your IDA patient returns to your office and finally admits she has not been able to take the iron because of side effects. She has started a prenatal vitamin for the folate. Her hemoglobin is now down to 7.2 g/dL. She still feels fatigued. The patient will not agree to take any further iron orally. However, she is willing to consider other suggestions. What is your next step? A. Encourage the patient to take the iron preparation along with calcium carbonate (Tums) to reduce the GI side effects B. Continue her prenatal vitamin only and encourage her to eat more red meat C. Give iron sucrose 200 mg IV weekly for 4 weeks D. Transfuse 2 units of PRBCs immediately

C

Your patient, who is on chemotherapy and complaining of back pain, undergoes MRI of the spine, which demonstrates a lesion compressing the cord at L1. Which of the following is NOT an appropriate therapeutic modality? A. Decompression surgery B. Dexamethasone 10 mg bolus IV, followed by 6 mg every 6 hours C. Observation with pain control (e.g., with morphine PCA) D. Radiation therapy to the affected area

C

A 4-year-old girl is brought to you after she is noted to have small pink spots on her lower extremities and bleeding from her gums. She had a URI a couple of weeks ago. She also recently received her second dose of her MMR vaccine (mom particularly wants to make sure she is protected from the recent resurgence in measles and mumps—thank you, anti-vaxers). You note petechiae on her lower extremities and purpura in her oropharynx. The mother and patient deny any other bleeding. You obtain a CBC, which is normal except for a platelet count of 15,000/mm3. You suspect immune thrombocytopenic purpura (ITP, also known as idiopathic thrombocytopenic purpura). Which of the following may have led to this patient's ITP? A. MMR vaccine B. Infection C. Food allergy D. A and B E. All of the above

D

A 50-year-old male is admitted to the hospital with a fractured tibia after a motor vehicle collision. You are asked to assist in his perioperative management. The patient is generally healthy but is taking warfarin for a DVT that he developed after a total knee arthroplasty 3 weeks ago. His INR is 1.8, and he is scheduled for open reduction/internal fixation tomorrow. Which of the following statements is INCORRECT? A. The patient has an approximate 50% risk of recurrent VTE without appropriate therapy B. Heparin should be started preoperatively C. Heparin should be continued postoperatively D. Resumption of warfarin alone postoperatively is adequate anticoagulation

D

A 52-year-old woman with atrial fibrillation is prescribed apixaban. What is the mechanism of action of this oral anticoagulant? A. It indirectly inhibits thrombin by activating antithrombin. B. It directly inhibits thrombin. C. It indirectly inhibits factor Xa by activating antithrombin. D. It directly inhibits factor Xa. E. It blocks the synthesis of active clotting factors.

D

A 61-year-old man has just had surgical resection of his entire stomach because of cancer. This type of surgery puts him at risk for a nutritional anemia because of the lack of: A. Cubilin B. Transcobalamin C. Haptocorrin D. Intrinsic factor E. Gastrin

D

A 67-year-old man presents with dizziness and a positive stool guaiac test. A. Normal MMA; decreased serum folate level B. Elevated MMA; decreased serum B12 level C. Elevated ferritin; normal MCV; decreased serum iron level D. Decreased ferritin; decreased MCV; decreased serum iron level

D

An African American soldier developed an acute hemolytic anemia shortly after taking the antimalarial drug dapsone. By mistake, he continued to take the drug continuously for the next 6 months. What would be the most likely life span of his red cells? A. 5 days B. 15 days C. 30 days D. 60 days E. 120 days

D

An important mechanism by which clinical resistance develops to imatinib in chronic myelogenous leukemia is A. increased excretion in the urine. B. increased hepatic metabolism. C. decreased bioactivation in cancer cells. D. spontaneous mutations in the BCR-ABL kinase. E. increased efflux from tumor cells.

D

In children with sickle cell disease (SCD), screening for increased risk of stroke is evaluated by which of the following imaging modalities? A. Brain MRI B. Head CT C. Electroencephalogram (EEG) D. Transcranial Doppler (TCD)

D

The molecular target of trastuzumab is A. BCR-ABL. B. VEGF. C. ErbB1. D. ErbB2. E. CD20.

D

What is the most reliable lab value to diagnose iron-deficiency anemia? A. Iron B. Total iron binding capacity (TIBC) C. Mean corpuscular volume (MCV) D. Ferritin

D

Where is the most common site for a lymphoma in the GI tract? A. Small bowel B. Duodenum C. Right colon D. Stomach

D

Which of the following electrolyte abnormalities would contribute to circumoral numbness in a patient who has received 4 U of packed red blood cells due to acute blood loss involving a motor vehicle accident? A. Hyponatremia B. Hypernatremia C. Hypomagnesemia D. Hypocalcemia

D

Which of the following agents kills multiple myeloma (MM) cells by indirectly preventing the transcriptional activity of NF-κB? A. Thalidomide B. Lenalidomide C. Bortezomib D. Sorafenib E. Sirolimus

C

What is the most common cause of death in both children and adults with homozygous sickle cell anemia? A. Acute chest syndrome B. Acute splenic infarction and splenic sequestration C. Infarctive stroke D. Hemorrhagic stroke E. Acute pain crisis

A

A 58-year-old woman comes to your office complaining of fatigue. She has also noticed a burning sensation in her feet over the past 6 months. A CBC shows anemia with an increased MCV. Which of the following is the most likely cause of her anemia? A. Lack of intrinsic factor B. Inadequate dietary folate C. Strict vegetarian diet for the past 6 months D. Chronic GI blood loss

A

A 23-year-old G1 P0 term female goes to emergency cesarean section after she is noted to have placental abruption. She has no other significant medical history. After the delivery, you note that she is having brisk vaginal bleeding and oozing from her venipuncture sites. You obtain laboratories: WBC 9,000/mm3, Hgb 8.2 g/dL, platelet count 80,000/mm3, INR 2.4, PTT 22 seconds, and fibrinogen 80 mg/dL (normal 190-420 mg/dL). Fibrin degradation products are elevated. A CBC at admission was normal. Which of the following statements is INCORRECT? A. The patient may benefit from platelet transfusion B. The patient may benefit from cryoprecipitate transfusion C. The patient may benefit from FFP transfusion D. The patient may benefit from crystalloid infusion

A

A 25-year-old woman comes to you for a Papanicolaou smear test. She says she is hoping to become pregnant and is planning to discontinue using her birth control pills. You do routine laboratory tests and find that she has an elevated mean cell volume, a low red blood cell folate level, a normal serum B12 level, and normal serum ferritin level. Which nutritionally related health risk to the fetus should you be most concerned about at this point? A. Neural tube defects B. Stunted growth C. Pernicious anemia D. Malabsorption

A

A 40-year-old violinist had a 2-year history of hemoglobinuria detected in early morning urine specimens. She was severely anemic (hemoglobin 6.4 g/dL, reticulocyte count 5%). Flow cytometry of her peripheral blood leukocytes revealed a deficiency of CD55 and CD59. What complication is of most concern? A. Life-threatening thrombosis B. Renal failure C. Transition to acute leukemia D. Sepsis

A

A 52-year-old woman presents to the ED with shortness of breath and pleuritic chest pain. She has been on warfarin for atrial fibrillation. Despite her anticoagulation, you suspect pulmonary embolism (PE) and obtain a spiral CT scan, which shows a thrombus in the right pulmonary artery. Prior to the initiation of any therapy, her coagulation studies return and show INR of 2.8 (normal = 1) and PTT 49 seconds (prolonged). Which of the following is the most appropriate next step? A. Test the patient for antiphospholipid antibodies B. Place an inferior vena cava filter C. Repeat the INR and PTT since the patient's sample was probably contaminated with heparin D. Confront the patient about her noncompliance with warfarin E. Throw up your hands in disgust. Aren't they done with the hematology chapter yet?

A

The risk of spontaneous bleeding (without trauma) increases when platelet counts get below what level? A. 10 000 per microliter B. 30 000 per microliter C. 50 000 per microliter D. 100 000 per microliter

A

A 60-year-old woman comes for her routine 6-month follow-up. She has a history of hypertension and dyslipidemia. She had a total hysterectomy 10 years ago due to abnormal bleeding. Her last mammogram 2 years ago was normal. Her gFOBT was negative for occult blood 1 year ago. Which of the following statements regarding cancer screening is true in this patient? A. She is due for breast cancer and colon cancer screening. Orders for a mammogram and a serial FOBT should be given. B. She is due for a mammogram, and given her age she should have an optical colonoscopy for colon cancer screening. C. She is due for breast cancer and colon cancer screening. A FOBT should be done during this visit and an order for a mammogram given. D. She is due for cervical cancer screening as her hysterectomy was performed less than 20 years ago. She is also due for a mammogram and a serial FOBT.

A

A 63-year-old male with a diagnosis of non-small cell lung cancer, undergoing weekly chemotherapy and radiation to a left upper lobe mass, presents to your office. He complains of dull, non-radiating back pain in the lower thoracic/upper lumbar area. He denies trauma or any new activities. He has no associated weakness or paresthesias. He denies difficulties with bowel or bladder function but does notice he is tripping more. What is your initial diagnostic and/or therapeutic approach to this patient? A. MRI of thoracic and lumbar spine B. Plain films of the thoracic and lumbar spine and a COX-2 inhibitor with a 2-week follow-up C. Plain films of the thoracic spine and NSAIDs D. Prescription for physical therapy and NSAIDs E. Urinalysis with culture and antibiotics

A

A 65-year-old patient undergoes a preoperative evaluation for knee replacement. Preoperative lab work revealed normal CBC, normal prothrombin time (PT), and prolonged aPTT. She is referred back to primary care clinic for further evaluation. She has never had surgery and has never given birth. She denies family history of bleeding disorders but does get frequent nose bleeds. Repeat lab work shows a prolonged aPTT. What is the next step in workup? A. Mixing study B. Peripheral smear C. Bone marrow biopsy D. Liver function evaluation

A

A 68-year-old man has an incidental finding of anemia while in the hospital for alcohol abuse. A. Normal MMA; decreased serum folate level B. Elevated MMA; decreased serum B12 level C. Elevated ferritin; normal MCV; decreased serum iron level D. Decreased ferritin; decreased MCV; decreased serum iron level

A

A 68-year-old man is found to have an incidental finding of anemia while hospitalized with pneumonia. His physical examination is normal except for crackles in the left lower lobe. Serum laboratory examinations reveal a normal MMA and a decreased serum folate level. Which of the following is the best next step? A. Administer CAGE questionnaire B. Esophagogastroduodenoscopy C. Serum iron assay D. Neurology consultation

A

A father brings to the clinic his 6-year-old son who currently is undergoing induction chemotherapy for ALL. The school will not allow the child to register until his immunizations are up to date. Which of the following is the best course of action? A. Call the school nurse or principal to inform him or her that this child should not receive immunizations while he is taking chemotherapy. B. Update all immunizations except for measles, mumps, and rubella (MMR) and varicella. C. Update all immunizations except for oral polio vaccine. D. Update all immunizations. E. Call the school nurse or principal to inform him or her that this child will never receive immunizations because of the alteration in his immune system.

A

A patient with uremia and severe anemia has an incomplete response to treatment with recombinant human erythropoietin (rhEpo). What is the most common cause for this problem? A. Inadequate iron stores B. Development of anti-rhEpo antibody C. The presence of acute inflammation D. Uremic waste products that suppress erythropoiesis E. Hemolysis

A

A previously healthy 3-year-old female with a history of anorexia and irritability for 3 days is brought to your ED by her mother. On the day of admission, the child is difficult to arouse. You learn that her 6-year-old brother has had some difficulty reaching appropriate developmental milestones and is a "fussy eater." Physical examination reveals a slightly pale-appearing child, who responds to tactile stimuli but not to voice. Vitals are normal and her examination is unremarkable except for her decreased level of consciousness. Laboratory studies include a WBC 8,000/mm3, Hgb 10 g/dL, platelet count 300,000/mm3, and MCV 75 fL (microcytic). Her urine dipstick is normal, except for 1 + glucose; there are no ketones in the urine. Her blood chemistries are within normal limits, with the exception of a phosphorous of 2 mg/dL (low). Her peripheral blood smear shows red cells with coarse basophilic stippling. What is the best working diagnosis at this time? A. Acute lead poisoning B. Anemia of chronic disease C. Early diabetic ketoacidosis (DKA) D. Severe iron deficiency anemia E. Unrecognized bacteremia secondary to pyelonephritis

A

Following a trans-Pacific flight from Australia, a 57-year-old man develops deep vein thrombosis in his right leg. He receives heparin to treat the DVT but after 6 days of heparin therapy he develops heparin-induced thrombocytopenia (HIT). What drug is he likely to receive instead of heparin? A. Argatroban B. Warfarin C. Activated protein C (drotrecogin alpha) D. Dabigatran E. Rivaroxaban

A

In the United States, what is the most common cause of microcytic anemia in children? A. Nutritional deficiency B. Epistaxis C. Gastrointestinal malignancy D. Lead toxicity

A

On a routine insurance physical examination, a 55-year-old man was found to have a total protein of 9 g/dL (elevated). The remainder of his serum chemistries and his CBC were normal. He is active, feels well, and is not taking any medications. His physical examination is unremarkable. You order a serum and urine electrophoresis with immunofixation and quantitative immunoglobulins. He has a monoclonal spike with 1,400 g/dL of IgG kappa (elevated). His other immunoglobulins are within normal limits. A skeletal survey demonstrates no lytic lesions, and his bone marrow aspirate and biopsy demonstrate 6% plasma cells (normal is 1-4%). After the bone marrow biopsy, the hematologist sends him back to you for follow-up. What is your next step in the management of this patient? A. Monitor blood, including serum immunoglobulins, every 3 to 6 months and, if stable after 1 year, annually thereafter B. Monitor blood, including serum immunoglobulins, every 4 weeks indefinitely C. Start on chemotherapy for multiple myeloma D. Obtain yearly bone marrow biopsy and skeletal survey E. No follow-up is necessary

A

Rituximab is approved as a single agent for relapsed indolent lymphomas. Its molecular target is A. the CD20 antigen on B cells. B. the CD52 antigen on B cells. C. the CD33 antigen on B cells and other hematopoietic cells. D. BCR-ABL in lymphoblasts. E. the IL-2 receptor on T cells.

A

A 16-year-old sub-Saharan African male presents to your office for progressive fatigue and dyspnea over the past few days. He also has some mild upper respiratory symptoms that are being "treated" with sulfamethoxazole—trimethoprim. (The doctor down the street is known to treat all respiratory infections with antibiotics.) On examination, you find a well-nourished male in no distress. He is afebrile but slightly tachycardic. You note mild scleral icterus and pallor of the palmar creases, but the remainder of the examination is unremarkable. A CBC shows normal WBC count and platelets, with Hgb 10.2 g/dL. On peripheral smear, "bite cells" and rare Heinz bodies are reported. The LDH and bilirubin are elevated and the serum haptoglobin is low, but the other serum chemistries are normal. Which of the following is the most likely diagnosis? A. Hereditary spherocytosis B. G6PD deficiency C. Sickle cell disease (homozygous) D. Sickle cell trait (heterozygous) E. Iron deficiency anemia

B

A 19-year-old gravid female presents during her second trimester and complains of left calf swelling. With the help of Doppler studies, you diagnose her with a DVT. Which of the following statements is correct? A. DVT occurs most commonly in the right lower extremity in pregnant women B. DVT is common in pregnancy due to increased venous stasis and increased levels of fibrinogen, factor VIII, and vWF C. Anticoagulation with heparin introduces no risk to the fetus or mother D. DVT is most common in the third trimester

B

A 20-year-old female with acute myeloid leukemia completed her second cycle of consolidation chemotherapy 5 days ago. She presents to the ED complaining of fatigue and fever. She denies cough, dysuria, abdominal pain, sinus drainage, or redness around her Hickman catheter. Her physical examination reveals a temperature of 38.4°C, pulse 100 bpm, BP 120/58 mm Hg, and respirations 14 breaths per minute. Her examination is otherwise unremarkable, including no redness or tenderness at the Hickman site. Your magic crystal ball tells you she does not have a line infection. Her laboratory results reveal the following: WBC 1300/mm3(absolute neutrophil count 500 cells/mm3), Hgb 9 g/dL, hematocrit 27%, and platelet count 47,000/mm3. Blood cultures have been drawn. What is your next step, and what is your rationale? A. Administer IV amphotericin B; a Candida urinary tract infection is most likely B. Administer IV cefepime; she requires empiric coverage for both Gram-negative and Gram-positive organisms C. Administer IV nafcillin; a Gram-positive bacterial infection is most likely and broader antibiotic coverage will encourage growth of resistant bacteria D. Administer IV vancomycin; she most likely has an MRSA sinus infection E. Close observation; there is no focus of infection and she looks well

B

A 25-year-old African-American man with sickle cell anemia, who has been hospitalized several times for painful sickle cell crises, has successfully been free of these crises since he has been on hydroxyurea therapy. Treatment with hydroxyurea results in which of the following? A. An increase in the oxygen affinity of HbS B. An increase in the levels of hemoglobin F (HbF) in red blood cells C. A decreased cooperativity in oxygen binding by HbS D. A post-translational modification of HbS that prevents polymerization E. A decreased ability of HbS to bind 2,3-bisphosphoglycerate (2,3-BPG)

B

A 34-year-old woman presents to your office with calf pain and swelling. She denies trauma to the leg. She has no other significant medical history and takes only oral contraceptives. She smokes half a pack of cigarettes daily but does not drink alcohol. Her physical examination is also unremarkable, with the exception of swelling and tenderness of the left calf. A lower extremity Doppler study demonstrates a new thrombus occluding the common femoral vein. Which of the following would NOT be appropriate in this patient? A. Start the patient on heparin or a heparinoid and warfarin to maintain an INR of 2 to 3 or start a factor Xa inhibitor (e.g., rivaroxaban) or a direct fibrin inhibitor (e.g., dabigatran) B. Have the patient scheduled for placement of an inferior vena cava filter C. Discontinue hormonal contraceptives D. Encourage the patient to stop smoking E. Obtain further history regarding her family

B

A 42-year-old male presents to the ED with a gastrointestinal (GI) bleeding due to ibuprofen use. His Hgb is 6.8 g/dL and he is hemodynamically unstable at this point. You are confident that this patient should receive a transfusion, but you remember that blood transfusions actually increase mortality if used incorrectly. Which of the following is an indication for transfusion? A. Hemodynamic instability in a trauma patient due to bleeding unresponsive to no less than 3 L of saline B. Preoperative Hgb of 7 to 8 g/dL with expected intraoperative blood loss C. Hemoglobin of 9.5 g/dL in a patient with angina D. A stable ICU patient with an Hgb of 8.7g/dL E. All of the above

B

A 52-year-old woman with a history of rheumatoid arthritis is in your clinic for a 1-month follow-up after having a knee prosthesis removed secondary to a joint infection and osteomyelitis (Staphylococcal aureus). You obtain a CBC, revealing a WBC 8,000/mm3, Hgb 9.5 g/dL, hematocrit 28%, platelet count 450,000/mm3, and MCV 83 fL (normal). Serum iron levels are low with a normal serum transferrin receptor and increased ferritin. What is the most likely diagnosis? A. Iron deficiency anemia due to rheumatoid arthritis B. Anemia of chronic disease due to rheumatoid arthritis and osteomyelitis C. Hemolytic anemia induced by antibiotics D. Acute blood loss during surgery E. Myelodysplastic syndrome (MDS) associated with rheumatoid arthritis

B

A 56-year-old male presents to the ED with an acute abdomen, likely from a perforated diverticulum. He is taking warfarin for a DVT that occurred after a total knee arthroplasty. He weighs 65 kg. You are evaluating him for surgery and find the following laboratory results: Hgb 14.3 g/dL, platelet count 478,000/mm3, INR 3.5, and PTT 28 seconds. Which of the following statements about his preoperative management is correct? A. Platelet transfusion perioperatively will produce the most immediate reduction in risk of bleeding from warfarin B. Fresh frozen plasma (FFP) transfusion will produce the most immediate reduction in risk of bleeding from warfarin C. Vitamin K administration orally (PO) will produce the most immediate reduction in risk of bleeding from warfarin D. Vitamin K administration subcutaneously (SC) will produce the most immediate reduction in risk of bleeding from warfarin E. Cryoprecipitate transfusion will produce the most immediate reduction in risk of bleeding from warfarin

B

Which of the following people with SCD should not be on hydroxyurea? A. A 12-month-old boy with SCD on prophylactic penicillin B. A 30-year-old woman with SCD who is breastfeeding her 3-month-old daughter C. A 16-year-old girl with frequent vaso-occlusive crisis (VOC) D. A 27-year-old man with a history of acute chest syndrome

B

A 6-month-old male infant is brought to you for a well-baby check-up. His mother reports that the child has had difficulty with feeding, has frequent colds, and is often irritable. She has noted recurrent episodes of jaundice, especially when he is sick. His physical examination reveals a small child, faintly jaundiced. His temperature is 37.5°C, pulse 160 bpm, BP 85/50 mm Hg, and respirations 30 bpm. His abdomen is soft with palpable splenomegaly. The remainder of the examination is unremarkable. Laboratories reveal a WBC 13,000/mm3, Hgb 9 g/dL, platelet count 260,000/mm3, and MCV 60 fL (low). He is noted to have target cells on peripheral blood smear. Which one of the following is the most appropriate next step? A. Order PT/PTT B. Order hemoglobin electrophoresis C. Transfuse with 1 unit of PRBCs D. Test for G6PD deficiency E. Test for sickle cell anemia

B

A 63-year-old woman presents to your office with complaint of fatigue. She states she felt like she spent the winter taking antibiotics because she developed "one infection after the other." Prior to this past winter, she had been well and did not take any prescription drugs regularly. Physical examination demonstrates a slightly pale, thin woman. Her temperature is 37.5°C, pulse 90 bpm, BP 120/58 mm Hg, and respirations 12 bpm. Her oropharynx demonstrates purpuric lesions. Her abdominal examination shows no organomegaly, and the remainder of the physical examination is unremarkable. You obtain blood tests: WBC 2,100/mm3, Hgb 8.4 g/dL, and platelet count 20,000/mm3. A bone marrow aspirate and biopsy are obtained, which demonstrate a hypercellular marrow with 4% blasts, 4% ringed sideroblasts, and megakaryocytes. You talk to the hematologist, who suspects that your patient has a myelodysplastic syndrome (MDS). Which of the following statements is INCORRECT? A. The small number of blasts in the bone marrow indicates a good prognosis B. The patient cannot have MDS because she has pancytopenia C. The patient may benefit from administration of erythropoietin D. The patient may develop acute myeloid leukemia E. The patient's gender may result in a better prognosis

B

A 65-year-old man with a history of rheumatoid arthritis is found to have a microcytic anemia. He had a colonoscopy 1 year ago that was normal, and a stool guaiac is negative. Which of the following is the most likely cause of his anemia? A. Iron deficiency B. Chronic disease C. Pernicious anemia D. Folate deficiency

B

A mother arrives at the clinic with her 4-year-old daughter, who began complaining of right knee pain 2 weeks ago. The patient is limping slightly, is fatigued, and has had a fever of 100.4 °F (38 °C) over the past week. Which of the following laboratory tests is most important? A. Antinuclear antibodies B. Complete blood count (CBC) with differential and platelets C. Epstein-Barr virus (EBV) titer D. Rheumatoid factor E. Sedimentation rate

B

An enzyme derived from Escherichia coli that deprives leukemia cells of a required amino acid is A. pentostatin. B. L-asparaginase (L-ASP). C. deoxycytidine kinase (dCK). D. trabectedin. E. asparagine synthase.

B

Heparin-induced thrombocytopenia is caused by which of the following mechanisms? A. Decreased platelet production B. Increased platelet consumption C. Splenic sequestration of platelets D. Normal platelet numbers but decreased platelet function

B

How long should you continue iron supplementation once the patient's labs have normalized? A. Stop immediately once anemia has resolved B. Continue 3 to 6 months after the anemia has resolved C. Continue for 1 year after the anemia has resolved D. Indefinite iron supplementation is indicated

B

If a pediatric patient does not respond appropriately to iron supplementation despite compliance to therapy and appropriate dietary changes, what is the next step in diagnosis? A. Referral to hematology B. Obtain a hemoglobin electrophoresis C. Colonoscopy to evaluate for gastrointestinal blood loss D. Continue supplementation and re-check in 4 weeks

B

In the United States, what is the most common cause of microcytic anemia in premenopausal women? A. Nutritional deficiency B. Menstrual blood loss C. Gastrointestinal malignancy D. Thalassemia trait

B

In which acquired anemia is the red cell morphology most similar to that of hereditary spherocytosis? A. Heart valve hemolysis B. Immune hemolytic anemia C. Paroxysmal nocturnal hemoglobinuria D. Myelodysplasia E. Aplastic anemia

B

Indicated for use in patients suffering from cyclic neutropenia to stimulate neutrophil production: A. Epoetin alfa B. Filgrastim C. Darbepoetin alfa D. Romiplostim E. Oprelvekin

B

Paclitaxel and the other taxanes have a central role in the therapy of ovarian, breast, lung, GI, genitourinary, and head and neck cancers. The cytotoxic effect of the taxanes in tumor cells is the result of A. inhibition of microtubule formation. B. inhibition of microtubule disassembly. C. enhancement of microtubule disassembly. D. inhibition of topoisomerase I. E. inhibition of topoisomerase II.

B

Von Willebrand Disease (vWD) is characterized by which of the following abnormalities? A. Elevated international normalized ration (INR) B. Impaired platelet aggregation and adhesion C. Decreased platelet number D. A history of amenorrhea in female patients

B

What combination of laboratory test findings is most consistent with iron deficiency? A. Low mean cell volume (MCV), normal mean cell hemoglobin concentration (MCHC), low serum iron level, low iron binding capacity, low serum ferritin level B. Low MCV, low MCHC, low serum iron level, high iron binding capacity, low serum ferritin level C. Low MCV, low MCHC, low serum iron level, low iron binding capacity, low serum ferritin level D. Low MCV, low MCHC, low serum iron level, high iron binding capacity, high serum ferritin level E. Low MCV, normal MCHC, low serum iron level, high iron binding capacity, high serum ferritin level

B

What diagnostic test is most indicative of autoimmune hemolysis? A. Red blood cell morphology B. Direct antiglobulin test C. Indirect antiglobulin test D. Cold agglutinin test E. Elevated serum globulin level

B

Which of the following blood levels is considered as an adequate clinical response after 2 U of platelet transfusion? A. 1000 to 3000/μL B. 5000 to 10,000/μL C. 10,000 to 20,000/μL D. 20,000 to 25,000/μL

B

Which of the following foods is low in iron? A. Dried prunes B. Yogurt C. Chickpeas D. Broccoli

B

What is the most common cause of anemia in children less than 24 months old? A. Anemia of prematurity B. Thalassemia C. Iron-deficiency anemia D. Sickle cell trait

C

A 23-year-old electrician is seen in the emergency room with a swollen, tender right knee after falling to the ground an hour ago, while working on a power line. An emergency medical resident aspirated the knee obtaining blood. The patient has a lifelong history of knee swelling that occasionally occurred spontaneously or with minor injuries. He also had an episode of prolonged bleeding after a dental extraction. The patient had not been previously hospitalized or received blood transfusions. The patient's maternal grandfather had similar bleeding problems. The patient was taking no medication at the time of the accident. Screening labs show: PT 10s (8-11.5), PTT 57s (24-37.5), Plts 450 (150-350). Additional studies show: PTT mixing study (50% pt plasma/50% pooled normal plasma) = 35s, Factor VIII:C = 120% Factor VIIIR:Ag = 118% Factor VIIIR:Rco = 110% Factor IX = 20% Which of the following is the most likely diagnosis? A. von Willebrand disease B. Hemophilia A C. Hemophilia B D. Lupus anticoagulant E. Bernard-Soulier syndrome

C

A 24-year-old female G1 P0 at 39 weeks of gestation presents to your office with a bruise on her anterior tibia, which she noticed after bumping into a coffee table. She has been healthy before and during her pregnancy and takes only prenatal vitamins. Her physical examination is unremarkable with the exception of an 8-cm bruise over her right anterior tibia. Her vital signs are normal. Her physical examination is remarkable for a gravid abdomen consistent with 39 weeks of gestation, fetal heart tones auscultated at 140 bpm, absence of right upper quadrant pain, and absence of peripheral edema. You obtain the following laboratory tests: CBC, which demonstrates white blood cell (WBC) 9,000/mm3, hemoglobin (Hgb) 11.8 g/dL, and platelet count 95,000/mm3; normal PTT and PT/INR; negative urinalysis; and normal liver enzymes. What is your next step? A. Recommend immediate delivery by cesarean section as the infant likely has thrombocytopenia as well and is at high risk for intracranial hemorrhage B. Recommend immediate delivery by cesarean section as this disorder will likely progress to eclampsia C. Recommend close observation and reassure the patient that this is typically a self-limited condition D. Start prednisone, 1 mg/kg daily, and taper slowly over the next 6 weeks E. Recommend splenectomy as soon as possible after delivery

C

A 40-year-old male who has just received his first course of chemotherapy for non-Hodgkin lymphoma (NHL) presents to your ED complaining of weakness, cramps, and decreased urine output. He has no other medical problems and takes no medications except for prochlorperazine as needed for nausea. He has been eating and drinking well. His physical examination reveals a tired-appearing male, with normal vital signs. His head-and-neck examination reveals bilateral palpable cervical lymph nodes (2 cm). His lungs are clear in the upper lung fields with crackles bilaterally at the bases. Muscle strength is normal, and reflexes are 3+ and symmetric. He exhibits 6 beats of clonus at the ankles. Chest radiograph shows evidence of early pulmonary edema. What is the most likely set of laboratory values you will find for this patient (reference ranges: potassium 3.5-5 mg/dL, phosphate 2.4-4.1 mg/dL, uric acid 3.5-7.2 mg/dL, calcium 8.5-10.2 mg/dL). A. Potassium 2.3 mEq/L, phosphorus 3.1 mg/dL, uric acid 4 mg/dL, calcium 9 mg/dL B. Potassium 2.6 mEq/L, phosphorus 6 mg/dL, uric acid 5 mg/dL, calcium 12 mg/dL C. Potassium 6.5 mEq/L, phosphorus 7 mg/dL, uric acid 18 mg/dL, calcium 6 mg/dL D. Potassium 6 mEq/L, phosphorus 6.8 mg/dL, uric acid 5 mg/dL, calcium 6.7 mg/dL E. Potassium 4.5 mEq/L, phosphorus 3.2 mg/dL, uric acid 9 mg/dL, calcium 8 mg/dL

C

A mother brings her 3-year-old son with Down syndrome to the clinic because his gums have been bleeding for 1 week. She reports that he has been less energetic than usual. Examination reveals that the child has an oral temperature of 100 °F (37.8 °C), pallor, splenomegaly, gingival bleeding, and bruises on the lower extremities. Which of the following is most likely? A. Aplastic anemia B. Immune thrombocytopenic purpura (ITP) C. Leukemia D. Leukemoid reaction E. Megaloblastic anemia

C

A woman brings her 10-week-old female infant for evaluation. The child is colicky and irritable after feeding. She was born full term but has not been gaining weight appropriately. The patient's sister has sickle cell trait, so you obtain an Hgb electrophoresis, which ultimately demonstrates SS genotype. Which of the following is INCORRECT regarding the child's care? A. The patient should remain on prophylactic antibiotics until the age of 5 years due to a high risk of pneumococcal sepsis B. The child may develop splenomegaly and lymphadenopathy related to her disease C. The disease provides protection against infection with parvovirus D. The child may not develop pain crisis until she is older due to protection from HbF E. The child is likely to have a delay in puberty

C

Aldesleukin is approved for use in metastatic renal-cell cancer and metastatic melanoma. Its mechanism of action in treating these cancers is to A. antagonize IL-2 receptors on T cells. B. antagonize IL-2 receptors on epithelial cells. C. stimulate the proliferation of activated T cells. D. stimulate the proliferation of activated B cells. E. inhibit the secretion of cytokines by immune effector cells.

C

An acute hemolytic transfusion reaction occurs due to which of the following? A. Presence of an atypical antibody in the recipient that was undetectable in the initial antibody screen B. Presence of antibody in the recipient that is directed against HLA antigens on donor leukocytes C. ABO mismatch or due to antibodies in the host against the antigens on donor RBCs D. Presence of anti-IgA

C

Beta thalassemia major is confirmed by hemoglobin electrophoresis for your patient. Which of the following regarding his management is NOT true? A. Untreated, mortality may approach 80% by 5 years of age B. Frequent blood transfusions may be required C. The condition will improve with age D. The child is likely to have growth retardation and delayed sexual maturation E. Without iron chelation therapy, there is a high incidence of mortality with this disease

C

The camptothecins, topotecan and irinotecan, are potent, cytotoxic neoplastic agents. They act by A. intercalating DNA. B. alkylating DNA. C. stabilizing the DNA-topoisomerase I cleavable complex. D. inhibiting DNA cleavage by topoisomerase I. E. inhibiting topoisomerase I binding to DNA.

C

Two weeks after a viral syndrome, a 2-year-old boy develops bruising and generalized petechiae that is more prominent over the legs. He has neither hepatosplenomegaly nor lymph node enlargement. Laboratory testing reveals a normal hemoglobin, hematocrit, and WBC count and differential. The platelet count is 15,000/mm3. Which of the following is the most likely diagnosis? A. Acute lymphoblastic leukemia (ALL) B. Aplastic anemia C. ITP D. Thrombotic thrombocytopenic purpura (TTP) E. von Willebrand disease

C

A 15-year-old female presents to your office complaining of fatigue. She reports menarche at age 13 and complains of heavy menses. Her physical examination reveals a well-developed, well-nourished, pale female. You find no hepatosplenomegaly. Her laboratory results reveal a WBC 6,000/mm3, Hgb 8.9 g/dL, hematocrit 27%, platelet count 400,000/mm3, MCV 72 fL (low), red blood cell distribution width (RDW) 16 (high). You order more laboratory tests. What are the expected findings in this patient? A. Increased iron, decreased ferritin, increased total iron binding capacity B. Decreased iron, decreased ferritin, decreased total iron binding capacity C. Increased iron, increased ferritin, increased total iron binding capacity D. Decreased iron, increased ferritin, decreased total iron binding capacity E. Decreased iron, decreased ferritin, increased total iron binding capacity

E

A 30-year-old female presents to your office for a routine visit. She was hospitalized for an appendectomy and at the time of surgery, her platelet count was found to be 1,400,000/mm3, which her surgeon felt was most likely reactive. She has no other past medical history, is asymptomatic, and exercises three times per week. You repeat the CBC, showing WBC 5,000/mm3, Hgb 13 g/dL, and platelet count 800,000/mm3. What is your next step in managing this patient? A. Anticoagulation with warfarin to a goal INR of 2 to 3 B. Counseling against becoming pregnant C. Initiation of hydroxyurea 500 mg BID D. No further evaluation or follow-up necessary E. Observation and periodic evaluation of her CBC

E

A 32-year-old woman presents to your office with complaints of dyspnea, constipation, menorrhagia, and fatigue that are new over the past few weeks. She has a distant history of Hodgkin lymphoma treated with chemotherapy and radiation to the chest. Her physical examination reveals a well-developed woman, who appears comfortable at rest with normal vital signs. She has no adenopathy and the remainder of her examination is unremarkable. Her CBC with WBC differential is normal. Which of these diagnoses can be absolutely ruled out based on this patient's history? A. Coronary ischemia B. Hypothyroidism C. Lung cancer D. Relapse of the Hodgkin lymphoma E. None of the above

E

A 6-year-old boy is brought to the pediatrician for gum bleeding while brushing his teeth. He is noted to have petechiae over the lower extremities. His mother says that he has been healthy other than an upper respiratory illness a couple of weeks ago. He has not had bleeding problems in the past. He is not taking any medications. There is no family history of abnormal bleeding. The peripheral blood smear shows decreased platelets, but no schistocytes or red blood cell fragments. Screening laboratory studies show PT: 10s (8-11.5), PTT: 35s (24-37.5), Plts: 12 (150-350) Which of the following is the most likely diagnosis? A. Lupus anticoagulant B. Factor V Leiden mutation C. Factor VIII deficiency D. von Willebrand disease E. Immune thrombocytopenic purpura

E

A previously healthy, 50-year-old diplomat recently developed fatigue, weight loss, and mild jaundice. He had a hemoglobin of 7 g/dL, a reticulocyte count of 14%, spherocytes on a peripheral blood film, and a serum bilirubin level of 4 mg/dL total, of which 0.2 mg/dL was conjugated. What underlying illnesses is of most concern? A. Human immunodeficiency virus (HIV) infection B. Tuberculosis C. Babesiosis D. Malaria E. Lymphoma

E

Deficiency in folic acid is characterized by A. microcytic, hypochromic anemia. B. sideroblastic anemia. C. neutropenia. D. red-cell aplasia. E. megaloblastic anemia.

E

Hemolytic anemia in G6PD deficiency is caused by oxidative stress on red cells, most commonly as the result of infection or administration of certain drugs. Which of the following can precipitate a hemolytic crisis in G6PD deficiency? A. Sulfa antibiotics B. Fresh fava beans C. Nitrofurantoin D. Some antimalarial drugs E. All of the above

E

Hydroxyurea has proven to be both effective and safe in the therapy of sickle cell disease. What is the primary mechanism by which hydroxyurea benefits these patients? A. Induction of arteriolar vasodilation, resulting in prevention of acute vaso-occlusion B. Enhancement of the ability of Hb S to unload oxygen to ischemic tissues C. Inhibition of thrombosis at the sites of sickle vaso-occlusion D. Maintenance of red cell hydration and prevention of sickle cell deformation E. Induction of Hb F production, thereby decreasing Hb S polymerization

E

Used prophylactically in pregnant women to prevent neural tube defects in the fetus: A. Riboflavin B. Pyridoxine C. Iron D. Vitamin B12 E. Folic acid

E

Which of the following can lead to a failure of iron therapy for iron deficiency anemia? A. Proton pump inhibitors (PPIs) B. Incorrect diagnosis C. Oral antacids (e.g., calcium carbonate) D. Atrophic gastritis, celiac disease, or Helicobacter pylori infection E. All of the above

E

Which of the following is indicated when evaluating for a suspected inherited coagulopathy? A. Prothrombin time (PT) B. Partial thromboplastin time (PTT) C. Platelet count D. PFA-100 E. All of the above

E