A 19-year-old African American man presents to the emergency department with severe abdominal pain and jaundice. His past medical history is unremarkable, although his mother reports “growing pains” as a child. Further questioning reveals that the patient is adopted. He is febrile and tachycardic. The abdomen is diffusely tender. No rebound is present, and bowel sounds are present throughout. A small skin ulcer is noted on his left lower extremity. Complete blood cell count shows white blood cells at 17 K/µL, hemoglobin at 6.3 g/dL, and mean corpuscular volume at 89 µm³. Aspartate transaminase and alanine transaminase values are normal. Indirect bilirubin is 3.6 mg/dL. A peripheral smear was performed and displays crescent-shaped RBCs. Which of the following statements regarding this patient’s condition is true?

The patient proves to have squamous cell carcinoma of the lung and receives a course of mediastinal radiation therapy. The patient does quite well, noting rapid improvement in both the symptoms and signs of her superior vena cava obstruction. A staging workup subsequently demonstrates evidence of asymptomatic bone metastases in rib, femur, and multiple vertebral bodies. Because the patient is feeling well, she declines any discussion of chemotherapy and is followed in your office. Four months later, the patient calls you with the complaint of a 2-week history of increasing mid-back pain. The patient is fully ambulatory, but the pain is causing difficulty sleeping. The patient specifically denies any weakness in the lower extremities, radicular pain, or incontinence. You would do which of the following?

In the office, you perform a 1-L thoracentesis for slightly bloody fluid, which on analysis proves exudative. Cultures are negative, and cytologies are not diagnostic. The patient feels immediately better after the thoracentesis but returns to the office 3 days later with increasing dyspnea and recurrence of this effusion. Your next step is which of the following?

You are following a 65-year-old man with a recently diagnosed acute myeloid leukemia initiated on induction chemotherapy. The patient has onset of heart palpitations, numbness and tingling in his hands and feet, and severe pain in his right big toe. You are concerned about tumor lysis syndrome. Tumor lysis syndrome is associated with all the following, except

A 24-year-old woman presents for an annual gynecologic examination. She has never had a Papanicolaou (Pap) smear and has been sexually active since age 19 years with five lifetime partners to date. She has not had any pregnancies or sexually transmitted diseases. What do you recommend regarding her gynecologic screening and care?

A 56-year-old woman had a recent diagnosis of breast cancer. She underwent breast lumpectomy with negative lymph nodes and negative margins, breast irradiation, and is now on tamoxifen. Due to the increased risk of endometrial cancer with tamoxifen use, you recommend

A 74-year-old obese white woman presents with vaginal bleeding. You do an endometrial biopsy and find a grade 1 endometrial carcinoma. She asks about her primary mode for therapy, and you tell her

A healthy 42-year-old female patient asks about screening for ovarian cancer. She has no symptoms suggestive of the disease, and the results of her physical examination are normal. You should

A 53-year-old female patient with abdominal bloating and a large pelvic mass, carcinomatosis, and CA-125 of 1,340 U/mL presents to discuss paracentesis results showing adenocarcinoma. She asks for your recommendation regarding treatment. Which one of the following would be the best recommendation in this setting?

A 67-year-old man, 4 years status post prostatectomy presents with low back pain and tenderness. His prostate-specific antigen is 185, and a bone scan is positive in multiple areas. The most appropriate treatment is

A 28-year-old male baseball star presents with a painless left testicular mass. Physical examination is otherwise normal. α-Fetoprotein is >400. The most appropriate next step is

A 22-year-old man with testicular cancer comes back to your office 5 months after a radical inguinal orchiectomy and chemotherapy for nonseminomatous germ cell tumor. The patient feels well and has no complaints. His markers (α-fetoprotein, β-HCG, and LDH) normalized with treatment and remain normal. A mass is palpated in the left midabdomen. This mass is most likely

A 35-year-old woman presents to the emergency room with 24 hours of fever and chills. In addition, she complains of increasing fatigue, dyspnea on exertion, and spontaneous bruising.

On physical examination, she appears ill; her vitals are temperature 39.5°C, blood pressure 80/40 mmHg, pulse 140 beats/minute, respiration rate 22 breaths/minute, petechiae on soft palate, no lymphadenopathy, clear lungs, tachycardia, I/VI systolic ejection murmur, no abdominal mass or hepatosplenomegaly, and scattered petechiae, especially on lower extremities.

Her laboratory values are hemoglobin, 8.7; platelets, 14,000; white blood cells, 3,000, with 2% neutrophils, 45% lymphocytes, and 53% blasts; international normalized ratio, 1.1; partial thromboplastin time, 23; and fibrinogen, 345.

Her peripheral blood smear shows normochromic, normocytic anemia; thrombocytopenia; rare neutrophils; and many blasts.

The best course of action is to immediately

A 25-year-old man presents to the emergency room complaining of dyspnea on exertion for several days. Recently, he has noted frequent nasal congestion and occasional epistaxis. He denies fevers, night sweats, and weight loss, and has noted a rash on his legs. He denies any hospitalizations or history of transfusions.

On physical examination, you find a well-developed man in no acute distress; temperature 36.8°C, blood pressure 126/74 mmHg, respiration rate 20 breaths/minute; his oral mucosa has a few petechial hemorrhages, the skin of the pretibial area is covered with petechial hemorrhages, and no palpable lymphadenopathy or splenomegaly is present; he is otherwise normal.

His laboratory values are hemoglobin, 8.3; platelets, 32,000; white blood cells, 1,100, with 1% neutrophils, 73% lymphocytes, 13% monocytes, and 13% blasts; prothrombin time, 20; international normalized ratio (INR), 2.1; partial thromboplastin time, 40; and fibrinogen, 90.

His peripheral smear shows pancytopenia, circulating blasts with Auer rods, and occasional schistocytes. A bone marrow aspirate and biopsy is hypercellular with 85% blasts and immature granulocytes.

The most important next step is to

A 29-year-old woman presents to your office for a Papanicolaou smear. She is asymptomatic and has a normal physical examination except for a moderately enlarged spleen.

Her laboratory values are hemoglobin, 11.9; platelets, 671,000; and white blood cells, 227,000, with 55% neutrophils, 7% metamyelocytes, 19% myelocytes, 2% promyelocytes, 2% blasts, 1% eosinophils, 7% basophils, and 3% lymphocytes. A bone marrow chromosome analysis shows 46,XX, t(9;22).

The most important next step is to

A 35-year-old man with acute myelogenous leukemia has been severely neutropenic for 10 days and has been febrile with temperatures >38.5°C for the past 5 days. He has been on piperacillin, gentamicin, and vancomycin for 8 days. No localizing signs of infection are present on examination, and all cultures are negative to date. The most appropriate course of action would be to

A 75-year-old man with a 5-year history of untreated, chronic lymphocytic leukemia presents with fatigue and a peculiar craving for ice. Examination reveals generalized, but small peripheral lymphadenopathy and a barely palpable spleen tip. His laboratory values are white blood cells, 34,000; hemoglobin, 5.2; and platelets, 133,000; reticulocytes 2%; direct Coombs’ test negative; and lactate dehydrogenase and bilirubin normal. The peripheral blood smear demonstrates normocytic red cells and no polychromasia. The most likely cause of anemia in this patient is

At 2:00 AM, a young woman presents to the emergency department of a small rural community hospital complaining of headache and fever. Except for some pallor, mild scleral icterus, and sleepiness, the physical examination is normal. The complete blood count report comes back with “low platelets” and a hematocrit of 28%. The prothrombin time/activated partial thromboplastin time and electrolytes are normal. The lab sends down the peripheral smear, which you examine under the microscope.

The next best step is

An asymptomatic 59-year-old woman was referred to you for preoperative clearance for a planned open colectomy. The routine laboratory examinations were all normal except for an elevated activated partial thromboplastin time (aPTT) of 57 seconds. She denied any history of excess bleeding or bruising. The lab calls you the next day to inform you that when they mixed her plasma 1:1 with pooled normal plasma, the aPTT was 43 seconds, normal being <31 seconds. Which of the following is most likely true?

Mr. Jones is a 77-year-old retired steel worker who is widowed and lives alone in a two-story house. He was brought to the emergency room (ER) by his daughter because of an extremely painful, swollen, red right leg. He believed that maybe he twisted his knee while walking down the stairs in his home, but when the pain and swelling did not improve after 24 hours and the swelling extended up into his thigh, he called his daughter who immediately brought him to the ER. A physical examination revealed normal vital signs; mild degenerative joint disease; and a swollen, erythematous right leg. A duplex Doppler was performed and revealed a large occlusive thrombus extending from the popliteal vein to the iliofemoral system. Chest x-ray and ECG were normal, and the physician in the infirmary gave him a prescription for enoxaparin and warfarin and referred him to your office. You saw him 3 days later, at which time his international normalized ratio was 2.8. You take a detailed history and discover that he has been feeling “poorly” for about 2 months. He notices a definite loss of energy, decreased appetite, and constipation. Physical examination reveals a rather frail elderly man with muscle wasting in the temporal region. Prostate is 3+ enlarged but without nodules. Stool is negative for occult blood. The remainder of the examination is negative except for the right leg, which is still swollen and tender, although no longer red. The most appropriate course of action at this point is to

Which of the following bleeding disorders can be present despite normal screening coagulation studies (PT, aPTT, and PFA-100)?

A 56-year-old man has an uneventful mitral valve replacement surgery. Heparin was given during the procedure and continued postoperatively. On the eighth postoperative day, he develops a painful, cold, pulseless leg. His activated partial thromboplastin time is subtherapeutic at 39 seconds. His platelet count is 55,000/µL (112,000 on postop day 1). The most important next step in his management is to

Which of the following is true of DDAVP (desmopressin)?

A 22-year-old sexually active female college student is referred to you from the Student Health Service because of a low platelet count (18,000/µL) that was discovered when a complete blood count (CBC) was obtained to evaluate a rash on her lower extremities. She has been feeling otherwise well, but has noted some gum bleeding when she brushes her teeth over the past few days. She takes no medications other than a multivitamin. She had a normal CBC at the time of her college physical. The following would be an appropriate next step:

You are called to the surgical intensive care unit to consult on a case of a 60-year-old 75 kg male chronic alcoholic who was admitted with a severe gastrointestinal bleed. After resuscitation with 4 units of packed RBCs, he was noted to have a hemoglobin of 11 g/dL, an activated partial thromboplastin time (aPTT) of 90 seconds, a prothrombin time (PT) of 24 seconds, a platelet count of 90,000, and a bilirubin of 12.

The lab reported that a 50:50 mix of his plasma with pooled normal plasma corrected both the aPTT and PT to normal. Appropriate therapeutic interventions include

Ms. Smith is an 82-year-old widow who lives alone and has been brought to your emergency department by her niece who notes that her aunt has been “failing” for the past 2 to 3 months. Other than long-standing hypertension, the medical history is noncontributory. Physical examination reveals a sleepy, thin elderly woman with pedal edema, blood pressure of 190/110 mmHg, and S3 gallop. Laboratory values are remarkable for hemoglobin of 7 g/dL, creatinine of 9.2, and blood urea nitrogen of 123. That evening, she develops a severe nose bleed that requires packing by the ear/nose/throat service and also notices bleeding external hemorrhoids. Which of the following can be used to improve her hemostasis?

You are asked to see a 62-year-old man who is 4 days status post elective total hip replacement. He has been treated since the night before surgery with enoxaparin, 40 mg/day, but now has developed a symptomatic deep vein thrombosis on the same side as the surgery. Your plan is to increase the low molecular weight heparin dose and start warfarin until you recall that these drugs can adversely affect hypercoagulability testing. What tests do you order before beginning therapy?

A 31-year-old woman presents with complaints of fatigue, dyspnea on exertion, and tinnitus. The symptoms started 1 month ago. She had previously been in “perfect health.” She has had three normal pregnancies. Her physical examination is remarkable for pallor. The hemoglobin concentration is 7.5 g/dL, the white blood cell count is 6,200, and her platelet count is 550,000/µL. After her last pregnancy 2 years ago, her hemoglobin was normal. Which of the following tests is the most appropriate first test in the initial evaluation of this patient’s anemia?

A 24-year-old Lebanese male exchange student comes to the college infirmary with a 3-day history of upper respiratory infection symptoms, cough, purulent sputum, and a low-grade fever. His chest examination is clear, and he is given available trimethoprim-sulfamethoxazole (Bactrim) samples for clinical bronchitis. The following day, he returns with shortness of breath, severe abdominal pain, a high spiking fever, and dark urine. A complete blood count reveals a hemoglobin of 7 g/dL and a white blood cell count of 12,500. Peripheral blood smear has fragmented RBCs, and distinct “bite cells” are present. The chest radiograph is normal. The patient is admitted to the hospital. Which of the following statements is true?