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 # 280

280) A 2 year old child is brought by her mother to the emergency department because the child has not been ambulating since yesterday after he tripped over an object and fell. Physical examination reveals tenderness and swelling in left mid-thigh. Eyes are normal without any hemorrhages. Skin reveals several bruises. Teeth are translucent and show yellow discoloration. Moderate scoliosis is evident. A skeletal survey reveals rib fractures and multiple fractures in various stages of healing. There is diffuse osteopenia. There is a spiral fracture of left femur shaft.  The limb is splinted and an orthopedic consult is obtained. Which of the following is the most appropriate action?

A) Contact social services

B) Contact Child Protection Services

C) Place the child in foster care

D) Obtain Head CT

E) Obtain detailed family history

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