Question #1

Hct = 27% WBC= 12,000/uL Platelets= 10,000/uL

TBili=5 mg/dL DB=0.6 mg/dL BUN=60 mg/dL Creat=4.5 mg/dL

PT/PTT=normal

RBC smear looks like this:

The most effective and appropriate therapeutic maneuver is likely to be:

1. plasmapheresis
2. administration of aspirin
3. administration of high-dose glucocorticoids
4. administration of high-dose glucocorticoids plus cyclophosphamide
5. splenectomy

Which of the following procedures would be the most sensitive in detecting early iron overload?

1. Quantitative iron determination in a liver biopsy specimen
2. Urinary iron excretion in response to a test dose of desferrioxamine
3. Serum ferriten concentration
4. Serum iron concentration, total iron binding capacity, and calculated transferrin saturation
5. Iron stain of a bone marrow aspirate

A 45 year-old woman with long-standing rheumatoid arthritis is diagnosed as having "anemia of chronic disease." The predominant mechanism causing this type of anemia in persons with chronic inflammatory disorders is

1. defective porphyrin synthesis
2. impaired incorporation of iron into porphyrin
3. intravascular hemolysis
4. depressed erythroid maturation due to decreased erythropoietin production
5. impaired transfer of reticuloendothelial storage iron to marrow erythroid precursors

Which of the following statements best characterizes the hemolysis associated with glucose-6-phosphate dehydrogenase (G6PD) deficiency?

1. It is more severe in affected blacks than in affected persons of Mediterranean ancestry
2. It is more severe in females than in males
3. It causes the appearance of Heinz bodies on Wright staining of a peripheral smear
4. It most often is precipitatied by infection
5. The best time to perform the diagnostic test is during a hemolytic crisis

Which of the following clinical scenarios is LEAST likely to describe a paraneoplastic syndrome resulting from small cell tumors of the lung?

1. Weakness and fatigability, primarily of proximal muscles; electromyographic results show increasing amplitude of contraction with repetitive stimulation
2. Cerebellar ataxia, dysarthria, deafness, pleocytosis of cerebrospinal fluid, and cerebellar atrophy on CT scan of the brain
3. Moon facies, truncal striae, hypertension, hypokalemia, and hyperglycemia
4. Hypercalcemia, polydipsia, polyuria, mental status changes in the absence of bony metastases
5. Mental status changes, muscle weakness, hyponatremia and decreased serum osmolality with inappropriately elevated urine osmolality

A 50 year old man presents with a 1-day history of recurrent swelling and pain of the left leg. He was discharged from the hospital 1 week ago after being treated for deep vein thrombophlebitis of the same leg. Since discharge he has been taking warfarin, 2.5 mg daily. His INR is 1.2. A venogram documents recurrent thrombosis extending to the inferior vena cava. Which therapy would you now recommend for this patient?

1. Increase the warfarin dose to bring the INR into therapeutic range
2. Switch to dicumarol
3. Interrupt the inferior vena cava with a filter
4. Discontinue warfarin and begin heparin at a therapeutic dose
5. Discontinue warfarin and begin thrombolytic therapy

As the E.D. physician you would:

Give the patient a "white slider" (a mixture of lidocaine & maalox)
Give the patient some Valium and tell him that the pain is all in his head
Give the patient an aspirin
Give the patient an aspirin, start Heparin and assess for thrombolytic contraindications
Give the patient a sublingual nitroglycerin tablet
Give the patient a dose of steroids and start on Ibuprofren

Where is the most likely location for a myocardial infarction to cause this follow-up rhythm:

1. Acute transmural anterior infarction
2. Acute subendocardial anterior infarction
3. Acute transmural inferior infarction
4. Acute subendocardial inferior infarction
5. Acute transmural lateral infarction

A patient comes to see you in your general medicine clinic complaining of long-standing generalized weakness. Initially, the weakness started several months ago with difficulty climbing up stairs and rising out of a chair. She had been seen for this several times in the E.D. and most recently had to have stiches placed for a forehead laceration incurred during a "weakness" fall. Having had enough, she comes to you specifically complaining of a 2 week history of difficulty combing her hair. On examination the patient has these two findings:

As this patient's physician you would:

1. Set up daily physical therapy
2. Get an MRI of the neck
3. Send off a 24 hour urine for VMA, Metanephrines, Norepinephrine, Epinephrine
4. Give a course of Prednisone 1mg/kg
5. Give a course of NSAID's
6. Start Cyclophosphamide 100 mg IV bolus with hydration

Question #10

A 53 year old woman presents to the emergency room with abdominal pain, nausea, vomiting, hypotensive, tachycardia and disoriented. A FSG check comes back as >500. You quickly get a urine sample and analyze it with a dipstick. It shows the following results:

Specific Gravity=1.005/pH=5.5/1+protein/4+glucose/+ketones/0 RBC,WBC, epithelials cells.

You promptly get IV access and draw the necessary blood studies. Your next step would be to:

1. Give a Normal Saline bolus and run IV fluids wide open
2. Do (1) and give 10 units of regular insulin IV and start an insulin drip at 0.1units/kg/hr
3. Do (1) and give 10 units of NPH and start an insulin drip at 0.1 units/kg/hr
4. Do (1) and start on Diabeta 10 mg
5. Do (1) await lab results and observe