You are on page 1of 4


1. What is the most likely cause of anemia in each of the following situations?
Microcytic anemia with neurological symptoms
Megaloblastic anemia with neurological symptoms
Anemia in a patient who eats ice
Anemia that develops after taking a sulfa drug
Anemia in a patient with rheumatoid arthritis

2. A 7-year-old girl is brought to the emergency department with dark urine and jaundice. She
has had 1 week of vague abdominal pain, occasional vomiting and bloody diarrhea. Physical
examination shows no dehydration. Abdominal examination reveals no distension, masses,
tenderness or guarding. There are some petechiae on the extremities. Results of laboratory
studies are shown:


7.9 mg/dL
Leukocyte count 8,700/mm3
Platelet count 90,000/mm3

Urea nitrogen
27 mg/dL
Creatinine 1.8 mg/dL
Specific gravity 1.015
Bilirubin 2+
Blood 2+
Nitrites negative
Leukocyte esterase negative

The peripheral blood smear reveals schistocytes and thrombocytopenia.

a. What is the most likely diagnosis?
b. What organism is most likely implicated?

[ 35 ]





3. You have admitted a 62-year-old woman to the inpatient ward for treatment of a deep
venous thrombosis (DVT) in the right thigh. There is no history of recent travel, recent
surgery or immobilization. Upon detailed questioning, the patient admits to intermittent
stinging or burning pain in the hands sometimes associated with redness. She also
complains of intense pruritus when taking a warm bath. Her hemoglobin concentration is
18.1 mg/dL. Serum erythropoietin is slightly low. Laboratory tests for coagulation factor
deficiencies and mutations are negative.
a. What underlying disorder most likely predisposed to this patients DVT?
b. Aside from treating her DVT, how should this underlying disorder be managed?

4. A patient presents with profound fatigue after being treated for a urinary tract infection.
The CBC shows normocytic anemia, and examination of the peripheral blood smear
demonstrates the presence of Heinz bodies and degmacytes (bite cells).
a. What is the most likely cause of this patients anemia?
b. What drugs will provoke this anemia?

5. A 66-year-old woman fractures her hip after falling from standing. Radiographs reveal
punched out lesions in the vertebrae, hips and femurs. The patient says that she has had
increasing back pain, weakness and fatigue, but she has attributed all of that to aging.
Laboratory evaluation demonstrates anemia, hypercalcemia, and increased BUN and
creatinine. What further studies would help to establish the diagnosis?

[ 36 ]

a. What is the most likely diagnosis?

b. What treatment options are available?

7. A 38-year-old man is being treated for a spontaneous deep venous thrombosis (DVT) and
pulmonary embolism. He had a previous DVT two years ago. Laboratory studies reveal a
guanine to adenine mutation in the gene for prothrombin. Other than routine treatment for
this patients current thrombosis, what is the most appropriate long-term management of
this patient?

8. A 48-year-old woman presents with pallor and fatigue. There is no history of bleeding. The
complete blood count reveals a hypochromic, microcytic anemia. Her hemoglobin is 9.4 mg/
dL, and iron studies are normal. What is the most appropriate next step?

9. A 26-year-old woman is brought to the emergency department because of prolonged

bleeding from a minor laceration on her arm. She cut her arm while doing some yard work,
and it has continued to ooze blood for 2 hours. She has always bruised easily, and she has
occasional nosebleeds. She admits to heavy menstrual bleeding. Laboratory studies show
normal platelet count, normal prothrombin time (PT) and increased partial thromboplastin
time (PTT). Bleeding time is elevated. Ristocetin cofactor activity is markedly reduced.
a. What normal substance is most likely deficient in this patient?
b. What is the treatment for this disorder?

[ 37 ]



6. A 21-year-old woman comes to the clinic because of recurrent gingival bleeding for the
past 3 weeks. She has had 2 episodes of epistaxis during this time, and she has noticed a
painless, non-pruritic rash on her ankles and lower legs. She denies any heavy menstrual
bleeding. She has no significant medical history and takes no medications. Physical
examination reveals a healthy-appearing woman. There is no visible bleeding or abnormality
of the oral cavity. There are numerous petechiae on her lower extremities. There is no
hepatosplenomegaly. Laboratory evaluation shows a platelet count of 40,000/mm3.
Prothrombin time and partial thromboplastin time are both normal.

[ 38 ]

10. A 66-year-old man undergoes a right total knee replacement for osteoarthritis. He is given
subcutaneous enoxaparin to prevent deep venous thrombosis (DVT). On post-operative
day 3 he is discharged to an inpatient rehab unit, and on post-op day 6 the nurse notices
some skin necrosis at the site of enoxaparin injection. On post-op day 7 the patient
complains of pain and swelling in the left calf, and Doppler ultrasound reveals a DVT in
the right popliteal vein. Laboratory evaluation shows a platelet count of 70,000/mm3. Prior
to admission to inpatient rehab the platelet count was 210,000/mm3. What is the most
appropriate management of this patients condition?