Q 1. A 68-year-old man seeks evaluation for fatigue,
weight loss, and early satiety that have been present for
about 4 months. On physical examination, his spleen is
noted to be markedly enlarged. It is firm to touch and
crosses the midline. The lower edge of the spleen reaches
to the pelvis. His hemoglobin is 11.1 g/dL, and hematocrit
is 33.7%. The leukocyte count is 6200/ μL, and platelet
count is 220,000/ μL. The white cell count differential
is 75% PMNs, 8% myelocytes, 4% metamyelocytes, 8%
lymphocytes, 3% monocytes, and 2% eosinophils. The
peripheral blood smear shows teardrop cells, nucleated
red blood cells, and immature granulocytes. Rheumatoid
factor is positive. A bone marrow biopsy is attempted, but
no cells are able to be aspirated. No evidence of leukemia
or lymphoma is found. What is the most likely cause of
the splenomegaly?
A. Chronic idiopathic myelofibrosis
B. Chronic myelogenous leukemia
C. Rheumatoid arthritis
D. Systemic lupus erythematosus
E. Tuberculosis
Answer A
Q 2 . The most common cause of high serum calcium in a
patient with a known cancer is
A. ectopic production of parathyroid hormone
B. direct destruction of bone by tumor cells
C. local production of tumor necrosis factor and IL-6
by bony metastasis
D. high levels of 1,25-hydroxyvitamin D
E. production of parathyroid hormone–like substance
Answer E
Q 3. A 72-year-old man with chronic obstructive pulmonary
disease and stable coronary disease presents to the
emergency room with several days of worsening productive
cough, fevers, malaise, and diffuse muscle aches. A
chest x-ray demonstrates a new lobar infiltrate. Laboratory
measurements reveal a total white blood cell count of
12,100 cells/μL, with a neutrophilic predominance of
86% and 8% band forms. He is diagnosed with community-
acquired pneumonia, and antibiotic treatment is initiated.
Under normal, or “nonstress,” conditions, what
percentage of the total body neutrophils are present in the
circulation?
A. 2%
B. 10%
C. 25%
D. 40%
E. 90%
Answer A
Q 4 . All of the following laboratory values are consistent
with an intravascular hemolytic anemia except
A. increased haptoglobin
B. increased lactate dehydrogenase (LDH)
C. increased reticulocyte count
D. increased unconjugated bilirubin
E. increased urine hemosiderin
Answer A
Q 5 . All the following match the anticoagulant with its
correct mechanism of action except
A. abciximab—GpIIb/IIIa receptor inhibition
B. clopidogrel—inhibition of thromboxane A 2 release
C. fondaparinux—inhibition of factor Xa
D. argatroban—thrombin inhibition
E. warfarin—vitamin K—dependent carboxylation of
coagulation factors
Answer B
Q 6 . All the following are late complications of bone
marrow transplant preparative regimens except
A. growth retardation
B. azoospermia
C. hypothyroidism
D. cataracts
E. dementia
Answer E
Q 7 . Which of the following best describes the mechanism
of action of clopidogrel?
A. Activates antithrombin and inhibits clotting enzymes
B. Binds to the activated GPIIb/IIIa receptor on the
platelet surface to block binding of adhesive molecules
C. Inhibits cyclooxygenase 1 (COX-1) on platelets to
decrease production of thromboxane A 2
D. Inhibits phosphodiesterase to block the breakdown
of cyclic adenosine monophosphate (cAMP) to inhibit
platelet activation
E. Irreversibly blocks P2Y 12 to prevent adenosine
diphosphate (ADP)–induced platelet aggregation
Answer E
Q 8 . A 45-year-old man is evaluated by his primary care
physician for complaints of early satiety and weight loss.
On physical examination, his spleen is palpable 10 cm below
the left costal margin and is mildly tender to palpation.
His laboratory studies show a leukocyte count of
125,000/μL with a differential of 80% neutrophils, 9%
bands, 3% myelocytes, 3% metamyelocytes, 1% blasts,
1% lymphocytes, 1% eosinophils, and 1% basophils. Hemoglobin
is 8.4 g/dL, hematocrit 26.8%, and platelet
count 668,000/μL. A bone marrow biopsy demonstrates
increased cellularity with an increased myeloid to eryth-
roid ratio. Which of the following cytogenetic abnormalities
is most likely to be found in this patient?
A. Deletion of a portion of the long arm of chromosome
5, del(5q)
B. Inversion of chromosome 16, inv(16)
C. Reciprocal translocation between chromosomes 9
and 22 (Philadelphia chromosome)
D. Translocations of the long arms of chromosomes 15
and 17
E. Trisomy 12
Answer C
Q 9 . A 35-year-old patient comes into your office with
persistent iron deficiency anemia. His past medical history
is significant for end-stage renal disease on hemodialysis,
hypertension, and rheumatoid arthritis. His
medications include calcium acetate, a multivitamin, nifedipine,
aspirin, iron sulfate, and omeprazole. His hemoglobin
6 months ago was 8 mg/dL. One week ago, it
was 7.9 mg/dL. His ferritin is 8 mg/dL. He reports no
bright red blood per rectum, and his stool guaiac examinations
have been repeatedly negative over the past 6
months. What is the most likely cause of this patient’s
iron deficiency anemia?
A. Celiac sprue
B. Colon cancer
C. Hemorrhoids
D. Medication effect
E. Peptic ulcer disease
Answer D
Q 10 . A 32-year-old male presents complaining of a testicular
mass. On examination you palpate a 1-by 2-cm painless
mass on the surface of the left testicle. A chest x-ray shows
no lesions, and a CT scan of the abdomen and pelvis shows
no evidence of retroperitoneal adenopathy. The α fetoprotein
(AFP) level is elevated at 400 ng/mL. Beta human
chorionic gonadotropin ( β-hCG) is normal, as is LDH.
You send the patient for an orchiectomy. The pathology
comes back as seminoma limited to the testis alone. The
AFP level declines to normal at an appropriate interval.
What is the appropriate management at this point?
A. Radiation to the retroperitoneal lymph nodes
B. Adjuvant chemotherapy
C. Hormonal therapy
D. Retroperitoneal lymph node dissection (RPLND)
E. Positron emission tomography (PET) scan
Answer D
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