D. Laboratory measurements in urine indicating accumulation
of porphyrin precursors at the time of symptoms
E. Laboratory measurements in stool indicating accumulation
of porphyrin precursors at the time of symptoms
Answer B
Q 5 . All but which of the following statements about the
lupus anticoagulant (LA) are true?
A. Lupus anticoagulants typically prolong the aPTT.
B. A 1:1 mixing study will not correct in the presence
of lupus anticoagulants.
C. Bleeding episodes in patients with lupus anticoagulants
may be severe and life-threatening.
D. Female patients may experience recurrent midtrimester
abortions.
E. Lupus anticoagulants may occur in the absence of
other signs of systemic lupus erythematosus (SLE).
Answer C
Q 6 . The most common inherited prothrombotic disorder is
A. activated protein C resistance
B. prothrombin gene mutation
C. protein C deficiency
D. protein S deficiency
E. antithrombin deficiency
Answer A
Q 7 . A 34-year-old woman presents for evaluation of left
lower extremity swelling and pain. She is obese and 8
weeks postpartum. She recently traveled 6 h by airplane
to visit her parents with her infant. She has had no dyspnea,
palpitations, or syncope. She is currently on no medications
except iron tablets. She is otherwise healthy. Her
vitals signs are: heart rate 86 beats/min, blood pressure
110/80 mm/Hg, temperature 37.0°C, and respiratory rate
12 breaths/min. Her weight is 98 kg, and height is 170
cm. The left lower extremity is swollen, tender, and warm
to touch. A Homan’s sign is present, but there are no palpable
cords. A lower extremity Doppler shows a thrombosis
in the common and superficial femoral veins of the
left leg. You are considering outpatient treatment with
enoxaparin. All of the following statements regarding
low-molecular-weight heparins (LMWH) are true except
A. In patients with uncomplicated deep venous thrombosis
(DVT), LMWH is a safe and effective alternative
to IV heparin and is associated with reduced
health care costs compared to IV heparin.
B. LMWH can be safely used in pregnancy, but factor
Xa levels should be monitored to ensure adequate
anticoagulation.
C. Monitoring of factor Xa levels is unnecessary in
most patients as there is a predictable dose-dependent
anticoagulation effect.
D. There is a decrease in the risk of development of heparin-
induced thrombocytopenia with use of LMWH.
E. This patient’s recent pregnancy is a contraindication
to use of LMWH because there is a greater risk of
bleeding with LWMH compared to IV heparin.
Answer E
Q 8 . A 65-year-old man is brought to the emergency room
by ambulance after his daughter found him to be incoherent
earlier today. She last spoke with him yesterday, and at
that time, he was complaining of 2 days of myalgias, headache,
and fever. He had attributed it to an upper respiratory
tract infection and did not seek evaluation from his
primary care physician. Today, he did not answer when she
called his home, and she found him lying in his bed smelling
of urine. He was minimally arousable but appeared to
be moving all of his extremities. His past medical history is
significant for hypertension, hypercholesterolemia, and
chronic obstructive pulmonary disease. He was evaluated
2 weeks previously for a transient ischemic attack after an
episode where he had numbness and weakness of his left
arm and leg that resolved over 6 h without intervention.
His current medications include aspirin, 81 mg daily, clopidogrel,
75 mg daily, atenolol, 100 mg daily, atorvastatin,
20 mg daily, and tiotropium, once daily. He is allergic to lisinopril,
which caused angioedema. He is a former smoker
and drinks alcohol rarely.
On physical examination, he is obtunded and minimally
arousable. He is febrile with a temperature of 38.9°C. His
blood pressure is 159/96 mmHg, and heart rate is 98 beats/
min. He is breathing at a rate of 24 breaths/min with a room
air oxygen saturation of 95%. He has minimal scleral icterus.
The oropharynx reveals dry mucous membranes. His
cardiovascular, pulmonary, and abdominal examinations
are normal. There are no rashes. His neurologic examination
is difficult to obtain. There are no cranial nerve findings.
He resists movement of his extremities but has normal
strength. Deep tendon reflexes are brisk, 3+ and equal.
The laboratory values are as follows: hemoglobin 9.3 g/
dL, hematocrit 29.1%, white blood cell count 14,000/ μL,
and platelets 42,000/ μL. The differential demonstrates
83% neutrophils, 2% band forms, 6% lymphocytes, and
9% monocytes. The sodium is 145 meq/L, potassium 3.8
meq/L, chloride 113 meq/L, bicarbonate 19 meq/L, blood
urea nitrogen 68 mg/dL, and creatinine 3.4 mg/dL. The
bilirubin is 2.4 mg/dL, and lactate dehydrogenase is 450
U/L. A peripheral blood smear shows diminished platelets
and many schistocytes.What is the next most appropriate
step in this patient’s care?
A. Discontinue clopidogrel.
B. Discontinue clopidogrel and initiate plasmapheresis.
C. Initiate therapy with intravenous immunoglobulin.
D. Obtain a head CT scan and initiate treatment with
factor VIIa, if subarachnoid hemorrhage is seen.
E. Perform a lumbar puncture and start broad-spectrum
antibiotic coverage with ceftazidime and vancomycin.
Answer B
Q 9 . A primary tumor of which of these organs is the
least likely to metastasize to bone?
A. Breast
B. Colon
C. Kidney
D. Lung
E. Prostate
Answer B
Q 10 . The triad of portal vein thrombosis, hemolysis, and
pancytopenia suggests which of the following diagnoses?
A. Acute promyelocytic leukemia
B. Hemolytic-uremic syndrome (HUS)
C. Leptospirosis
D. Paroxysmal nocturnal hemoglobinuria (PNH)
E. Thrombotic thrombocytopenia purpura (TTP)
Answer D
