Questions 08/09/2012

Hematology, Oncology,
Immunology

Question 1
A 25 year-old-man with history of acute
myelogenous leukemia (AML) presnets with acute
onset generalized weakness. He received his first
dose of chemotherapy 3 days before. Which of the
following is the most likely abnormality on
laboratory analysis?
a) Hyperkalemia
b) Hypercalcemia
c) Hypophosphatemia
d) Hyponatremia
e) Hypomagnesemia

Answer 1
Tumor lysis syndrome
Typically occurs 1-5 days after chemotherapy
Most common laboratory abnormalities are
hyperkalemia, hyperuricemia,
hypophosphatemia
Serious complications include renal
insufficiency and dysrhythmias
Management involves normalization of
electrolyte abnormalities, IV fluids, and
treatment of renal insufficiency

Question 2
A 34-year-old woman has a hemoglobin
level of 10.0 g per dL with a low mean
corpuscular volume. Which of the
following is the most likely cause?
a) Alpha-Thalassemia
b) Beta-Thalassemia
c) Iron-deficiency anemia
d) Sideroblastic anemia
e) Folate deficiency

Answer 2
Iron-deficiency anemia
Most common cause of all anemias in
women of child bearing age
Folate deficiency is associated with
macrocytic anemia

Question 3
Which of the following is true regarding the peripheral
WBC count?
a) Elevation in the WBC count is specific for an
infectious process
b) The presence of 95% neutrophils is also known as a
left shift
c) Exercise can elevate the WBC count to more than
15,000 cells per mm3
d) The degree of leukocytosis distinguishes between
viral and bacterial infection
e) A WBC count > 50,000 cells per mm3 is specific for
chronic myeloid leukemia

Answer 3
Leukocytosis can be seen in any body
stress (pain, exercise, pregnancy)
Left shift refers to presence of
immature WBC forms such as bands,
metamyelocytes, or myelocytes
Differential for extremely elevated WBC
count includes leukemias, C. difficile
colitis, disseminated candidiasis

Question 4
Which of the following is true regarding allergic
reactions?
a) Like infants, many adults with food allergies will
outgrow their allergies over time
b) Patients allergic to honeybee stings will also have
similar reactions to wasp stings
c) Most adverse drug reactions are allergic
d) Oral allergen exposure provokes a stronger
anaphylactic response than topical exposure
e) Atopy predisposes patients to develop
anaphylaxis

Answer 4
Little cross reactivity occurs between
Apidae (honeybees, bumblebees)
and Vespidae (wasps, yellow jackets,
hornets) families
Atopy refers to genetic predisposition
to develop hypersensitivity to
environmental allergens as well as
anaphylaxis

Question 5
Which of the following is the most
common presenting symptom of
multiple sclerosis (MS)?
a) Urinary retention
b) Hemiparesis of the upper extremities
c) Ataxia
d) Aphasia
e) Eye pain and monocular visual loss

Answer 5
Optic neuritis
Syndrome of monocular eye pain,
decreased color perception, variable visual
loss primarily affecting central vision
20% of multiple sclerosis patients will
present with optic neuritis
50% of multiple sclerosis patients will
experience optic neuritis at some point in
the disease course

Question 6
Which of the following is true regarding patients
with temporal (or giant cell) arteritis?
a) The most specific finding is jaw claudication
b) Permanent visual loss occurs in 50% of
patients
c) Treatment with corticosteroids should be
withheld until there is a biopsy-proved disease
d) Vertigo is the most sensitive clinical finding
e) The peak age of onset is 40 years

Answer 6

Temporal (giant cell arteritis)

Rare before 50, incidence peaks in 70s
Most sensitive finding is new headache
Most specific finding is jaw claudication
Permanent visual loss occurs in 15% of
patients
Steroids are the treatment of choice and
do not affect biopsy results if performed
within a few weeks

Question 7
Which of the following is true regarding
idiopathic thrombocytopenic purpura?
a) Five-year mortality is 50%
b) Aspirin is the treatment of choice in adults
c) Treatment in children is usually supportive
d) There is a male predominance in adults
e) Platelet therapy is indicated in patients
with < 50,000 cells per mm3

Answer 7

Idiopathic thrombocytopenic purpura (ITP)

Immune mediated destruction of platelets
Acute form in children, chronic form in adults.
Most common clinical finding is bleeding.
Most common cause of death is intracranial bleeding.
Aspirin is contraindicated
Supportive care in children (spontaneous resolution)
High dose steroids and/or IVIG in adults
Transfusion is not indicated until platelets reach <
10,000-20,000 cells per mm3

Question 8
The most common cause of distal
symmetric polyneuropathy is
a) Amyotrophic lateral sclerosis
b) Guillain-Barre syndrome
c) Alcoholism
d) Diabetes mellitus
e) Paraneoplastic syndrome

Answer 8
Distal neuropathy typically positive
(burning, tingling) rather than
negative (numbness)
Symptoms begin distally and
progress proximally

Question 9
A 45-year-old woman is referred to the ED from an
optometrist with a diagnosis of bilateral papilledema and
rule out pseudotumor cerebri. Which of the following is
true about pseudotumor cerebri (also known as idiopathic
intracranial hypertension)?
a) Blurry vision is the most common presenting complaint
b) CT scanning will demonstrate hydrocephalus in 80% of
cases
c) Oculomotor nerve palsy is the most common associated
cranial nerve palsy
d) Men outnumber women 4:1
e) Headaches associated with the disorder are usually worse
in the recumbent position

Answer 9
Peudotumor cerebri (idiopathic intracranial
hypertension)
Increased intracranial pressure without
identifiable cause.
Most common presenting symptom is
headache, worse with recumbency and in
the morning
CT never has hydrocephalus
Woman more commonly affected than men

Question 10
The most common cause of
intracranial tumor is
a) Meningioma
b) Astrocytoma
c) Medulloblastoma
d) Metastases
e) Pituitary adenoma

Answer 10
Most common cause of brain
metastasis is lung cancer follow by
breast and colon carcinoma

Question 11
Which of the following is the most
common cause of large bowel
obstruction?
a) Malignancy
b) Sigmoid volvulus
c) Adhesions
d) Diverticular disease
e) Fecal impaction

Answer 11
Malignant neoplasms account for
more than half of all cases
Second most common cause is due
to volvulus
Third most common cause is due to
diverticulitis

Question 12
Which of the following is true regarding lumbar puncture
in patients with Guillain-Barre syndrome (GBS)?
a) Campylobacter jejuni can often be visualized in the
cerebrospinal fluid (CSF) of pateints with GBS
b) The classic CSF finding is an elevated protein level
with a normal number of white blood cells
c) Lumbar puncture is necessary to make a diagnosis of
GBS
d) Lumbar puncture is contraindicated in the acute phase
of GBS due to elevated intracranial pressure (ICP)
e) The finding of oligoclonal bands is pathognomonic of
GBS

Answer 12
Guillain Barre
Cytoalbumin dissociation refers to the
fact that protein levels are elevated
without a concomitant rise in WBC
Two requirements for diagnosis of GBS
include motor weakness of more than
one limb and areflexia (typically global)
Oligoclonal bands are most commonly
associated with multiple sclerosis

Question 13
A 35-year-old man with history of sickle cell disease presents
with acute onset of fever, malaise, fatigue, and
lightheadedness. Physical exam demonstrates a tachycardic
patient with pale conjunctivae. You suspect aplastic crisis and
draw a complete blood count with reticulocyte count. You
review his old records and nose that the patients baseline
hemoglobin level is 8 g per dL. Which of the following
laboratory abnormalities is most consistent with an aplastic
crisis?
a) Hemoglobin 8 g per dL, reticulocyte count 6%
b) Hemoglobin 8 g per dL, reticulocyte count 1%
c) Hemoglobin 6 g per dL, reticulocyte count 6%
d) Hemoglobin 6 g per dL, reticulocyte count 1%
e) Hemoglobin 4 g per dL, reticulocyte count 6%

Answer 13
Aplastic crises
Characterized by worsening anemia
(drop of hemoglobin from stable
levels) and inadequate reticulocyte
response (> 2%)
Usually post-infectious
Responsible for 5% of all deaths in
sickle cell patients

Question 14
Which of the following is true regarding
anaphylaxis?
a) Bee stings are the most common cause
b) Exercise may trigger anaphylaxis
c) Anaphylaxis usually occurs upon first
exposure to an allergen
d) Anaphylaxis is a type IV hypersensitivity
reaction
e) The risk of anaphylaxis is greatest in the
very young and elderly

Answer 14
Anaphylaxis
Type I hypersensitivity mediated by
IgE
Require prior sensitization (as
opposed to anaphylactoid reactions)

Question 15
The treatment of Kawasaki Syndrome
is intended to prevent:
a) Coronary artery aneurysms
b) Fistula formation from the draining
lymph nodes
c) Fulminant liver failure
d) Meningoencephalitis
e) Paraplegia or quadriplegia

Answer 15
Kawasaki Disease
Autoimmune disease of blood vessels
Criteria for diagnosis
Erythema/cracking of lips or oral cavity
Rash on the trunk
Swelling or erythema of the hands or feet
Red eyes (conjunctival injection)
Swollen lymph node in the neck

Treatment is IVIG and aspirin