Ho: Good Cases Questions

Front 1

A 51 y.o. man presents to the emergency room with the complaints of vomiting blood and abdominal pain. He admits to drinking a fifth of whisky and two cases of beer on the weekends. He takes 5-6 aspirin for pain or headaches. Lately, he has noticed a severe pain in his upper abdomen, and he has been taking extra aspirin for this, as well. His stools have been black and tarry for several weeks.

Physical examination reveals an ill-appearing man with dried blood crusted over his face and chest. His vital signs are pulse=140, BP 80/40, RR 24. He is afebrile. He has rales bilaterally in the lower half of his lung fields, his heart sounds are distant. His abdomen is tender, with involuntary guarding in the mid-epigastric region. His liver is not enlarged. His spleen is non-palpable. His stool is dark maroon and is 4+ hemoccult positive for blood. As you examine him, he vomits approximately 200 cc of bright red blood.

Laboratory data include WBC 12.0 x 109/L (4.5-11)
Normal ranges are given in parentheses Hgb 6.2 G/dl (13.5-17.5)
MCV 65 (80-98)
Platelets 737 x 109/L (150-450)

The peripheral smear shows microcytosis and hypochromasia. The red blood cells are small, with increased central pallor and only a thin rim of hemoglobin around the center.

All of the following statements are true EXCEPT:

a) The patient is having a GI bleed, probably exacerbated by alcohol and aspirin
b) The patient’s platelets will be hypofunctional because of the aspirin he has ingested.
c) The patient’s elevated platelet count is most likely caused by essential thrombocythemia.
d) The patient’s tachycardia and hypotension and lung rales indicate that you should strongly consider giving him blood.
e) The patient’s low MCV and anemia may indicate iron deficiency

Back 1

C

Front 2

A 22 y.o. woman in her 9th month of pregnancy presents to the ER with complaints of fever, confusion, and abnormal bruising. Her pregnancy has been otherwise uncomplicated, and she is only taking iron and prenatal vitamins. Her husband notes that she has become increasingly confused and lethargic over the past two days. He has noticed large bruises appearing on her arms and legs today.

Physical examination reveals a pale, lethargic, pregnant young woman.
Vital signs: T 103°F HR 120 BP 120/80 RR 18
She has ecchymoses and petechiae over her arms and legs and torso. She is difficult to arouse, but her neurologic exam has no focal deficits. She has scleral icterus. Her abdomen is pregnant with good fetal heart tones. There is some diffuse abdominal pain

Laboratory data reveal

WBC 18.0 x 109/L (4.5-11)
Hgb 6.2 G/dl (13.5-17.5)
Platelets 7 x 109/L (150-450)

BUN 75 mg/dl (0.8-1.4)
Creatinine 3.8 mg/dl (0.8-1.4)

Total bilirubin 3.0 mg/dl (0-1.2)
LDH 3200 U/L (340-610)

PT 12.0 sec , PTT 24 sec
The urine is dark brown.

Her peripheral smear shows a marked number of schistocytes, a few nucleated red blood cells and low numbers of platelets.

Which of the following statements is UNTRUE?

a. The patient’s platelets may be hypofunctional because of her uremia.
b. Because of the low platelet count and abnormal mental status, the patient should undergo a CT of the head to look for intracranial hemorrhage.
c. Despite the degree of thrombocytopenia, the patient should not emergently receive a platelet transfusion.
d. The patient should be treated with plasma exchange, and she should be carefully monitored by the obstetricians.
e. The patient should be emergently heparinized to prevent thrombin generation.

Back 2

e

Front 3

Which of the following statements is INCORRECT?

a) Aggregation is the process by which platelets bind to each other, via crosslinking with fibrinogen.
b) Aspirin is useful in the treatment of coronary artery disease.
c) Heparin can lead to immune-mediated thrombocytopenia
d) Emergent splenectomy is indicated in the initial management of ITP.
e) Patients with platelet counts below 10,000 are at risk for spontaneous intracranial hemorrhage.

Back 3

D