Emergency Medicine Examination & Board Review

Susan Promes

Chapter 11 Hematologic and Oncologic Emergencies - all with Video Answers

Educators

Chapter Questions

Problem 1

In iron, vitamin $\mathrm{B}_{12}$, or folate deficiency anemias, which of the following red blood cell (RBC) indices may change before the mean corpuscular volume (MCV)?
(A) Hematocrit.
(B) Mean corpuscular hemoglobin (MCH).
(C) Mean cellular hemoglobin concentration (MCHC).
(D) Red cell distribution width (RDW).

Dennis Howard

Numerade Educator

Problem 2

Paramedics bring in a 70-year-old woman with coffee-ground emesis after selfmedicating with aspirin for three days to treat her osteoarthritis. Vital signs are blood pressure $130 / 90 \mathrm{mmHg}$, pulse 124 beats per minute, respirations 26 per minute, temperature $98.6{ }^{\circ} \mathrm{F}$, and oxygen saturation $94 \%$. The patient has a nasal cannula delivering oxygen at $3 \mathrm{~L} / \mathrm{min}$, and an IV of Ringer's lactate. The patient is alert and complains of mild epigastric pain and shortness of breath, but she denies chest pain. Her abdomen is soft, mildly tender, and her rectal exam reveals melena. A nasogastric tube produces $300 \mathrm{cc}$ of dark blood. Her hemoglobin is $9 \mathrm{~g} / \mathrm{dL}$. An electrocardiogram reveals sinus tachycardia without ST-segment elevation or depression. A chest x-ray is normal. What is the next MOST appropriate immediate action or intervention?
(A) Obtain an arterial blood gas.
(B) Administer platelets.
(C) Administer morphine $2 \mathrm{mg}$ intravenously.
(D) Transfuse the patient with packed red blood cells.

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02:14

Problem 3

Which of the following conditions is LEAST likely associated with a platelet disorder?
(A) Epistaxis.
(B) Retroperitoneal bleeding.
(C) Ecchymoses.
(D) Petechiae.

Eric Goldman

Numerade Educator

01:09

Problem 4

Which of the following conditions is LEAST likely to be associated with a coagulation factor deficiency?
(A) Intra-articular bleeding.
(B) Delayed bleeding.
(C) Retroperitoneal bleeding.
(D) Petechiae.

Joanna Quigley

Numerade Educator

Problem 5

Which of the following conditions is LEAST likely to be associated with coagulation factor II, V, VII, VIII, IX, or $\mathrm{X}$ deficiency?
(A) Hemarthrosis.
(B) Delayed bleeding.
(C) Retroperitoneal bleeding.
(D) Arterial and venous thrombosis.

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Problem 6

What clinical finding is MOST commonly associated with the onset of idiopathic thrombocytopenic purpura (ITP)?
(A) Ecchymoses.
(B) Purpura.
(C) Petechiae.
(D) Gingival bleeding.

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Problem 7

Which of the following statements regarding chronic ITP is TRUE?
(A) It is more likely to develop in female children.
(B) Spontaneous remissions are typical.
(C) Underlying disease or autoimmune disorders are common.
(D) Platelet transfusions constitute initial, definitive therapy.

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Problem 8

Which thrombocytopenia-producing condition is NOT due to increased platelet destruction?
(A) Radiation therapy.
(B) Idiopathic thrombocytopenic purpura (ITP).
(C) Thrombotic thrombocytopenic purpura (TTP).
(D) Hemolytic uremic syndrome (HUS).

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Problem 9

Which lab finding would suggest the patient has severe liver disease and not disseminated intravascular coagulation (DIC)?
(A) Thrombocytopenia with bleeding.
(B) Prolonged prothrombin time.
(C) Hypofibrinogenemia.
(D) Normal or minimally elevated D-dimer assay.

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Problem 10

A 50-year-old man with known cirrhosis and ascites presents with fever and abdominal pain, and is suspected of having acute spontaneous bacterial peritonitis. The patient is hemodynamically stable and not actively bleeding (negative nasogastric tube aspiration and no occult blood in rectal exam). Initial labs include a prolonged prothrombin time, increased INR, decreased platelets, and a minimally decreased fibrinogen level. Which of the following is indicated prior to performing a paracentesis?
(A) Cryoprecipitate.
(B) Fresh frozen plasma (FFP).
(C) Platelet transfusion.
(D) Desmopressin (DDAVP).

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Problem 11

Which of the following is the MOST commonly observed abnormality in patients with DIC?
(A) Prolonged prothrombin time.
(B) Thrombocytopenia.
(C) Hypofibrinogenemia.
(D) Elevated fibrin degradation products and D-dimer assay.

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Problem 12

A 60-year-old woman presents with urosepsis, hematuria, petechiae, and mucosal bleeding. She has a hemoglobin of $12 \mathrm{~g} / \mathrm{dL}$, an elevated prothrombin time, a platelet pressors, antibiotics, and fresh frozen plasma are being administered. What other treatment modality is indicated next?
(A) Platelet transfusion.
(B) Packed red blood cell transfusion.
(C) Cryoprecipitate.
(D) Heparin.

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02:02

Problem 13

Which of the following is the MOST common cause of DIC?
(A) Adenocarcinoma.
(B) Trauma due to burns, crush injury, or fat embolism.
(C) Infection due to gram-negative sepsis.
(D) Acute promyelocytic leukemia.

Scott Rhodes

Numerade Educator

Problem 14

Paramedics bring in a 19-year-old male who was the restrained back-seat passenger in a vehicle that was rear-ended at approximately 35 miles per hour. He is on a backboard and is wearing a cervical collar. The patient states he struck his head on the front seat headrest, and though he did not lose consciousness, he does have a headache. He denies neck pain. His past medical history is significant for hemophilia B. His vital signs are stable and his physical examination is entirely normal except for a forehead contusion. What is the next MOST appropriate step in this man's care?
(A) Obtain cervical spine films.
(B) Obtain a CT scan of the head.
(C) Administer factor IX.
(D) Administer cryoprecipitate.

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Problem 15

A 7-year-old male presents with left lower quadrant abdominal pain after being hit by a knee in his lower torso 2 hours ago while wrestling with his twin brother. The patient has severe hemophilia A. His vital signs are normal. The physical examination is notable for a contusion in the left inguinal area, above and below the inguinal crease. The patient is mildly tender to palpation in the left lower quadrant. Bowel sounds are present. The genitalia are normal and not contused. His rectal examination is negative for blood. Obturator sign is negative. The patient has pain with extension of his left lower extremity, and he walks with his trunk slightly flexed forward. What is the appropriate treatment plan?
(A) Give factor VIII and order a CT scan of the abdomen.
(B) Give factor IX and order a CT scan of the abdomen.
(C) Give desmopressin (DDAVP) and order a CT scan of the abdomen.
(D) Give fresh frozen plasma and order an ultrasound of the abdomen.

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Problem 16

A 9-year-old female with mild type I von Willebrand's disease presents with mild gingival bleeding after her first overly vigorous attempt to use dental floss. She stopped as soon as she noticed bleeding, which is limited to the space between her upper central incisors. She is somewhat anxious, but her vital signs are normal. The physical exam is normal except for gingival bleeding between the upper central
incisors. Bleeding has continued despite applying pressure to the site for 30 minutes. What is the MOST appropriate action?
(A) Subcutaneous DDAVP $0.03 \mu \mathrm{g} / \mathrm{kg}$.
(B) Intravenous DDAVP $0.03 \mu \mathrm{g} / \mathrm{kg}$ over 30 minutes.
(C) Intranasal DDAVP $150 \mu \mathrm{g}$ (one spray in one nostril).
(D) Cryoprecipitate.

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00:23

Problem 17

Which of the following would be the MOST appropriate over-the-counter analgesic for a patient with type I von Willebrand's disease?
(A) Aspirin $80 \mathrm{mg}$.
(B) Aspirin $325 \mathrm{mg}$.
(C) Ibuprofen $200 \mathrm{mg}$.
(D) Acetaminophen $325 \mathrm{mg}$.

Nicole Smina

Numerade Educator

Problem 18

Which of the following statements regarding patients with sickle cell anemia is TRUE?
(A) Acute chest syndrome is the leading cause of death from sickle cell disease in the United States.
(B) Hydroxyurea effectively decreases the frequency and severity of painful crises in children.
(C) Infants often present at around 3 months of age with dactylitis (hand-foot syndrome).
(D) Simple or exchange transfusion is indicated for dactylitis.

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01:30

Problem 19

Which of the following statements regarding clopidogrel is TRUE?
(A) It inhibits platelet aggregation by blocking the adenosine diphosphate (ADP) release.
(B) It is contraindicated in patients with aspirin hypersensitivity who have unstable angina or non-ST-segment elevation myocardial infarction.
(C) Thrombotic thrombocytopenic purpura can rarely occur.
(D) It is poorly tolerated due to side effects.

Maryam Riaz

Numerade Educator

04:14

Problem 20

A transfusion of 2 units of packed red blood cells is started on a 40-year-old man with a hemoglobin of $7 \mathrm{~g} / \mathrm{dL}$, due to a bleeding gastric ulcer. Ten minutes later, he complains of low back pain and chills. Vital signs are blood pressure $95 / 60 \mathrm{mmHg}$, pulse 110 beats per minute, respirations 24 breaths per minute, room air oxygen saturation of $96 \%$, and temperature $37^{\circ} \mathrm{C}$. The patient appears flushed and dyspneic. The transfusion is stopped immediately, and crystalloid is infused at $300 \mathrm{~mL} / \mathrm{hour}$. The donor blood and the patient's posttransfusion blood are sent to the lab. Which laboratory findings are MOST likely?
(A) Elevated serum haptoglobin, elevated lactate dehydrogenase, elevated plasma free hemoglobin, and hemoglobinemia.
(B) Elevated serum haptoglobin, decreased lactate dehydrogenase, elevated plasma free hemoglobin, and hemoglobinuria.
(C) Decreased serum haptoglobin, decreased lactate dehydrogenase, elevated plasma free hemoglobin, and hemoglobinuria.
(D) Decreased serum haptoglobin, increased lactate dehydrogenase, elevated plasma free hemoglobin, and hemoglobinuria.

Ronald Prasad

Numerade Educator

Problem 21

The oncology clinic refers a 7-year-old boy who is currently undergoing chemotherapy for acute lymphocytic leukemia to the ED for fever of $38^{\circ} \mathrm{C}$ and an absolute neutrophil count of $450 / \mathrm{mm}^3$. His blood pressure is $110 / 70 \mathrm{mmHg}$, pulse is 110 beats per minute, respiratory rate is 20 breaths per minute, and oxygen saturation on room air is $100 \%$. He denies headache, vision changes, oral pain, cough, shortness of breath, or abdominal pain but does report pain with defecation. The clinic reports his funduscopic examination was normal. Which of the following is the appropriate action at this time?
(A) Complete a physical examination including a digital rectal examination, then administer broad-spectrum antibiotics.
(B) Complete a physical examination but not the rectal examination, then administer broad-spectrum antibiotics.
(C) Complete a physical examination but not the rectal examination, obtain blood cultures, and administer broad-spectrum antibiotics.
(D) Complete a physical examination and the rectal examination, obtain blood cultures, and administer broad-spectrum antibiotics.

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Problem 22

A 60-year-old man presents to the ED after accidentally cutting his left index finger with a knife while cutting onions. A 3-cm laceration through the finger pad actively bleeds if pressure is released. There is full range of motion of the DIP, good two point discrimination, and distal capillary refill. He tells you that he takes coumadin $5.0 \mathrm{mg}$ every day since he had a deep venous thrombosis 5 months ago. He has not had his INR checked in 3 months. He denies chest pain, shortness of
breath, or new leg swelling. You send a stat PT and INR and have the patient apply pressure while you prepare to anesthetize and clean the laceration. The INR is 6 . Which of the following is the MOST appropriate action?
(A) Repair the laceration and instruct the patient to skip the next dose of coumadin.
(B) Repair the laceration and instruct the patient to contact his private provider as soon as possible.
(C) Repair the laceration and administer oral vitamin K 1-2 mg.
(D) Repair the laceration and administer intravenous vitamin K 5-10 mg slowly.

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03:01

Problem 23

Which of the following statements regarding thrombotic thrombocytopenic purpura (TTP) is TRUE?
(A) The metalloprotease enzyme that forms von Willebrand factor multimers is qualitatively or quantitatively deficient.
(B) Microvascular platelet-fibrin thrombi shear red blood cells and cause microangiopathic hemolytic anemia (MAHA).
(C) Preeclampsia commonly precipitates TTP.
(D) Serum unconjugated bilirubin is elevated and the direct Coombs' test is negative.

Sylvia Puglisi

Numerade Educator

Problem 24

A 65-year-old man with lung cancer who presents with a 5-day history of generalized weakness, anorexia, and constipation is found to have a serum calcium of $14 \mathrm{mg} / \mathrm{dL}$. An electrocardiogram shows sinus tachycardia 120, a widened T wave, and a shortened QT interval. The sodium is $148 \mathrm{mEq} / \mathrm{L}$, potassium is $3.0 \mathrm{mEq} / \mathrm{L}$, chloride is $108 \mathrm{mmol} /$ $\mathrm{L}$, bicarbonate is 18, glucose is $80 \mathrm{mg} / \mathrm{dL}$, blood urea nitrogen is 40, and creatinine is $1.8 \mathrm{mg} / \mathrm{dL}$. The serum albumin is $4.0 \mathrm{~g} / \mathrm{dL}$. The patient is awake, diffusely weak, with diminished reflexes. Vital signs are blood pressure 140/90 mmHg, pulse 120 beats per minute, respirations 22 breaths per minute, and temperature $37^{\circ} \mathrm{C}$. The first troponin is negative. After he receives $1.5 \mathrm{~L}$ normal saline over 1 hour, the infusion is continued at $300 \mathrm{~mL} /$ hour. What would be the next MOST appropriate course of action?
(A) Administer oral glucocorticoids.
(B) Administer intravenous glucocorticoids.
(C) Administer furosemide 40-80 mg IV every 2 hours.
(D) Administer calcitonin $4 \mathrm{IU} / \mathrm{kg}$ SC or IM every 6-12 hours.

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