A 65-year-old man presents to the hospital with complaints of fatigue, nausea, vomiting, and diarrhea for the past five days. He also states numbness and tingling of the legs, joint pain, and decreased urination that developed around the same time. He was recently diagnosed with non-Hodgkin lymphoma and started on chemotherapy two weeks ago. Vital signs show a blood pressure of 95/65 mm Hg, a pulse of 98/min, a respiratory rate of 19/min, and a temperature of 100˚F. Physical examination reveals a pale and cachectic man. Laboratory investigations reveal serum potassium 6.0 mEq/L (normal: 3.5-5.0 mEq/L), serum creatinine 3.2 mg/dL (normal: 0.6-1.2 mg/dL), serum calcium 7.0 mg/dL (normal: 8.6-10.2 mg/dL), and serum uric acid 9 mg/dL (normal: 2.4-6.5 mg/dL). What could have been done to prevent this condition?

A 59-year-old woman is brought to the emergency department by ambulance complaining of acute onset shortness of breath and a “racing pulse” that began after a 16-hour flight for a business trip. Her past medical history is significant for Type 2 diabetes mellitus and for a hospitalization 2 months ago for a myocardial infarction, during which she received low-molecular-weight heparin following cardiac catheterization. Her current medications include metformin, aspirin, propranolol, and atorvastatin. On arrival, her temperature is 99.1°F (37.3°C), blood pressure is 112/74 mmHg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 88% on room air. A chest radiograph is normal and an EKG shows sinus tachycardia. Lab results are obtained with the following results:Serum:Hemoglobin: 14.0 g/dLLeukocyte count: 6,800Platelet count: 260,000After appropriate imaging is performed, intravenous unfractionated heparin is started for treatment of possible pulmonary embolus and the patient is admitted to the hospital overnight. The next morning, the patient reports she is feeling better. Vital signs: T: 98.9°F (37.1°C),      BP: 118/73 mmHg, HR: 88/min, RR: 15/min, and oxygen saturation is 97% on room air. Repeat lab results are as follows:Serum:Hemoglobin: 13.5 g/dLLeukocyte count: 7,200Platelet count: 118,000Which of the following statements about this condition is correct?

 A 7-year-old boy is brought to his pediatrician by his mother for recent fatigue and intermittent fevers over the past month. She also reports that her son has appeared much paler recently. Vital signs at today’s visit are within normal limits. Physical examination is significant for pallor, petechiae, lymphadenopathy, and hepatosplenomegaly. A complete blood count reveals anemia, thrombocytopenia, and neutropenia. A peripheral blood smear is shown (see image). Bone marrow aspiration reveals 47% lymphoblasts. Which of the following is associated with this patient’s presenting condition?

A 25-year-old female with a recent history of systemic lupus erythematosus (SLE) for which she takes corticosteroids, presents to the emergency department complaining of shortness of breath and dizziness. On examination, she is found to be pale and tachycardic. Laboratory tests reveal the following: WBC: 9,600; Hemoglobin: 7.2 g/dL; Hematocrit: 23%; Platelet count: 530,000; MCV: 70; RDW: 18; Retic count: 2.5%; serum LDH and serum haptoglobin are normal. Which of the following is the most useful clinical intervention to determine the underlying cause of this patient’s anemia?

In a patient diagnosed with essential thrombocythemia and a high risk of thrombosis, which of the following is the most appropriate treatment?

A 61-year-old woman presents to your office complaining of mild fatigue and weight loss over the past 6 months. She states she has felt generally unwell and has had decreased appetite during this time frame. Her temperature is 98.1°F (36.7°C), blood pressure is 122/80 mmHg, pulse is 88/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam reveals splenomegaly and a nontender abdomen. A complete blood count with differential shows the following:Hemoglobin: 10 g/dLHematocrit: 30%Leukocyte count: 166,500Diff: WBC precursors at all stages of maturationPlatelet count: 92,000A bone marrow biopsy is performed. Which of the following translocations is likely to be seen in this patient?

Match each clinical finding with the correct diagnosis.

A 13-year-old female patient with known sickle cell disease presents to the primary pediatrician’s office with chest pain, tachypnea, and fever. This chest x-ray was obtained (see image). What is the most likely diagnosis?

A 54-year-old male presents with 1 month of low back pain, feeling tired easily, and constipation. He denies any fever, night sweats, cough, trauma, or tingling/weakness in the limbs. On examination, the vital signs are normal. Physical examination reveals tenderness along the L4/L5 area. Abdominal and chest exams are normal. X-ray of the lumbar spine shows lytic bone lesions. Laboratory results are a hemoglobin level of 9 g/dL, a serum calcium level of 12.5 mg/dL, and increased urea nitrogen and creatinine. Urine electrophoresis reveals Bence Jones protein. Which of the following is most likely present in the peripheral blood smear?

During your Emergency Medicine rotation, you are asked to evaluate a 5-year-old male child who presents after falling off a scooter.  The patient reports that he fell sideways off the scooter as he rounded a curve in the road, and he describes dull, aching pain along his left side where he hit the ground. The patient’s parents report that he has never had any previous serious injury, but the mother recalls that he had increased bleeding following circumcision during infancy.  There is no other history of surgery or trauma.  On physical exam, the patient has extensive bruising of the lateral left thigh and tenderness to palpation. Initial CBC is performed and reveals normal WBC, Hgb, and HCT. Additional laboratory results are as follows: (Normal ranges in parentheses; abnormal results are in bold type)   Initial Test Results PT 12.6 sec (11.0-13.5) PTT 50.0 sec (25.0-35.0) Plt 250,000 (150,000-400,000) Based on these findings, what clotting factor deficiency is most likely in this patient?