Welcome to your #Internal Medicine/#Clinical_COMLEX_Level_2/#Lecturio
A 32-year-old gravida 1, para 0, woman at 24 weeks' estimated gestational age presents with colicky periumbilical and epigastric abdominal pain and fatigue that has worsened over the last 3 days. The pain worsens after meals, and she says she has difficulty swallowing. She reports red-colored urine, particularly in the morning, since the onset of the pain. She denies any similar pain in the past. She has had good prenatal care that started around week 8 after her last menstrual period. Her most recent prenatal visit was last week and was reassuring with no evidence of complications. She denies any tobacco, drug, or alcohol use. Her only medication is a prenatal vitamin. Her temperature is 37.8°C (100.0°F), pulse is 88/min, blood pressure is 110/88 mm Hg, and respirations are 18/min. Her fundus is 6 cm above the umbilicus. The abdomen is distended, and there is epigastric and periumbilical tenderness without guarding or rebound. An obstetric ultrasound shows a normal intrauterine pregnancy with an anterior placenta. There is no evidence of appendicitis or gallstones. A pelvic exam reveals a thick and closed cervix with no evidence of blood, discharge, or clear fluid in the posterior fornix. A nonstress test shows a baseline fetal heart rate of 150/min, moderate variability with accelerations, and no decelerations. The following additional laboratory studies are obtained:
Laboratory test
Hemoglobin: 6.9 g/dL
Platelets: 145,000/µL
Leukocytes: 9,500/µL
Reticulocyte count: 1%
Lactate dehydrogenase (LDH): 800 U/L
Mean corpuscular volume (MCV): 82 µm3
Haptoglobin: 25 mg/dL
Aspartate aminotransferase (AST): 37
Alanine aminotransferase (ALT): 43
Total bilirubin: 8.0 mg/dL
Direct bilirubin: 2.5 mg/dL
Urinalysis
Color: Pink
Glucose: Negative
Protein: 3+
Hemosiderin: Positive
Nitrite: Negative
Leukocyte esterase: Negative
Bacteria: None
Red blood cells (RBCs): 2–3/hpf
White blood cells (WBCs): 1/hpf
Magnetic resonance venography shows thrombosis of the mesenteric veins. The patient is started on heparin and scheduled for a blood transfusion. Which of the following interventions is most appropriate for the long-term management of this patient's condition?
Hint
A 45-year-old African American man presents with nausea and severe abdominal pain. He denies vomiting. He says that his divorce was finalized 2 days ago, after which he went to a bar and had multiple shots of tequila and vodka. This morning he noticed his urine was red, which lasted throughout the day. The patient denies any history of similar symptoms. Past medical history is significant for low blood counts diagnosed on routine laboratory work 6 months ago, which was not followed up due to the stress of the divorce. A review of systems is significant for erectile dysfunction and chronic fatigue. His temperature is 37.2°C (99.0°F), pulse is 90/min, blood pressure is 136/88 mm Hg, and respirations are 20/min. Physical examination shows scleral icterus. Mucous membranes are pale. Cardiac auscultation reveals a systolic flow murmur loudest along the left sternal border. There is moderate right upper quadrant abdominal tenderness with no rebound or guarding. The remainder of the exam is unremarkable. Laboratory findings are significant for the following:
Hematocrit: 27%
Mean corpuscular volume (MCV): 81 µm3
Leukocytes: 6,000/mm3
Platelets: 130,000/µL
Haptoglobin: 30 mg/dL (50–150 mg/dL)
Reticulocyte count: 3%
Total bilirubin: 7.1 mg/dL
Lactate dehydrogenase (LDH): 766 U/L
Aspartate aminotransferase (AST): 150 U/L
Alanine aminotransferase (ALT): 195 U/L
HbA1: 96%
HbA2: 2%
HbF : 2%
CD55: 50% of expected
The peripheral smear is unremarkable. Which of the following would be the most likely cause of mortality given this patient’s likely diagnosis?
Hint
Seven days after initiation of induction chemotherapy for acute myeloid leukemia (AML), a 56-year-old man develops neutropenia. He feels well and has no history of serious cardiopulmonary disease. His temperature is 36.7°C (98.1°F), blood pressure is 110/65 mm Hg, heart rate is 72/min, and respiratory rate is 14/min. Examination of the skin, head and neck, heart, lungs, abdomen, and perirectal area reveals no abnormalities. Laboratory studies show:
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| | Patient values |
| Blood pressure | 54/22 mm Hg |
| Heart rate | 180/min |
| Respiratory rate | 66/min |
| Hemoglobin | 9.0 g/dL |
| Leukocyte count | 900/mm3 |
| Percent segmented neutrophils | 50% |
| Platelet count | 85,000/mm3 |
Which of the following drugs is recommended to reduce the likelihood of complications in this patient?
Hint
A 30-year-old woman presents to her primary care provider after she was diagnosed with a deep vein thrombosis (DVT) in her leg at an urgent care clinic last week and started on anticoagulation. She has no known risk factors for DVT and was found to have significant anemia. Review of systems is positive for fatigue, abdominal pain, and dark urine for the past month. Vital signs are within the normal range. On physical exam, the patient appears mildly jaundiced. The cardiac exam is normal. A urine pregnancy test is negative. Laboratory studies are significant for anemia with a hemoglobin of 7.1 g/dL, normocytic, and decreased haptoglobin consistent with paroxysmal nocturnal hemoglobinuria. A mutation of which of the following genes is most likely responsible for this patient’s anemia?
Hint
A 72-year-old man presents to his physician because of a 3-month history of severe lower back pain and fatigue. The pain increases with activity, and he takes ibuprofen for pain relief. He is otherwise in good health and takes medication for hypertension and hyperlipidemia. He does not smoke. Temperature is 36.7°C (98.1°F), blood pressure is 130/78 mm Hg, heart rate is 86/min, and respiratory rate is 16/min. On physical exam, the conjunctivae are pale. No lymphadenopathy is noted. Palpation of the lumbar spine reveals tenderness over L1. Heart, lung, and abdominal examinations are normal. Laboratory studies show:
Hemoglobin: 10.9 g/dL
MCV: 90 μm3
WBC: 5,500/mm3 with a normal differential
Platelets: 350,000/mm3
Serum calcium: 11.5 mg/dL
Albumin: 3.8 g/dL
Urea nitrogen: 54 mg/dL
Creatinine: 2.8 mg/dL
Serum uric acid: 9.0 mg/dL
Lumbosacral X-ray shows an osteolytic lesion in the L1 vertebra and several similar lesions in the pelvic bone. Serum protein electrophoresis shows an IgG monoclonal protein of 40 g/L. A bone marrow biopsy shows 20% clonal plasma cells. A kidney biopsy was performed, and a photomicrograph of a representative section is shown. What is the most likely cause of this patient’s renal impairment?
Hint
A 43-year-old woman was admitted to the hospital for anticoagulation following a pulmonary embolism. She was found to have a deep venous thrombosis after a long plane ride coming back from visiting China. She denies any personal history of blood clots in her past, but she says that her mother has also had to be treated for pulmonary embolism in the recent past. Her past medical history is significant for preeclampsia, hypertension, polycystic ovarian syndrome, and hypercholesterolemia. She currently smokes one pack of cigarettes per day, drinks a glass of wine per night, and denies any illicit drug use. Her temperature is 36.7°C (98.0°F), blood pressure is 126/74 mm Hg, pulse is 111/min, and respirations are 23/min. On physical examination, her pulses are bounding, and her complexion is pale, but her breath sounds remain clear. Oxygen saturation was initially 81% on room air, with a new oxygen requirement of 8 L by face mask. On the fifth day of combined heparin and warfarin anticoagulation, her platelet count decreased from 182,000/mcL to 63,000/mcL. Her international normalized ratio (INR) is not yet therapeutic. What is the next best step in therapy?
Hint
