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Usmle questions. RBCs.

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A 37-year-old woman visits her physician because of a cough and fever of 1 weeks duration. On physical examination, her temperature is 38.3oC. She has diffuse crackles in all lung fields. A chest radiograph shows bilateral extensive infiltrates. CBC shows hemoglobin of 13.9 g/dL, hematocrit 42.0%, MCV 89 m3, platelet count 210,000/mm3, and WBC count 56,000/mm3 with 63% segmented neutrophils, 15% bands, 6% metamyelocytes, 3% myelocytes, 1% blasts, 8% lymphocytes, 2% monocytes, and 2% eosinophils. The peripheral blood leukocyte alkaline phosphatase score is increased. Which of the following is the most likely diagnosis?1. Chronic myelogenous leukemia

2. Hairy cell leukemia

3. Hodgkin disease, lymphocyte depletion type

4. Leukemoid reaction *5. Acute lymphoblastic leukemiaA 12-year-old boy is taken to the physician because he has had increasing abdominal distention and pain for the past 3 days. Physical examination shows lower abdominal tenderness, and the abdomen is tympanitic with reduced bowel sounds. An abdominal CT scan shows a 7-cm mass involving the region of the ileocecal valve. Surgery is performed to remove the mass. Histologic examination for the mass shows sheets of intermediate-sized lymphoid cells, with nuclei having coarse chromatin, several nucleoli, and many mitoses. A bone marrow biopsy sample is negative fro this cell population. Cytogenetic analysis of the cells from the mass shows a t(8;14) karyotype. Flow cytometric analysis reveals 40% of the cells are in S-phase. The tumor shrinks dramatically in size following a course of chemotherapy. Which of the following is the most likely diagnosis?1. Diffuse large B-cell lymphoma

2. Follicular lymphoma

3. Acute lymphoblastic leukemia

4. Burkitt lymphoma*A 53-year-old man comes to his physician because he felt a lump near his shoulder 1 week ago. On physical examination, there is an enlarged nontender, supraclavicular lymphnode, as well as enlargement of the Waldeyer ring of orophyngeal lymphoid tissue. There is no hepatosplenomegaly. CBC is normal except for findings of mild anemia. A lymph node biopsy specimen shows replacement by a monomorphous population of large lymphoid ells with enlarged nuclei and prominent nucleoli. Immunohistolchemical staining and flow cytometry of the node indicates that most lymphoid cells are CD19+, CD10+, CD3-, CS15- and terminal deoxynucleotidyl transferase negative (TdT). Which of the following is the most likely diagnosis?

1. Chronic lymphadenitis

2. Diffuse large B-cell lymphoma

3. Hodgkin disease*4. Lymphoblastic lymphoma

5. Small lymphocytic lymphomaA 63-year-old woman experiences a burning sensation in her hands and feet. Two months ago, she had an episode of swelling with tenderness in the right leg, followed by dyspnea and then right-sided chest pain. On physical examination, the spleen and liver now appear to be enlarged. CBC shows hemoglobin of 13.3 g/dL, hematocrit 40.1%. MCV 91 m3, platelet count 657,000/mm3, and WBC count 17,400/mm3. The peripheral blood smear shows abnormally large platelets. Which of the following is the most likely diagnosis?

1. Essential thrombocythemia*

2. Chronic myelogenous leukemia

3. Myelofibrosis with myeloid metaplasia

4. Acute myelogenous leukemia

5. Polycythemia vera

A 9-year-old boy living in Uganda has had increasing pain and swelling on the right side of his face over the past 8 months. On physical examination, there is a large, nontender mass involving the mandible, which deforms the right side of his face. There is no lymphadenopathy and no splenomegaly, and he is afebrile. A biopsy of the mass is performed. Microscopically, the specimen is composed of intermediate-sized lymphocytes with a high mitotic rate. A chromsosome analysis shows a 46,XY,t(8;14) karyotype in these cells. The hemoglobin concentration is 13.2 g/dL, platelet count 272,000/mm3, and WBC count 5820/mm3. Infection with which of the following is most likely to be causally related to the development of these findings?

1. Cytomegalovirus

2. Epstein-Barr virus*3. Hepatitis B virus

4. HIV human papillomavirus

5. Respiratory syncytial virusA 26-year-old man has noted lumps in his neck that have been enlarging for the past 6 months. On physical examination, he has a group of enlarged, nontender right cervical lymph nodes. A biopsy of one of the lymph nodes shows scattered Reed-Sternberg cells, as well as macrophages, lymphocytes, neutrophils, eosinophils, and a few plasma cells. Which of the following factors elaborated by the Reed-Sternberg cells has led to the appearance of the eosinophils within this lesion?

1. Platelet-derived growth factor

2. TGF B

3. Interleukin-5

4. Trans-retinoic acid

5. Erythropoietin*A 65-year-old female is being evaluated for "generalized depression". The patient is feeling weak and fatigued, since her husband died 4 months ago. She does not have any suicidal thoughts but is losing interest in daily activities. She quit smoking 24 years ago, and drinks 1-2 beers/wk. On examination, she is pale with both cervical and supra-clavicular lymphadenopathy. Blood work reveals:

WBC 28,600mm3

Hematocrit 40%,: Platelets 96,000mm3

The distribution of leukocytes was as under

Lymphocytes 77%: Bands 6%: Neutrophils 16%

Some variants of lymphocytes and smudge type cells were also present. What is the most probable diagnosis?

1. Lymphoblastic lymphoma

2. Hodgkin's disease*3. Chronic lymphocytic leukemia

4. Chronic myeloid leukemia

Ms. Gunner, a 46-year-old female, is brought to ER because of visual blurring and altered mental status. Patient was recently treated for gout. Exam showed moderate to severe splenomegaly and positive sternal tenderness. Her labs showed WBC of 120,000/uL with left shifted myeloid series and basophilia. Bone marrow exam showed 3% blasts. A new set of CBC is ordered and a hematologist is called and he starts leukopharesis emergently. What other drug should be given immediately to this patient?

A. Cladribine

B. Hydroxyurea

C. Cyclophosphamide

D. Interferon alpha

E. Imatinib mesylate *F. Busulfan

A 70 year old man has experienced increasing fatigue for the past 6 months. On physical examination, he has nontender axillary and cervical lymphadenopathy, but ther is no hepatosplenomegaly. The hematoligic workup shows hemoglobin of 9.5 g.dL, hematocrit 28%, MCV 90 m3, platelet count 120,000/mm3, and WBC count 42,000/mm3. The peripheral blood smear shows a monotonous population of small, round, mature-looking lymphocytes. Flow cytometry shows these cells to be CD19+, and TdT-. Which of the following is most likely to be seen with cytoghenetic and molecular analysis of the cells in the patients blood?

1. T(9;22) leading to BCR-ABL rearrangement

2. Clonal rearrangement of immunologlobin genes

3. t(8;14) leading to C-MYC overexpression

4. t(14;18) leading to C-MYC overexpression* A 4 year old child has appeared listless for about 1 week. He now complains of pain when he is picked up by his mother, and he demonstrates irritability when his arms or legs are touched. In the past 2 days, several large ecchymoses have appeared on the right thigh and left shoulder. CBC shows hemoglobin of 10.2 g/dL, hematocrit 30.5%, MCV 96m3, platelet count 45,000/mm3, and WBC count 13,900/mm3. Examination of the peripheral blood smear shows blasts that lack peroxidase-positive granules but contain PAS-positive aggregates and stain positively for TdT. Flow cytometry shows the phenotype of blasts to be CD19+, CD3-. Which of the following is the most likely diagnosis?1. Chronic myelogenous leukemia

2. Idiopathic thrombocytopenic purpura

3. Acute myelongenous leukemia

4. Chronic lymphocytic leukemia

5. Acute lymphoblastic leukemia*A 62 year old man visits his physician because of prolonged fever and a 4-kg weight loss over the past 6 months. On physical examination, his temperature is 38.60C. He has generalized nontender lymphadenopathy, and the spleen tip is palpable. Laboratory studies show hemoglobin of 10.1 g/dL, hematocrit 30.3%, platelet count 140,000/mm3, and WBC count 24,500/mm3 with 10% segmented neutorphils, 1% bands, 86% lymphocytes, and 3% monocytes. A cervical lymph node biopsy specimen shows a nodular pattern of small lymphoid cells. A bone marrow specimen shows infiltrates of similar small cells having surface immunoglobulin that are CD5+ but CD10-. Cytogenetic analysis indicated t(11;14) in these cells. Which of the following is the most likely diagnosis?

1. Mantle cell lymphoma*2. Follicular lymphoma

3. Acute lymphoblastic leukemia

4. Burkitt lymphoma

5. Small lymphocytic lymphoma

A 45 year old man has experienced recurrent fevers and a 60kg weight loss over the past 5 months. On physical examination, his temperature is 37.5oC, and has had cervical lymphadenopathy. The patient reports that the edenopathy becomes very tender after he drinks a six-pack of beer. A lymph node biopsy specimen shows effacement of the nodal architecture by a population of small lymphocytes, plasma cells, eosinophils, and macrophages. Which of the following additional cell types, which stains positively for CD15, is most likely to be found in this disease?

1. Reed-Sternberg cell*2. Immunoblast

3. Epitherlioid cell

4. Nuetorphils

5. Mast cellIn an experiment, cell samples are collected from the bone marrow aspirated of patients who were diagnosed with lymphoporliferative disorders. Cytogenetic analyses are performed on these cells, and a subset of the cases is

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