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Question 1 A 61-year-old man has had dull, constant back pain for 3 months. He recently developed a cough productive of yellowish sputum. On physical examination there are crackles at the right lung base. A plain film radiograph of the spine reveals several 1 to 2 cm lytic lesions of the vertebral bodies. Laboratory studies show sodium 140 mmol/L, potassium 4.4 mmol/L, chloride 101 mmol/L, CO2 26 mmol/L, glucose 78 mg/dL, urea nitrogen 49 mg/dL, creatinine 5 mg/dL, total protein 8.3 g/dL, albumin 3.7 g/dL, alkaline phosphatase 176 U/L, AST 45 U/L, ALT 22 U/L, and total bilirubin 1.2 mg/dL. A sputum culture grows Streptococcus pneumoniae. Which of the following pathologic findings is most likely to be seen in a bone marrow biopsy from this man? A B C D E Scattered small granulomas Nodules of small mature lymphocytes Occasional Reed-Sternberg cells Numerous plasma cells Hypercellularity with many blasts
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Question 2 A 33-year-old woman has experienced low grade fevers, night sweats, and generalized malaise for the past 2 months. On physical examination she has nontender cervical and supraclavicular lymphadenopathy. A cervical lymph node biopsy is performed. On microscopic examination at high magnification there are occasional Reed-Sternberg cells along with large and small lymphocytes and bands of fibrosis. Which of the following is the most likely diagnosis? A B C Burkitt lymphoma Hodgkin lymphoma Cat scratch disease

D E

Mycosis fungoides Multiple myeloma


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Question 3 A 17-year-old adolescent has had malaise for the past 3 weeks. He has a mild pharyngitis on physical examination, as well as tender axillary and inguinal lymphadenopathy. A CBC shows Hgb 14.0 g/dL, Hct 42.2%, MCV 90 fL, platelet count 301,300/microliter, and WBC count 8120/microliter with "atypical lymphocytes" on the peripheral blood smear. His illness is most likely to be acquired via which of the following mechanisms? A B C D E From a genetic abnormality While on a date As a result of an insect bite Through an environmental exposure at work Without any known etiology
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Question 4 A 42-year-old man has had fevers for the past 4 weeks. On physical examination his temperature is 37.8 C. Laboratory studies show a Hgb of 12.2 g/dL, Hct 37.1%, MCV 92 fL, platelet count 243,000/uL, and WBC count 75,000/uL. The WBC differential count shows 82 segs, 8 bands, 3 metamyelocytes, 1 myelocyte, 4 lymphocytes, and 1 monocyte. The leukocyte alkaline phosphatase (LAP) score is high at 130. Which of the following laboratory test findings is most likely to be present in this man?

A B C D E

Bone marrow karyotype of 46, XY, t(9;22) Serologic titer of 1:1024 for anti-double stranded DNA Serum vitamin B12 level of 100 pg/mL 4+ ketonuria and 4+ proteinuria Blood culture positive for Streptococcus, viridans group
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Question 5 A clinical study is conducted involving adults from 18 to 80 years of age who underwent splenectomy for blunt force abdominal trauma. An age-matched control group of patients consists of patients who have congestive splenomegaly. The laboratory findings from these subjects are analyzed. Which of the following laboratory test findings is most likely to be observed in the study group following splenectomy? A B C D E Thrombocytopenia RBC Howell-Jolly bodies Decreased RBC distribution width Leukopenia Nucleated RBCs
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Question 6 A 30-year-old man gives a history of a sore throat with fever followed by 6 weeks of malaise. On physical examination he has mildly tender generalized lymphadenopathy. A cervical lymph node biopsy is performed and on microscopic examination shows prominent germinal centers in follicles with a diffuse polyclonal hyperplasia composed of lymphocytes, plasma cells, and macrophages. Which of the following is the most likely diagnosis? A B C D E Lymphocytic lymphoma Hodgkin lymphoma Infectious mononucleosis Human immunodeficiency virus infection Brucellosis
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Question 7 A 30-year-old man has had a progressively worsening productive cough for one month. On physical examination, a few small non-tender lymph nodes are palpable in the axillae, and the tip of the spleen is palpable. Laboratory studies show Hgb 10.2 g/dl, Hct 31.1%, MCV 90 fL, WBC count 67,000/microliter, and platelet count 36,000/microliter. Microscopic examination of his peripheral blood smear shows many blasts with Auer rods. Which of the following is the most likely diagnosis? A B C D Leukemoid reaction Acute myelogenous leukemia Chronic lymphocytic leukemia Acute lymphoblastic leukemia

Leukoerythroblastosis
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Question 8 A 68-year-old man has had malaise for over a year. On physical examination, there are no abnormal findings. His Hgb is 10.5 g/dL, Hct 31.5%, MCV 88 fL, platelet count 211,000/microliter, and WBC count 6980/microliter. His total serum iron is 130 microgm/dL total iron binding capacity (TIBC) 230 microgm/dL, and soluble serum transferrin receptor is normal. A bone marrow biopsy is performed and microscopic examination shows that maturation is occurring in all cell lines and there are no abnormal cells seen. Stainable iron in the bone marrow is increased. Which of the following underlying diseases is he most likely to have? A B C D E Diverticulosis Hepatitis C infection Systemic lupus erythematosus Atrophic gastritis Fanconi anemia
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Question 9 A 68-year-old man has noted the presence of several lumps on the right side of his neck for the past 5 months. On physical examination he has firm, non-tender, movable lymph nodes palpable in right posterior cervical region. He does not have splenomegaly or hepatomegaly. Laboratory studies show Hgb 11.3 g/dL, Hct 40%, MCV 88 fL, platelet count 256,000/microliter, and WBC count 7230/microliter. A cervical lymph node biopsy is performed and on microscopic examination shows numerous crowded follicles composed of small,

monomorphic lymphocytes. Which of the following is the most likely diagnosis? A B C D E Chronic lymphocytic leukemia Poorly differentiated lymphocytic lymphoma Infectious mononucleosis Hodgkin lymphoma, lymphocyte predominance type Reactive hyperplasia
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Question 10 A 45-year-old man has had increasing abdominal discomfort with abdominal enlargement for the past two years. On physical examination, the spleen can be felt below the left costal margin. There is no fluid wave. An abdominal CT scan reveals massive (estimated 3000 gm size) splenomegaly. Which of the following underlying conditions is he most likely to have? A B C D E Myelofibrosis Sickle cell anemia Portal hypertension Infectious mononucleosis Hemochromatosis
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Question 11 A 72-year-old Caucasian man has had increasing fatigue for the past year. On physical examination there are no abnormal findings. Laboratory studies show a Hgb of 9.1 gm/dL, Hct 27.9%, MCV 96 fL, WBC count 3700/microliter, and platelet count 125,000/microliter. The WBC differential count on the peripheral blood smear shows 53 segs, 5 bands, 2 metamyelocytes, 1 myelocyte, 32 lymphs, 7 monos, and 5 nucleated RBCs/100 WBCs. He has a negative direct and indirect Coombs test. Which of the following diseases is he most likely to have? A B C D E F Metastatic carcinoma Chronic alcoholism Malabsorption Hemoglobinopathy Chronic blood loss Systemic lupus erythematosus
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Question 12 A 40-year-old woman has had a week long course of fever and mental confusion. Physical examination shows T 38.2 C, P 100/minute, RR 20/minute, and BP 100/60 mm Hg. She has widespread petechiae of skin and mucosal surfaces. Laboratory studies show her serum urea nitrogen is 52 mg/dL with creatinine 5.3 mg/dL. She has a hemoglobin of 12.2 g/dL, hematocrit 36.8%, MCV 93 fL, platelet count 19,000/microliter, and WBC count 8180/microliter. Schistocytes are seen on her peripheral blood smear. Her condition deteriorates rapidly following platelet transfusion. At autopsy, pink hyaline thrombi are found in small myocardial arteries. Which of the following is the most likely diagnosis? A B Disseminated intravascular coagulopathy Idiopathic thrombocytopenic purpura

C D E

Thrombotic thrombocytopenic purpura Trousseau syndrome Warm autoimmune hemolytic anemia


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Question 13 For the past 4 months, a 62-year-old man has noted increasing fatigue and shortness of breath with minimal exercise. He has noted some abdominal discomfort over the past month. He has been healthy all his life. On physical examination he has non-tender cervical lymphadenopathy. The liver span is 10 cm in the right mid-clavicular line; the edge is smooth and palpable just below right costal margin. The spleen is palpated 3 cm below left costal margin on inspiration. A CBC shows WBC count 23,100/microliter with 16 segs, 2 bands, 78 lymphs, and 4 monos, Hgb 11.9 g/dL, Hct 36%, MCV 90, and platelet count 277,300/microliter. The direct Coombs test is positive. Which of the following is the most likely diagnosis? A B C D E F Leukemoid reaction Chronic myelogenous leukemia Acute myelogenous leukemia Acute lymphocytic leukemia Chronic lymphocytic leukemia Systemic lupus erythematosus
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Question 14 A 16-year-old boy has had a low energy level for as long as he can remember. On physical examination he has a palpable spleen tip. A CBC shows Hgb of 8.8 g/dL, Hct 24.1%, MCV 65 fL, platelet count 187,000/microliter, and WBC count 7400/microliter. His serum ferritin is 3740 ng/mL. A bone marrow biopsy is performed and on microscopic examination reveals a myeloid:erythroid ratio of 1:4, and there is 4+ stainable iron. Which of the following is the most likely diagnosis? A B C D E G6PD deficiency Beta-thalassemia Sickle cell anemia Hereditary spherocytosis Malaria
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Question 15 An 83-year-old woman fell and broke her left wrist. She underwent open reduction with internal fixation of the radial head fracture. Postoperatively she received heparin prophylaxis for thromboembolism and diuretics to treat pulmonary edema. Laboratory studies showed: On admission: Hgb 13.2 g/dL, Hct 39.1%, MCV 85 fL, platelet count 209,000/microliter, WBC count 5720/microliter, prothrombin time 13 seconds, partial thromboplastin time 28 seconds 1 week later: Hgb 13 g/dL, Hct 38.8%, MCV 86 fL, platelet count 101,000/microliter, WBC count 6310/microliter, prothrombin time 12 seconds, partial thromboplastin time 27 seconds She suddenly developed difficulty in moving her right arm. What is the most likely cause for her findings? A Hypersplenism

B C D E

Idiopathic thrombocytopenic purpura Disseminated intravascular coagulation Drug-induced thrombocytopenia Thrombotic-thrombocytopenic purpura
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Question 16 A 48-year-old man has experienced increasing malaise and difficulty concentrating at work for the past 6 months. On physical examination he has splenomegaly but no lymphadenopathy. He is afebrile. Laboratory studies show Hgb 12.0 g/dL, Hct 35.8%, MCV 92 fL, platelet count 390,000/uL, and WBC count 190,000/uL with differential count 73 segs, 12 bands, 6 metamyelocytes, 2 myelocytes, 2 myeloblasts, and 5 lymphs. The leukocyte alkaline phosphatase (LAP) score is only 8. A bone marrow biopsy is performed. Which of the following microscopic findings is most likely to be found in this biopsy? A B C D E Sheets of plasma cells Atypical cytokeratin positive glands Numerous mature and immature myeloid cells A decrease in all cell lines Granulomas that have many acid fast bacilli
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Question 17

A 30-year-old woman has the sudden onset of fever, abdominal pain, tachycardia, and nausea. On physical examination her vital signs include T 37.6 C, P 90/minute, RR 18/minute, and BP 100/60 mm Hg. Her conjunctivae are icteric. The spleen tip is palpable. Laboratory studies shows Hgb 9.0 g/dL, Hct 27.3%, MCV 99 fL, platelet count 209,500/microliter, and WBC count 6840/microliter. Her reticulocyte count is 0.1%. On microscopic examination of her peripheral blood smear, the RBC's are small and lack central pallor. Which of the following most likely initiated this woman's acute illness? A B C D E Quinacrine use Parvovirus infection Decreased oxygen tension Exposure to cold Transfusion therapy
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Question 18 A 35-year-old man has had fatigue, fever, and episodes of epistaxis for the past 3 months. On physical examination his temperature is 37.4 C. Laboratory studies show Hgb 12.5 g/dL, Hct 37.6%, MCV 89 fL, platelet count 170,000/microliter, and WBC count 52,000/microliter. Examination of his peripheral blood smear shows large blasts with Auer rods. Which of the following is the most likely diagnosis? A B C D Chronic myelogenous leukemia Infectious mononucleosis Plasma cell leukemia Chronic lymphocytic leukemia

Acute myelogenous leukemia


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Question 19 A 42-year-old woman has noticed during the past month that even minor bumps produce major bruises over her body. On physical examination she has areas of purpura on the skin of her arms and legs. She is afebrile. Laboratory studies shows her prothrombin time is 12.9 seconds (control 13 sec) and partial thromboplastin time 26.2 seconds (control 25 sec). Her CBC shows a Hgb of 11.1 g/dL, Hct 33.1%, MCV 84 fL, platelet count 790,000/uL, and WBC count 45,400/uL. A bone marrow biopsy is performed and on microscopic examination shows hypercellularity with myeloid and megakaryocytic hyperplasia. Which of the following is the most likely diagnosis? A B C D E Epstein-Barr virus infection Myeloproliferative disorder Drug reaction to recent antibiotic therapy Wiskott-Aldrich syndrome Megaloblastic anemia
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Question 20 A clinical study is performed with subjects who are adults found to have anemia. Their clinical histories and laboratory findings are reviewed. It is observed that ingestion of a drug preceded development of the anemia in some of the subjects, but not in others. Which of the following conditions is most likely to be found in persons without a history of drug ingestion?

A B C D E

G6PD deficiency Autoimmune hemolytic anemia Macrocytic anemia Aplastic anemia Microcytic anemia
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Question 21 A 25-year-old African-American man is given anti-malarial prophylaxis for a trip to West Africa. Over the next week he develops increasing fatigue. On physical examination there are no abnormal findings. Laboratory studies show a hematocrit of 30%. Examination of his peripheral blood smear shows red blood cells with numerous Heinz bodies. There is a family history of this disorder, with males, but not females, affected. Which of the following is the most likely diagnosis? A B C D E Beta-thalassemia Sickle cell anemia Alpha-thalassemia Hereditary spherocytosis G6PD deficiency
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Question 22 An autopsy study is conducted to determine what changes in the size of the spleen take place with hematologic disorders. The spleen weights are recorded for adult patients who died from complications of their hematologic disease. For which of the following diseases is the spleen most likely to remain normal in size? A B C D E Hemolytic anemia Alcohol abuse Myelofibrosis Idiopathic thrombocytopenic purpura Sickle cell anemia
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Question 23 A 51-year-old man has become increasingly fatigued for the past 10 months. On physical examination there are no abnormal findings. Laboratory studies show his Hgb is 9.2, Hct 27.9%, MCV 132 fL, platelet count 242,000/microliter, and WBC count 7590/microliter. Which of the following morphologic findings is most likely to be present on examination of his peripheral blood smear? A B C D E Hypersegmented neutrophils Nucleated red blood cells Blasts Hypochromic, microcytic RBC's Schistocytes

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Question 24 A 72-year-old man has been feeling tired for the past 8 months. On physical examination there are no abnormal findings. Laboratory studies show Hgb 10.4 g/dL, Hct 30.3%, MCV 72 fL, platelet count 239,000/uL, and WBC count 7500/uL with automated differential count of 70.1% grans, 18.8% lymphs, and 11.1% monos. His total bilirubin is 1.0 mg/dL. Which of the following morphologic findings is most likely to be seen on his peripheral blood smear? A B C D E Fragmentation Many nucleated forms Hypochromasia Spherocytosis Howell-Jolly bodies
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Question 25 A 19 year old primigravida of Southeast Asian ancestry gives birth at 35 weeks gestation a male infant. On physical examination the infant is markedly hydropic. Laboratory studies show his hematocrit is 17% and the peripheral blood smear reveals numerous nucleated red blood cells and even a few erythroblasts. The red blood cells display marked anisocytosis and poikilocytosis. Which of the following diseases is most likely to be present in this infant? A B Sickle cell anemia Alpha-thalassemia

C D E

Hemoglobin E disease G6PD deficiency Hereditary elliptocytosis


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Question 26 A 45-year-old man has had worsening arthritis and swelling of his feet for the past year. On physical examination he has rales audible in all lung fields. A chest radiograph shows cardiomegaly and pulmonary edema. Laboratory studies show Hgb 13.0 g/dL, Hct 39.1%, MCV 86 fL, platelet count 255,500/uL, and WBC count 5920/uL. His serum iron is 406 microgram/mL with iron binding capacity 440 microgram/mL and ferritin 3830 ng/mL. Which of the following is the most likely diagnosis? A B C D E F Beta-thalassemia Autoimmune hemolytic anemia Anemia of chronic disease Polycythemia vera Pernicious anemia Hereditary hemochromatosis
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Question 27 A 50-year-old man has had a fever with cough for a month. On physical

examination his temperature is 37.5 C. There are crackles auscultated in upper lung fields. A chest radiograph shows a reticulonodular pattern with upper lobe cavitary lesions. His sputum is positive for acid fast bacilli. A CBC shows: Hgb 14.2 g/dL, Hct 42.5%, MCV 92 fL, platelet count 225,000/uL, and WBC count 44,500/uL with differential count of 59 segs, 20 bands, 8 metas, 4 myelos, 2 promyelos, 5 lymphs, and 2 monos. A bone marrow biopsy is performed and on microscopic examination shows myeloid hyperplasia with <5% blasts. Which of the following laboratory test findings is most likely to be present in this man? A B C D E Elevated leukocyte alkaline phosphatase Karyotype with 46, XY, t(9;22) Monoclonal gammopathy Elevated D-dimer Positive TdT
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Question 28 A 5-year-old boy has become increasingly lethargic for the past 2 months. On physical examination his temperature is 37.3 C. There are ecchymoses noted on the skin of his lower legs. Laboratory studies show Hgb 9.2 g/dL, Hct 27.8%, MCV 91 fL, platelet count 101,000/microliter, and WBC count 12,128/microliter. A bone marrow biopsy is performed and on microscopic examination shows nearly 100% cellularity with replacement by primitive cells that have large nuclei with delicate chromatin and indistinct nucleoli with scanty cytoplasm. These cells mark for CD10 (CALLA) antigen. Which of the following is the most likely diagnosis? A B C Acute myeloid leukemia Hodgkin lymphoma Acute lymphoblastic leukemia

D E F

Epstein-Barr virus infection Leukemoid reaction Chronic lymphocytic leukemia


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Question 29 A 79-year-old woman has developed increasing dyspnea for the past 2 weeks. On physical examination she has diffuse rales in all lung fields. A CBC shows Hgb 7.1, Hct 22.2, MCV 93 fL, platelet count 205,000/microliter, and WBC count 6500/microliter with differential count of 60 segs, 4 bands, 25 lymphs, 9 monos, and 2 eos with 10 nucleated RBCs/100 WBCs. Which of the following is the most likely diagnosis? A B C D E Iron deficiency anemia Pernicious anemia Anemia of chronic disease Sickle cell anemia Hemolytic anemia
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Question 30 A 40-year-old man has had constant dull pain in his lower right back for the past 4 months. On physical examination there is tenderness on percussion of his right costovertebral angle. An abdominal CT scan reveals a 6 cm mass in the upper pole of the right kidney. A CBC shows: Hgb 21.3 g/dL, Hct 64.0%, MCV 96 fL,

platelet count 199,000/microliter, and WBC count 8230/microliter. Serum chemistries include sodium 141 mmol/L, potassium 4.3 mmol/L, chloride 102 mmol/L, CO2 25 mmol/L, glucose 77 mg/dL, urea nitrogen 18 mg/dL, and creatinine 1.3 mg/dL. Which of the following is the most likely diagnosis? A B C D E Polycythemia vera Erythroleukemia Hemophilia A Dehydration Increased erythropoietin
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Question 31 A 38-year-old woman has become increasingly fatigued for the past 3 months. During the past week she has noted purple blotches on her skin. On physical examination there are purpuric areas of skin on her trunk and extremities. She has no hepatosplenomegaly and no lymphadenopathy. Laboratory studies show Hgb 6.8 g/dL, Hct 20.7%, MCV 91 fL, platelet count 28,760/microliter, and WBC count 1940/microliter. Which of the following is the most likely diagnosis? A B C D E Aplastic anemia Chronic myelogenous leukemia Infectious mononucleosis Large B cell lymphoma Hereditary spherocytosis
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Question 32 A 45-year-old man has noted a change in the appearance of his face over the past 7 months. On physical examination his facial skin is thickened and reddened. A punch biopsy of skin is performed and on microscopic examination shows infiltration by neoplastic T lymphocytes. Which of the following is the most likely diagnosis? A B C D E Hodgkin lymphoma Mycosis fungoides Burkitt lymphoma Acute lymphocytic leukemia Hairy cell leukemia
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Question 33 A 49-year-old man has had increasing fatigue for the past 4 months. On physical examination he has massive splenomegaly but no lymphadenopathy. Laboratory studies show a Hgb of 10.1 g/dL, Hct 30.3%, MCV 90 fL, WBC count 1600/microliter, and platelet count 48,000/microliter. Examination of his peripheral blood smear shows increased numbers of peripheral blood lymphocytes containing tartrate-resistant acid phosphatase. Which of the following is the most likely diagnosis? A B C Chronic lymphocytic leukemia HTLV-1 infection with leukemia Hairy cell leukemia

D E

Gaucher disease Myelodysplasia


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Question 34 A 10-year-old girl has exhibited increasing sluggishness with poorer performance in school over the past year. She has not had increased numbers of infections. The child now complains of headaches. A physical examination shows no hepatosplenomegaly or lymphadenopathy. A CBC shows: Hgb 11.8 g/dL, Hct 33.9%, MCV 71 fL, platelet count 293,000/microliter, and WBC count 8160/microliter. Examination of her peripheral blood smear shows basophilic stippling of erythrocytes. The serum haptoglobin is 5 mg/dL. Which of the following laboratory test findings is most likely to be present in this girl A B C D E Hemoglobin S on electrophoresis Increased osmotic fragility Positive direct Coombs test Decreased serum iron Elevated free erythrocyte protoporphyrin
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Question 35 A 2-year-old boy has had a seborrheic eruption over the scalp and trunk over the past month. He then develops a right ear ache. On physical examination the right tympanic membrane is erythematous and bulging. He has hepatosplenomegaly and generalized lymphadenopathy. Laboratory studies show Hgb 9.5 g/dL, Hct 28.7%, MCV 90 fL, platelet count 58,000/microliter, and WBC count

3540/microliter. A bone marrow biopsy is performed and on microscopic examination shows 100% cellularity with extensive infiltration by cells resembling macrophages that express CD1a antigen and, by electron microscopy, have prominent HX bodies (Birbeck granules). Which of the following conditions is most likely to produce this boy's findings? A B C D E Myeloproliferative disorder Plasmodium vivax infection Hodgkin' disease, lymphocyte depletion type Langerhans cell histiocytosis AIDS
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Question 36 A 72-year-old woman has had increasing fatigue with a 3 kg weight loss over the past 7 months. Her hands become purple and painful upon exposure to cold. On physical examination she has a palpable spleen tip. Laboratory studies show Hgb 10.5 g/dL, Hct 31.7%, MCV 99 fL, platelet count 193,600/microliter, and WBC count 5390/microliter. The direct Coombs test is positive at 4 C and negative at 37 C. Which of the following underlying diseases is this woman most likely to have? A B C D E Non-Hodgkin lymphoma Systemic lupus erythematosus Pernicious anemia Scleroderma Thalassemia minor

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Question 37 A 12-year-old girl has the sudden onset of severe abdominal pain and back pain. On physical examination her abdomen is diffusely tender, but there are no masses. She is afebrile. A CBC shows Hgb 6.5 g/dL, Hct 19.0%, MCV 99 fL, platelet count 149,000/microliter, and WBC count 11,200/microliter. Examination of her peripheral blood smear shows nucleated RBCs and sickled RBCs. Which of the following gene mutations is she most likely to have? A B C D E F G Deletion Duplication Insertion Missense Nonsense Splice site Tandem repeat
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Question 38 A 32-year-old man has had worsening headaches for the past 2 months. On physical examination he is afebrile. He has no lymphadenopathy or hepatosplenomegaly. A head CT scan reveals a 3 cm mass lesion to the right of midline next to the lateral ventricle. A stereotaxic brain biopsy is performed and microscopic examination shows diffuse large B cell lymphoma. A bone marrow biopsy is performed and on microscopic examination shows slightly decreased cellularity of all cell lines. Which of the following laboratory test findings is this

patient most likely to have? A B C D E Elevated terminal deoxyribonucleodidyl transferase Bence-Jones proteinuria Elevated serum IgM HIV-1 RNA of 8000 copies/mL Lymphoma positive for tartrate-resistant acid phosphatase
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Question 39 A 28-year-old African-American woman has had worsening fatigue for the past 2 months. On physical examination she has an erythematous macular rash on her upper chest, forearms, and face. Laboratory studies show Hgb 9.2 g/dL, Hct 27.9%, MCV 101 fL, platelet count 179,000/microliter, and WBC count 5850/microliter. The red blood cell distribution width is markedly increased. Her peripheral blood smear shows polychromasia. Her reticulocyte count is 4.2%. The serum haptoglobin is 3 mg/dL. Serum chemistries show total protein 7.9 g/dL, albumin 3.8 g/dL, alkaline phosphatase 49 U/L, AST 81 U/L, ALT 27 U/L, total bilirubin 3.3 mg/dL, and direct bilirubin 0.8 mg/dL. Hemoglobinuria is detected on urinalysis. Which of the following underlying conditions is she most likely to have? A B C D E Multiple myeloma Systemic lupus erythematosus Hepatitis C infection Hereditary spherocytosis Vitamin B12 deficiency

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Question 40 A 37-year-old man known to be infected with HIV for the past 10 years has had abdominal pain for the past 3 days. Physical examination reveals abdominal distension with diffuse tenderness and absent bowel sounds. An abdominal CT scan reveals a mass lesion involving the small intestine. He is taken to surgery, and an area of bowel obstruction in the ileum is removed. Gross examination of the specimen shows a near-encircling firm white mass 10 cm long and 3 cm in greatest depth that infiltrates through the wall of the bowel. Which of the following neoplasms is this man most likely to have? A B C D E F Plasmacytoma Hodgkin lymphoma, lymphocyte predominant type High-grade B cell lymphoma Metastatic adenocarcinoma Myeloproliferative disorder Adenocarcinoma
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Question 41 A 20-year-old healthy man incurs blunt force trauma to the abdomen in a motor vehicle accident. On physical examination he has upper abdominal tenderness. An abdominal CT scan reveals a splenic hematoma. At laparotomy a splenectomy is performed. Following splenectomy, which of the following peripheral blood morphologic findings is most likely to be present? A Tear drop cells

B C D E

Elliptocytes Target cells Macro-ovalocytes RBC inclusions


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Question 42 A 10-year-old girl is noted to have increasing facial distortion for the past 8 months from a lesion involving her jaw. On physical examination she has a right mandibular mass. A biopsy is performed and on microscopic examination reveals a monotonous pattern of small non-cleaved lymphocytes. Infection with which of the following organisms is most likely to be associated with development of this girl's mass lesion? A B C D E F G Adenovirus Cytomegalovirus Epstein-Barr virus Hepatitis C virus Herpes simplex virus HIV HTLV-1
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Question 43 Two teenage siblings in the same family are noted to have frequent nosebleeds and easy bruising from even minor trauma. The girl has had menorrhagia since menarche. The girl's CBC shows Hgb 14 g/dL, Hct 42.3%, MCV 90 fL, platelet count 242,000/microliter, and WBC count 7720/microliter. Her prothrombin time is 12 seconds and partial thromboplastin time 25 seconds. Platelet function studies show decreased aggregation in response to ADP, collagen, epinephrine, and thrombin. Which of the following disorders are these siblings most likely to have? A B C D E Hemophilia A Antithrombin III deficiency Glanzmann thrombasthenia Systemic lupus erythematosus Von Willebrand disease
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Question 44 A 46-year-old man has been chronically fatigued for the past year. A physical examination yields no abnormal findings. A CBC shows: Hgb 10.8 g/dL, Hct 33.1%, MCV 104 fL, platelet count 239,000/microliter, and WBC count 7720/microliter. His peripheral blood smear shows normal WBC morphology and RBCs with mild poikilocytosis and a few target cells. His serum vitamin B12 is 512 pg/mL and folate 4.7 ng/mL. His serum haptoglobin is 151 mg/dL. Direct and indirect Coombs tests are negative. Which of the following underlying conditions is most likely to explain his findings? A B Chronic lymphocytic leukemia Peptic ulcer disease

C D E

Lead poisoning Chronic alcoholism Hereditary spherocytosis


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Question 45 A 59-year-old man has had back pain for the past 6 months. On physical examination his prostate is palpably enlarged and firm on digital rectal examination. Laboratory studies show his serum prostate specific antigen is 23 ng/mL. His CBC shows Hgb 9.4 g/dL, Hct 28.1%, MCV 89 fL, platelet count 135,000/microliter, and WBC count of 8800/microliter with WBC differential count of 61 segs, 15 bands, 14 lymphs, 5 monos, 3 metas, and 2 myelos with 4 NRBCs/100 WBCs. Which of the following is the most likely diagnosis? A B C D E Iron deficiency anemia Leukoerythroblastosis Acute myelogenous leukemia Disseminated intravascular coagulation Leukemoid reaction
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