Question 1

A 62-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 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   Scattered small granulomas

B   Nodules of small mature lymphocytes

C   Occasional Reed-Sternberg cells

D   Numerous plasma cells

E   Hypercellularity with many blasts

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 non-tender cervical and supraclavicular lymphadenopathy. A cervical lymph node biopsy is performed. On

microscopic examination at high magnification there are occasional CD15+ and CD30+ Reed-Sternberg cells along with large and small

lymphocytes and bands of fibrosis. Which of the following is the most likely diagnosis?

A   Burkitt lymphoma

B   Hodgkin lymphoma

C   Cat scratch disease

D   Mycosis fungoides

E   Multiple myeloma

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. The spleen is palpable. 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   Congenital genetic abnormality

B   From close contact on a date

C   As a result of an insect bite

D   Through an environmental exposure at work

E   Without any known etiology

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   Bone marrow karyotype of 46, XY, t(9;22)

B   Serologic titer of 1:1024 for anti-double stranded DNA

C   Serum vitamin B12 level of 100 pg/mL

D   4+ ketonuria and 4+ proteinuria

E   Blood culture positive for Streptococcus, viridans group

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 only in the study group following

splenectomy?

A   Thrombocytopenia

B   RBC Howell-Jolly bodies

C   Decreased RBC distribution width

D   Leukopenia

E   Nucleated RBCs

Question 6

A 30-year-old man has had a sore throat with fever for 5 days. On physical examination he has mildly tender generalized cervical

lymphadenopathy. Laboratory findings include Hgb 13 g/dL, platelet count 277,000/microliter, and WBC count 12,670/microliter with

differential count of 75 segs, 10 bands, and 15 lymphs Which of the following is the most likely diagnosis?

A   Lymphocytic lymphoma

B   Hodgkin lymphoma

C   Group A Streptococcus infection

D   Human immunodeficiency virus infection

E   Brucellosis

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   Leukemoid reaction

B   Acute myelogenous leukemia

C   Chronic lymphocytic leukemia

D   Lymphoblastic leukemia

E   Leukoerythroblastosis

Question 8

A 68-year-old man has had malaise for the past 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   Diverticulosis

B   Hepatitis C infection

C   Systemic lupus erythematosus

D   Atrophic gastritis

E   Fanconi anemia

Question 9

A 69-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 87 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 nodules of

small, monomorphic lymphocytes. Which of the following is the most likely diagnosis?

A   Chronic lymphocytic leukemia

B   Follicular lymphoma

C   Infectious mononucleosis

D   Hodgkin lymphoma, lymphocyte predominance type

E   Reactive hyperplasia

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. Laboratory data include Hgb 9 g/dL, WBC count 5,000/microliter, and platelet count

50,000/microliter. Which of the following underlying conditions is he most likely to have?

A   Myelofibrosis

B   Sickle cell anemia

C   Portal hypertension

D   Infectious mononucleosis

E   Hemochromatosis

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 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   Metastatic carcinoma

B   Chronic alcoholism

C   Malabsorption

D   Hemoglobinopathy

E   Chronic blood loss

F   Systemic lupus erythematosus

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 22/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 prothrombin time,

partial thromboplastin time, and D-dimer are not elevated. Which of the following is the most likely diagnosis?

A   Disseminated intravascular coagulopathy

B   Idiopathic thrombocytopenic purpura

C   Thrombotic thrombocytopenic purpura

D   Trousseau syndrome

E   Warm autoimmune hemolytic anemia

Question 13

For the past 4 months, a 62-year-old previously healthy man has noted increasing fatigue and shortness of breath with minimal

exercise. He has felt some abdominal discomfort over the past month. On physical examination he has non-tender cervical

lymphadenopathy. The liver span is 15 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   Leukemoid reaction

B   Chronic myelogenous leukemia

C   Acute myelogenous leukemia

D   Acute lymphocytic leukemia

E   Chronic lymphocytic leukemia

F   Systemic lupus erythematosus

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   G6PD deficiency

B   Beta-thalassemia

C   Sickle cell anemia

D   Hereditary spherocytosis

E   Malaria

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  Idiopathic thrombocytopenic purpura

C  Disseminated intravascular coagulation

D  Drug-induced thrombocytopenia

E  Thrombotic-thrombocytopenic purpura

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 very low. A bone marrow biopsy is

performed. Which of the following microscopic findings is most likely to be found in this biopsy?

A   Sheets of plasma cells

B   Atypical cytokeratin positive glands

C   Numerous mature and immature myeloid cells

D   Predominance of adipocytes

E   Granulomas that have many acid fast bacilli

Question 17

A 29-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   Quinacrine use

B   Parvovirus infection

C   Decreased oxygen tension

D   Exposure to cold

E   Transfusion therapy

Question 18

A 55-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 risk factors most

likely preceded development of his current illness?

A   Malaria

B   Infectious mononucleosis

C   Diabetes mellitus

D   Beta-thalassemia

E   Myelodysplasia

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   Epstein-Barr virus infection

B   Myeloproliferative disorder

C   Drug reaction to recent antibiotic therapy

D   Wiskott-Aldrich syndrome

E   Megaloblastic anemia

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   G6PD deficiency

B   Autoimmune hemolytic anemia

C   Macrocytic anemia

D   Aplastic anemia

E   Microcytic anemia

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   Beta-thalassemia

B   Sickle cell anemia

C   Alpha-thalassemia

D   Hereditary spherocytosis

E   G6PD deficiency

Question 22

A study is conducted to determine what changes in the size of the spleen take place with hematologic disorders. The spleen sizes are

estimated from CT scans for adult patients who developed complications of their hematologic disease. For which of the following

diseases is the spleen most likely to remain normal in size?

A   Autoimmune hemolytic anemia

B   Chronic alcohol abuse

C   Myeloproliferative disorder

D   Idiopathic thrombocytopenic purpura

E   Sickle cell anemia

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   Hypersegmented neutrophils

B   Nucleated red blood cells

C   Blasts with Auer rods

D   Hypochromic, microcytic RBC's

E   Schistocytes

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   Fragmentation

B   Many nucleated forms

C   Hypochromasia

D   Spherocytosis

E   Howell-Jolly bodies

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   Sickle cell anemia

B   Alpha-thalassemia

C   Hemoglobin E disease

D   G6PD deficiency

E   Hereditary elliptocytosis

Question 26

A 46-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 830 ng/mL. Which of the following is the most likely diagnosis?

A   Beta-thalassemia

B   Autoimmune hemolytic anemia

C   Anemia of chronic disease

D   Polycythemia vera

E   Pernicious anemia

F   Hereditary hemochromatosis

Question 27

A 52-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. Which of the following laboratory

test findings is most likely to be present in this man?

A   High leukocyte alkaline phosphatase

B   Karyotype with 46, XY, t(9;22)

C   Monoclonal gammopathy

D   Elevated D-dimer

E   Positive TdT assay

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   Acute myeloid leukemia

B   Hodgkin lymphoma

C   Acute lymphoblastic leukemia

D   Epstein-Barr virus infection

E   Chronic myelogenous leukemia

F   Chronic lymphocytic leukemia

Question 29

A 78-year-old woman has developed increasing dyspnea for the past 2 weeks. On physical examination she has diffuse rales in all lung

fields. Scleral icterus is noted. 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   Iron deficiency anemia

B   Pernicious anemia

C   Anemia of chronic disease

D   Sickle cell anemia

E   Hemolytic anemia

Question 30

A 53-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 glucose 77 mg/dL, urea nitrogen 17 mg/dL, and creatinine 1.1 mg/dL. Which of the following is the most likely cause

for his findings?

A   Polycythemia rubra vera

B   Erythroleukemia

C   Hemophilia A

D   Diabetes insipidus

E   Increased erythropoietin

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   Aplastic anemia

B   Myeloproliferative disorder

C   Immune thrombocytopenic purpura

D   Large B cell lymphoma

E   Hereditary spherocytosis

Question 32

A 44-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 that are CD4 positive. Which of the following is the most likely diagnosis?

A   Hodgkin lymphoma

B   Mycosis fungoides

C   Burkitt lymphoma

D   Acute lymphocytic leukemia

E   Hairy cell leukemia

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   Chronic lymphocytic leukemia

B   HTLV-1 infection with leukemia

C   Hairy cell leukemia

D   Gaucher disease

E   Myelodysplasia

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   Hemoglobin S on electrophoresis

B   Increased osmotic fragility

C   Positive direct Coombs test

D   Decreased serum iron

E   Elevated free erythrocyte protoporphyrin

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   Myeloproliferative disorder

B   Plasmodium vivax infection

C   Hodgkin lymphoma, lymphocyte depletion type

D   Langerhans cell histiocytosis

E   AIDS

Question 36

A 73-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   Non-Hodgkin lymphoma

B   Systemic lupus erythematosus

C   Pernicious anemia

D   Scleroderma

E   Thalassemia minor

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 types of gene mutation is she most likely to have?

A   Deletion

B   Duplication

C   Insertion

D   Missense

E   Nonsense

F   Splice site

G   Tandem repeat

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. Laboratory studies shows Hgb 12 g/dL, platelet count 250,000/microliter, and WBC count

6000/microliter with differential count of 80% granulocytes, 10% lymphocytes, and 10% monocytes. 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. Which of the following laboratory test findings is this patient most likely to have?

A   Elevated terminal deoxyribonucleodidyl transferase

B   Bence-Jones proteinuria

C   Elevated serum IgM

D   HIV-1 RNA of 80,000 copies/mL

E   Lymphoma positive for tartrate-resistant acid phosphatase

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   Multiple myeloma

B   Systemic lupus erythematosus

C   Hepatitis C infection

D   Hereditary spherocytosis

E   Vitamin B12 deficiency

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   Plasmacytoma

B   Hodgkin lymphoma, lymphocyte predominant type

C   High-grade B cell lymphoma

D   Metastatic adenocarcinoma

E   Myeloproliferative disorder

F   Adenocarcinoma

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   Elliptocytes

C   Target cells

D   Macro-ovalocytes

E   RBC inclusions

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. Cytogenetic analysis of these cells shows t(8;14). Infection with which of the following organisms is

most likely to be associated with development of this girl's mass lesion?

A   Adenovirus

B   Cytomegalovirus

C   Epstein-Barr virus

D   Hepatitis C virus

E   Herpes simplex virus

F   HIV

G   HTLV-1

Question 43

Two teenage siblings in the same family are noted to have frequent nosebleeds and easy bruising from even minor trauma. Both have

had menorrhagia since menarche. One 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   Hemophilia A

B   Antithrombin III deficiency

C   Glanzmann thrombasthenia

D   Systemic lupus erythematosus

E   Von Willebrand disease

Question 44

A 47-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   Chronic lymphocytic leukemia

B   Peptic ulcer disease

C   Lead poisoning

D   Chronic alcohol abuse

E   Hereditary spherocytosis

Question 45

A 42-year-old man has had multiple episodes of painful red nodules on his skin from dermal venous thrombosis, as well as abdominal

pain from mesenteric vein thrombosis over the past year. He notes passing darker urine. Laboratory studies show Hgb 9.4 g/dL, Hct

29.2%, MCV 100 fL, platelet count 215,000/microliter, and WBC count of 8800/microliter. His RBCs show increased sensitivity to

complement lysis. Flow cytometry is most likely to show reduction in which of the following markers on his RBCs?

A   CD4

B   CD19

C   CD33

D   CD55

E   CD68