A 73-year-old woman with DVT, platelet drop to 74,000 on heparin. Best next step?

Correct Answer: C

Rationale: The correct answer is C: Keep in hospital, discontinue heparin, start lepirudin. In this scenario, the patient has heparin-induced thrombocytopenia (HIT) with a platelet drop and is at risk for thrombosis. Lepirudin, a direct thrombin inhibitor, is the preferred anticoagulant in HIT. Dismissing on heparin and warfarin (choice A) is not appropriate due to HIT. Discontinuing heparin and adding aspirin (choice B) is not sufficient in managing HIT. Adding low-molecular-weight heparin (choice D) may worsen the thrombocytopenia.

Correct Answer: D

Rationale: The correct answer is D: Migratory thrombophlebitis. In a patient with a pancreatic mass and weight loss, migratory thrombophlebitis, also known as Trousseau syndrome, is a paraneoplastic syndrome commonly associated with pancreatic adenocarcinoma. This syndrome results from the release of procoagulant substances by the tumor, leading to migratory superficial thrombophlebitis. The other choices are not typically associated with pancreatic cancer. A: Hypercalcemia is more commonly seen in hyperparathyroidism or certain types of cancer. B: SIADH is commonly associated with small cell lung cancer. C: Hypoglycemia is seen in pancreatic insulinomas, not pancreatic adenocarcinoma.

Correct Answer: B

Rationale: The correct answer is B because applying cold packs can worsen vaso-occlusive crisis by causing vasoconstriction and increasing pain. Cold can exacerbate sickling of red blood cells. Immediate intervention is necessary to prevent further harm. Option A is not urgent during a crisis. Option C may be appropriate for infection control but is not the most critical action. Option D is important but not as urgent as avoiding cold packs.

Correct Answer: C

Rationale: The correct answer is C: Abdominal pain with palpation. After a splenectomy, patients are at risk for splenic complications such as splenic infarction or abscess. Abdominal pain with palpation could indicate an emergency situation requiring immediate medical attention to rule out these complications. Unprotected sex (A) is not the most immediate concern in this scenario. Temp of 100°F (B) may not be directly related to post-splenectomy complications. Occasional marijuana use (D) is not an immediate concern post-splenectomy.

Correct Answer: C

Rationale: The correct answer is C: Hb-F. Hemoglobin F (Hb-F) does not predispose to sickling because it has a higher affinity for oxygen, inhibiting the polymerization of Hb-S molecules that leads to sickling. Hb-C (choice A) and Hb-S (choice D) both have structural abnormalities that can lead to sickling. Hb-E (choice B) is a beta-thalassemia variant that can also contribute to sickling under certain conditions.