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Retired NBME 22 Answers

nbme22/Block 3/Question#40 (reveal difficulty score)
A 49-year-old man has had the gradual onset ...
Essential thrombocythemia ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
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 +13  upvote downvote
submitted by โˆ—link981(208)
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Per First Aid 2018 (pg 421) & Merck Manual

a) CML is not the answer because in CML you have HIGH WBCs & Platelets. In the stem there is only high platelets. b) Is the answer because in Essential Thrombocythemia we have normal WBCs and RBCs, just high platelets. c) Myeloid metaplasia refers to well a metaplasia in myeloid cells which are basophils, eosinophils, etc. d) In Polycythemia Vera we have HIGH RBCs, WBCs, and Platelets. e) Reactive thrombocytosis- is a elevated platelet count that occurs secondary to another disorder like:

-Chronic inflammatory disorders (eg, rheumatoid arthritis, inflammatory bowel disease, tuberculosis, sarcoidosis, granulomatosis with polyangiitis) -Acute infection

-Hemorrhage

-Iron deficiency

-Hemolysis

-Cancer

-Splenectomy or hyposplenism

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impostersyndromel1000  perfect response right here +
paloma  Essential thrombocythemia presents with platelets > 1 million, not reactive thrombocytosis +2



 +5  upvote downvote
submitted by โˆ—lola915(57)
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Just want to add that the pale, blue mottled finger is a symptom of essential thrombocythemia called erythromelalgia. Also a symptom in Polycythemia Vera but this dudes erythrocyte count is normal.

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madamestep  erythromelalgia is red swelling, pain, and heat seen with polycythemia most commonly and sometimes with ET. An index finger being mottled blue and pale is describing Raynauds, which you can also see with ET. +1
drdoom  @madamestep Is there a source for your second statement? Please add if possible! thx! +
madamestep  "Erythromelalgia is found in 6% of cases, and livedo reticularis, minor bleeding, acrocyanosis, and Raynaud's phenomenon are rare manifestations." https://pubmed.ncbi.nlm.nih.gov/26432058/ I'm thinking also that they could also be describing peripheral cyanosis (acrocyanosis). But definitely not erythromelalgia. +



 +3  upvote downvote
submitted by โˆ—bubbles(79)
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Take a look at that massive platelet count -- over a million per mm3! That should point you towards a myeloproliferative disorder of some sort since this fella isn't bleeding out as far as we can tell from the blood panel (which would put reactive thrombocytosis on the ddx).

Now let's look at those erythrocytes. Normal -- so it's not polycythemia vera, and considering the lack of leukocytosis, probably not CML or myeloid metaplasia.

So our answer must be essential thrombocythemia!

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 +2  upvote downvote
submitted by โˆ—haliburton(224)
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FA 2017: Characterized by massive proliferation of megakaryocytes and platelets. Symptoms include bleeding and thrombosis. Blood smear shows markedly increased number of platelets, which may be large or otherwise abnormally formed. Erythromelalgia may occur.

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 +1  upvote downvote
submitted by djinn(6)
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Essential thromcythemia is a neoplastic proliferation of mature myeloid cells, especially platelets.

High neutrophils and eosinophils

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 +0  upvote downvote
submitted by โˆ—peterngo1994(1)
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The thing that threw me of was the 74% neutrophil count. Does anyone have an explanation for this?

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drdoom  Neutrophil count is different than neutrophil percentage (%). Percentages can be influenced by changes in volume, e.g., if the patient is dehydrated, percentage by volume can be skewed. +



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