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Old 07-14-2014
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Default NBME 6 - question help (don't open if u plan to do nbme 6)

A 47-year-old man comes to the physician because of fever and chills for 1 day. He has a 20-year history of alcoholism and cirrhosis of the liver. One month ago, he underwent evacuation of a subdural hematoma. His postoperative course was complicated by generalized tonic-clonic seizures; he has been receiving carbamazepine therapy since then. He continues to drink 12 beers daily. His temperature is 38.9C (102F), and blood pressure is 120/80 mm Hg. Examination shows scleral icterus, ascites, and splenomegaly. Laboratory studies show:
Hematocrit 39%
Mean corpuscular volume 102 μm3
Leukocyte count 1200/mm3
Segmented neutrophils 6%
Eosinophils 1%
Basophils 1%
Lymphocytes 80%
Monocytes 12%
Platelet count 210,000/mm3

Which of the following is the most likely cause of this patient's decreased leukocyte count?

A) Carbamazepine therapy

B) Folic acid deficiency

C) Hypersplenism

D) Sepsis

E) Suppression of bone marrow by alcohol
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Old 07-14-2014
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Guy's developed fever and if you look at the WBC count, the picture looks more like a neutropenic one, specially with the numbers provided. Total WBC count is given as 1200 and 6% of neutrophils would make around 72 neutrophil, which is way below into the neutropenic level. Given the Hx of carbamazepine use in the stem, things start to make sense. Carbamazepine and Phenytoin are notorious for bone marrow suppression.
Regarding other options provided, Sepsis can be ruled out given the BP is in the normal range (Sepsis would give more of a HYPOTENSIVE picture). Hypersplenism can cause Thrombocytopenia, not neutropenia in particular. Alcohol is not known for such levels of bone marrow suppression targetting only neutrophils. Folic Acid deficiency can be seen with Phenytoin use, not carbamezipine. Moreover, Folic acid deficiency gives more of an anemic picture with a patient coming in with main complants of fatigue.

Last edited by usmleqx; 07-14-2014 at 08:36 AM.
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The above post was thanked by:
exudate (07-14-2014), HopefulIMG (11-18-2016), hrid112 (09-24-2014), nakeya52 (07-05-2017)


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