35-year-old man is brought to the emergency department by his roommate, who says that he has been acting
“weird” for the past 2 days. The patient has spent most of the time in his room and has not been eating much. He
has no headaches, focal weakness, or sensory symptoms. His medical history is significant for untreated HIV and
hepatitis C infections. Temperature is 37.9 C (100.2 F), blood pressure is 140/86 mm Hg, pulse is 96/min, and
respirations are 16/min. Mild scleral icterus is present. The oropharynx is normal and there is no nuchal rigidity.
Examination of the chest and abdomen are unremarkable. Neurologic examination reveals no focal deficits.
Laboratory results are as follows
Complete blood count
Hemoglobin 7.6 g/dL
Mean corpuscular volume 85 μm3
Reticulocytes 8.1 %
Platelets 45,000/mm3
Leukocytes 4500/mm3
Serum chemistry
Blood urea nitrogen 30 mg/dL
Creatinine 2.2 mg/dl
Calcium 9.4 mg/dl
Glucose 98 mg/dl
Total bilirubin 3.2 mg/dl
Indirect bilirubin 2.2 mg/dl
Alkaline phosphatase 108 U/L
Aspartate aminotransferase 62 U/L
Alanine aminotransferase 64 U/L
A CT scan of the head with and without contrast reveals no abnormalities. Which of the following is the most
appropriate next step in the management of this patient?
- Q A. Bone marrow biopsy
- 0 B. Flow cytometry of peripheral blood
- 0 C. Liver biopsy
- 0 D. Peripheral blood smear
- 0 E. Right upper quadrant ultrasound
0 voters