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USMLE 2CK Practice Question for May 11th

A 40-year-old woman is admitted to the hospital because of fever, headache, confusion, and jaundice for one week. She underwent hysterectomy two months ago and began estrogen replacement therapy with ethinyl estradiol and a progestin. On admission, her temperature is 38.7°C (102°F), pulse is 98/min, respirations are 20/min, and blood pressure is 140/90 mm Hg. She is disoriented to time and place. Physical examination reveals jaundiced sclerae and skin, purpura on the trunk, and bleeding gums. A stool guaiac test is positive for occult blood. Blood and urine cultures are negative, but urinalysis reveals hemoglobinuria. Laboratory studies show:

Hematocrit 28%
Red blood cells 2.5 million/mm3
Leukocytes 10,000/mm3
Platelets 15,000/mm3
BUN 40 mg/dL
Creatinine 2.8 mg/dL
LDH 800 U/L
Bilirubin
Total 4.0 mg/dL
Direct 0.8 mg/dL

Coagulation tests are within normal limits; fibrin-split products and Coombs test are negative. A peripheral blood smear shows schistocytes. Which of the following is the most likely diagnosis?

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