<prompt> Please answer with one of the option in the bracket. Write reasoning in between . Write answer in between .Q:A 38-year-old woman comes to the physician for a follow-up examination. She was diagnosed with immune thrombocytopenic purpura at the age of 37 years and has been treated with glucocorticoids and intravenous immune globulin. She has visited the emergency department 3 times in the past 4 months for nose bleeds, which required cauterization. Her platelet counts on her previous visits were 18,320mm3, 17,500mm3, and 19,100mm3. Current medications include dexamethasone and a multivitamin. She has no children. Her immunizations are up-to-date. Vital signs are within normal limits. Examination shows petechiae on the bilateral lower extremities. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender; there is no organomegaly. Her hemoglobin concentration is 13.3 gdL, leukocyte count is 8,100mm3, and platelet count is 13,000mm3. Her blood type is A negative. Serology for hepatitis C and HIV is negative. Which of the following is the most appropriate next step in management?? A: Romiplostim therapy, B: Rituximab therapy, C: Danazol therapy, D: Observation and follow-up, E: Schedule splenectomy,  <response>: This is a question about the management of a patient with immune thrombocytopenic purpura ITP. The key findings in the patient are:- 38 year old woman diagnosed with ITP 1 year ago- Treated with glucocorticoids and IVIG but still having low platelet counts - Has had multiple episodes of severe nosebleeds requiring cauterization - Current platelet count is 13,000mm3 - No evidence of other autoimmune disorders or infections like hepatitis CHIVThe answer choices include different medical therapies like romiplostim, rituximab, danazol as well as observation or splenectomy. To choose the best next step, we need to consider guidelines on managing refractory ITP. Splenectomy is usually recommended for patients who do not respond adequately to medical therapy and are at high risk of bleeding. Since this patient has very low platelet counts and recurrent severe bleeding episodes, splenectomy would be the most appropriate next step.E: Schedule splenectomy 