MSN 621 FINAL EXAM ACTUAL QUESTIONS AND
SOLUTIONS RATED A+
✔✔A 67-year-old female with a performance status of 0, is brought to the clinic with
symptomatic anemia and has required several transfusions over the past 2 to 3 months.
Currently, her hemoglobin is 7.5 g/dL, absolute neutrophil count 1500/microL and
platelet count is 119,000/microL. She had a bone marrow biopsy performed that reveals
myelodysplastic syndrome (MDS) with 6% blasts and cytogenetics positive for 5q
deletion. She did not have any mutations or other cytogenetic abnormalities. Which of
the following is the best initial course of treatment? - ✔✔A thalidomide derivative
✔✔A 36-year-old woman with a past medical history significant for menorrhagia from
uterine fibroids presents with exertional dyspnea and fatigue. Examination shows
conjunctival pallor. Laboratory tests reveal a hemoglobin of 6.2 grams/dL, mean
corpuscular volume (MCV) 60 fl (normal: 80-100 fl), and normal liver function tests.
What is the most likely diagnosis? - ✔✔Iron deficiency anemia
✔✔A 59-year-old male patient with a history of non-Hodgkins lymphoma treated with
cyclophosphamide, adriamycin, vincristine, and prednisone eight years ago presents
with a new diagnosis of myelodysplastic syndrome. Bone marrow biopsy reveals 12%
blasts and greater than 10% dysplasia in the erythroid and granulocytic lineages.
Fluorescence in situ hybridization (FISH) revealed monosomy 7. He asks you about the
risk of transformation into acute myeloid leukemia (AML). What is the risk of treatment-
related myelodysplastic syndrome transforming into AML - ✔✔50% of patients will
transform into AML
✔✔A 45-year-old asymptomatic man is found to have leukocytosis on a preoperative
complete blood count. His physical examination is significant for the spleen tip being
palpable 2 cm below the left costal margin. Enlarged, rubbery, nontender lymph nodes
up to 1.5 cm in size are present in the axillae and inguinal regions. Laboratory workup
reveals a hemoglobin of 13.3 g/dL, leukocytes 40,000/microliter, and platelets
238,000/microliter. His peripheral blood smear shows mature lymphocytes with smudge
cells. If he fails first-line therapy, which of the following cytogenetic changes would be
an indication for stem cell transplant in this patient? - ✔✔17p deletion
✔✔A 60-year-old asymptomatic man is found to have leukocytosis on a preoperative
CBC. Physical examination shows the spleen tip to be palpable 2 cm below the left
costal margin. Rubbery, nontender lymph nodes up to 1.5 cm in size are present in the
axillae and inguinal regions. Laboratory data include the following: Hgb: 13.3 g/dL
(normal 14 to 18) Leukocytes: 40,000/microL (normal 4300 to 10,800) Platelet count:
238,000 (normal 150,000 to 400,000) His peripheral blood smear is shown in the
accompanying photo. Which of the following is the most likely diagnosis? (see photo) -
✔✔Chronic lymphocytic leukemia
,✔✔A 65-year-old female with renal cancer presents with dyspnea, fatigue, and
dizziness. She is on warfarin to treat a left leg deep vein thrombosis. Her hematocrit is
22%, hemoglobin is 7.1 g/dL, platelets 109,000/mL, PT 1.3, PTT 36, INR 1.45, and
WBC 12,000 mm3. What is the next step in the management of the patient? -
✔✔Transfuse packed red blood cells
✔✔A 67-year-old female presents with a history of high fevers and productive cough
with green sputum for the last three days. The patient received the influenza vaccine
this year. Her past medical history is unremarkable. She has a smoking history of 25
pack years. She does not drink alcohol or use illicit drugs. Temperature is 102F, blood
pressure is 115/70mmHg, the pulse is 101/min, and respirations are 23/min. Her oxygen
saturation is 91% on room air. On examination, her anterior cervical lymph nodes are
enlarged and nontender. Chest auscultation reveals crackles in the left lower lobe.
Hepatosplenomegaly is present. A chest x-ray shows a developing left lower lobe
consolidation. Labs show a WBC count of 45000, with lymphocytes being 85%.
Empirical pharmacotherapy is initiated, and blood cultures are sent to the lab. Which of
the following is the most appropriate step next? - ✔✔Flow cytometry of blood
✔✔A 49-year-old male with fatigue and easy bruising is found to have terminal
deoxynucleotidyl transferase (TdT) positive cells in the blood. He may have which of the
following conditions - ✔✔Acute lymphoblastic leukemia
✔✔Which of the following is associated with the CD10 antigen? - ✔✔Acute lymphocytic
leukemia
✔✔A 16-year-old patient presents because she believes she was bitten by a tick while
hiking in the woods a few days ago. She mentions swelling in her right ear and general
malaise. On exam, she has a 1 x 2 cm bluish-red nodule on the right ear lobe. What is
the next best step in management for this patient? - ✔✔lyme serology
✔✔A 26-year-old male comes to the emergency department complaining of fatigue,
dyspnea, chest pain, and syncope, especially when playing soccer. This has been going
on for the past 2 weeks. He has no significant past medical history. He denies smoking,
caffeine intake, tinnitus, vomiting, or coughing. He has been taking NSAIDs regularly for
the past year due to headaches that he attributes to "being stressed out from my new
job." On examination, BP: 120/81 mmHg, HR: 55 bpm, RR: 18/min, and O2: 99% on
room air. Skin examination: no rashes, abdominal examination: mild epigastric
tenderness but no organomegaly, chest examination: equal air entry bilaterally with no
abnormal sounds. ECG shows P waves and QRS complexes that are independent of
each other. Blood tests show antibodies to the organism in the picture. Which of the
following is the most appropriate treatment for this patient's case? (see photo) -
✔✔Hospitalization for close monitoring with telemetry and IV ceftriaxone
, ✔✔An adolescent presents to you with sore throat, fever, lymphadenopathy, and
splenomegaly. He also complains of headache but has been previously well. Which
should be done? - ✔✔Treat symptomatically
✔✔A healthy 17-year-old male presents with three days of worsening fatigue,
rhinorrhea, nasal congestion, myalgias, and subjective fever. He is severely allergic to
eggs and therefore does not receive the annual influenza vaccine. His blood pressure is
125/75 mmHg, pulse 100 beats per minute, temperature 100 F (37.7 C), and respiratory
rate 18 breaths per minute. Examination demonstrates conjunctivitis, oropharyngeal
erythema, and clear breath sounds. Given the likely diagnosis, what is the most
appropriate treatment? - ✔✔Symptomatic treatment only
✔✔A 33-year-old inmate is brought to the clinic for a routine annual checkup. The
patient says that he has been in good health and does not have any medical problems.
He, however, does complain of disturbed sleep, constipation, and weight loss. A review
of systems is negative for cough, shortness of breath, burning urination, abdominal
discomfort, or weakness. Examination shows normal vitals, a soft, nontender abdomen
with no organomegaly, normal S1 and S2 with no added sounds, and normal bronchial
breathing bilaterally. A purified protein derivative test shows an induration of 11 mm.
What is the next best step in the management of this patient? - ✔✔Chest x-ray
✔✔A 16-year-old patient presents to the hospital with fever, fatigue, lymphadenopathy,
and sore throat. Exudative pharyngitis is noted on the throat examination. However,
rapid strep testing is negative. His blood pressure is 135/85 mmHg, the pulse rate is
92/min regular, and his respiratory rate is 16/min. Past medical history is positive for
asthma, and his father had leukemia. Social history is notable for being involved in
multiple school sporting activities. What is the most appropriate piece of advice for this
patient? - ✔✔Avoid contact sports for a minimum of 6 weeks
✔✔A 38-year-old man presents with numbness and tingling in his extremities for the
past week. He says his hands have been feeling unusual, and that this interferes with
his sleep. He has no muscle weakness or memory impairment. His past medical history
includes pulmonary tuberculosis, for which he takes isoniazid, rifampin, pyrazinamide,
and ethambutol. All his vital signs are within normal limits. Examination reveals
diminished breath sounds in the left upper lobe. A chest x-ray shows a cavitating lesion
in the left lung. What is the most appropriate next step in the management of this
patient? - ✔✔Add pyridoxine
✔✔A female presents with progressive confusion over weeks with memory loss. She
has a slight fever at 100.4 F. Prior to cognitive changes, she had been complaining of
arthralgias. History is otherwise unremarkable except for the fact she is an avid camper.
What is her most likely diagnosis? - ✔✔Lyme disease
SOLUTIONS RATED A+
✔✔A 67-year-old female with a performance status of 0, is brought to the clinic with
symptomatic anemia and has required several transfusions over the past 2 to 3 months.
Currently, her hemoglobin is 7.5 g/dL, absolute neutrophil count 1500/microL and
platelet count is 119,000/microL. She had a bone marrow biopsy performed that reveals
myelodysplastic syndrome (MDS) with 6% blasts and cytogenetics positive for 5q
deletion. She did not have any mutations or other cytogenetic abnormalities. Which of
the following is the best initial course of treatment? - ✔✔A thalidomide derivative
✔✔A 36-year-old woman with a past medical history significant for menorrhagia from
uterine fibroids presents with exertional dyspnea and fatigue. Examination shows
conjunctival pallor. Laboratory tests reveal a hemoglobin of 6.2 grams/dL, mean
corpuscular volume (MCV) 60 fl (normal: 80-100 fl), and normal liver function tests.
What is the most likely diagnosis? - ✔✔Iron deficiency anemia
✔✔A 59-year-old male patient with a history of non-Hodgkins lymphoma treated with
cyclophosphamide, adriamycin, vincristine, and prednisone eight years ago presents
with a new diagnosis of myelodysplastic syndrome. Bone marrow biopsy reveals 12%
blasts and greater than 10% dysplasia in the erythroid and granulocytic lineages.
Fluorescence in situ hybridization (FISH) revealed monosomy 7. He asks you about the
risk of transformation into acute myeloid leukemia (AML). What is the risk of treatment-
related myelodysplastic syndrome transforming into AML - ✔✔50% of patients will
transform into AML
✔✔A 45-year-old asymptomatic man is found to have leukocytosis on a preoperative
complete blood count. His physical examination is significant for the spleen tip being
palpable 2 cm below the left costal margin. Enlarged, rubbery, nontender lymph nodes
up to 1.5 cm in size are present in the axillae and inguinal regions. Laboratory workup
reveals a hemoglobin of 13.3 g/dL, leukocytes 40,000/microliter, and platelets
238,000/microliter. His peripheral blood smear shows mature lymphocytes with smudge
cells. If he fails first-line therapy, which of the following cytogenetic changes would be
an indication for stem cell transplant in this patient? - ✔✔17p deletion
✔✔A 60-year-old asymptomatic man is found to have leukocytosis on a preoperative
CBC. Physical examination shows the spleen tip to be palpable 2 cm below the left
costal margin. Rubbery, nontender lymph nodes up to 1.5 cm in size are present in the
axillae and inguinal regions. Laboratory data include the following: Hgb: 13.3 g/dL
(normal 14 to 18) Leukocytes: 40,000/microL (normal 4300 to 10,800) Platelet count:
238,000 (normal 150,000 to 400,000) His peripheral blood smear is shown in the
accompanying photo. Which of the following is the most likely diagnosis? (see photo) -
✔✔Chronic lymphocytic leukemia
,✔✔A 65-year-old female with renal cancer presents with dyspnea, fatigue, and
dizziness. She is on warfarin to treat a left leg deep vein thrombosis. Her hematocrit is
22%, hemoglobin is 7.1 g/dL, platelets 109,000/mL, PT 1.3, PTT 36, INR 1.45, and
WBC 12,000 mm3. What is the next step in the management of the patient? -
✔✔Transfuse packed red blood cells
✔✔A 67-year-old female presents with a history of high fevers and productive cough
with green sputum for the last three days. The patient received the influenza vaccine
this year. Her past medical history is unremarkable. She has a smoking history of 25
pack years. She does not drink alcohol or use illicit drugs. Temperature is 102F, blood
pressure is 115/70mmHg, the pulse is 101/min, and respirations are 23/min. Her oxygen
saturation is 91% on room air. On examination, her anterior cervical lymph nodes are
enlarged and nontender. Chest auscultation reveals crackles in the left lower lobe.
Hepatosplenomegaly is present. A chest x-ray shows a developing left lower lobe
consolidation. Labs show a WBC count of 45000, with lymphocytes being 85%.
Empirical pharmacotherapy is initiated, and blood cultures are sent to the lab. Which of
the following is the most appropriate step next? - ✔✔Flow cytometry of blood
✔✔A 49-year-old male with fatigue and easy bruising is found to have terminal
deoxynucleotidyl transferase (TdT) positive cells in the blood. He may have which of the
following conditions - ✔✔Acute lymphoblastic leukemia
✔✔Which of the following is associated with the CD10 antigen? - ✔✔Acute lymphocytic
leukemia
✔✔A 16-year-old patient presents because she believes she was bitten by a tick while
hiking in the woods a few days ago. She mentions swelling in her right ear and general
malaise. On exam, she has a 1 x 2 cm bluish-red nodule on the right ear lobe. What is
the next best step in management for this patient? - ✔✔lyme serology
✔✔A 26-year-old male comes to the emergency department complaining of fatigue,
dyspnea, chest pain, and syncope, especially when playing soccer. This has been going
on for the past 2 weeks. He has no significant past medical history. He denies smoking,
caffeine intake, tinnitus, vomiting, or coughing. He has been taking NSAIDs regularly for
the past year due to headaches that he attributes to "being stressed out from my new
job." On examination, BP: 120/81 mmHg, HR: 55 bpm, RR: 18/min, and O2: 99% on
room air. Skin examination: no rashes, abdominal examination: mild epigastric
tenderness but no organomegaly, chest examination: equal air entry bilaterally with no
abnormal sounds. ECG shows P waves and QRS complexes that are independent of
each other. Blood tests show antibodies to the organism in the picture. Which of the
following is the most appropriate treatment for this patient's case? (see photo) -
✔✔Hospitalization for close monitoring with telemetry and IV ceftriaxone
, ✔✔An adolescent presents to you with sore throat, fever, lymphadenopathy, and
splenomegaly. He also complains of headache but has been previously well. Which
should be done? - ✔✔Treat symptomatically
✔✔A healthy 17-year-old male presents with three days of worsening fatigue,
rhinorrhea, nasal congestion, myalgias, and subjective fever. He is severely allergic to
eggs and therefore does not receive the annual influenza vaccine. His blood pressure is
125/75 mmHg, pulse 100 beats per minute, temperature 100 F (37.7 C), and respiratory
rate 18 breaths per minute. Examination demonstrates conjunctivitis, oropharyngeal
erythema, and clear breath sounds. Given the likely diagnosis, what is the most
appropriate treatment? - ✔✔Symptomatic treatment only
✔✔A 33-year-old inmate is brought to the clinic for a routine annual checkup. The
patient says that he has been in good health and does not have any medical problems.
He, however, does complain of disturbed sleep, constipation, and weight loss. A review
of systems is negative for cough, shortness of breath, burning urination, abdominal
discomfort, or weakness. Examination shows normal vitals, a soft, nontender abdomen
with no organomegaly, normal S1 and S2 with no added sounds, and normal bronchial
breathing bilaterally. A purified protein derivative test shows an induration of 11 mm.
What is the next best step in the management of this patient? - ✔✔Chest x-ray
✔✔A 16-year-old patient presents to the hospital with fever, fatigue, lymphadenopathy,
and sore throat. Exudative pharyngitis is noted on the throat examination. However,
rapid strep testing is negative. His blood pressure is 135/85 mmHg, the pulse rate is
92/min regular, and his respiratory rate is 16/min. Past medical history is positive for
asthma, and his father had leukemia. Social history is notable for being involved in
multiple school sporting activities. What is the most appropriate piece of advice for this
patient? - ✔✔Avoid contact sports for a minimum of 6 weeks
✔✔A 38-year-old man presents with numbness and tingling in his extremities for the
past week. He says his hands have been feeling unusual, and that this interferes with
his sleep. He has no muscle weakness or memory impairment. His past medical history
includes pulmonary tuberculosis, for which he takes isoniazid, rifampin, pyrazinamide,
and ethambutol. All his vital signs are within normal limits. Examination reveals
diminished breath sounds in the left upper lobe. A chest x-ray shows a cavitating lesion
in the left lung. What is the most appropriate next step in the management of this
patient? - ✔✔Add pyridoxine
✔✔A female presents with progressive confusion over weeks with memory loss. She
has a slight fever at 100.4 F. Prior to cognitive changes, she had been complaining of
arthralgias. History is otherwise unremarkable except for the fact she is an avid camper.
What is her most likely diagnosis? - ✔✔Lyme disease
