Total Course Duration: 5 hrs, 154 Qs (with many having multiple parts)
1.An 89 yo M is brought to the ED from a nursing home. He is described by staff as being “out
of it” for the past 2 days. Vital signs on admission are a temp of 103, BP 90/65, HR 107 bpm,
RR 32. CBC is notable for-WBC Count 95k, HCT-15%, Plt-37. PE is notable for fullness on
palpation of the left and right upper quadrants. He recently recovered from a mild upper
respiratory infection. After initiating broad spectrum antibiotic therapy, further testing of this
patient will reveal?
a. Atypical T lymphocytes on a blood smear.
b. B Cells with Reed Sternberg morphologies.
c. Hypersegmented neutrophilia.
d. CD5+ B lymphocytes with weakened cell membranes.
e. Epithelial cells with intranuclear inclusions.
2.A 44 yo M comes to his PCP for an annual physical. He appears to be in good health but is
worried about losing his job. His colleagues have noticed him falling asleep and snoring on
multiple occasions over the last few months. BP is 145/85, HR 87 bpm, RR 16, WBC 7500, HCT
45%, BMI 32. He receives an influenza vaccine and is referred to a respiratory specialist for a
sleep study. Further testing would most likely reveal?
a. An elevated pulmonary capillary wedge pressure.
b. Hyperchloremic, high anion gap metabolic acidosis.
c. Severe hypocapnia.
d. Reduced levels of erythropoietin.
e. Compensated metabolic alkalosis.
3.A 62 yo M presents with an unintentional 15 Lb weight loss over the last 2 months. PE is
notable for a cachectic man with severe temporal wasting. He quit smoking 6 months ago but
previously had a 74 pack year smoking history. CXR is notable for a spiculated cavitary lesion in
the left upper lung lobe. Bronchoscopy with biopsy reveals dysplastic, undifferentiated, keratin
+ve cells. There is no evidence of hilar lymphadenopathy or a pleural effusion. Chest,
abdominal, and brain CT with PET imaging is negative. What is the next best step in the
management of this patient?
a. Preoperative pulmonary function testing.
b. Referral for home hospice care.
c. Resection with negative margins and adjunctive chemotherapy.
d. Broad spectrum antibiotic therapy.
e. High dose corticosteroid therapy to induce remission.
,4.A 66 yo F presents to her PCP complaining of severe shoulder pain for the past 1 week. She
has also had pain over her left shin and right upper extremity. PE is notable for a palpable “step-
off” on the left shoulder. Vital signs are within normal limits. Lab studies reveal-WBC 8500,
Hct-28%, Plts-192, 000, Na-138, K-3.9, Cl-101, Ca-12.7, P-2.6, BUN-45, Cr-3.0, Glucose-102.
All other labs are unremarkable. Her last pap smear was 2 years ago. She has no history of an
abnormal pap smear and is judicious with yearly screenings and preventive guidance. What is the
next best step in the management of this patient?
a. Dual Energy XRay Absorptiometry.
b. Risedronate therapy.
c. Immediate transfusion of packed red blood cells.
d. Broad spectrum antibiotic therapy.
e. Serum protein electrophoretic studies.
5.65 yo F with a T of 103. Her left thigh is swollen and exquisitely ttp. Physical exam is notable
for red and purple splotches around the involved area.
Dx:
NBSID:
Tx strategy:
Classically affected patient:
DM drug:
6.34 yo M with a h/o HIV presents with a 2 week h/o of visual difficulty. Head CT is notable for
a solitary ring enhancing supratentorial lesion.
Algorithm:
Bone marrow suppression:
7.32 yo Japanese F with fever, arthralgias, chronic arm/leg claudication, and a unilaterally absent
radial pulse.
8.33 yo F presents with a 2 week history of pain and a burning sensation in her L thigh that
radiates to the left leg. She has lost 10 Lbs within the past month. She also reports significant
abdominal pain with meals. Angiography shows a segmental aneurysmal dilation of the SMA
and IMA.
Dx:pn
Potential NBME biopsy finding:
Biopsy findings in kids with the dz:
Unaffected organ? lungs
,9.27 yo M with recurrent otitis media, saddle nose deformity, cavitary pulmonary infiltrates on
imaging, 3+ proteinuria, and RBC casts. Wegners “GPA” assoc. w C-ANCA.. tx w/
cyclophosphamide
10.38 yo M presents with a 2 week history of wrist drop. A new S3 heart sound is heard on
auscultation of the chest. He was diagnosed with asthma a year ago that has been well controlled
with albuterol and inhaled budesonide. Serum IgE is markedly elevated. CHURG STRAUS
“EPA”.. tx w/ steroids and cyclophophamide… p-anca pos.
11.45 yo Caucasian F presenting with worsening epigastric pain and vomiting. She was
diagnosed with H.Pylori gastritis 3 mo ago and completed triple therapy. EGD with this
admission is notable for persistent gastric ulcers and a large posterior antral ulcer with raised
edges. Potential maltoma(b cell lymphoma)
NBSIM? biopsy
Likely biopsy finding on histopathological analysis: germinal centers
Other potential site of a similar lesion in the GI Tract: terminal ileum
Test of cure for H. Pylori gastritis: urea breathe test
12.What is the most likely dx given the pathognomonic feature?
65 yo M with pancytopenia. A peripheral smear reveals teardrop shaped RBCs primary
myelofibrosis
88 yo F has a 6 mo hx of recurrent infections. WBC is 87000. A peripheral smear reveals
“smudge cells” cll
78 yo M. A peripheral smear is notable for RBCs stacked like coins. Multiple myeloma (rouleux)
78 yo M with pancytopenia. Bone marrow aspiration is consistent with a “dry tap”
aplastic anemia or primary myelofibrosis
66 yo F presents with a 6 mo hx of recurrent infections, WBC is 47k with a preponderance of
cells in different stages of maturation. These cells have reduced leukocyte alkaline phosphatase
activity CML 9:22 BCR-ABL, TX W/ IMATINIB OR DASATINIB
, 55 yo M is S/P Day 5 from recent treatment for a hematologic malignancy. Plts are 40K, D-
dimers are elevated, he is bleeding from every IV Site DIC ASSOC W/ APL t15:17, tx w/ all
trans retinoic acid
5 yo F presents with a 6 week hx of weight loss and fever. CBC is notable for pancytopenia.
Cytologic studies reveal TDT +ve cells ALL
55 yo M presents with fever, weight loss, and night sweats. Peripheral smear reveals B cells with
a bilobate nucleus
PSEUDO PELGER HUET ANOMALY ASSOC. W/ MYELODYSPLASTIC SYMDROME
HODGKIN’S LYMPHOMA
45 yo F with a hx of CML presents with a 3 week hx of diffuse lymphadenopathy and
feverBLAST CRISIS
13.Given the following clinical descriptors, what is the most likely associated antibody?
45 yo F with a 6 month history of intense pruritus. BMP is notable for conjugated
hyperbilirubinemia. PRIMARY BILIARY CHOLANGITIS ASSOC. W ANTI-
MITOCHONDRIAL AB’S, TX W/ URSODIOL/ URSODEOXYCHOLIC ACID.
45 yo M with a history of ulcerative colitis presents with a 6 month history of pruritus and
worsening jaundice. PSC ASSOC. W/ P-ANCA
35 yo F presents with episodic discoloration of her fingers when she steps out of her home in
winter. PE is notable for diffuse skin thickening. CREST SCLERODERMA ASSOC. W/ ANTI-
CENTROMERE AB’S
14.A 35 yo F comes to her PCP in April for an annual physical. She appears to be in good health
and enjoys her daily job. BP 120/80, HR 79 bpm, RR 14, other vital signs, CBC, and labs are all
within normal limits. There is no jugular venous distension or peripheral edema. Peripheral
pulses are 2+ bilaterally. There is no evidence of respiratory distress and she had a flu shot last
year. She is up to date on all her vaccinations. Cardiac auscultation reveals a 2/6 diastolic
murmur with an opening snap heard best at the apex. Breath sounds are equal bilaterally with
good airflow and no wheezing, crackles, or rhonchi. What is the next best step in the
management of this patient?
a. Influenza vaccination.
b. Reassurance.
c. Transthoracic echocardiography.
1.An 89 yo M is brought to the ED from a nursing home. He is described by staff as being “out
of it” for the past 2 days. Vital signs on admission are a temp of 103, BP 90/65, HR 107 bpm,
RR 32. CBC is notable for-WBC Count 95k, HCT-15%, Plt-37. PE is notable for fullness on
palpation of the left and right upper quadrants. He recently recovered from a mild upper
respiratory infection. After initiating broad spectrum antibiotic therapy, further testing of this
patient will reveal?
a. Atypical T lymphocytes on a blood smear.
b. B Cells with Reed Sternberg morphologies.
c. Hypersegmented neutrophilia.
d. CD5+ B lymphocytes with weakened cell membranes.
e. Epithelial cells with intranuclear inclusions.
2.A 44 yo M comes to his PCP for an annual physical. He appears to be in good health but is
worried about losing his job. His colleagues have noticed him falling asleep and snoring on
multiple occasions over the last few months. BP is 145/85, HR 87 bpm, RR 16, WBC 7500, HCT
45%, BMI 32. He receives an influenza vaccine and is referred to a respiratory specialist for a
sleep study. Further testing would most likely reveal?
a. An elevated pulmonary capillary wedge pressure.
b. Hyperchloremic, high anion gap metabolic acidosis.
c. Severe hypocapnia.
d. Reduced levels of erythropoietin.
e. Compensated metabolic alkalosis.
3.A 62 yo M presents with an unintentional 15 Lb weight loss over the last 2 months. PE is
notable for a cachectic man with severe temporal wasting. He quit smoking 6 months ago but
previously had a 74 pack year smoking history. CXR is notable for a spiculated cavitary lesion in
the left upper lung lobe. Bronchoscopy with biopsy reveals dysplastic, undifferentiated, keratin
+ve cells. There is no evidence of hilar lymphadenopathy or a pleural effusion. Chest,
abdominal, and brain CT with PET imaging is negative. What is the next best step in the
management of this patient?
a. Preoperative pulmonary function testing.
b. Referral for home hospice care.
c. Resection with negative margins and adjunctive chemotherapy.
d. Broad spectrum antibiotic therapy.
e. High dose corticosteroid therapy to induce remission.
,4.A 66 yo F presents to her PCP complaining of severe shoulder pain for the past 1 week. She
has also had pain over her left shin and right upper extremity. PE is notable for a palpable “step-
off” on the left shoulder. Vital signs are within normal limits. Lab studies reveal-WBC 8500,
Hct-28%, Plts-192, 000, Na-138, K-3.9, Cl-101, Ca-12.7, P-2.6, BUN-45, Cr-3.0, Glucose-102.
All other labs are unremarkable. Her last pap smear was 2 years ago. She has no history of an
abnormal pap smear and is judicious with yearly screenings and preventive guidance. What is the
next best step in the management of this patient?
a. Dual Energy XRay Absorptiometry.
b. Risedronate therapy.
c. Immediate transfusion of packed red blood cells.
d. Broad spectrum antibiotic therapy.
e. Serum protein electrophoretic studies.
5.65 yo F with a T of 103. Her left thigh is swollen and exquisitely ttp. Physical exam is notable
for red and purple splotches around the involved area.
Dx:
NBSID:
Tx strategy:
Classically affected patient:
DM drug:
6.34 yo M with a h/o HIV presents with a 2 week h/o of visual difficulty. Head CT is notable for
a solitary ring enhancing supratentorial lesion.
Algorithm:
Bone marrow suppression:
7.32 yo Japanese F with fever, arthralgias, chronic arm/leg claudication, and a unilaterally absent
radial pulse.
8.33 yo F presents with a 2 week history of pain and a burning sensation in her L thigh that
radiates to the left leg. She has lost 10 Lbs within the past month. She also reports significant
abdominal pain with meals. Angiography shows a segmental aneurysmal dilation of the SMA
and IMA.
Dx:pn
Potential NBME biopsy finding:
Biopsy findings in kids with the dz:
Unaffected organ? lungs
,9.27 yo M with recurrent otitis media, saddle nose deformity, cavitary pulmonary infiltrates on
imaging, 3+ proteinuria, and RBC casts. Wegners “GPA” assoc. w C-ANCA.. tx w/
cyclophosphamide
10.38 yo M presents with a 2 week history of wrist drop. A new S3 heart sound is heard on
auscultation of the chest. He was diagnosed with asthma a year ago that has been well controlled
with albuterol and inhaled budesonide. Serum IgE is markedly elevated. CHURG STRAUS
“EPA”.. tx w/ steroids and cyclophophamide… p-anca pos.
11.45 yo Caucasian F presenting with worsening epigastric pain and vomiting. She was
diagnosed with H.Pylori gastritis 3 mo ago and completed triple therapy. EGD with this
admission is notable for persistent gastric ulcers and a large posterior antral ulcer with raised
edges. Potential maltoma(b cell lymphoma)
NBSIM? biopsy
Likely biopsy finding on histopathological analysis: germinal centers
Other potential site of a similar lesion in the GI Tract: terminal ileum
Test of cure for H. Pylori gastritis: urea breathe test
12.What is the most likely dx given the pathognomonic feature?
65 yo M with pancytopenia. A peripheral smear reveals teardrop shaped RBCs primary
myelofibrosis
88 yo F has a 6 mo hx of recurrent infections. WBC is 87000. A peripheral smear reveals
“smudge cells” cll
78 yo M. A peripheral smear is notable for RBCs stacked like coins. Multiple myeloma (rouleux)
78 yo M with pancytopenia. Bone marrow aspiration is consistent with a “dry tap”
aplastic anemia or primary myelofibrosis
66 yo F presents with a 6 mo hx of recurrent infections, WBC is 47k with a preponderance of
cells in different stages of maturation. These cells have reduced leukocyte alkaline phosphatase
activity CML 9:22 BCR-ABL, TX W/ IMATINIB OR DASATINIB
, 55 yo M is S/P Day 5 from recent treatment for a hematologic malignancy. Plts are 40K, D-
dimers are elevated, he is bleeding from every IV Site DIC ASSOC W/ APL t15:17, tx w/ all
trans retinoic acid
5 yo F presents with a 6 week hx of weight loss and fever. CBC is notable for pancytopenia.
Cytologic studies reveal TDT +ve cells ALL
55 yo M presents with fever, weight loss, and night sweats. Peripheral smear reveals B cells with
a bilobate nucleus
PSEUDO PELGER HUET ANOMALY ASSOC. W/ MYELODYSPLASTIC SYMDROME
HODGKIN’S LYMPHOMA
45 yo F with a hx of CML presents with a 3 week hx of diffuse lymphadenopathy and
feverBLAST CRISIS
13.Given the following clinical descriptors, what is the most likely associated antibody?
45 yo F with a 6 month history of intense pruritus. BMP is notable for conjugated
hyperbilirubinemia. PRIMARY BILIARY CHOLANGITIS ASSOC. W ANTI-
MITOCHONDRIAL AB’S, TX W/ URSODIOL/ URSODEOXYCHOLIC ACID.
45 yo M with a history of ulcerative colitis presents with a 6 month history of pruritus and
worsening jaundice. PSC ASSOC. W/ P-ANCA
35 yo F presents with episodic discoloration of her fingers when she steps out of her home in
winter. PE is notable for diffuse skin thickening. CREST SCLERODERMA ASSOC. W/ ANTI-
CENTROMERE AB’S
14.A 35 yo F comes to her PCP in April for an annual physical. She appears to be in good health
and enjoys her daily job. BP 120/80, HR 79 bpm, RR 14, other vital signs, CBC, and labs are all
within normal limits. There is no jugular venous distension or peripheral edema. Peripheral
pulses are 2+ bilaterally. There is no evidence of respiratory distress and she had a flu shot last
year. She is up to date on all her vaccinations. Cardiac auscultation reveals a 2/6 diastolic
murmur with an opening snap heard best at the apex. Breath sounds are equal bilaterally with
good airflow and no wheezing, crackles, or rhonchi. What is the next best step in the
management of this patient?
a. Influenza vaccination.
b. Reassurance.
c. Transthoracic echocardiography.
