MSN 621 UPDATED 2026 STUDY GUIDE QUESTIONS AND
SOLUTIONS RATED A+
✔✔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?
Well done!You answered successfully
A. Trisomy 12
B. 13q deletion
C. 17p deletion
D. 19p deletion - ✔✔C. 17p deletion
✔✔A 65-year-old woman presents with an 8-month history of recurrent low-grade
fevers, a 3-month history of abdominal fullness, and more recently, fatigue and
moderately reduced exercise tolerance. Before this, she was in good health with no
major medical conditions. Upon examination, she appeared to be stable and in no acute
distress. She has a heart rate of 95 bpm and blood pressure of 128/60 mmHg. She had
several palpable cervical and axillary lymph nodes (1-2 cm) that were non-tender and
freely mobile. She also had palpable splenomegaly. No other abdominal
masses/hepatomegaly appreciated on examination. Her complete blood count showed
a leukocyte count of 32,000/mm3, hemoglobin of 9.8 g/dL, platelet count of
145,000/mm3, neutrophil count 1,900/mm3, lymphocyte count 30,000/mm3, elevated
LDH, and elevated reticulocyte count. Peripheral blood smear showed an increasing
number of mature lymphocytes, spherocytes, and pol - ✔✔B. Autoimmune hemolytic
anemia
✔✔A 43-year-old man presents to the clinic for evaluation after abnormalities noted on
a routine set of labs. CBC with differential demonstrated hemoglobin 14 g/dL, WBC
count 26,000/microL, lymphocytes 21,000/microL, neutrophils 4500/microL, and
platelets 260,000/microL. The basic metabolic panel demonstrates normal electrolytes
and renal function. LFTs show total bilirubin 1.2 mg/dL and normal liver enzymes. On
examination in office, his examination is normal, with no palpable lymph nodes or
hepatosplenomegaly. He denies any B symptoms. Peripheral smear shows
lymphocytosis with many small lymphocytes and smudge cells. Which of the following is
the next best step in the management of this patient?
Well done!You answered successfully
A. Dexamethasone monotherapy
B. Initiate chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine, and
prednisone)
C. Rituximab monotherapy
,D. Observation and close follow up - ✔✔D. Observation and close follow up
✔✔A 16-year-old female presents with complaints of fever, lethargy, and night sweats.
The patient also reports a 6-kilogram (13.2 pound) weight loss in the past 3 months. On
examination, painless, enlarged cervical and supraclavicular lymph nodes are palpated.
A fine-needle aspiration biopsy of one of the lymph nodes is shown in the image. The
patient's findings are most suggestive of which of the following?
A. Follicular lymphoma
B. Hodgkin lymphoma
C. Non-Hodgkin lymphoma
D. Multiple myeloma - ✔✔B. Hodgkin lymphoma
✔✔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?
Well done!You answered successfully
A. 50% of patients will transform into AML
B. 2% of patients will transform into AML
C. 10% of patients will transform into AML
D. There is no risk of transformation into AML - ✔✔A. 50% of patients will transform into
AML
✔✔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?
Well done!You answered successfully
A. An erythropoietin stimulating agent
B. A thalidomide derivative
C. A hypomethylating agent
D. Stem cell transplant - ✔✔B. A thalidomide derivative
✔✔A 30-year-old female patient presents with complaints of abdominal pain and
diarrhea for six months. She describes her pain as abdominal cramps. She is unable to
localize her pain. She states it is intermittent, rated 8/10 at its worst and 0/10 currently.
She states her pain is worse right before she has a bowel movement and relieves after
having a bowel movement. She describes her bowel movements as loose, unformed
,stools. Given the patient's most likely diagnosis, which of the following would be most
likely in this patient?
Well done!You answered successfully
A. Blood and mucus in her stool
B. Recent problems with marriage resulting in divorce
C. Ova in her stool
D. Nocturnal diarrhea - ✔✔B. Recent problems with marriage resulting in divorce
✔✔A 12-year-old male is brought to the clinic with complaints of fever and abdominal
cramps. He has also been having bloody diarrhea since yesterday. The detailed history
reveals him to have consumed smoked chicken two days ago. On presentation, he has
a temperature of 100.5 F (37.8 C), a pulse rate of 96 beats per minute, a blood pressure
of 100/70 mmHg, and a respiratory rate of 19 breaths per minute. The physical
examination does not reveal any significant findings, except for hyperactive bowel
sounds. He has a hemoglobin level of 10.5 g/dl, a white cell count of 11500/mm3, and a
platelet count of 350,000/mm3. The treatment is initiated to rehydrate the patient. Which
of the following investigations would help best in establishing the diagnosis?
Well done!You answered successfully
A. Serological studies
B. Stool evaluation
C. Blood culture
D. Abdominal ultrasonography - ✔✔B. Stool evaluation
✔✔A 35-year-old woman presents with sneezing, rhinorrhea, nasal congestion, fatigue,
and myalgias. She developed these complaints one day back and decided to seek
immediate care. A review of symptoms reveals mild itching in the eyes and a frontal
headache. She admits to smoking two packs of cigarettes daily; however, she denies
alcohol and illicit drug use. The patient's medical history is significant for
gastroesophageal reflux disease and irritable bowel syndrome. The patient cannot recall
her last vaccination and says that she prefers "natural immunity." Her blood pressure is
130/75 mmHg, pulse is 105/min, temperature 100 F (37.7 C), and respiratory rate is
19/min. Examination shows red eyes, erythema over the pharynx, and dry mucous
membranes. Which of the following is the next best step in the management of this
patient?
Well done!You answered successfully
A. Amantadine
B. Oseltamivir
C. Symptomatic management
D. - ✔✔B. Oseltamivir
✔✔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?
Well done!You answered successfully
A. Amoxicillin-clavulanic acid
B. Amantadine
C. Oseltamivir
D. Symptomatic treatment only - ✔✔D. Symptomatic treatment only
✔✔A 6-month-old girl is brought to the office for a routine check-up. The patient has no
health issues and has met all her developmental milestones. The patient has started to
stand up with help, can say the words "mama" and "dada," smile socially, and hold a
spoon with two fingers. She also recognizes her name. Her past medical history is
significant for an urticarial reaction to egg white. She was born at 36 weeks of gestation
and had an uneventful delivery. She has been given the 3rd dose diphtheria, tetanus, &
acellular pertussis vaccine (DTaP), pneumococcal conjugate vaccine (PCV 13), and
inactivated polio vaccine. What is the next best step in the management of this patient?
Well done!You answered successfully
A. Give influenza vaccine intramuscularly
B. Give influenza vaccine intranasally
C. Hold the influenza vaccine until the age of 1
D. Do not give influenza vaccine because of egg protein allergy - ✔✔A. Give influenza
vaccine intramuscularly
✔✔A 40-year-old woman from the New England area of the United States presents with
complaints of malaise, headache, rash, and fever. She went hiking in a local park with
her family seven days ago. She has a history of depression and hypothyroidism, for
which she takes paroxetine and levothyroxine. She was an occasional smoker but quit
five years ago. On examination, her temperature is 99 F (37.2 C), heart rate is 80/min,
respiratory rate is 16/min, and blood pressure is 125/75 mmHg. A rash is noted on her
right upper extremity (see image). The rest of her physical exam is unremarkable. What
is the recommended treatment for this patient's condition?
A. A 10-day course of penicillin
B. A 7-day course of cefuroxime
C. A 7-day course of amoxicillin
D. A 10-day course of doxycycline - ✔✔D. A 10-day course of doxycycline
✔✔A patient is diagnosed with Lyme disease and started on doxycycline 100 mg PO
BID for 4 weeks. After the first dose, the patient is worse with dizziness, shaking, and
fever. What is the cause of the change in the patient's condition?
Well done!You answered successfully
A. Reaction to the antibiotic
B. Resistance to the doxycycline
C. Jarisch-Herxheimer reaction
D. Sepsis secondary to B. burgdorferi
Submit - ✔✔C. Jarisch-Herxheimer reaction
SOLUTIONS RATED A+
✔✔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?
Well done!You answered successfully
A. Trisomy 12
B. 13q deletion
C. 17p deletion
D. 19p deletion - ✔✔C. 17p deletion
✔✔A 65-year-old woman presents with an 8-month history of recurrent low-grade
fevers, a 3-month history of abdominal fullness, and more recently, fatigue and
moderately reduced exercise tolerance. Before this, she was in good health with no
major medical conditions. Upon examination, she appeared to be stable and in no acute
distress. She has a heart rate of 95 bpm and blood pressure of 128/60 mmHg. She had
several palpable cervical and axillary lymph nodes (1-2 cm) that were non-tender and
freely mobile. She also had palpable splenomegaly. No other abdominal
masses/hepatomegaly appreciated on examination. Her complete blood count showed
a leukocyte count of 32,000/mm3, hemoglobin of 9.8 g/dL, platelet count of
145,000/mm3, neutrophil count 1,900/mm3, lymphocyte count 30,000/mm3, elevated
LDH, and elevated reticulocyte count. Peripheral blood smear showed an increasing
number of mature lymphocytes, spherocytes, and pol - ✔✔B. Autoimmune hemolytic
anemia
✔✔A 43-year-old man presents to the clinic for evaluation after abnormalities noted on
a routine set of labs. CBC with differential demonstrated hemoglobin 14 g/dL, WBC
count 26,000/microL, lymphocytes 21,000/microL, neutrophils 4500/microL, and
platelets 260,000/microL. The basic metabolic panel demonstrates normal electrolytes
and renal function. LFTs show total bilirubin 1.2 mg/dL and normal liver enzymes. On
examination in office, his examination is normal, with no palpable lymph nodes or
hepatosplenomegaly. He denies any B symptoms. Peripheral smear shows
lymphocytosis with many small lymphocytes and smudge cells. Which of the following is
the next best step in the management of this patient?
Well done!You answered successfully
A. Dexamethasone monotherapy
B. Initiate chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine, and
prednisone)
C. Rituximab monotherapy
,D. Observation and close follow up - ✔✔D. Observation and close follow up
✔✔A 16-year-old female presents with complaints of fever, lethargy, and night sweats.
The patient also reports a 6-kilogram (13.2 pound) weight loss in the past 3 months. On
examination, painless, enlarged cervical and supraclavicular lymph nodes are palpated.
A fine-needle aspiration biopsy of one of the lymph nodes is shown in the image. The
patient's findings are most suggestive of which of the following?
A. Follicular lymphoma
B. Hodgkin lymphoma
C. Non-Hodgkin lymphoma
D. Multiple myeloma - ✔✔B. Hodgkin lymphoma
✔✔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?
Well done!You answered successfully
A. 50% of patients will transform into AML
B. 2% of patients will transform into AML
C. 10% of patients will transform into AML
D. There is no risk of transformation into AML - ✔✔A. 50% of patients will transform into
AML
✔✔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?
Well done!You answered successfully
A. An erythropoietin stimulating agent
B. A thalidomide derivative
C. A hypomethylating agent
D. Stem cell transplant - ✔✔B. A thalidomide derivative
✔✔A 30-year-old female patient presents with complaints of abdominal pain and
diarrhea for six months. She describes her pain as abdominal cramps. She is unable to
localize her pain. She states it is intermittent, rated 8/10 at its worst and 0/10 currently.
She states her pain is worse right before she has a bowel movement and relieves after
having a bowel movement. She describes her bowel movements as loose, unformed
,stools. Given the patient's most likely diagnosis, which of the following would be most
likely in this patient?
Well done!You answered successfully
A. Blood and mucus in her stool
B. Recent problems with marriage resulting in divorce
C. Ova in her stool
D. Nocturnal diarrhea - ✔✔B. Recent problems with marriage resulting in divorce
✔✔A 12-year-old male is brought to the clinic with complaints of fever and abdominal
cramps. He has also been having bloody diarrhea since yesterday. The detailed history
reveals him to have consumed smoked chicken two days ago. On presentation, he has
a temperature of 100.5 F (37.8 C), a pulse rate of 96 beats per minute, a blood pressure
of 100/70 mmHg, and a respiratory rate of 19 breaths per minute. The physical
examination does not reveal any significant findings, except for hyperactive bowel
sounds. He has a hemoglobin level of 10.5 g/dl, a white cell count of 11500/mm3, and a
platelet count of 350,000/mm3. The treatment is initiated to rehydrate the patient. Which
of the following investigations would help best in establishing the diagnosis?
Well done!You answered successfully
A. Serological studies
B. Stool evaluation
C. Blood culture
D. Abdominal ultrasonography - ✔✔B. Stool evaluation
✔✔A 35-year-old woman presents with sneezing, rhinorrhea, nasal congestion, fatigue,
and myalgias. She developed these complaints one day back and decided to seek
immediate care. A review of symptoms reveals mild itching in the eyes and a frontal
headache. She admits to smoking two packs of cigarettes daily; however, she denies
alcohol and illicit drug use. The patient's medical history is significant for
gastroesophageal reflux disease and irritable bowel syndrome. The patient cannot recall
her last vaccination and says that she prefers "natural immunity." Her blood pressure is
130/75 mmHg, pulse is 105/min, temperature 100 F (37.7 C), and respiratory rate is
19/min. Examination shows red eyes, erythema over the pharynx, and dry mucous
membranes. Which of the following is the next best step in the management of this
patient?
Well done!You answered successfully
A. Amantadine
B. Oseltamivir
C. Symptomatic management
D. - ✔✔B. Oseltamivir
✔✔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?
Well done!You answered successfully
A. Amoxicillin-clavulanic acid
B. Amantadine
C. Oseltamivir
D. Symptomatic treatment only - ✔✔D. Symptomatic treatment only
✔✔A 6-month-old girl is brought to the office for a routine check-up. The patient has no
health issues and has met all her developmental milestones. The patient has started to
stand up with help, can say the words "mama" and "dada," smile socially, and hold a
spoon with two fingers. She also recognizes her name. Her past medical history is
significant for an urticarial reaction to egg white. She was born at 36 weeks of gestation
and had an uneventful delivery. She has been given the 3rd dose diphtheria, tetanus, &
acellular pertussis vaccine (DTaP), pneumococcal conjugate vaccine (PCV 13), and
inactivated polio vaccine. What is the next best step in the management of this patient?
Well done!You answered successfully
A. Give influenza vaccine intramuscularly
B. Give influenza vaccine intranasally
C. Hold the influenza vaccine until the age of 1
D. Do not give influenza vaccine because of egg protein allergy - ✔✔A. Give influenza
vaccine intramuscularly
✔✔A 40-year-old woman from the New England area of the United States presents with
complaints of malaise, headache, rash, and fever. She went hiking in a local park with
her family seven days ago. She has a history of depression and hypothyroidism, for
which she takes paroxetine and levothyroxine. She was an occasional smoker but quit
five years ago. On examination, her temperature is 99 F (37.2 C), heart rate is 80/min,
respiratory rate is 16/min, and blood pressure is 125/75 mmHg. A rash is noted on her
right upper extremity (see image). The rest of her physical exam is unremarkable. What
is the recommended treatment for this patient's condition?
A. A 10-day course of penicillin
B. A 7-day course of cefuroxime
C. A 7-day course of amoxicillin
D. A 10-day course of doxycycline - ✔✔D. A 10-day course of doxycycline
✔✔A patient is diagnosed with Lyme disease and started on doxycycline 100 mg PO
BID for 4 weeks. After the first dose, the patient is worse with dizziness, shaking, and
fever. What is the cause of the change in the patient's condition?
Well done!You answered successfully
A. Reaction to the antibiotic
B. Resistance to the doxycycline
C. Jarisch-Herxheimer reaction
D. Sepsis secondary to B. burgdorferi
Submit - ✔✔C. Jarisch-Herxheimer reaction
