MSN 621 EXAM EVALUATION QUESTIONS AND SOLUTIONS
RATED A+
✔✔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 67-year-old woman with a performance status of 0 presents with breathlessness
and fatigue. She says she has needed several blood transfusions over the past 3
months. Her hemoglobin is 7.5 g/dL, absolute neutrophil count is 1500 cells/microliter,
and platelet count is 119,000 cells/microliter. A bone marrow biopsy reveals
myelodysplastic syndrome (MDS) with 6% blasts and cytogenetics positive for a 5q
deletion. There are no mutations or other cytogenetic abnormalities. What is the best
initial treatment for this patient? - ✔✔A thalidomide derivative
✔✔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 - ✔✔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? - ✔✔Observation and close follow
up
✔✔A 57-year-old patient with lymphoma complains of nausea after starting morphine.
Which of the following is most accurate regarding nausea and vomiting due to opioids? -
✔✔After starting opioids, nausea often improves within a few days.
,✔✔A 16-year-old male presents with fatigue, easy bruisability, and weight loss. On
examination, hepatosplenomegaly is noted. After a detailed evaluation, the patient is
diagnosed with acute lymphocytic leukemia. Which of the following is used in the
management of this patient's condition? - ✔✔L-asparaginase
✔✔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? - ✔✔Hodgkin
lymphoma
✔✔A 16-year-old male presents with lethargy, fatigue, and occasional mucosal
bleeding. The patient also reports weight loss in the past 5 months. Laboratory analysis
reveals a white blood cell count of 32,000 cells/microL. On examination,
hepatosplenomegaly is noted. Further evaluation shows findings suggestive of acute
lymphocytic leukemia. What is the most likely cause of the patient's mucosal bleeding? -
✔✔Decreased platelet count
✔✔A healthy patient is administered a subcutaneous injection of purified protein
derivative (PPD) on the anterior aspect of the forearm. At 48 hours, 15 mm of induration
develops. What is the diagnosis? - ✔✔Exposure to tuberculosis
✔✔A 17-year-old presents with tonsillar hypertrophy, bilateral cervical
lymphadenopathy, low-grade fever, and general malaise. Which of the following is the
gold standard test for diagnosing this condition? - ✔✔Epstein-Barr specific antibodies
✔✔A 40-year-old woman from the New England area of the United States presents with
malaise, headache, rash, and fever. She went hiking in a local park with her family 7
days ago. She has a history of depression and hypothyroidism, for which she takes
paroxetine and levothyroxine. Her vitals are temperature 99 °F (37.2 °C), heart rate 80
bpm, respiratory rate 16 breaths/min, and blood pressure 125/75 mm Hg. A rash is
noted on her right upper extremity (see image). The rest of the physical exam is
unremarkable. What is the recommended treatment for this patient's condition? - ✔✔A
10-day course of doxycycline
✔✔A 16-year-old boy with a low-grade fever and a cough is seen in the ER. The
clinician sends blood work for the measurement of heterophile antibodies because they
suspect which of the following? - ✔✔Infectious mononucleosis
✔✔A 17-year-old girl presents with a severe sore throat and fever for 4 days. The
patient's voice is muffled, and she prefers not to speak secondary to pain. She has not
been able to eat solids for 2 days and has refused to drink for 1 day. Vital signs are
, temperature 39.8 C (103.6 F), heart rate 140 bpm, respiratory rate 20 breaths/min, and
blood pressure 110/70 mmHg. The physical examination shows the tonsils to be 4+
enlarged with partial airway obstruction and grey-white exudates, cervical
lymphadenopathy, and splenomegaly. A rapid strep screen is negative. A CBC shows
atypical lymphocytes. What is the most appropriate management? - ✔✔Admission for
hydration and corticosteroids
✔✔A 35-year-old woman presents with 1 day of sneezing, rhinorrhea, nasal congestion,
fatigue, and myalgias. A review of systems reveals mild itching in the eyes and a frontal
headache. She smokes 2 packs of cigarettes daily and denies alcohol and illicit drug
use. Her 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." Vital signs are blood pressure 130/75 mmHg, heart rate 105 bpm,
temperature 100 F (37.7 C), and respiratory rate 19 breaths/min. Physical examination
shows red eyes, erythema of the pharynx, and dry mucous membranes. Which of the
following is the next best step in management? - ✔✔Oseltamivir
✔✔A 34-year-old man presents with dizziness, syncope, and increasing fatigue for 2
weeks. He has no significant history and is employed as a forest ranger. Vital signs are
temperature 98 °F (36.7 °C), blood pressure 110/80 mm Hg, and heart rate 38 bpm.
Physical examination reveals weakness of the right facial muscles. An
electrocardiogram (EKG) shows a complete heart block. Which joint is most likely
painful? - ✔✔Knee
✔✔A 17-year-old woman from Wisconsin presents with arthralgias, progressive
confusion, a rash with central clearing over several weeks, and memory loss. She has
no significant history and is an avid camper. Her temperature is 100.4 °F (38 °C). What
is her most likely diagnosis? - ✔✔Lyme disease
✔✔A 38-year-old man presents with one week of numbness and tingling in his
extremities, which have been interfering with his sleep. He denies muscle weakness or
memory impairment. He is being treated for pulmonary tuberculosis and has completed
8 weeks of isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB).
On exam, Vital signs are normal. He has diminished breath sounds in the left upper
lobe. A chest X-ray shows an improving cavitary lesion in the left lung. Lab tests show
his complete blood count, liver enzymes, and renal function are within normal limits.
What is the most appropriate next step in management? - ✔✔Add pyridoxine
✔✔A 16-year-old boy presents with fever, fatigue, lymphadenopathy, and sore throat.
His medical history is positive for asthma; his father had leukemia. Social history is
notable for being involved in multiple school sporting activities. Vital signs are blood
pressure 135/85 mm Hg, heart rate 92 bpm, and respiratory rate 16 breaths/min.
Physical examination shows exudative pharyngitis and splenomegaly. Rapid
streptococcal testing is negative. What is the most appropriate recommendation? -
✔✔Avoid contact sports for a minimum of 6 weeks
RATED A+
✔✔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 67-year-old woman with a performance status of 0 presents with breathlessness
and fatigue. She says she has needed several blood transfusions over the past 3
months. Her hemoglobin is 7.5 g/dL, absolute neutrophil count is 1500 cells/microliter,
and platelet count is 119,000 cells/microliter. A bone marrow biopsy reveals
myelodysplastic syndrome (MDS) with 6% blasts and cytogenetics positive for a 5q
deletion. There are no mutations or other cytogenetic abnormalities. What is the best
initial treatment for this patient? - ✔✔A thalidomide derivative
✔✔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 - ✔✔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? - ✔✔Observation and close follow
up
✔✔A 57-year-old patient with lymphoma complains of nausea after starting morphine.
Which of the following is most accurate regarding nausea and vomiting due to opioids? -
✔✔After starting opioids, nausea often improves within a few days.
,✔✔A 16-year-old male presents with fatigue, easy bruisability, and weight loss. On
examination, hepatosplenomegaly is noted. After a detailed evaluation, the patient is
diagnosed with acute lymphocytic leukemia. Which of the following is used in the
management of this patient's condition? - ✔✔L-asparaginase
✔✔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? - ✔✔Hodgkin
lymphoma
✔✔A 16-year-old male presents with lethargy, fatigue, and occasional mucosal
bleeding. The patient also reports weight loss in the past 5 months. Laboratory analysis
reveals a white blood cell count of 32,000 cells/microL. On examination,
hepatosplenomegaly is noted. Further evaluation shows findings suggestive of acute
lymphocytic leukemia. What is the most likely cause of the patient's mucosal bleeding? -
✔✔Decreased platelet count
✔✔A healthy patient is administered a subcutaneous injection of purified protein
derivative (PPD) on the anterior aspect of the forearm. At 48 hours, 15 mm of induration
develops. What is the diagnosis? - ✔✔Exposure to tuberculosis
✔✔A 17-year-old presents with tonsillar hypertrophy, bilateral cervical
lymphadenopathy, low-grade fever, and general malaise. Which of the following is the
gold standard test for diagnosing this condition? - ✔✔Epstein-Barr specific antibodies
✔✔A 40-year-old woman from the New England area of the United States presents with
malaise, headache, rash, and fever. She went hiking in a local park with her family 7
days ago. She has a history of depression and hypothyroidism, for which she takes
paroxetine and levothyroxine. Her vitals are temperature 99 °F (37.2 °C), heart rate 80
bpm, respiratory rate 16 breaths/min, and blood pressure 125/75 mm Hg. A rash is
noted on her right upper extremity (see image). The rest of the physical exam is
unremarkable. What is the recommended treatment for this patient's condition? - ✔✔A
10-day course of doxycycline
✔✔A 16-year-old boy with a low-grade fever and a cough is seen in the ER. The
clinician sends blood work for the measurement of heterophile antibodies because they
suspect which of the following? - ✔✔Infectious mononucleosis
✔✔A 17-year-old girl presents with a severe sore throat and fever for 4 days. The
patient's voice is muffled, and she prefers not to speak secondary to pain. She has not
been able to eat solids for 2 days and has refused to drink for 1 day. Vital signs are
, temperature 39.8 C (103.6 F), heart rate 140 bpm, respiratory rate 20 breaths/min, and
blood pressure 110/70 mmHg. The physical examination shows the tonsils to be 4+
enlarged with partial airway obstruction and grey-white exudates, cervical
lymphadenopathy, and splenomegaly. A rapid strep screen is negative. A CBC shows
atypical lymphocytes. What is the most appropriate management? - ✔✔Admission for
hydration and corticosteroids
✔✔A 35-year-old woman presents with 1 day of sneezing, rhinorrhea, nasal congestion,
fatigue, and myalgias. A review of systems reveals mild itching in the eyes and a frontal
headache. She smokes 2 packs of cigarettes daily and denies alcohol and illicit drug
use. Her 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." Vital signs are blood pressure 130/75 mmHg, heart rate 105 bpm,
temperature 100 F (37.7 C), and respiratory rate 19 breaths/min. Physical examination
shows red eyes, erythema of the pharynx, and dry mucous membranes. Which of the
following is the next best step in management? - ✔✔Oseltamivir
✔✔A 34-year-old man presents with dizziness, syncope, and increasing fatigue for 2
weeks. He has no significant history and is employed as a forest ranger. Vital signs are
temperature 98 °F (36.7 °C), blood pressure 110/80 mm Hg, and heart rate 38 bpm.
Physical examination reveals weakness of the right facial muscles. An
electrocardiogram (EKG) shows a complete heart block. Which joint is most likely
painful? - ✔✔Knee
✔✔A 17-year-old woman from Wisconsin presents with arthralgias, progressive
confusion, a rash with central clearing over several weeks, and memory loss. She has
no significant history and is an avid camper. Her temperature is 100.4 °F (38 °C). What
is her most likely diagnosis? - ✔✔Lyme disease
✔✔A 38-year-old man presents with one week of numbness and tingling in his
extremities, which have been interfering with his sleep. He denies muscle weakness or
memory impairment. He is being treated for pulmonary tuberculosis and has completed
8 weeks of isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB).
On exam, Vital signs are normal. He has diminished breath sounds in the left upper
lobe. A chest X-ray shows an improving cavitary lesion in the left lung. Lab tests show
his complete blood count, liver enzymes, and renal function are within normal limits.
What is the most appropriate next step in management? - ✔✔Add pyridoxine
✔✔A 16-year-old boy presents with fever, fatigue, lymphadenopathy, and sore throat.
His medical history is positive for asthma; his father had leukemia. Social history is
notable for being involved in multiple school sporting activities. Vital signs are blood
pressure 135/85 mm Hg, heart rate 92 bpm, and respiratory rate 16 breaths/min.
Physical examination shows exudative pharyngitis and splenomegaly. Rapid
streptococcal testing is negative. What is the most appropriate recommendation? -
✔✔Avoid contact sports for a minimum of 6 weeks
