MSN 621 Final Exam with complete
solutions latest version
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? .- .CORRECT .ANSWER-Decreased .platelet .count
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? .(see .photo) .- .CORRECT .ANSWER-Hodgkin .lymphoma
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 .- .CORRECT .ANSWER-L-
asparaginase
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? .- .CORRECT .ANSWER-After .starting .opioids, .nausea,
.often .improves .within .a .few .days
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? .- .CORRECT .ANSWER-Observation .and .close
.follow .up
,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 .- .CORRECT .ANSWER-Autoimmune
.hemolytic .anemia
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? .- .CORRECT .ANSWER-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? .- .CORRECT .ANSWER-
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 .- .CORRECT .ANSWER-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? .- .CORRECT .ANSWER-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) .- .CORRECT .ANSWER-
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? .- .CORRECT .ANSWER-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? .- .CORRECT
.ANSWER-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 .- .CORRECT .ANSWER-Acute .lymphoblastic
.leukemia
Which .of .the .following .is .associated .with .the .CD10 .antigen? .- .CORRECT
.ANSWER-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? .-
.CORRECT .ANSWER-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
solutions latest version
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? .- .CORRECT .ANSWER-Decreased .platelet .count
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? .(see .photo) .- .CORRECT .ANSWER-Hodgkin .lymphoma
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 .- .CORRECT .ANSWER-L-
asparaginase
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? .- .CORRECT .ANSWER-After .starting .opioids, .nausea,
.often .improves .within .a .few .days
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? .- .CORRECT .ANSWER-Observation .and .close
.follow .up
,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 .- .CORRECT .ANSWER-Autoimmune
.hemolytic .anemia
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? .- .CORRECT .ANSWER-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? .- .CORRECT .ANSWER-
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 .- .CORRECT .ANSWER-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? .- .CORRECT .ANSWER-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) .- .CORRECT .ANSWER-
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? .- .CORRECT .ANSWER-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? .- .CORRECT
.ANSWER-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 .- .CORRECT .ANSWER-Acute .lymphoblastic
.leukemia
Which .of .the .following .is .associated .with .the .CD10 .antigen? .- .CORRECT
.ANSWER-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? .-
.CORRECT .ANSWER-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
