Day 16 Flashcards
Q1-A man with a history of prostate cancer comes to the emergency department with severe back pain and leg weakness. He has tenderness of the spine, hyperreflexia, and decreased sensation below his umbilicus.
What is the most appropriate next step in the management of this patient?
A-Dexamethasone B-MRI C-X-ray D-Radiation E-Flutamide F-Finasteride
Ans: A. When there is obvious cord compression; the most important step is to begin steroids urgently in order to decrease the pressure on the cord. Radiation is necessary in those with metastatic cancer to the cord, but it does not work as fast as giving steroids. X-ray may show vertebral damage, and MRI is the most accurate imaging study, but preventing permanent paralysis with steroids is more important to do first. Leuprolide is actually dangerous without first blocking the peripheral receptors to testosterone with flutamide. GnRH agonists will give a transient burst up in testosterone levels. Finasteride is a 5-alpha reductase inhibitor that is not helpful for prostate cancer. Finasteride is used for benign prostatic hypertrophy and male pattern hair loss. Ketoconazole is a second-line agent in inhibiting androgens. The fastest way to lower androgen levels is with orchiectomy, but this step is rarely necessary. Biopsy is done if the etiology is not clear. The key issue in this question is timing: What decompresses the spine fastest? The answer is glucocorticoids like dexamethasone.
Q2-A patient with long-standing Rhumatoid arthritis is to have coronary bypass surgery. Which of the following is most important prior to surgery?
A-Cervical spine x-ray B-Rheumatoid factor C-Extra dose of methotrexate D-ESR E-Pneumococcal vaccination
Ans: A. RA is associated with C1/C2 subluxation. Cervical spine imaging to detect possible instability of the vertebra is essential prior to the hyperextension of the neck that typically occurs with endotracheal intubation. Methotrexate does not work acutely and additional doses are not useful. Although pneumococcal vaccination is useful in any immunocompromised person, there is no particular indication for vaccination surrounding surgical procedures.
Q3-A 34-year-old woman with a history of SLE is admitted with pneumonia and confusion. As you are wrestling with the decision over a bolus of high-dose steroids in a person with an infection, you need to determine if this is a flare of lupus, or simply an infection with sepsis causing confusion.
Which of the following will help you the most?
A-Rise in anti-Sm B-Rise in ANA C-Decrease in complement D-Decrease in complement and rise in anti-DS DNA E-MRI of the brain F-Response to steroids
Ans: D. although anti-Sm is specific for SLE, the level does not change in an acute flare. ANA levels do not tell severity of disease. MRI of the brain is most often normal in lupus cerebritis unless there has been a stroke. In an acute lupus flare, complement levels drop and anti-DS DNA levels rise.
Q4-A 75-year-old man comes to the office with fatigue that has become progressively worse over the last several months. He is also short of breath when he walks up one flight of stairs. He drinks 4 vodka martinis a day. He complains of numbness and tingling in his feet. On physical examination he has decreased sensation of his feet. His hematocrit is 28% and his MCV is 114 fL (elevated).
What is the most appropriate next step in management?
A-Vitamin B12 level B-Folate level C-Peripheral blood smear D-Schilling test E-Methylmalonic acid level
Ans: C. although a macrocytic anemia could be from B12 or folate deficiency, direct alcohol effect on the bone marrow, or liver disease, the first step is a peripheral smear. This is to detect hypersegmented neutrophils. Once hypersegmented neutrophils are seen, then you would get B12 and folate levels.
Q5-A 75-year-old woman comes with decreased position and vibratory sensation of the lower extremities, a hematocrit of 28%, MCV of 114 fL, and hypersegmented neutrophils.Her B12 level is decreased, but near the borderline of normal. What is the most appropriate next step in the management of this patient?
A-Methylmalonic acid level B-Anti-intrinsic factor antibodies C-Anti-parietal cell antibodies D-Schillings test E-Folate level
Ans: A. USMLE Step 2 CK frequently tests the fact that while both B12 and folate deficiency increase homocysteine levels, only B12 is associated with an increased MMA.The B12 level can be normal in as many as a third of patients with B12 deficiency because the carrier protein, transcobalamin, is an acute phase reactant and can be elevated from many forms of stress such as infection, cancer, or trauma. When the story suggests B12 deficiency and the B12 level is equivocal, use an increased MMA level to confirm the diagnosis of vitamin B12 deficiency.
Q6-Which of the following is a complication of B12 or folate replacement?
A-Seizures B-Hemolysis C-Hypokalemia D-Hyperkalemia E-Diarrhea
Ans: C. Hyperkalemia from massive tissue or cellular breakdown has many causes. Hypokalemia from cell production is rare. When replacing B12 and folate, particularly if there is pancytopenia, cells in the marrow are produced so rapidly that the marrow packages up all the potassium, lowering the serum level. Observe and replace.
Q7-Which of the following can be found on smear in sickle cell disease?
A-Basophilic stippling B-Howell-Jolly bodies C-Bite cells D-Schistocytes E-Morulae
Ans: B. these are precipitated remnants of nuclear material seen inside the red cells of a patient who does not have a spleen. There is no change in therapy or management based on the presence of Howell-Jolly bodies. Basophilic stippling is associated with a number of causes of sideroblastic anemia, especially lead poisoning. Bite cells are seen in glucose 6 phosphate dehydrogenase deficiency. Schistocytes are fragmented red cells seen with intravascular hemolysis. Morulae are seen inside neutrophils in Ehrlichia infections.
Q8-A 46-year-old man with sickle cell disease is admitted with an acute pain crisis. His only routine medication is folic acid. His hematocrit on admission is 34%. On the third hospital day, the hematocrit drops to 22%.
What is the best initial test?
A-Reticulocyte count B-Peripheral smear C-Folate level D-Parvovirus B-19 IgM level E-Bone marrow
Ans: A. Patients with sickle cell disease usually have very high reticulocyte counts because of the chronic compensated hemolysis. Parvovirus B-19 causes an aplastic crisis which freezes the growth of the marrow. Nothing will be visible on blood smear. Although the bone marrow will show giant pronormoblasts, this would not be done routinely, and certainly never as the initial test. The first clue to parvovirus is a sudden drop in reticulocyte level.
Q9-A 57-year-old man comes to the emergency department for shortness of breath, blurry vision, confusion, and priapism. His WBC count is found to be 225,000/μL. The cells are predominantly neutrophils with about 4% blasts.
What is the most appropriate next step in the management of this case?
A-Leukapheresis B-BCR-ABL testing C-Bone marrow biopsy D-Bone marrow transplant E-Consult hematology/oncology F-Hydroxyurea
Ans: A. In acute leukostasis reaction, it is more important to remove the excessive white cells from the blood than to establish a specific diagnosis. Specific testing is not as important as treatment. No matter what the etiology, you still have to take the cells off. The symptoms are caused by blocking the delivery of oxygen to tissues because the red cells simply cannot get to the tissues. Afterward, you can establish a specific diagnosis. Hydroxyurea will lower the cell count, but not as rapidly as leukapheresis.
Q10-Which of the following is the most useful to determine dosing of chemotherapy in Hodgkin’s disease?
A-Echocardiogram
B-Bone marrow biopsy
C-Gender
D-MUGA or nuclear ventriculogram
Ans: D. Adriamycin (or doxorubicin) is cardiotoxic. The nuclear ventriculogram is the most accurate method of assessing left ventricular ejection fraction. Use the MUGA scan to determine whether cardiac toxicity has occurred prior to the development of symptoms.
Q11-A 69-year-old woman is admitted with severe back pain that has suddenly worsened. She also feels a “pop” when she coughs followed by tenderness over the ribs. X-ray shows lytic lesions. Her calcium level is 2 points above normal, the hematocrit is 27%, and her creatinine is elevated. Urinalysis shows trace protein, but the 24-hour urine show 5 grams of protein.
What do you expect to find on technetium bone scan?
A-Normal
B-Lytic lesions at the site of the fractures
C-Increased uptake diffusely
D-Decreased uptake
Ans: A. The radionuclide bone scan will be normal because lytic lesions do not pick up the nuclear isotope. Nuclear bone scan shows increased uptake with osteoblastic activity, which is absent in myeloma.
Q12-What is the explanation for the difference between the urinary level of protein on urinalysis and the 24-hour urine?
A-False positive 24-hour urine is common in myeloma.
B-Calcium in urine creates a false negative urinalysis.
C-Uric acid creates a false positive 24-hour urine.
D-Bence-Jones protein is not detected by dipstick.
E-IgG in urine inactivate the urine dipstick.
Ans: D. Bence-Jones protein is detected by urine immunoelectrophoresis. The urine dipstick will detect only albumin.
Q13-What is the single most accurate test for myeloma?
A-Skull x-rays B-Bone marrow biopsy C-24-hour urine D-SPEP (Serum Protein Electrophoresis) E-Urine immunoelectrophoresis (Bence-Jones protein)
Ans: B. Nothing besides myeloma is associated with greater than 10% plasma cells on bone marrow biopsy. The most common wrong answer is SPEP(Serum Protein Electrophoresis). Of those with an “M-spike” of immunoglobulins, 99% do not have myeloma. Most IgG spikes are from monoclonal gammopathy of unknown significance that does not progress or need treatment. Skull x-rays show lytic lesions, but this is not as specific as massive plasma cell levels in the marrow.
Q14-A 26-year-old woman comes to the emergency department with markedly increased menstrual bleeding, gum bleeding when she brushes her teeth, and petechiae on physical examination. Physical examination is otherwise normal. The platelet count is 17,000/μL.
What is the most appropriate next step in therapy?
A-Bone marrow biopsy B-Intravenous immunoglobulins C-Prednisone D-Antiplatelet antibodies E-Platelet transfusion
Ans: C. The bleeding in this case is mild, meaning there is no intracranial bleeding or major GI bleeding, and the platelet is not profoundly low. Prednisone is the best initial therapy. Initiating prednisone is more important than checking for increased megakaryocytes or the presence of antiplatelet antibodies, which is characteristic of ITP.
Q15-A 41-year-old man recently diagnosed with AIDS comes to the emergency department with pain on swallowing that has become progressively worse over the last several weeks. There is no pain when not swallowing. His CD4 count is 43 mm3.The patient is not currently taking any medications.
What is the most appropriate next step in management?
A-Esophagram B-Upper endoscopy C-Intravenous amphotericin D-Oral fluconazole E-Oral nystatin
Ans: D. The most commonly asked infectious esophagitis question is esophageal candidiasis in a person with AIDS. Oral candidiasis (thrush) need not be present in order to have esophageal candidiasis. One does not automatically follow from the other. Although other infections such as CMV and herpes can also cause esophageal infection, over 90% of esophageal infections in patients with AIDS are caused by Candida.Empiric therapy with fluconazole is the best course of action. If fluconazole does not improve symptoms, then endoscopy is performed. Intravenous amphotericin is used for confirmed candidiasis not responding to fluconazole. Oral nystatin swish and swallow is not sufficient to control esophageal candidiasis. Nystatin treats oral candidiasis.