Hematology
A 48-year-old man is evaluated as part of routine annual examination. Medical history is significant for hyperlipidemia. He has a 28-pack-year history of cigarette smoking. His only medication is pravastatin.
On physical examination, vital signs and other findings are normal.
Laboratory studies:
Hemoglobin 14.6 g/dL (146 g/L)
Leukocyte count 12,500/μL (12.5 × 109/L) (80% neutrophils, 15% lymphocytes, 5% monocytes)
Absolute neutrophil count 10,000/μL (10 × 109/L)
Platelet count 302,000/μL (302 × 109/L)
Peripheral blood smear is unremarkable.
Which of the following is the most likely cause of the patient's elevated leukocyte count?
A. Chronic myeloid leukemia
B. Occult infection
C. Pravastatin
D. Smoking
D. Smoking
A 34-year-old woman is evaluated in the emergency department for a 3-day history of increasing urinary frequency, urgency, and burning accompanied by right flank pain, fever, chills, nausea, and vomiting. She was treated with trimethoprim-sulfamethoxazole for cystitis 2 weeks ago. Medical history is also significant for nephrolithiasis. Her only other medication is an oral contraceptive pill. She reports experiencing a rash with amoxicillin in childhood, but no adverse reactions to cephalosporin medications.
On physical examination, temperature is 38.9 °C (102 °F), blood pressure is 92/60 mm Hg, and pulse rate is 96/min. Palpation elicits right-sided costovertebral angle punch tenderness.
Urinalysis reveals cloudy urine with greater than 100 leukocytes/hpf, 0-5 erythrocytes/hpf, and 4+ bacteria. A urine pregnancy test is negative.
Bilateral, nonobstructing, small ureteral-pelvic junction calculi are seen on kidney ultrasound.
Which of the following is the most appropriate intravenous treatment?
A. Aztreonam
B. Ceftriaxone
C. Ciprofloxacin
D. Levofloxacin
E. Trimethoprim-sulfamethoxazole
B. Ceftriaxone
A 37-year-old woman is evaluated for left knee pain. She is training for a marathon. The pain is worse toward the end of a run and also occurs when she goes down stairs. Ibuprofen has not provided any benefit.
On physical examination, crepitus is noted on range of motion testing of the left knee. Pain is reproduced with squatting and with palpation of and pressure on the patella. The remainder of the knee examination is normal.
Which of the following is the most appropriate treatment?
A. Arthroscopic surgery
B. Glucocorticoid injection
C. Knee brace
D. Physical therapy
D. Physical therapy
A 35-year-old woman is evaluated in the emergency department for sudden vision loss in the left eye. Two years ago, she had developed intermittent fever, myalgia, and chronic fatigue. She reports recent postprandial abdominal pain and effort-related left arm pain.
On physical examination, blood pressure is 160/100 mm Hg in the left arm and 130/80 mm Hg in the right arm. Pulse rate is 88/min. Radial pulse in the left arm is absent; left-sided subclavian bruit is present.
Laboratory studies reveal an erythrocyte sedimentation rate of 76 mm/h and a blood hemoglobin level of 9.2 g/dL (92 g/L).
Magnetic resonance angiogram of the chest and abdomen shows focal luminal narrowing in several areas, including the ascending aorta, left subclavian artery, superior mesenteric artery, and right renal artery.
Which of the following is the most likely diagnosis?
A. Cryoglobulinemic vasculitis
B. Giant cell arteritis
C. Polyarteritis nodosa
D. Takayasu arteritis
D. Takayasu arteritis
A 29-year-old man is evaluated in the emergency department for pain and discomfort with movement of his left eye that began yesterday morning. He awoke this morning with blurry vision and a dark spot in the center of the visual field of his left eye. He has no other medical problems and takes no medications.
On physical examination, vital signs are normal. Funduscopic examination is normal. Pupils are reactive, with an afferent pupillary defect in the left eye. Visual acuity is 20/20 in the right eye and 20/100 in the left eye with a central scotoma. There is no proptosis, conjunctival erythema, or pain on palpation of the orbit.
Results of laboratory studies show a normal leukocyte count and erythrocyte sedimentation rate.
Which of the following is the most likely diagnosis?
A. Central retinal artery occlusion
B. Giant cell arteritis
C. Optic neuritis
D. Orbital cellulitis
C. Optic neuritis
A 27-year-old woman is evaluated for shortness of breath and palpitations. She reports no chest pain, cough, or hemoptysis. She is pregnant at 34 weeks' gestation. Her only medication is a prenatal vitamin.
On physical examination, vital signs are normal. Oxygen saturation is 97% breathing ambient air. She has a gravid uterus. Lungs are clear to auscultation. She has no edema, erythema, or tenderness of the legs.
Laboratory studies show a D-dimer level of 0.88 μg/mL (0.88 mg/L).
Doppler ultrasonography of the legs is normal.
Which of the following is the most appropriate diagnostic test to perform next?
A. CT pulmonary angiography
B. Perfusion-only lung scan
C. Pulmonary MRI with gadolinium
D. Ventilation-perfusion lung scan
E. No further tests
E. No further tests
A 62-year-old man is evaluated for a fever. An indwelling urinary catheter was inserted during coronary artery bypass surgery 12 hours ago. Nurses obtained a urinalysis.
On physical examination, temperature is 38.1 °C (100.6 °F); the remainder of the vital signs and physical examination are noncontributory. The urinary catheter is removed.
Urinalysis shows 20 leukocytes/hpf.
Which of the following is the most appropriate management?
A. Obtain urine culture
B. Repeat urinalysis
C. Start empiric antibiotics
D. Clinical observation
D. Clinical observation
A 79-year-old woman is evaluated for weight loss. She is brought to the office by her niece, with whom she moved in 3 months ago. There are several adult family members in the home. The patient is able to ambulate short distances in the home with a walker. She does not toilet independently and requires assistance with feeding, bathing, and dressing. Current medical problems include type 2 diabetes mellitus, hypertension, and osteoarthritis. Medications are metformin, losartan, atorvastatin, and acetaminophen.
On physical examination, vital signs are normal. BMI is 22. The patient is disheveled. She speaks very little and only to answer yes-or-no questions. Dry mucous membranes are noted. The perineum is soiled with caked feces and urine, and skin in the area is erythematous. An early stage 2 sacral decubitus ulcer is noted. There is bruising on the right upper arm. The remainder of the examination is normal.
Which of the following is the most appropriate management?
A. Adult Protective Services referral
B. Enteral nutritional supplementation
C. Hwalek-Sengstock Elder Abuse Screening Test
D. Hydrocolloid wound dressing
A. Adult Protective Services referral
A 62-year-old man is evaluated for worsening exertional dyspnea and nonproductive cough over the past year. He has a 6-year history of seropositive rheumatoid arthritis. Current medications are tofacitinib, methotrexate, and folic acid.
On physical examination, vital signs are normal. Cardiac examination reveals normal jugular venous pressure and S2 without extra sounds. There are reduced breath sounds throughout the lung fields, with bibasilar inspiratory crackles. Lung percussion is resonant throughout. Joint examination shows advanced changes of rheumatoid arthritis involving the hands and wrists. The remainder of the examination is unremarkable.
Which of the following is the most likely cause of this patient's exertional dyspnea?
A. Heart failure
B. Interstitial lung disease
C. Pulmonary arterial hypertension
D. Rheumatoid arthritis pleural effusion
B. Interstitial lung disease
A 48-year-old man is evaluated for a 25-year history of headaches that have become increasingly frequent. Headaches previously occurred four to five times per month but now occur 16 to 20 times per month and last 12 to 24 hours. The headaches are bilateral, throbbing, moderate in intensity, aggravated by physical activity, and accompanied by photophobia and phonophobia. He has had no other associated symptoms. The patient takes amitriptyline and sumatriptan for the headaches and has been taking sumatriptan four to five times weekly for the past 3 months.
Physical examination findings, including vital signs, are all normal.
A brain MRI with contrast is normal.
Which of the following is the most appropriate next step in treatment?
A. Begin butalbital
B. Begin verapamil
C. Discontinue amitriptyline
D. Discontinue sumatriptan
D. Discontinue sumatriptan
A 40-year-old woman is hospitalized with acute shortness of breath. Medical history is significant for two pregnancy losses in the second trimester. Laboratory testing 3 months ago after her second pregnancy loss was positive for lupus anticoagulant, high titer IgG anticardiolipin antibodies, and high titer IgG anti–β2-glycoprotein antibodies. She is otherwise well and takes no medications.
On physical examination, pulse rate is 120/min and respiration rate is 20/min; oxygen saturation is 92% breathing ambient air.
Laboratory studies show a positive lupus anticoagulant, high-titer IgG anticardiolipin antibodies, and high-titer IgG anti–β2-glycoprotein antibodies.
CT angiography shows a pulmonary embolism in the right main pulmonary artery.
Low-molecular-weight heparin is initiated.
Which of the following is the most appropriate long-term treatment?
A. Dabigatran plus aspirin
B. Rivaroxaban
C. Warfarin
D. Warfarin plus inferior vena cava filter
C. Warfarin
A 30-year-old man is hospitalized for sudden onset of severe left biceps swelling and pain beginning 36 hours ago, which has rapidly progressed in the past 6 hours. He also reports fever and chills. Medical history is significant for daily subcutaneous (“skin popping”) heroin use into the left biceps. He takes no medications.
On physical examination, temperature is 38.7 °C (101.7 °F), blood pressure is 110/60 mm Hg, pulse rate is 110/min, and respiration rate is 24/min. The left biceps area is exquisitely tender, with associated edema, warmth, and overlying ecchymotic bullous lesions; crepitus and induration are appreciated with palpation.
CT imaging reveals gas in deep tissues.
Piperacillin-tazobactam and vancomycin are initiated, and the patient is taken for surgical debridement where necrotizing fasciitis and myonecrosis are confirmed; subsequent cultures identify Clostridium perfringens.
Which of the following is the most appropriate antibiotic treatment?
A. Ceftazidime plus doxycycline
B. Ciprofloxacin plus doxycycline
C. Penicillin plus clindamycin
D. Current antibiotics
C. Penicillin plus clindamycin
A 32-year-old man is evaluated in the emergency department for low back pain of several weeks' duration. The pain is in the lumbar area and does not radiate. He has no other symptoms. Medical history is significant for injection drug use.
On physical examination, temperature is 37.4 °C (99.4 °F); other vital signs are normal. Pain is present with gentle palpation of L3 and L4. The pain worsens with hyperextension or flexion of the spine. Marks from injection drug use are seen on the forearms. The remainder of the examination is normal.
Interferon-γ release assay, HIV test results, and blood and urine cultures are pending.
Which of the following is the most appropriate next step in management?
A. CT of the lumbar spine
B. Empirical antibiotic therapy
C. MRI of the lumbar spine
D. Radiography of the lumbar spine
C. MRI of the lumbar spine
A 30-year-old woman is seen in follow-up. She was diagnosed with systemic lupus erythematosus 12 years ago. She was treated for lupus nephritis, which is now quiescent. Clinical and laboratory findings have been stable for 5 years, with no disease flares. Medications are hydroxychloroquine and azathioprine.
Which of the following health risk assessments should be performed now?
A. Breast cancer
B. Cardiovascular disease
C. Iron overload
D. Pulmonary disease
B. Cardiovascular disease
A 47-year-old man is evaluated in the emergency department for a prolonged seizure. According to the family, the initial seizure lasted for 3 minutes and stopped, but the patient did not regain consciousness and a second generalized tonic-clonic seizure started within 5 minutes and has continued. The patient received 4 mg intravenous lorazepam in the ambulance on the way to the hospital. In the emergency department, the seizure continues and he receives an additional 4 mg of intravenous lorazepam followed by another 2 mg 10 minutes later without benefit. The patient has a history of generalized tonic-clonic seizures treated with levetiracetam.
On physical examination, blood pressure is 147/92 mm Hg, pulse rate is 122/min, and respiration rate is 18/min. Oxygen saturation with the patient breathing ambient air is 90%. Pupils are reactive. Clonic seizure activity persists.
Twenty minutes have elapsed since admission to the emergency department. The patient is intubated, an intravenous line is placed, a blood specimen is obtained, and fingerstick glucose is obtained (126 mg/dL [7.0 mmol/L]).
Which of the following is the most appropriate additional management?
A. Head CT
B. Immediate continuous electroencephalography
C. Intravenous fosphenytoin
D. Rectal administration of diazepam
C. Intravenous fosphenytoin
A 46-year-old woman is evaluated following discovery of an elevated hemoglobin level. She is asymptomatic, her history is unremarkable, and she takes no medications.
On physical examination, vital signs are normal. The spleen tip is palpable.
Laboratory studies:
Erythropoietin 2 mU/mL (2 U/L)
Hematocrit 51%
Hemoglobin 17 g/dL (170 g/L)
Leukocyte count 7000/μL (7 × 109/L)
Platelet count 750,000/μL (750 × 109/L)
Genetic testing is positive for the JAK2 V617F mutation.
Low-dose aspirin is started. Phlebotomy is scheduled.
Which of the following is the most appropriate additional management?
A. Hydroxyurea
B. Imatinib
C. Interferon-α
D. Ruxolitinib
E. No further management
E. No further management
A 24-year-old woman is evaluated for HIV pre-exposure prophylaxis. She shares needles and other equipment for injection drug use. She has one sexual partner who is HIV negative; she uses condoms regularly.
Vital signs and physical examination are normal.
Laboratory studies:
Fourth-generation HIV-1/2 antigen/antibody combination assay Negative
Hepatitis B surface antibody Positive
Hepatitis B surface antigen Negative
Hepatitis C antibody Negative
A urine pregnancy test is negative.
The patient is counseled regarding consistent condom use and use of clean needles and equipment. She is referred to substance abuse treatment.
Which of the following is the most appropriate additional management?
A. Tenofovir alafenamide, emtricitabine, and darunavir
B. Tenofovir alafenamide or tenofovir disoproxil fumarate
C. Tenofovir disoproxil fumarate and emtricitabine
D. No additional management
C. Tenofovir disoproxil fumarate and emtricitabine
A 47-year-old man is evaluated in the hospital after treatment for acute alcoholic pancreatitis. During the hospitalization, he is diagnosed with moderately severe alcohol use disorder. Medical history includes hypertension. He has been prescribed antihypertensives in the past but struggled with medication adherence; he recognizes this as a potential problem. Medical history is otherwise unremarkable, and screens for depression, other mood disorders, and additional substance use disorders are negative. He takes no medications at the present time.
He agrees to attend a 12-step facilitation program after hospital discharge, but he is concerned that it will not help sufficiently.
Which of the following is the most appropriate additional treatment?
A. Bupropion
B. Injectable naltrexone
C. Lorazepam
D. Oral naltrexone
B. Injectable naltrexone
A 26-year-old woman is evaluated for a 3-month history of increasing left hip pain that is worse with prolonged standing. Systemic lupus erythematosus was diagnosed 5 years ago, characterized by small joint arthralgia, malar rash, cytopenias, and Raynaud phenomenon. At diagnosis she required high-dose prednisone, hydroxychloroquine, and azathioprine therapy. Prednisone dosage was tapered over 6 months. Periodic flares have been treated with increased dosages of prednisone. Current medications are hydroxychloroquine, azathioprine, and low-dose prednisone.
On physical examination, internal rotation and full flexion of the left hip are limited and elicit pain. The remainder of the examination is normal.
Complete blood count, erythrocyte sedimentation rate, and serum complement levels are normal. Anti–double-stranded DNA antibody titer is low and has been unchanged for 6 months.
Radiograph of the left hip is normal.
Which of the following is the most appropriate management?
A. Change azathioprine to mycophenolate mofetil
B. Increase prednisone dosage
C. MRI of left hip
D. Physical therapy
C. MRI of left hip
A 73-year-old woman is evaluated for progressive left arm weakness. One year earlier, she noted difficulty with fine movements of her left hand. Within a few months, her entire left upper extremity became stiff and slow, such that she now cannot use this limb. Her left leg has also become rigid. She notes brief jerky movements of her left arm. She takes no medication.
On physical examination, vital signs are normal. Language and memory are intact, but she speaks slowly and has difficulty with multistep commands. Results of cranial nerve testing, including extraocular movements, are normal. Muscle strength is preserved throughout. Her left upper and lower extremities are rigid and slow. Her left hand is forced into a bent position and cannot be opened by the examiner. She needs support during ambulation because of stiffness of her left leg. Her sensory perception is preserved, but she cannot identify an object placed into her left hand when her eyes are closed. Cerebellar examination findings, plantar response, and deep tendon reflexes are unremarkable.
Which of the following is the most likely diagnosis?
A. Amyotrophic lateral sclerosis
B. Corticobasal degeneration
C. Multiple system atrophy
D. Parkinson disease
E. Progressive supranuclear palsy
B. Corticobasal degeneration
A 32-year-old woman is evaluated for dyspnea with exertion of 2 weeks' duration. Medical history is significant for systemic lupus erythematosus. Family history is unremarkable. Her only medication is hydroxychloroquine.
On physical examination, blood pressure is 98/60 mm Hg and pulse rate is 107/min; other vital signs are normal. Oxygen saturation is 98% breathing ambient air. Other than tachycardia, the physical examination is normal.
Laboratory studies:
Haptoglobin Undetectable
Hemoglobin 9.8 g/dL (98 g/L)
Leukocyte count 4200/μL (4.2 × 109/L)
Platelet count 125,000/μL (125 × 109/L)
Reticulocyte count 15% of erythrocytes
Lactate dehydrogenase 475 U/L
Peripheral blood smear shows spherocytes.
Which of the following is the most appropriate diagnostic test to perform next?
A. ADAMTS13 activity and inhibitor
B. Bone marrow biopsy
C. Direct antiglobulin test
D. Osmotic fragility test
C. Direct antiglobulin test
A 35-year-old man is evaluated for potential anthrax exposure. He was informed that three coworkers with whom he has had no close contact are being evaluated for suspected anthrax. Medical history is notable for a torn Achilles tendon that was repaired 9 months ago. He takes no medications.
On physical examination, vital signs are normal, and the examination is unremarkable.
A chest radiograph is normal.
Which of the following is the most appropriate management?
A. Ciprofloxacin and raxibacumab
B. Doxycycline and anthrax vaccination
C. Doxycycline, meropenem, ciprofloxacin, and raxibacumab
D. Isolation
E. Clinical observation
B. Doxycycline and anthrax vaccination
A study compares a new treatment for symptom reduction in fibromyalgia versus treatment with pregabalin over a 1-year period. The target symptom reduction on a standard symptom inventory was reached in 30% of patients in the new treatment group and 25% of patients in the pregabalin group. However, 15% of patients in the new treatment group had to discontinue the treatment because of adverse effects; treatment was discontinued for this reason in 5% of patients in the pregabalin group.
Which of the following is the number needed to treat for one patient to benefit from the new medication for fibromyalgia?
A. 10
B. 20
C. 30
D. 40
B. 20
A 62-year-old man is evaluated in the hospital for an arthrocentesis-confirmed diagnosis of acute polyarticular gout involving the right knee, left ankle, and forefoot. Joint fluid Gram stain and culture were negative. He was hospitalized 4 days ago with heart failure complicated by pulmonary embolism. He has a history of recurrent acute gout. The first night of his hospital stay, he developed polyarticular gout that has not responded to appropriate prednisone doses. He also has hypertension, hyperlipidemia, type 2 diabetes mellitus, and stage G3a chronic kidney disease; he underwent kidney transplantation 10 years ago. Current medications include low-molecular-weight heparin, metoprolol, losartan, furosemide, insulin glargine, and tacrolimus.
The right knee, left ankle, and forefoot are swollen, tender, and warm.
Which of the following is the most appropriate treatment?
A. Anakinra
B. Colchicine
C. Intra-articular triamcinolone
D. Naproxen
A. Anakinra
A 20-year-old woman is evaluated for intermittent double vision that occurs when she looks from the corner of her eyes and disappears when she covers one eye. She also reports fluctuating weakness and frequent nausea and diarrhea. She has had a history of exercise intolerance and intermittent muscle cramps since middle school. She also has postural orthostatic tachycardia syndrome, irritable bowel syndrome, and fibromyalgia. Her sister, brother, mother, and maternal aunt have similar muscle, neurologic, and multiorgan symptoms, but her father and a second brother do not. Current medications are propranolol and duloxetine.
On physical examination, vital signs are normal. BMI is 20. There is bilateral impairment of ocular adduction along with bilateral ptosis. Lower facial muscles show weakness. Muscle tone is reduced, but deep tendon reflexes are preserved. Proximal weakness is noted in all extremities. There is no delayed relaxation with grip or percussion. Mental status, sensory examination, and coordination are intact.
Electromyogram shows myopathic changes.
Which of the following is the most likely diagnosis?
A. Acid maltase deficiency
B. Becker muscular dystrophy
C. Inclusion body myositis
D. McArdle disease
E. Mitochondrial myopathy
E. Mitochondrial myopathy