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November 24, 2020

Question Recap:  A 57-year-old man presents to clinic with left hand and right foot pain. His symptoms started 24 hours ago. During the past three days, he has been feeling a tingling sensation in both affected extremities. His medical history is significant for diabetes mellitus and hypertension.

His blood pressure is 150/90 mmHg, pulse 85/min, respiratory rate 15/min, and temperature 98F. Upon physical examination, there are varicose veins in the right leg with stasis dermatitis and an absence of pain sensation in the right leg with preserved vibratory sensation. Cranial nerve examination is unremarkable. Reflexes are normal in both arms but absent in both ankles.

Laboratory results include: hemoglobin 11 g/dL, hematocrit 40%, platelets 145,000/cc, RPR nonreactive, homocysteine 10 umol/L, methylmalonic acid (MMA) 0.1 umol/L, creatinine 0.9 mg/dL, sodium 140 mEq/L, potassium 3.7 mEq/L, INR 0.9.

What is the most likely diagnosis?

Responses Received from Members (411 Total):

November 24th results graph


 

 

 

 

 

Correct Response is: D. Mononeuritis multiplex

Question Explanation:  The most likely diagnosis in this diabetic patient with multiple asymmetric peripheral neuropathy is mononeuritis multiplex. Mononeuritis multiplex is a painful asymmetrical sensory and motor peripheral neuropathy. It affects two or more nerves in the body located at two separate but distinct anatomical locations. Long nerves like sciatic, tibial, radial, and ulnar are affected first. In advanced cases, shorter nerves are affected and the disease is more symmetrical in nature.

Mononeuritis multiplex is commonly present in PAN, diabetes, SLE, and other connective tissue diseases, or with vascular inflammation. Clinical manifestations in a patient with a disease strongly associated with mononeuritis multiplex is often sufficient to make the diagnosis, but the most accurate test is biopsy of the nerve in the affected area. Treatment is directed towards the underlying cause. If symptoms persist, tricyclic antidepressants, gabapentin, or pregabalin can be used. Steroids are not effective.

ALS does not affect sensory neurons. MS does not affect the peripheral nervous system. The hands are not affected in L5 radiculopathy. The only two diseases that affect the posterior column are syphilis and vitamin B12 deficiency. However, the RPR is nonreactive in this patient and neither the MMA nor homocysteine levels are elevated, thus excluding syphilis and vitamin B12 deficiency, respectively.

Defects of the posterior column would affect position and vibratory sense, and this question specifically says vibratory sense is preserved.


November 17, 2020

Question Recap:  A 46-year-old woman presents to clinic for follow-up. She was diagnosed with celiac disease six months ago, but her symptoms improved after adhering to a gluten-free diet. Endoscopy with biopsy showed no lymphoma. Her vitals are normal and physical exam is unremarkable. She has no other medical conditions and does not smoke or drink.

Which of the following vaccinations should be administered at this time?

Responses Received from Members (497 Total):

November 17th results graph


 

 

 

Correct Response is: E. Pneumococcus

Question Explanation:  Hyposplenism (functional asplenia) is common in celiac disease, and vaccination against encapsulated microorganisms like pneumococcus and meningococcus is warranted regardless of age.

Shingles vaccine is recommended at age 50, and the age cut-off for HPV vaccine is 45. Celiac disease patients are not at an increased risk for HBV or HAV. However, all diabetics should receive HBV vaccine and men who have sex with men as well as homeless persons should get HAV vaccine.


November 10, 2020

Question Recap:  A 69-year-old woman with a history of depression, congestive heart failure, and mitral valve replacement surgery presents to clinic with fatigue. Her blood pressure is 115/75 mmHg, pulse 68/min, respiratory rate 14/min, and temperature 98F.

Upon physical examination, there is no jugular venous distention, and the lungs are clear. Her heart exam reveals a laterally displaced point of maximum impulse and 2/6 crescendo-decrescendo systolic murmur at the left sternal border. Laboratory results include hemoglobin 10 g/dL, hematocrit 30%, WBC 5,000/cc, platelet 205,000/cc, MCV 96 fL, reticulocyte count 8%, and creatinine 0.9 mg/dL. Her aPTT, PT, and INR are within normal range. Peripheral blood smear is obtained and shown below.

Blood smear image

What is the best next step in the management of this patient?

Responses Received from Members (450 Total):

November 10 2020 results graph


 

 

 

 

 

Correct Response is:  A.  Obtain echocardiogram

Question Explanation:  The correct answer is obtain echocardiogram. The peripheral blood smear in this case shows schistocytes, which is consistent with microangiopathic hemolytic anemia (MAHA). The differential diagnosis of MAHA includes thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), disseminated intravascular coagulation (DIC), uncontrolled hypertension, and prosthetic valvular disease.

This patient does not have fever, thrombocytopenia, neurologic changes, or renal disease, so TTP and HUS are unlikely. Additionally, she does not have hypertension, and her coagulation parameters are normal, so DIC is also unlikely.

MAHA in a patient with a prosthetic valve requires evaluation with an echocardiogram to ensure that the valve is functioning properly and rule out the need for valve replacement.


November 3, 2020

Question Recap:  A 27-year-old man with pancytopenia is found to have hypocellularity and absence of hematopoietic cells on bone marrow biopsy. Cytogenetic analysis of the bone marrow does not reveal abnormalities. Despite red blood cell and platelet transfusions, his pancytopenia worsens. He is an only child and his parents died in a motor vehicle accident when he was a teenager.

What is the best next step in the management of this patient?

Responses Received from Members (492 Total):


 

 

 

 

 

Correct Response is:  A.  Antithymocyte globulin, cyclosporine, and prednisone.

Question Explanation:  The correct answer is antithymocyte globulin, cyclosporine, and prednisone.

This patient has aplastic anemia, which is characterized by the T-cells attacking the bone marrow. While supportive treatment with transfusions is necessary, most aplastic anemia cases are not self-limited and have high recurrence rate.

Allogeneic bone marrow transplantation is the most efficacious option for patients with a suitable donor because survival rate is greater than 90%. If a marrow transplantation from a live match is not an option, a combination regimen consisting of antithymocyte globulin, cyclosporine (T-cell suppressor), and prednisone is the treatment of choice because the response rate is 75-85%.This patient has no donors.

Alemtuzumab is a monoclonal antibody against CD52 also used in the treatment of aplastic anemia.

Eculizumab is a monoclonal antibody against C5 compliment used in the treatment of hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria, and myasthenia gravis. It is not efficacious against aplastic anemia.

You cannot do an autologous bone marrow transplantation when the person is not producing bone marrow.


October 27, 2020

Question Recap:  A 63-year-old man with a history of diabetes presents to clinic with two weeks of fatigue and right foot pain. His blood pressure is 130/80 mmHg, pulse 85/min, respiratory rate 15/min, and temperature 100F.  Upon physical examination, there is a one-inch ulcer on the dorsal surface of the first metatarsal with surrounding erythema. Rectal examination reveals heme-positive stool. X-ray of the right foot shows periosteal elevation of the first metatarsal.
Laboratory results include: hemoglobin 12 g/dL, hematocrit 32%, MCV, 81 fL, WBC 12,200/cc (83% neutrophils and 17% lymphocytes), platelets 350,000/mm3, creatinine 1.1 mg/dL, serum iron 25 mg/dL (low), TIBC 80 mg/dL (low), ferritin 250 ng/mL.

Which of the following is the best option to treat this patient’s anemia?

Responses Received from Members (484 Total):


 

 

 

 

Correct Response is:  A.  Bone biopsy and IV antibiotics

Question Explanation:  The correct answer is Bone biopsy and IV antibiotics. The most likely diagnosis in this case is anemia of chronic disease (ACD) due to osteomyelitis. The iron and TIBC are low, but the ferritin is normal. The most effective treatment of this anemia is correcting the underlying cause. In this case, antibiotic therapy is the treatment of choice.
Osteomyelitis takes weeks to progress, and therefore it is appropriate to biopsy the bone and obtain a culture in order to determine the best therapy. In the absence of sickle cell disease, the most common cause of osteomyelitis is Staphylococcus. Parenteral therapy with cefazolin or ceftriaxone is best when the bacteria is sensitive. Vancomycin, dalbavancin, oritavancin or linezolid are used in case of MRSA infection. If the infection is caused by Gram-negative rods such as E. coli, oral fluoroquinolone agents such as ciprofloxacin can be used only after testing for sensitivity.
Parenteral iron is incorrect because ferritin level above 100 ng/mL is not usually seen in patients with iron deficiency anemia even with associated inflammation. Iron therapy is not appropriate for treatment of ACD because it is a state of distribution dysfunction rather than an actual iron deficiency.
Erythropoietin is incorrect because it will not address the infection.
Blood transfusion is not indicated in cases of ACD. This patient’s labs and clinical presentation are inconsistent with megaloblastic anemia; therefore, vitamin B12 supplementation is not indicated.


October 20, 2020

Question Recap:  A 60-year-old man presents to clinic with dyspnea on exertion and fatigue. His laboratory results show: hemoglobin 7 g/dL, hematocrit 17%, RBC 3 million/uL, reticulocyte count 4%. The cell shape is normal. WBC count is normal.

Which of the following drugs is this patient most likely taking?

 

Responses Received from Members (515 Total):

 

 

 


 

 

Correct Response is:  B. Methotrexate

Question Explanation:  The correct answer is methotrexate. This patient presents with anemia and an elevated reticulocyte percentage. An increased reticulocyte percentage could be hemolytic anemia. Drugs such as ribavirin cause hemolysis, which gives an increased reticulocyte percentage. However, the reticulocyte count should first be corrected before making the final diagnosis. To correct the reticulocyte count, the reticulocyte index (RI) is calculated.

RI = Reticulocyte Count x (Hematocrit/Normal hematocrit)
RI = 4 x (17/45)
RI = 1.5

In the presence of anemia, RI count < 2 indicates decreased production of RBCs (hypoproliferative sate). Methotrexate causes bone marrow suppression and is the most likely cause of the anemia. Methotrexate is the only choice associated with decreased red cell production.

In the presence of anemia, RI > 2 indicates increased hemolysis. However, this patient’s RI is 1.5, excluding ribavirin as the cause of anemia.

Warfarin overdose can cause acute hemorrhage. Metformin is associated with vitamin B12 malabsorption that could lead to megaloblastic anemia. Megaloblastic anemia is associated with both hypersegmentation of neutrophils and macro-ovalocytes, neither of which are present here.

PPIs, such as omeprazole, are not associated with marrow suppression or hemolysis.


October 13, 2020

Question Recap:  A 50-year-old male undergoes his first colonoscopy and was found to have a firm sub-epithelial lesion in the distal colon (see picture). An ultrasound guided fine needle aspiration (FNA) was performed which revealed spindle cells that stained positive for CD117. He has no significant medical history, and his family history is unremarkable. He does not drink or smoke and is up to date with all age-appropriate vaccines.

What is the most likely diagnosis?

Responses Received from Members (450 Total):

 

 


 

 

Correct Response is:  D. Stromal Tumor

Question Explanation:  Stromal tumor is a sub-epithelial lesion arising from the interstitial Cajal cells in the muscularis propria. The lesion is typically hypoechoic on ultrasound with cystic spaces indicating necrosis in large or malignant lesions. The majority of cases are due to activation of the proto-oncogene c-KIT. FNA is required for diagnosis and CD117 is the hallmark histopathological finding that establishes the diagnosis. Leiomyoma stains positive for desmin. Schwannoma stains positive for S100. Adenocarcinoma is the most common type of colon cancer and does not stain positive for CD117. Carcinoid is of the small, not large, intestine.


October 6, 2020

Question Recap:  A 47-year-old man presents to clinic with two months of anal pain, especially during bowel movements. His symptoms persisted despite extra hydration; increased fiber intake; and 12-week treatment with stool softeners,  topical calcium channel blockers, and nitroglycerin. He is monogamous with his cis-female wife and only has vaginal/oral sex. Vital signs are within normal range. Physical examination of the rectum is shown below.

What is the best next step in the management of this patient?

Responses Received from Members (471 Total):

 

 


 

 

Correct Response is:  A. Colonoscopy

Question Explanation:  The correct answer colonoscopy.  The physical examination of the rectum shows a posterior midline fissure that is persistent despite optimum medical treatment and lifestyle modification. Patients who do not respond to more than eight weeks of medical therapy should undergo colonoscopy to exclude Crohn’s disease, since it is a common cause of anal fissures, especially those that do not heal with medical therapy.

Hemorrhoids usually present with pruritus and painless bleeding. If pain is present, it is more likely due to vein thrombosis. Rubber band ligation is reserved for symptomatic hemorrhoids refractory to medical management.

Anal ulcer biopsy is performed to rule out cancer, which is associated with perianal fistulas accompanied by excessive granulation tissue. Anal cancer takes years to develop, and this patient’s symptoms started only two months ago, so malignancy is unlikely.

RPR is used to diagnose syphilis. However, this patient is low risk for STDs and lacks the typical signs and symptoms of syphilis infection such as painless chancre or a rash on the soles of hands and feet.

The cut-off age for HPV vaccine is now 45. This patient is beyond the recommended age. Additionally, anal HPV infection causes condyloma accuminata and warts that are usually painless.


 

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