NYACP/MedQuest Board Review Question of the Week

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April 13, 2021

Question Recap:  A 60-year-old man presents to clinic with back pain that started a few weeks ago. He tried over the counter analgesics with some relief, but the pain persisted. His father was diagnosed with colon cancer at the age of 65. The patient has no significant medical history. His vital signs are normal and his physical exam reveals no hepatomegaly or splenomegaly. There are no skin rashes, and he is up to date with all age appropriate vaccines. Laboratory results include: hemoglobin 8.7 g/dL, MCV 85 fL, platelets 200,000/cc, sodium 142 mEq/L, potassium 4 mEq/L, chloride 107 mEq/L, HCO3 23 mEq/L, calcium 11.5 mg/dL, creatinine 2.1 mg/dL, albumin 4.0 mg/dL. Serum electrophoresis does not reveal an M-spike. Spine X-ray is shown below.

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

Responses Received from Members (530 Total):

Correct Response is:  D.    Urine immunofixation

Question Explanation:  The most likely diagnosis in this case is multiple myeloma. Bone pain, hypercalcemia, normocytic anemia, and renal insufficiency are suggestive of the diagnosis. Multiple myeloma diagnosis is confirmed with serum electrophoresis (detecting M-spike) and urine electrophoresis (detecting light and heavy chains). However, 1 in 4 multiple myeloma patients secrete only urine light chains, which does not produce M-spike on serum electrophoresis. Thus, urine immunofixation is necessary to detect monoclonal light chains.
Bone marrow biopsy is sometimes used quantitatively to determine the number of plasma cells. It is most useful in the rare multiple myeloma patient who does not secrete monoclonal proteins (non-secretory multiple myeloma). However, this is an invasive procedure and the patient must be thoroughly investigated through urine immunofixation before undergoing bone marrow biopsy.
Chest and abdomen CT scans are used to look for bone disease among multiple myeloma patients who present with bone pain but have negative X-ray. This patient’s X-ray shows compression fracture at the L4 level; therefore a CT scan is unnecessary. Once a fracture is confirmed with X-ray, a CT does not give additional information.
Persons with no family history of colon cancer should start colonoscopy screening at the age of 50 and every 10 years thereafter. Those with family history of colon cancer should start screening at the age of 40, or 10 years younger than the age at which the relative got diagnosed, whichever comes earlier. Colonoscopy will not alter the course of management in this multiple myeloma case.
Tramadol is a prodrug that is converted by the CYP450 system into morphine and another metabolite that inhibits the reuptake of norepinephrine and serotonin.

April 6, 2021

Question Recap:  A 65-year-old man presents to clinic with dyspnea on exertion and tension headaches. His symptoms started eight weeks ago. He is retired and lives alone. His medical history is significant for GERD, COPD, and hypertension. He used to smoke one pack of cigarettes daily but quit 10 years ago. He drinks beer socially. His BP is 150/90 mmHg, pulse 87/min, respiratory rate 15/min, O2 saturation 90% (room air). His BMI is 31. Physical exam is unremarkable.

Laboratory results include hemoglobin 20 g/dL, serum erythropoietin (EPO) 95 IU/L (3x upper normal limit).

Which of the following is most likely to determine a diagnosis?

Responses Received from Members (533 Total):

Correct Response is:  C. Exercise Oxygen Saturation

Question Explanation:  The most likely diagnosis in this case is secondary polycythemia, evidenced by the high hemoglobin level and elevated EPO. In primary polycythemia or polycythemia vera (PCV), the hemoglobin is raised but the EPO is not. The most common cause of primary PCV is JAK2 mutation, which can be confirmed by bone marrow biopsy and JAK2 testing.
In secondary polycythemia, both hemoglobin and EPO are raised. Causes of secondary polycythemia include:

• Chronic hypoxemia
• EPO producing tumors
• Androgen supplements
• Growth hormone administration

The most likely cause in this case is COPD induced hypoxemia, which in turn stimulates the kidney to produce EPO. The confirmatory test is post-exercise oxygen saturation, which will be markedly decreased. Abdomen CT is used to look for EPO-producing tumors in the kidney or liver if the exercise oxygen saturation is normal.
Upper endoscopy is not useful in the diagnosis of PCV.

March 30, 2021

Question Recap:  A 67-year-old man presents to clinic with frequent urination and nocturia. His symptoms began one month ago and have progressively worsened. He has a history of benign prostatic hyperplasia (BPH), congestive heart failure (CHF) with reduced ejection fraction, and GERD. There is no dysuria or hematuria. He takes metoprolol, furosemide, lisinopril, and omeprazole. His blood pressure is 140/70 mmHg, pulse 73/minute, respiratory rate 13/minute. Pulmonary examination reveals bilateral basal crackles and bilateral lower extremity edema.

Laboratory results include: sodium 140 mEq/L, potassium 4.1 mEq/L, and serum creatinine 1 mg/dL. Prostate specific antigen (PSA) is elevated. Urinalysis is normal. Transthoracic echo reveals LVEF greater than 25%.

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

Responses Received from Members (426 Total):

Correct Response is:  D. Increase furosemide dose

Question Explanation:  This BPH patient has worsening urination symptoms as well as evidence of deteriorating CHF (bilateral edema, and pulmonary crackles). Volume overload should be corrected with appropriate doses of diuretic. Other causes that worsen BPH include COPD exacerbation and pneumonia. BPH is a common cause of elevated PSA.
Oxybutynin is a muscarinic receptor antagonist that can be used to treat urinary urgency incontinence. However, the first step is to correct volume status by increasing the diuretic’s dose. If BPH and associated symptoms do not improve after addressing the fluid overload status, alpha-1 receptor antagonists (tamsulosin) or 5-alpha reductase inhibitors (finasteride) can be used to control the symptoms.
Sacubitril is a neprilysin inhibitor used to treat CHF with reduced ejection fraction and lower mortality, similar to ACE inhibitors. Switching between these two classes will not address the fluid overload status and urinary symptoms in this case.

March 23, 2021

Question Recap:  A 43-year-old woman presents with a six-month history of diarrhea and weight loss. The patient’s tissue transglutaminase antibody is positive, and upper endoscopy with biopsy confirms the diagnosis. She has no other medical issues and does not drink or smoke. Vital signs are normal and physical exam is unremarkable.

What should be obtained at this time?

Responses Received from Members (521 Total):

Correct Response is:  C. T-score

Question Explanation:  This patient is at risk for early onset osteoporosis secondary to vitamin D malabsorption, which is common among celiac disease patients. The deficiency in vitamin D results in hyperparathyroidism which leads to bone disease. Thus, DEXA scan should be obtained at the time of diagnosis of celiac disease. Biopsy is also crucial to rule out T-cell lymphoma. In addition to gluten-free diet, celiac patients with bone disease should receive vitamin D and calcium supplementation. None of the other answer options in this case are indicated in celiac disease and will not change the management of this patient.
If the tissue transglutaminase antibody and the small bowel biopsy are abnormal, there is no point in doing a D-Xylose test. D-Xylose testing is a non-specific method of assessing whether the bowel wall is intact.
Steroids to do not help celiac disease which is caused by IgA attacking the bowel wall. Steroids do not help any IgA mediated illness; this is why they have little or no efficacy in Henoch-Schonlein purpura or IgA nephropathy.

March 16, 2021

Question Recap:  A 60-year-old man presents to clinic with a three-month history of bloating and persistent watery diarrhea. He has also had a few episodes of fecal incontinence during sleep. There is no fever, rectal pain, or abdominal tenderness. He has not traveled outside the U.S and is not sexually active. He was diagnosed with type 1 diabetes at the age of 21 and is on insulin plus metformin. A year ago, he was treated with 12 weeks of sofosbuvir plus ledipasvir for HCV infection and achieved SVR12.

Vitals are normal. Physical examination is unremarkable except for absent vibratory sensation in both feet.

Laboratory results include: Hemoglobin 11 mg/dL, hematocrit 35%, leukocytes 7,200/cc, albumin 3.5 g/dL, ALT 15 U/L, AST 19 U/L, HbA1c 7.5%, TSH 3.5 mU/L, HIV Ag/Ab combo negative, hepatitis C virus (HCV) Ab positive, INR 0.9. Stool is negative for occult blood and parasites. Stool culture does not grow pathogenic bacteria. Upper and lower endoscopies are unremarkable.

What is the most likely diagnosis?

Responses Received from Members (487 Total):

Correct Response is:  A. Intestinal bacterial overgrowth

Question Explanation:  The most likely diagnosis in this case of long-standing diabetes mellitus is autonomic neuropathy leading to diabetic diarrhea and small intestine bacterial overgrowth. Intestinal hypomotility with fluid hypersecretion leads to bacterial overgrowth and loss of normal peristaltic movements, resulting in watery diarrhea and fecal incontinence. Severe cases can be associated with lactose intolerance and malabsorption of nutrients and vitamins. The loss of vibratory sensation in this patient is most likely attributable to vitamin B12 deficiency.
Diabetic diarrhea in the absence of intestinal bacterial overgrowth is a diagnosis of exclusion (stool studies and endoscopy should be performed first) and treated with anti-motility agents like loperamide. Patients who have diabetic diarrhea and intestinal bacterial overgrowth should be treated with anti-motility agents and antibiotics like rifaximin.
Both celiac disease and microscopic colitis are common in diabetes. However, this patient’s upper and lower endoscopies are negative, which effectively rules out both these conditions.
IBS is associated with alternating painful episodes of diarrhea and constipation, and pancreatic insufficiency is associated with steatorrhea but not watery diarrhea or fecal incontinence.

March 9, 2021

Question Recap:  A 55-year-old woman presents to clinic with fatigue and occasional gingival bleeding. Her symptoms started a few weeks ago. She was diagnosed with breast cancer five years ago and received cyclophosphamide, doxorubicin, and paclitaxel. She also takes lansoprazole for GERD and metformin for type 2 diabetes mellitus. BP is 110/60 mmHg, pulse is 77/min, and respiratory rate is 14/min. Her BMI is 31. Physical exam is unremarkable. Laboratory results include: hemoglobin 9.1 g/dL, MCV 95 fL, platelets 32,000/cc, leukocytes 19,000/cc, neutrophils 50%, eosinophils 2%, lymphocytes 35%, monocytes 10%, sodium 135 mEq/L, potassium 4.1 mEq/L, creatinine 1.3 mg/dL, albumin 3.5 g/dL, alkaline phosphatase 70 u/L, ALT 19 u/L AST 21 u/L, INR 1.0, HbA1c 6.4%. Peripheral blood smear is shown below.

What is the most likely diagnosis?

Responses Received from Members (470 Total):

Correct Response is:  B. Anthracycline toxicity

Question Explanation:  Thrombocytopenia, leukocytosis, and myeloblasts on peripheral blood smear are all suggestive of acute myeloid leukemia (AML). Approximately 20% of AML cases are related to chemotherapy exposure. Anthracycline-induced leukemias are dose related, typically present 5-10 years post-treatment and are usually preceded by myelodysplastic syndrome. Anthracyclines are also associated with cardiomyopathy. Doxorubicin is an anthracycline agent.

Metformin (biguanide) blocks the calcium-dependent binding of vitamin B12 to the intrinsic factor in the intestines, resulting in decreased vitamin B12 absorption, which can cause megaloblastic anemia, hypersegmented neutrophils, and peripheral neuropathy, none of which exists in this case.

Bone metastasis can occur in breast cancer in which the alkaline phosphatase is typically greatly elevated. This patient’s alkaline phosphatase is not elevated and the blood smear is more consistent with AML. The lack of schistocytes make microangiopathic anemia an unlikely diagnosis.

Paraneoplastic syndrome in breast cancer includes scleroderma, nephrotic syndrome, and cerebral dysfunction, none of which exist in this patient. Additionally, paraneoplastic syndrome in breast cancer does not cause myeloblasts on peripheral blood smear.

Anthracycline induced AML has poor prognosis because it does not respond well to AML treatment or bone marrow transplant (unlike de novo AML).

March 2, 2021

Question Recap:  A 51-year-old man presents to clinic with fatigue and upper left quadrant pain. His symptoms began two months ago. He has non-valvular atrial fibrillation for which he takes apixaban. He has never been hospitalized or traveled outside the continental U.S. Vital signs are within normal range. Physical exam reveals hepatosplenomegaly. Laboratory results include: hemoglobin 8.3 g/dL, MCV 87 fL, platelets 110,000/cc, leukocytes 6.900/cc, alkaline phosphatase 350 u/L. Peripheral blood smear is shown below.

What is the most likely diagnosis?

Responses Received from Members (509 Total):

Correct Response is:  D. Primary myelofibrosis

Question Explanation:  Normocytic anemia, hepatosplenomegaly, and teardrop cells on peripheral blood smear are all consistent with primary myelofibrosis. Primary myelofibrosis causes overproduction of megakaryocytes and stromal cells in the bone marrow. Because tissue growth factors and cytokines are initially released in the bone marrow, patients will eventually have anemia and thrombocytopenia as fibrotic tissue replaces healthy marrow. Hepatosplenomegaly is due to extramedullary hematopoiesis.
The clinical presentation and blood smear are inconsistent with chronic myeloid leukemia (immature granulocytes, basophilia, and thrombocytosis), acute myeloid leukemia (M3 protein and Auer rids), or disseminated intravascular coagulopathy (schistocytes).

Myelodysplastic syndrome does not usually present with hepatosplenomegaly or teardrop cells.

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