NYACP Board Review Question of the Week

Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam.  Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.

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May 5th, 2026

MKSAP 19 Extension Questions Set 4, Question 1

A 72-year-old woman is evaluated for progressive fatigue of 3 months' duration. She has additionally noted mild left upper quadrant abdominal discomfort for the past month that is accompanied by early satiety. She has lost 6.8 kg (15 lb) since symptom onset. Medical history is significant for hypertension, and her only medication is hydrochlorothiazide.

On physical examination, vital signs are normal. Conjunctival pallor is noted. There is bruising on the lateral surfaces of the arms and legs. Splenomegaly is present 10 centimeters below the left inferior costal margin.

Laboratory studies:    
Activated partial thromboplastin time    31 s
Haptoglobin    109 mg/dL (1090 mg/L)
Hemoglobin    6.8 g/dL (68 g/L)
Leukocyte count    175,000/μL (175 × 109/L) (78% neutrophil, 0% lymphocytes,
8% basophils, 6% eosinophils)
Platelet count    22,000/μL (22 × 109/L)
Prothrombin time    11.9 s
Fibrinogen    227 mg/dL (2.27 g/L)
Lactate dehydrogenase    1272 U/L
 

Which of the following is the most appropriate diagnostic test to perform next?

A.    ADAMSTS13 activity
B.    Peripheral blood flow cytometry
C.    Peripheral blood smear
D.    Reverse transcriptase polymerase chain reaction for BCR:ABL1

Responses Received from Members (Graph is uploaded on Thursday afternoon):

The Correct Answer is: D. Reverse transcriptase polymerase chain reaction for BCR:ABL1

Educational Objective: Diagnose chronic phase chronic myeloid leukemia.

A reverse transcriptase polymerase chain reaction (RT-PCR) test for the BCR-ABL translocation to confirm the diagnosis of chronic myelogenous leukemia (CML) is the most appropriate diagnostic study to perform (Option D). CML is a clonal hematopoietic stem cell disorder defined by the presence of the Philadelphia chromosome, a reciprocal translocation of the ABL gene on chromosome 9, to the BCR gene on chromosome 22, resulting in a BCR-ABL fusion gene. Patients with CML often present with asymptomatic neutrophil elevation on routine laboratory testing, but may also experience symptoms such as weight loss, splenomegaly, fatigue, or fever.

A leukocytosis demonstrating elevations in the levels of myeloid-lineage leukocytes (such as neutrophils, basophils, or eosinophils) and thrombocytosis are often present. BCR-ABL studies are the key tools for diagnosing Philadelphia chromosome-positive CML and for differentiating CML from other myeloid neoplasms. RT-PCR tests are both sensitive and specific in diagnosing Philadelphia chromosome- positive CML. Direct bone marrow biopsy for molecular, flow cytometric, and morphologic evaluation are also important for differentiating CML from acute myeloid leukemia and classifying CML as chronic, accelerated, or blast phase. This patient's clinical presentation and available peripheral blood studies suggest leukocytosis consistent with chronic myeloid leukemia, and a RT-PCR BCR:ABL1 test is the best way of confirming the diagnosis.

ADAMSTS13 activity studies measure the activity of a zinc-containing metalloprotease enzyme important in cleaving von Willebrand factor. Reduced activities of ADAMSTS13 are associated with thrombotic thrombocytopenic purpura (TTP). Despite the presence of both anemia and thrombocytopenia, this patient's presentation is more consistent with CML than TTP given the presence of leukocytosis and the lack of intravascular hemolysis, as demonstrated by normal haptoglobin. ADAMSTS13 activity study would not be appropriate for this patient (Option A).
Peripheral blood flow cytometry is often most helpful in differentiating acute and chronic leukemia and ascertaining the phase of CML (Option B). Although peripheral blood flow cytometry could detect abnormalities present in the leukocyte count, it cannot fully prove the presence of CML and therefore would not be an appropriate diagnostic test for this patient.
A peripheral blood smear (Option C) is important for assessing morphologic changes and evaluating hematologic abnormalities but is neither as sensitive nor specific in diagnosing CML compared to RT- PCR for the BCR-ABL gene. At diagnosis, testing peripheral blood is as accurate as bone marrow samples.

Key Point

• Chronic myeloid leukemia is defined by the presence of the Philadelphia chromosome, a reciprocal translocation of the ABL gene on chromosome 9, to the BCR gene on chromosome 22, resulting in a BCR-ABL fusion gene.
• Patients with chronic myeloid leukemia may present with asymptomatic neutrophil elevation on routine laboratory testing, but can also experience symptoms such as weight loss, splenomegaly, fatigue, or fever.

Bibliography

Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2025 American College of Physicians. All Rights Reserved All Rights Reserved.

April 21st, 2026

MKSAP 19 General Internal Medicine 1, Question 29

A 74-year-old woman is evaluated before hospital discharge. She was hospitalized 3 days ago for surgical repair of a left hip fracture after a fall. She has been evaluated by physical and occupational therapists and is thought to be unsafe for discharge home, where she lives alone, because of her inability to safely stand with a walker and ambulate in the hospital room. Her tolerance for physical therapy is estimated to be less than 3 hours per day. Medical history is significant for hypertension and prior stroke with residual right-sided weakness. She required a cane to ambulate before the fall. Medications are aspirin, amlodipine, atorvastatin, and acetaminophen as needed for pain.

On physical examination, blood pressure is 130/80 mm Hg and pulse rate is 78/min. Physical examination confirms the findings of the physical and occupational therapists and reveals frailty and right-sided arm and leg weakness. There is a healing surgical incision on the left hip.

Which of the following is the most appropriate management of this patient?

A.    Continue care in the hospital until she is able to ambulate safely
B.    Discharge home with home physical and occupational therapy
C.    Discharge to a skilled nursing facility
D.    Discharge to an acute rehabilitation hospital

Responses Received from Members (694 Responses):

The Correct Answer is: C. Discharge to a skilled nursing facility

Educational Objective: Select an appropriate level of care for posthospital rehabilitation.

Subacute rehabilitation in a skilled nursing facility (Option C) is most appropriate for this frail older woman who no longer requires acute inpatient hospital care. In this setting, she can gradually improve her functional status over a period of up to 100 days, such that she can be discharged to independent living. Her current functional status, coupled with a medical history of preexisting functional impairment due to stroke, suggests that she requires a rehabilitation environment that allows for a slow recovery pace.

Continued care in the inpatient setting (Option A), where rehabilitation resources are limited, is not a reasonable or cost-effective strategy for this patient, whose medical condition no longer substantiates a need for acute inpatient treatment.

For this patient to be discharged home with outpatient or home physical and occupational therapy (Option B), she would need to be able to function unsupervised or have continuous assistance to compensate for any functional deficiencies. This patient lives alone and has demonstrated that she is in need of supervision when working with therapists in the inpatient setting.

Discharge to an acute rehabilitation hospital (Option D) would require that the patient be able to participate in 3 hours of therapy on 5 days per week. A clinical estimation of her tolerance for therapy is less than 3 hours daily.

Key Point

• In patients requiring posthospitalization care to improve functional status who cannot tolerate 3 hours of physical or occupational therapy on 5 days per week, subacute rehabilitation is an appropriate option.

Bibliography

Boland L, Légaré F, Perez MM, et al. Impact of home care versus alternative locations of care on elder health outcomes: an overview of systematic reviews. BMC Geriatr. 2017;17:20. PMID:

28088166 

Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2025 American College of Physicians. All Rights Reserved All Rights Reserved

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Last Updated:  5.1.26