MKSAP Questions of the Week

Oncology Q 18

A 56-year-old man is evaluated for an enlarging, painful inguinal lymph node he first noticed 1 month ago. He has a history of follicular lymphoma of 8 years' duration. The patient was treated in the past with two courses of rituximab 8 and 3 years ago with durable partial responses. For the past 3 years, he had stable diffuse adenopathy managed with observation. He has no other symptoms. On physical examination, vital signs are normal. The patient has diffuse adenopathy in the neck, axillae, and right inguinal area and a new left inguinal conglomerate nodal mass measuring 5 × 7 cm. Complete blood count and metabolic profile are normal. PET/CT scan shows diffuse uptake in axillary, mediastinal, hilar, and mesenteric nodes with elevated standardized uptake values in the 4 to 12 range, but 28 in the left inguinal area.

Publish date: 12/01/2021

Infectious Diseases Q 12

A 26-year-old woman is seen for follow-up discussion of test results. Three days ago, she was evaluated for a 1-week history of a nonpruritic rash that appears to be resolving since the initial evaluation. The patient reports no recent history of oral or genital ulcers. She is transgender. She has multiple sexual partners (men and women) and reports consistent use of condoms except for oral sex. Medical history is notable for two instances of gonorrhea and treatment for early latent syphilis 1 year ago. Medications are combination tenofovir-emtricitabine. On physical examination, temperature is 37.9 °C (100.2 °F); other vital signs are normal. Enlarged cervical, axillary, and epitrochlear lymph nodes are present. Faint, erythematous macules and papules are spread over the trunk and extremities; a few lesions are noted on the left palm. Rapid plasma reagin (RPR) is 1:128; RPR 3 months ago was 1:2. Testing of urine and throat and anal swabs for gonorrhea and chlamydia is negative. HIV testing is negative.

Publish date: 11/17/2021

Gastroenterology Q 3

A 50-year-old man is evaluated for newly developed ascites. He has cirrhosis due to nonalcoholic steatohepatitis. Paracentesis confirms cirrhosis as a cause of the ascites and excludes infection, and a low-sodium diet is implemented. Medical history includes type 2 diabetes mellitus, hypertension, and dyslipidemia. Current medications are metformin, lisinopril, and atorvastatin. On physical examination, vital signs are normal. The abdomen is nontender and mildly distended, with normal bowel sounds. Serum creatinine level is 1.1 mg/dL (97.2 μmol/L). Random urine protein-creatinine ratio is 16 mg/g. Which of the following is the most appropriate additional treatment?

Publish date: 11/10/2021


A 70-year-old woman is evaluated for pain in the left great toe that has been present for 5 years and has steadily worsened. The pain is exacerbated by standing for long periods and wearing shoes with higher heels. At times the toe becomes inflamed, and throbbing pain may persist throughout the day and night. Oral and topical NSAIDs do not help. She is otherwise well and takes no medications. Findings on physical examination are shown. No palpable masses or interdigital clicks are observed when the foot is compressed.

Publish date: 11/04/2021

General IM Q11

An 82-year-old man is evaluated during a routine evaluation. He is accompanied to the visit by his son. The patient lives alone, and his son expresses reservations about his father continuing to drive. The patient no longer drives after dark or on the interstate highway. He limits his driving to within a 10-mile radius of his home and mainly drives for local errands and to church on Sundays. He has had no traffic accidents, but he had two recent incidents in which he misjudged the angle of his car in the grocery store parking lot and ran into the shopping cart stand. Medical history is significant for coronary artery disease, hypertension, and mild cognitive impairment. Medications are atorvastatin, aspirin, hydrochlorothiazide, lisinopril, and metoprolol. On physical examination, blood pressure is 132/82 mm Hg, and pulse rate is 64/min; other vital signs are normal. The patient appears frail with a pleasant demeanor. He wears eyeglasses and hearing aids, and he has impaired hearing as measured by the whispered voice test. On musculoskeletal examination, limited mobility of the cervical spine is noted. He scores 26/30 on the Mini–Mental State Examination. The remainder of the examination is unremarkable.

Publish date: 10/28/2021

General IM Q10

A 32-year-old woman is evaluated during a domestic airline flight for an episode of weakness and lightheadedness. She is pregnant at 35 weeks' gestation. She has had several contractions since take-off but without regularity. She reports no abdominal pain. She has no medical problems, and her only medication is a prenatal vitamin. On physical examination, the patient appears weak. Temperature is normal, blood pressure is 105/60 mm Hg, pulse rate is 99/min, and respiration rate is 14/min. Her skin is clammy. Cardiovascular examination is unremarkable. Lungs are clear to auscultation. On abdominal examination, she has a gravid uterus. Oxygen, 2 L/min by nasal cannula, is started. An intravenous line is placed, and fluids are initiated

Publish date: 10/20/2021

General IM Q9

A 22-year-old man is evaluated during a pre-employment examination. The patient is starting a new job as a registered nurse. He is asymptomatic. He received the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine 7 years ago and the influenza vaccine during the last influenza season. Approximately 6 months ago, he received one dose of the measles, mumps, and rubella (MMR) vaccine because of lack of documented immunity on serologic testing. Medical history is negative for chronic medical conditions. He is a nonsmoker, and he does not plan to travel outside of the United States in the near future. He takes no medications. Physical examination is normal. Laboratory studies are significant for a positive result on a hepatitis B surface antibody test. Hepatitis B surface antigen, hepatitis B core antibody, and hepatitis A IgG antibody levels are undetectable.

Publish date: 10/13/2021

General IM Q8

A 68-year-old man is evaluated for fever, perineal pain, dysuria, frequency, and intermittent straining that began yesterday. Symptoms began 48 hours after a prostate biopsy due to an elevated prostate-specific antigen level detected during routine screening. On physical examination, temperature is 38.7 °C (101.7 °F), blood pressure is 145/82 mm Hg, pulse rate is 105/min, and respiration rate is normal. The prostate is enlarged and boggy, and it is tender to gentle palpation. There is no penile discharge, and no scrotal pain occurs with palpation. Dipstick urinalysis is positive for leukocyte esterase and nitrates. Urine Gram stain reveals gram-negative rods. Urine culture is pending.

Publish date: 10/07/2021

General IM Q6

A 52-year-old man is evaluated for a 2-day history of painless red eye, which began on the right side and quickly spread to the left. He reports that his eyes have a thin mucopurulent discharge and that his eyelids are matted shut in the morning upon waking. He has had no photophobia, change in visual acuity, or itching in the eyes, but he has experienced some mild rhinorrhea. He does not use contact lenses. He is sexually monogamous. Medical history is significant for type 2 diabetes mellitus treated with metformin. On physical examination, vital signs are normal. There is redness of the sclerae bilaterally, with a white crust-like residue along the edges of the eyelids. The tarsal vessels are obscured by the conjunctival erythema. Visual acuity is intact, and there is no tenderness around the globes.

Publish date: 10/01/2021

General IM Q5

A 23-year-old woman is evaluated for depression as she prepares for discharge from the hospital to home hospice care. She was diagnosed with metastatic ovarian cancer 2 years ago, and she progressed through four lines of chemotherapy, a trial of immunotherapy, and a failed attempt at a phase 1 clinical trial. Her life expectancy is measured in weeks. She is currently hospitalized with volume depletion, and after consultation with her oncologist and palliative care team, she has decided to be discharged home with hospice care. On physical examination, the patient exhibits substantial fatigue and poor concentration. She has a flat affect except when intermittently tearful. Previously upbeat despite all of the setbacks, she is now withdrawn and describes feeling hopeless. She has pervasive guilt over the burden she believes she has caused her family. Medications are a fentanyl patch, oxycodone, ondansetron, polyethylene glycol, senna, and zolpidem.

Publish date: 09/23/2021

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