View source for WBR0820

 {{WBRQuestion
|QuestionAuthor=Vendhan Ramanujam
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Hematology, Oncology, Hematology, Oncology
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Hematology, Oncology, Hematology, Oncology
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Hematology, Oncology, Hematology, Oncology
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Hematology, Oncology, Hematology, Oncology
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Hematology, Oncology, Hematology, Oncology
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Hematology, Oncology, Hematology, Oncology
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Hematology, Oncology, Hematology, Oncology
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Hematology, Oncology, Hematology, Oncology
|Prompt=A 49 year old Caucasian male presents to his physicians office with complaints of intermittent fever, night sweats, fatigue and itching for the past 2 months.  He denies similar illness in his past or among any family members and any recent history of travel.  He smokes one pack of cigarette and drinks a glass of wine everyday.  His vital signs are heart rate 88 beats/min, respiratory rate 16/minute, blood pressure 120/80 mm Hg and oral temperature 36.8 C.  On physical examination there is diffuse, nontender lymphadenopathy, including small supraclavicular, epitrochlear, and scalene nodes.  A chest x-ray revealed a hilar lymphadenopathy. The next best step in evaluation is<BR>
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[[File:Non-Hodgkin lymphoma Lymphadenopathy.jpg|left|300px]]<BR>
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|Explanation=The long-term nature of symptoms like intermittent fever, night sweats, fatigue (B symptoms) along with itching, nontender nodes and their location, including scalene and supraclavicular loci, all suggest the likelihood of malignancy.  Excisional biopsy is necessary to rule out malignancy, particularly [[lymphoma]].  Hence Toxoplasmosis, Epstein-Barr virus and Cytomegalovirus are unlikely causes of this clinical picture.

'''Educational Objective:'''
Symptoms like intermittent fever, night sweats, fatigue (B symptoms) along with itching, nontender nodes and their location, including scalene and supraclavicular loci, for a long term, suggest the likelihood of malignancy.  Excisional biopsy is necessary to rule out malignancy, particularly lymphoma.
|AnswerA=Angiotension converting enzyme
|AnswerAExp='''Incorrect'''-[[Angiotensin converting enzyme]] test would be a nonspecific evidence for [[sarcoidosis]], which can be a possible diagnosis.  But the nature of symptoms will warrant a lymph node biopsy to rule out malignancy as the next best step in evaluation.
|AnswerB=Monospot test
|AnswerBExp='''Incorrect'''-[[Infectious Mononucleosis]] due to [[Ebstein-Barr virus]] follows a contact with individuals with pharyngitis.  They present with fatigue, malaise and sore throat.  Low-grade fever is usually present and chills are relatively uncommon. Anorexia, nausea and vomiting are the accompanying symptoms.  Early physical examination findings will include pharyngitis and posterior cervical lymphadenopathy while late findings will include tender hepatomegaly and splenomegaly.
|AnswerC=Excisional lymph node biopsy
|AnswerCExp='''Correct'''-Symptoms like intermittent fever, night sweats, fatigue (B symptoms) along with itching, nontender nodes and their location, including scalene and supraclavicular loci, for a long term, suggest the likelihood of malignancy that requires an excisional biopsy.
|AnswerD=Toxoplasmosis IgG
|AnswerDExp='''Incorrect'''-[[Toxoplasmosis]] will present with symptoms like fatigue and sore throat along with physical findings like unilateral localized lymphadenopathy and splenomegaly.
|AnswerE=CMV blood culture
|AnswerEExp='''Incorrect'''-[[Cytomegalovirus]] can present similar to infectious mononucleosis like fatigue, malaise, sore throat, low-grade fever, pharyngitis, posterior cervical lymphadenopathy, tender hepatomegaly and splenomegaly.
|RightAnswer=C
|WBRKeyword=Lymphoma, Sarcoidosis, Infectious Mononucleosis, Ebstein-Barr virus, Toxoplasmosis, Cytomegalovirus
|Approved=Yes
}}