GI Clinical Questions (Clin Med Exam 3)

A 25-year-old man presents for evaluation of intermittent chest pain. He reports a burning sensation in his chest 1-2 days per week after eating. The symptoms are worse with large meals, eating late at night, and excessive alcohol consumption. He denies difficulty swallowing, weight loss, night sweats, chest pain, use of tobacco, or coughing up blood. His vital signs and physical examination are unremarkable. Most appropriate treatment?

H2 blockers/dietary modifications then can try PPI

A 27-year-old woman presents with intermittent epigastric pain of 6 months duration. She explains that her pain worsens 2 hours after eating breakfast, particularly cereal and other milk products. She also endorses symptoms of diarrhea, flatulence, and postprandial bloating. Upon physical exam, temperature is 98.1°F, blood pressure is 120/80 mm Hg, and there are no signs of epigastric pain on light or deep palpation. Diagnosis?

Lactose intolerance

A 36-year-old woman presents with a 24-hour history of sudden severe diarrhea described as profuse, gray, cloudy, watery stools without blood or fecal odor. She was recently in Bangladesh for work and returned yesterday, which was when the diarrhea began. She is also experiencing a mildly elevated temperature with a very dry mouth, headache, and severe fatigue. most likely pathogen?

Vibrio cholerae

A 3-year-old boy presents with his mother; she reports that he is unable to walk without support. He is an only child who rarely leaves his tenth-floor apartment home. On examination, he has a rachitic rosary and genu valgum. Diagnosis?

Vitamin D deficiency

A 49-year-old woman presents with dysphagia. She is having difficulty swallowing both liquids and solids; she also notes regurgitation of undigested food. X-ray reveals a bird's beak appearance of the esophagus. diagnosis?

achalasia

A 35-year-old Hispanic man presents due to a sore that will not heal around his rectum and anal area. This lesion has been draining pus consistently for the last week. He has had intermittent pain with this lesion (4/10 on a 0-10 pain scale) that is made slightly worse when he has a bowel movement (ranking it a 6/10). More recently, especially in the last few days, he has noted pain increases with just sitting. The patient also admits to intermittent periods of itching. He denies fever or diarrhea. No past medical history of inflammatory bowel disease. Physical examination of the anorectal area reveals excoriated and inflamed perianal skin with a palpated induration. Diagnosis?

anorectal fistula.

A 35-year-old man has a routine physical examination with no abnormal findings. His family history, however, is positive for familial adenomatous polyposis. Best screening test?

colonoscopy

An obese 45-year-old woman presents with intermittent epigastric pain of 3 weeks duration. She explains that her pain worsens in the evenings and when lying down in bed. Her pain worsens when she eats chocolate. Upon physical exam, temperature is 98.1°F, blood pressure is 120/80 mm Hg, and there are no signs of epigastric pain on light or deep palpation. Diagnosis?

GERD

A 20-year-old female college student presents due to a 7-day history of daily heartburn. She has never experienced heartburn as bad as she does currently. She is treating it with over-the-counter histamine-2 receptor antagonist, famotidine, 1 tablet daily. The patient denies any other significant past medical history and is currently taking a daily multivitamin and an antihistamine for seasonal allergies. She recently admits to having increased episodes of headaches that she believes are due to stress. For this reason, she has been taking ibuprofen 600 mg every 8 hours. She states that she has been taking this consistently every 8 hours for the last 10 days; she hopes that her headaches will subside after finals are finished. She also states that she was given amoxicillin 2 weeks ago for a middle ear infection, which resolved without any further intervention. She denies any difficulty swallowing, weight loss, night sweats, chest pain, black tarry stool, use of tobacco or alcohol, or coughing up blood. Physical examination is unremarkable. What medication is most likely causing her increased gastrointestinal symptoms?

NSAID (GERD)

A 66-year-old man with a history of obesity and hyperlipidemia presents with an 8-month history of progressing "burning in his chest." This sensation is noted in the midline of his chest, and it is provoked when he bends over, when he wears tight clothing, after he eats a large meal, and when lying supine. He denies any chest pressure, cough, shortness of breath, palpitations, dizziness, lightheadedness, and diaphoresis. His physical examination is unremarkable. An upper endoscopy is performed. An upper endoscopy is performed and inflammation in the esophagus is noted. Treatment?

PPI

A 58-year-old man with a history of COPD, hyperlipidemia, a 40 pack-year smoking history, and obesity is being evaluated at his primary care office for complaints of post-prandial regurgitation that is associated with an acidic sensation in his mouth and a chronic, nonproductive cough, all of which have been occurring over the past year. He has taken over the counter famotidine (Pepcid) without any relief. He denies any fever, chills, changes in weight, diaphoresis, chest pain, shortness of breath, sputum, palpitations, abdominal pain, or changes in bowel habits. His physical exam reveals an obese BMI, but it is otherwise unremarkable. His stool hemoccult is negative. Bloodwork reveals an iron-deficiency anemia; a chest radiogram was without pulmonary disease. An upper barium esophagram noted an outpouching of barium at the lower end of the esophagus and a wide hiatus through which gastric folds are visible above the diaphragm. H. pylori antibody testing and urea breath tests were negative. Most effective treatment?

PPI (hiatal hernia)

A 52-year-old man presents with a 3-day history of persistent diarrhea, having up to 7 watery bowel movements without bleeding a day. He has associated lower-abdominal cramping and notes mild nausea. He denies travel outside of the country. He does not recall eating anything unusual, and none of his family members are sick. Past medical history is significant for GERD, for which he takes pantoprazole daily. He recently had an upper respiratory infection and completed a course of oral levofloxacin approximately 3 weeks ago. A stool sample is obtained. Stool is negative for ova and parasites, but PCR testing is positive for Clostridium difficile.

Vanco

A 65-year-old man with a past medical history of hypertension, chronic arthritis, and herniated lumbar discs presents with a 1-week history of severe, tearing pain to his rectal area that occurs while he defecates. Following his bowel movement, he notes relief of the tearing pain, but he feels a throbbing sensation in the area. He has noted small drops of bright red blood on the toilet paper. He presently takes amlodipine and hydrochlorothiazide for hypertension as well as hydrocodone-acetaminophen for pain. He has noticed a reduced frequency of bowel movements of late due to pain. The physical examination is notable for a 5-mm midline crack-like lesion at the anus in the 6 o'clock position. The remainder of the physical exam is unremarkable. Diagnosis?

anal fissure

A 35-year-old Hispanic man presents due to a sore that will not heal around his rectum and anal area. This lesion has been draining pus consistently for the last week. He has had intermittent pain with this lesion (4/10 on a 0-10 pain scale) that is made slightly worse when he has a bowel movement (ranking it a 6/10). More recently, especially in the last few days, he has noted pain increases with just sitting. The patient also admits to intermittent periods of itching. He denies fever or diarrhea. No past medical history of inflammatory bowel disease. Physical examination of the anorectal area reveals excoriated and inflamed perianal skin with a palpated induration. diagnosis?

anal fistula

A 50-year-old man presents with a 3-month history of weakness, fatigue, and abdominal discomfort. He acknowledges a lack of sexual desire. He denies any photosensitivity. On physical examination, his liver is enlarged, and his spleen is palpable. He has abnormal skin pigmentation on his face, neck, and elbows that gives his skin a metallic gray hue. What complication is associated with patient's condition ?

hepatocellular carcinoma (hemachromatosis)

A 33-year-old woman presents for an annual physical. She has past medical history of GERD, asthma, and irritable bowel syndrome. She drinks 1-2 alcoholic beverages per week and has never smoked; she does not use illicit drugs, and she consumes a vegetarian diet. Her past surgical history includes an appendectomy at age 14. Her father passed away from a heart attack at age 63. Her mother is alive with history of colorectal cancer, which was diagnosed at age 41.' recommended colorectal cancer screening?

immediate (she is already 33 and mom was diagnosed at 41...should start 10 years before)

A 45-year-old man presents with extreme asthenia and weight loss. He has been suffering from celiac disease for the past 12 years. He is at the highest risk of developing what type of intestinal malignancy?

intestinal lymphoma

A 40-year-old man presents with a 2-year history of severe, burning epigastric pain. A detailed history reveals that the pain is greatest in the early hours of the morning and wakes him up from sleep. The pain is also felt 2-3 hours after meals. He reports diarrhea for the past 2 years. On examination, his pulse is 74/min and blood pressure 136/84 mm Hg. There is slight epigastric discomfort on palpation. Lab examination shows hyperchlorhydria. source of his symptoms?

intestinal ulcers secondary to gastrinoma (Zollinger-Ellison disease)

A 2-year-old boy presents with acute abdominal pain. The boy has passed stool with blood and mucus and has vomited. He has had intermittent severe abdominal pain, which has caused inconsolable crying and drawing up of his legs in episodes of 15-20 minutes. On examination, the abdomen is tender diffusely with guarding and bowel sounds are absent. He has a fever of 100.5°F. The boy is taken to surgery. diagnosis ?

intussesecption

A 6-week-old male infant presents with a 2-day history of vomiting after every feeding of cow's milk-based formula with iron, 4 ounces per feeding. There has been no fever, diarrhea, or other symptoms except increased crying. The child appears alert and hungry. The mother describes the vomiting as forceful, traveling about 2 feet. Physical evaluation reveals minimal tear production with mild skin tenting. Bowel sounds are decreased. BUN 29 mg/dL; serum sodium 129 mg/dL; serum potassium 3.4 mg/dL; serum chloride 89 mg/dL; serum bicarbonate 34 mg/dL. next step in patient care?

iv fluids and ultrasound (pyloric stenosis)

A 61-year-old man with known cirrhosis presents with a 1-week history of "puffy" ankles and increased shortness of breath. A week before symptom onset, he was on vacation, where he engaged in walking, sightseeing, and eating out. He admits more dyspnea with lying down and with increased exertion. His shoes feel snug, and he notes a definite line from wearing socks. The patient denies chest pain, leg pain, fevers, claudication, nausea, headache, lethargy, and hemoptysis. His past medical history is remarkable for cirrhosis and a history of alcoholism. He is awaiting a liver transplant. He had a liver biopsy, but no other surgeries. He takes no medications, has no allergies, and has abstained from alcohol for 9 months. He lives with his wife, works as an electrician, and smokes a pack of cigarettes per day. Vitals are normal, including oxygen saturation. On physical exam, the patient appears in no acute distress and with normal mental status. His physical exam is remarkable for mild jugular venous distention, 2-3+ edema in lower extremities, and mild dullness to lung percussion. No hepatomegaly or ascites are noted. once stable, how should your patient manage this condition?

low sodium intake

A 57-year-old woman is undergoing a workup by her primary care provider for abdominal pain. The pain is in her left lower quadrant, intermittent, "crampy," and has been present for about 2 months. As an initial imaging study, she underwent an abdominal ultrasound. The ultrasound was unremarkable except for the presence of a few small (<1 cm) stones in her gallbladder. She is currently following up to discuss the results of the ultrasound. Most likely suggested for treatment?

no treatment

A 35-year-old man presents with a groin mass. The patient states that the mass is painless; there is no known trauma to the region. The mass is present when the patient stands, and it disappears when the patient is lying flat. Past medical history is significant for obesity, hypertension, and hyperlipidemia. Past surgical history is significant for lipoma removal from the left shoulder. The patient denies tobacco use; he tells you that he drinks about 6 beers per week. In office ultrasound confirms diagnosis and surgical repair is scheduled. Most significant risk factor for this patient's condition?

obesity (inguinal hernia)

A 10-year-old boy presents with a 2-month history of intermittent burning pain in the epigastrium. Pain is felt more during the night and between meals; it is partly relieved by eating food or by taking antacids. Pain usually lasts 30-60 minutes and is accompanied by nausea and vomiting. He often has a feeling of bloating and burping. He remains asymptomatic for several days between. There is no history of taking analgesics or anti-inflammatory drugs. Physical examination shows epigastric tenderness. The rest of the examination is essentially normal. Stool examination for occult blood is positive. Diagnosis? Diagnostic study?

peptic ulcer; Upper GI endoscopy

A 47-year-old man presents with abdominal pain and difficulties breathing. He has a history of alcohol abuse and confirmed cirrhosis of the liver. On examination, you see a malnourished and jaundiced patient with a distended belly. Percussion of the abdomen reveals a huge amount of fluid and wave sign Primary cause of ascites?

portal hypertension

A 16-year-old girl with a 2-year history of ulcerative colitis presents with signs of an acute exacerbation: abdominal pain and frequent passing of large quantities of blood and mucus from the rectum. It is treated with sulfasalazine, glucocorticoids, and intravenous alimentation. Diarrhea decreases markedly, but her status continues to deteriorate. Tachycardia, volume depletion, and electrolyte imbalance develop; temperature is 101.8° F. Physical examination finds abdominal tenderness but no mass. Plain radiography shows the transverse colon is dilated up to 7 cm. next best step?

preform colectomy (toxic megacolon)

A 45-year-old woman presents with diarrhea and vomiting that started last evening. She says she warmed up leftover rice for supper last night and symptoms began shortly thereafter. She has no fever, and her blood pressure and pulse are within normal limits. how would you treat? pathogen

reassurance, instructions for rehydration b cereus

A 15-year-old girl presents with a 1-year history of intermittent abdominal pain with nausea and occasional bloody diarrhea. She denies fever and weight loss; there is no travel history. Past medical history is significant only for migraines. She takes a multivitamin. Her vital signs are within normal limits. She has mild diffuse abdominal tenderness to palpation and guaiac-positive stool. Her exam is otherwise normal. Her hemoglobin is 9.7, hematocrit is 28%, WBC is 12,000/uL. Next best step in management?

send stool studies and refer for colonoscopy

A 28-year-old woman presents with bloody diarrhea for 1 week. After further questioning, she reveals that she had similar attacks in the past that subsided on their own. Her stool specimen is negative for ova and parasites. Stool culture did not grow any pathogens. A sigmoidoscopy is performed. There is friable erythematous mucosa extending from the rectum to the mid-descending colon, with broad-based ulcers in the descending colon. A biopsy taken from the rectum shows diffuse mononuclear inflammatory infiltrates in the lamina propria with crypt abscesses, but no granulomas are seen. diagnosis?

ulcerative colitis

A 22-year-old man presents with a right groin bulge. During physical assessment, a single sac is found protruding just lateral to the epigastric vessels. Although the clinical scenario is highly suggestive of a hernia, what initial imaging study would be the best choice to support this diagnosis?

ultrasound

A 41-year-old man presents with right upper quadrant pain. His pain began gradually, following a meal, but it has now become constant. He notes that he has had previous episodes of similar pain, but it has never been quite this severe. The pain radiates to his right shoulder and is worsened with inspiration. He has experienced nausea and vomiting, and he notes feeling chilled. Examination reveals an overweight man in moderate distress. He develops rigors during the physical exam. He has scleral icterus, and his skin has a yellow hue. Heart and lungs are clear. His abdomen is soft and non-distended with positive Murphy's sign. Most appropriate initial diagnostic study?

ultrasound (cholangitis)

A 47-year-old Latina woman presents with a 2-month history of persistent abdominal pains. She becomes uncomfortable after eating, especially after consuming fats, eggs, chocolate, fried foods, fatty foods, and rich desserts. Her pains are primarily located in her right upper abdominal quadrant and often radiate to her right shoulder blade. Physical examination is essentially unremarkable. Blood pressure is 122/82 mm Hg, she has a pulse of 72 per minute, and a temperature of 98.6°F with respirations 16 per minute. Her abdominal examination reveals no tenderness, no guard, no rebound, and normally active bowel sounds. Her liver and spleen are not palpable. She has no readily palpable abdominal masses. She is not jaundiced. She has no scleral icterus. diagnostic test?

ultrasound (cholelithiasis)

A 75-year-old woman presents with heartburn and dyspepsia. She was diagnosed with osteoarthritis 4 years ago. For the past 18 months, she has been managing pain with naproxen. The gastroenterologist suggests that the patient be tested for Helicobacter pylori infection. What is the most sensitive and specific non-invasive method to diagnose this infection?

urea breath test

A 32-year-old woman presents with a 1-month history of bleeding gums when brushing her teeth. She also reports that her wounds are taking longer than usual to heal. She is a stay-at-home mother and is breastfeeding her 6-month-old twins. On examination, you note multiple splinter hemorrhages on her nails and ecchymoses over her lower limbs. diagnosis?

vitamin c deficiency

A 55-year-old woman presents with poor appetite and nausea. She has vomited 2 times over the past week and lost 4 pounds in the past month. Past medical history is significant for 20 years of alcoholism, 5 years with diabetes, and hypertension. She takes no medications; she is not involved in any therapy for her alcoholism. She has been drinking 4 12oz beers almost every day for the past 20 years, consuming greater quantities on weekends. Her vitals include a heart rate of 102 BPM, blood pressure of 140/100 mm Hg, respiratory rate of 20/min, and a temperature of 99.8°F. Physical exam reveals hepatomegaly. A liver biopsy reveals macrovesicular fat, spotty necrosis, and polymorphonuclear infiltration. What lab finding would be characteristic of this patient's condition?

AST>ALT by a factor of 2

A 44-year-old premenopausal Caucasian woman with a BMI of 36 presents with persistent upper right quadrant abdominal pain that radiates to the back. It has gotten so bad that she has difficulty eating any food and needs to force herself to eat. She has nausea with some episodes of vomiting. She denies bulimia but admits to anorexia. On exam, the patient has a positive Murphy's sign and tenderness to palpation in the epigastric and upper right quadrant area. Patient has a slightly elevated temperature. The physician assistant is awaiting labs and imaging. Diagnosis?

Acute cholecystitis

A 47-year-old man presents to an urgent care center with 18 hours of abdominal pain, nausea, vomiting, and chills. He is a single construction worker, denies smoking, and has at least a 10-year history of drinking 2-4 alcoholic beverages daily. A series of lab work is performed on the patient to evaluate his abdominal pain prior to abdominal imaging. Question What laboratory results would be most indicative of the patient suffering from acute pancreatitis?

Amylase 310 U/L and lipase 760 U/L

A 40-year-old Asian American man presents with a 3-day history of nausea and vomiting. He also reports mild fatigue and loss of appetite. He reports he is in good health besides having a positive PPD test 2 months ago. He was started on medication after the positive test. Surgical history includes an appendectomy. He is a non-smoker, drinks 7 alcohol beverages a week, and exercises 4 times a week. What lab values would you expect?

Elevated AST and ALT

A 44-year-old white man comes in with reports of heartburn, substernal pain, regurgitation, and difficulty swallowing. He relates that he likes to eat foods that have substance to them, such as hamburgers, steaks, fries, rich desserts, etc. He also tells you that his wife is a great cook and prepares all his favorite dishes with extra butter. He tells you he has had heartburn for years. To relieve the heartburn, he has taken antacids. This time the pain is worse. He has just eaten a large fatty meal in the last hour. He denies other medical problems. He does not smoke and only occasionally uses alcohol. On physical exam, you note he weighs 280 lb and he is 5'10". Diagnosis?

GERD

A 60-year-old Caucasian man comes to your office to establish care. He has no known medical problems and his only medication is daily ibuprofen for 5 years for musculoskeletal aches associated with his work as a handyman risk with this type of NSAID use?

GI Bleed

A 35-year-old man presents with a painful perirectal lump. It began 6 days ago as a small firm mass and has gradually increased in size. As the mass has grown, it has become more tender. On examination, there is a 4 cm fluctuant red perirectal mass. Treatment?

I&D

A 50-year-old man presents to the emergency department with epigastric pain. Pain is sharp with radiation into the back and accompanied by nausea and vomiting. On exam, the patient exhibits tenderness to palpation of the upper right quadrant and upper left quadrant without rigidity or guarding Most important part of patient's treatment?

IV saline

A 57-year-old man presents with intermittent heaviness and pain in his groin over the last 2 months. He works in construction and states his symptoms are worsened by the end of the day. He denies any nausea/vomiting, constipation, dysuria, or urinary frequency. He smokes 1-1.5 packs daily for the last 40 years. During physical assessment, a single sac is found protruding just lateral to the inferior epigastric vessels. Diagnosis?

Indirect inguinal hernia

A 52-year-old man presents with heartburn associated with reflux of sour-tasting material into the mouth. Some of these episodes are accompanied by increased salivation, coughing, and occasional regurgitation of food. Such episodes have become more frequent during the past 6 months despite treatment over the past several years with various treatment combinations, including antacids, histamine 2 receptor antagonists (H2RAs), and protein pump inhibitors (PPIs). He denies any bleeding or abnormalities in his stools. He is slightly overweight and has mild hypertension, which is well-controlled with an antihypertensive medication. Vital signs are within normal ranges and the physical examination is unremarkable. An upper endoscopy reveals a large hiatal hernia and coalescing linear erosions throughout the esophageal circumference and a 5.5 cm circumferential cherry red patch above the gastroesophageal junction. Biopsy of the patch reveals columnar metaplasia, but no dysplasia. What would be the next step surgically?

Laparoscopic fundoplication

A 2-year-old boy with his parents presents with colicky pain, a history of irritability, and a 2-day history of lethargy. There is also history of rectal bleeding and passage of "currant jelly" stool for the past 2 days. Vital signs reveal blood pressure of 105/70 mm Hg, heart rate of 90 bpm, respiration of 18/minute, and temperature 99.2°F. Plain abdominal film shows evidence of obstruction, and barium enema detects coiled-spring appearance to the bowel. Based on the most likely diagnosis, what is the best next step in management of this patient?

Reduction by air enema

A 46-year-old woman presents with nausea, vomiting, crampy abdominal pain, and loud bowel sounds for the past several hours. She denies weight loss. She has had one normal bowel movement since the symptoms began, but it did not help her symptoms. She has a past surgical history of an abdominal hysterectomy 7 years prior. On physical exam, she is afebrile, with hyperactive and high-pitched bowel sounds localized to the left upper quadrant. She also has mild diffuse abdominal tenderness. diagnosis?

small bowl obstruction

A 25-year-old man from China presents with a 1-month history of an inability to see well while walking home from work at night. He also reports that he has been getting sore throats more frequently. He is a recent immigrant from his home country; he lives alone and eats mainly a rice-based diet. On examination, you note pericorneal and corneal opacities. diagnosis?

Vitamin A deficiency

A 14-year-old boy presents with a 1-week history of acute watery diarrhea with vague abdominal discomfort and vomiting. He has developed fever, malaise, facial and periorbital edema, and myalgias. He is experiencing pain and swelling of the calf muscles. The patient ate some food prepared from pork and game meat in a restaurant 3-4 weeks ago. Blood examination shows moderate eosinophilia. Most likely etiological agent?

Trichinella spiralis

A 28-year-old woman presents to the emergency department due to a 3-hour history of nausea, abdominal cramping, vomiting, and watery diarrhea. She recounts her lunch approximately 8 hours ago, which consisted of a shrimp salad and a diet soda. She denies any neurological or other symptoms. She also denies any similar problems prior to this episode and was feeling well just before this incident. She denies fever or recent travel. Most likely pathogen?

Vibrio parahaemolyticus.

A 50-year-old woman with a family history of colon cancer underwent a total colonoscopy per screening guidelines for colon cancer. 2 polyps, 1 cm each, were noted on exam. The doctor advises the patient to repeat her colonoscopy in 3 years due to her polyp pathology. Type of polyp?

Villous adenoma

An 8-month-old female infant presents with a 2-day history of increasing irritability and decreased appetite. She has also had some diarrhea and low-grade fever. On exam, she is afebrile, fussy, and hard to console, but she appears alert and active. She lies with her hips and knees flexed, crying harder with any movement. A few petechiae are noted on her skin. Leg X-rays are done to look for a possible fracture that shows a pencil-thin cortex and a ground glass appearance of the bones. Further history reveals that she has been given evaporated milk since birth to save money, and she has not yet been started on solids. What vitamin deficiency would most likely cause this infant's symptoms?

Vitamin C

A 48-year-old Caucasian woman with a chronic history of inability to tolerate oral intake is admitted to the hospital for J-tube placement. The patient also reports a rash that has developed on her upper extremities. Examination reveals diffuse petechiae and perifollicular hemorrhage. Deficiency?

Vitamin C (ascorbic acid)

A 51-year-old woman presents with difficulty swallowing. She reports a 2-month history of problems swallowing liquids and solids and bringing up undigested food. X-ray reveals a bird's beak appearance of the esophagus. Diagnosis?

achalasia

A 58-year-old man presents with a recent episode of rectal bleeding. A brief history reveals that his bowel patterns have been increasingly erratic over the past 6 weeks. He reports periods of 2-6 days without bowel movements followed by copious production of thin coils of stool. He has lost 10 lb over the last month. His family history is significant for the death of his cousin from colon cancer. Physical exam reveals the patient is pale and febrile (temperature 101°F); the rectal exam is heme-positive with scant stool, and his prostate is soft and moderately enlarged. appropriate diagnoistic test?

colonoscopy

A 20-year-old woman presents with anorectal pain; there are streaks of blood on her stool and toilet paper. She states that "she has a tearing pain during each bowel movement." She dreads having a bowel movement, and she attempts to hold it as long as she can. The symptoms have been occurring over the past 2 weeks. Her history is also significant for breaking her leg in a skiing accident 4 weeks ago; she was prescribed oxycodone/acetaminophen (Percocet) for the first few days due to her pain. An anoscope reveals an acute anal fissure. first line?

stool softeners and fiber

A 38-year-old man presents with a 2-day history of a mass and severe pain in his scrotum. Physical examination reveals that his right testicle appears much larger than his left. On palpation, you note a small hole in his inguinal canal, and you are unable to place the contents into the canal. The contents of the hernia appear ischemic. What is the best description of this hernia ?

strangulated

A 14-year-old boy presents with a 2-week history of 4-5 loose bowel movements a day with blood and mucus accompanied by tenesmus and cramping abdominal pain with a low-grade fever. These episodes have been occurring intermittently for the past 6 months. Physical examination shows mild pallor, temperature 99°F, pulse 88/min, BP 100/70 mm Hg. Oral mucosa and perianal examination are normal. Abdominal tenderness is present. The rest of the examination is normal. Stool examination for ova and parasites and culture for pathogens are negative. Laboratory analysis shows mild anemia and elevated ESR and CRP. Perinuclear anti-neutrophil cytoplasmic auto-antibodies (pANCA) are positive, and anti-Saccharomyces cerevisiae antibodies (ASCA) are negative. Colonoscopy shows hyperemic, edematous, friable, and ulcerated rectal and colonic mucosa; there is no normal mucosa in between. Upper intestinal endoscopy shows normal mucosa. Most likely complication?

toxic megacolon

A 63-year-old woman presents with a 6-month history of worsening difficulty in swallowing. Shortly after swallowing, she feels like something is getting stuck in her upper chest, and the sensation lasts long enough to begin causing significant chest discomfort just behind her breastbone. The difficulty swallowing is often extremely variable and intermittent; it has not been progressive. It gets to the point that she feels like she is going to regurgitate her food, and she is also experiencing substantial episodes of acid reflux. The difficulty swallowing seems to be worsened by when the patient is extremely stressed and when she eats hot or cold food. She denies any weight loss, night sweats, or other significant issues. Physical examination of the patient is otherwise noncontributory. An extensive gastrointestinal evaluation, which included a comprehensive endoscopic evaluation, is negative. Medication?

Diltiazem- calcium channel blocker (esophageal dysphagia)

A 53-year-old man presents with increased difficulty swallowing and occasional regurgitation of his meals. His symptoms have been occurring with greater frequency and severity over the last 4 months. He also gets some shortness of breath but attributes that to his weight and lack of physical activity. His past medical history is remarkable for chronic heartburn, which he treats intermittently with over-the-counter antacids. He takes no regular medications and he has no allergies. He has not had any surgeries. He is a smoker, but he denies use of alcohol and drugs. He works as a building inspector and he lives with his wife and children. The patient is obese, but the rest of his physical exam is normal. Blood tests, electrocardiogram, and chest X-ray are done in the clinic; they are normal. He is referred for endoscopy, and esophageal biopsy shows specialized intestinal metaplastic cells (of columnar epithelium). Best pharmacological intervention?

Esomeprazole (Barrett's esophagus)

A 62-year-old woman presents to her physician with persistent reflux symptoms despite medical management. An upper endoscopy is performed, revealing the attached image. Biopsy findings reveal replacement of the esophageal squamous epithelium with columnar epithelium. Serious complication?

Esophageal adenocarcinoma (Barrett's)

A 45-year-old man presents with a 24-hour history of severe anal pain and swelling. The pain started after straining at defecation and has worsened over the course of the day. There is no history of fever. Examination of the anal area reveals a swollen ecchymotic mass in the perianal skin, very close to the anal verge. What is the treatment of choice for this condition?

Excision of thrombosed external hemorrhoid

A 45-year-old man presents with a 30-minute history of substernal chest pain. He describes the pain as burning. He denies any trauma to the chest. He has had similar episodes like this many times. He denies any additional symptoms such as shortness of breath or diaphoresis, but he states that his voice is often hoarse. His medical issues include diabetes mellitus and heavy alcohol use. Most likely cause of chest pain?

GERD

A 50-year-old woman presents with "swelling in my right groin" when she stands. On physical examination, you note a reducible bulge that is 3 cm below her right groin crease and is lateral to her pubis. The bulge is on the ventromedial surface of the anterior thigh. diagnosis?

femoral hernia

A 4-month-old girl has been gaining weight well and achieving normal milestones. She was a full-term infant born via vaginal delivery without complication. Her past medical history is significant only for a mild URI the previous month, and she is current with her vaccines. She has been exclusively breastfed since birth. Her mother eats a well-rounded diet that includes meat and dairy. What supplementation does the infant need?

Vitamin D

A 48-year-old woman with a past medical history of obesity presents with a 4-hour history of moderate severity epigastric and right upper quadrant pain. The pain is intermittent and occurs in "waves." She also notes nausea, vomiting, and radiation of pain to the right shoulder. Her physical exam reveals normal vital signs, but tenderness is noted in the right upper quadrant. There is no guarding or rebound. A bedside ultrasonography is obtained. what type of diet is recommended?

A low-fat, low-cholesterol diet is recommended.

A 65-year-old man presents because a morsel of meat he had eaten 3 days ago reappeared on his pillow this morning. About a year ago, he noticed difficulty swallowing—particularly solid foods—which seems to be worsening. His wife complains about his bad breath, and he notes that people avoid being close to him. He does not drink, does not smoke, and was in a good health before. His physical examination is within normal range for his age, except that you notice that he is repeatedly clearing his throat as if he is embarrassed. Next best step?

Barium swallow (Zanker diverticulum)

A 14-year-old girl presents with a 4-day history of flatulence, foul-smelling stools, and abdominal distention. Her appetite has also been decreased. She has not seen any blood in her stools. She returned from a 2-week camping trip in the mountains of the western United States 1 week ago. Others in her expedition group are asymptomatic. Her physical examination reveals a well developed and well nourished adolescent with slight abdominal distention and tenderness; otherwise, everything is within normal limits. Most likely pathogen?

Giardia lamblia

An 18-year-old man presents for a screening physical exam to join his college freshman lacrosse team. He reports no medical problems, and he does not take any medications. Physical exam is unremarkable. His immunizations are up-to-date, and he denies sexual activity or smoking. Review of routine labs reveals an elevation in unconjugated bilirubin. Liver enzymes, serum electrolytes, complete blood count, and conjugated bilirubin level are within normal limits. Diagnosis?

Gilbert's syndrome

You are performing an annual physical examination on a 14-year-old girl. In the last couple of years, she started having constipation "every other day or so," followed by loose stools. She still feels depressed because of her parents' recent divorce. She has no problems at school, her grades are good, and she participates in sports. Her mother is worried because she is so slim despite excellent appetite: that she has not grown enough. She still has not gotten her period. Her mother had her first period when she was 13. The rest of personal and family history is non-contributory. The patient's height is 5 ft, weight 79 lb (BMI 15.46; 3rd percentile); she is in Tanner stage 2 (the same as last year, according to her records); and her bone age is 12.5 years. The rest of physical examination is normal. Laboratory shows Hct of 31% and MCV of 73, low insulin-like growth factor (IGF), low FSH, positive anti-tissue transglutaminase antibodies. The rest of laboratory results are within normal limits, including TSH and prolactin. Question What will restore normal puberty, growth, and weight in your patient?

Gluten free diet

A 30-year-old man presents with a 1-week history of a painful tongue. He has been having diarrhea and forgetting things more easily. He recently emigrated from India and lives alone on a maize-based diet. On examination, you note that the tip and margins of his tongue are a bright scarlet color. He also has a symmetrical erythematous rash on his forearms. Diagnosis?

Niacin deficiency

A 28-year-old man presents with rectal bleeding. He had noticed blood with bowel movements 3 times. The blood is described as bright red in color and small in amount. He also complains of rectal pain, especially with passing hard stools. He has tried some over-the-counter hemorrhoid creams without relief. The patient admits episodic constipation. He denies dark tarry stools, easy bruising, and prior episodes of rectal bleeding. He has not noticed blood in his urine or with brushing his teeth. He denies nausea, vomiting, diarrhea, fevers, and weight loss. He has no known medical conditions. Family history is negative for gastrointestinal disorders. Social history reveals he is in a heterosexual relationship and denies anal intercourse. On physical exam, abdomen is normal. The anus has no visible protrusions or rash, but there is a very small erythematous and tender area that appears like a "paper cut" or crack in the skin. The patient experiences pain with digital rectal exam (DRE). No masses are noted in the rectal vault. Most appropriate treatment?

Nitroglycerin ointment (fissure)

A 27-year-old man presents with a burning sensation in his chest, dry cough, hoarseness, and a sensation of a lump in his throat. He also experiences belching followed by a sour liquid taste in the mouth. Symptoms started 2 hours ago, and he thinks that they are worsening. He has had several similar episodes over the past 2-3 years that recently have become more frequent of 3 episodes per week, probably because there is more stress in his life now. Namely, each episode of chest pain is associated with an anticipated or experienced stressful event (exams, job interviews, etc.). Symptoms are severe enough to interfere with his daily living. The rest of his history, family history, and physical are non-contributory. His EKG, chest X-ray, and CBC are normal. How should you treat ?

PPI

A 33-year-old man with no past medical history presents with groin mass. He denies pain and trauma to the region. When the patient stands, there is a round swelling in the inguinal area. If the patient is supine, the mass disappears. Correct treatment plan?

Refer to general surgery (inguinal hernia which can be repaired electively)

Early one afternoon, a 12-year-old boy presents with his parents to the ER with lower right abdominal pain, anorexia, nausea, and vomiting. He rates his pain at 8/10. Pain started around the umbilical area and has moved to the right lower abdomen worsening since the onset of symptoms of nausea and vomiting this morning. He denies any known history of gastrointestinal disease or recent illnesses. He denies any known ill contacts. Vital signs include temperature of 101°F, heart rate 80 bpm and regular, blood pressure 118/70 mm Hg. What do you expect to find on physical exam?

Rovsing sign

A 15-year-old girl presents with a 1-year history of intermittent abdominal pain with nausea and occasional bloody diarrhea. She denies fever and weight loss; there is no travel history. Past medical history is significant only for migraines. She takes a multivitamin. Her vital signs are within normal limits. She has mild diffuse abdominal tenderness to palpation and guaiac-positive stool. Her exam is otherwise normal. Her hemoglobin is 9.7, hematocrit is 28%, WBC is 12,000/uL. next step?

Send stool studies and refer to for colonoscopy.

A 20-year-old woman presents with intermittent nose bleeds for the past 2 weeks. She also reports that her menstrual periods have increased in number in the past 2 months. She recently underwent surgery for small bowel resection and eats only one meal a day. Laboratory investigations reveal prolonged prothrombin time, prolonged activated partial thromboplastin time, and a normal platelet count. Diagnosis?

Vitamin K deficiency

A 12-year-old boy presents with fatigue and jaundice. His past medical history is not significant for recent illness, fever, infectious exposures, medication, alcohol, or drug use. He denies gastrointestinal (GI) symptoms and a history of GI disease. On physical examination, he appears ill; the liver edge is palpable and slightly tender. Skin and sclera are icteric, and there is corneal discoloration. On further eye examination using a slit lamp, brown-yellow rings encircling the iris in the rim of the cornea are noted bilaterally. AST and ALT are elevated, and a serum ceruloplasmin level is reported as low and confirms the diagnosis. diagnosis?

Wilson's disease

A 43-year-old man arrives at the emergency department via ambulance. His wife indicated that she found him lying on the living room floor when she came home from running errands around town. She also stated that he seemed "fine" before she left approximately 2 hours prior. He has a history of acid peptic disease. Upon arrival, he is conscious and indicates that he became dizzy upon standing. For the last couple of days, his stools have been coffee ground in color and he has had increasingly worse upper middle abdominal pain and nausea. His vitals are BP 90/48 mm Hg, pulse 145/min and thready, respirations 24/min, and pulse oximetry 88%. You order a hemoglobin and hematocrit, and the results are 8.2 g/dL and 24.8%, respectively. You review his records and find that 2 weeks ago his H&H was 15.6 g/fL and 48.2%, respectively. What is your initial assessment?

acute massive hemorrhage due to perforation

A 35-year-old man presents after several episodes of vomiting in the last 24 hours; there is loose stool and strong pain localized in the upper middle region of the abdomen. Physical examination indicates a temperature of 101°F and a tender epigastrium. Lab tests reveal an initial WBC count of 18x109/L. C-reactive protein level is 325 mg/L, and amylase is 130 U/L. There is a lactate dehydrogenase level of 816 U/L. The patient has no history of pancreatic disease and denies alcohol use. He is overweight. He has a history of type 2 diabetes and hypertension. He takes medicine to control his high blood pressure and obesity diagnosis?

acute pancreatitis

A 43-year-old man presents with jaundice, weight gain, enlarged abdomen, and peripheral edema in his legs for the last several weeks. He reports fatigue, malaise, and insomnia. His wife and adult son are with him. They tell the ER physician assistant that his oral intake has been limited to excessive alcohol ingestion and very little food in the last few weeks. He has a history of hypertension being treated with amlodipine 5 mg. Family history is significant for his father having hypertension and having an older brother with alcoholism. He has smoked 1 pack of cigarettes daily since he was 18 years old. He has been drinking 12-24 cans of beer daily for the last 15 years. On examination, his temperature is 99.2°F, BP 140/86 mm of Hg, pulse 86/minute, respiratory rate 18/minute. His sclerae are icteric. Lungs have decreased air entry at the bases. Heart sounds are normal. Abdominal exam shows ascites and caput medusae without hepatomegaly. He has pitting pedal edema bilaterally and a fine tremor in his hands. He is alert and fully oriented. Labs are ordered and are pending. In the management of this patient, what is the most important factor in regard to his liver disease?

alcohol abstinence

A 35-year-old Hispanic man presents for an appointment but is too embarrassed to tell the nurse his chief complaint. You enter the room and coerce him to give you the reason he has come in to seek medical treatment. He admits to severe, intense itching around his anus that has been worsening the last several weeks. He further states that he has noticed increasingly severe and tearing pain in the anal area with each bowel movement. He would rank this pain as a 10/10 on a pain scale and it lasts hours afterward. This intense pain makes him not want to have any bowel movements. He admits to only 1 episode of a small amount of bright red blood on the toilet paper as well as on the stool itself. The patient denies fever, diarrhea, or ever being diagnosed with inflammatory bowel disease. Diagnosis?

anal fissure

Early one afternoon, a 15-year-old boy presents with abdominal pain, nausea, and vomiting. The pain has been worsening since the onset of symptoms in the morning. There is no known gastrointestinal disease in the history; no one in the immediate environment has one, either. Physical examination finds no abdominal tenderness, but Psoas sign and tenderness on rectal examination are detected. Temperature and pulse are slightly elevated. Skin turgor is reduced, and there is a 10 mm Hg drop in postural blood pressure. Laboratory studies find 18,000 white blood cells per microliter. diagnosis?

appendicitis

A 60-year-old man presents with a 6-month history of dysphagia to solids, regurgitation of undigested food, and halitosis. He denies a decrease in appetite, abdominal pain, weight loss, or change in bowel habits. His past medical history is significant for a total hip replacement. What should you do next?

barium swallow (zanker diverticulum)

A 40-year-old woman is seen in the emergency department because of right upper quadrant pain and fever. She has been experiencing episodic epigastric pain over the past few months, but this is the worst her symptoms have been. She also reports anorexia and vomiting. She is in obvious distress. On physical examination, her doctor notes the presence of jaundice. Diagnosis?

cholangitis

A 52-year-old man presents with vomiting and epigastric distress for the past few hours. He has been drinking alcohol for over 20 years, and he has been a moderate-to-heavy drinker. 5 years ago, he was diagnosed with a "gastric/duodenal ulcer," for which he has been taking cimetidine and antacids. The pain now radiates towards the left along the costal margin. He has noticed his appetite has been reduced lately, and his stools are bulky and foul smelling. His friends have commented on his sickly look and weight loss. Diagnosis?

chronic pancreatitis

A 65-year-old man presents with a 2-day history of diffuse colicky abdominal pain originating in the RUQ (right upper quadrant). It is not aggravated by food or activity. There has been nausea, but there has not been any vomiting. His skin and eyes have turned yellow in the last several days. His urine has been dark brown, and his stools have been white and chalky. He stopped drinking alcohol about 2 years ago and has been sober since. There is no history of drug abuse. He smokes 2 packs of cigarettes a day. He had gallstones diagnosed at the time he stopped drinking, but he refused surgery. There is a history of previously diagnosed but untreated hypertension. He denies temperature elevation, but he has felt "warm." There was an episode of "shaking chills" earlier in the day. When he walks, he gets dizzy. Vital signs are: T-103°F (oral); P-115/min; BP-100/65 mm Hg; R-32/min (labored); Pulse Ox-90% (room air). He is mildly icteric. Abdomen is slightly protuberant, and there is tenderness and rebound tenderness restricted to the RUQ. No surgical scars are present. Chest examination is within normal limits except for scattered wheezes and rhonchi. Cardiac examination reveals mild cardiomegaly. On rectal examination, pale soft stool is obtained; it is guaiac negative. Good sphincter tone is present. Mild atrophy of the testicles is noted. The remainder of the physical examination, including a neurological exam, is within normal limits. What is the most likely cause of this patient's primary issue?

common bile duct stones (cholangitis)

A 15-year-old boy presents with bloody diarrhea and abdominal cramping. A double contrast barium enema shows fine serrations and narrowing of the rectum and sigmoid. Stool contains mucus, blood, and white blood cells, but no parasites or bacterial pathogens. Endoscopy shows inflamed mucosa and pseudopolyps. A biopsy finds an extensive inflammatory process in the mucosa and submucosa. The glands are filled with eosinophilic secretions; there is also mild involvement of the terminal ileum. Sulfasalazine treatment is attempted without improvement. next best step?

corticosteroids (ulcerative colitis)

A 54-year-old man has had long-term GERD symptoms. He has been on proton pump inhibitors and has had fair control of his symptoms. Other past history is unremarkable. He is a non-smoker and drinks socially. Family history is significant for hypercholesterolemia in his father. Physical examination is unremarkable. An endoscopy a few years ago revealed Barrett's esophagus by biopsy of the esophageal mucosa. He was recommended to have follow-up endoscopy every 2-3 years with mucosal biopsy. Why was this screening recommended to him?

esophageal adenocarcinoma

A 45-year-old chronic alcoholic man presents with history of massive hematemesis. This hematemesis followed a bout of prolonged vomiting. Patient has been a known alcoholic for 20 years. On examination, he has a pulse rate of 100/min and a BP of 90/70 mm Hg with cold extremities. what is most likely to be found on physical exam?

esophageal lacerations (mallory weiss)

A 60-year-old African American man presents due to dysphagia. The dysphagia started 3-4 months ago and has progressively gotten worse. He has also lost weight; current weight and height are 170 lb and 72". He appears older than his stated age. He wants something to help him in swallowing. He does not report heartburn. You note he does not eat on a regular basis, and when he does eat, it is usually fast food. He has smoked for the last 40 years, 2 packs a day. He drinks 12 cans of beer on weekdays and approximately 48 cans of beer during the weekend. He uses recreational drugs occasionally. Most likely diagnosis?

esophageal neoplasm

A 66-year-old man presents with a 2-month history of fatigue. He reports that he has recently joined Alcoholics Anonymous. On examination, he is malnourished and pale, but his neurological examination is essentially normal. A peripheral blood smear reveals macrocytic red cells. Deficiency?

folic acid (anemic like symptoms)

A 48-year-old man presents with a 2-day history of left-sided groin and scrotal pain. He has had similar pain episodically for several months, but it has recently become much worse after a weekend of helping his brother move furniture. He admits that he is not in good physical shape, and he thinks he may have pulled a groin muscle. He is in a monogamous relationship with his wife of 17 years. He has never had any testicular or scrotal conditions, and he has a negative surgical history. He denies fever and urinary symptoms. He has no allergies and takes no other medications. On physical exam, the patient has normal sexual development, with no edema, warmth or erythema present in the scrotum. No skin lesions are present. On palpation, there is mild tenderness on the left scrotum. However, with Valsalva, a small bulge is palpable in the left scrotum, and the patient's reported pain level increases. When he lies supine, the bulge is no longer palpable. Most appropriate next step?

referral for surgery (inguinal hernia)

In the winter, an 11-month-old male infant presents with a 2-day history of vomiting, diarrhea, and fever. He has not had routine medical care since birth. Mother reports no significant past medical history. His temperature is 102°F. Clinically, he appears dehydrated; his white blood cell count is 5400 cells/mm3 with a normal differential. His stool and urine are negative for white blood cells. most likely cause of the gastroenteritis?

rotavirus