PRETEST gi

d. Vitamin B12 deficiency

162. A 22-year-old college student with a 7-year history of Crohn disease presents to her gastroenterologist with a 2-month history of numbness and tingling of her feet and fingertips. Her past surgical history is significant for several previous bowel resections. On physical examination, there is loss of vibration and position sense of the hands and feet. Motor and cerebellar examinations are normal. Deep tendon reflexes are intact. Which of the followingis the most likely diagnosis? a. Vitamin D deficiency b. Vitamin E deficiency c. Vitamin A deficiency d. Vitamin B12 deficiency e. Vitamin K deficiency

a. Enteral formula nutrition

163. A 52-year-old man is 48 hours postlaryngectomy for malignancy. On physical examination, he has inflammation around the surgical incision, which prevents him from swallowing easily. He has no abdominal pain, nausea, vomiting, or diarrhea. Abdominal examination reveals normal bowel sounds and no tenderness. Which of the following is the most appropriate method of feeding this patient? a. Enteral formula nutrition b. Pureed soft food diet c. Total parenteral nutrition d. Intravenous dextrose e. Peripheral alimentation

c. Dimethyl iminodiacetic acid (HIDA) scan

164. A 42-year-old woman presents to the emergency room complaining of the sudden onset of right upper abdominal pain. Her pain started after she ate a hamburger for lunch. She is nauseated and vomited twice at home. She denies diarrhea. Her temperature is 39oC (102.2oF), blood pressure is 140/90 mm Hg, and pulse is 110 beats per minute. She appears anxious and distressed. She is not jaundiced. Abdominal examination reveals normal bowel sounds. While you are palpating under her right costal margin, the patient abruptly halts her inspiration and pulls away because of sharp pain. Which of the following is the best test to diagnose the cause of her pain? a. Abdominal radiograph b. Ultrasound of the abdomen c. Dimethyl iminodiacetic acid (HIDA) scan d. Magnetic resonance imaging(MRI) of the abdomen e. Upper endoscopy

d. Ruptured spleen

165. A 16-year-old adolescent presents to the emergency room with a history of a football injury to the left flank earlier that day while at practice. He reports that at the time of the injury he only had the wind knocked out of him and he recovered in a few minutes. About 1 hour later he began to experience pain in the left upper quadrant and left shoulder. He also feels dizzy and lightheaded on standing. Physical examination demonstrates orthostatic changes in blood pressure and heart rate. His chest wall is non-tender and his heart and lung examinations are normal. Abdominal auscultation reveals normal bowel sounds, but the patient complains of tenderness when palpating the left upper quadrant. Rectal examination and urinalysis are normal. Which of the following is the most likely diagnosis? a. Dislocation of the left shoulder b. Left rib fracture c. Left pneumothorax d. Ruptured spleen e. Contusion of the left kidney

a. Gastric cancer

166. A 71-year-old Asian American man presents to your office with the chief complaint of a 40-lb weight loss over the last 4 months. He has anorexia, dyspepsia, and generalized weakness. Abdominal examination is positive for a scaphoid abdomen, a supraclavicular lymph node on the left and a palpable nodule found in the area of the umbilicus. Which of the following is the most likely cause of the physical examination findings? a. Gastric cancer b. Lung cancer c. Hepatocellular cancer d. Renal cell carcinoma e. Hodgkin lymphoma

c. Necrotizing pancreatitis

167. A 40-year-old man presents to the emergency room complaining of 3 days of severe abdominal pain that radiates to his back, accompanied by several episodes of vomiting. He drinks alcohol daily. On physical examination, the patient is found on the stretcher lying in the fetal position. He is febrile and appears ill. The skin of his abdomen has an area of bluish periumbilical discoloration. There is no flank discoloration. Abdominal examination reveals decreased bowel sounds. The patient has severe midepigastric tenderness on palpation and complains of exquisite pain when your hands are abruptly withdrawn from his abdomen. Rectal examination is normal. Which of the following is the most likely diagnosis? a. Acute cholecystitis b. Pyelonephritis c. Necrotizing pancreatitis d. Chronic pancreatitis e. Diverticulitisf. Appendicitis

e. Abdominal radiograph

168. A 60-year-old man with a history of appendectomy 30 years ago presents to the emergency room complaining of abdominal pain. He describes the pain as colicky and crampy and feels it builds up, then it improves on its own. He has vomited at least 10 times since the pain started this morning. He states that he has not had a bowel movement for 2 days and cannot recall the last time he passed flatus. The abdomen is slightly distended. Abdominal auscultation reveals high-pitched bowel sounds and peristaltic rushes. Percussion reveals a tympanic abdomen. The patient is diffusely tender with palpation but has no rebound tenderness. Rectal examination reveals the absence of stool. Which of the following is the most appropriate first test to confirm your diagnosis? a. Thick barium upper gastrointestinal series b. MRI of the abdomen c. HIDA scan d. Spiral CT scan e. Abdominal radiograph

c. IgA endomysial antibody test

169. A 3-year-old boy is accompanied by his mother to your office. She describes an almost year-long history of him having loose bowel movements that often float on the water of the toilet bowl, along with excessive gas and weight loss. He is short for his age. On examination, he has abdominal distention with hyperactive bowel sounds. Over his trunk, neck, and scalp he has a papulovesicular skin rash. What would be the next appropriate step in diagnosis? a. Endoscopic mucosal biopsy b. Hydrogen breath test c. IgA endomysial antibody test d. Flat and upright abdominal x-ray e. No further diagnostic testing is needed

d. Carcinoma of the pancreas

170. A 51-year-old woman presents to the emergency room complaining of right upper quadrant and epigastric pain for 5 hours, which improves when she leans forward. She has nausea and vomiting but does not have hematemesis or melena. She is a smoker and admits to drinking several beers daily. She is afebrile, but you note icterus of her eyes and sublingual area. On abdominal examination you feel a nontender mass in her right upper quadrant. Which of the following is the most likely diagnosis? a. Cholelithiasis b. Acute cholecystitis c. Cirrhosis of the liver d. Carcinoma of the pancreas e. Acute viral hepatitis

d. Upright abdominal radiograph

171. A 32-year-old man presents with severe abdominal pain, which he describes as sharp and diffuse. He does not drink alcohol or take any medications. He has a medical history significant for peptic ulcer disease over 5 years ago. He has stable vital signs and has no orthostatic changes. You observe that the patient is lying very still on the emergency room stretcher. On physical examination, he has a rigid abdomen and decreased bowel sounds. He has localized left upper quadrant guarding and rebound tenderness. He has referred rebound tenderness on palpation of the right upper quadrant. Rectal examination is fecal occult blood test (FOBT) negative. Which of the following is the best method of confirming the diagnosis in this patient? a. Barium swallow b. Leukocytosis c. Upper endoscopy d. Upright abdominal radiograph e. Colonoscopy

b. Diverticulitis

172. A 74-year-old man presents with the abrupt onset of pain in the left lower abdomen, which has been progressively worsening over the last 2 days. He states that the pain is unremitting. He has some diarrhea but no nausea or vomiting. He has no dysuria or hematuria. His temperature is 38.9oC (102oF). Bowel sounds are decreased. The patient has involuntary guarding. There is tenderness and rebound tenderness when the left lower quadrant is palpated. The referred rebound test is positive. There is no costovertebral angle (CVA) tenderness. Rectal examination reveals brown stool, which is fecal occult blood test (FOBT) positive. Blood work demonstrates a leukocytosis. Which of the following is the most likely diagnosis? a. Colon cancer b. Diverticulitis c. Pancreatitisd. Pyelonephritis e. Appendicitis

a. CT of the abdomen

173. A 32-year-old man presents with fever, vomiting, and diffuse abdominal pain. On physical examination, his temperature is 39.4oC (103oF) and his heart rate is 120 beats per minute. He reports worsening of his abdominal pain when hitting bumps in the car on the way to the emergency room and on examination, has severe pain when palpating one-third of the way along a line drawn from the right anterior superior iliac spine to the umbilicus. He has a positive Rovsing sign. Which of the following is the most appropriate next step in diagnosis? a. CT of the abdomen b. Ultrasound of the abdomen c. Surgical intervention d. Paracentesis e. Plain film of the abdomen

b. Mesenteric ischemia

174. A 71-year-old woman with a history of a previous myocardial infarction presents to her family physician for a routine checkup. The physician notices that she has lost 20 lb since her last visit 6 months ago. When questioned, the patient gives a history of intermittent periumbilical pain that begins 30 minutes after eating and lasts for 2 to 3 hours. She claims the pain is worse after large meals, so she has begun to eat less out of fear of precipitating the pain. Her physical examination is unremarkable. Which of the following is the most likely diagnosis? a. Pancreatitis b. Mesenteric ischemia c. Cholecystitis d. Small-bowel obstruction e. Peptic ulcer disease

b. Serum ammonia level

175. A patient with a long history of cirrhosis presents with asterixis. He is alert and oriented to person, place, and time. His breath is positive for fetor hepaticus. His abdomen is significant for caput medusae and a positive fluid wave. He has no focal neurologic deficit. His wife states that the patient is very functional at home but is moderately confused and drowsy. Which is the most helpful test to confirm the diagnosis in this patient? a. Serum lactate level b. Serum ammonia level c. Serum iron level d. Serum alkaline phosphatase level e. Serum sodium level

a. Candida esophagitis

176. A 24-year-old HIV-positive patient who has had AIDS for 3 years presents with painful swallowing and dysphagia to solids and liquids. He has no previous history of heartburn or reflux disease. His CD4 count is 41/μL, and he recently required 3 weeks of antibiotics for Pneumocystis jirovecii pneumonia. Examination of the pharynx reveals no oral thrush. Barium swallow demonstrates multiple nodular filling defects of various sizes that resemble a cluster of grapes. Which of the following is the most likely diagnosis? a. Candida esophagitis b. Gastroesophageal Reflux disease c. Barrett esophagus d. Achalasia e. Plummer-Vinson syndrome f. Schatzki ring

d. Splenomegaly

177. A 47-year-old woman admits to excessive alcohol use on a thorough history. What finding on physical examination can be attributed to her alcohol use? a. Palmar creases b. Increased body hair c. Tympany of the abdomen d. Splenomegaly e. Livedo reticularis

c. Gastroparesis

178. A 70-year-old woman with a 25-year history of diabetes mellitus presents with early satiety, bloating, and nausea after meals. She has had previous surgery for gallbladder stones and appendicitis. Her diabetes is complicated by retinopathy and peripheral neuropathy. On physical examination, bowel sounds are normal. A succussion splash is audible. The abdomen is tympanic, and there is no hepatosplenomegaly. There is no tenderness. Rectal examination is normal. Serum glucose is 310 mg/dL. Which of the following is the most likely diagnosis? a. Celiac sprue b. Whipple disease c. Gastroparesis d. Gluten-sensitive enteropathy e. Tropical sprue

e. Gilbert syndrome

179. A 23-year-old man presents with mild, persistent jaundice. His serum bilirubin is always less than 5 mg/dL and is primarily unconjugated bilirubin. The jaundice is exacerbated by fasting, surgery , fever, infection, and alcohol ingestion. Which of the following is the most likely diagnosis? a. Dubin-Johnson syndrome b. Rotor syndrome c. Crigler-Najjar type 1 syndrome d. Crigler-Najjar type 2 syndrome e. Gilbert syndrome

b. Upper endoscopy

180. A 42-year-old morbidly obese woman complains of a nonproductive cough for 8 months. She reports regurgitation after eating, and when she does, it has a sour taste. She has been on a proton pump inhibitor for 3 months without relief. Abdominal examination is normal. Rectal examination is FOBT negative. Which of the following is the most appropriate next step in diagnosis? a. Barium esophagography b. Upper endoscopy c. Esophageal manometry d. Esophageal pH monitoring e. Bernstein test

d. Hirschsprung disease

181. A 16-year-old adolescent has had lifelong constipation. He requires suppositories and, often, enemas to initiate bowel movements. His abdomen is distended. Palpation reveals a tubular mass in the left lower quadrant. Rectal examination reveals no stool in the vault. Barium enema reveals a dilated colon above a normal- appearing rectum. Which of the following is the most likely diagnosis? a. Colon carcinoma b. Gardner syndrome c. Peutz-Jeghers syndrome d. Hirschsprung disease e. Volvulus

d. Acetaminophen toxicity

182. A 49-year-old patient presents with altered mental status. His wife states that over the last week her husband has been taking several over-the-counter pills every few hours for some headache and abdominal discomfort. He uses no illicit drugs but drinks four to five beers daily. Over the last 24 hours, the patient has become progressively lethargic. Vital signs reveal a temperature of 36.1oC (97oF), blood pressure of 100/70 mm Hg, heart rate of 120 beats per minute, and respiratory rate of 26 breaths per minute. The patient is jaundiced with right upper quadrant (RUQ) abdominal tenderness on palpation. He has no rebound tenderness or splenomegaly but has an enlarged liver. There is no ascites or peripheral edema. Heart and lung examinations are normal. The patient responds to painful stimuli and has asterixis. He has no focal neurologic deficit. Which of the following is the most likely diagnosis? a. Alcohol intoxication b. Alcohol withdrawal c. Delirium tremens d. Acetaminophen toxicity e. Wilson disease

b. Ulcerative colitis

183. A 19-year-old woman attending school in Massachusetts presents with the chief complaint of bloody diarrhea for 2 months. She has abdominal discomfort and feels she has lost some weight. She also complains of tenesmus. Abdominal examination is normal. Rectal examination reveals stool containing blood and pus. Which of the following is the most likely diagnosis? a. Irritable bowel syndrome b. Ulcerative colitis c. Giardiasis d. Hemorrhoids e. Diverticulosis

a. International normalization ratio (INR)

184. A 50-year-old man has a 10-year history of chronic active hepatitis from the hepatitis C virus. He is brought to the emergency room because of cachexia and disturbed mental status. On physical examination, the patient has palmar erythema and clubbing. He is jaundiced with massive ascites. He has asterixis. Laboratory data reveal severe hypoalbuminemia and hyperbilirubinemia. Which of the following is used to determine prognosis in this patient with end-stage liver disease? a. International normalization ratio (INR) b. Unconjugated bilirubin c. Presence of jaundice d. Presence of hepatomegaly e. Serum blood urea nitrogen

e. Malabsorption

185. A 44-year-old man with a history of Roux-en-Y gastric bypass surgery 1 year ago presents with fatigue, paresthesias in his feet and hands, and some difficulty with balance. Which of the following is the most likely etiology of his symptoms? a. Dumping syndrome b. Bacterial overgrowth c. Gastric carcinoma d. Gastritis e. Malabsorption

a. Hepatitis A

186. A 21-year-old woman presents with jaundice and hepatomegaly. She has nausea, vomiting, and diarrhea. She recalls eating raw oysters 1 to 2 months ago. She has not traveled recently and denies drug use or unprotected sexual intercourse. She has no history of blood transfusion. Which of the following is the most likely viral et iology ? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D e. Hepatitis E f. Hepatitis G

d. Mallory-Weiss tear

187. A 38-year-old man arrives at the emergency room with the chief complaint of hematemesis for 3 hours. He spent the previous night vomiting approximately 10 to 12 times after eating some "bad chicken." a. Gastric cancer b. Erosive gastritis c. Dieulafoy lesion d. Mallory-Weiss tear e. Gastrinoma f. Esophageal varices

f. Esophageal varices

188. A 44-year-old man with a history of heavy alcohol use for years presents to the emergency room with the acute onset of hematemesis. He appears jaundiced and has some mild ascites. a. Gastric cancer b. Erosive gastritis c. Dieulafoy lesion d. Mallory-Weiss tear e. Gastrinoma f. Esophageal varices

b. Erosive gastritis

189. A 51-year-old man has massive coffee ground emesis and melena. He has been taking nonsteroidal anti-inflammatory medications daily because of arthritis pain. a. Gastric cancer b. Erosive gastritis c. Dieulafoy lesion d. Mallory-Weiss tear e. Gastrinoma f. Esophageal varices

b. Primary biliary cirrhosis

192. A 54-year-old woman presents with generalized pruritus that keeps her awake at night. Liver size by percussion in the midclavicular line is 17 cm. There is no splenomegaly. Serum alkaline phosphatase level is three times the normal value. a. Hemochromatosis b. Primary biliary cirrhosis c. Sclerosing cholangitis d. Hepatocellular carcinoma e. Zollinger-Ellison syndrome f. Alcoholic hepatitis g. Wilson disease h. α1-Antitrypsin deficiency i. Metastatic carcinoma of the liver j. Budd-Chiari syndrome

c. Sclerosing cholangitis

193. A 44-year-old man with a 20-year history of ulcerative colitis presents with fever and RUQ pain. Physical examination reveals jaundice and RUQ tenderness with palpation. Endoscopic retrograde cholangiopancreatography (ERCP) shows multifocal strictures of the extrahepatic biliary tree. a. Hemochromatosis b. Primary biliary cirrhosis c. Sclerosing cholangitis d. Hepatocellular carcinoma e. Zollinger-Ellison syndrome f. Alcoholic hepatitis g. Wilson disease h. α1-Antitrypsin deficiency i. Metastatic carcinoma of the liver j. Budd-Chiari syndrome

e. Zollinger-Ellison syndrome

194. A 41-year-old woman has a history of recurrent duodenal ulcer disease. She takes no medications and has no evidence of Helicobacter pylori infection. Her serum gastrin level is 800 pg/mL. a. Hemochromatosis b. Primary biliary cirrhosis c. Sclerosing cholangitis d. Hepatocellular carcinoma e. Zollinger-Ellison syndrome f. Alcoholic hepatitis g. Wilson disease h. α1-Antitrypsin deficiency i. Metastatic carcinoma of the liver j. Budd-Chiari syndrome

f. Alcoholic hepatitis

195. A 53-year-old alcoholic presents with mild RUQ tenderness and jaundice. Liver function tests reveal an elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) level, but the AST is two times greater than the ALT. a. Hemochromatosis b. Primary biliary cirrhosis c. Sclerosing cholangitis d. Hepatocellular carcinoma e. Zollinger-Ellison syndrome f. Alcoholic hepatitis g. Wilson disease h. α1-Antitrypsin deficiency i. Metastatic carcinoma of the liver j. Budd-Chiari syndrome

a. Hemochromatosis

196. A 39-year-old man presents with jaundice and ascites. He has a history of diabetes mellitus and was recently diagnosed as having heart disease. On physical examination, he has a bronze appearance to his skin, arthritic changes of the fingers, and testicular atrophy. a. Hemochromatosis b. Primary biliary cirrhosis c. Sclerosing cholangitis d. Hepatocellular carcinoma e. Zollinger-Ellison syndrome f. Alcoholic hepatitis g. Wilson disease h. α1-Antitrypsin deficiency i. Metastatic carcinoma of the liver j. Budd-Chiari syndrome

g. Wilson disease

197. A 43-year-old man presents with cirrhosis. Slit-lamp examination reveals a yellow-brown ring in the limbus of the cornea. The patient has recently developed an unsteady gait, tremors, and involuntary chorea-like movements. a. Hemochromatosis b. Primary biliary cirrhosis c. Sclerosing cholangitis d. Hepatocellular carcinoma e. Zollinger-Ellison syndrome f. Alcoholic hepatitis g. Wilson disease h. α1-Antitrypsin deficiency i. Metastatic carcinoma of the liver j. Budd-Chiari syndrome

a. Clostridium difficile

198. A 51-year-old woman complains of 10 soft and watery, but nonbloody, stools per day. She was recently treated for pneumonia. a. Clostridium difficile b. Giardia lamblia c. Enterotoxigenic Escherichia coli d. Bacillus cereus e. Escherichia coli O157:H7 f. Cryptosporidium g. Entamoeba histolytica h. Shigella

e. Escherichia coli O157:H7

199. A 6-year-old boy ate a hamburger at a fast food restaurant and 2 days later developed fever, abdominal pain, and bloody diarrhea. He was subsequently admitted to the hospital and diagnosed with acute renal failure, microangiopathic hemolytic anemia, and thrombocytopenia. a. Clostridium difficile b. Giardia lamblia c. Enterotoxigenic Escherichia coli d. Bacillus cereus e. Escherichia coli O157:H7 f. Cryptosporidium g. Entamoeba histolytica h. Shigella

a. Shifting dullness

The border of dullness moves to the dependent side and tympany moves toward the top when the patient turns to the side from the supine position. a. Shifting dullness b. Fluid wave c. Puddle sign d. Bulging flanks e. Flank dullness

b. Fluid wave

The patient is on his back, and with a push from one side of the abdomen, fluid is felt on the opposite side. a. Shifting dullness b. Fluid wave c. Puddle sign d. Bulging flanks e. Flank dullness