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A 34-year-old man, with no significant past medical history, presents to the emergency department complaining of burning epigastric pain radiating to the back for the last 3 months. The pain starts a couple of hours after eating and occurs at night. The patient does not take any medications. Vital signs are T 37°C, HR 82 bpm, BP 138/62 mm Hg, RR 18/min, and oxygen saturation 100% on room air. Physical examination is significant for brown, heme-positive stool. Once the diagnosis is confirmed, which of the following is the most appropriate to treat this condition? A. Antacids B. Aspirin C. Clarithromycin, amoxicillin, and a proton-pump inhibitor D. Sucralfate

Clarithromycin, amoxicillin, and a proton-pump inhibitor

A 69-year-old woman presents to the emergency department with a complaint of three days of left lower quadrant abdominal pain, nausea, vomiting, and a sudden change in bowel habits. What are you most likely to find on an abdominal and pelvic computed tomography scan? A. Appendiceal wall thickening B. Colonic diverticula C. Dilated loops of small bowel D. Enlarged pericolonic lymph nodes

Colonic diverticula

A 68-year-old man presents to the emergency department with left lower quadrant pain and fever for one day duration. Laboratory results reveal a WBC 14,800,Hb 12.0 g/dL, sodium 138 mEq/L, potassium 4.0 mEq/L, and creatinine 1.0 mg/dL Which of the following studies is contraindicated in the workup of this patient? A. Colonoscopy B. Contrast computed tomography C. Magnetic resonance imaging D. Ultrasound

Colonoscopy* In addition to stool softeners, which of the following can be used topically in the management of midline anal fissures? A. Fentanyl B. Mupirocin C. Nitroglycerin D. Sucrose [Nitroglycerin* A patient presents to the clinic complaining of a tearing pain with bowel movements and reports small streaks of blood on the toilet paper. A physical examination of the patient's anus reveals a lesion most likely in which of the following anatomic locations? A. Anterior midline B. Circumferential C. Lateral D. Posterior midline [Posterior midline* A 57-year-old man with HIV complains of gradually increasing pain and difficulty with swallowing despite use of omeprazole that was prescribed for suspected gastroesophageal reflux. An endoscopy reveals yellow-whitish nodular plaques adherent to an erythematous mucosa. What is the next most appropriate step in management of this patient? A. Esophageal dilation B. Fluconazole C. Pantoprazole D. Prednisone [Fluconazole

A 56-year-old man presents to the emergency room with a five-day history of constipation. He has a history of seasonal allergies, hypertension, and ulcerative colitis. His vital signs are within normal limits. Laboratory studies reveals microcytic, hypochromic anemia. Physical exam reveals an empty rectal vault. A fecal occult blood test is positive. Which of the following is the most likely diagnosis? A. Colorectal carcinoma B. Drug-induced constipation C. Intestinal obstruction due to adhesions D. Toxic megacolon

Colorectal carcinoma

A previously healthy 30-year-old woman presents to your office with complaints of abdominal pain and diarrhea for the past year. Her abdominal pain is located in the lower abdomen with relief after defecation. Her diarrhea symptoms include a small volume of loose stool, typically after meals. She has experienced some improvement in symptoms with dietary modifications, but overall is still having regular loose stools. Recently she has been feeling more fatigue than normal. Which of the following is the most appropriate initial laboratory test? A. Complete blood count B. Giardia antigen C. Stool culture D. Thyroid stimulating hormone

Complete blood count

Perforation of what gastrointestinal structure is associated with the highest mortality? A. Cecum B. Duodenum C. Esophagus D. Stomach

Complete blood count

A 52-year-old man with a history of cirrhosis presents with worsening confusion. His wife reports he has been compliant with his lactulose at home. Which of the following is a common cause of worsening hepatic encephalopathy? A. Cardiac ischemia B. Constipation C. Hyperkalemia D. Pancreatitis

Constipation

Which of the following findings is most likely to occur with acute diverticulitis? A. Constipation B. Gross lower GI bleeding C. Right lower quadrant tenderness D. Testicular pain

Constipation

A 35-year-old man with a history of gastroesophageal reflux disease presents to the emergency department with chest pain and fever. An outpatient esophagogastroduodenoscopy was performed three days ago and revealed no gastric ulcers. On exam, he is ill-appearing and tachycardic. Which of the following is the next best step in management of this patient? A. Arrange for repeat emergent esophagogastroduodenoscopy B. Consult thoracic surgery C. Order a barium esophagogram D. Place a nasogastric tube

Consult thoracic surgery

A 67-year-old woman presents complaining of dark urine. Over several months she has had increased fatigue and weight loss. There has not been any fever or night sweats. On physical examination, she has scleral icterus and mild jaundice. Her abdomen is soft, non-distended with a palpable mass in the right upper quadrant that is non-tender. Her laboratory values are notable for a total bilirubin of 6.4 mg/dl and a direct bilirubin of 5.0 mg/dl. Which of the following imaging studies is the next best step in the workup? A. Abdominal CT scan B. Endoscopic retrograde cholangiopancreatography C. Right upper quadrant ultrasound D. Upper GI series

Abdominal CT scan

A 3-week-old boy presents with nonbilious, forceful emesis for 2 days. On examination, the infant appears active and feeds vigorously, followed immediately by vomiting. Which of the following is the most appropriate diagnostic study? A. Abdominal radiograph B. Abdominal ultrasound C. CT scan of the abdomen and pelvis D. Urine dipstick

Abdominal radiograph

A 35-year-old-man with a long history of occasional bloody diarrhea and abdominal pain presents with acute-onset severe abdominal pain. Vital signs are significant for a temperature of 102.2°F (39°C), heart rate 140 bpm, and blood pressure 82/55 mm Hg. On physical exam, his abdomen is distended and tympanitic. Which of the following diagnostic studies is indicated first at this time? A. Abdominal radiograph B. Barium enema C. CT scan of the abdomen pelvis with IV contrast D. Sigmoidoscopy

Abdominal radiograph

Abdominal ultrasound

A 50-year-old woman presents to the emergency department with a two-day history of right upper quadrant pain. She has a history of hypercholesterolemia and her examination is significant for a positive Murphy sign. What is the preferred imaging modality? A. Abdominal barium meal B. Abdominal computed tomography scan C. Abdominal plain film D. Abdominal ultrasound

Abdominal ultrasound

A mother brings her 11-month-old infant into a rural ED for inconsolable crying. You note the infant is lying in the stretcher, crying with his knees drawn to his chest. You perform a physical exam and leave the room to order blood work. When you return to the examination room, you note the infant now appears lethargic. An abdominal radiograph is obtained and interpreted by the radiologist as nonspecific. Which of the following diagnostic tests should be performed next? A. Abdominal CT scan B. Abdominal ultrasound C. Nasogastric tube lavage D. Upper GI series

Abdominal ultrasound

A patient presents with "food getting stuck" for the past 6 months. She also is having trouble swallowing liquids, and reports regurgitation, chest pain, and indigestion as well. Cardiac work-up is negative, and a chest radiograph shows no significant abnormalities. A barium swallow study reveals severe distal esophageal narrowing without any pharyngoesophageal junction abnormalities. Which of the following disorders is the most likely diagnosis? A. Achalasia B. Gastroesophageal reflux disease C. Hiatal hernia D. Zenker's diverticulum

Achalasia

Which of the following is classified as an esophageal motility disorder? A. Achalasia B. Esophageal web C. Schatzki ring D. Zenker diverticulum

Achalasia

A student health volunteer presents for evaluation after a needle stick. You review the labs of the source patient which are as follows: Anti-HAV negative; HBsAg positive; HBsAb negative; anti-HBc IgM positive, Anti-HCV negative. What is the most appropriate explanation of these labs? A. Active infection with hepatitis B B. Previous exposure to hepatitis A C. Previous infection with both hepatitis B and C D. Vaccination against hepatitis B

Active infection with hepatitis B

An otherwise healthy 28-year-old woman presents with two days of gradually worsening right lower quadrant abdominal pain and nausea. Her last menstrual period ended one week ago. Vital signs are BP 110/72, HR 88, RR 16 and T 100.6 F. Your exam reveals right lower quadrant tenderness as well as pain in the right lower quadrant with palpation of the left lower quadrant and passive right hip extension. Laboratory testing reveals a white blood cell count of 12,000. What is the most likely diagnosis? A. Acute appendicitis B. Ectopic pregnancy C. Ovarian torsion D. Ruptured ovarian cyst

Acute appendicitis

A 43-year-old woman comes to the emergency department with a 5-hour history of right upper quadrant pain, fever, nausea, vomiting, and anorexia. She says she began experiencing these symptoms shortly after eating at her favorite fast food restaurant. Her temperature is 38.8C (101.8F). Palpation of the abdomen shows voluntary guarding. Laboratory studies shows leukocytosis with a left shift. Which of the following is the most likely diagnosis? A. Acute cholecystitis B. Acute pancreatitis C. Appendicitis D. Peptic ulcer disease

Acute cholecystitis

A 72-year-old man presents to the emergency department with a 6-hour history of severe, diffuse abdominal pain. He has a past medical history diabetes mellitus, hypertension, and colon cancer. Physical exam reveals an abdomen that is extremely tender to light palpation and an irregularly, irregular heart rate. Digital rectal exam is notable for grossly bloody mucous. Laboratory findings are notable for leukocytosis, metabolic acidosis, elevated amylase, and elevated lactate dehydrogenase. Which of the following is the most likely diagnosis? A. Acute mesenteric ischemia B. Appendicitis C. Diverticulitis D. Pancreatitis

Acute mesenteric ischemia

A 42-year-old man with a history of human immunodeficiency virus infection presents to his primary care provider with complaints of odynophagia and dysphagia. He also reports nausea and generalized chest pain. The man's last CD4 count was 90 cells/μL. Upper endoscopy reveals multiple, small ulcers in the distal esophagus. Which of the following is the most appropriate management? A. Acyclovir B. Fluconazole C. Ganciclovir D. Trimethoprim/sulfamethoxazole

Acyclovir

In the United States, which of the following conditions, other than postoperative adhesions, is most likely responsible for causing the diagnosis seen in the image above? A. Adenocarcinoma B. Crohn disease C. Intussusception D. Volvulus

Adenocarcinoma

A 57-year-old man presents complaining of a change in stools over the last 4 months. His stools are intermittently bloody, and he has experienced a decline in his appetite associated with a 15-pound unintentional loss of weight. Which of the following is the most likely explanation for his symptoms? A. Adenocarcinoma of the colon B. Gastrointestinal carcinoid tumor C. Primary colorectal lymphoma D. Squamous cell carcinoma of the colon

Adenocarcinoma of the colon

Which of the following is the most common cause of small-bowel obstruction in a 70-year-old man with a history of an appendectomy 50 years ago? A. Adhesions B. Incarcerated hernia C. Intussusception D. Neoplasm

Adhesions

What is the overall most common cause of small bowel obstruction in adults? A. Adhesions from prior surgery B. Colon cancer C. Intussusception D. Volvulus

Adhesions from prior surgery

A 59-year-old man presents to the ED with 12 hours of emesis and abdominal pain. Vital signs include a T 38.2°C, BP 110/79 mm Hg, and HR 109 bpm. On exam, you note a tender 2 x 2 cm bulge with erythema in the abdominal midline above the umbilicus. There is abdominal distension, and an occasional high-pitched bowel sound is heard. After placing an IV line and nasogastric tube, which of the following is the most appropriate course of management? A. Administer broad-spectrum antibiotics and attempt reduction B. Administer broad-spectrum antibiotics and obtain a plain radiograph C. Administer broad-spectrum antibiotics and obtain emergent surgical consultation D. Administer broad-spectrum antibiotics then obtain a CT scan of abdomen

Administer broad-spectrum antibiotics and obtain emergent surgical consultation

A 35-year-old previously healthy man presents to your office with a complaint of diarrhea 24 hours after returning from a mission trip to Sierra Leone. He endorses hourly bouts of large volumes of stool that now have a white-colored liquid appearance. Physical exam findings include decreased skin turgor, dry buccal mucous membranes and a rapid, thready radial pulse. Which of the following is the most appropriate next step in management? A. Administer intravenous fluids B. Administer vitamin C C. Chloroquine D. Trimethoprim-sulfamethoxazole

Administer intravenous fluids

A 19-year-old woman presents to your clinic with complaints of abdominal pain, bloating, flatulence, and loose stools. Lactose hydrogen breath test is positive. Which of the following is the most appropriate first step in management? A. Advise a lactose-restricted diet B. Computed tomography of the abdomen C. Endoscopy D. Symptomatic treatment of diarrhea

Advise a lactose-restricted diet

A 12-month-old girl is brought in for evaluation of abdominal pain. She has been intermittently lying on the floor and "doubling up" with abdominal pain. The episodes last about one minute and then resolve. She had one episode of emesis. Physical exam reveals a palpable mass in the right lower quadrant of the abdomen. Which of the following is the most appropriate diagnostic test? A. Air/contrast enema B. Colonoscopy C. Plain abdominal radiographs D. Upper GI series with contrast

Air/contrast enema

A 53-year-old man presents with a distended abdomen. Examination reveals a protuberant abdomen without specific point tenderness. A fluid wave is appreciated. Right upper quadrant percussion demonstrates hepatomegaly. There is yellowing of the skin, reddening of the palms, and the proximal nail beds are rounded. Which of the following is most likely included in this patients past medical history? A. Alcohol abuse B. Asbestos exposure C. Crohn's disease D. Diverticulosis

Alcohol abuse

A 55-year-old man presents to the emergency department complaining of epigastric pain that radiates to his back, nausea, and vomiting. Abdominal exam reveals epigastric tenderness and voluntary guarding, but no rebound tenderness or distention. Laboratory tests show a serum amylase of 1,075 U/L and a white blood cell count of 16,000 /mL. Abdominal radiograph shows several small bowel air-fluid levels. Which of the following historical factors likely contributed to the most likely diagnosis? A. Alcohol abuse B. Chronic corticosteroid use C. Hypertriglyceridemia D. Obesity

Alcohol abuse

A 45-year-old woman with a history of ethanol abuse presents to the ED complaining of nausea and vomiting. Vital signs include a BP of 110/70 mm Hg, HR 98 bpm, RR 16/min, and T 38°C. On exam, you note scleral icterus and elicit mild RUQ tenderness of her abdomen. Lab results reveal an AST of 300 U/L, ALT of 175 U/L, total bilirubin of 2.7 mg/dL, and alkaline phosphatase of 200 U/L. A RUQ ultrasound is performed, as seen above. Which of the following is the most likely diagnosis? A. Acute viral hepatitis B. Alcoholic hepatitis C. Ascending cholangitis D. Cholecystitis

Alcoholic hepatitis

Which of the following is the most common cause of cirrhosis in the United States? A. Alcoholic liver disease B. Autoimmune hepatitis C. Hepatitis A D. Primary sclerosing cholangitis

Alcoholic liver disease

An 88-year-old woman presents complaining of substernal chest burning and difficulty swallowing that started earlier today. She was taking her pills when one of them "got stuck in her throat." She has an extensive medical history and is on multiple medications. Which of the following medications is most likely responsible for her symptoms? A. Alendronate B. Lisinopril C. Metformin D. Simvastatin

Alendronate

A 17-year-old previously healthy boy presents with abdominal cramping, nausea, vomiting, and diarrhea two hours after eating at a picnic. Physical examination is unremarkable. What management is indicated? A. Anitiemetics and fluids B. Ciprofloxacin C. CT scan of the abdomen and pelvis D. Stool cultures

Anitiemetics and fluids

A 37-year-old woman presents with a one week history of increasing anal pain and swelling. The pain is throbbing and constant, even while not having a bowel movement. There is an area of swelling with erythema along a portion of the anus which is very tender to palpation on rectal exam. Which of the following is the most likely cause of this patient's condition? A. Anal fissure B. Anorectal abscess C. Anorectal fistula D. Pruritus ani

Anorectal abscess

A 15-year-old boy comes to the emergency department due to yellowish discoloration of the eyes for two days. He is noted to have generalized body weakness, poor appetite, nausea, and vomiting. The physical examination reveals a febrile boy with a temperature of 37.9°C in no cardiorespiratory distress with icteric sclerae, yellow-tinged oral mucosa, clear breath sounds, a soft abdomen with mild tenderness at the right upper quadrant, full and equal pulses, and no edema noted. Which of the following laboratory results will point to an acute hepatitis A infection? A. Anti-Hepatitis A Virus IgG positive B. Anti-Hepatitis A Virus IgM positive C. Elevated serum alanine aminotransferase, aspartate aminotransferase, and bilirubin D. Elevated serum alkaline phosphatase and 5′-nucleotidase

Anti-Hepatitis A Virus IgM positive

Which of the following is contraindicated in children with bloody diarrhea and no confirmatory infection by stool culture? A. Antibiotics B. Blood transfusion C. Hemodialysis D. Intravenous fluid hydration with normal saline

Antibiotics

Which of the following patients is at highest risk for developing cholelithiasis? A. 21-year-old woman of European descent B. 35-year-old thin man with gastric ulcers C. 41 year-old obese, pregnant woman D. 55-year-old man on a statin medication

41 year-old obese, pregnant woman

A 17-year-old girl presents to the ED complaining of lower abdominal pain over the past eight hours associated with a loss of appetite and mild nausea. She states she is sexually active and on oral contraceptives. Her last menstrual period was three weeks ago. Her temperature is 37.8°C. On exam, there is tenderness to palpation in the right lower quadrant of the abdomen. Bowel sounds are absent. Pelvic exam reveals scant white discharge from the cervical os. There is no cervical motion tenderness, and the adnexa and ovaries appear normal on exam. Which of the following is the most likely diagnosis? A. Appendicitis B. Ectopic pregnancy C. Pelvic inflammatory disease D. Tubo-ovarian abscess

Appendicitis

A 25-year-old woman, whose last menses was one week ago, presents to the emergency department complaining of severe lower abdominal pain. She has a 4-hour history of right lower quadrant abdominal pain, anorexia, and nausea. She says the pain initially began around the bellybutton and then moved to the right lower quadrant. Her temperature is 38.3°C (101°F). Palpation of the left lower quadrant produces pain in the right lower quadrant. Pelvic examination shows right adnexal tenderness. Which of the following is the most likely diagnosis? A. Appendicitis B. Ectopic pregnancy C. Ovarian torsion D. Pelvic inflammatory disease

Appendicitis

Which of the following is the most common surgical emergency in pregnant women? A. Appendicitis B. Cholecystitis C. Small bowel obstruction D. Uterine rupture

Appendicitis

Which of the following findings on X-ray is suggestive of colorectal cancer? A. Apple core sign B. Bird's beak sign C. Egg-on-a-string sign D. String sign

Apple core sign

A 54-year-old man presents complaining of epigastric pain that started several hours ago. The pain is moderate and sharp but does not radiate. He has a history of hypertension and an exploratory laparotomy 20 years ago. His vital signs on presentation include T 37°C, HR 95 bpm, and BP 136/80 mm Hg. His exam reveals a firm, mildly tender protruding mass in the epigastric region with no overlying skin changes. Which of the following is the best next step? A. Apply gentle steady pressure to the mass B. Obtain computed tomography scan of the abdomen C. Perform bedside abdominal aortic ultrasound D. Perform incision and drainage of the mass

Apply gentle steady pressure to the mass

A 54-year-old man with cirrhosis presents for evaluation of abdominal pain. The pain is diffuse throughout the abdomen and associated with subjective fever at home. He has no vomiting, diarrhea or change in mental status. His vital signs are T 100.6°F, HR 102, BP 140/88, RR 12, and oxygen saturation of 100% on room air. Bedside ultrasound demonstrates ascites. Which of the following is an indication for intravenous antibiotics? A. Ascitic fluid neutrophil count of 300 cells/mcL B. Ascitic fluid pH of 7.35 C. AST of 340 U/L D. Peripheral white blood cell count of 15,000 cells/mcL

Ascitic fluid neutrophil count of 300 cells/mcL

A 42-year-old man presents to the emergency department with nausea, vomiting, and right upper quadrant abdominal pain. He drinks alcohol daily. Which of the following laboratory results would be most consistent with alcoholic hepatitis? A. Alkaline phosphatase 350 U/L B. Aspartate transaminase 1000 U/L and alanine transaminase 1200 U/L C. Aspartate transaminase 250 U/L and alanine transaminase 120 U/L D. Mean corpuscular volume 60 fL

Aspartate transaminase 250 U/L and alanine transaminase 120 U/L

An 83-year-old woman with a history of constipation presents to the ED complaining of a rectal mass. On exam, you note the mass seen in the image above. What is the most appropriate next step in management? A. Attempt manual reduction B. Consultation to a colorectal surgeon C. Immediately begin broad-spectrum antibiotics D. Inject local anesthesia and perform an excisional thrombectomy

Attempt manual reduction

A 24-year-old woman presents to her primary care provider with complaints of diarrhea and a pruritic rash for the past four months. She reports an unintentional weight loss of five pounds despite increasing her calorie intake. On exam, her abdomen is slightly distended but nontender. Multiple small papulovesicles are noted on the extensor surface of her elbows and knees. A biopsy of these lesions reveals a granular pattern of immunoglobulin A deposition in the upper papillary dermis. Based upon the likely diagnosis, which of the following is the most appropriate management? A. Avoidance of oats, rice, and soy B. Avoidance of wheat, rye, and barley C. Oral prednisone D. Reduction of lactose-containing foods

Avoidance of wheat, rye, and barley

A 29-year-old pregnant patient presents with a three day history of diarrhea following a trip to Mexico. The patient describes having seven to eight loose, watery stools per day. She does not note any blood in the diarrhea and is otherwise asymptomatic. Vital signs are BP 116/72, HR 86, RR 15, T 38.7°C. Physical exam reveals mild dehydration, but is otherwise normal. After providing fluid replacement, what is the indicated treatment? A. Azithromycin B. Ciprofloxacin C. Symptomatic therapy with loperamide D. Trimethoprim-Sulfamethoxazole

Azithromycin

A 16-month-old boy presents to the emergency department with a 12-hour history of severe, intermittent abdominal pain. Approximately every 20 minutes, the child draws his legs up to his chest and cries inconsolably. Between episodes, the child behaves normally. The child's vital signs are within normal limits. Physical exam is notable for a sausage-shaped mass on the right side of his abdomen. What is most common complication of the first-line treatment of his condition? A. Bowel ischemia B. Bowel perforation C. Dumping syndrome D. Nutrient malabsorption

Bowel perforation

A 40-year-old woman presents with acute onset right upper quadrant pain, nausea, and vomiting. It began 18 hours ago after a fatty meal, and has progressively worsened. She is febrile and has tenderness in the right upper quadrant. She is not jaundiced. Blood tests are significant for a leukocytosis but only mildly elevated liver enzymes, bilirubin, and amylase. Ultrasound examination reveals gallbladder wall thickening and pericholecystic fluid. The common bile duct is patent. Which of the following is the most likely diagnosis? A. Biliary colic B. Cholangitis C. Cholecystitis D. Choledocholithiasis

Cholecystitis

A 44-year-old woman presents to the emergency department complaining of abdominal pain, nausea, and vomiting. The pain began last night and woke her up from sleep approximately six hours ago. The pain is located in the epigastric area and the right upper quadrant of the abdomen and she describes it as a squeezing pain. Physical exam reveals a positive Murphy sign. What is the most likely diagnosis? A. Cholangitis B. Cholecystitis C. Duodenal ulcer D. Pancreatitis

Cholecystitis

A 37-year-old obese woman presents with symptoms of biliary colic for the past 3 months. An ultrasound is negative for any gallstones. Which of the following is the most appropriate management for this patient? A. Cholecystectomy B. Cholecystokinin-HIDA scan C. CT scan D. Endoscopic Retrograde Cholangiopancreatography (ERCP)

Cholecystokinin-HIDA scan

Which of the following is a risk factor associated with the development of pancreatic cancer? A. Alcohol consumption B. Cigarette smoking C. Diet high in red meats D. Sedentary lifestyle

Cigarette smoking

A 34-year-old woman returns from travel outside of the US. Two days later, she presents with acute onset, frequent, green-colored and voluminous stooling. She has abdominal pain and a temperature of 101.9°F. A stool culture is positive for Shigella. Which of the following do you recommend? A. Ciprofloxacin B. Lactulose C. Sulfasalazine D. Tenofovir

Ciprofloxacin

Which of the following is the most common cause of esophageal varices in the United States? A. Cirrhosis B. Hepatic steatosis C. Parasitic infestation D. Prolonged standing

Cirrhosis

A 43-year-old woman presents to the ED with abdominal pain. She reports that the pain is epigastric and worse with food. She denies any fevers, chills, vomiting, or diarrhea. She recently visited a gastroenterologist who told her she had a bacterial infection in her stomach. However, she did not follow up or receive treatment. On exam, her abdomen is soft and nontender. Which of the following is the most appropriate treatment regimen for this patient's condition? A. Amoxicillin 1 g bid, metronidazole 500 mg bid, lansoprazole 30 mg bid for 10-14 days B. Clarithromycin 500 mg bid, amoxicillin 1 g bid, lansoprazole 30 mg bid for 10-14 days C. Clarithromycin 500 mg bid, amoxicillin 1 g bid, metronidazole 500 mg bid for 10-14 days D. Clarithromycin 500 mg bid, amoxicillin 1 g bid, metronidazole 500 mg bid, lansoprazole 30 mg bid for 10-14 days

Clarithromycin 500 mg bid, amoxicillin 1 g bid, lansoprazole 30 mg bid for 10-14 days

A 45-year-old woman uses ibuprofen daily for the last 12 months to help with her chronic back pain. She comes to you with new onset epigastric pain. Endoscopic examination reveals a duodenal ulcer. Helicobacter pylori serologic testing is positive. She has no known drug allergies. In addition to stopping the ibuprofen, which of the following is the most appropriate therapy at this time? A. Clarithromycin plus amoxicillin plus a proton pump inhibitor B. Clarithromycin plus an H2-antagonist C. Metronidazole plus amoxicillin plus bismuth subsalicylate D. Metronidazole plus bismuth subsalicylate

Clarithromycin plus amoxicillin plus a proton pump inhibitor

Which one of the following tests can be used to confirm lactose intolerance? A. Anti-gliadin antibodies B. Hydrogen breath test C. Sweat test D. Urea breath test

Hydrogen breath test

Hypochloremic, hypokalemic, metabolic alkalosis

A 3-week-old boy presents with two days of non-bilious, projectile vomiting. Examination reveals a mass in the infant's right upper quadrant. On a barium upper GI series report, the radiologist states a "string sign" is present. Which of the following is this infant at greatest risk of developing? A. Hyperchloremia B. Hyperkalemia C. Hypokalemia D. Hyponatremia

Hypokalemia

A 48-year-old woman presents with nausea and vomiting. She underwent an appendectomy 3 days ago. A contrast-enhanced CT of the abdomen and pelvis reveals an ileus. What electrolyte abnormality commonly causes an ileus? A. Hyperkalemia B. Hypernatremia C. Hypokalemia D. Hyponatremia

Hypokalemia

Which of the following metabolic abnormalities is most commonly noted in bulimia nervosa secondary to vomiting? A. Hyperalbuminemia B. Hypernatremia C. Hypokalemia D. Metabolic acidosis

Hypokalemia

You examine a 17-year-old girl due to anorexia nervosa. She has low self-esteem with intense fear of gaining weight. She restricted her diet for the past three months. On physical exam, her BMI is 18 with heart rate of 35 beats per minute at rest. You decide to admit her for inpatient management. You plan to start nutritional therapy but worry about the risk of refeeding syndrome. Which laboratory finding is most consistent with refeeding syndrome? A. Hyperkalemia B. Hypermagnesemia C. Hypophosphatemia D. Thrombocytopenia

Hypophosphatemia

A thin woman of Afghan descent who recently emigrated to the USA, presents for a new patient evaluation. She always wears a burqa, an enveloping outer garment worn by many Muslim women. Her baseline laboratory testing is unremarkable, but a bone densiometry test reveals osteomalacia. Further specific laboratory testing would most likely reveal which of the following disorders? A. Hypervitaminosis E B. Hypervitaminosis K C. Hypovitaminosis A D. Hypovitaminosis D

Hypovitaminosis D

Which of the following is the most common cause of an esophageal perforation? A. Acid ingestions B. Alkaline ingestions C. Iatrogenic D. Vomiting

Iatrogenic

A 19-year-old Asian man presents with compl1aints of diarrhea, flatulence, and bloating that occur everyday after breakfast. His breakfast is usually fruit with cottage cheese and a glass of milk. He denies weight loss, constipation, steatorrhea, bloody stools, or tenesmus. Which of the following tests will most likely diagnose his condition? A. Colonoscopy B. Hydrogen breath test C. IgA endomysial antibody test D. Qualitative fecal fat assay

IgA endomysial antibody test

A 32-year-old woman presents with abdominal pain, nausea, vomiting, and change in skin color for 6 days. She states that she had unprotected intercourse 4 weeks ago. Which one of the following tests indicates acute infection with hepatitis B as the cause of the patient's symptoms? A. Antibody to hepatitis B e antigen (Anti-HBe) B. Antibody to hepatitis B surface antigen (Anti-HBs) C. IgG antibody to B core antigen (Anti-HBc-IgG) D. IgM antibody to B core antigen (Anti-HBc-IgM)

IgM antibody to B core antigen (Anti-HBc-IgM)

A man with a strangulated, indirect inguinal hernia undergoes hernia repair surgery. Three weeks later, he presents with a complaint of numbness about his "beltline." Examination reveals no recurrent hernia. During light touch testing, he reports partial numbness and paresthesias in the anterior L1 dermatome. Irritation of which of the following nerves is most likely causing these symptoms? A. Iliohypogastric B. Lateral femoral cutaneous C. Obturator D. Pudendal

Iliohypogastric

A 60-year-old woman with a history of well-controlled diabetes mellitus presents to your office with a complaint of constipation. She has a bowel movement about twice per week with straining and hard stools. She has had intermittent constipation for many years, but over the past four months it has been constant. Which of the following is the most appropriate initial management? A. Fecal disimpaction B. Fiber restricted diet C. Increased fiber intake D. Suppository use as needed

Increased fiber intake

An overweight 29-year-old roofer presents with acute groin swelling after lifting an 80-pound sack of shingles. Examination reveals a minimally tender mass in the right scrotum. There is no mass in the proximal thigh or abdomen. Which of the following types of hernia do you most likely suspect? A. Direct inguinal B. Epigastric C. Femoral D. Indirect inguinal

Indirect inguinal

A 4-week-old male presents to the pediatrician's office with his mother for projectile nonbilious vomiting just after being fed that started five days ago. The mother states that the child wants to be fed almost immediately after the vomiting occurs. She reports the child is having 5-6 wet diapers and 1-2 liquid yellow-brown stools per day. Other than the episodes of vomiting, the mother reports her infant to be very content. Physical exam reveals moist mucous membranes and a nondistended abdomen with a right upper quadrant olive-shaped mass on the lateral border of the rectus abdominus muscle. Bowel sounds are noted to be normoactive and of normal pitch. What is the most likely diagnosis? A. Cow-milk intolerance B. Gastroesophageal reflux C. Infantile hypertrophic pyloric stenosis D. Intussusception

Infantile hypertrophic pyloric stenosis

An 82-year-old man presents with acute symptoms of ischemic colitis. He subsequently undergoes emergent bowel resection surgery. The surgical report details an infarction of the descending colon and recto-sigmoid junction. Pathology in which of the following arteries is the most likely cause of this condition? A. Celiac trunk B. Inferior mesenteric artery C. Portal vein D. Superior mesenteric artery

Inferior mesenteric artery

A 43-year-old man is admitted to the hospital with nausea, vomiting, and intermittent diarrhea for the past two weeks. He has a history of abdominal surgery following a motor vehicle crash five years ago. Vital signs are BP 120/70, HR 80, RR 14, and T 37.1°C. On physical exam, you note a distended abdomen. A plain film abdominal X-ray is seen above. Which of the following is the most appropriate step in management? A. Administer antibiotics B. Insert a nasogastric tube C. Perform a paracentesis D. Perform manual fecal disimpaction

Insert a nasogastric tube

A 35-year-old man presents with intermittent rectal bleeding and mucoid discharge for two weeks. His diet is low in fiber. He reports some bright red bloody streaks on the toilet paper after each bowel movement. Rectal pain is absent. On physical exam, no nodules are initially seen. With Valsalva, a purple nodule covered by mucosa is seen protruding through the anus. Which of the following is the most likely diagnosis? A. Anal abscess B. Anal fissure C. External hemorrhoid D. Internal hemorrhoid

Internal hemorrhoid

A 1-year-old boy is brought to the emergency department for severe abdominal pain, vomiting, and diarrhea. His mother says he has had several episodes of intermittent abdominal pain occurring about every 15 to 20 minutes. He appears to be in distress and is continuously crying. Physical examination reveals a "sausage-shaped" abdominal mass palpated on the right side of the abdomen. Which of the following is the most likely diagnosis? A. Gastroenteritis B. Hirschsprung disease C. Intussusception D. Meckel diverticulum

Intussusception

A 17-month-old boy presents with bilious vomiting, fever, and abdominal distention for the past 3 days. The mother states she noticed blood in the last diaper she changed. What is the most likely diagnosis? A. Intussusception B. Meckel diverticulum C. Milk protein allergy D. Pyloric stenosis

Intussusception

A 9-month-old boy presents for repeated vomiting and lethargy for the past several hours. He has been irritable and intermittently crying. Mom noticed that he was episodically drawing his knees up toward his chest. Physical exam reveals a palpable mass in the right lower quadrant. What is the most likely diagnosis? A. Acute appendicitis B. Congenital duodenal obstruction C. Intussusception D. Pyloric stenosis

Intussusception

What is the most common cause of intestinal obstruction in children under two years of age? A. Adhesions B. Incarcerated inguinal hernia C. Intussusception D. Malrotation with midgut volvulus

Intussusception

A 10-month-old boy is being evaluated for bilious vomiting, diarrhea, and rectal bleeding. He appears to be in severe distress and is continuously crying. Which of the following is the most appropriate next step in management? A. Abdominal CT scan B. Abdominal ultrasound C. Abdominal X-ray D. Contrast enema

Contrast enema

The treatment for celiac disease is a gluten-free diet. Which one of the following may be included in the diet of a patient with celiac disease? A. Barley B. Corn C. Rye D. Wheat

Corn

A 3-year-old boy presents after swallowing a quarter. He now feels it is stuck. At which location is an obstruction most likely to occur? A. Aortic arch B. Cricopharyngeus muscle C. Gastroesophageal junction D. Tracheal bifurcation

Cricopharyngeus muscle

A 34-year-old woman presents to the clinic with the skin lesions shown above. She also complains of recent unintentional weight loss, low-grade fevers, and nonbloody diarrhea. Which of the following is the most likely diagnosis? A. Acute myelogenous leukemia B. Crohn disease C. Hodgkin lymphoma D. Sarcoidosis

Crohn disease

A 28-year-old man presents with 2 months of nonbloody diarrhea and abdominal pain. Stool culture is negative for an infectious etiology. Endoscopic examination reveals small and large bowel fissuring and cobblestoning. Microscopic examination shows a transmural inflammatory infiltrate, but no crypt hyperplasia or villous atrophy. Hydrogen breath testing is negative. Which of the following is the most likely diagnosis? A. Celiac disease B. Crohn's disease C. Lactose intolerance D. Ulcerative colitis

Crohn's disease

Over the last 7 months a 13-year-old girl has had intermittent abdominal pain, which has made her quite irritable. The abdominal pain is associated with arthralgias and general malaise. Review of systems reveals that she has lost 5 kg (11 lb) and has painful bowel movements. Which one of the following is the most likely cause of these symptoms? A. Celiac disease (gluten enteropathy) B. Crohn's disease C. Irritable bowel syndrome D. Ulcerative colitis

Crohn's disease

Of the following, which is the most common infectious etiology of diarrhea in patients with AIDS? A. Clostridium difficile B. Cryptosporidium C. Cytomegalovirus D. Mycobacterium avium complex

Cryptosporidium

Which of the following is an appropriate therapy for a patient with severe acute pancreatitis? A. Antibiotics B. Anticholinergic agents C. Calcium chloride D. Crystalloid infusion

Crystalloid infusion

An 18-month-old boy is brought to his pediatrician's office by his parents with concern for developmental delays. The child was born at home and has had irregular healthcare. He has not started speaking and just started sitting upright unassisted. He also has unusual, musty smelling urine. On exam, the child has fair skin and hair. He has poor interaction with the pediatrician. After confirmation of the likely diagnosis, which of the following is the most appropriate management? A. Dietary restriction of branched-chain amino acid B. Dietary restriction of lactose and galactose C. Dietary restriction of phenylalanine D. Vitamin C supplementation

Dietary restriction of phenylalanine

A patient presents with new onset odynophagia. Chest imaging reveals a lower esophageal stricture but rules out the possibility of neoplasia. Endoscopy shows mucosal inflammation and fibrosis. Which of the following is the most appropriate initial treatment? A. Dilation B. Diltiazem C. Famotidine D. Lactulose

Dilation

You diagnose a 43-year-old man with alcohol withdrawal. Lab results reveal a hemoglobin of 12 g/dL and an MCV of 115 fL. Which of the following is the most likely cause of these findings? A. Direct ethanol toxicity B. Pyridoxine deficiency C. Thiamine deficiency D. Vitamin B12 deficiency

Direct ethanol toxicity

An 18-year-old man with schizophrenia presents after ingesting a razor blade. The patient indicates that he feels a foreign body sensation in his lower chest. The patient is tolerating secretions and appears to be in no acute distress. X-ray shows a metal foreign body in the distal esophagus. What management is indicated at this point? A. CT scan of the chest B. Emergent endoscopy C. Glucagon D. Observation

Emergent endoscopy

A 33-year-old man presents with a painful, irreducible indirect inguinal hernia. You suspect strangulation. Which of the following is the most appropriate management step? A. Elective hernia repair B. Emergent herniorrhaphy C. Hernia truss D. Monitor for worsening symptoms

Emergent herniorrhaphy

A 45-year-old woman presents to her primary care provider because of recurrent epigastric pain that usually occurs after heavy meals and with sitting in a reclined position. She reports transient relief when she sits upright or drinks milk. She denies weight loss, early satiety, dysphagia, and melena. Physical examination is notable for obesity, but is otherwise unremarkable. Which of the following is most appropriate next step? A. Ambulatory 24-hour pH monitoring B. Empiric trial of omeprazole C. Fundoplication D. Upper endoscopy

Empiric trial of omeprazole

A 47-year-old woman with a history of human immunodeficiency virus infection, hypertension, and schizophrenia, presents with a 1-day history of epigastric abdominal pain, nausea and vomiting. Vital signs are notable for BP 135/86 mm Hg, pulse of 104 beats/minute, RR 14 breaths/minute, temperature of 37.9, and oxygen saturation of 98% on room air. On examination, she is exquisitely tender in the epigastrium. Lipase is elevated at 4,500 U/L. Which of the following of her medications is the most likely cause of her symptoms? A. Aripiprazole B. Enalapril C. Penciclovir D. Tenofovir

Enalapril

A four-week-old baby boy presents to the emergency department with projectile vomiting over the past three days. On physical exam, he is found to have a palpable olive-like mass in the right upper quadrant. On laboratory analysis he has a hypochloremic metabolic alkalosis. Which of the following is a risk factor for development of this condition? A. Erythromycin use B. Female sex C. Full-term birth D. Second born child

Erythromycin use

A 43-year-old man comes to the clinic complaining of a 3-week history of a "burning" sensation in his chest and nocturnal cough. He says he wakes up several times at night coughing and wheezing. He weighs 350-lbs and has a BMI of 48. If this patient's condition is left untreated, which of the following complications can most likely develop? A. Esophageal adenocarcinoma B. Hepatocellular carcinoma C. Small cell carcinoma of the lung D. Squamous cell carcinoma of the esophagus

Esophageal adenocarcinoma

Which of the following is the recommended treatment of benign esophageal stricture disease? A. Esophageal dilation B. Esophogram C. H2 blockers D. Radiation treatment

Esophageal dilation

A 27-year-old woman presents to her primary care physician with dysphagia. Her symptoms began several months ago. She has trouble swallowing solids and liquids though liquids seem to make her choke and sputter the most; therefore, she has been unable to eat and has thus experienced significant weight loss. She has no significant past medical history apart from a 20-pack-per-year smoking history. She denies any recent travel. Physical examination is within normal limits. A barium esophagram reveals a "bird's beak" appearance. What is the next best step in diagnosis? A. Begin a calcium channel blocker B. Begin botulinum toxin injections C. Esophageal manometry D. Upper endoscopy

Esophageal manometry

Which of the following is the most sensitive diagnostic study for diagnosing achalasia? A. Barium swallow B. Electromyography C. Esophageal manometry D. Esophagogastroduodenoscopy

Esophageal manometry

A 52-year-old man comes to the clinic complaining of difficulty swallowing, upper abdominal pain, and heartburn. He says he has a difficult time swallowing solid foods and the food frequently gets "stuck" in his throat. He has a history of food allergies, asthma, and atopic dermatitis. Laboratory studies show markedly elevated serum IgE levels. Upper endoscopy shows stacked circular rings. Which of the following is the most likely diagnosis? A. Achalasia B. Esophageal stricture C. Esophagitis D. Gastroesophageal reflux disease (GERD)

Esophagitis

A 68-year-old man presents with complaints of vague abdominal pain, unintentional weight loss, and early satiety for the past two months. Which of the following diagnostic studies is likely to provide a definitive diagnosis? A. Contrast-enhanced computed tomography scan of the abdomen and pelvis B. Double-contrast radiography C. Endoscopic sonography D. Esophagogastroduodenoscopy

Esophagogastroduodenoscopy

Which of the following represents appropriate management of a thrombosed external hemorrhoid in the acute 48-hour setting? A. Excision B. Reduction C. Sitz baths D. Surgery referral

Excision

A 55-year-old-man with known alcoholic cirrhosis presents with a fever and abdominal pain. He is mildly confused and has asterixis on exam. His abdomen is distended and tender to palpation. Paracentesis is completed. The ascitic fluid has a neutrophil count of 280/mm3. Which of the following is the most appropriate intravenous antibiotic for treatment of this condition? A. Ampicillin B. Cefotaxime C. Sulfamethoxazole/trimethoprim D. Vancomycin

Extraintestinal manifestations such as hallucinations, confusion, and seizures may occur

What is the most common cause of acute pancreatitis worldwide? A. Alcohol B. Gallstones C. Medications D. Trauma

Gallstones

A woman presents with significant family and work related stress. She has been drinking alcohol more frequently than usual. For the past two weeks, she has noticed upper central abdominal pain, nausea, and loss of appetite. Initial laboratory testing reveals a mild anemia. You decide to order an esophagogastroduodenoscopy, which only reveals gastric epithelial inflammation. Which of the following is the most likely diagnosis? A. Esophagitis B. Gastritis C. Pancreatitis D. Peptic ulcer disease

Gastritis

A 24-year-old man presents to an urgent care clinic with complaints of diarrhea. His stools are foul-smelling and float in the toilet. He reports a 2-pound unintentional weight loss but does not have bloody stools. When questioned, he reports drinking unfiltered water during a hiking trip 2 weeks ago. Which of the following is the most likely etiology of his man's illness? A. Entamoeba histolytica B. Escherichia coli C. Giardia lamblia D. Shigella sonnei

Giardia lamblia

A 24-year-old man with HIV was recently started on trimethoprim-sulfamethoxazole. He complains of two days of worsening fatigue and dyspnea. The patient appears pale with scleral icterus. Laboratory testing shows a marked anemia and elevated total and indirect bilirubin. What is the most likely diagnosis? A. Crigler-Najjar syndrome B. Gilbert's syndrome C. Glucose-6-phosphate dehydrogenase deficiency D. Immune reconstitution syndrome

Glucose-6-phosphate dehydrogenase deficiency

Which of the following is characterized by macrocytic anemia with increased reticulocytes and Heinz bodies? A. Alpha thalassemia B. Glucose-6-phosphate dehydrogenase deficiency C. Sickle cell anemia D. Vitamin B12 deficiency

Glucose-6-phosphate dehydrogenase deficiency

Which of the following laboratory results signifies acute hepatitis B? A. HBsAg +, anti-HBc IgG +, HBeAg -, HBV DNA + B. HBsAg +, anti-HBc IgM +, HBeAg +, HBV DNA + C. HBsAg -, anti-HBs +, HBeAg -, HBV DNA - D. HBsAg -, anti-HBs -, HBeAg -, HBV DNA -

HBsAg +, anti-HBc IgM +, HBeAg +, HBV DNA +

Which of the following combinations of hepatitis B serologic markers is indicative of hepatitis B immunity secondary to vaccination? A. HBsAg negative, anti-HBc negative, anti-HBs positive B. HBsAg negative, anti-HBc positive, anti-HBs positive C. HBsAg positive, anti-HBc positive, IgM anti-HBc negative, anti-HBs negative D. HBsAg positive, anti-HBc positive, IgM anti-HBc positive, anti-HBs negative

HBsAg negative, anti-HBc negative, anti-HBs positive

Which of the following is prominently visualized in the image above? A. Haustra B. Plicae circulares C. Teniae coli D. Valvulae conniventes

Haustra

A 35-year-old woman presents for evaluation of chest pain. The patient describes a burning pain that begins in the subxiphoid area and radiates up into her neck. Occasionally she has a bitter taste in her mouth. Her electrocardiogram and chest radiograph are normal. Which of the following is most likely to help her symptoms? A. Avoidance of fatty foods B. Calcium channel blocker therapy C. Eradication of H. pylori D. Head of bed elevation while sleeping

Head of bed elevation while sleeping

Which of the following is demonstrated on a peripheral blood smear of a patient with glucose 6-phosphate dehydrogenase deficiency? A. Heinz bodies B. Howell-Jolly bodies C. Rouleaux formation D. Target cells

Heinz bodies

A 65-year-old Norwegian man presents with hematemesis. His past medical history includes alcohol abuse, tobacco use, Helicobacter pylori infection, heavy intake of smoked fish, and diabetes mellitus. Endoscopic examination reveals a large pyloric mass. Which of the following is the most common cause of this type of gastric cancer? A. Diabetes mellitus B. Helicobacter pylori C. Smoked fish diet D. Tobacco use

Helicobacter pylori

What is a principal risk factor for peptic ulcer disease? A. Alcohol consumption B. Emotional stress C. Helicobacter pylori infection D. High-fat diet

Helicobacter pylori infection

A 45-year-old man presents with severe rectal pain and bleeding for three hours. He is known to have chronic stage IV internal hemorrhoids that bleed severely from time to time. Vital signs are temperature 98.6°F, respiratory rate 22 breaths/minute, blood pressure 100/55 mm Hg, heart rate 105 bpm, and oxygen saturation 98% on room air. Physical exam shows purple, necrotic nodules covered by mucosa that is protruding through the anal canal. Complete blood count shows white blood cell count 5.8/L, hemoglobin 10 mg/dL, hematocrit 30%, and platelet count 265,000/microL. Which of the following is the most effective management? A. Bipolar cautery B. Hemorrhoidectomy C. Injection sclerotherapy D. Rubber band ligation

Hemorrhoidectomy

What is the most common cause of rectal bleeding in an adult? A. Colon cancer B. Diverticulitis C. Hemorrhoids D. Inflammatory bowel disease

Hemorrhoids

A patient of yours becomes acutely jaundiced. She has had no contact with blood, body fluids, medical specimens, or needles. She is currently sexually inactive. Which of the following is she most likely infected with? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D

Hepatitis A

A 31-year-old nurse presents to the emergency department after being stuck with a blood-filled hollow bore needle during a resuscitation. She discovers the patient has hepatitis B. That same day, she has her blood drawn. Which of the following serologic markers indicates prior hepatitis B immunization? A. Hepatitis B core antibody (anti-HBc) B. Hepatitis B envelope antigen (HBeAg) C. Hepatitis B surface antibody (anti-HBs) D. Hepatitis B surface antigen (HBsAg)

Hepatitis B surface antibody (anti-HBs)

Which of the following profiles is consistent with immunity to hepatitis B virus secondary to vaccination? A. Hepatitis B core antibody positive, hepatitis B surface antibody positive B. Hepatitis B surface antigen negative, hepatitis B surface antibody positive C. Hepatitis B surface antigen positive, hepatitis B e antigen positive D. Hepatitis B surface antigen positive, hepatitis B surface antibody negative

Hepatitis B surface antigen negative, hepatitis B surface antibody positive

A 32-year-old man develops malaise, anorexia, fever, nausea, vomiting, and abdominal discomfort. AST and ALT are markedly elevated. Which of the following hepatitis viruses is associated with the highest risk of progression to chronic infection in adults? A. Hepatitis A virus B. Hepatitis B virus C. Hepatitis C virus D. Hepatitis E virus

Hepatitis C virus

Which of the following is the most appropriate diagnostic test in a patient with suspected infantile hypertrophic pyloric stenosis? A. Abdominal ultrasound B. CT of the abdomen C. MRI of the abdomen D. Plain X-ray of the abdomen A 60-year-old woman presents with two days of right upper quadrant abdominal pain that is constant in nature and associated with subjective fever, nausea, and vomiting. Vital signs are significant for a temperature of 38.1°C, heart rate 87 bpm, blood pressure 140/80 mm Hg, respiratory rate 14 breaths/min, and oxygen saturation of 99% on room air. On physical examination, her abdomen is soft with right upper quadrant tenderness and a positive Murphy sign. Which of the following tests is most sensitive and specific in diagnosing this patient's condition? A. Computed tomography scan with intravenous contrast B. Hepatobiliary iminodiacetic acid (HIDA) scan C. MRI with gadolinium D. Ultrasound

Hepatobiliary iminodiacetic acid (HIDA) scan

To properly treat an individual with phenylketonuria, a life-long strict adherence to a diet consisting of which of the following is recommended? A. High in beans, low in vegetables B. High in meats, low in beans C. High in starches, low in fruits D. High in vegetables, low in meats

High in vegetables, low in meats

A 76-year-old woman presents with abdominal pain and distention for the past two hours. Upright films of the abdomen are obtained and shown above. Which of the following physical exam findings would be most consistent with this diagnosis? A. Cullen's sign B. Dullness to percussion C. Fluid wave D. High-pitched bowel sounds

High-pitched bowel sounds

A 73-year-old man presents with vomiting and abdominal pain for 2 days. The patient has a remote history of cholecystectomy and appendectomy. Examination reveals a markedly distended abdomen and absent bowel sounds. Lab studies show an elevated WBC count and lactate of 4.3 mmol/L. An abdominal radiograph is obtained that is shown above. Which of the following is the most appropriate management at this time? A. Administer intravenous fluids and obtain a CT of the abdomen and pelvis B. Arrange for emergent colonoscopy C. Perform a soap suds enema and administer polyethylene glycol D. Place a nasogastric tube, begin antibiotics, and obtain a surgical consultation

Place a nasogastric tube, begin antibiotics, and obtain a surgical consultation

A 23-year-old man with a history of ulcerative colitis presents with abdominal pain and vomiting. On exam, he is febrile with a heart rate of 125 beats per minutes and blood pressure of 92/63 mm Hg. He has diffuse abdominal tenderness and distention. Which of the following imaging studies is most appropriate to diagnose toxic megacolon? A. Colonoscopy B. Computed tomography C. Plain radiography D. Ultrasound

Plain radiography

A 25-year-old woman presents to your office with complaints of abdominal pain and constipation for the past year. She has seen a number of doctors and specialists with extensive testing revealing all normal results. She is following the dietary recommendations given to her previously, but is still only having bowel movements twice per week. Which of the following is the most appropriate next step in management? A. Cholestyramine B. Loperamide C. Polyethylene glycol D. Rifaximin

Polyethylene glycol

A 53-year-old woman presents complaining of abdominal pain and vomiting that is worsening over the last 2 days. She denies chronic medical issues. She has a history of an appendectomy and cholecystectomy, as well as two vaginal deliveries. Her exam is remarkable for abdominal rushes, gurgles and high-pitched sounds, as well as abdominal tenderness to palpation. Plain abdominal radiography shows dilated loops of small bowel with air-fluid levels. What is the most likely etiology of her diagnosis? A. Abdominal hernia B. Diverticulosis C. Intussusception D. Post-operative adhesions

Post-operative adhesions

A 32-year-old man presents with a severe, tearing pain during defecation, followed by throbbing discomfort. His diet is low in fiber. He reports small bloody streaks on the toilet paper. On physical exam, a 4 mm linear lesion is noted along the anoderm. What is the most likely location of the lesion based on the suspected diagnosis? A. Anterior midline B. Circumferential C. Lateral D. Posterior midline

Posterior midline

Which of the following is the most common location for primary anal fissures? A. Anterior midline B. Anterolateral to the midline C. Lateral to the midline D. Posterior midline

Posterior midline

A young woman presents to the ED with 3 days of new-onset intermittent, crampy abdominal pain. She reports one day of diarrhea and one episode of vomiting, but for the last two days, reports little to no bowel movements and increasing abdominal distension. Her medical history is significant for hyperthyroidism, irritable bowel syndrome, laparoscopically treated endometriosis, asthma and chronic tension-type headaches. Abdominal radiograph reveals excessive air in the proximal small bowel and a lack of air in the colon. Which of the following is the most likely cause of this patient's symptoms? A. Hyperthyroidism B. Irritable bowel syndrome C. Opioid analgesics D. Postoperative adhesions

Postoperative adhesions

Which of the following conditions most commonly results in symptomatic hemorrhoids? A. Pancreatitis B. Peptic ulcer disease C. Pregnancy D. Ulcerative colitis

Pregnancy

A 16-year-old girl returns from a summer abroad volunteering at an HIV clinic in Zimbabwe. She is going to volunteer at her local hospital, which requires tuberculosis skin testing. Her skin test is read as 14 mm of induration. Chest X-ray is negative and she is asymptomatic so she is started on a 9-month course of isoniazid. What vitamin should she concurrently be started on? A. Cobalamin B. Niacin C. Pyridoxine D. Thiamine

Pyridoxine

A 60-year-old woman with a history of heart failure presents with substernal chest pain that awoke her from sleep. She has dysphagia when swallowing solids and odynophagia when swallowing both solids and liquids. She reports a history of chest pain in the past but states that this pain is different in that it is sharp and occurs only after swallowing. Her medications include metoprolol succinate, furosemide, potassium chloride, simvastatin, isosorbide dinitrate, and levothyroxine. Which of the following is most likely to lead to the correct diagnosis? A. Barium esophagram B. CT angiogram of the chest C. Electrocardiogram D. Questioning her about her medication use

Questioning her about her medication use

A 43-year-old woman presents with right upper quadrant abdominal pain for 3 weeks. She states that she intermittently gets sharp pain that occurs after eating and is associated with nausea and occasionally vomiting. The pain lasts for 10-15 minutes, and then spontaneously improves. Currently, she has no pain. Her vital signs and bloodwork are normal. A right upper quadrant ultrasound is shown above. What management is indicated? A. Administer antibiotics and admit for observation B. Admit patient for cholecystectomy C. Obtain CT scan of he abdomen and pelvis D. Referral for surgical consultation and pain medication as needed

Referral for surgical consultation and pain medication as needed

A 35-year-old man presents with worsening dyspepsia for 11 months. He was initially treated with ranitidine and then with omeprazole, but his symptoms have not improved. He also reports postprandial belching, nausea, steatorrhea, and weight loss. Epigastric tenderness is noted upon palpation of the abdomen. A fasting serum gastrin level of 1,200 pg/mL is seen in laboratory study. Which of the following history and physical exam findings most likely supports the suspected diagnosis? A. Belching B. Refractory dyspepsia C. Steatorrhea D. Weight loss

Refractory dyspepsia

A 53-year-old woman with chronic alcohol use presents with confusion and blurred vision. Her vital signs are normal. Physical examination reveals a wide-based gait, inability to abduct her right eye fully, nystagmus, and difficulty with memory. Her alcohol level is 0.0 mg/dL. Which of the following is most likely to diagnose this patient's disease? A. Administration of edrophonium B. Noncontrast head CT C. Response to thiamine administration D. Serum magnesium

Response to thiamine administration

A 40-year-old woman with a history of anemia presents to your office with complaints of abdominal bloating and pain with defecation. When she was younger she had daily bowel movements. Now she has a bowel movement every 3-4 days that is hard. She has to strain and has even had to use her finger to get the stool out. Which of the following historical factors is most important to discuss at this time? A. Asking the patient if she is constipated B. Determination of past sexual abuse C. Review of current medications D. Review of most recent laboratory testing

Review of current medications

A four-year-old boy is new to your practice and comes into the clinic with his mother for a health supervision visit. The family recently migrated to the United States. The mother does not have any concerns. On exam, you note height at 5th percentile, enlargement of the costochondral junction, widening of the wrist and varus deformities of the legs. X-ray shows osteopenic epiphyseal centers. Laboratory tests reveal elevated alkaline phosphatase and low serum phosphorus and calcium. Which of the following is the most likely diagnosis? A. Blount disease B. Hypophosphatasia C. Rickets D. Skeletal dysplasia

Rickets

A 47-year-old man with a history of alcohol use disorder presents with severe abdominal pain, nausea, and vomiting for 1 day. Examination reveals marked epigastric tenderness to palpation. Labs show the following: Lipase: 4,300 U/L AST: 451 U/L ALT: 532 U/L Alkaline phosphatase: 313 U/L Total bilirubin: 5.3 µmol/L Which of the following is the best next step? A. CT scan of the abdomen and pelvis B. Discharge home if patient tolerates oral fluids C. Intravenous antibiotics and admission D. Right upper quadrant ultrasound

Right upper quadrant ultrasound

An 18-year-old man presents complaining of fever, right-sided abdominal pain, anorexia, and vomiting. When you palpate his left lower quadrant, he complains of pain in his right lower quadrant. Based on this information, which of the following signs is considered positive? A. McBurney sign B. Obturator sign C. Psoas sign D. Rovsing sign

Rovsing sign

You suspect appendicitis in a 30-year-old woman with acute abdominal pain, anorexia, fever, and vomiting. Interestingly, she has right lower quadrant pain when the left lower quadrant is palpated. Which of the following signs describes this finding? A. Dunphy sign B. Markle sign C. Psoas sign D. Rovsing sign

Rovsing sign

Which of the following physical exam findings is most suggestive of appendicitis? A. Kehr's sign B. Murphy's sign C. Rovsing's sign D. Scarf sign

Rovsing's sign

A patient experiences painless bright-red blood per rectum after bowel movements. Perianal examination reveals no abnormalities. You diagnose non-strangulated, large internal hemorrhoids, and then prescribe topical anesthetics and stool softeners. Three weeks later, the patient reports no improvement. At this point in management, which of the following is the most recommended treatment for this patient's non-strangulated internal hemorrhoids? A. Injection sclerotherapy B. Lord's procedure C. Operative hemorrhoidectomy D. Rubber band ligation

Rubber band ligation

Which of the following is one of the most common causes of bacterial foodborne disease in the United States? A. Enterotoxigenic Escherichia coli B. Salmonella C. Shigella D. Vibrio cholerae

Salmonella

Twenty-four hours after eating a salad containing bean sprouts, a 25-year-old man became ill with fever, abdominal pain and diarrhea. Which of the following organisms is the most likely cause of his symptoms? A. Clostridium perfringens B. Cryptosporidium parvum C. Enterotoxigenic Escherichia coli D. Salmonella enterica

Salmonella enterica

A 54-year-old man is unable to swallow after feeling a piece of steak "get stuck" while eating dinner. What is the most likely cause of his dysphagia? A. Achalasia B. Barrett esophagus C. Neoplasm D. Schatzki ring

Schatzki ring

A 46-year-old obese man presents to the clinic complaining of recurrent heartburn. He reports compliance with optimal medical management and dietary modifications and has been unsuccessful at losing weight. Which of the following is a contraindication to surgical intervention and should be ruled out before proceeding? A. Benign esophageal strictures B. Gastroparesis C. Hiatal hernia D. Scleroderma

Scleroderma

A previously healthy 30-year-old man presents to your clinic with questions about hepatitis C. He has no history of intravenous drug use, blood transfusions, or needlestick injury. Which of the following is the most appropriate next step in management? A. Administration of hepatitis C vaccine B. Referral to gastroenterology C. Screening with hepatitis C antibody test D. Screening with hepatitis C RNA test

Screening with hepatitis C antibody test

An 85-year-old nursing home patient presents with diffuse abdominal pain and distension and nausea, but no vomiting. The above abdominal radiograph is obtained. What is the management of this patient? A. Enema B. Nasogastric tube and bowel rest C. Sigmoidoscopy D. Surgical intervention

Sigmoidoscopy

Which of the following studies can definitively diagnose celiac disease? A. Barium contrast radiography B. Schilling test C. Small bowel biopsy D. Urinary metanepherines

Small bowel biopsy

For patients with lactose intolerance, in which of the following parts of the gastrointestinal tract does malabsorption of lactose occur? A. Colon B. Mouth C. Small intestine D. Stomach

Small intestine

A 57-year-old woman with cirrhosis complains of worsening distension of the abdomen and edema up to her lower legs despite compliance with eating less than 2 grams daily of sodium. She denies abdominal pain, constipation, dyspnea or fevers. On exam, her abdomen is distended and has a notable fluid wave. She has 2+ pitting edema to the level of her ankles. Which medication is the most appropriate next step in the management of this patient? A. Hydrochlorothiazide B. Lactulose C. Omeprazole D. Spironolactone

Spironolactone

A 43-year-old-man with known alcoholic cirrhosis presents to the emergency department with fever and abdominal pain. His family notes he has also been more confused and sleepy than usual. He has not been feeling well for a few days. He denies trauma, change bowel habits, and blood in his stool. His abdomen is distended with a fluid wave and is diffusely tender to palpation. What is the most likely diagnosis? A. Appendicitis B. Cholecystitis C. Colitis D. Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis

Which of the following supports the diagnosis of biliary colic? A. An ultrasound that shows an empty gallbladder and duct B. Pain that is relieved by eating food C. Radiation of abdominal pain to the lumbar region D. Steady abdominal pain localized in the right upper quadrant

Steady abdominal pain localized in the right upper quadrant

A 47-year-old man with chronic low back pain presents to the emergency department with epigastric pain for 3 weeks. The pain is burning, without radiation, and occurs 2-3 hours after eating. Vital signs are normal. He takes ibuprofen and naproxen for his back pain. What management is indicated? A. Admit for endoscopy B. Start esomeprazole and refer for outpatient evaluation C. Start ranitidine and refer for outpatient evaluation D. Stop ibuprofen and naproxen and refer for outpatient evaluation

Stop ibuprofen and naproxen and refer for outpatient evaluation

A 12-month-old boy is brought to the emergency department by his mother for three days of intermittent episodes of inconsolable crying. This morning the boy became lethargic and difficult to awaken. He has had several episodes of nonbilious vomiting and grossly bloody stools. His vital signs are T 38.3°C, HR 140, BP 80/50, RR 22. On examination, he is lethargic but diffusely tender on abdominal palpation with involuntary guarding. His abdominal X-ray reveals free air under the diaphragm. Which of the following is the most appropriate definitive management of this patient's condition? A. Administration of broad spectrum antibiotics B. Air-contrast enema C. Nasogastric suction D. Surgical reduction

Surgical reduction

A 45-year-old woman presents for evaluation of right upper quadrant pain. The pain was initially intermittent but has become more constant without radiation. She does not have fever. Her examination is notable for tenderness in the right upper quadrant without a Murphy sign. She undergoes a right upper quadrant ultrasound as seen above. Which of the following is the most likely diagnosis? A. Cholangitis B. Cholecystitis C. Choledocholithiasis D. Symptomatic cholelithiasis

Symptomatic cholelithiasis

A 45-year-old woman presents to the ED with three hours of constant right upper quadrant abdominal pain that radiates to her right scapula. The pain was sudden in onset and awoke her from sleep. Vital signs are BP 130/70 mm Hg, HR 90, RR 16, T 98.8℉, and oxygen saturation 99% on room air. On exam, the patient is well appearing, with no pallor, jaundice or abdominal tenderness. Her AST, ALT, total bilirubin, alkaline phosphatase, and lipase are normal. Which of the following is the most likely diagnosis? A. Biliary leak B. Cholangitis C. Cholecystitis D. Symptomatic cholelithiasis

Symptomatic cholelithiasis

A 32-year-old woman presents to her primary care provider complaining of diarrhea and bloating associated with eating bread products. She notes that her stools are bulky and float. She also reports increased flatulence. She denies any weight-loss or any blood or pus in the stool. What is the first test that should be ordered? A. Deamidated gliadin peptide B. Human leukocyte antigen DQ2 and DQ8 testing C. Small bowel biopsy D. Tissue transglutaminase antibody

Tissue transglutaminase antibody

A 72-year-old man presents with progressive dysphagia. He initially had difficulty swallowing solid foods, but is now having difficulty swallowing liquids. An esophagogastroduodenoscopy reveals a fungating mass on the middle third of the esophagus. Biopsy of the lesion is positive for squamous cell carcinoma. Which of the following historical features does this man most likely have? A. Exposure to industrial dyes B. Gastroesophageal reflux disease C. Lynch syndrome D. Tobacco use

Tobacco use

A 38-year-old woman presents with rectal pain and blood on the toilet paper when she wipes after bowel movements for the last two days. Physical examination reveals a mildly tender, external, non-thrombosed hemorrhoid without active bleeding. Which of the following is the most appropriate pharmacotherapy? A. Oral docusate B. Topical hydrocortisone C. Topical lidocaine D. Topical nifedipine

Topical hydrocortisone

An 18-month-old boy is brought to the emergency department by his mother for two days of intermittent episodes of inconsolable crying. During these episode, the child is noted to stop playing, lay down, and draw his legs up to his chest. His mother denies any emesis or bloody bowel movements. Physical examination and vital signs in the emergency department are normal. Which of the following is the most appropriate imaging modality for the confirmation of a diagnosis of intussusception in this patient? A. Abdominal X-ray B. Air-contrast enema C. Computed tomography D. Ultrasonography

Ultrasonography

A 14-month-old boy presents to the emergency department with irritability. His parents report episodes of irritability that have been occurring every 2 hours over the past 12 hours. The episodes last for about 15 minutes then seem to resolve. He also seems sleepier than usual. His last stool was 2 days prior. On examination, the infant appears lethargic. He has mild abdominal distension and has involuntary guarding. Which of the following is the best diagnostic test? A. CT scan of the abdomen B. Hemoccult of the stool C. Ultrasound of the abdomen D. X-rays of the abdomen

Ultrasound of the abdomen

A 65-year-old man presents to the clinic with several weeks of dull, gnawing epigastric pain that is usually relieved by eating. He has been taking omeprazole for five weeks, but has had no improvement. His only other daily medication is ibuprofen for knee pain. An abdominal exam is normal and fecal occult blood testing is negative. The next best step in management includes which of the following diagnostic tests? A. Abdominal CT B. Barium upper gastrointestinal series C. H. pylori fecal antigen assay D. Upper endoscopy

Upper endoscopy

A patient presents with hematemesis. What test is most likely to determine the etiology of the bleeding? A. CT scan of the abdomen and pelvis B. Nasogastric tube lavage C. Right upper quadrant ultrasound D. Upper endoscopy

Upper endoscopy

A 66-year-old man presents with nausea and recurrent vomiting. His wife accompanies him and adds she thinks his voice has changed. His past medical history is significant for alcohol abuse, tobacco abuse, hypertension, COPD, and celiac disease. During examination, his voice is raspy and hoarse. You order a chest and neck CT scan which reveals a mass. Which of the following is the most likely location of this mass? A. Gastric cardia B. Gastric pylorus C. Lower one-third of the esophagus D. Upper two-thirds of the esophagus

Upper two-thirds of the esophagus

A 32-year-old man presents to your office with a new diagnosis of celiac disease. He wants to make sure that he is adhering to a gluten-free diet and is confused about what he can eat. Which of the following foods can he safely include on his diet? A. Fried chicken with gravy B. Spaghetti with marinara sauce C. Tuna fish sandwich on whole wheat bread D. Vegetables with brown rice

Vegetables with brown rice

A 12-year-old boy is brought to the clinic for progressively worsening blurry vision and generalized headaches that are worse in the morning. On further questioning, he is also revealed to have nausea, joint pain, itchy and peeling skin, dizziness, and irritability. Historically, he has been a healthy child and his family follows an organic diet with additional supplements that include 2 tablespoons of cod liver oil and a multivitamin tablet a day. On exam, his weight dropped from the 50th percentile a year before to the 10th percentile currently. He has oily skin and hair and cracking at the corners of his mouth. Chronic overdose of which of the following most likely caused his symptoms? A. Vitamin A B. Vitamin C C. Vitamin D D. Vitamin E

Vitamin A

A 12-year-old girl with cystic fibrosis has been non-compliant with her vitamin and enzyme supplements. She presents with dry eyes and difficulty seeing at night. She is most likely deficient in which vitamin? A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K

Vitamin A

A 15-year-old girl presents to the emergency department complaining of headaches. The patient denies fever, sore throat, vomiting, and head trauma. Physical exam reveals facial acne, papilledema, and splenomegaly. Excess of which of the following vitamins is most likely causing her symptoms? A. Vitamin A B. Vitamin B3 C. Vitamin B6 D. Vitamin C E. Vitamin E

Vitamin A

A 71-year-old man presents to your clinic with complaints of worsening vision in dim or dark environments. On physical exam, he has bilaterally dry conjunctiva and diffuse dry skin. There are small white patches on his conjunctiva. The suspected diagnosis can be confirmed by testing for which of the following vitamin deficiencies? A. Niacin B. Thiamine C. Vitamin A D. Vitamin C

Vitamin A

A 55-year-old man with a history of alcoholism presents with an unsteady gait. He is slightly confused with ophthalmoplegia noted on neurologic examination. Which of the following is the primary treatment of this syndrome? A. Dextrose B. Folic acid C. Magnesium D. Vitamin B1

Vitamin B1

A 17-year-old young woman is brought by her mother to clinic for concerns for depression and irritability. She is generally a very health-conscious individual who plays tennis competitively and follows a strict vegan diet. Upon further questioning the girl reports chronic fatigue, diarrhea, and decreased sensation in her fingers. Her mother has also noticed that her gait has become uncoordinated. What vitamin is she most likely deficient in? A. Vitamin B1 B. Vitamin B12 C. Vitamin B2 D. Vitamin B6

Vitamin B12

A 60-year-old missionary woman is being evaluated for dementia. She also has diarrhea. She was recently treated for tuberculosis with isoniazid. Physical examination shows a symmetric hyperpigmented rash on both arms. Deficiency of which of the following vitamins most likely resulted in this patient's condition? A. Vitamin B1 B. Vitamin B12 C. Vitamin B3 D. Vitamin B9

Vitamin B3

A 38-year-old man who recently emigrated from Southeast Asia was treated several weeks ago at a local hospital for pulmonary tuberculosis. He was started on therapy including rifampin, isoniazid, pyrazinamide, and ethambutol. He now reports numbness in all of his extremities which began one week ago and has been progressing. On physical exam he has an uncoordinated gait and paresthesias on his hands and feet. What is the most likely cause of his symptoms? A. Vitamin A deficiency B. Vitamin B12 deficiency C. Vitamin B3 deficiency D. Vitamin B6 deficiency

Vitamin B6 deficiency

A 85-year-old was found unconscious in his home by emergency medical services and was brought to the hospital. He lives by himself and appears emaciated on physical exam. Bleeding of his gums and multiple chronic appearing wounds on the extremities are also noted on physical exam. Which vitamin deficiency does this patient most likely have? A. Vitamin A B. Vitamin B C. Vitamin C D. Vitamin D

Vitamin C

Which one of the following groups of lab results is most consistent with a complication that commonly occurs 6 to 12 weeks after acute hepatitis? A. WBC decreased, RBC decreased, platelets decreased B. WBC decreased, RBC increased, platelets increased C. WBC increased, RBC decreased, platelets decreased D. WBC increased, RBC increased, platelets increased

WBC decreased, RBC decreased, platelets decreased

A 63-year-old man with a history of hepatitis C presents to the ED with complaints of generalized abdominal pain and distension. Vital signs are HR 110 beats per minute, RR 22 per minute, BP 130/67 mm Hg, T 103.64°F (39.8°C), and oxygen saturation 97% on room air. On exam, his abdomen is tender and moderately distended. Diagnostic paracentesis is performed. Which of the following results should prompt treatment with antibiotics? A. Ascitic fluid pH of 7.35 B. WBC of 275 cells/mm3 with 20% lymphocytes C. WBC of 370 cells/mm3 with 90% neutrophils D. WBC of 500 cells/mm3 with 40% neutrophils

WBC of 370 cells/mm3 with 90% neutrophils

You are seeing in your office a four-week-old boy with vomiting. Which of the following findings is most concerning for pyloric stenosis as an underlying cause? A. Bilious emesis B. Hyperkalemic, hypochloremic metabolic acidosis C. Vomitus with the appearance of "curdled milk" D. Weight loss

Weight loss

Which of the following conditions is characterized by ataxia, oculomotor dysfunction, and altered mental status? A. Korsakoff syndrome B. Normal pressure hydrocephalus C. Vitamin B12 deficiency D. Wernicke encephalopathy

Wernicke encephalopathy

A 56-year-old man with a ten year history of alcoholism presents to the emergency room with nausea and dull, epigastric pain that radiates to the back for the past 2 hours. Which of the following lab values is associated with a poor prognosis for the suspected diagnosis? A. Aspartate aminotransferase 200 units/L B. Glucose 172 mg/dL C. Serum lactate dehydrogenase 300 units/L D. White blood cell count 18,000

White blood cell count 18,000

A 23-year-old man presents with abdominal pain, vomiting, and two loose, nonbloody stools. Physical examination reveals right lower quadrant tenderness to palpation. A CT is performed showing a normal appendix and some inflammation at the ileocecal junction. What pathogen is commonly implicated in this disorder? A. Aeromonas species B. Salmonella enterica C. Vibrio parahaemolyticus D. Yersinia enterocolitica

Yersinia enterocolitica

A 22-year-old man who just returned from a trip to Scandinavia presents to the ED with complaints of severe cramping abdominal pain and diarrhea. The diarrhea was initially profuse and watery and is now bloody. His vital signs are a HR of 105 beats per minute, RR of 18 per minute, BP of 110/64 mm Hg, temperature of 101.84°F (38.8°C), and oxygen saturation of 99% on room air. He has right lower quadrant tenderness on exam. Fecal occult blood test is positive; wet mount of the stool shows fecal leukocytes. Which of the following is the most likely diagnosis? A. Salmonellosis B. Shigellosis C. Vibrio parahaemolyticus infection D. Yersinia enterocolitis

Yersinia enterocolitis

A 28-year-old woman presents to her primary care provider complaining of abdominal bloating, cramping and diarrhea most days of the week for the last four months. The diarrhea commonly occurs in the morning or following meals. Episodes occur four or five times per day and are of moderate volume. She denies fever, nausea, vomiting, periods of constipation, or change in appetite. The diarrhea does not wake her from her sleep and she reports no blood or pus in her stool. She states the periods of diarrhea will last several months and then seem to resolve without explanation. In between diarrhea episodes, she has normal formed bowel movements once per day. A review of her symptom diary reveals no food associations. She denies any recent travel. What is the most likely diagnosis? A. Celiac disease B. Infectious diarrhea C. Inflammatory bowel disease D. Irritable bowel syndrome

Irritable bowel syndrome

A 43-year-old woman presents with a several year history of irregular bowel habits characterized by alternating diarrhea and constipation and associated with intermittent, occasional crampy abdominal pain and bloating. She denies loss of appetite, weight loss or vomiting, and she has never seen blood in her stools. The pain does not awaken her at night, and she has been unable to identify any particular dietary triggers. Her body mass index (BMI) is 24, she is afebrile, and her abdominal exam is unremarkable. A series of three fecal occult blood tests are all negative. What is the most likely diagnosis? A. Abdominal migraine B. Acute diverticulitis C. Crohn's disease D. Irritable bowel syndrome

Irritable bowel syndrome

A 48-year-old man presents with a 4-week history of rectal pain associated with minimal rectal bleeding. On examination there is a small tear of the anorectal mucosa at the 6 o'clock position. Which of the following is the most appropriate initial treatment? A. Botulinum toxin B. Nitroglycerin C. Sitz baths, psyllium fiber, and bulking agents D. Sphincterotomy

Ischemic colitis

An 80-year-old man who presents to the emergency department with a complaint of sudden onset left-sided abdominal pain and bloody diarrhea. Abdominal CT demonstrates thickening of the bowel wall and free peritoneal fluid. What is the most likely diagnosis? A. Diverticulitis B. Infectious colitis C. Ischemic colitis D. Small bowel obstruction

Ischemic colitis

An 82-year-old man suffers a myocardial infarction. On day two of his ICU admission, he complains of severe left-sided abdominal pain. Nursing staff report his last bowel movement was bloody. His past medical history is significant only for Parkinson's disease, hypertension, hyperthyroidism, hypercholesterolemia, and the recent MI. His abdomen is tender, and the left lower quadrant bowel sounds are diminished. Which of the following is the most like diagnosis? A. Cholecystitis B. Diverticulitis C. Intestinal angina D. Ischemic colitis

Ischemic colitis

An 82-year-old nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of vascular dementia, hypertension, and hyperlipidemia. The facility nurse notes that he seems to have the most abdominal pain and blood in his stools after eating. On examination, he is afebrile and a nasogastric aspirate is negative for evidence of bleeding. Which of the following is the most likely cause of this patient's bleeding? A. Angiodysplasia B. Diverticular bleeding C. Ischemic colitis D. Peptic ulcer disease

Ischemic colitis

Which of the following findings best distinguishes cholangitis from acute cholecystitis? A. Elevated alkaline phosphatase B. Fever C. Jaundice D. Leukocytosis

Jaundice

A 20-month-old girl presents with abdominal pain and bilious vomiting for the past 2 days. The father reports that she has episodes where she is inconsolable and is drawing her legs up to her chest. Between the episodes, she behaves normally. He noticed blood in the last diaper he changed. Where is the most likely anatomic location of the suspected diagnosis? A. Junction of descending colon and cecum B. Junction of ileum and ascending colon C. Junction of transverse colon and ascending colon D. Junction of transverse colon and descending colon

Junction of ileum and ascending colon

A 52-year-old man with a long history of alcoholism presents with epigastric pain and vomiting. You diagnose him with pancreatitis. Which of the following laboratory values is associated with an increased risk of mortality on admission? A. ALT 350 mmol/L B. LDH 400 IU/L C. Lipase 14,000 U/L D. WBC 15,000 cells/mm3

LDH 400 IU/L

Which one of the following is characteristic of Mallory-Weiss syndrome? A. Gastrin-secreting tumor of the pancreas B. Lacerations of the gastric cardia due to forceful vomiting C. Noniatrogenic traumatic injury to the esophagus D. Spontaneous esophageal hematoma

Lacerations of the gastric cardia due to forceful vomiting

A 4-year-old boy presents to your office with watery nonbloody diarrhea for the last three months. He has occasional abdominal pain prior to the onset of the diarrhea and his mother noted worsening flatulence, especially after meal times. Mom denies any recent travel or camping and the patient does not go to school or daycare. On exam, he is 60th percentile for weight and height (similar to his last well-child check), appears well, and has a normal abdominal exam. What is the most likely diagnosis? A. Celiac disease B. Inflammatory bowel disease C. Irritable bowel syndrome D. Lactase deficiency

Lactase deficiency

A 57-year-old man with a history of chronic kidney disease (baseline creatinine of 3.3 mg/dL) and liver cirrhosis presents with confusion. Examination reveals scleral icterus and asterixis. Vital signs and serum glucose are normal. What management is indicated? A. Head CT and lumbar puncture B. Lactulose C. Neomycin D. Protein-restricted diet

Lactulose

Which of the following findings seen on rectal examination is most consistent with a concomitant systemic process? A. Anal fissure with bleeding B. Anal fissure with deep ulcer C. Anterior midline anal fissure D. Lateral anal fissure

Lateral anal fissure

A 40-year-old man presents with bloody stools for six months. He also reports a severe, tearing pain during defecation followed by throbbing discomfort. Medical history is significant for constipation. He has undergone multiple conservative treatments without improvement of his symptoms. He continues to have painful defecations. A fibrotic skin tag at the outermost edge of the anoderm is noted on physical exam. Which of the following is the most appropriate next step in management? A. Diltiazem 2% ointment B. Lateral internal sphincterotomy C. Silver nitrate 2% D. Sitz baths

Lateral internal sphincterotomy

Which of the following is considered the gold standard in the treatment of chronic anal fissures? A. Cryosurgery B. Lateral internal sphincterotomy C. Rubber band ligation D. Sclerotherapy

Lateral internal sphincterotomy

Which of the following statements is most correct regarding appendicitis? A. An appendicolith is identified in the majority of cases B. Leukocytosis is seen in the majority of cases C. Perforation is rare in patients younger than 2 years of age D. The presence of an appetite makes the diagnosis unlikely

Leukocytosis is seen in the majority of cases

A nine-year-old girl is seen in the clinic for a well child visit and is found to have a body mass index in the 94th percentile. What additional studies should be ordered according to the American Academy of Pediatrics? A. Abdominal ultrasound to look for fatty liver disease B. Hemoglobin A1C and complete metabolic panel C. Lipid panel and complete metabolic panel D. No additional studies are recommended until age 11

Lipid panel and complete metabolic panel

A 66-year-old woman has been on estrogen-replacement therapy for nine years. Her social history is significant for 20 years of alcohol abuse and 30 years of tobacco use. Her family history is positive for familial adenomatous polyposis. Which of the following organs is most likely to undergo malignant transformation due to this patient's alcohol abuse? A. Breast B. Colorectal C. Liver D. Lung

Liver

A patient of yours with a history of diverticulosis develops acute diverticulitis. He is admitted to the hospital for inpatient care. He is successfully treated and discharged home. He follows up with you a few days later. Which of the following should you most likely recommend to him at this time? A. Colonoscopy within 3 days B. High fiber diet until 6 weeks of no symptoms C. Low fiber diet until 6 weeks of no symptoms D. Sigmoidoscopy within 3 days

Low fiber diet until 6 weeks of no symptoms

A 40-year-old man presents to the emergency department after an episode of blood-streaked vomiting. This happened following a night of excessive drinking and a few episodes of forceful vomiting. He presents with no other symptoms and is in otherwise good health. Which of the following is the most likely diagnosis? A. Bleeding esophageal varices B. Boerhaave syndrome C. Mallory-Weiss syndrome D. Ruptured peptic ulcer

Mallory-Weiss syndrome

A 21-year-old previously healthy man presents to clinic after several nights of partying. He complains of headache, nausea, and emesis that now contains blood. He also endorses a constant burning sensation in the left upper quadrant of his abdomen that started after the retching began. What is the most likely diagnosis? A. Esophageal varices B. Esophagitis C. Mallory-Weiss tear D. Peptic ulcer disease

Mallory-Weiss tear

Which of the following findings is classically associated with pyloric stenosis? A. Bilious vomiting B. Elevated lipase C. Metabolic alkalosis D. Poor feeding

Metabolic alkalosis

A 70-year-old woman presents to your office with a complaint of difficulty having bowel movements. She tells you that she has a bowel movement every 2-3 days, the stool is hard and she has to strain. Which of the following is the most appropriate initial therapy? A. Docusate sodium B. Methylcellulose C. Polyethylene glycol D. Senna

Methylcellulose

You are evaluating a 73-year-old woman with a history of weakness, fatigue, and difficulty walking. She lives alone and unassisted. She has no past medical history and takes no medications. Physical examination shows an enlarged, smooth, and tender tongue. Pallor of the conjunctivae is also seen. Which of the following laboratory studies would be most likely to confirm the diagnosis? A. Iron panel B. Mean corpuscular volume C. Methylmalonic acid and homocysteine levels D. Peripheral blood smear

Methylmalonic acid and homocysteine levels

A 26-year-old G1P1 woman with a history of peptic ulcer disease was recently placed on a daily nonsteroidal anti-inflammatory medication therapy to treat joint pain. A medication to reduce nonsteroidal anti-inflammatory medication induced ulcers was recommended. Which of the following medications carries a black box warning and should be avoided or used in extreme caution in this patient? A. Famotidine B. Misoprostol C. Omeprazole D. Pantoprazole

Misoprostol

Which of the following is true regarding elderly patients with abdominal pain? A. More likely to need an emergent surgical procedure B. More likely to present with an elevated white blood cell count C. More likely to present with fever D. More likely to present with peritoneal signs

More likely to need an emergent surgical procedure

Which of the following is true regarding intestinal intussusception? A. Adults are more affected than children B. Most adult intussusception cases involve the small bowel C. Most children with intussusception have a pathologic lesion D. The classic triad of abdominal pain, mass, and heme-positive stools is usually seen in adults with intussusception

Most adult intussusception cases involve the small bowel

A young woman suffers from chronic diarrhea. A detailed history provides no evidence of provocative medications as the cause. You send a stool sample to the laboratory and obtain the following results: Color: Yellow-brown Water: High Fat: Negative Blood: Negative WBCs: Negative Osmotic gap: Normal These results suggest which of the following as the most likely causative of this patient's diarrhea? A. Infectious B. Malabsorption C. Motility D. Osmotic

Motility

A 37-year-old woman is in the emergency room for right-sided abdominal pain and excessive flatulence. This episode has persisted for several hours. On physical exam you palpate her right upper quadrant while she takes a deep breath. The patient experiences pain and has a transient pause in inspiration. This physical exam finding is consistent with which of the following signs? A. Levine sign B. C. McBurney point tenderness D. Murphy sign E. Psoas sign

Murphy sign

An obese 37-year-old woman presents for right-sided abdominal pain. She normally has the pain after eating, but it usually resolves on its own. This episode has persisted for several hours. On physical exam, you palpate her right upper quadrant while she takes a deep breath. The patient experiences pain and has a transient pause in inspiration. This physical exam finding is associated with which of the following signs? A. Brudzinski sign B. Levine sign C. Murphy sign D. Psoas sign

Murphy sign

Which of the following physical exam findings is suggestive of the diagnosis of acute cholecystitis? A. Kehr sign B. Markle sign C. Murphy sign D. Rovsing sign

Murphy sign

Which of the following vitamin deficiencies causes the triad of dermatitis, diarrhea and dementia? A. Ascorbic acid B. Niacin C. Pyridoxine D. Thiamine

Niacin

Which vitamin deficiency presents with photosensitive dermatitis, diarrhea, and dementia? A. Cyanocobalamin B. Niacin C. Pyridoxine D. Thiamine

Niacin

Which of the following antibiotics may precipitate hemolysis in a patient with G6PD deficiency? A. Amoxicillin/Clavulanate B. Cephalexin C. Nitrofurantoin D. Streptomycin

Nitrofurantoin

A 61-year-old man presents with loss of appetite, unintentional weight loss and dyspepsia. Endoscopy shows a gastric mass at the curvature of the stomach and he is diagnosed with gastric carcinoma. Which of the following is true about his condition? A. Caucasians are at highest risk for developing this condition B. Chemotherapy and radiation are standard initial therapy for localized disease C. Five-year survival rate of advanced disease is 80% D. Men have a higher risk of developing this condition Which of the following is the most common form of liver disease in the United States? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease

A 35-year-old meat cutter comes to your office with persistent symptoms of nausea, vomiting, and diarrhea, which began about 36 hours ago on the last day of a 5-day Caribbean cruise. His wife was sick during the first 2 days of the cruise with similar symptoms. Findings on examination are negative, and a stool specimen is negative for white blood cells. Which one of the following is the most likely cause of his illness? A. Giardia B. Hepatitis A C. Norovirus D. Rotavirus

Norovirus

A 53-year-old man with a history of atrial fibrillation and hypertension presents with severe abdominal pain. He states the pain has been there for 3 days but got more severe today. Over the last 3 days, he has been unable to eat because the pain occurs after eating. Vital signs are T 99.7°F, HR 123 bpm, BP 101/66 mm Hg, and RR 24/min. Examination reveals an uncomfortable patient with diffuse mild abdominal tenderness to palpation without rebound or guarding. Stool guaiac is positive, and serum lactate is 4.8 mmol/L. A surgical consultation is requested. Which of the following represents the appropriate management? A. Obtain abdominal X-rays B. Obtain CT angiogram of the abdomen and pelvis C. Obtain CT scan of the abdomen and pelvis without IV contrast D. Obtain right upper quadrant abdominal ultrasound

Obtain CT angiogram of the abdomen and pelvis

A 66-year-old white woman presents to your office for a routine physical examination. Her medical problems include hypertension, diabetes mellitus, hypercholesterolemia, and gastroesophageal reflux, all controlled with medications. A bone density study is consistent with osteopenia. She is taking a multivitamin and calcium carbonate 1200 mg daily. Which of the following medications act to reduce calcium absorption? A. Atorvastatin B. Hydrochlorothiazide C. Metformin D. Omeprazole

Omeprazole

Which of the following is true regarding diverticulitis? A. All patients should have CT imaging performed B. Complicated diverticulitis can be treated with oral antibiotics C. Oral antibiotics should be given in uncomplicated diverticulitis D. Ultrasound is the imaging modality of choice

Oral antibiotics should be given in uncomplicated diverticulitis

A 35-year-old woman presents to your office to establish care as a new patient. She has a history of ulcerative colitis with multiple flare-ups. Which of the following is the most appropriate maintenance therapy? A. Hydrocortisone suppositories B. Oral mesalamine C. Oral metronidazole D. Oral prednisone

Oral mesalamine

A 7-year-old girl has a history of cerebral palsy, static encephalopathy, seizure disorder, and recent aspiration pneumonia. She completed treatment for pneumonia two days ago but now has developed foul-smelling, watery diarrhea and abdominal cramping. Her vital signs are within normal limits for age. What is the treatment of choice? A. Intravenous clindamycin B. Intravenous vancomycin C. Oral metronidazole D. Reassurance regarding antibiotic-associated diarrhea

Oral metronidazole

A 66-year-old man presents with nausea, intermittent abdominal cramping, and frequent diarrhea for the past three days. He was recently hospitalized for pneumonia and was discharged one week ago. He was feeling better until yesterday. Physical examination reveals mild lower abdominal tenderness but is otherwise unremarkable. Of the following choices, which is the most appropriate initial treatment? A. Intravenous vancomycin B. Oral ciprofloxacin C. Oral diphenoxylate and atropine D. Oral vancomycin

Oral vancomycin

A 43-year-old woman presents with episodic epigastric pain that frequently follows a fatty meal and can last anywhere from 15 minutes to approximately two hours. At times the pain radiates toward her right shoulder. She has associated nausea without vomiting. Which of the following is the most appropriate next step in managing this patient? A. Obtain serum amylase and lipase levels B. Order a contrast-enhanced computed tomography scan C. Order a right upper quadrant abdominal ultrasound D. Prescribe oral omeprazole

Order a right upper quadrant abdominal ultrasound

A 55-year-old patient just had his first colonoscopy and uncomplicated polypectomy for 1-2 small (<10 mm) tubular adenomas. He has no family history of cancer. In the majority of patients with 1-2 small adenomas, what is the time frame recommended for a repeat colonoscopy after an initial colonoscopy and polypectomy is performed? A. 1 year to 3 years B. 3 years to 5 years C. 5 years to 10 years D. 6 months to 1 year What is the most common cause of pruritus ani in the pediatric patient? A. Candida B. Lichen planus C. Pinworms D. Seborrheic dermatitis

Pinworms

What is the most common cause of upper gastrointestinal bleeding? A. Aortoenteric fistula B. Boerhaave syndrome C. Esophageal varices D. Peptic ulcer disease

Peptic ulcer disease

A woman with chronic constipation and poorly controlled diabetes mellitus presents with acute anal pain that is exacerbated by defecation. Inspection of the anal border reveals no abnormalities. Which of the following is the most likely diagnosis? A. Anal fistula B. Perianal hematoma C. Perirectal abscess D. Thrombosed external hemorrhoid

Perirectal abscess

Which of the following is a contraindication to the use of air-contrast enema in the reduction of pediatric intussusception? A. Air contrast enema for a prior episode of intussusception in the last 24 hours B. Fever greater than 39°C C. Lethargy D. Peritonitis

Peritonitis

In addition to benzodiazepines, which of the following should be administered to patients in alcohol withdrawal? A. Carbamazepine B. Haloperidol C. Propanolol D. Thiamine

Thiamine

Which of the following patients with Salmonella enteritis should receive antibiotics? A. 13-month-old with diarrhea and no signs of volume depletion B. 13-year-old boy with sickle cell disease C. 19-year-old man living in a college dorm D. 8-year-old boy with no medical problems

13-year-old boy with sickle cell disease

A 40-year-old obese, nonpregnant woman presents with left-sided pelvic pain that has been increasing for two days. She has left adnexal tenderness on pelvic exam. Which of the following would point to a gastrointestinal rather than gynecological cause of her pain? A. A history of constipation B. A history of nausea and vomiting C. A history of ovarian cysts D. A wet mount with sheets of white blood cells

A history of constipation

Which of the following antibiotics is most appropriate to use in a 64-year-old man with a history of benign prostatic hyperplasia, glucose-6-phosphate dehydrogenase deficiency, and a recently diagnosed urinary tract infection? A. Cephalexin B. Ciprofloxacin C. Nitrofurantoin D. Phenazopyridine

Cephalexin

Which of the following patients meet criteria for metabolic syndrome? A. A 35-year-old man with a waist circumference of 108 cm, triglycerides of 130 mg/dL, and blood pressure of 140/90 mm Hg B. A 40-year-old woman with a body mass index of 35, triglycerides 150 mg/dL, and fasting glucose of 110 mg/dL C. A 45-year-old man with a waist circumference of 110 cm, triglycerides of 155 mg/dL, and fasting glucose of 120 mg/dL D. A 50-year-old man with waist circumference of 110 cm, triglycerides of 150 mg/dL, and high density lipoprotein cholesterol of 50 mg/dL

A 45-year-old man with a waist circumference of 110 cm, triglycerides of 155 mg/dL, and fasting glucose of 120 mg/dL

Which of the following is the most common cause of acute pancreatitis? A. Biliary tract pathology B. Endoscopic retrograde cholangiopancreatography C. Ethanol ingestion D. Medication side effect

Biliary tract pathology

A man presents with difficulty walking and painful calves. He has a history of alcohol use disorder and ulcerative colitis, both untreated. He denies a history of chronic diarrhea. A blood tox screen is negative for alcohol and illicit drugs. His examination is significant for several neurologic findings: altered proprioception, distal numbness, hyporeflexia, confusion, and nystagmus. Perioral and tongue examination is normal. These symptoms are most likely related to a deficiency of which of the following vitamins? A. B1 B. B2 C. B3 D. C

A 15-year-old boy is brought by his mother to the Emergency Department due to nausea, multiple episodes of vomiting previously ingested food, and three loose bowel movements. His mother notes that the boy reheated the leftover rice stored in the refrigerator the night before. Physical examination reveals a tired child who is afebrile with dry mucous membranes. He has pink palpebral conjunctivae, clear breath sounds, a soft abdomen with mild tenderness at the epigastric area, and full pulses. Which of the following is the most likely causative agent? A. Bacillus cereus B. Campylobacter jejuni C. Clostridium botulinum D. Vibrio cholerae

Bacillus cereus

Which of the following is the most effective initial treatment for a benign esophageal stricture? A. Balloon dilation B. Balloon dilation and proton pump inhibitor C. Esophageal stent D. Nissen fundoplication

Balloon dilation and proton pump inhibitor

What class of medication should be used for primary prophylaxis to prevent variceal hemorrhage? A. ACE inhibitor B. Antihistamine C. Beta blocker D. Proton pump inhibitor

Beta blocker

Which of the following cells located in the pancreas produces and secretes insulin? A. Alpha cells B. Beta cells C. Delta cells D. Pancreatic polypeptide cells

Beta cells

A patient with irritable bowel syndrome complains mainly of lower abdominal pain. She denies diarrhea or constipation, and rarely has problematic flatulence. For this patient's abdominal pain, which of the following medications do you recommend? A. Desipramine B. Loperamide C. Lubiprostone D. Rifaximin

Desipramine

A 53-year-old man presents with weight loss, anorexia, abdominal pain, jaundice and early satiety. Which of the following is the most appropriate initial diagnostic test to diagnose and stage pancreatic cancer? A. Biopsy B. CA 19-9 antigen C. CT scan D. MRI

CT scan

A 63-year-old man with a history of a cholecystectomy and appendectomy presents with abdominal cramping, vomiting, and decreased bowel movements. Bowel sounds are decreased. Which of the following is true regarding this patient? A. Abdominal X-ray can be used to rule out the diagnosis B. CT scan of the abdomen is highly specific for this diagnosis C. Serum lactate is highly sensitive early on in patients with this diagnosis D. Serum white blood count is always elevated in this diagnosis

CT scan of the abdomen is highly specific for this diagnosis

A 34-year-old man presents with "heartburn." His evaluation leads the provider to believe that gastroesophageal reflux disease is the etiology of his symptoms. Which of the following increases symptoms of reflux? A. Beta-blockers B. Caffeine C. Spearmint D. Testosterone supplements

Caffeine

A patient presents with abdominal bloating and flatulence. She denies diarrhea. Physical examination is significant only for borborygmi. You suspect lactose intolerance and start the patient on lactase supplementation and diet modification. Which of the following supplements should also be prescribed? A. Calcium B. Pancreatase C. Sevelamer D. Sodium

Calcium

An elderly woman with a recent 21-day course of oral antibiotics for pneumonia presents with difficulty swallowing. Her past medical history is significant for hypertension, interstitial cystitis, and alcoholism. A upper endoscopy shows longitudinal plaques along the lining of the esophagus. Which of the following is the most likely causative agent for this patient's symptoms? A. Candida B. Cytomegalovirus C. Herpes simplex virus type I D. Mycobacterium tuberculosis

Candida

A patient complains of a change in bowel habits over the past 3 months. A fecal occult-blood test is positive. During a digital rectal examination, you palpate a solid 2cm by 2cm mass in the rectum. Which of the following serum tests would you order in the initial laboratory evaluation of a patient with suspected rectal neoplasia? A. Alpha fetoprotein (AFP) B. Cancer antigen 125 (CA-125) C. Cancer antigen 15-3 (CA-15-3) D. Carcinoembryonic antigen (CEA)

Carcinoembryonic antigen (CEA)

A 23-year-old man presents with rectal pain. He also reports yellow discharge and tenesmus. He is sexually active with men and has receptive anal intercourse. Which of the following is the most appropriate treatment? A. Ceftriaxone 1 gm IV and azithromycin 1 gm PO B. Ceftriaxone 500 mg IM and doxycycline 100 mg PO BID for 7 days C. Ciprofloxacin 500 mg PO BID for 7 days and metronidazole 500 mg PO TID for 7 days D. Metronidazole 500 mg PO TID for 7 days

Ceftriaxone 500 mg IM and doxycycline 100 mg PO BID for 7 days

A 23-year-old woman comes to the emergency department complaining of a 3-week history of diarrhea, abdominal pain, fatigue, and weight loss. Her blood pressure is 100/65 mm Hg and her temperature is 37.1°C (98.7°F). She denies fever, chills, and night sweats. She has a 10-year history of type 1 diabetes mellitus that is well controlled with daily insulin. Physical examination of the abdomen reveals diffuse tenderness. Examination of the skin shows several areas of pruritic papules and vesicles occurring in groups on the elbows, forearms, and knees. Laboratory studies show anti-endomysial antibodies and anti-tTG antibodies. Which of the following is the most likely diagnosis? A. Celiac disease B. Crohn disease C. Diverticular disease D. Ulcerative colitis

Celiac disease

A 32-year-old man presents with a 1-year history of frequent abdominal cramping, nonbloody diarrhea, and a 20-lb weight loss. He has no history of foreign travel, antibiotic use, or consumption of well water. He complains of a chronic, pruritic rash that is vesicular in nature. Which of the following is the most likely diagnosis? A. Celiac disease B. Collagenous colitis C. Crohn disease D. Irritable bowel syndrome

Celiac disease

Which of the following is the most likely cause of phenylketonuria? A. Conversion of phenylalanine to tyrosine B. Conversion of tyrosine to phenylalanine C. Deficiency of phenylalanine hydroxylase D. Excess of phenylalanine hydroxylase

Deficiency of phenylalanine hydroxylase

What structure helps differentiate between internal and external hemorrhoids? A. Anal verge B. Dentate line C. Linea alba D. Perineum

Dentate line

A 55-year-old man with a past medical history of hypertension presents to the emergency department with two days of left lower quadrant pain and a fever of 38.2°C at home. He denies nausea or vomiting and has been able to tolerate oral intake at home. He endorses some intermittent painless hematochezia over the last year but states that he has never had a colonoscopy. His vitals are HR 89 beats per minute, RR 16, and BP 142/90. His abdominal exam is significant for moderate tenderness to palpation of the left lower quadrant without rebound or rigidity. His CBC shows a white blood cell count of 12,000. A CT scan confirms diverticulitis without perforation or abscess formation. Which of the following is the most appropriate next step in the management of this patient's diverticulitis? A. Admit for inpatient intravenous antibiotics B. Discharge home with oral antibiotics C. Surgery consult for colon resection D. Urgent colonoscopy to rule out colon cancer

Discharge home with oral antibiotics

A mom brings in her 16-year-old daughter, with concerns of increasing weight loss. Over the past 3 months, her weight went from 60 kg to 55 kg, placing her at the 10th percentile for weight and BMI. She states she is just very conscious of her food choices and wants a regimented exercise routine, as she is training for High School track. She does admit to irregular scant menstrual periods. What constellation of signs and symptoms should you be concerned about in this patient? A. Anemia, bradycardia, osteopenia B. Anemia, easy bruising, multiple fractures C. Disordered eating, amenorrhea, abnormal body image D. Disordered eating, amenorrhea, osteopenia

Disordered eating, amenorrhea, osteopenia

A 55-year-old woman presents with a complaint of left lower quadrant abdominal pain, constipation, and fever. On palpation, she is tender in the left lower quadrant with guarding and rebound tenderness. Which of the following is the most likely diagnosis? A. Appendicitis B. Diverticulitis C. Inflammatory bowel disease D. Small bowel obstruction

Diverticulitis

A 25-year-old truck driver presents with a 1-day history of throbbing rectal pain. Your examination shows a large thrombosed external hemorrhoid. Which one of the following is the preferred initial treatment for this patient? A. Elliptical excision of the thrombosed hemorrhoid B. Infrared coagulation C. Rubber band ligation of the hemorrhoid D. Stool softeners and a topical analgesic

Elliptical excision of the thrombosed hemorrhoid

A young woman complains of daily diarrhea without abdominal pain. She brings in a sample that appears to contain much more fat than water. She has a family history of diarrhea. She denies any recent antibiotic therapy. Her vital signs are within normal limits and her physical exam is unremarkable. Laboratory testing reveals iron deficiency anemia, an elevated stool osmotic gap, and positive anti-endomysial antibodies. Which of the following is the most likely diagnosis? A. Bile acid deficiency B. Celiac disease C. Clostridium difficile infection D. Irritable bowel syndrome A patient with alcohol abuse and cirrhosis presents with acute upper gastrointestinal bleeding, hypotension, and tachycardia. His past medical history also includes portal hypertension. In addition to cardiopulmonary stabilization and blood transfusion, which of the following is the most appropriate emergent interventional treatment? A. Distal splenorenal shunt B. Endoscopic band ligation C. Large volume paracentesis D. Transjugular intrahepatic portosystemic shunt

Endoscopic band ligation

A 51-year-old woman has been treated twice with appropriate therapy for documented Helicobacter pylori disease. She continues to complain of abdominal pain that is worse with eating. What is the next test that should be done for this patient? A. Endoscopic biopsy for culture and sensitivity testing B. Serum IgG antibody to Helicobacter pylori C. Stool testing for Helicobacter pylori antigen D. Urea breath test

Endoscopic biopsy for culture and sensitivity testing

A 75-year-old woman with a history of hypertension presents to the ED with right upper quadrant pain that has been gradually worsening over the past day. Her vital signs are: T 103°F, BP 100/60, HR 100, RR 22, and oxygen saturation 97% on room air. Physical exam reveals scleral icterus and right upper quadrant tenderness without rebound or guarding. A bedside right upper quadrant ultrasound demonstrates a common bile duct measuring 1 cm. Laboratory results are pending. What is the definitive management of this condition? A. Broad spectrum antibiotics B. Cholecystectomy C. Endoscopic retrograde cholangiopancreatography D. Percutaneous transhepatic cholangiography

Endoscopic retrograde cholangiopancreatography

A 45-year-old woman presents to your office with complaints of worsening heartburn and food regurgitation that occur several times every week. Treatment with a proton pump inhibitor has not relieved her symptoms. Which of the following diagnostic studies is used to confirm the diagnosis? A. Computed tomography B. Endoscopy C. Magnetic resonance imaging D. Ultrasound

Endoscopy

A 63-year-old man with a 40-year history of alcohol and tobacco abuse presents with solid food dysphagia. The patient has also had a 21 lb weight loss over the past 7 months. Which of the following studies should be performed for a definitive diagnosis? A. Barium esophagram B. Chest X-ray C. CT Scan D. Endoscopy

Endoscopy

What is the gold standard for diagnosing peptic ulcer disease? A. Endoscopy B. Helicobacter pylori testing C. Upper GI series D. Urea breath test

Endoscopy

Which of the following is recommended in the treatment of an acute anal fissure? A. Antibiotics B. Antifungal cream C. Sitz bath D. Surgery A patient presents with hematemesis. What test is most likely to determine the etiology of the bleeding? A. CT scan of the abdomen and pelvis B. Nasogastric tube lavage C. Right upper quadrant ultrasound D. Upper endoscopy A 14-year-old girl with a 2-year history of bulimia nervosa presents to the emergency department with hematemesis. Which of the following will most likely be found on upper endoscopy? A. H.pylori infection B. Hematochezia C. Mallory-Weiss tear D. Meckle's diverticulum A patient with a complete C5 spinal cord injury presents to the ED with dysautonomia. He has not passed stool for the last 48 hours. Due to his quadriplegia, his nursing aide performs digital rectal stimulation and disimpaction. However, he has been unable to remove any stool as of late. An abdominal radiograph shows a significant amount of stool in the lower rectum. Which of the following is the next best step in managing this patient's fecal impaction? A. Balloon tamponade with a Sengstaken-Blakemore device B. Colonoscopy C. Enema washout D. Phrenic nerve stimulation

Enema washout

Which of the following organisms is the most common cause of traveler's diarrhea? A. Campylobacter jejuni B. Enterohemorrhagic Escherichia Coli C. Enterotoxigenic Escherichia Coli D. Giardia lamblia

Enterotoxigenic Escherichia Coli

A healthy 6-year-old boy presents to the ED with bloody diarrhea. He was in his usual state of health until one week ago when loose, watery stools (up to 10 per day) were noted. He was seen by his pediatrician four days ago but has since developed increasing amounts of blood and pus in his stools along with a low-grade fever. Mom states there is no recent travel, antibiotic use, or known sick contacts. His vitals are a heart rate 118 beats per minute, oxygen saturation 100% on room air, and rectal temperature of 100.94°F (38.3°C). Your physical exam reveals a mildly tender abdomen without localization, rebound, guarding, or peritoneal signs. You note grossly bloody stool on rectal exam. A brief discussion with his pediatrician confirms your suspicion of an invasive bacterial diarrhea; a stool culture was positive for Shigella. Which of the following statements is true regarding this condition? A. Antibiotics should be avoided because this is a severe case and the patient is at highest risk of developing hemolytic uremic syndrome B. Antidiarrheal agents (such as diphenoxylate and atropine) are indicated, given the frequency of loose stools C. Extraintestinal manifestations such as hallucinations, confusion, and seizures may occur D. Oral rehydration should be avoided; IV fluids should be initiated

Extraintestinal manifestations such as hallucinations, confusion, and seizures may occur

A 3-week-old infant presents with projectile vomiting. Mom reports he has vomited after each feed for the last 24 hours. What electrolyte abnormality do you expect to see? A. Hyperchloremic, hyperkalemic, metabolic alkalosis B. Hyperchloremic, hypokalemic, metabolic alkalosis C. Hypochloremic, hyperkalemic, metabolic alkalosis D. Hypochloremic, hypokalemic, metabolic alkalosis A 45-year-old woman comes to the urgent care clinic with a 5-hour history of right upper quadrant pain, fever, nausea, vomiting, and anorexia. She says the pain radiates to her shoulder and back. She says she began experiencing these symptoms shortly after eating a hot dog and chili cheese fries. She smokes 2 packs of cigarettes per day, drinks 2-3 alcoholic beverages every night, and occasionally smokes marijuana. The patient states that her two sisters both have had cholecystectomies. Her temperature is 38.8°C (101.8°F). Palpation of the abdomen shows voluntary guarding. An abdominal ultrasound shows a gallbladder wall of 6 mm. Which of the following contributed the most to the development of this patient's condition? A. Alcohol consumption B. Cigarette smoking C. Family history D. Marijuana smoking

Family history

A 52-year-old man with a history of obesity presents to your office with complaints of burning chest pain, food regurgitation and cough approximately once every week. He tells you that he likes to eat spicy foods and often eats a large meal shortly before bedtime to help him sleep. Which of the following is the most appropriate initial therapy? A. Bismuth subsalicylate B. Famotidine C. Metoclopramide D. Omeprazole

Famotidine

A 67-year-old woman presents to the emergency department complaining of constipation, fecal seepage, and rectal pressure for the past two days. She fell three weeks ago and broke two ribs. At that time, she was prescribed hydrocodone for pain. Her pulse is 67 beats/min, respiratory rate is 18 breaths/min, blood pressure is 138/90 mm Hg, and temperature is 98.5F. On exam, her abdomen is mildly tender to palpation and distended, but is without guarding or rebound tenderness. Digital rectal exam reveals a dilated rectal vault filled with hard stool. Fecal occult blood test is negative. Which of the following is the most likely diagnosis? A. Colon cancer B. Diverticulitis C. Fecal impaction D. Sigmoid volvulus

Fecal impaction

A 24-year-old man with HIV presents with severe dysphagia and odynophagia for one week. Physical examination reveals the above image. What management is indicated? A. Acyclovir B. Clotrimazole troches C. CT scan of the neck D. Fluconazole

Fluconazole

A 43-year-old woman with a history of HIV (last CD4 count 231 cells/µL, viral load undetectable) presents with a sore throat that has progressively worsened over 1 week. She has been unable to tolerate solids for the last 3 days and also has pain with swallowing liquids. Her vital signs are normal. On exam, you note the findings seen in the image above. What management is indicated at this time? A. Acyclovir B. Clotrimazole troches C. Fluconazole D. Penicillin V potassium

Fluconazole

In a patient with chronic abdominal pain, which additional finding suggests a diagnosis of irritable bowel syndrome? A. Decreased hemoglobin B. Improvement with defecation C. Nocturnal or progressive abdominal pain D. Weight loss A previously healthy 42-year-old man presents to your office with questions about screening for colon cancer. He has no family history of colon cancer, but heard that he should start getting a colonoscopy every 5 years starting at age 40. Which of the following recommendations do you provide? A. He does not need screening because he has no family history of colon cancer B. He should be scheduled for a colonoscopy as soon as possible C. He should start screening at age 50 and continue indefinitely D. He should start screening at age 50 and continue until age 75 An 83-year-old man from a nursing home is sent for evaluation of abdominal distention and vomiting. Nursing home records report no bowel movement for two days and no fevers. His X-ray is shown above. On CT scan, no obstructing lesion is identified. What of the following may be beneficial in relieving this condition? A. Barium enema B. Exploratory laparotomy C. Magnesium citrate D. Neostigmine A 35-year-old man with a history of ulcerative colitis presents to the emergency department with complaints of fever, mild abdo minal pain, vomiting and diarrhea. His temperature is 102F, pulse is 125/min, and blood pressure is 88/52 mm Hg. Abdominal X-ray reveals colonic dilatation. In addition to fluid resuscitation, which of the following is the most appropriate initial step in management? A. Bowel rest and nasogastric tube B. Initiation of total parenteral nutrition C. Obtain CT scan of abdomen and pelvis with intravenous contrast D. Pain control with intravenous morphine A 52-year-old man with a history of alcohol abuse presents with hematemesis. He has had several episodes of bright red vomitus over the last two hours. His blood pressure is 136/84 mm Hg, and his heart rate is 86 beats/minute. A complete blood count reveals a hematocrit and hemoglobin that is within normal limits. What is the next best step in managing this patient? A. Admission to the intensive care unit for further observation B. Insert a nasogastric tube to evacuate gastric contents C. Order a type and screen and begin fluid resuscitation D. Send the patient for endoscopy

Order a type and screen and begin fluid resuscitation

You are called to examine a 3-year-old boy in the emergency department for possible ingestion. He was found by his father drooling and playing with an opened drain cleaner. After suspecting a caustic ingestion, he immediately called poison control and was advised to bring the boy to the emergency department. The boy is irritable and drooling. His physical examination is otherwise normal. Which of the following is the most appropriate next step in management? A. Give activated charcoal B. Give prophylactic antibiotics C. Order an upper endoscopy D. Perform gastric lavage

Order an upper endoscopy

A 72-year-old man presents with concerns of "looking yellow." He is asymptomatic but reports an unintentional 15-pound weight loss over the last two months. Physical examination reveals jaundice, mild epigastric tenderness, and palpable periumbilical nodules. Which of the following is the most likely diagnosis? A. Colon cancer B. Esophageal cancer C. Gastric cancer D. Pancreatic cancer

Pancreatic cancer

A 77-year-old man presents to his primary care provider with progressive jaundice for the past 2 weeks. He also reports a 15 lb unintentional weight loss. The man has a 50 pack-year smoking history. On physical exam, jaundice and hepatomegaly are noted. Additionally, his gallbladder is able to be palpated but is nontender. Which of the following is the most likely diagnosis? A. Cholecystitis B. Cirrhosis C. Hepatocellular carcinoma D. Pancreatic cancer

Pancreatic cancer

A 42-year-old woman presents to the emergency department with epigastric abdominal pain for two days. The pain radiates to her back and is associated with nausea and vomiting. Her past history is significant for alcohol use disorder. Which of the following is the most likely diagnosis? A. Cholecystitis B. Duodenal ulcer C. Pancreatitis D. Renal colic

Pancreatitis

Which of the following is the most likely cause of the finding seen above? A. Pancreatitis B. Ruptured gastric ulcer C. Severe pyelonephritis D. Splenic rupture

Pancreatitis

Absorption of vitamin B12 requires intrinsic factor. Which of the following cells of the stomach secretes intrinsic factor? A. Chief cells B. G-cells C. Mucous cells D. Parietal cells

Parietal cells

A 60-year-old man comes to the clinic complaining of difficulty swallowing, heartburn, chest pain, and mild weight loss. He has difficulty swallowing solids and liquids and often regurgitates undigested food. He has no significant past medical history and takes no medications. He denies any travel-related infection. Esophageal manometry reveals aperistalsis in the distal two-thirds of the esophagus and incomplete lower esophageal sphincter relaxation. Which of the following is the most likely diagnosis? A. Barrett's esophagus B. Infectious esophagitis C. Plummer-Vinson syndrome D. Primary achalasia

Primary achalasia

A 42-year-old woman presents to your office with complaints of fatigue, pruritus and abdominal discomfort. Laboratory testing reveals elevated serum alkaline phosphatase and hyperlipidemia. Physical exam findings include jaundice, skin excoriations and hepatomegaly. Which of the following is the most likely diagnosis? A. Acute pancreatitis B. Pancreatic cancer C. Polycythemia vera D. Primary biliary cholangitis

Primary biliary cholangitis

In the United States, which of the following is the most common risk factor for mechanical small bowel obstruction? A. Abdominal hernia B. Foreign body ingestion C. History of gastrointestinal tract malignancy D. Prior abdominal surgery

Prior abdominal surgery

An obese man presents with a 1-month history of dyspepsia. He denies dysphagia, odynophagia, vomiting, or weight loss. His exam reveals no concerning findings. You start him on antacids and order a fecal occult blood test (FOBT). He returns 1-month later unchanged. His FOBT is negative. Which of the following would be most likely used to aid in the clinical diagnosis of gastroesophageal reflux disease (GERD) in this patient? A. Esophagogastroduodenoscopy B. HIDA scan C. High resolution manometry D. Proton pump inhibitor trial

Proton pump inhibitor trial

A 32-year-old man presents with right upper quadrant pain that started earlier today. His symptoms initially included mild generalized abdominal discomfort and nausea before localizing to the right side of his abdomen. He has a low-grade fever but his vital signs are otherwise unremarkable. He has minimal tenderness in the right lower quadrant to palpation. Which of the following signs would be indicative of a retrocecal location of the appendix? A. Murphy sign B. Obturator sign C. Psoas sign D. Rovsing sign

Psoas sign

An otherwise healthy patient presents with 4 months of constipation. Her physical exam is unremarkable. Other than educating her on increasing exercise, which of the following initial treatments would you recommend? A. Disimpaction B. Linaclotide C. Polyethylene glycol D. Psyllium

Psyllium

A 2-month-old child presents with projectile vomiting. The child initially remains hungry following the episodes of vomiting but, in time, loses interest in feeding and presents to the emergency department appearing wasted and severely dehydrated. On physical exam, the patient appears dehydrated, and a small olive-like structure can be palpated in the right upper quadrant. What is the most likely diagnosis? A. Formula intolerance B. Gastroesophageal reflux disease C. Hirschsprung disease D. Pyloric stenosis

Pyloric stenosis

A 6-week-old boy presents with a 3-week history of progressive non-bilious vomiting. There is no history of recent fever, diarrhea or blood in his stool. The physical exam reveals minimal weight gain over the past two weeks. Which of the following is the most likely diagnosis? A. Intussusception B. Jejunal atresia C. Midgut volvulus D. Pyloric stenosis

Pyloric stenosis

A 6-week-old newborn is being evaluated for projectile vomiting and failure to thrive. The mother tells you the infant vomits immediately after every feeding. The vomitus appears to be nonbilious. Palpation of the right upper quadrant of the abdomen reveals an "olive-like" mass. Laboratory studies show a hypochloremic, metabolic alkalosis. Which of the following is the most likely diagnosis? A. Duodenal atresia B. Gastroesophageal reflux C. Hirschsprung disease D. Pyloric stenosis

Pyloric stenosis

You are caring for a patient who is diagnosed with pancreatic adenocarcinoma. The oncologist makes a note of a positive Trousseau syndrome in the documentation. Which of the following is she referring to? A. Nontender palpable gallbladder B. Palpable left supraclavicular lymph node C. Popliteal pain with abrupt ankle dorsiflexion D. Tender migratory thrombophlebitis

Tender migratory thrombophlebitis

A mother brings in her 2-week-old infant for a well child check. She reports that she is primarily breastfeeding him, with occasional formula supplementation. Which one of the following should you advise her regarding vitamin D intake for her baby? A. Breastfed infants do not need supplemental vitamin D B. Intake of vitamin D in excess of 200 IU/day is potentially toxic C. The baby should be given 400 IU of supplemental vitamin D daily D. Vitamin D supplementation should not be started until he is at least 6 months old

The baby should be given 400 IU of supplemental vitamin D daily

A pediatric patient presents to your office for a new patient evaluation. He has a history of Hirschsprung's disease. Which of the following complications is associated with this congenital disease? A. Diverticulosis B. Fatty liver disease C. Fistula D. Toxic megacolon

Toxic megacolon

You are treating a patient who is admitted to the hospital with a severe flare of ulcerative colitis. You have prescribed antibiotics, corticosteroids, and a biologic medication only. Which of the following is this patient most at risk for in this acute phase? A. Colon cancer B. Pancreatitis C. Peptic ulcer D. Toxic megacolon

Toxic megacolon

A 19-year-old man with a previous history of abdominal pain and diarrhea presents to your office with complaints of fatigue, weight loss, sweats and malaise. He tells you that his mother has experienced similar symptoms, but doesn't like to go to the doctor so has never been evaluated. Which of the following is most suggestive of Crohn's disease rather than ulcerative colitis? A. Genetic predisposition B. Lesions affecting the colon C. Symptoms of diarrhea and abdominal pain D. Transmural inflammation

Transmural inflammation

Which of the following characteristics is associated with Crohn disease? A. Continuous uninterrupted inflammation of the colonic mucosa B. Rectal involvement occurs in all cases C. Smoking appears to confer a protective effect D. Transmural involvement with cobblestone appearance

Transmural involvement with cobblestone appearance

A 40-year-old man with a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency is diagnosed with a urinary tract infection. Which of the following medications should be avoided? A. Amoxicillin B. Ceftriaxone C. Gentamicin D. Trimethoprim-sulfamethoxazole

Trimethoprim-sulfamethoxazole

An African American man is sent home with a prescription for an antibiotic after being diagnosed with a urinary tract infection. Two days later, he returns because his eyes are yellow. Which of the following antibiotics was most likely initially prescribed? A. Amoxicillin B. Cephalexin C. Doxycycline D. Trimethoprim-sulfamethoxazole

Trimethoprim-sulfamethoxazole

Which of the following disorders is associated with celiac disease? A. Medullary thyroid cancer B. Parathyroid hyperplasia C. Pheochromocytoma D. Type 1 diabetes mellitus

Type 1 diabetes mellitus

A 32-year-old man presents to clinic with worsening colicky stomach pains, and bloody, mucous streaked diarrhea. He reports he has no fever, nausea or vomiting. His symptoms began vaguely a week ago and have progressed in severity since then. He reports he is otherwise healthy, not on any medications and has not travelled recently. He has no family history of colon cancer and reports the symptoms are so bad he is no longer able to go out in public for fear of having to use the toilet. Stool studies are negative. Colonoscopy reveals edema, friability, mucous and erosions of the mucosal surface of the rectosigmoid region. Which of the following is the most likely diagnosis? A. Colon cancer B. Crohn's disease C. Irritable bowel syndrome D. Ulcerative colitis

Ulcerative colitis

A 5-year-old boy presents with abdominal pain, grogginess, and vomiting. His father states his son's stools have had a jelly-like appearance for the past 36 hours. You appreciate a sausage-shaped mass during abdominal palpation. Which of the following diagnostic tests is the most appropriate during this child's diagnostic evaluation? A. Abdominal radiograph B. Computed tomography C. Magnetic resonance imaging D. Ultrasonography

Ultrasonography

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