98 pt 2

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?

Hypokalemia

Which of the following metabolic abnormalities is most commonly noted in bulimia nervosa secondary to vomiting?

Hypokalemia

A 5-week-old boy is brought to the office by his mother for evaluation of vomiting. For the past 4 days, the boy has been vomiting forcefully right after drinking his formula. The patient has had fewer wet diapers today and had 1 dark brown stool yesterday. At age 2 weeks, the patient was at the 25th percentile weight and today he is at the 10th percentile for weight. Temperature is 36.7 C (98.1 F) and pulse is 138/min. The lips and mucous membranes are slightly dry. The abdomen is soft and nondistended with active bowel sounds. There is no hepatosplenomegaly or tenderness to palpation. Serum electrolytes are as follows:

Abdominal ultrasound

Which of the following is the most appropriate diagnostic test in a patient with suspected infantile hypertrophic pyloric stenosis?

Abdominal ultrasound

A 2-year-old boy presents with vomiting and episodes of crying. The patient started crying 4 hours ago and was inconsolable for 20 minutes. Afterward, he was happy and playful but began crying again an hour later and then had 6 episodes of emesis, which became bilious. On examination, he appears tired but not ill. Temperature is 37.2 C (99 F), blood pressure is 92/46 mm Hg, and pulse is 156/min. Physical examination is normal. The boy is given a normal saline bolus. Which of the following is the best next step in management?

Abdominal ultrasound Intussusception is most common in infants age 6-36 months and typically presents with episodes of crampy abdominal pain and vomiting. A "target sign" is classically seen on abdominal ultrasound, the diagnostic test of choice. First-line treatment consists of a water-soluble or air-contrast enema.

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?

Achalasia

Which of the following is classified as an esophageal motility disorder?

Achalasia Achalasia is the most common esophageal motility disorder producing dysphagia. Its exact etiology is unknown, but it is thought to be due to loss of Auerbach plexus in the esophagus.

A 19-year-old woman presents with abdominal pain that was initially mid-abdominal and crampy, but now is constant pain in the right lower quadrant with an associated vomiting episode. Temperature is 38 C (100.4 F), blood pressure is 118/70 mm Hg, and pulse is 96/min. The patient is supine on the bed with her hips flexed and reports worsening of the pain when her hips are extended. There is mild tenderness in the right lower quadrant, with guarding. Leukocyte count is 14,000/mm3 and urinalysis shows 10-20 leukocytes/hpf, 1+ blood, and no bacteria. Urine pregnancy test is negative. Which of the following is the most likely diagnosis?

Acute appendicitis

A 37-year-old woman presents with severe sudden-onset, sharp, right lower quadrant pain that began this morning. The pain has increased, and now she has persistent vomiting. Temperature is 37.8 C (100 F), blood pressure is 140/80 mm Hg, and pulse is 92/min. There is tenderness over the right lower quadrant with guarding and rebound tenderness. On bimanual examination, there is tenderness in the right adnexa but no palpable masses. Leukocyte count is 16,000/mm3. β-hCG is 2,840 mIU/mL. Transvaginal pelvic ultrasound shows an intrauterine pregnancy and normal ovaries. Which of the following is the most likely diagnosis?

Acute appendicitis Acute appendicitis can present with right adnexal tenderness and may mimic obstetric or gynecologic conditions. Patients with acute appendicitis typically have fever, nausea, vomiting, peritoneal signs, and normal adnexa on pelvic ultrasound.

A 17-year-old girl is brought to the emergency department by her older sister who found the patient writhing on the floor with severe abdominal pain. Since then, the patient has had several episodes of coffee-ground emesis and 2 episodes of dark green diarrhea. She has major depressive disorder and was hospitalized a month ago for a suicide attempt. The patient also has anemia, treated with supplementation. She is sexually active, and her last menstrual period was 3 weeks ago. Temperature is 37 C (98.6 F), blood pressure is 80/50 mm Hg, pulse is 120/min, and respirations are 28/min. On physical examination, she is lethargic and appears uncomfortable. Capillary refill is 5 seconds. The abdomen is soft but diffusely tender to palpation. Which of the following is the most likely diagnosis in this patient?

Acute iron poisoning Acute iron poisoning initially presents with symptoms of direct injury to the gastrointestinal tract (eg, hematemesis) and is followed by shock and anion gap metabolic acidosis. Hepatic necrosis and bowel scarring/obstruction may also occur.

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?

Acyclovir

A 56-year-old woman is evaluated for nighttime cough and wheezing that have increased in recent months. The patient now needs to use her albuterol inhaler after meals. She has no dyspnea on exertion but reports sore throat and hoarseness in the morning that clear during the day. The patient has gained 5 kg (11 lb) over the last 6 months. Medical history is significant for bronchial asthma and hypertension. Medications include low-dose inhaled fluticasone, an albuterol inhaler, lisinopril, and aspirin. Blood pressure is 128/82 mm Hg, pulse is 80/min, and respirations are 16/min. BMI is 32 kg/m2. Heart and breath sounds are normal without wheezing. Which of the following is the most appropriate next step in management of this patient?

Add esomeprazole Comorbid gastroesophageal reflux disease (GERD) is common in patients with asthma and can worsen asthma symptoms as a result of microaspiration. In asthma patients with signs and/or symptoms suggestive of comorbid GERD, proton-pump inhibitor therapy has shown benefit in improving asthma symptoms and peak expiratory flow rates.

An 18-month-old-boy is brought to the emergency department because he has become difficult to arouse for about an hour. For the past 6 hours, the boy has had 10-15 minute episodes of crying inconsolably that resolve and the patient is asymptomatic. His appetite is decreased and he has had multiple episodes of emesis. His only bowel movement today was a dark red and "sticky" stool that contained streaks of blood. Temperature is 36.7 C (98 F), blood pressure is 100/62 mm Hg, pulse is 128/min, and respirations are 18/min. On physical examination, he is lethargic. The abdomen is soft and nondistended with mild right lower quadrant tenderness with a palpable mass and hypoactive bowel sounds. Which of the following is the best next step in management of this patient?

Air contrast enema Intussusception is a pediatric emergency in which a segment of bowel telescopes into an adjacent segment, causing characteristic episodic pain, emesis, "currant jelly" stool, and lethargy. Rapid diagnosis and treatment with ultrasound-guided air contrast enema is critical for avoiding ischemia and peritonitis.

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?

Alendronate

Which of the following is the most effective initial treatment for a benign esophageal stricture?

Balloon dilation and proton pump inhibitor Balloon dilation and proton pump inhibitor is the most effective initial treatment for a benign esophageal stricture. An esophageal stricture is the narrowing of the esophagus caused by the buildup of acid and is one of the complications of gastrointestinal reflux disease.

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 pyloriserologic 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?

Bismuth plus metronidazole plus tetracycline plus a proton pump inhibitor

A 45-year-old woman is evaluated for nausea and vomiting on postoperative day 3 after a total abdominal hysterectomy complicated by ureteral stent placement. She was placed on a clear liquid diet on postoperative day 2, when she began to have some nausea. Since then, the patient has had multiple episodes of vomiting but no hematemesis. She has not passed flatus or had a bowel movement since the surgery. Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, and pulse is 80/min. The abdomen is mildly distended and has decreased bowel sounds. The incision has no surrounding erythema or discharge. Complete blood count and serum chemistry panel are normal. Abdominal x-ray is shown above. In addition to intravenous fluid administration, which of the following is the best next step in the management of this patient?

Bowel rest and serial examinations Prolonged postoperative ileus, the delayed return of bowel function >72 hours after surgery, is typically self-resolving; therefore, management is conservative with bowel rest and serial examinations.

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?

Caffeine

An older 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 alcohol use disorder. 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?

Candida

A 34-year-old man is brought to the emergency department by paramedics. His friend called emergency medical services after receiving a text message saying he was going to commit suicide. At the hospital, the patient is conscious and alert. He repeats, "It's not worth it anymore," but refuses to give any history. Temperature is 36.8 C (98.2 F), blood pressure is 130/70 mm Hg, pulse is 90/min, and respirations are 28/min. The patient is conscious and alert but in severe pain. The pupils are 3 mm bilaterally. The oropharynx is erythematous with some mild ulcerations. There is heavy drooling. The abdomen is benign with normal bowel sounds. Ingestion of which of the following is the most likely explanation for this patient's symptoms?

Caustic cleaning product A caustic ingestion causes injury to the upper aerodigestive tract and most commonly presents with pain, dysphagia, and oropharyngeal erythema and ulcerations. It does not cause alterations in consciousness.

An 83-year-old woman comes to the office due to a yearlong history of progressively severe, crampy abdominal pain that occurs immediately after she eats. The pain is diffuse but more pronounced in the epigastric area and is associated with frequent bloating and nausea and occasional diarrhea. The patient has had a 15-kg (33-lb) weight loss over the past year. She has lost her appetite since the pain began. The patient has hypertension, type 2 diabetes mellitus, hypercholesterolemia, peripheral vascular disease, and coronary artery disease. Three years ago, she had an inferior wall myocardial infarction. Blood pressure is 140/92 mm Hg. BMI is 24 kg/m2. The abdomen is soft, nontender, and nondistended. Bowel sounds are present. Abdominal x-ray is normal. Which of the following is the most likely cause of this patient's presentation?

Chronic mesenteric ischemia

Which of the following is the most common cause of esophageal varices in the United States?

Cirrhosis

A 54-year-old man with a history of gastroesophageal reflux disease and hypertension presents to the office for a new patient physical exam. He currently takes omeprazole 20 mg twice daily and lisinopril 10 mg once daily. He has taken omeprazole for 5 years but states he has struggled with heartburn for almost 15 years. He also reports a 20 pack-year smoking history. His vital signs are heart rate 70 bpm, blood pressure 125/85 mm Hg, respirations 20/min, oxygen saturation 98% on room air. His physical exam is normal, with no abdominal tenderness to palpation. You order an upper endoscopy, which shows the findings represented in the image above. According to the American College of Gastroenterology, what endoscopy findings are consistent with the most likely diagnosis?

Columnar-lined surface epithelium with goblet cells Barrett esophagus is a condition that results from chronic gastroesophageal reflux disease (GERD). Chronic GERD changes the cellular makeup of the distal esophagus from stratified squamous epithelium to columnar-lined epithelium with goblet cells and is diagnosed via endoscopy with biopsy.

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 3 days ago and revealed no gastric ulcers. On exam, he is ill-appearing and tachycardic. Which of the following is the best next step in management?

Consult thoracic surgery This patient presents with esophageal perforation, and an emergent thoracic surgery consult is indicated

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?

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?

Direct ethanol toxicity

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?

Disordered eating, amenorrhea, osteopenia

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?

Cricopharyngeus muscle Swallowed foreign bodies in pediatrics most commonly obstruct at the level of C6, the cricopharyngeus muscle, one of the four natural areas of luminal narrowing in the esophagus.

A 45-year-old man presents to the clinic reporting retrosternal chest pain and a bitter, metallic taste in his mouth for the past several months. The symptoms occur about 2 to 3 times per week, about 30 minutes after meals, and sometimes cause him to wake up from sleep at night. His symptoms are relieved by taking antacids and standing up from a supine position. He has a body mass index of 34 kg/m2, a temperature of 98.4°F, blood pressure of 128/72 mm Hg, and a heart rate of 82 bpm. Which of the following is the primary mechanism of his underlying condition?

Decreased lower esophageal sphincter tone Gastroesophageal reflux disease (GERD) is a common condition in which the contents of the stomach flow back into the esophagus. The primary mechanism of this disease is caused by decreased tonicity of the lower esophageal sphincter (LES)

A 50-year-old man presents to the gastroenterology clinic with progressive dysphagia that has developed gradually over 6 months. He initially had dysphagia with only solids but now also has dysphagia with liquids. Vital signs today include a heart rate of 80 bpm, blood pressure of 122/78 mm Hg, respiratory rate of 20/minute, oxygen saturation of 98% on room air, and temperature of 98.4°F. Physical examination reveals a regular rate and rhythm, no stridor or signs of respiratory distress, and no abdominal tenderness to palpation. The patient has a barium esophagram performed that is shown above. Which of the following describes the pathogenesis of the suspected condition?

Degeneration of the ganglion cells in the myenteric plexus of the esophageal wall

A 10-hour-old boy in the newborn nursery has bilious emesis. He was born at 38 weeks gestation by vaginal delivery to a 39-year-old woman who received no prenatal care. The patient has voided once but has not yet passed meconium. Physical examination shows a hypotonic neonate with a flat face, prominent tongue, low-set ears, and slanted palpebral fissures. The abdomen is soft and without distension, guarding, or rigidity. Auscultation reveals a loud holosystolic murmur most prominent at the left lower sternal border with a precordial thrill. A nasogastric tube is placed. Abdominal x-ray reveals air trapped in the stomach and proximal duodenum with no distal intestinal air. Which of the following is the most likely cause of this patient's clinical presentation?

Duodenal atresia Duodenal atresia is strongly associated with Down syndrome and presents with bilious vomiting in the first 2 days of life and double bubble sign on abdominal x-ray.

A 49-year-old man presents to his gastroenterologist's office for a follow-up on his abdominal pain and recent diagnosis of a gastrointestinal bleed. For the past few weeks, the patient has had intermittent epigastric pains, which he has correlated to occur a few hours after eating, and at times, he has even been woken up at night. The pain improves after he eats a snack. His vitals today are heart rate of 90 bpm, respiratory rate of 17/minute, oxygen saturation on room air of 99%, and blood pressure of 124/82 mm Hg. The patient had a recent positive fecal occult blood test and was scheduled for an endoscopy and colonoscopy. Both procedures were completed 2 days ago. There were no acute findings on the colonoscopy, but on the endoscopy, the presence and location of ulcers were confirmed. The patient was told the ulcers were unlikely to be malignant, given their location. Where is the most likely location of this patient's ulcer?

Duodenum

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?

Emergent endoscopy The patient presents with a non-obstructing, sharp foreign body in the lower esophagus that will require immediate removal by endoscopy to prevent further damage

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?

Empiric trial of omeprazole

A patient with excessive alcohol use 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 initial emergent interventional treatment?

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?

Endoscopic biopsy for culture and sensitivity testing Endoscopic biopsy for culture and sensitivity testing should be offered to a patient after they have failed two courses of appropriate antibiotics in the treatment of Helicobacter pylori infection.

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?

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?

Endoscopy

What is the gold standard for diagnosing peptic ulcer disease?

Endoscopy

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?

Hypophosphatemia Refeeding syndrome is a complication that occurs during nutritional therapy of malnourished patients. It is marked by hypophosphatemia, hypokalemia, thiamine deficiency, congestive heart failure and peripheral edema

A 4-week-old boy presents to the emergency department with projectile vomiting over the past 3 days. On physical exam, he is found to have a palpable olive-like mass in the right upper quadrant. On laboratory analysis, he has hypochloremic metabolic alkalosis. Which of the following is a risk factor for the development of this condition?

Erythromycin use

Which of the following is the recommended treatment of benign esophageal stricture disease?

Esophageal dilation

A 34-year-old man comes in due to chest pain for the past 3 months. The patient describes frequent episodes of substernal, squeezing-type chest discomfort that radiates to his neck. The episodes are not related to any particular activity, often occur at rest, and consist of constant pain lasting up to 2 hours. He has no dyspnea, wheezing, palpitations, syncope, or leg swelling. The patient does not use tobacco, alcohol, or recreational drugs. He works as an airline pilot. Family history is unremarkable. Blood pressure is 118/72 mm Hg, and pulse is 76/min. BMI is 30 kg/m2. ECG is normal. Exercise stress test shows no abnormalities. Which of the following is the most likely cause of this patient's chest pain?

Esophageal disease Esophageal chest pain is the most common mimicker of angina. Features include prolonged episodes (>1 hour), postprandial symptoms, associated heartburn or dysphagia, and relief with antacids.

Which of the following is the most sensitive diagnostic study for diagnosing achalasia?

Esophageal manometry Esophageal manometry is the most sensitive diagnostic study for the diagnosis of achalasia. Achalasia is a primary esophageal motility disorder characterized by loss of peristalsis in the distal esophagus and a failure of the lower esophageal sphincter to relax with swallowing

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-year smoking history. She reports no recent travel. Physical examination is within normal limits. A barium esophagram reveals a bird beak appearance. What is the next best step in diagnosis?

Esophageal manometry Achalasia is a motor disorder of the distal esophagus resulting from degeneration of the Auerbach plexus.

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?

Esophagitis Dysphagia to solids, upper abdominal pain, GERD-like symptoms (eg, heartburn), food impaction, and a history of allergies suggests eosinophilic esophagitis

A 72-year-old man comes to the office due to upper abdominal pain and weight loss. The abdominal pain is worse when eating and is sometimes relieved with over-the-counter antacids. He has not had dysphagia, melena, or rectal bleeding. The patient has well-controlled hypertension. He does not use tobacco, alcohol, or illicit drugs. The patient emigrated from South Korea 20 years ago. Temperature is 36.8 C (98.2 F), blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 14/min. BMI is 17.2 kg/m2. Mucous membranes are dry. Epigastric fullness and tenderness are present, but there is no hepatosplenomegaly. Peripheral pulses are full and capillary refill is normal. Which of the following is the best next step in management?

Esophagogastroduodenoscopy Gastric cancer is endemic to Eastern Asia, Eastern Europe, and the Andean portions of South America due to diets high in salt-preserved food and nitroso compounds

Perforation of what gastrointestinal structure is associated with the highest mortality?

Esophagus Perforation of any viscus is associated with significant morbidity and mortality. Perforation of the esophagus is most often diagnosed late, resulting in a fulminant course ending in death.

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?

Famotidine Step-up therapy is recommended for patients with mild GERD, which is defined as episodes occurring less than twice every week. Initial treatment is with a histamine 2 receptor antagonists, such as famotidine.

A 10-year-old girl is seen in the clinic for a well-child visit and is found to have a BMI in the 96th percentile. What additional studies should be ordered, according to the American Academy of Pediatrics?

Fasting lipid panel, fasting glucose, alanine aminotransferase

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?

Fluconazole

Which of the following is the most common cause of an esophageal perforation?

Iatrogenic Most esophageal perforations are iatrogenic and often result from complications of instrumentation (about 60% of all cases). The rigid endoscope is the most common offender.

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?

Head of bed elevation while sleeping

What is a principal risk factor for peptic ulcer disease?

Helicobacter pylori infection

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?

Hypochloremic, hypokalemic, metabolic alkalosis

A 35-year-old man presents to the primary care clinic with heartburn after eating. Pain occurs mostly in the evening, approximately 30 minutes after consuming his evening meal. He also reports mild regurgitation and belching at night. He reports no dysphagia, bloody stools, or weight loss. For the past 2 months, he has taken omeprazole 20 mg every morning but is on no other medication, and he has no other significant medical history. He does not smoke. His vitals are BP 122/78 mm Hg, pulse 78 bpm, RR 15 breaths/minute, temperature 98.6°F, and O2 saturation 99% on room air. He is nontender on abdominal physical exam with no guarding or rigidity. What is the best next step in the treatment of this patient?

Increase omeprazole to twice a day If symptoms do not resolve, increasing the PPI (e.g., omeprazole) to twice daily is the next step in treatment. The second dose should be taken 30 minutes before the evening meal, and patients should avoid laying down for 3 hours.

A 45-year-old woman with a history of osteoarthritis, hypertension, hypercholesterolemia, and tobacco use presents to clinic. The patient states that she has been experiencing a burning epigastric pain that occurs several hours after eating a meal and is relieved by antacids or food. Several times, the pain has awakened her from sleep. She reports no nausea, vomiting, diarrhea, or bloody stools. Her current medications include lisinopril, rosuvastatin, and naproxen. Vitals are temperature 37°C, BP 120/80 mm Hg, pulse 76 bpm, SpO2 99% on room air. Her physical examination reveals mild epigastric tenderness to palpation. The remainder of the physical exam is unremarkable. Laboratory tests reveal hemoglobin 13 g/dL, WBC 5,000/µL, and platelets 200,000/µL. A urea breath test is negative. Upper endoscopy shows evidence of ulceration in the duodenum. Which of the following is the correct pathogenesis of the disease described above?

Inhibition of cyclooxygenase-1 leading to prostaglandin deficiency This patient presents with peptic ulcer disease (PUD). Ulcers, which can occur in the stomach, duodenum, or both, are defined as disruptions of mucosal integrity due to inflammation that extends through the muscularis mucosa.

A 72-year-old man presents to his primary care PA with his daughter, who is worried about his burps. She worries this is a sign of esophageal cancer, which the patient's brother recently died of. The patient has lost 8 pounds since his last visit 7 months ago. Approximately 2 months ago, he had a bad "chest cold" that took a while to clear. Vital signs are BP of 135/90 mm Hg, HR of 80 bpm, RR of 15/min, oxygen saturation of 98% on room air, and T of 98.1°F. The patient says he "just does not enjoy eating" anymore. His breath is foul. Physical exam reveals no tonsillar or pharyngeal abnormalities, lymphadenopathy, or erythema of the neck. A finding of which of the following on a barium esophagogram would indicate the most likely diagnosis?

Irregularity above the cricopharyngeal muscle Zenker diverticulum is a rare herniation of the mucosal and submucosal layers of the esophagus in the Killian triangle, a weak point defined on the sides by the bilateral inferior pharyngeal constrictor muscles and at the base by the cricopharyngeal muscle, which comprises a vital part of the upper esophageal sphincter.

Which one of the following is characteristic of Mallory-Weiss syndrome?

Lacerations of the gastric cardia due to forceful vomiting

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?

Mallory-Weiss syndrome Mallory Weiss syndrome is a common cause of upper GI bleeding. It is often associated with alcoholism and eating disorders that are associated with forceful and recurrent vomiting or retching

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?

Mallory-Weiss tear

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?

Mallory-Weiss tear Mallory-Weiss tears are described as longitudinal mucosal lacerations of the distal esophagus, especially occurring at the gastroesophageal junction. Although 25% of cases are idiopathic, these tears commonly occur as a result of repeated retching, vomiting (as in bulimia nervosa),

A 69-year-old man is evaluated for abdominal pain. Upper gastrointestinal endoscopy shows a single shallow, 1-cm ulcer in the duodenal bulb and mild gastric erythema. Biopsy specimens from the gastric antrum do not show Helicobacter pylori, and stool testing for H pylori antigen is negative. Which of the following parts of the history is most likely to reveal the cause of this patient's current condition?

Medication use Peptic ulcers are most commonly caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drug (NSAID) use.

Which of the following findings is classically associated with pyloric stenosis?

Metabolic alkalosis Vomiting from pyloric stenosis classically causes a hypochloremic metabolic alkalosis

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?

Methylmalonic acid and homocysteine levels This patient most likely has vitamin B12 (cobalamin) deficiency. Vitamin B12 deficiency typically presents with paresthesias (eg, numbness and tingling), ataxia, glossitis, and megaloblastic anemia

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?

Metronidazole, tetracycline, bismuth, and a proton pump inhibitor This patient presents with symptoms suggestive of peptic ulcer disease (PUD). PUD is the collective term for gastric and duodenal ulcers. PUD is a prevalent condition affecting 4 million patients in the U.S. each year. The most common etiologic agent of PUD is infection with Helicobacter pylori,

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?

Misoprostol Misoprostol should be avoided or used with extreme caution in this woman of childbearing age.

Which of the following vitamin deficiencies causes the triad of dermatitis, diarrhea and dementia?

Niacin A deficiency of niacin, or vitamin B3, classically causes the triad of dermatitis, diarrhea and dementia.

A 41-year-old woman comes to the office for follow-up of abnormal liver function test results. She has no jaundice, abdominal pain, or nausea. Medical history is notable for type 2 diabetes mellitus, hypertension, and hypercholesterolemia. Current medications include metformin and lisinopril, both of which she has taken for several years. The patient drinks 1-2 glasses of wine on weekends. Vital signs are normal. BMI is 36 kg/m2. Examination shows mild hepatomegaly.

Nonalcoholic fatty liver disease Nonalcoholic fatty liver disease is characterized by hepatomegaly, with mild elevations in liver transaminase levels in the absence of other causes of secondary hepatic fat accumulation (eg, alcohol). It is most common in patients with obesity and diabetes. Management includes weight loss and control of metabolic risk factors.

A 36-month-old boy is being evaluated at your office. Parents are concerned because he is short and has evidence of developmental delay with hypotonia. He was born at term with a birth weight of 3250 grams. He has a history of poor suck that required physical therapy. Recent fluorescence in situ hybridization was positive for a deletion on chromosome 15. This patient is at a higher risk of suffering from which of the following conditions?

Obesity Prader-Willi syndrome is the most common syndromic form of obesity. The syndrome is caused by absence of expression of the paternally active genes on the long arm of chromosome 15, also known as maternal uniparental disomy.

A 38-year-old man with a history of heavy alcohol use presents with hematemesis. After obtaining a history and performing a physical exam, a Mallory-Weiss tear is suspected. The patient's vital signs are stable with a normal heart rate and blood pressure. Which of the following is the next best step in caring for this patient?

Obtain intravenous access Obtaining intravenous (IV) access is the most important first step in caring for a patient with gastrointestinal (GI) bleeding. Intravenous access allows blood to be drawn for a type and screen, coagulation studies, and determination of hematocrit and hemoglobin levels. It also allows for fluid resuscitation to maintain intravascular volume.

A man who is pale and ill-appearing presents to the emergency department with reports of two episodes of bright red vomitus. A medical history review reveals alcohol use disorder, chronic hepatitis, and cirrhotic liver disease. Vitals include a HR of 105 bpm, RR of 18/min, BP of 96/55 mm Hg, T of 97.7°F, and SpO2 of 95% on room air. Laboratory testing reveals hemoglobin 10.1 g/dL, hematocrit 38.7%, INR 1.7, and platelet count 82,000/μL. Two large-bore intravenous access lines are placed with aggressive fluid repletion and prophylactic antibiotic administration initiated. What is the next step in treatment?

Octreotide infusion Esophageal varices are dilated submucosal veins that develop secondary to portal hypertension.

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?

Omeprazole Proton pump inhibitors (omeprazole) decrease gastric acidity which leads to a decrease in calcium absorption. However, it is thought that calcium citrate does not have this same consequence when taken with omeprazole.

A 52-year-old man with a history of heavy alcohol use presents with hematemesis. He has had several episodes of bright red vomitus over the last 2 hours. His blood pressure is 136/84 mm Hg, and his heart rate is 86 bpm. A complete blood count reveals a hematocrit and hemoglobin that is within normal limits. What is the next best step in management?

Order a type and screen and begin fluid resuscitation Ordering a type and screen and beginning fluid resuscitation are important first steps in the management of hematemesis with suspected esophageal varices

Parents bring their previously healthy four-week-old boy to the ED due to repeated "projectile vomiting" immediately after he nurses for the past 24 hours. The parents report the emesis looks just like breast milk. He has had a normal pattern of wet diapers. The parents deny any rectal bleeding. He has not had any difficulty nursing before, and attempts at burping him have not brought any relief. Vital signs include a temperature of 98.8°F. Physical exam reveals an alert, crying infant with a small, firm right upper quadrant mass. Blood analysis is within normal limits. Which of the following choices is the best next step for this patient?

Order transabdominal ultrasound

A 55-year-old woman with a history of chronic back pain for which she takes ibuprofen daily presents to the emergency department following two episodes of coffee ground emesis. She reports mild upper abdominal pain and black stools overnight but reports no bright red blood per rectum, no history of gastrointestinal bleed, and no liver disease or alcohol use. Physical exam reveals temperature 37°C, heart rate 90 beats per minute, respiratory rate 14 breaths per minute, blood pressure 120/70 mm Hg, and pulse oximetry 97% on room air. Abdomen is tender to palpation in epigastric region with no rebound. Digital rectal exam reveals melenic stool. Which of the following is the most likely etiology of her bleed?

Peptic ulcer disease

What is the most common cause of upper gastrointestinal bleeding?

Peptic ulcer disease

A 68-year-old woman comes in due to sudden onset of severe epigastric pain 2 hours ago, accompanied by nausea and an episode of vomiting. The patient has had intermittent abdominal discomfort over the past several months. Her only other medical condition is osteoarthritis, for which she regularly takes ibuprofen. She has a 30-pack-year smoking history. Temperature is 38 C (100.4 F), blood pressure is 150/92 mm Hg,and pulse is 112/min. Cardiopulmonary examination is normal. There is marked upper abdominal tenderness with guarding. ECG reveals no acute ST-segment or T-wave changes. Chest x-ray shows free air under the diaphragm, as seen in the image above. Which of the following is the most likely diagnosis?

Perforated peptic ulcer

A 38-year-old man presents to the primary care clinic for a 6-week follow-up. He was recently diagnosed withHelicobacter pylori-associated peptic ulcer disease (PUD) after an upper endoscopy. At his last visit, he was placed on omeprazole 40 mg BID and bismuth subcitrate potassium 140 mg/metronidazole 145 mg/tetracycline 125 mg four times daily for 14 days. Today, he states his dyspepsia has significantly improved, and he is no longer having any other gastrointestinal symptoms. Vital signs are BP 118/78 mm Hg, pulse 77 bpm, RR 13 breaths/minute, and temperature 99°F. Physical exam reveals a nontender abdomen with no rigidity or guarding. What is the best next step in the treatment of this patient?

Perform urea breath test for Helicobacter pylori After 4-6 weeks of treatment, clinicians should confirm successful eradication of H. pylori via a noninvasive test, such as the urea breath test.

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?

Pyridoxine Pyridoxine (vitamin B6) supplementation is recommended when taking isoniazid because isoniazid alters the activity of vitamin B6

A 52-year-old man presents to the clinic with concerns over his worsening dysphagia. He describes difficulty with both solids and liquids and occasionally regurgitates bland, undigested food. He has been diagnosed previously with gastroesophageal reflux disorder, which was unresponsive to a 4-week trial of omeprazole. His vitals include a HR of 83 bpm, RR of 16/min, BP of 128/88 mm Hg, T of 98.7°F, and SpO2 100% on room air. Physical exam reveals a well-appearing man in no acute distress without palpable lumps or defects on his throat. A barium swallow study is obtained with the results shown above. Which of the following is the best treatment?

Pneumatic balloon dilation

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?

Primary achalasia Primary achalasia is a disease of unknown etiology in which there is a loss of peristalsis in the distal esophagus and a failure of lower esophageal sphincter (LES) relaxation with swallowing.

A 78-year-old man comes to the office due to gallstones that were found on imaging following a motor vehicle collision. Abdominal ultrasound revealed 2 small gallstones with no gallbladder wall thickening or dilation of the common bile duct. The patient has had intermittent abdominal bloating and mild nausea in the past but reports no fever, chills, pain in the right upper quadrant, or jaundice. Temperature is 36.6 C (97.9 F), blood pressure is 144/83 mm Hg, and pulse is 78/min. BMI is 34 kg/m2. The abdomen has no tenderness to palpation

Provide reassurance with no further intervention Incidental gallstones are a common finding in patients with abdominal pain but do not require treatment if they are not the cause of the symptoms.

A 5-week-old boy presents with his father to the emergency room because of a ten day history of vomiting that has become more frequent and more forceful. The vomitus is not bile stained. The infant sucks vigorously and is active, but he is observed to be losing weight. There are no other symptoms noted. Abdominal examination reveals a small, olive-shaped mass upon palpation. Which of the following is the most likely diagnosis?

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?

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?

Pyloric stenosis

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?

Response to thiamine administration

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?

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?

Scleroderma

A 36-year-old man comes to the office due to frequent "loose stools" for the past 10 months. The stools are large in volume, liquid to semisolid, occur up to 3-4 times a day, and often foul-smelling. He also reports excessive flatulence, occasional nausea and abdominal cramping, and has lost 4.5 kg (9.9 lbs). He has no prior medical conditions and has had no recent travel. He consumes a balanced diet and notes no specific association of diarrhea to food. Vital signs are normal. Weight is 63.5 kg (140 lb). The abdomen is soft, nondistended, and nontender, with no organomegaly. Bowel sounds are increased. Rectal examination shows no masses or tenderness and an empty rectal vault. Stool occult blood testing is negative. Samples for blood count, erythrocyte sedimentation rate, TSH, and serum electrolytes are obtained. Which of the following additional interventions is most appropriate in management of this patient's diarrhea?

Send stool for microscopy, electrolytes, and fat content The evaluation and management of chronic diarrhea involves a comprehensive history (eg, clear description of stool characteristics, duration and timing of symptoms), basic serum analysis, and, importantly, stool analysis.

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?

Stop ibuprofen and naproxen and refer for outpatient evaluation The patient presents with clinical gastritis, likely secondary to the use of nonsteroidal anti-inflammatory drugs (NSAIDs).

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?

Upper endoscopy

A 59-year-old man with a history of hypertension, dyslipidemia, and chronic low back pain presents for evaluation of sudden-onset abdominal pain that radiates to his right shoulder. His current medication regimen includes enalapril, propranolol, aspirin, ibuprofen, and atorvastatin. He describes intense, diffuse abdominal pain that began 2 hours ago and has since decreased in severity. Vital signs are HR 133 bpm, RR 20/min, BP 102/82 mm Hg, T 95.7°F, and SpO2 95% on room air. Physical exam reveals an ill-appearing man with a weak radial pulse and cool extremities. Abdominal palpation demonstrates marked abdominal rigidity and right lower quadrant tenderness. Cardiac biomarkers are within normal limits, and initial ECG monitoring reveals left ventricular hypertrophy without signs of ischemia or infarct. Abdominal radiograph images are shown above. Which of the following is the best next step in intervention following initial stabilization?

Surgical consultation Peptic ulcer disease is a gastrointestinal disorder most commonly caused by nonsteroidal anti-inflammatory drug use and Helicobacter pylori infection that results in ulcerative lesions within the stomach and duodenum. Free perforation may occur when a lesion ulcerates through the gastrointestinal wall.

What is the classic finding in pyloric stenosis seen on upper GI series?

The "string sign" which represents the slow passage of contrast through a narrowed pyloric sphincter.

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?

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

A 13-year-old girl is evaluated because her mother is concerned about the girl's growth. The girl eats well but does not gain weight. Over the past month, the patient has had a few episodes of loose stools but no fever, fatigue, nausea, vomiting, abdominal pain, or weakness. Blood pressure is 90/60 mm Hg and pulse is 72/min. Height and weight are at the 5th and 15th percentiles, respectively. Her weight has decreased by 2.3 kg (5.1 lb) in the last year. Cardiopulmonary examination is normal. The breasts and pubic hair are Tanner stage 1. The abdomen is soft and nontender with no hepatosplenomegaly. An erythematous papulovesicular rash is seen bilaterally on the knees and elbows. Which of the following tests is most likely abnormal in this patient?

Tissue transglutaminase IgA antibody Dermatitis herpetiformis, another extraintestinal sign of celiac disease, presents with a pruritic papulovesicular rash on extensor surfaces (eg, knees, elbows), as seen in this patient.

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 one-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?

Tobacco use Tobacco use is one of the most common risk factors for the development of squamous cell carcinoma (SCC) of the esophagus

A 3-year-old boy is brought to the emergency department after swallowing a battery. About an hour ago, his father was changing his watch battery when the patient grabbed and swallowed it and then coughed for several minutes. Since then, he has been able to drink and talk normally. Vital signs are normal. The patient appears alert and comfortable. He is not drooling, and the posterior oropharynx is clear. The lungs are clear to auscultation. Chest x-ray on anteroposterior view shows a radiopaque, circular object with a halo sign in the esophagus. Which of the following is the best next step in management of this patient?

Upper gastrointestinal endoscopy A button battery lodged in the esophagus can cause tissue corrosion, necrosis, and life-threatening perforation. A circular object with a halo sign on chest x-ray is consistent with a button battery, and management is immediate endoscopic removal.

A 78-year-old man is brought to the emergency department after he was found obtunded and moaning in bed at his nursing care facility. For 2 days prior, he refused to eat most of his food. Medical history is significant for early Alzheimer disease, hypertension, hyperlipidemia, and right hemicolectomy for stage I colon cancer. Temperature is 38.7 C (101.7 F), blood pressure is 102/54 mm Hg, pulse is 114/min, and respirations are 22/min. The patient is groaning and does not follow commands. The abdomen is distended, tympanic to percussion, and rigid to palpation. Stool guaiac test is negative. The patient cannot tolerate sitting upright. Lateral decubitus x-ray of the abdomen shows multiple air-fluid levels and a small amount of free air below the diaphragm, as seen in the image above. Which of the following is the best next step in management of this patient?

Urgent surgical referral for exploratory laparotomy Small-bowel obstruction can be complicated by bowel perforation. Free air on x-ray and clinical signs of peritonitis should prompt emergent surgical exploration.

A 12-year-old girl with cystic fibrosis has been noncompliant with her vitamin and enzyme supplements. She presents with dry eyes and difficulty seeing at night. She is most likely deficient in which vitamin?

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?

Vitamin A

A 55-year-old man with a history of alcohol use disorder 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?

Vitamin B1 Wernicke-Korsakoff syndrome is actually made up of two individual syndromes that often occur simultaneously and are both caused by thiamine deficiency (vitamin B1).

A 17-year-old girl 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?

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?

Vitamin B3 A patient presenting with dementia, dermatitis, and diarrhea, who was recently treated with isoniazid, strongly suggests niacin (vitamin B3) deficiency.

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?

Vitamin B6 deficiency

A 2-month-old term girl is brought to the office for a routine well-child visit. She is exclusively breastfed every 3-4 hours for 15 minutes on each side. The patient has been growing well and developing normally. She takes no medications and has no allergies. Her mother eats a well-balanced diet and takes no medications. Which of the following nutritional deficiencies is this child at greatest risk of developing?

Vitamin D

A 15-year-old girl is brought to the office by her parents for a wellness visit. The patient and her family live on a farm and recently started following a vegan diet with exclusive consumption of unprocessed, locally produced foods, including a variety of fruits, vegetables, grains, legumes, and nuts, and strictly avoiding all animal-based products. Physical examination is normal. This patient's diet places her at increased risk for deficiency in which of the following vitamins?

Vitamin D A vegan diet is characterized by abstinence from all animal-sourced products. Calcium, vitamin D, vitamin B12, and iron are commonly deficient in a vegan diet and may require supplementation.

Surgical treatment of peptic ulcer disease is reserved for those patients with complications associated with ulcer lesions, those refractory to medical intervention, or patients with giant (greater than 3 cm) gastric ulcers. Which of the following is considered the most common postsurgical complication experienced by patients undergoing surgical treatment for peptic ulcer disease?

Weight loss

You are seeing a 4-week-old boy with vomiting. Which of the following findings is most concerning for pyloric stenosis as an underlying cause?

Weight loss Infantile pyloric stenosis should be considered in a neonate with vomiting and weight loss.

Which of the following conditions is characterized by ataxia, oculomotor dysfunction, and altered mental status?

Wernicke encephalopathy

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 kg/m2. If this patient's condition is left untreated, which of the following complications can most likely develop?

esophageal adenocarcinoma