Rosh GI

A. Anitiemetics and fluids

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

C. Polyethylene glycol

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

C. Psoas sign

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

B. Crohn disease

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

D. Vitamin B6 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? A. Vitamin A deficiency B. Vitamin B12 deficiency C. Vitamin B3 deficiency D. Vitamin B6 deficiency

D. Vitamin B1

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

B. Cefotaxime

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

D. 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

C. Vitamin B3

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

D. 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 metronidazole

A. Abdominal CT scan

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

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

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

C. Lipid panel and complete metabolic panel

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

D. Carcinoembryonic antigen (CEA)

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 127- (CA-125) C. Cancer antigen 15-3 (CA-15-3) D. Carcinoembryonic antigen (CEA)

A. Active infection with hepatitis B

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

D. Hypovitaminosis D

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

B. Gastritis

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

C. Perirectal abscess

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

B. Celiac disease

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, 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

D. Rovsing sign

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's sign B. Obturator sign C. Psoas sign D. Rovsing sign

D. 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

D. Neostigmine

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. Attempt manual reduction

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

A. Candida

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

C. 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

B. Improvement with defecation

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

D. Prior abdominal surgery

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

C. Beta blocker

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

C. Helicobacter pylori infection

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

A. 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

B. Dentate line

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

A. Cephalexin

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. Nitrofurantoin C. Phenazopyridine D. Trimethoprim-sulfamethoxazole

C. Nitrofurantoin

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

B. Beta cells

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

D. Transmural involvement with cobblestone appearance

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

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

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

D. Wernicke encephalopathy

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

D. Type 1 diabetes mellitus

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

D. Peritonitis

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

D. Crystalloid infusion

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

A. Alcoholic liver disease

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

A. Adhesions

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

C. Deficiency of phenylalanine hydroxylase

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

C. 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

A. Esophageal dilation

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

A. More likely to need an emergent surgical procedure

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

13-year-old boy with sickle cell disease

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

C. Rovsing's 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

B. Hepatitis B surface antigen negative, hepatitis B surface antibody positive

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

A. Excision

Which of the following represents appropriate management of a thrombosed external hemorrhoid in the acute 48-hour setting?83 A. Excision B. Reduction C. Sitz baths D. Surgery referral

C. Small bowel biopsy

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

B. Niacin

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

A.WBC decreased, RBC decreased, platelets decreased

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

D. 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

C. Hypophosphatemia

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

D. 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

B. Alcoholic hepatitis

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

C. Pancreatitis

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

D. Primary biliary cholangitis

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

A. Esophageal adenocarcinoma

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

B. Hemorrhoidectomy

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

D. Spironolactone

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

C. Administer broad-spectrum antibiotics and obtain emergent surgical consultation

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

C. Increased fiber intake

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

B. CT scan of the abdomen is highly specific in small bowel obstruction

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 of small bowel obstruction B. CT scan of the abdomen is highly specific in small bowel obstruction C. Serum lactate is highly sensitive early on in patients with small bowel obstruction D. Serum white blood count is always elevated in small bowel obstruction

C. WBC of 370 cells/mm3 with 90% neutrophils

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

D. Proton pump inhibitor trial

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

C. Liver

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

A. Advise a lactose-restricted diet

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

D. Tissue transglutaminase antibody

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

C. Mallory-Weiss syndrome

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

D. 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's disease D. Pyloric stenosis

B. Cryptosporidium

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

C. Esophagus

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

B. Corn

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

D. High in vegetables, low in meats

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

C. Hemorrhoids

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

A. Adhesions from prior surgery

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

D. Nonalcoholic fatty liver disease

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

D. 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

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

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

B. Hydrogen breath test

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

C. Norovirus

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

B. Refractory dyspepsia

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

D. Clarithromycin, amoxicillin, and a proton-pump inhibitor

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. Carafate D. Clarithromycin, amoxicillin, and a proton-pump inhibitor

A. Ciprofloxacin

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

C. Hepatitis B surface antibody (anti-HBs)

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)

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

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)

B. Emergent herniorrhaphy

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

D. Surgical reduction

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

A. Anti-Hepatitis A Virus IgG positive

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

B. Vitamin B12

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

A. Celiac disease

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

B. Misoprostol

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

B. Crohn's 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

B. Cricopharyngeus muscle

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

C. Family history

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

D. Scleroderma

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

C. Sitz baths, psyllium fiber, and bulking agents

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

D. Ultrasonography

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. Computed tomography B. KUB radiograph C. Magnetic resonance imaging D. Ultrasonography

C. Order a type and screen and begin fluid resuscitation

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

C. CT scan

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

C. Fecal impaction

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

B. Methylcellulose

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

C. Dietary restriction of phenylalanine

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

B. Emergent endoscopy

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 to further evaluate the location of the foreign body B. Emergent endoscopy C. Glucagon D. Observation

A. Alendronate

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

C. 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

C. Pinworms

What is the most common cause of pruritus ani in the pediatric patient? A. Candida B. Lichen planus C. Pinworms D. Seborrheic dermatitis

C. Oral antibiotics should be given for 7-10 days in uncomplicated diverticulitis

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 for 7-10 days in uncomplicated diverticulitis D. Ultrasound is the imaging modality of choice

B. Most adult intussusception cases involve the small bowel

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

C. 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

C. 41 year-old obese, pregnant woman

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

B. Lacerations of the gastric cardia due to forceful vomiting

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

C. 5 years to 10 years

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, 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

B. Topical hydrocortisone

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

A. A history of constipation

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

C. Giardia lamblia

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 admits a 2 pound unintentional weight loss, but denies bloody stools. When questioned, he admits to 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

B. Avoidance of wheat, rye, and barley

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 admits to 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

D. Head of bed elevation while sleeping

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

C. Cholecystitis

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

A. Acute cholecystitis

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

D. Spontaneous bacterial peritonitis

A 43-year-old-man with known alcoholic cirrhosis presents to the Emergency Department with fever and abdominal pain. He has not been feeling well for a few days. He denies trauma, change bowel habits, and blood in his stool. He is mildly confused and has asterixis on exam. His abdomen is distended with a fluid wave and is tender to palpation. What is the most likely diagnosis? A. Appendicitis B. Cholecystitis C. Colitis D. Spontaneous bacterial peritonitis

B. 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

D. Symptomatic cholelithiasis

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

B. Empiric trial of omeprazole

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

D. Right upper quadrant ultrasound

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

D. 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's sign. What is the preferred imaging modality? A. Abdominal barium meal B. Abdominal computed tomography scan C. Abdominal plain film D. Abdominal ultrasound

B. LDH 400 IU/L

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

D. Post-operative adhesions

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

C. Response to thiamine administration

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

A. Ascitic fluid neutrophil count of 300 cells/mcL

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

A. 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

D. White blood cell count 18,000

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

B. Lactulose

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

D. 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

A. Colonoscopy

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

D. Esophagogastroduodenoscopy

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

B. Colonic diverticula

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

C. 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

A. Acute mesenteric ischemia

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

D. Pancreatic cancer

A 72-year-old man presents with concerns of "looking yellow." He is asymptomatic but admits to 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

D. Tobacco use

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

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

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

D. High-pitched bowel sounds

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

C. Rickets

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

A. Iliohypogastric

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

D. Disordered eating, amenorrhea, osteopenia

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

D. Rubber band ligation

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

A. Calcium

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

C. Enema washout

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

C. Screening with hepatitis C antibody test

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

A. Complete blood count

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

D. Postoperative adhesions

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

C. 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. 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