UWorld- Internal Medicine BLOCK 3

E. Schistocytes Disseminated IV coagulation is a common complication of gram-negative bacterial sepsis due to activation sepsis due to activation of the coagulation cascade by bacterial endotoxins, which leads to the formation of micro thrombi. Peripheral smear shows fragmented erythrocytes (schistocytes) & thrombocytopenia. Lab tests show decreased fibrinogen levels & prolonged PT & PTT.

20-year-old man is brought to the ED due to a day of fever, HA & neck pain. Temp is 38.7C (101.7F), BP is 120/72, HR is 112/min, RR are 26/min. There is neck stiffness & a petechial rash on the trunk. CSF analysis reveals the following: Glucose: 30mg/dL (normal: 40-70) Protein: 180 mg/dL (< 40) Leukocytes: 1,500/mm3 Neutrophils: 70% CSF gram stain shows gram-negative diplococci. In the ED, the patient's hemodynamic status deteriorates rapidly. BP drops to 80/50 & the venous access sites are oozing blood Which of the following findings most likely to be seen on this patient's peripheral smear? A. Eosinophilia B. Howell-Jolly Bodies C. Hypersegmented neutrophils D. Rouleaux formations E. Schistocytes

E. von Willebrand disease prolonged mucocutaneous bleeding, easy bruising & prolonged PTT

22-year-old woman presents to ED due to continuous gum bleeding after a mouth injury a few hours ago. She was playing doubles tennis & was accidentally struck on her bottom lip by a racquet. The patient has a Hx of bruising with minor trauma & of heavy menstruation with cramps pain. Her mother also had a history of "bleeding issues." BP: 120/70, HR: 80/min. Exam shows blood oozing from a gum abrasion. A fading ecchymosis is present on the right calf, but there are no other skin abnormalities. A fading ecchymosis is present on the right calf , but there is no other skin abnormalities. The remainder of the PE is normal. Lab results: CBC- Hemoglobin: 10.2 MCV: 76uM Platelets: 170,000/mm3 Coagulations- PT: 12 secs INR: 1 Activated PPT: 44 sec What is the most likely cause of this patient's bleeding problem? A. disseminated IV coagulation B. hemophilia A C. immune thrombocytopenia D. vitamin K deficiency E. von Willebrand disease

D. Normal glucose, increased lymphocyte & erythrocytes counts Viral infections of the CNS are usually characterized by elevated protein, normal glucose, & an elevated WBC count with a lymphocytic predominance. Patients with herpes encephalitis also usually have elevated erythrocytes in the CSF due to hemorrhagic inflammation of the temporal lobes

23-year-old with no prior history of seizure is brought to the ED after experiencing a generalized tonic-clinic seizure. His roommate says that the patient has had a fever & headache for the past 2 days & that today he was talking nonsensically. The patient has no chronic medical conditions but has had a cold sore on his upper lip for the past few days. Temp: 38.6C (101.5F). MRI of the brain shows swelling of the temporal lobes. In addition to an elevated CSF protein content, CSF analysis is most likely to reveal which of the following? A. Low glucose, increased lymphocyte count B. Low glucose, increased neutrophil count C. Normal glucose, increased erythrocytes count D. Normal glucose, increased lymphocyte & erythrocytes counts E. Normal glucose, normal cell counts

B. avascular necrosis occurs due to impaired blood supply to a segment of bone. The femoral head is the m/c location. Common causes include sickle cell disease, glucocorticoid therapy, vasculitis & alcoholism.

24-year-old woman presents with left hip & pelvic pain. She has a constant, dull, achy pain at rest that is exacerbated by mov't of the hip or weight bearing. Her medical Hx is significant for sickle cell disease, pneumococcal pneumonia & acute chest syndrome. Temp: 26.8C (98.2F). Patient appears mildly uncomfortable. Pedal pulses are full & there is normal capillary refill & sensation in the feet. No redness or warmth is present over the hip joint but she has decreased passive internal rotation, extension, & abduction at the hip. What is the likely cause of this patient's pain? A. acute bursitis B. avascular necrosis C. osteoarthritis D. RA E. septic arthritis

E. post strep glomerulonephritis acute post-strep glomerulonephritis occurs 10-20 days after strep throat or strep skin infections. It presents with hematuria, HTN, red cell casts & mild proteinuria. Most patients have spontaneous remission & management is primarily supportive.

27-year old man presents with a 2-day history of malaise & dark urine. He has no chronic medical conditions but was treated with oral Dicloxacillin for a blistering skin infection 3 weeks ago. Temp: 37.4C(99.4F), BP: 150/90, HR: 80/min, RR: 15/min. Exam shows periorbital swelling. UA shows 8 RBC/hpf with RBC casts & mild proteinuria. Lab show low serum C3 levels; BUN: 40mg/dL & serum creatinine: 2mg/dL. What is the most likely diagnosis? A. acute pyelonephritis B. drug-induced acute interstitial nephritis C. IgA nephropathy D. Membrano- proliferative glomerulonephritis E. post strep glomerulonephritis

E. SLE SLE is an autoimmune disorder affecting multiple organ systems. Renal involvement may present with nephritic syndrome (hematuria, RBC casts). Nephrotic syndrome may also occur

28-year-old woman comes to the ED due to persistent bilateral headaches. The patient was initially seen at an urgent care clinic for the same symptoms 4 weeks ago & had a normal PE. The headache has failed to improve with Ibuprofen & now the patient also feels fatigued. She has had no fever, cough, SOB, chest or abdominal pain or diarrhea. The patient has no chronic medical conditions but says she sunburns easily. BP: 170/110. PE shows 1+ pitting edema of the bilateral lower extremities but is otherwise unremarkable. Lab results: hemoglobin: 10.8g/dL (normal: 12.0-16.0) platelets: 92,000 (normal: 150,000-400,000) leukocytes: 5,500 (normal: 4,500-11,000) BUN: 40mg/dL (normal: 7-18) creatinine: 2.5mg/dL (normal: 0.6-1.2) UA- protein: 3+ RBC: 20-30/hpf casts: erythrocytes casts Which of the following is the most likely diagnosis? A. Hemolytic uremic sydrome B. Hypertensive emergency C. NSAID-induced interstitial nephritis D. Poststreptococcal glomerulonephritis E. SLE

B. Immune thrombocytopenia purpura immune thrombocytopenia purpura is caused by acquired autoantibodies to platelet antigens & is often associated with a preceding viral illness or ongoing medical condition. Manifestations include mucocutaneous bleeding (heavy menstrual bleeding, epistaxis) and petechiae. Thrombocytopenia may be mild or severe, but platelet morphology on peripheral smear is normal. Coagulation studies, leukocytes & erythematous typically are unaffected.

28-year-old woman presents due to several months of intermittent heavy menstrual bleeding & epistaxis. The patient & her family have no major chronic medical conditions. VS are normal. Cardiopulmonary exam is unremarkable. The abdomen has no hepatomegaly or splenomegaly. There are several non palpable erythematous/violaceous lesions on the lower extremities that do not blanche with pressure. Hemoglobin: 11.8mg/dL & platelets: 16,000/mm3. PT & PTT are normal. A peripheral smear shows normal RBCs & a reduced number of morphologically normal platelets. Which of the following is the most likely diagnosis for this patient? A. Eosinophilia granulomatosis with polyangiitis B. Immune thrombocytopenia purpura C. SLE D. Thrombotic thrombocytopenia purpura E. Von Willebrand disease

C. Performance-enhancing substance abuse Growth hormone abuse can produce a temporary increase in lean body mass & sprint performance. Risks include hyperglycemia, sodium retention, hypertension & MSK complications (myopathy, arthralgias, carpal tunnel syndrome)

28-year-oldman presents due to pain & numbness in the right hand. For the past month, the pain has awakened him at night. The patient also had pain occasionally in other joints but no swelling or stiffness. He is a professional body builder & is training for an upcoming championship. The patient is sexually active with multiple partners. BP: 150/92; BMI: 35kg/m2. The patient is muscular & has normal body hair distribution. Tapping the volar surface of the right wrist elicits tingling of the right thumb & index finger. Mild, bilateral pedal edema is present. Fasting labs: Hemoglobin: 14.4g/dL (13.5-17.5g/dL) Platelets: 320,000/mm3 (normal: 150,000-400,000) Leukocytes: 8,200/mm3 (4500-11,000) Glucose: 142mg/dL (normal: 80-100) AST (SGOT): 38U/L (normal: 8-20U/L) Which of the following is the most likely underlying cause of this patient's current condition? A. Cushing syndrome B. Hereditary hemochromatosis C. Performance-enhancing substance use D. Reactive arthritis E. Rheumatoid arthritis

B. Eosinophilic esophagitis Eosinophilic esophagitis (EoE) usually presents as intermittent solid food dysphagia & most common affects younger men (20-30) with atopic conditions (asthma, allergies & eczema). Untreated disease can lead to fibrosis leading to esophageal stricture that result in progressive dysphagia & food impaction. Management includes dietary therapy (allergen avoidance, elimination diet), PPIs & topical glucocorticoids (Fluticasone, Budesonide). Other common symptoms include refractory gastroesophageal reflux & chest/upper abdominal pain. Endoscopic appearance includes furrowing; small whites exudates & multiple stacked, ringlike esophageal indentations (trachealization of the esophagus). Dx is confirmed with esophageal biopsy demonstrating > 15 eosinophils per high-power field.

29-year-old man comes to the office due to difficulty swallowing for the past 2 years. Pork, chicken & steak occasionally "get stuck" in his mid-chest seconds after he swallows. These episodes occur intermittently but with increasing frequency. He has no trouble swallowing water to alleviate his symptoms, but the patient occasionally vomits to eject solid foods. The patient takes antihistamines for allergies & Ibuprofen for knee pain. Vital signs & PE are unremarkable. Endoscopy shows circular rings & thickened, linear furrowing of the esophagus. The lower esophageal sphincter opens spontaneously. Which of the following is the most likely diagnosis? A. Achalasia B. Eosinophilic esophagitis C. Esophageal cancer D. Herpes esophagitis E. Pill esophagitis

A. Low Na, High K, High Cl Primary adrenal insufficiency (Addison Disease) is most commonly caused by autoimmune adrenalitis. Due to pathology within adrenal glands, ACTH stimulation does not cause an increase in cortisol level. Electrolyte abnormalities include hyponatremia, hyperkalemia, hyperchloremia & nonanion gap metabolic acidosis.

30-year-old woman is evaluated for 3 months of progressive fatigue, decreased appetite & 10-lb weight loss. The patient has DM1 & has noticed decreased insulin requirements over this time. She has no other medical conditions. Physical exam shows a generalized increase in pigmentation of the skin, especially involving the palmar creases. Measurement of serum cortisol before & after administration of exogenous adrenocorticotropic hormone (ACTH) shows no difference in levels. Which of the following changes in serum lab values is most likely present in this patient? A. Low Na, High K, High Cl B. Low Na, Low K, Low Cl C. Normal Na, High K, normal Cl D. Normal Na, Low K, High Cl E. Normal Na, Low K, Low Cl

E. Transmural bowel inflammation Crohn's disease can involve any component of the GI tract from the mouth to the anus, such as aphthous ulcers & perianal skin tags & fistulas. Biopsy typically reveals focal ulceration with transmural inflammation

34-year-old man presents with foul-smelling anal discharge & perianal discomfort for the past several weeks. The patient has recurrent anal fissures & uses stool softeners & a topical analgesic. He also has occasional caked sores & recurrent abdominal pain & diarrhea. The patient has not traveled since a trip to South America 1 year ago. Temp: 38C (100.4F). Tenderness is present in the RLQ on deep palpation. Perianal exam shows a large posterior skin tag. A fistula anterolateral to the anus is draining whitish material. Further evaluation of this patient is most likely to reveal which of the following? A. Colonic ulcers containing protozoal cysts B. Diffuse colitis with no skip areas C. Lymph nodes with caseating granulomas D. Segmental inflammation of the mesenteric arteries E. Transmural bowel inflammation

E. Send stool for microscopy, electrolytes & fat content The eval & management of chronic diarrhea involves a comprehensive Hx (clear description of stool characteristics, duration & timing of symptoms), basic serum analysis & importantly, stool analysis.

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, & often foul-smelling. He also reports excessive flatulence, occasional nausea & abdominal cramping & has lost 4.5kg (9.9lbs). He has no prior medical conditions & has had no recent travel. He consumes a balanced diet & notes no specific association of diarrhea to food Vital signs are normal. Weight is 63.5kg (140lb). The abdomen is soft, non distended & nontender with no organomegaly. Bowel sounds are increased. Rectal exam shows no masses or tenderness & an empty rectal vault. Stool occult blood testing is negative. Samples for blood count, ESR, TSH & serum electrolytes are obtained. Which of the following additional interventions is most appropriate in management of this patient diarrhea? A. Advise a trial of lactose-free diet B. Arrange for GI endoscopy C. Obtain CT scan of the abdomen & pelvis D. Recommend symptomatic treatment with an anti motility agent E. Send stool for microscopy, electrolytes & fat content

D. Lateral neck XR Epiglottits should be suspected in patients with sore throat, hoarseness, stridor, pooled oral secretions & drooling. Risk factors include DM, obesity & preceding URIs. The diagnosis can be confirmed (in those with stable status) using lateral neck XR showing "thumb-print sign"

40-year-old man comes to the clinic due to runny nose, cough & sore throat. He began having rhinorrhea 5 days ago & subsequently developed a cough that is worse at night. The patient has been taking OTC cough medication, but it has not improved his symptoms. 3 days ago, he developed a sore throat, which he attributes to frequent coughing. Today, his throat is more painful & he has been having difficulty swallowing liquids. The patient has DM2, for which he takes several meds for glycemic control. Temp is 37.9C (100.2F); BP is 148/90; HR is 110/min, RR are 22/min. BMI is 35kg/m2. Pulse ox shows 99% on room air. The patient winces when swallowing. Exam shows pooling of oral secretions & several dental carries. The posterior oropharynx appears mildly erythematous due to postnasal drip. The anterior neck is soft but tender to palpation. Lung exam reveals faint stridor with no crackles or rhonchi. Which of the following is the best next step for establishing a diagnosis in this patient? A. Chest XR B. Diptheria PCR C. Group A Strep Rapid Antigen D. Lateral neck XR E. Sputum gram stain & culture

B. Measure serum TSH & FSH Vasomotor symptoms, insomnia & irregular menses could be due to hyperthyroidism or menopause in middle-age women. Serum TSH & FSH levels should be measured in patients < 45 with these symptoms. Menopause is defined as absent menses for 12 months. In women >45 with menopausal symptoms, no lab eval is indicated but in women <45 with menopausal symptoms (like this patient) require a serum FSH level to evaluate for other causes of amenorrhea (primary ovarian insufficiency) & a serum TSH to evaluate for thyroid disease. Vaginal rugae = structures of the vagina that are transverse ridged formed out of the supporting tissues & vaginal epithelium - minimal rugation indicates vaginal atrophy which is a symptom of menopause

41-year-old woman comes to the office due to night sweats & insomnia. For the past month, she has awakened completely soaked with perspiration almost every night. She has also had difficulty concentrating at work. The patient has had irregular menstrual periods for the past 6 months. Temp is 36.7C (98F); BP is 140/90; HR is 80/min; RR are 14/min. Skin is normal & there is no periorbital edema. The thyroid is nonenlarged & nontender & there are no masses. The uterus is small & anteverted & the vagina has minimal rugation (ridges). There are no adnexal masses. Urine pregnancy test is negative. Which of the following is the best next step in management of this patient? A. Measure 24-hour urinary catecholamines B. Measure serum TSH & FSH C. Order urine toxicology screen D. Prescribe oral hormone replacement E. Provide reassurance & education about menopause

E. Syphilis Secondary syphilis is characterized by systemic symptoms (fever, malaise), widespread LAD (particularly epitrochlear) & a diffuse maculopapular rash that begins on the trunk & extends to the extremities, including the palms & soles (+/- oral lesions & condyloma latum) Diagnosis is made with serology (using both a treponemal & nontreponemal test). 1 IM dose of PCN G Benzathine is standard treatment.

42-year-old man comes to the office due to a week of subjective fear, sore throat, malaise, HA & skin rash. The rash began on his trunk 1 week ago & has no spread to his entire body. He has had no chest pain, SOB, diarrhea, or urethral d/c. He has had 3 new female sex partners over the last year. Temp is 37.2C (99F). Exam shows a full-body maculopapular rash, including the palms & soles, with no excoriations. Several raised, grey mucosal patches are seen in the mouth. Cervical, axillary, inguinal & epitrochlear LAD is present. HIV testing is negative. Which of the following is the most likely cause of this patient's symptoms? A. Bacterial endocarditis B. Disseminated gonococcal infection C. EPV infection D. Rocky Mountain spotted fever E. Syphilis

A. acute pancreatitis characterized by epigastric abdominal pain associated with nausea & vomiting. Alcohol abuse & gallstone disease are the m/c causes. Potential complications include pleural effusion, acute respiratory distress syndrome, ileum & renal failure

45-year-old man presents to ED with upper abdominal pain. He describes it as "nagging" & constant & rates at 6/10. The pain started 6 hours ago & was not relieved by OTC antacids. It gets somewhat better when he sits up & leans forward. Patient has had 2 episodes of vomiting since pain started. He smokes a pack of cigarettes daily. He drinks 4-6 cans of beer a day & several more on the weekends. Temp: 37.8C (100F), BP: 100/70, HR: 110/min, RR: 20/min. Abdominal exam shows mild epigastric tenderness without guarding or rebound. CXR shows a small left-sided pleural effusion. Which is the most likely diagnosis in this patient? A. acute pancreatitis B. intra-abdominal abscess C. mesenteric ischemia D. MI E. peptic ulcer perforation

E. Lisinopril ACE inhibitors & angiotensin receptor blockers (ARBs) are effective agents agents that can lower BP & slow progression of proteinuric chronic kidney disease, even in patients with serum creatinine concentrations up to 3mg/dL. With careful dietary instruction & monitoring, ACE inhibitor therapy is appropriate for many of these patients

50-year-old woman presents for a follow-up for chronic kidney disease diagnosed during routine lab work up. Her history, PE & screening lab findings did not indicate a course for her chronic kidney disease. A 24-hour urine showed 1.5g/day of proteinuria. A renal US revealed echogenic kidneys measuring about 9cm bilaterally without evidence of obstructive uropathy. She takes no medications. Her BP is 152/92 and previously recorded BP was 156/92. The PE is within normal limits. The patient's most recent lab results are as follows: Sodium: 140mEq/L Potassium: 4.4mEq/L Chloride: 104mEq/L Bicarb: 22mEq/L Creatinine: 1.7mEq/L Glucose: 100mg/dL Which of the following would be the best therapeutic agent for this patient? A. Amlodipine B. Carvedilol C. Clonidine D. Hydrocholothiazide E. Lisinopril

A. Advanced HIV infection Patients with HIV have much higher rates of lymphoma than the general population. Many cases are due to underlying EPV.

52-year-old man comes to the office due to progressively enlarging neck mass, fatigue & weight loss over the past 2 months. PE shows enlarged, firm & nontender cervical lymph nodes. The patient also has enlarged tonsils, bilateral axillary LAD & splenomegaly. Excisions lymph node Bx is performed & reveals non-Hodgkin lymphoma that is positive for EPV. Which of the following is a risk factor for this patient's condition? A. Advanced HIV infection B. Aspirin & NSAID use C. Cigarette smoking D. Radiation exposure E. Socioeconomic status

A. Ankle-brachial index Peripheral artery disease should be suspected in patients with risk factors for atherosclerosis who have an extremity with shiny, hairless skin, particularly if a non healing ulcer is present. The ankle-brachial index is a helpful noninvasive assessment for peripheral artery disease.

53-year-old obese man comes to the office due to frequent discomfort in his R foot that limits his daily activities. His PMH is significant for DM2, HTN & gout. He has been poorly compliant with is prescribed med regimen. The patient has a 20 pack-year smoking Hx & drinks 2-3 alcoholic beverages per week. BP is 128/76 & HR is 82/min. On PE, the skin of the right foot is thin, shiny & devoid of hair. There is a small shallow ulcer on the outer aspect of the R great toe. Which of the following is most likely to diagnose the cause of this patient's foot discomfort? A. Ankle-brachial index B. Electromyography C. Serum uric acid level D. Skin Bx E. Ulcer swab for Gram stain & culture

E. CML is caused by translocation of chromosomes 9 & 22 that produces the BCRIABL gene (Philadelphia chromosome), resulting in unregulated tyrosine kinase activity. Tyrosine kinase inhibitors such as imantinib are the initial treatment of choice in almost all patients

54-year old man has experienced fatigue for the last 6 months. He has no significant med Hx. Exam shows mild splenomegaly. Cytogenic testing reveals a BRCIABL translocation consistent with chronic myeloid leukemia. Which of the following is the best initial treatment option for this patient? A. alkylating agent B. bone marrow transplantation C. leukapheresis D. therapeutic phlebotomy E. tyrosine kinase inhibitor

B. Canagliflozin Metformin is the recommended first-line medication for most patients with DM2. Options for add-on therapy in patients with established CV disease include glucagon-like peptide-1 agonists & sodium-glucose cotransporter 2 (SGLT2) inhibitors. SGLT2 inhibitors are associated with decreased BP, decreased risk of heart failure & CV events & minor weight loss

54-year-old presents for a diabetes follow-up. The patient has a 5-year history of DM2, which is treated with Metformin. He also has HTN & had coronary stunting for a MI 1 month ago. BP: 130/74; HR: 68/min; BMI: 30kg/mm2. PE is normal. A serum creatinine level is 0.8mg/dL & hemoglobin A1c is 7.8%. Which of the following meds has an added protective effect on this patient's cardiac & weight-related comorbidities? A. Basal insulin B. Canagliflozin C. Glipizide D. Pioglitazone E. Repaglinide

A. fluid accumulation in the alveolar spaces ARDS is caused by injury of the pulmonary epithelium &/or endothelium & occurs most often due sepsis or pneumonia. ARDS causes capillary damage & leakage of protein-rich fluid into the alveoli.

56-year old woman is brought to the ED due to 3 days of dysuria & back pain. Temp is 39.2C (102.6F), BP: 70/40, HR: 130/min, RR: 28/min. The patient is confused and has suprapubic & costovertebral angle tenderness. The skin is diffusely warm but there are no rashes or edema. CBC demonstrates leukocytosis with increased neutrophils. UA is positive for leukocyte esterase & nitrites & microscope shows numerous bacteria. Several hours later, the patient becomes increasingly hypoxic & requires mechanical ventilation. This patient's respiratory Sx are most likely due to which of the following pathologic conditions? A. fluid accumulation in the alveolar spaces B. necrotizing inflammation with pulmonary hemorrhage C. scattered noncaseating granulomas D. thick mucus plugs in the bronchi & bronchioles E. wedge-shaped areas of hemorrhagic necrosis

D. start the patient on oral Valacyclovir

56-year-old woman presents with a low grade fever & rash. 2 days ago patient had stabbing pain in left torso & became itchy& red over the past day. What is the next step in management? A. order a varicella-zoster PCR from a skin lesion B. prescribe topical acyclovir cream C. prescribe topical clobetasol propionate ointment D. start on oral Valacyclovir E. swab a lesion for viral culture

B. Gastric adenocarcinoma Acanthosis nigricans is characterized by pigmented thickened plaques that arise in flexural regions such as the axillae or back of the neck. It is usually associated with benign conditions such as insulin resistance or obesity. However, sudden appearance or rapid spread can signal the presence of malignancy within the GI tract or lungs

57-year-old man present with complaint of poor appetite & weight loss. His symptoms have been present for 6 weeks & are progressively worsening. He has no associated blurry vision, polydypsia or polyuria. The patient has smoked 2-packs of cigarettes daily for 30 years & drinks 3-5 alcoholic drinks daily. VS are normal. On PE, the patient is thin & has pale conjunctivae & a shiny tongue. Velvety, hyperpigmented plaques on the skin are noted in the axillae & neck. There is mid tenderness to palpation in the epigastric region. The remainder of the abdomen is nontender. Lab studies show a moderate, hypochromic microcytic anemia & glucose level of 98mg/dL. Which of the following is the most likely diagnosis in this patient? A. Adrenal insufficiency B. Gastric adenocarcinoma C. Diabetes mellitus D. Tuberculosis E. Vitamin B12 deficiency

A. Foot imaging for osteomyelitis Osteomyelitis can arise in those with diabetic neuropathy and peripheral vascular disease without evidence of infection therefore foot imaging (XR, MRI) is generally recommended for all diabetic foot ulcers that are at least 1 of the following: - deep (exposed bone, positive probe-to-bone testing) - long-standing (present >7-14 days) - large (>2cm) - associated with elevated ESR/CRP - associated with adjacent soft tissue infection

58-year-old man presents due to an ulcer on the sole of the right foot fo 4 weeks. The ulcer has failed to heal despite wound care with moisture-retentive dressings & pressure offloading orthotic devices. The patient has had no right foot pain, redness, swelling, fever or chills. He has a 10-year history of DM complicated by diabetic neuropathy. PE shows a 3-cm ulcer under the 1st metatarsal head of the right foot; the wound has a clean base & no significant discharge. There is no surrounding erythema or areas of fluctuant or tenderness. Which of the following is the best next step in management of this patient' foot ulcer? A. Foot imaging for osteomyelitis B. Hyperbaric oxygen therapy C. Lower extremity angiography D. VItamin C & zinc supplementation E. Wound dressing with a topical ABX

C. Pramipexole patient has Idiopathic Parkinson Disease Deep brain stimulation is considered in patients who have medically refractory resting tremor, Levodopa-induced dyskinesia or significant motor fluctuations Donepezil is used to increase AcetylCoA levels in the frontal lobes of patients with dementia. This patient scored a 29/30 on the MMS, making dementia unlikely Propranolol is used to treat an essential tremor (worse with action) Trihexyphenidyl is used to treat idiopathic Parkinson disease induced resting tremor but does not that symptoms of bradykinesia and rigidity

58-year-old man presents due to tremor of his right hand. The patient first noticed the tremor 1 year ago & it has progressively worsened to the point that he has difficulty writing. Mini-Mental-State Exam score is 29/30. A low-frequency resting tremor is noted in the right hand. The tremor is exacerbated by mental distraction & becomes less prominent when the patient reaches for a pen. When the patient writes, his words become progressively smaller & illegible. Mild rigidity of the bilateral upper extremities & decreased arm swing during ambulation are present. Lab tests & MRI of brain are normal. What is the next best step in management of this patient? A. deep brain stimulation B. Donepezil C. Pramipexole D. Propranolol E. Trihexyphenidyl

A. Acyclovir Esophagitis is usually the result of a noninfectious process such as GERD. However, patients with impaired cell-mediated immunity (chemotherapy, post-transplantation, AIDS) are also at risk for esophageal infections. The leading causes are Candida, Cytomegalovirus & HSV. The classic HSV finding on a biopsy is multinucleated giant cells.

58-year-old woman comes to the office due to a week of pain with swallowing. Her symptoms have progressively worsened, & now she cannot eat comfortably. The patient has primary biliary cholangitis progressing to cirrhosis. She underwent a liver transplant 2 years ago & is on immunosuppressive therapy. Vital signs are normal. The patient has epigastric tenderness with no abdominal distention or guarding. Upper endoscopy shows several small esophageal ulcerations with distinct borders located in the middle & lower portions of the esophagus. A biopsy taken at the edge of an ulcer shows multinucleated giant cells. Which of the following is the most appropriate treatment for this patient? A. Acyclovir B. Azithromycin C. Fluconazole D. Omeprazole E. Tenofovir

B. Ciprofloxacin Acute bacterial prostatitis is characterized by fever, dysuria & a swollen, tender prostate. Most cases are caused by coliform organisms (E. coli). Urine culture is required to define the underlying pathogen, but 6 weeks of therapy with Trimethoprim-Sulfamethoxazole (Bactrim) or a Fluoroquinolone is generally required to ensure eradication.

59-year-old man comes to the ED due to lower abdominal pain. The patient has had 2 days of fever, chills, dysuria & pelvic pain; this morning, he was unable to pass any urine. He has never had similar symptoms before. Temp is 39C (102.2F). Suprapubic fullness & tenderness present. DRE shows an edematous & exquisitely tender prostate. The external genitalia are normal. A suprapubic catheter is placed, which drains 800mL of urine. Lab exam shows: CBC- leukocytes: 17,800/mm3 (normal: Serum Chemistry- creatinine: 1.7 mg/dL (normal: 0.6-1.2) UA- leukocyte esterase: positive nitrites: positive WBC: 10-20/hpf Which of the following is the most appropriate med for this patient? A. Azithromycin B. Ciprofloxacin C. Clindamycin D. Doxycycline E. Nitrofurantoin

A. Bladder cancer This patient's smoking history, subacute voiding symptoms (dysuria, urgency, frequency), suprapubic pain & hematuria likely indicated bladder cancer. Most cases arise in adults > 40y/o who have chronic exposure to chemical carcinogens such as cigarette smoke or industrial chemicals (dyes, paints, rubber). Common manifestations include: Hematuria: tumors are fed by new, friable blood vessels that often bleed into the urinary tract. Hematuria is commonly painless & tends to occur throughout micturition & may be gross (visible) or microscopic. Voiding Symptoms: tumors often protrude into the bladder & reduce bladder volume or cause detrusor overactivity, leading to subacute/chronic voiding symptoms such as dysuria, frequency & urgency. Although bladder cancer is often associated with painless hematuria, some patients with bladder cancer have dysuria as part of their voiding symptoms. Suprapubic pain: this usually indicates a more advanced tumor that has penetrated the muscle & invaded the surrounding soft tissue or nerves.

59-year-old man comes to the office due to a month of dysuria, urinary urgency & frequency. Over the past few days, he has also had dull, non radiating suprapubic pain. The patient has smoked a pack of cigarettes daily for 40 years. Vital signs are normal. Mild suprapubic tenderness is present. Rectal exam reveals a smooth, firm enlargement of the prostate with no tenderness, induration or asymmetry. Lab results are as follows: UA- Specific gravity: 1.016 Protein: none Blood: moderate Leukocyte esterase: negative Nitrites: negative Bacteria: none WBC: 1-2/hpf RBC: 20-30/hpf Casts: none Which of the following is the most likely explanation for this patient's symptoms? A. Bladder cancer B. Bladder infection C. Chronic bacterial prostatitis D. Prostate cancer E. Urethral stricture

D. Hyporeflexia Guillain-Barre syndrome is characterized by rapidly progressive symmetric weakness (usually beginning in the legs) & diminished or absent DTRs. Patients also frequently have paresthesias, autonomic dysfunction & respiratory muscle weakness.

62-year-old man comes to the ED due to SOB & weakness. Over the past 4 days, he has had progressive difficulty walking due to bilateral leg weakness & has stumbled several times. The patient has also had tingling & numbness of his hands & feet as well as palpitations & light-headedness when he stands suddenly. For the past day, his hands have been weak, & he has had difficulty swallowing. The patient has had no fever, chest or abdominal pain or bowel/bladder dysfunction. Which of the following is most expected on physical exam of this patient? A. Bilateral papilledema B. Cogwheel rigidity C. Extensor plantar response D. Hyporeflexia E. Sensory level

B. Atropine Acute angle-closure glaucoma results from an acute rise in IOP due to impaired aqueous humor drainage in the anterior chamber, necessitating an emergency ophthalmology referral. Meds that may precipitate an attack include asthma meds, decongestants & mydriatics. Mydriatics such as Atropine are contraindicated during an acute attack.

62-year-old woman is brought to the hospital due to severe, right-sided HA, nausea & eye pain. The patient was fixing a light bulb when she saddening felt pain in her right eye. Over the next few minutes, she developed loss of vision, photophobia & redness in the same eye. The patient has not experienced any trauma. On PE, she appears to be in intense pain. The right eye is red, has conjunctival flushing & feels hard on palpation. The right pupil is mid-dilated & nonreactive to light. Visual activity of the eye is 20/200. Which of the following meds should be avoided in this patient? A. Acetazolamide B. Atropine C. Mannitol D. Pilocarpine E. Timolol

C. protamine sulfate protamine sulfate is used as a reversal agent for heparin. Vitamin K & fresh frozen plasma can be used to reverse warfarin effects.

63-year-old man is brought to hospital due to sudden-onset chest pain & dyspnea. The patient has glioblastoma multiforme for which he has been undergoing radiation treatment. Temp 36.1C (97F), BP: 110/80, HR: 118/min & RR: 26/min. Pulse ox shows 90% on room air. CT pulmonary angiogram reveals a left-sided pulmonary embolism & he started on continuous unfractionated heparin infusion. Several hours later, the patient begins to experience severe HA & quickly becomes unconscious. CT scan of the head reveals bleeding into the tumor. After stopping the heparin infusion, administration of which of the following is indicated for immediate anticoagulant reversal? A. fresh frozen plasma B. platelets C. protamine sulfate D. prothrombin complex concentrate E. Vitamin K

C. Legionella pneumophilia Legionella pneumophilia has a propensity to affect older adults with chronic lung disease who smoke. It causes Legionnaires' disease which is characterized by high fever, diarrhea, headache & confusion. L pneumonphilia is a gram-negative rod that is typically not detected on a Gram stain.

63-year-old man is brought to the ED after recent onset of high fever, confusion, headache, watery diarrhea & cough. The patient has been smoking 2 packs of cigarettes daily for more than 30 years & has been diagnosed with chronic bronchitis. He lives in a nursing home & several other residents have similar symptoms. Temp: 40.1C (104F); BP: 100/70; HR: 91/min; RR: 28/min. Sputum gram staining reveals numerous neutrophils but no bacteria. Which of the following is the most likely cause of this patient's clinical presentation? A. Coccidioides immitis B. Klebsiella pneumoniae C. Legionella pneumophilia D. Mycobacterium avium E. Mycoplasma pneumoniae

B. E. coli this patient with unilateral testicular pain & palpable swelling of the epididymis likely has an acute epididymitis acute epididymitis typically manifests with unilateral testicular pain & epididymal swelling. Those age > 35 usually develop epididymitis due to bacteriuria from bladder outlet obstruction; ascending coliform organisms such as E. coli are the most likely pathogens. Patients < 35 are more likely to have epididymitis due to sexually transmitted infections with Chlamydia trachoma's or Neisseria gonorrhoeae.

63-year-old man presents due to 2 days of increasing scrotal pain. Pain is worse with touch or mov't & is not relieved by Ibuprofen. He also complains of mild burning on urination & increased urinary frequency. His medical Hx includes BPH. The patient is married & sexually active with his wife. Temp is 38.1C (100.8F). PE shows scrotal mass in the left scrotum this is mildly erythematous. Cremasteric reflex intact. No urethral discharge present. Which is the most likely cause of the patient's current condition? A. Chlamydia trochomatis B. E. coli C. mumps virus D. Neisseria gonorrhoeae E. Staph. aureus

E. supraclavicular this patient has progressive epigastric pain (only partially relieved with antacids), weightless, GI bleeding most likely has gastric cancer. intraabdominal malignancies can metastasize via lymphatic Chanels which travel along side organ's respective blood supply. The thoracic duct receives all lymphatic drainage from the abdominal viscera & lymph from this duct is sampled by the left supraclavicular lymph node. Enlargement of this node (Virchow's node) may signify an occult abdominal malignancy.

64-year old man presents with 6 months of progressive epigastric pain that is worsened by food ingestion. The patient also reports a 10kg (22lb) weight loss within this & several episodes of vomiting in the last 2 weeks. He has been taking OTC omeprazole without any relief. PE shows epigastric fullness. Fecal occult blood test is positive. Gastric outlet obstruction due to malignancy is suspected. Bx of which of the following lymph node structures is most likely to show deposits of malignant cells? A. axillary B. deep cervical C. epitrochlear D. inguinal E. supraclavicular

B. CT of the abdomen This patient has some features of major depression (low mood, weight loss) & anxiety. However, given his age, smoking history, jaundice & recent diagnosis of DM (despite lack of obesity), this presentation is concerning for pancreatic cancer. Depression, weight loss & new-onset DM may occur as early manifestations of pancreatic cancer. CT of the abdomen is indicated as part of the initial diagnostic eval.

64-year-old man comes to the office for eval of low mood began 2 months ago. The patient has been feeling sad & anxious for no reason, but feels like something bad is going to happen. The patient has been skipping lunch due to a decreased appetite & has lost 9kg (20lbs) in the last few months. He continues to enjoy reading & has no difficulty falling or remaining asleep. The patient formerly smoked tobacco, with a 20-pack-year history. Medical history includes recently diagnosed diabetes mellitus. Vital signs are normal. BMI is 19kg/m2. The patient is thin, appears anxious & is slightly jaundice. He reports not suicidal ideation, hallucinations or delusions. TSH level is 4.0 uU/mL (normal: 0.5-5.0). Which of the following is the best next step in management of this patient? A. Brain MRI B. CT of the abdomen C. Electroconvulsive therapy D. Mirtazapine E. Paroxetine

C. degenerative joint disease patient has slowly progressive pain relieved by rest indicating osteoarthritis (degenerative joint disease) of the hip

64-year-old man presents due to increasing pain in his right groin for the past several months. The pain increases with activity, is relieved with rest and sometimes radiates to upper thigh. The patient denies trauma or falls. VS are nml. Exam shows pain on passive internal rotation of the right hip but no focal tenderness on palpation of the groin & hip region. Reflexes are 2+ in lower extremities & no sensory deficits noted. Muscle bulk, tone & strength normal. Posterior tibial pulses 2+ bilaterally. What is the cause of this patient's hip pain? A. aortoilliac vascular occlusion B. cutaneous nerve compression C. degenerative joint disease D. inflammation of the trochanteric bursa E. referred pain from lumbosacral spine

A. Being hospitalized & taking ABX for pneumonia ABX disrupt the normal intestinal flora, which can allow overgrowth of Clostridioides (Clostridium) difficile, an anaerobic, spore-forming bacillus. C. diff produces toxins that penetrate colonic epithelial cells, leading to watery diarrhea, abdominal cramping & colitis. The present of pseudomembranes (white-yellow plaques on colonic mucosa) is tightly suggestive of C. diff infection.

65-year-old man comes to the ED due to abdominal pain & diarrhea. 3 weeks ago, he drove from Texas to Mexico for a family vacation. Temp is 38.3C (100.9F), BP is 115/70 and HR is 98/min. Abdominal exam shows mild, generalized tenderness with no rebound tenderness or guarding. Leukocyte count is 14,000/mm3. Sigmoidoscopy demonstrates white-yellow plaques on the colonic mucous, findings consistent with pseudomembranes. Further questioning regarding this patient's trip to Mexico is most likely to reveal what? A. Being hospitalized & taking ABX for pneumonia B. Consuming shellfish from the hotel buffet C. Drinking unpurified tap water on several occasions D. Eating undercooked pork at a resort BBQ E. Preparing home-canned foods to consume during the trip

C. Diabetic nephropathy Patients with diabetes for > 10 years can develop diabetic nephropathy. Risk factors include poor glycemic control, elevated blood pressure, smoking & increasing age. Clinical findings include mild-to-moderate proteinuria & chronic kidney disease with elevated creatinine.

65-year-old man presents due to straining during urination & a weak urinary stream for the past 6 months. He wakes up on average twice a night to urinate. The patient was diagnosed with DM2 14 years ago & takes Metformin & Insulin. His other medical conditions include hypertension, gout & moderately decreased visual acuity. BP: 160/100; HR: 70/min. BMI: 30kg/m2. Exam shows trae bilateral edema. Post-void bladder residual volume is normal. UA shows 3+ protein (900mg/dL) & no blood. Serum clearance level is 2.1mg/dL. Which of the following is most likely cause of this patient's chronic kidney disease? A. Ascending infection B. Cystic kidney disease C. Diabetic nephropathy D. Membranous nephropathy E. Obstructive uropathy

C. Increased peripheral conversion of testosterone to estrogen 5-alpha reductase inhibitors (Finasteride, Dutasteride) are used in treatment of BPH. These meds block the conversion of testosterone to dihydrostestosterone; the excess of testosterone is then available for conversion to estrogens by aromatase, which can lead to gynecomastia.

65-year-old man with BPH comes to the office for a follow-up appointment. He has a Hx of obstructive urinary symptoms & was on Tamsulosin. Tamsulosin caused symptomatic hypotension & Finasteride was prescribed 8 months ago. Since the med change, the patient has had improvement in his urinary symptoms, however he has noticed an increase in the size of his breasts. Glandular tissue, approximately 2cm in diameter, is palpated under the nipples & is mildly tender to palpation. There is no nipple d/c, breast asymmetry or rash. This patient's breast findings are most likely due to which of the following effects? A. Decreased testicular production of testosterone B. Displacement of estrogen from sex hormone-binding globulin C. Increased peripheral conversion of testosterone to estrogen D. Increased prolactin production E. Increased testosterone receptor inhibition

B. excessive calcium carbonate intake

65-year-old woman present for a followup. 2 months ago patient was found to have a low bone mineral density on screening DXA. Her serum calcium & vitamin D levels were WNL & weekly Alendronate therapy was prescribed. After starting the bisphosphonates, patient had burning epigastric discomfort for which she takes chlorthalidone. BP: 110/66, HR: 88/min. PE is normal. Serum creatinine was 0.8mg/dL 2 months ago & 1.7mg/dL today. Serum calcium is 12.8mg/dL today. What is the most likely cause of this patient's hypercalcemia? A. bisphosphonate-induced osteonecrosis B. excessive calcium carbonate intake C. increased release of PTH D. increased renal activation of vitamin D E. renal tubular effect of thiazide diuretic

C. Ischemic optic neuropathy giant cell arteritis (GCA) is characterized by granulomatous inflammation of the media, with fragmentation of the internal elastic laminate of medium & small branches of the carotid artery. Anterior ischemic optic neuropathy is a severe complication of GCA resulting in irreversible blindness, & patients with suspected GCA require immediate glucocorticoid therapy

67-year-old man comes to the office with a persistent headache & pain in the jaw when chewing food. For the past 2 months, he has been unable to eat "tough foods like steak b/c the pain makes it take too long to chew them." The patient has hypertension, DM2 & hyperlipidemia. BP: 130/70; HR: 76/min & regular. PE is unremarkable. The patient is immediately started on appropriate therapy & an arterial biopsy is performed. Histopathy shows multinuclear giant cells & internal elastic membranous fragmentation. Prompt institution of therapy in this patient most likely reduces the risk of which of the following complications? A. Glomerulonephritis B. Hepatic necrosis C. Ischemic optic neuropathy D. MI E. Pulmonary hemorrhage

B. Chronic hyperglycemia-induced microvascular injury Chronic hyperglycemia in patients with DM can leaded to increased permeability & arteriolar obstruction in retinal vessels. The resulting ischemia stimulates production of vascular endothelial growth factor & other angiogenic factors, leading to neovascularization (proliferative diabetic retinopathy). Complications include retinal hemorrhage, retinal detachment & vision loss.

68-year-old woman is evaluated for vision impairment. The patient has a decrease in both distant & near vision & has had occasional floaters. She has had no pain or redness in her eyes, HA, focal weakness or sensory loss. Medical Hx is notable for DM2, HTN & CKD. BP is 138/84, HR is 76/min. The pupils are equal & reactive to light bilaterally. Anterior chambers are clear & there are no opacities of the cornea or lens. Funduscopic exam reveals scattered retinal micro aneurysms, dot-and-blot hemorrhages & cotton-wool spots as well as new blood vessel formation. Which of the following contributed most to the pathogenesis of this patient's current ocular condition? A. Age-related degeneration of retinal pigment epithelium B. Chronic hyperglycemia-induced microvascular injury C. Ganglion cells death due to to high IOP D. Retinal artery occlusion from atherosclerotic disease E. Vascular injury from increased intraluminal pressure

E. lactated ringer soln the initial management of septic shock requires rapid fluid resuscitation to replace intravascular volume & restore adequate end-organ perfusion. The is best accomplished with IV bolus of isotonic crystalloid in the form of 0.9% (normal) saline or lactated ringer soln

68-year-old woman with COPD is brought to ED due to worsening fever, cough, & confusion. The patient has had a "cold & congestion" since last week, which initially improved but she began feeling worse again 3 days ago & is now eating poorly. Temp is 39.4C (102.9F), BP: 74/46, HR: 128/min, RR: 30/min. O2 sat is 94% on 2L/min. On PE the patient is lethargic with dry mucous membranes. Lung exam reveals dullness to percussion & crackles at the right base. CXR shows a right lower lobe consolidation. IV access is established. IV of which of the following is the best next step in management? A. 0.45% saline B. 3% saline C. 5% dextrose in 0.45% saline D. albumin soln E. Lactated Ringer soln

D. Vitamin B12 level The initial workup of suspected dementia should include neuropsychological testing (Montreal Cognitive Assessment), selected lab tests (CBC, CMP, TSH, B12) & neuroimaging (MRI). Patients in specific risk groups may warrant additional targeted testing.

69-year-old woman is brought to the office by her husband due to forgetfulness. The patient is a retired law professor who taught classes until 2 years ago when she began to have difficulty remembering lessons plans. Since then, her memory has worsened, and she has gotten lost during her normal neighborhood walk on more than 1 occasion. Her husband has taken over all cooking & cleaning; moreover, the patient is unable to drive or use public transportation on her own. Vital signs are normal. She scores a 22/30 on Montreal Cognitive Assessment (normal: >26). There are no focal neurologic deficits. Which of the following is the best next step in evaluation of this patient? A. Cerebrospinal fluid testing B. Electroencephalogram C. No additional testing indicated D. Vitamin B12 level E. Vitamin D level

D. Parkinson disease dementia Characterized by executive & visuospatial dysfunction with relatively mild memory impairment at first. PDD may be distringuished from dementia with Lewy bodies by the timing of symptom onset; if Parkinsonism predates cognitive impairment by > 1 year, PDD should be diagnosed.

74-year-old man is brought to the office by his wife due to a change in behavior. Over the last year, the patient has had difficulty recognizing his grandchildren & has gotten lost in his local grocery store more than once. He enjoys playing Sudoku but has had increasing difficulty completing the puzzles. He sometimes sees animals in the house despite the couple not owning any. The patient has not seen a doctor in > 20 years & takes no meds. His wife says that he started "slowing down" and developed stiffness & a hand tremor that started approximately 4 years ago, preceding his current behavioral symptoms. Exam shows intact cranial nerves & pinprick & light touch sensations. There is rigidity in the bilateral upper & lower extremities that is worse on the left. Tremor is present in both hands at rest & is worse in the left hand. Movements & speech are slowed. Gait is unsteady & marked by a shortened stride. Which of the following is the most likely diagnosis? A. Alzheimer disease B. Dementia with Lewy bodies C. Normal pressure hydrocephalus D. Parkinson disease dementia E. Vascular dementia

C. Metoprolol anticoagulation in addition to rate &/or rhythm control are the accepted treatments for atrial fibrillation. In the presence of tachycardia, beta-adrenergic antagonists or non-dihydropyridine calcium channel blockers can be used to rapidly control the heart rate.

76-year-old man presents to office due to increased fatigue over the last 2 months. His exercise tolerance has also decreased. He has not had any chest pain, N/V, dizziness or syncope. The patient's other medical conditions include HTN & hyperlipidemia. BP: 124/79. On exam his lungs are CTA & a short mid systolic murmur is heard over the right upper sternal border. His ECG shows atrial fibrillation. Which is the best initial medical treatment for this patient? A. Quinidine B. Clonidine C. Metoprolol D. HCTZ E. Amlodipine

E. Thrombocytopenia Disseminated intravascular coagulation (DIC) typically presents with signs of bleeding (oozing from venipuncture sites) in the setting of sepsis, malignancy or severe trauma. Widespread activation of the coagulation cascade leads to the formation of IV microthrombi, which consumes coagulation factors (prolonged PT/PTT), platelets (thrombocytopenia) & fibrinogen. Subsequent fibrinolysis increases D-dimer

78-year-old resident of an extended care facility is brought to the ED due to lethargy, fevers & poor oral intake for the last day. Temp: 39C (102F); BP: 70/40; HR: 120/min & regular. On exam, the patient is lethargic but arousable. His extremities are warm. A Foley catheter is inserted into the bladder & drains 500mL of cloudy urine consistent with UTI. 5 hours after admission, the patient begins to bleed from the nose & venipuncture sites & the Foley catheter begins to drain blood-tinged urine. Which of the following lab findings would most likely to be seen in this patient? A. Increased fibrinogen B. Normal D-dimer C. Normal PTT D. Normal PT E. Thrombocytopenia

B. Chronic mesenteric ischemia This patient with a Hx of vascular disease most likely has chronic mesenteric ischemia, which commonly presents with cramps, postprandial epigastric pain, food aversion & weight loss. PE may show signs of malnutrition, as well as an abdominal bruit in approximately 50% of patients, but otherwise is unremarkable. Diagnosis is with CT angiography. Treatment involves risk reduction (tobacco cessation), nutritional support & revascularization.

83-year-old woman comes to the office due to a yearlong Hx of progressively severe, cramps abdominal pain that occurs immediately after she eats. The pain is diffuse but more pronounced in the epigastric area & is associated with frequent bloating & occasional diarrhea. The patient has had a 15-kg (33lb) weight loss over the past year. She has lost her appetite since the pain began. The patient has HTN, DM2, hypercholesterolemia, peripheral vascular disease & coronary artery disease. 3 years ago, she had an inferior wall myocardial infarction. BP is 140/92. BMI is 24kg/mm2. The abdomen is soft, nontender & non distended. Bowel sounds are present. Abdominal XR is normal. Which of the following is the most likely cause of this patient's presentation? A. Biliary colic B. Chronic mesenteric ischemia C. Chronic pancreatitis D. Crohn disease E. Irritable bowel syndrome