Cardio/GI PA Easy

A transthoracic echocardiogram reveals significant aortic stenosis secondary to congenital bicuspid aortic valve, left ventricular hypertrophy, and normal left ventricular systolic function. Which of the following is the most appropriate next step in management?

A transthoracic echocardiogram reveals significant aortic stenosis secondary to congenital bicuspid aortic valve, left ventricular hypertrophy, and normal left ventricular systolic function. Which of the following is the most appropriate next step in management?

Administration of a drug that inhibits acetylcholinesterase would most likely lead to which of the following?

Acetylcholinesterase is the enzyme responsible for metabolizing acetylcholine, which is the major neurotransmitter released from postganglionic neurons of the parasympathetic nervous system. Inhibition of acetylcholinesterase increases the level of acetylcholine at target tissues and can thereby create parasympathomimetic effects. These would include bronchoconstriction, increased lacrimation, increased salivation, bradycardia, and increased gastric juice secretion.

A 54-year-old man with a history of chronic alcohol abuse presents to the emergency department with complaints of a subjective fever and severe epigastric pain radiating to the back. The pain has been present for the past 8 hours and is associated with nausea and vomiting, which has not relieved the pain. Laboratory data reveal a WBC of 14,000/mm 3 and a serum amylase of 500 U/L (reference range 0-286 U/L). Plain films of the abdomen were unremarkable. Which of the following is the most likely diagnosis?

Acute pancreatitis typically presents with severe, steady midepigastric abdominal pain that radiates through to the back; pain is associated with fever, nausea, and vomiting. The most common causes of acute pancreatitis are gallstones and alcohol. Laboratory studies will show elevated WBC and serum amylase levels. Amylase elevations are nonspecific and can be elevated with perforated ulcers and mesenteric ischemia. A perforated ulcer will show evidence of free air on plain film; mesenteric ischemia will not present with fever or an elevated WBC unless there is the presence of infarcted bowel at which point the patient would appear septic. Acute cholecystitis may be associated with elevations in amylase but they are typically only a modest increase

A 47-year-old female patient is diagnosed with a duodenal ulcer. She was determined to have H. pylori infection. Which of the following medications used to treat peptic ulcer disease is specifically used to eradicate H. pylori? A Omeprazole B Amoxicillin C Ranitidine D Lansoprazole E Misoprostol

Amoxicillin is an antibiotic that is specifically used to eradicate the H. pylori bacteria.

A 50-year-old woman presents with constipation and crampy abdominal pain for the past 3 months. She is also undergoing a divorce and has had a 15-lb weight loss in the past 3 months. You note mild tenderness to palpation in the left lower quadrant; no masses are noted. Rectal exam result is negative, but her stool tests positive for fecal occult blood. Which of the following is the most appropriate next step to evaluate her symptoms?,

Any symptomatic adult with a positive fecal occult blood test should undergo colonoscopy to rule out colorectal cancer.

A 70-year-old man with a history of hypertension, DM Type 2, and hyperlipidemia is seen for pre-operative evaluation prior to left knee replacement. On auscultation, a very soft high-frequency decrescendo early diastolic murmur is heard at the upper left sternal border. Utilizing isometric hand grip exercises, the murmur increases in intensity and can be heard radiating to the left sternal border and apex. Given the patient's physical exam findings, which of the following is the most likely diagnosis?

Aortic regurgitation/insufficiency Isometric hand grip exercises will increase the intensity of the murmur of aortic regurgitation, which is usually described as a high-frequency decrescendo early diastolic murmur that is heard best at the left upper sternal border or at the right upper sternal border. Radiation, if it occurs, is frequently to the lower left sternal border and the apex. Isometric hand exercises increase arterial and left ventricular pressure, which increases the flow across the aortic valve, thereby increasing the murmur's intensity. (Crawford et al., 2009, Chapter 1)

A 64-year-old African American female presents to the clinic for evaluation of her hypertension, which she has had for several years. In the past she had been taking hydrochlorothiazide and lisinopril, with little effect on her blood pressure management. At today's visit, she has no complaints and feels well. Her vitals show T m 96.6, P 85, R 18, BP 191/99. She has no jugular venous distention seen on the neck exam, her lungs are clear, and cardiac exam has a regular rate and rhythm without murmur or gallop. Her abdomen is soft, non-tender, and a bruit is appreciated at the mid-abdomen just a few centimeters below the epigastric region. There is no fullness or enlargement of the abdominal aorta on palpation. Based on the history and clinical findings, what is the most appropriate next test for this patient?

Based on the information of the presentation, the patient most likely has renal artery stenosis, which is causing uncontrolled hypertension. The most appropriate test for confirmation of this is a renal duplex ultrasound (C). This test will have a higher specificity and sensitivity than the other listed tests (A, B, D, and E), as well as determine flow.

An 84-year-old female is taking prednisone for the past year, secondary to a diagnosis of biopsy-confirmed giant cell arteritis. Her dose was tapered to 20 mg/day, but her symptoms returned several months ago and her dose was increased. In addition she is taking hydrochlorothiazide (HCTZ) for hypertension, but denies any other medications or medical problems. What treatment should you recommend to this patient at this time?

Before initiation of fosamax the patient should have a bone density scan to look for osteopenia/osteoporosis. In the meantime, calcium supplementation with vitamin D is warranted for prevention of osteoporosis. Simvastatin is not indicated, and naprosyn may increase risk of gastrointestinal bleeding with chronic prednisone.

In your family practice, you perform an ankle brachial index (ABI) on your 66-year-old diabetic who smokes with the results being 0.71 on the left and 0.68 on the right. Which of the following is the most appropriate next step?

Begin the patient on aspirin 81 mg and clopidogrel 75 mg daily.

A 65-year-old man presents to the emergency department with an acute ischemic stroke. His CT scan is normal. His blood pressure is 180/100 mm Hg. What is the most appropriate treatment for his hypertension?

Blood pressure is typically elevated at the time of presentation in acute ischemic stroke. It will decline without medication in the first few hours to days. Aggressively lowering blood pressure in an acute ischemic stroke may decrease the blood flow to the ischemic but salvageable brain tissue. This potentially salvageable brain tissue is referred to as the penumbra. Decreasing blood flow to the ischemic penumbra by acutely lowering blood pressure may result in eventual infarction of this brain tissue. Treatment of previously undiagnosed hypertension should be deferred for several days. Blood pressure should be treated if there are other indications, such as angina or heart failure. Control of blood pressure is appropriate in patients who are receiving tissue plasminogen activator (t-Pa) for their stroke. Blood pressure should be lowered cautiously to a systolic of less than 185 mm Hg and a diastolic of less than 110 mm Hg. This is thought to decrease the incidence of intracerebral hemorrhage in these patients.

A 36-year-old nurse states she will be traveling to Honduras for a medical mission and wants to ensure that she has adequate protection against hepatitis B. Which of the following laboratory values is consistent with immunity against hepatitis B from prior immunization?

C +anti-HBs

Which one of the following is a characteristic finding on computed tomography (CT) of the abdomen in a patient with acute diverticulitis?,

CT findings consistent with diverticulitis include soft tissue thickening of the pericolic fat (98%), diverticula, and thickening of the bowel wall. In immunosuppressed patients, findings may include intraperitoneal and extraperitoneal gases without fluid or abscess formation

During a hospitalization for acute exacerbation of COPD, troponin levels are drawn on a 62-year-old man with a history of hypertension, hyperlipidemia, and chronic tobacco use, and found to be elevated above the 99 th percentile of normal. Which of the following choices would qualify this patient for the most recent ACC/AHA consensus guideline's definition of myocardial infarction?

Choice A is the most appropriate choice, as troponin elevation may occur in the setting of patients who do not suffer from acute coronary syndrome. Therefore, the 2007 consensus guidelines recommended that the definition of myocardial infarction be applied to those patients who not only had troponin elevation above the 99 th percentile, but also met one of the following criteria: "ischemic symptoms, new left bundle branch block (not right bundle branch-block as in choice B), new ST and T-wave changes, new Q waves, or imaging evidence of a new loss of viable myocardium or new regional wall-motion abnormality." Choice C, J wave, is characteristic of patients with hypothermia. Choice D, pulmonary vascular congestion, is frequently noted on CXR of patients with congestive heart failure. Choice E, an elevated WBC count, is indicative of an infectious process. (Tintinalli et al., 2011, Chapter 52)

Examination of a female newborn demonstrating cyanosis after feeding reveals a systolic ejection click that is heard best at the third left intercostal space, and a short grade III/VI systolic ejection murmur that is heard best at the second left intercostal space. Given this patient's physical exam findings, which of the following is the most likely finding on an echocardiogram?

Choice A, pulmonic stenosis, is the most likely finding on echocardiogram, as severe pulmonic stenosis frequently presents with a newborn infant presenting with cyanosis after feeding, and a systolic ejection murmur heard best at the second left intercostal space

A 55-year-old woman with a history of hypertension and 2 vessel CABG presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that for the last 2 weeks she has also noticed palpitations. On physical examination, her vital signs are stable, with a normal physical exam. On EKG, she demonstrates atrial flutter with 2:1 AV block. Which of the following is the most appropriate next diagnostic study for this patient?

Choice A, transthoracic echocardiogram, is the most appropriate next diagnostic study in this patient with atrial flutter, as it can demonstrate the presence of valvular heart disease.

A 57-year-old woman with a history of rheumatic fever is seen complaining of dyspnea while vacuuming her apartment, which has been worsening over the last few months. On physical exam, a very soft systolic murmur is auscultated. With inspiration, the murmur increases, and is heard best at the left lower sternal border. A large and early v jugular venous wave is noted. Which of the following is the most likely finding on echocardiogram given this patient's physical exam findings?

Choice A, tricuspid regurgitation, is the most likely finding in a patient with a history of rheumatic fever who is presenting with a systolic murmur that increases with inspiration The murmur of tricuspid stenosis, however, is a diastolic murmur, which increases with inspiration, and is also heard best at the left lower sternal border Choice B, ventricular septal defect, would present with a harsh holosystolic murmur, heard best at the third and fourth left interspaces along the sternum. Choice C, an atrial septal defect, if large, could present with similar symptoms of exertional dyspnea secondary to a large shunt, but auscultation would reveal a moderately loud systolic ejection murmur heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow. Choice D, aortic stenosis, presents with a systolic ejection murmur heard best at the right upper sternal border, frequently radiating to the carotid arteries. The murmur of mitral stenosis, choice E, is also frequently associated with a history of rheumatic fever; however, it is heard best in the left lateral decubitus position, with the bell of the stethoscope at the apex

A 57-year-old woman with a history of rheumatic fever is seen complaining of dyspnea while vacuuming her apartment, which has been worsening over the last few months. On physical exam, jugular venous distension is appreciated. Auscultation of the chest reveals a possible opening snap, loud S 1 , and a very soft diastolic rumbling murmur is auscultated at the left lower sternal border. When the patient is placed in the left lateral decubitus position, the murmur is accentuated, and heard best at the apex. Both hepatomegaly and splenomegaly are noted. On transthoracic echocardiogram, which of the following findings is most likely to be seen in addition to mitral valve stenosis?

Choice A, tricuspid stenosis, is frequently seen in association with mitral valve stenosis in patients with a history of rheumatic heart disease (between 5% and 10% of the time). Both murmurs are similar in character, with the main difference that the murmur of tricuspid stenosis is heard best at the left lower sternal border, and the murmur of mitral stenosis is heard best in the left lateral decubitus position, with the bell at the apex. Because they are similar in nature, a high level of suspicion for tricuspid stenosis should be maintained, so that tricuspid stenosis is not overlooked. Tricuspid regurgitation may also be seen in association with tricuspid stenosis. Patients frequently present with signs and symptoms of right-sided heart failure, including hepatic congestion and splenomegaly.

A 55-year-old woman with a history of mitral stenosis, secondary to rheumatic heart disease, presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that recently she has also noticed palpitations. She also admits to lower extremity edema, which is new within the last week. Which of the following tachyarrhythmias is she most likely to demonstrate on EKG?

Choice B is correct. As patients with mitral stenosis age, and their mitral stenosis progresses to moderate or moderately severe mitral stenosis (most commonly after their fourth decade), the incidence of atrial arrhythmias—including premature atrial contractions, paroxysmal tachycardia, atrial flutter, and atrial fibrillation—increases.

A 70-year-old man, with a history of HTN and aortic valve replacement 3 months ago, presents with complaints of arthralgia, myalgia, anorexia, fatigue, and weight loss over the last month, with recent dyspnea on exertion and lower extremity edema. Vital signs are as follows: Temperature 38°C, BP 102/64, P 98, RR 20. On physical exam, a new high-pitched, blowing, decrescendo diastolic murmur is noted along the left lower sternal border. Two separate blood cultures are positive for S. aureus. Which of the following is the most appropriate next diagnostic study

Choice E, TEE or transesophageal echocardiogram, would be most useful in establishing a diagnosis of infective endocarditis, as a positive echocardiogram demonstrating presence of a vegetation would satisfy one of the Duke criteria's major criteria, as well as determine the extent of the prosthetic valvular dysfunction, if present. TEE is more sensitive than TTE, transthoracic echocardiogram, for detecting vegetations, so choice C is incorrect. C

A 65-year-old recent alcoholic comes to the emergency department with recent onset of dyspnea, with exertion, 3 pillow orthopnea, lower extremity edema, and palpitations, in which he describes his heart as racing. Which of the following is most likely to be the cause of his high-output congestive heart failure?

Choice E, beriberi, also known as thiamine deficiency, is common among alcoholics, and the only high-output cause of congestive heart failure among the choices offered. Other causes include severe anemia, thyrotoxicosis, and arteriovenouis shunting (for example, in hemodialysis patients). Choice A, mitral regurgitation, is a cause of excessive preload, leading to heart failure. Choice D, ruptured chordate tendinae associated with mitral regurgitation, would also be a cause of excessive preload, leading to heart failure. Choices B and C, aortic stenosis and uncontrolled hypertension, are causes in which too much afterload leads to heart failure.

A 50-year-old woman with a history of hypertension complains of chest tightness and dyspnea while walking up one flight of stairs. She recently experienced an episode of near-syncope while walking her dog. She denies a history of rheumatic fever. On auscultation, a crescendo-decrescendo systolic ejection murmur is heard at the upper right sternal border, radiating to the carotids bilaterally. Troponin levels are negative at 0, 3, and 6 hours. Her EKG demonstrates evidence of left ventricular hypertrophy. Given the patient's physical exam findings and recent symptoms, which of the following is the most appropriate next diagnostic study? A Chest X-ray B Transesophageal echocardiogram C Holter monitor D Treadmill exercise stress test E Transthoracic echocardiogram

Choice E, transthoracic echocardiogram, is a simple, sensitive, and non-invasive diagnostic tool which can evaluate for the presence of valvulopathy in a patient in this age group, who is likely demonstrating severe aortic stenosis secondary to a congenital bicuspid valve. Patients with a congenital bicuspid aortic valve typically develop symptoms once the valve leaflets have become calcified and thickened, secondary to the undue stress over many years on a structurally abnormal aortic valve. Choice A might be able to give evidence of cardiomegaly or calcification of heart valves, but would not be sensitive enough to detect the degree of valvulopathy, if present. Choice B, transesophageal echocardiogram, would give information regarding valvulopathy, but is a more invasive test; therefore, choice E is more appropriate.

A 68-year-old woman with a history of hypertension and diabetes mellitus type 2 comes to the emergency department with her son, who noticed that while decorating for Christmas she seemed more dyspneic than normal, and had to sit down frequently. In addition, he noticed that she was pale and diaphoretic, and insisted on driving her to the emergency department. On questioning, she denies chest pain, but admits to being more fatigued than usual, with frequent jaw discomfort during activity. Activities such as vacuuming her house cause dyspnea, and she now has to stop several times while carrying laundry up from the basement. On physical examination, the patient's blood pressure is 90/50, pulse 99 bpm, respirations 22, and she is afebrile. Auscultation of the chest demonstrates a new systolic murmur. An EKG demonstrates normal sinus rhythm with nonspecific ST and T wave changes. Serial troponin elevations above the 99 th percentile of normal are noted. Which of the following would be the most appropriate next step in the management of this patient?

Clopidogrel, heparin, and aspirin, followed by cardiac catheterization

A 67-year-old female presents to the emergency department with abdominal pain, bloating, inability to pass gas or stool, and vomiting. Which of the following, if present, would be a contraindication to placing a nasogastric tube? A Esophagitis B Esophageal strictures C Esophageal varices D Peptic ulcer disease E Gastroesophageal refulx disease

Contraindications to nasogastric tube placement include choanal atresia, significant facial trauma, basilar skull fracture, esophageal stricture or atresia, esophageal burn, zenker's diverticulum, recent surgery on the esophagus or stomach, or a history of gastrectomy or bariatric surgery.

A 32-year-old male presents with odynophagia, dysphagia, and chest pain. His past medical history consists of him being HIV positive. He is currently not taking any medications, as he cannot afford to pay for them. An endoscopy is ordered, and the results show several shallow, superficial ulcerations. What is the most likely diagnosis?,

Cytomegalovirus esophagitis can occur in patients with HIV. Gastroesophageal reflux disease typically presents with heartburn and regurgitation

A 39-year-old male patient, who underwent a kidney transplant four months ago, reports to the clinic complaining of pain on swallowing and difficulty swallowing solids. On physical exam, you note a few white plaques present on his tongue. You order an upper endoscopy, which reveals small, yellow-white plaques with surrounding erythema present along the esophagus. What is your treatment of choice for this patient?,

Diflucan (fluconazole)

Which of the following symptoms is most frequently reported in patients that have peptic ulcer disease?

Dyspepsia

A 67-year-old woman with a history of gastric ulcers is admitted with complaints of recent onset of dyspnea with exertion, 3 pillow orthopnea, lower extremity edema, and palpitations, in which she describes her heart as racing. Which of the following is likely to be the cause of her high-output congestive heart failure?

E Severe anemia Choice E, severe anemia, may result with progression of gastric ulcers, and is the only high-output cause of congestive heart failure among the choices offered. Other causes include severe anemia, thyrotoxicosis, and arteriovenouis shunting (for example, in hemodialysis patients). Choice A, mitral regurgitation, is a cause of excessive preload leading to heart failure. Choice D, ruptured chordate tendinae, associated with mitral regurgitation, would also be a cause of excessive preload leading to heart failure. Choices B and C, aortic stenosis and uncontrolled hypertension, are causes in which too much afterload leads to heart failure.

A 34-year-old male presents to the primary care office with a complaint of heartburn that has been present for three months. He has symptoms two to three times a week, which occurs about 30 minutes after eating. He has tried over-the-counter antacids and they were helping to relieve his symptoms for a few months, but they are not working well now. He denies dysphagia, odynophagia, or weight loss. You decide to treat him with a proton pump inhibitor at this visit, and he achieves good symptomatic relief with this therapy. What length of therapy is appropriate in this patient?

Eight to twelve weeks

A 52-year-old male undergoes an upper endoscopy for evaluation of GERD, and is diagnosed with Barrett's esophagus. There is no evidence of dysplasia at this time. In addition to placing him on a PPI, the most appropriate management includes which of the following?

Endoscopy every three years

A 36-year-old male returns to the office for follow up of his heartburn symptoms. He continues to have heartburn three to four times a week, even though he has been compliant with his proton pump inhibitor medication since it was prescribed three months ago. He underwent an endoscopy three weeks ago, which was normal. He denies dysphagia, early satiety, or weight loss. Which of the following tests is the most appropriate next step in evaluating this patient?

Esophageal monometry is the answer, and this is useful in patients who have persistent symptoms, despite PPI therapy and individuals who have had normal findings on endoscopy. Urea breath test is used in the detection of H. pylori, which is an uncommon cause of dyspepsia in the absence of peptic ulcer disease.

A 64-year-old man has been experiencing intermittent left lower abdominal pain associated with alternating diarrhea and constipation. The pain has been increasing over the past 24 hours and is now associated with a fever. The abdomen is tender with evidence of peritoneal signs. Which of the following diagnostic studies is most appropriate to evaluate this patient?

For a patient with diverticular disease, the preferred study to evaluate complications, such as a perforation or abscesses, is a CT scan. A barium enema or endoscopic procedure is contraindicated due to increased risk of perforation during an acute exacerbation.

A 32-year-old male presents with odynophagia, dysphagia, and chest pain. His past medical history consists of him being HIV positive. He is currently not taking any medications, as he cannot afford to pay for them. An endoscopy is ordered and the results show several large, deep ulcerations. Initial treatment consists of which of the following medications?

Ganciclovir

You are reviewing laboratory results on a 60-year-old male from 2 days prior and note that the patient's potassium was 5.6 mEq/L but otherwise his BMP is normal. You speak to the patient on the phone; he states he feels fine. Which of the following medications would most likely be responsible for the abnormal potassium?

Hyperkalemia is a potential adverse reaction of ACE inhibitors such as enalapril. ACE inhibitors should be suspected as a cause of hyperkalemia and may require discontinuation.

A 58-year-old man is in the hospital postoperative day 3 after a laparoscopic right colon resection. Your morning labs reveal a serum potassium level of 2.9 mEq/L (normal 3.5-5.0 mEq/L) despite aggressive potassium replacement during the previous shift. At this time you should check which of the following laboratory values?

Hypokalemia is a common electrolyte disturbance in surgical patients. It can be caused by enhanced losses, hyperaldosteronism, inappropriate replacement, and intracellular shifts caused by alkalosis. Symptoms of hypokalemia may include constipation, neuromuscular weakness, diminished tendon reflexes, paralysis, and distinctive electrocardiographic changes. Concomitant deficiencies in magnesium can contribute significantly to the development of hypokalemia as well as hypocalcemia.

A 46-year-old man with a history of EtOH abuse is brought to the emergency department in the morning by his wife. She has noted that he has developed tremors in both arms, and he seems mildly confused to her. He complains of feeling weak, with some cramping in the legs. On physical examination, his blood pressure is noted to be 162/95 mm Hg, and his heart rate is 108 beats/min. There is no asterixis. Which of the following electrolyte disorders are you likely to find in this patient?

Hypomagnesemia is a common finding in the patient who abuses alcohol. Other leading causes include diarrhea, diuretics, aminoglycosides, and amphotericin B. The etiology of hypomagnesemia in the patient with a history of alcohol abuse is thought to be a combination of malabsorption and inadequate dietary intake, possibly with alcohol exerting an antagonistic effect on absorption. Signs and symptoms are those of neuromuscular and central nervous system hyperirritability, including weakness and muscle cramps, tremors, nystagmus, a positive Babinski response, confusion, and disorientation. Hypertension, tachycardia, and ventricular arrhythmias may develop. (Fukagawa et al, 2008, pp. 774-775) Fukagawa M , Kurokawa K , Papadakis M. Fluid and electrolyte disorders. In: Tierney LM , McPhee SJ , Papadakis MA, eds. Current Medical Diagnosis and Treatment. 47th ed. New York, NY: McGraw-Hill; 2008.

A 49-year-old female with a known history of hypertension presents to the emergency department with a generalized headache that is throbbing. She states she had run out of her normal blood pressure medication about a week ago and since then she has noticed that her headache came about and has been getting worse. She denies any nausea, vomiting, visual changes, chest pain, or other symptoms. On exam the patient has a BP 227/120, P 78, R 18. Her HEENT exam is essentially normal, lungs are clear to auscultation, and heart is a regular rhythm without murmur or gallop. Given this clinical situation, which medication would be the most appropriate to address the patients condition?

IV labetalol

In patients with dilated cardiomyopathy who have multiple runs of symptomatic non-sustained ventricular tachycardia, what is the best intervention to treat this condition?

Implantable defibrillator

A 56-year-old male is diagnosed with an H. pylori associated ulcer. The ulcer was 0.8 mm in size on endoscopy. He is placed on a proton pump inhibitor, clarithromycin, and amoxicillin. If his dyspeptic symptoms resolve after starting this regimen, how many days should he take the proton pump inhibitor to complete the treatment?

In an H. pylori associated ulcer that is < 1cm in size and dyspeptic symptoms resolve with therapy, 10 to 14 days is the recommended length of treatment. For patients with large or complicated ulcers, antisecretory therapy should be continued for an addition two to four weeks (duodenal ulcer) or four to six weeks (gastric ulcer) after completion of the antibiotic regimen.

Mrs. Jones was referred for screening colonoscopy at the age of 50. She has no personal or family history of colorectal cancer. No polyps or lesions were found during the exam. She should be advised that colonoscopy should be repeated in how many years?

In average-risk individuals aged 50 or greater than 50, screening colonoscopy should be repeated every 10 years following an initial normal exam. If the individual has a first-degree relative with a history of adenomas or colorectal cancer, screening should begin earlier, generally at age 40 or 10 years younger than the age at diagnosis of the youngest affected relative

A 46-year-old female complains of heartburn, steatorrhea, and a 20-lb weight loss. She was diagnosed with a solitary ulcer in the duodenal bulb, but it has been refractory to treatment. Which of the following laboratory findings are most likely to be present in this patient?

Increased fasting serum gastrin

A 2-year-old baby girl is brought to the ED with a history of abdominal pain and diarrhea. Mother states that the child was playing normally and then "doubled over" with what appears to be abdominal pain. The abdomen appears slightly distended and is tender to palpation. While in the ED the child has a bloody, diarrheal bowel movement. Which of the following is the most likely diagnosis?,

Intussusception is the most frequent cause of intestinal obstruction in the first 2 years of life.

Pyloric Stenosis What laboratory finding is most consistent with the suspected diagnosis?

Laboratory findings that are consistent with the suspected diagnosis of pyloric stenosis include hypochloremic alkalosis with potassium depletion.

A 66-year-old woman presents to the emergency department with a complaint of abdominal pain and distension for the past 3 days. Examination reveals a protuberant abdomen with diminished bowel sounds and tympany to percussion. Flat and upright abdominal radiographs reveal distended loops of bowel with prominent haustral markings. Which of the following etiologies is the most likely cause of the patient's condition?,

Large bowel obstructions are most commonly caused by an adenocarcinoma (65%). This is followed in decreasing incidence by diverticular scarring and volvulus. Adhesions are the most common cause of small-bowel obstruction but are rare as a cause of large bowel obstruction. The presence of haustral markings on radiographic evaluation helps differentiate between small and large bowel involvement.

Which of the following conditions is the most common cause of massive lower gastrointestinal bleeding?

Massive lower gastrointestinal hemorrhage is most commonly due to diverticular disease.

An elderly patient is brought in to the emergency department (ED) complaining of incontinence of liquid "like tea water" stool. He is complaining of rectal pressure and lower abdominal pain. The pain is cramping in quality and the patient's abdomen is "bloated." Digital rectal exam reveals hard stool in the rectum. Which of the following should be selected as the initial treatment for this patient?

Mechanical bowel obstruction in the rectum does not usually respond to oral laxatives.

A 6-year-old girl presents to the emergency department with abdominal distension of 1-day duration. She has not had a bowel movement or passed flatus in 72 hours. Examination reveals markedly diminished bowel sounds with tympany to percussion. She has also passed bloody mucus from her rectum. There is no evidence of hernia, and surgical history is negative. Which of the following is the most likely diagnosis?

Meckel diverticulum is prevalent in 2% of the population, has a 2:1 male:female predominance, and is usually located 2 ft from the ileocecal valve. The most common clinical presentations are bleeding, intestinal obstruction, and inflammation. Bright red or maroon bleeding is the most frequent complication in children younger than 2 years of age. Obstruction may develop secondary to a volvulus that occurs at the site of the diverticulum or from an intussusception with the diverticulum acting as the lead point. An air contrast barium enema may be able to reduce intussusceptions in children

Which of the following symptoms is most concerning for gastric cancer?,

New-onset of dyspepsia in a 58 year-old patient

The triad of "dermatitis, diarrhea, and dementia" (pellagra) results from a severe deficiency of which of the following vitamins? A thiamine B vitamin K C riboflavin D niacin E pyridoxine

Niacin deficiency is known as pellagra. It is rare in the United States and is most often a complication of alcoholism or malabsorption syndrome. Clinical signs of pellagra are known as the 3 Ds—dermatitis, diarrhea, and dementia.

A 47-year-old female patient is diagnosed with a duodenal ulcer. She was determined to have H. pylori infection. Which of the following antibiotics is indicated for the eradication of H. pylori in the treatment of peptic ulcer disease?

Of the antibiotics listed, metronidazole is the only one that has the indication in the treatment of H. pylori induced peptic ulcers.

A 52-year-old female is taking daily ibuprofen due to severe degenerative joint disease. She is concerned about developing an ulcer, but refuses to stop the ibuprofen. Which of the following medications is approved for the prevention of NSAID-induced gastric and duodenal ulcers, and should be recommended to this patient?

Omeprazole is a proton pump inhibitor, and is the only medication listed that is indicated for the prevention of NSAID induced ulcers

A 63-year-old white male is seen in the ambulatory outpatient clinic with complaints of midepigastric pain, weight loss, and jaundice. On examination, he is jaundiced and his sclerae are icteric. On palpation of the abdomen, you find a distended nontender gallbladder. Which of the following is the most likely diagnosis

Pancreatic carcinoma

A 54-year-old man complains of persistent midepigastric abdominal pain 2 weeks following the diagnosis of acute pancreatitis. The patient also complains of anorexia but no fever or chills. There is a palpable mass in the midepigastrium; bowel sounds are normal in all four quadrants. Which of the following is most likely diagnosis?,

Pancreatic pseudocysts are the most common complication associated with acute pancreatitis.

A 3-week-old male infant is brought in by his mother due to his vomiting. The mother notes that a few days ago, her son started vomiting after feeding and it has become projectile in nature. The vomitus is non-bilious and contains no blood. The child seems hungry and nurses regularly, but the vomiting has become more frequent and is occurring with every feeding now. On physical examination, an oval mass is palpated in the right upper quadrant. What is the most likely diagnosis?

Pyloric stenosis is the result of muscular hypertrophy with gastric outlet obstruction. The patient's symptoms and signs are most consistent with this diagnosis.

A 5-week-old male infant presents with a 1-week history of vomiting which occurs shortly after feeding. The mother describes the vomiting as forceful and the vomitus is occasionally blood streaked; the infant has not had diarrhea. You note that the infant appears slightly dehydrated and has lost weight since a routine check at 2 weeks. Which of the following is the most likely diagnosis?

Pyloric stenosis usually presents with forceful/projectile vomiting between 2 and 4 weeks of age. There is a 4:1 male predominance; dehydration and failure to thrive may develop. Peptic ulcer disease can occur at any age and commonly affects more men but is more common from 12 to 18 years of age. Intussusception is more common in men but presents with colicky abdominal pain with subsequent development of vomiting and bloody diarrhea.

our 36-year-old obese female patient complained of a single episode of right upper quadrant pain after eating fast food (a double cheeseburger, fries, and a vanilla shake) last week. The symptoms have resolved and have not reoccurred when she presents to your family practice. Your psychical examination is completely normal, as is blood work, including a complete blood count, comprehensive metabolic panel, acute viral hepatitis panel, amylase, and lipase. You suspect cholecystitis and order an abdominal sonogram. The radiologist makes note that the gall bladder appears thickened with an associated calcification with a single, large gallstone. Of the following, what is the most appropriate next step?

Refer the patient to a surgeon for a laparoscopic cholecystectomy due to the risk of gall bladder cancer. Calcification of the gall bladder, frequently referred to as a porcelain gall bladder, and single, solitary, large, gall stone are a common presentation of gall bladder cancer on imaging. Especially in the face of a symptomatic patient, cholecystectomy with an associated biopsy should be a strong consideration

A 56-year-old male is diagnosed with a duodenal ulcer through endoscopy. He is placed on an appropriate regimen of medications to heal the ulcer. Which of the following lifestyle choices is known to retard the rate of ulcer healing and should be discouraged? A Moderate alcohol intake B Ingestion of spicy foods C Eating at regular intervals D Smoking cigarettes E Ingestion of fruit juices

Smoking cigarettes does retard the rate of ulcer healing and increases the frequency of recurrence. Patients should be encouraged to eat balanced meals at regular intervals. There is no justification for bland or restrictive diets. Moderate alcohol intake is not harmful.

Which of the following diagnostic tests is the imaging study of choice in patients suspected of having Zollinger-Ellison syndrome?,

Somatostatin receptor scintography

A 42-year-old man is prescribed a drug classified as a "bile acid sequestrant." Which of the following will most likely be diminished as a result of administering this drug? A activity of pancreatic amylase B bile flow from the gall bladder to the duodenum C emulsification of triglycerides D secretion of gastric acid E synthesis of plasma proteins

The Correct Answer is: C Bile acids are constituents of the bile that are synthesized into bile salts by liver hepatocytes or by intestinal bacteria. One of the major roles of bile salts is to emulsify dietary lipids within the lumen of the small intestine. Emulsification is an important first step in lipid digestion, as it increases the surface area for lipases to function. Bile salts also help to form micelles, which transport the products of lipid digestion from the lumen and into the cells (enterocytes) lining the small intestine. Without bile salts, digestion and absorption of dietary lipids is incomplete and therefore decreased

Which of the following signs and symptoms is associated with the abdominal pain secondary to chronic intestinal ischemia?

The clinical symptoms associated with chronic intestinal ischemia include severe epigastric pain following meals, which results in weight loss and fear of eating. Nausea, bloody diarrhea, and vomiting as well as guarding and rigidity are consistent with acute intestinal ischemia.

A 66-year-old female with a history of nephrotic syndrome presents to the emergency department complaining of a non-productive cough and dyspnea on exertion following a recent vacation to Orlando. She is currently taking prednisone. What diagnosis is highly suspected in this patient due to her history of nephrotic syndrome?

The correct answer is (B). Patient's with nephrotic syndrome commonly have a hypercoagulable state and are at risk for deep venous thrombosis (DVT) with resultant PE. Patients on chronic prednisone may have a risk of developing Cushing's syndrome, but this is not consistent with the patient's history.

Your patient is asked to see you in followup for his fasting labs. His total cholesterol = 230 mg/dl, triglycerides = 1200 mg/dl, unable to calculate LDL. Your patient should be advised that due to these findings he is at risk for which of the following?

The correct answer is (B). Very elevated triglycerides, especially over 1000 mg/dl, increase the patient's risk of acute pancreatitis.

You are evaluating a 67-year-old male with known cirrhosis of the liver secondary to alcoholic liver disease, although he has been sober for the past year. He is brought in to the emergency department by his daughter, who notes that for the past few days he has seemed to be more confused. On examination you note the patient to be mildly confused but alert to person and place. He has noticeable asterixis. He is not currently taking any medications and his blood alcohol level is undetectable. What is the treatment of choice in this case based on your physical examination findings? A amoxicillin B prednisone C lactulose D folic acid E thiamine

The correct answer is (C). This patient most likely has hepatic encephalopathy due to end-stage liver disease. Asterixis indicates an increase in serum ammonia. The treatment of choice is lactulose.

A 32-year-old female returns to the office following an emergency department visit for abdominal pain that has since resolved. A computed tomography (CT) scan performed in the emergency department reveals a 1 cm cavernous hemangioma in the right lobe of the liver. What are your recommendations to the patient regarding the CT findings?

The correct answer is (D). Cavernous hemangiomas are common benign lesions of the liver that rarely require surgical intervention unless they are very large (>10 cm) and symptomatic. No further imaging follow-up is necessary.

A 72-year-old male presents to you for a routine physical exam. He complains of increasing abdominal distention, weight loss, and night sweats over the past 2 months. He admits to having a blood transfusion as a young adult. His labs include +anti-HCV and HCV RNA. Which of the following is the most likely explanation for his history and laboratory findings?

The correct answer is (E). The patient's symptoms are consistent with a possible malignancy. Labs indicate chronic hepatitis C, likely longstanding with liver cirrhosis, which is associated with an increased risk of hepatocellular carcinoma

This is a protrusion of pharyngeal mucosa that develops at the phayngoesophageal junction, between the inferior pharyngeal constrictor and the cricopharyngeus. It often presents in older patients, with symptoms of dysphagia and regurgitation that develop slowly over many years. Late in the disease process patients may note halitosis, spontaneous regurgitation of undigested food, or nocturnal choking. Which of the following choices is the correct term for this condition?

The correct answer is Zenker diverticulum. Meckel's diverticulum is a pouch on the wall of the lower part of the small bowel, which is congenital. A hiatal hernia is a protrusion of a portion of the stomach into the chest through a hole in the diaphragm. An esophageal web is a thin, diaphragm-like membrane of squamous mucosa. Achalasia is a motility disorder, characterized by loss of peristalsis in the distal two-thirds of the esophagus and impaired relaxation of the LES.

A 58-year-old female patient has a history of cirrhosis. She undergoes a diagnostic endoscopy, which shows large varices. Which of the following medications is the most appropriate to reduce the risk of a first variceal hemorrhage?

The correct answer is a beta blocker. This is the recommended medication to reduce the risk of first variceal hemorrhage in patients with large or small varices, who either have variceal red wale marks or advanced cirrhosis.

A 52-year-old male presents to the office with a complaint of intermittent dysphagia. His symptoms occur mostly when he eats steak, and have been ongoing for about six months. The symptoms have not worsened and he denies weight loss. You are concerned that he may have an esophageal web or ring. The diagnostic test that best visualizes an esophageal web or ring is which of the following?

The correct answer is barium esophagram, which provides the best visualization of an esopahgeal web or ring. Endoscopy and CT scan of the abdomen are less sensitive than barium esophagography. Esophageal manometry is used to measure and record esophageal pressures. pH monitoring is used to assess for reflux into the esophagus.

You are evaluating a 59-year-old male with history of heavy alcohol use for the past 5 years who appears acutely ill. Which of the following findings is most likely to be an indicator of increased mortality in this patient with severe alcoholic hepatitis? A fatty liver B INR of 7 C AST > ALT by a factor of 2:1, but less than 300 units/L D serum bilirubin 1.8mg/dl E folic acid deficiency

The correct answer is choice (B). A significantly elevated PT/INR as well as bilirubin > 10 mg/dl are indicators of severe alcoholic hepatitis and increased mortality requiring hospitalization.

A 42-year-old female has an endoscopy performed, which shows a smooth, sessile nodule with normal overlying mucosa present in the esophagus. A biopsy is performed and the results show a benign esophageal neoplasm. What is the most likely diagnosis?

The correct answer is leiomyoma, which is the most common benign esophageal neoplasm

What is the most common embolic source of acute arterial occlusion in the lower extremities?

The heart accounts for 80% of all emboli, with atrial fibrillation making up 70% of that.

A 45-year-old man with a history of NSTEMI, CABG X 3, HTN, and hyperlipidemia presents to your office with complaints of progressive dyspnea over the last three weeks, to the point that he is now dyspneic while walking across the room. In the last few days, he has noticed bilateral lower extremity edema. Which of the following findings on physical exam would meet the criteria for a diagnosis of congestive heart failure, according to the modified Framingham clinical criteria for the diagnosis of heart failure?

The patient demonstrates two minor criteria: bilateral lower extremity edema and dyspnea on ordinary exertion. Only choice C (third heart sound) falls under the heading of major criteria.

A 4-month-old male presents for a well child check. He is healthy, and the mother feels that the child is eating and growing well. On examination, there is no evidence of cyanosis. The peripheral pulses are normal and equal. There is a medium-pitched harsh pansystolic murmur heard best at the left sternal border at the fourth intercostal space. There is no heave or thrill present. The murmur radiates over the entire precordium and the S2 is physiologically split. What is the most likely diagnosis?

The patient in this scenario is exhibiting the classic signs of a ventricular septal defect. An atrial septal defect has a fixed, widely split S2, with a right ventricular heave as well as a systolic ejection murmur, which is best heard at the left sternal border second intercostal space. Coarctation of the aorta has absent or diminished femoral pulses and a blowing systolic murmur. A patent ductus arteriosus murmur is classically described as a rough machinery systolic murmur, and there are bounding pulses with a widened pulse pressure. Tetralogy of fallot can have associated cyanosis, with hypoxemic spells during infancy, easy fatigability, and dyspnea on exertion. Tetralogy of fallot has the presence of a right ventricular lift and a rough, systolic ejection murmur that is present along the left sternal border in the third intercostal space that radiates to the back. Aortic stenosis has a harsh systolic ejection murmur present at the right sternal border, and associated thrill in the carotid arteries.

A 24-month-old infant presents for his routine physical examination. The parents state that he has been following all of his developmental milestones. On examination, the clinician hears a grade II/VI murmur along the left sternal border, which radiates into the left axilla and the left side of the back. The child also has decreased femoral pulses bilaterally. The clinician orders a chest X-ray. Which of the following is the expected finding on X-ray based on the presentation?

The patient's presentation is consistent with findings of coarctation of the aorta. The pathognomonic finding in coarctation is decreased or absent femoral pulses. and rib notching on xray

The best initial diagnostic study for a suspected perforated peptic ulcer is which of the following?

The presence of free intraperitoneal air on an upright or decubitus film in the majority of patients with peptic ulcer perforation. This finding along with a classic history of sudden onset of severe abdominal pain and a rigid, quiet abdomen should establish the diagnosis in most cases without the need for further studies. Barium studies are contraindicated in patients with a possible perforation

A 46-year-old female complains of heartburn, steatorrhea, and a 20-lb weight loss. She was diagnosed with a solitary ulcer in the duodenal bulb, but it has been refractory to treatment. Imaging reveals the tumor but no hepatic metastasis. What is the recommended treatment in this patient to cure the disease?

The recommended treatment to cure localized disease in patients with Zollinger-Ellison syndrome is resection of the gastrinoma, before hepatic metastasis spread has occurred.

What is the most common heart sound that is heard in patients with pulmonary hypertension?

The splitting on the second heart sound is also accompanied by the louder second sound of a split of the pulmonary component. There should not be a change in the rhythm with the patient due to pure pulmonary hypertension.

A 49-year-old male presents to the clinic with symptoms of nausea, occasional vomiting, vague epigastric pain, fatigue and weight loss of 35 lbs. over the past few months. On exam you find a palpable abdominal mass. Which of the following laboratory findings are most consistent with the suspected diagnosis?,

The suspected diagnosis is gastric carcinoma. The most common laboratory finding is iron deficiency anemia related to chronic blood loss. Tumor markers are of no value, and an elevated CRP is not commonly present. Megaloblastic anemia is not the type of anemia typically present in gastric carcinoma

A 3-week-old male infant is brought in by his mother due to his vomiting. The mother notes that a few days ago her son started vomiting after feeding, and it has become projectile in nature. The vomitus is non-bilious and contains no blood. The child seems hungry and nurses regularly, but the vomiting has become more frequent and is occurring with every feeding now. On physical examination, an oval mass is palpated in the right upper quadrant. What imaging study is the best initial test to obtain in this patient?

The suspected diagnosis is pyloric stenosis. An upper GI series with barium is the best test to obtain in this instance. A barium enema is a good choice in suspected intussusception cases. An upper GI endoscopy is best used when a gastric or duodenal ulcer is suspected. An abdominal plain film or CT could be ordered, but aren't the best initial tests to obtain in this patient's presentation.

A 48-year-old African American male presents with dyspnea, 2-pillow orthopnea, and swelling to his lower legs that has developed over the last month. He also complains of fatigue and decreased exercise tolerance, stating that he has trouble climbing one flight of steps. On physical examination, his blood pressure is 178/98, pulse rate is 102, and respiratory rate is 20. There is 5 cm JVD, crackles at the bilateral lung fields, tachycardia, and an S3 is heard on cardiac auscultation. There is 2+ pitting edema to the lower extremities. His electrocardiogram reveals a sinus tachycardia at a rate of 105 and left ventricular hypertrophy. The chest x-ray reveals cardiomegaly with increased interstitial markings in all lung fields. There is a small right pleural effusion that blunts the costophrenic angle. He is on a thiazide diuretic. On repeat examination, the patient's blood pressure remains high. Which medication should be added to better control the patient's blood pressure?

The use of an ACE inhibitor is a logical second order medication for this patient. Along with the diuretic, the ACE will further lower blood pressure. Calcium channel blockers are not an optimal choice, as they can worsen heart failure. ACE inhibitors can also have a protective effect on renal function, as well as improve morbidity and mortality in diabetics. While hydralazine can also be used for pressure control, ACE inhibitors would be a choice above hydralazine.

A 48-year-old African American male presents with dyspnea, 2-pillow orthopnea, and swelling to his lower legs that has developed over the last month. He also complains of fatigue and decreased exercise tolerance, stating that he has trouble climbing one flight of steps. On physical examination, his blood pressure is 178/98, pulse rate is 102, and respiratory rate is 20. There is 5 cm JVD, crackles at the bilateral lung fields, and tachycardia and an S 3 is heard on cardiac auscultation. There is 2+ pitting edema to the lower extremities. His electrocardiogram reveals a sinus tachycardia at a rate of 105 and left ventricular hypertrophy. The chest x-ray reveals cardiomegaly with increased interstitial markings in all lung fields. There is a small right pleural effusion that blunts the costophrenic angle. Which medication is the treatment of choice for controlling this patient's heart rate?

The use of beta-blockers is indicated for heart rate control. The other choices are not indicated for rate control and have no primary action on rate, but rather on blood pressure. Metoprolol

A 71-year-old male who has a history of hypertension presents with a new finding of atrial fibrillation. He is independent, drives his own car, and tends to his daily activities without assistance. He is currently having no symptoms, and his heart rate is 90, with a blood pressure of 146/76. Given this clinical scenario, what is the best pharmacologic anticoagulation treatment for this patient?

This patient has a lower CHADS2 score of 1 (HTN) and would have adequate risk reduction with the therapy of aspirin alone (B). Higher risk patients with a CHADS2 score of 2 or higher qualify for adding warfarin (C), and the use of aspirin and clopidogrel (D) is not indicated. No anticoagulation (A) would put the patient at risk for CVA, and warfarin and clopidogrel (E) would create an over anticoagulated environment and increase risk for bleeding.

A 76-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations, tachypnea, and chest pain. He denies history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 3. His echocardiogram demonstrates normal LV systolic function and normal valvular function. Which of the following questions, when answered, will help to determine the next course of therapy?

This patient has atrial fibrillation. Choice E is the most important question to ask to determine the next course of therapy. If the patient has been experiencing definitive symptoms for less than 48 hours, direct current cardioversion can be performed, as the risk of atrial clot formation and thromboembolism is low. Choice A is incorrect because the CHADS2 scoring system does not take into account how long the patient has been diabetic. Choice B is incorrect because aspirin therapy is not utilized. Choice C is incorrect because family history is not a factor in determining the patient's treatment plan. Choice D is incorrect because smoking status is used in calculating Framingham risk score, not a CHADS2 score. (Fauci et al., 2008, Chapter 226)

A 70-year-old man with a history of pulmonary hypertension and obstructive sleep apnea presents with complaints of increasing dyspnea while walking his dog. He has also recently noted increased lower extremity edema. On physical examination, jugular venous distension is noted. Auscultation of the chest demonstrates a high-pitched blowing diastolic murmur. With inspiration, the murmur increases in intensity and is heard over the second and third left intercostal spaces. An S 3 is appreciated. Palpation of the precordium reveals a hyperdynamic right ventricle, and both a systolic and diastolic thrill. The abdominal exam reveals hepatomegaly and splenomegaly. Based on this patient's history and physical exam findings, which of the following is the most likely finding on echocardiogram?

This patient is demonstrating signs and symptoms of right heart failure, and with a history of pulmonary hypertension and a high-pitched diastolic blowing murmur (Graham Steell murmur), A blowing holosystolic murmur at the left lower sternal border is characteristic for tricuspid regurgitation, Choice A. Choice B, aortic stenosis, presents with a systolic ejection murmur. An atrial septal defect, Choice C, if large, could present with similar symptoms of exertional dyspnea secondary to a large shunt, but auscultation would reveal a moderately loud systolic ejection murmur that is heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow. Choice E, mitral stenosis, presents with a diastolic murmur heard best in the left lateral decubitus position, with the bell of the stethoscope at the apex. (McPhee et al., 2011, Chapter 10)

His chest x-ray is negative for any acute cardiopulmonary disease, and his electrocardiogram has an irregularly irregular rate of 142 with visible delta waves. Based on the information provided, what anatomical pathway is responsible for the above findings of the delta waves?

This patient is exhibiting Wolff-Parkinson-White (WPW) syndrome by evidence of the delta waves on the electrocardiogram. The anatomic pathway that is known to be the causative abnormality in WPW is the Bundle of Kent (D). Intranodal pathway (A), Bachmann's bundle (B), Perkinje (C), and His bundles (E) are not the anatomic pathways found with WPW.

Aortic Dissection

This patient is exhibiting a history and physical examination that is consistent with a thoracic aneurysm. The patient's history of hypertension, along with the "ripping" sensation in his back and hypotension give a clinical presentation that is suggestive of a thoracic aneurysm dissection. Given this clinical situation, the best test to evaluate for a potential dissection is by computed tomography

WPW Management

This patient is presenting with Wolff-Parkinson-White syndrome, as evidenced by the delta waves on the ECG. These conditions will generally occur in individuals at the onset of early adulthood. Management for this condition pharmacologically includes the use of class IC drugs, such as flecanide. Other choices include procainamide, sotalol, and amiodarone. Digoxin therapy may worsen and widen the QRS complex and place the patient into a ventricular tachycardia.

A 9-year-old female child presents with tachycardia, tachypnea, shortness of breath, bibasilar rales, and distended jugular veins. Which of the following is the most likely cause for her signs and symptoms?

This patient is presenting with signs of congestive heart failure. The most common causes of heart failure in children/adolescents are due to acquired heart disease.

A 64-year-old man has been experiencing signs and symptoms compatible with diverticular disease for the past 3 weeks. He now presents to the emergency department malnourished with severe left-sided lower abdominal pain. After appropriate workup and hydration, he is taken to the operating room where a perforated sigmoid colon is discovered with gross contamination. What is the most appropriate surgical intervention at this time?

This vignette is consistent with an emergent resection in an unprepared patient. The most appropriate therapy for an acute perforation is a Hartmann procedure, which includes resection of the affected portion of the bowel, a temporary diverting colostomy, and oversewing of the distal rectal stump; the second stage of the procedure will involve taking down the colostomy with anastomosis to the rectal stump

A 34-year-old male presents to the primary care office with a complaint of heartburn. He has symptoms two to three times a week, and it occurs about 30 minutes after eating. He has tried over-the-counter antacids and they were helping to relieve his symptoms for a few months, but they are not working well now. He denies dysphagia, odynophagia, or weight loss. What is the next, most appropriate step in managing this patient?

Treat empirically with a proton pump inhibitor The correct answer is to treat empirically with a proton pump inhibitor. This is the treatment of choice in a patient with typical symptoms of heartburn and regurgitation. If the patient fails therapy with a proton pump inhibitor, or had any alarm symptoms present, then it would be reasonable to start with an upper endoscopy, barium esophagography, or esophageal pH monitoring. Increasing the dose of the antacids is not appropriate management for this patient.

A 33-year-old IV drug user presents to the emergency department with pleuritic chest pain, cough, chills, diaphoresis, anorexia, and malaise. On physical exam, her temperature is 40°C, BP 98/55, P 115 bpm, and RR 22. No murmur could be appreciated. Two separate blood cultures are positive for S.aureus. An EKG, CXR, and transesophageal echocardiogram are ordered. Which of the following lesions is most likely to be seen on TEE in this patient?

Tricuspid valve vegetation

A 38-year-old woman diagnosed with pancreatic cancer 2 months ago develops jaundice and steatorrhea. Which of the following is most likely to be diminished in the blood?

Tumors in the pancreatic head region can often block the flow of bile from the gall bladder and liver to the duodenum, resulting in jaundice and steatorrhea. The bile salts are important for micelle formation within the lumen of the small intestine. Micelles provide a mechanism whereby the hydrophobic products of lipid digestion as well as fat-soluble vitamins (eg, A, D, E, and K) can be absorbed in the small intestine.

A 77-year-old male is admitted to the ICU with community acquired pneumonia and sepsis. There is a concern for the possible development of stress gastritis. Which of the following is an important risk factor in the development of stress gastritis?,

Two of the most important risk factors in the development of stress gastritis are coagulopathy (platelets < 50,000/mcl or INR > 1.5) and respiratory failure, requiring mechanical ventilation for > 48 hours

A 46-year-old African American male is seen in the emergency department with upper right quadrant pain that radiates to the right infrascapular area. The pain is colicky and was precipitated by a meal of fried fish and French fries. Which of the following diagnostic studies is the initial study of choice for this patient?,

Ultrasonography

A 49-year-old male presents to the clinic with symptoms of nausea, occasional vomiting, vague epigastric pain, fatigue, and weight loss of 35 lbs. over the past few months. On exam you find a palpable abdominal mass. Which of the following diagnostic tests is the best initial test to obtain?

Upper endoscopy allows for a biopsy, which is highly sensitive in detecting gastric carcinoma, the suspected diagnosis. An upper GI series cannot distinguish a benign from a malignant lesion.

A 52-year-old male presents to the office with a complaint of abdominal pain. He describes the pain as epigastric, dull, and achy. Antacids do help the pain for a few hours, but it then returns. He also notes that the pain often wakes him from sleep. He denies significant vomiting, dysphagia, heartburn, or weight loss. Which of the following diagnostic tests is the procedure of choice in this patient?

Upper endoscopy is the procedure of choice for diagnosing peptic ulcer disease, which is the concern in this patient. Abdominal CT is obtained in patients suspected of having complications from an ulcer. Barium upper GI series is not as sensitive as upper endoscopy in detecting ulcer disease. Colonsocopy is used to evaluate the colon, and this patient's symptoms do not suggest a problem in that area. Esophageal manometry is used to evaluate dysphagia, which this patient denies having.

What is the most common cause of restrictive cardiomyopathy?

While restrictive cardiomyopathy is seen in such cases as hemochromatosis, glycogen deposition, endomyocardial fibrosis, sarcoidosis, hypereosinophilic disease, and scleroderma, amyloidosis is the most common cause among the choices provided.

What is the most likely reason for a patient to have cardiogenic shock?

While trauma can account for a patient being subjected to cardiogenic shock, the overwhelming etiology for the shock comes from an MI.

You are called for a consult of a 30-year-old female who appears well, but is noted to have hepatomegaly, spider nevi, and elevated serum amino transaminases greater than 1000 units/L. Because of your suspected diagnosis, you decide to give her a trial of corticosteroids resulting in improvement of her serum amino transaminases. What is the most likely diagnosis?,

autoimmune hepatitis

Your 65-year-old patient with a history of tobacco abuse was recently diagnosed with stage III lung cancer. He has not started treatment yet and presents to his oncologist with complaints of nausea, anorexia, and increasing fatigue over the last several days. He has been eating less than usual but has been able to maintain a normal fluid intake. His wife reports that he has been more forgetful and confused than usual. His medical history includes hypertension, for which he has been taking 25 mg of hydrochlorothiazide for 12 years, and gastro-esophageal reflux disease (GERD), for which he takes omeprazole. He has no history of significant side effects from his medications. You order labs, and the calcium level is elevated at 11.9 mg/dL. What is the most likely etiology of his hypercalcemia?,

malignancy

Of the following choices, which regimen is considered first-line therapy for Helicobacter pylori-positive individuals with peptic ulcer disease?

omeprazole & clarithromycin & amoxicillin

A 74-year-old man with end-stage renal failure is suffering from a number of bone abnormalities, including osteomalacia. Which of the following is most likely diminished in this patient?,

production of 1,25-dihydroxycholecalciferol

In Western society, diverticulosis most often occurs in which portion of the colon?

sigmoid

In a patient with chronic hepatitis C infection, which of the following medical conditions would be considered a contraindication to starting the patient on interferon? A hypertension B hyperlipidemia C diabetes D migraine headaches E systemic lupus erythematosus

systemic lupus erythematosus