GI Practice Part II
A middle-aged woman presents with elevated cholestatic liver enzyme levels. She is not taking any medications, does not drink alcohol, and does not complain of abdominal pain. She has not had any previous biliary tract surgery. Which of the following is the most likely diagnosis? A. primary biliary cirrhosis B. pancreatitis C. cholecystitis D. fatty liver E. primary sclerosing cholangitis
A. primary biliary cirrhosis
A 2-week-old male infant presents for a routine checkup. The mother complains that he nurses every hour, but vomits (nonbilious) after every time he eats. He has only had three bowel movements since he has been home. On examination, the infant has not gained any weight since leaving the hospital, and the clinician notes gastric peristaltic waves. Which of the following is the treatment of choice for this patient? A. pyloromyotomy B. metoclopramide C. laparotomy D. omeprazole
A. pyloromyotomy
A 50-year-old Jewish man comes to the clinic because of back pain that has been worsening for about a week. He says that he has recently noticed small, painful bumps around his body and slight ankle swelling, but these symptoms come and go and do not bother him much. He does not smoke or use illicit drugs, and says he has "a few drinks sometimes on weekends with his friends." Which of the following is the most likely location of the cause of this patient's symptoms? A. Antrum of the stomach B. Centrilobular region of the liver C. Extrahepatic bile ducts D. Fundus of the gallbladder E. Head of pancreas
E. Head of pancreas
A 32-year-old male presents with the acute onset of 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 small, deep ulcerations. What is the most likely diagnosis? A. Cytomegalovirus esophagitis B. Gastroesophageal reflux disease C. Candidal esophagitis D. Barrett's esophagus E. Herpetic esophagitis
E. Herpetic esophagitis
A 34-year-old Caucasian woman presents unwell to the emergency department because she has severe epigastric pain radiating to her back over the past hour. This pain came on suddenly, has gradually increased in severity, and is associated with a sensation of nausea. She has a history of biliary colic with confirmed gallstones, but states that this episode "feels different" to her usual colic. She has a BMI of 33kg/m2. Her temperature is 36.8°C (98°F), pulse is 87/min, respirations are 18/min, and blood pressure is 117/78 mm Hg. Which of the following biochemical tests has the highest positive predictive value for determining a biliary etiology for this patient's symptoms? A. ALT B. ALP C. AST D. Serum amylase E. Total bilrubin
A. ALT
A 43-year-old woman comes to the emergency department because of sudden onset of severe right upper quadrant abdominal pain, nausea, and vomiting. She says the sharp pain began 30 minutes after eating a hamburger and french fries. She denies chest pain, shortness of breath, diarrhea, and vision changes. Her temperature is 38.3°C (101.0°F), pulse is 98/min, respirations are 22/min, and blood pressure is 140/98 mm Hg. She is visibly uncomfortable and diaphoretic. Her heart rate is tachycardic with normal rhythm and lungs have normal sounds bilaterally on auscultation. She has right upper quadrant tenderness with rebound with a positive sonographic Murphy sign. Which of the following processes, under normal physiological conditions, occurs in this patient's malfunctioning organ? A. Absorption of water and ions in an isoosmotic fashion B. Contraction in direct response to distention of the duodenum C. Production of glucagon in direct response to decreased blood glucose levels D. Reabsorption of bile salts into the the portal vein E. Release of pepsinogen from chief cells
A. Absorption of water and ions in an isoosmotic fashion
A 28-year-old male is concerned because he has a friend who was diagnosed with chronic hepatitis C and wants to know if he is at risk for this disease as well. Which of the following answers elicited in your history would make you the most suspicious? A. previous intravenous drug use B. blood transfusion last year C. monogamous relationship D. recent negative HIV test E. previous history of hepatitis A
A. previous intravenous drug use
A 50-year-old woman comes to the emergency department because of severe abdominal pain that started the day before and is getting progressively worse. She states that she has not experienced this pain before and rates it as an 8 on a 10 point scale. She also has light-colored foul-smelling diarrhea. Physical examination shows mild jaundice and a fever of 39°C (102.2°F). Abdominal examination shows tenderness in the right upper quadrant but no palpable masses. Laboratory studies show the following: WBC: 15,000 with 10% bands Hgb: 13.3 Platelets: 230,000 Alk phos: 300 Total bilirubin: 7.4 Direct bilirubin: 6.3 Based on the patient's presentation, which of the following is the most likely diagnosis? A. Ascending cholangitis B. Cholecysitis C. Choledocholithiasis D. Gastroenteritis E. Hereditary spherocytosis
A. Ascending cholangitis
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? A. Beta blocker B. ACE inhibitor C. Calcium channel blocker D. Angiotensin receptor blocker E. Alpha blocker
A. Beta blocker
Which of the following symptoms is most frequently reported in patients that have peptic ulcer disease? A. Dyspepsia B. Sharp abdominal pain C. Relief of pain with food D. Pain that awakens the patient at night E. Significant vomiting
A. Dyspepsia
A 42-year-old man with a prior history of gallstones comes to the emergency department because of severe upper abdominal pain. The pain began about 6 hours ago, has gradually worsened, and is now constant with associated nausea. The patient rates the pain as an 8 on a 10-point scale. He states that the pain radiates to his back and is partially relieved by sitting up and bending forward. Physical examination shows upper abdominal tenderness and reduced bowel sounds. Which of the following is the patient's most likely laboratory abnormality? A. Elevated serum amylase B. Hypercalcemia C. Hypoglycemia D. Low C-reactive protein (CRP) E. Low serum lipase
A. Elevated serum amylase
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. in the past few months. On exam, you find a palpable abdominal mass. What is his most likely diagnosis? A. Gastric adenocarcinoma B. Crohn's disease C. Peptic ulcer disease D. Nonfamilial adenmatous polyposis E. Anorexia nervosa
A. Gastric adenocarcinoma
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? A. Metronidazole B. Cephalexin C. Trimethoprim-sulfamethoxazole D. Gentamycin E. Ofloxacin
A. Metronidazole
Patient is having recurrent episodes of pancreatitis and there is a CA19-9 is elevated. If ERCP is not available, what other methods could be used to evaluated and treat this patient? A. Multiphasic CT scan B. MRI Abdomen C. EUS D. Percutaneous cholangiography E. Push enteroscopy
A. Multiphasic CT scan
A 50 year old female presents to the office with elevated Alk Phos. She denies abdominal pain. The history is negative for medications of any kind, and she denies alcohol use. Surgical history negative. Which is the most likely diagnosis? A. Primary biliary cirrhosis B. Pancreatitis C. Cholecystitis D. Fatty Liver E. Primary Sclerosing Cholangitis
A. Primary biliary cirrhosis
A 46-year-old female presents to the emergency department with a complaint of hematemesis, nausea, and epigastric pain. The hematemesis started earlier this morning, while the epigastric pain started three days prior and was a dull ache. She has vomited three times. She denies fever, diarrhea, or weight loss. She has not had blood in her stool. Her current medications include ibuprofen. She has been taking this medication daily for the past three months for right knee pain. What is the test that is the most sensitive for diagnosing this disease process? A. Upper endoscopy B. Hemoccult test C. Esophageal manometry D. Barium esophagography E. Urea breath test
A. Upper endoscopy
A 65-year-old man who immigrated from China to the United States 15 years ago comes to the office because of increased abdominal girth, weight loss, and fever. Physical examination shows for right upper quadrant tenderness on palpation and organomegaly. A tissue biopsy is obtained and tests positive for a primary malignancy. Which of the following tumor markers is most likely to be elevated in this patient? A. alpha-fetoprotein (AFP) B. CA 19-9 C. CA-125 D. Carcinoembryonic antigen (CEA) E. S-100
A. alpha-fetoprotein (AFP)
A 48-year-old man presents to the emergency department with acute right upper quadrant tenderness, fever, and mild jaundice. Which of the following is most likely to be elevated in the blood? A. bilirubin B. creatinine C. glucose D. ketones E. uric acid
A. bilirubin
A 55-year-old generally healthy male returns from a vacation to Mexico with a 5-day history of nausea, vomiting, fever of 100.5°F, and vague RUQ abdominal discomfort. Which of the following physical examination findings would be most consistent with your suspected diagnosis? A. jaundice B. ascites C. macular diffuse rash D. white tonsillar exudate E. petechial rash extremities
A. jaundice
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? A. malignancy B. hyperparathyroidism C. thiazide diuretic use D. dehydration E. vitamin D toxicity
A. malignancy
Of the following choices, which regimen is considered first-line therapy for Helicobacter pylori-positive individuals with peptic ulcer disease? A. omeprazole & clarithromycin & amoxicillin B. omeprazole & ranitidine & clarithromycin C. esomeprazole & clarithromycin & ampicillin D. ranitidine & amoxicillin & bismuth subsalicylate E. misoprostol & clarithromycin & metronidazole
A. omeprazole & clarithromycin & amoxicillin
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? A. 5 to 7 days B. 10 to 14 days C. 14 to 21 days D. 4 to 6 weeks E. Indefinitely
B. 10 to 14 days
A 42-year-old man comes to the emergency department because of upper abdominal pain, nausea, and vomiting for the past 24 hours. He has a history of heavy alcohol use. Vital signs show temperature is 37.8°C (100.1°F), pulse is 114/min, respirations are 22/min, and blood pressure is 108/68 mm Hg. Physical examination shows upper abdominal tenderness and flank bruising. Which of the following conditions is the most likely cause of his symptoms and signs? A. Acute cholecystitis B. Acute pancreatitis C. Gastritis D. GERD E. Peptic ulcer disease
B. Acute pancreatitis
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? A. Volvulus B. Adenocarcinoma C. Diverticular disease D. Strangulated hernia E. Adhesions
B. Adenocarcinoma
A 35-year-old woman comes to the emergency department because of progressively worsening right upper abdominal pain for two days. The patients states that for the past 3 months she's had a similar pain 1-2 hours after meals, but now the pain is more severe and constant. She admits to fever, dark-colored urine, and clay-colored stools. She denies pain radiation, nausea, or vomiting. Physical examination shows a middle aged female in moderate distress with mild jaundice. Abdominal examination shows tenderness to palpation in the upper right quadrant. A pregnancy test is negative. A complete blood count shows leukocytosis and elevated alkaline phosphatase. Blood culture is positive for Escherichia coli. Based on the patient's presentation, which of the following is the most likely diagnosis? A. Acute cholecystitis B. Ascending cholangitis C. Biliary colic D. Choledochlolithiasis E. Chronic pancreatitis
B. Ascending cholangitis
A 58 year old male presents with acute onset of abdominal pain associated with fever and shaking chills. He is hypotensive and febrile. He is confused and disoriented and complains of right upper quadrant abdominal pain during palpation. He has scleral icterus. Which of the following is the most likely diagnosis? A. Acute cholecystitis B. Ascending cholangitis C. Acute pancreatitis D. Choledocholithiasis
B. Ascending cholangitis
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? A. Barium enema B. Computed tomography (CT) C. Sigmoidoscopy D. Colonoscopy
B. Computed tomography (CT)
A 42-year-old woman comes to the emergency department because of recurrent abdominal pain that has persisted over the past 3 weeks. The pain is dull, postprandial, and located in right upper quadrant. She denies nausea and vomiting. Her temperature is 37.5°F (99.5°F), pulse is 75/min, respirations are 16/min, and blood pressure is 125/75 mm Hg. Examination shows that her abdomen is non-distended with minimal tenderness. The liver, rectal, and pelvic examinations are normal. Laboratory studies show: Leukocyte count: 13,000/mm3 Total bilirubin: 0.8 mg/dL Direct bilirubin: 0.6 mg/dL Alkaline phosphatase: 52 U/L AST: 18 U/L ALT: 15 U/L Serum lipase and amylase concentrations are normal. Which of the following anatomical landmarks, if obstructed, is most likely involved in this patient's disease process? A. Common bile duct B. Cystic duct C. Gallbladder D. Ileum E. Pancreatic duct
B. Cystic duct
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? A. Amphotericin lozenges B. Diflucan (fluconazole) C. Septra (TMP/SMX) D. Nexium (esomeprazole) E. Nystatin swish and swallow
B. Diflucan (fluconazole)
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? A. Two to four weeks B. Eight to twelve weeks C. Four to six months D. One year E. Continue indefinitely
B. Eight to twelve weeks
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. Gastritis D. Peptic ulcer disease E. Gastroesophageal reflux disease
B. Esophageal strictures
Which of the following signs and symptoms is associated with the abdominal pain secondary to chronic intestinal ischemia? A. Guarding and rigidity B. Fear of eating C. Nausea and vomiting D. Bloody diarrhea E. Positive obturator and psoas signs
B. Fear of eating
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? A. Left colectomy with primary anastomosis B. Hartmann procedure C. Proctocolectomy D. Abdominoperineal resection E. Low anterior resection
B. Hartmann procedure
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
B. INR of 7
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? A. Elevated CEA B. Iron deficiency anemia C. Elevated CA 125 D. Megaloblastic anemia E. Elevated CRP
B. Iron deficiency anemia
An anxious 60-year-old male presents to the ED with acute onset of LUQ and epigastric pain radiating to his left scapula. The pain is severe, constant and worsening over the last 2 hours. He has vomited once. There is no rebound or masses noted. Vitals: Temp 100.8, BP 90/40mmHg, Pulse 120 bpm, RR 26/min. What is the most likely diagnosis? A. Cholecystitis B. Pancreatitis C. Diverticulitis D. Appendicitis E. Gastroenteritis
B. Pancreatitis
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? A. Plain abdominal x-ray B. Ultrasonography C. Radionuclide scan (HIDA scan) D. Computed tomography (CT)
B. Ultrasonography
Which of the following is a complication of Barrett esophagus? A. achalasia B. adenocarcinoma C. diffuse spasm D. varices E. stricture
B. adenocarcinoma
A 63 -year-old male returns to the office for follow-up complaining of increasing abdominal girth and weight gain of 10 pounds in the past month, despite his usual caloric intake. His vital signs are normal. He continues to drink at least a six-pack of beer daily despite your previous recommendations. On examination you note ascites, palmer erythema, and gynecomastia. The patient finds his increasing abdominal girth to be uncomfortable and is requesting treatment. He admits that his diet is low in salt. What treatment is indicated at this time? A. increase in salt intake B. amiloride with furosemide C. hydrochlorothiazide (HCTZ) D. large volume paracentesis E. spironolactone
B. amiloride with furosemide
You are examining a 48-year-old male with a history of liver cirrhosis from chronic hepatitis C. Which of the following physical examination findings is a result of the effects of portal hypertension? A. gynecomastia B. caput medusae C. testicular atrophy D. jaundice E. ecchymosis
B. caput medusae
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? A. blood urea nitrogen (BUN) B. production of 1,25-dihydroxycholecalciferol C. secretion of parathyroid hormone (PTH) D. secretion of thyroid hormones E. serum concentration of creatinine
B. production of 1,25-dihydroxycholecalciferol
In Western society, diverticulosis most often occurs in which portion of the colon? A. transverse B. sigmoid C. descending D. ascending E. equally common in all parts of the colon
B. sigmoid
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? A. +HBsAg, +anti-HBc IgM B. +HBsAg, +anti-Hbc IgG C. +anti-HBs D. +anti-HBs, +anti-HBIgG E. +anti-HCV
C. +anti-HBs
A 42-year-old male presents with a three year history of progressive dysphagia, weight loss, and nocturnal aspiration. An upper GI study (barium swallow) shows a moderately dilated esophagus with a smooth, tapered, distal "bird's beak" deformity. What is the most likely diagnosis? A. Diffuse esophageal spasm B. Barrett's esophagus C. Achalasia D. Gastroesophageal reflux disease E. Esophagitis
C. Achalasia
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? A. Perforated duodenal ulcer B. Acute cholecystitis C. Acute pancreatitis D. Mesenteric ischemia E. Choledocholithiasis
C. Acute pancreatitis
A 64-year-old caucasian male presents to the office with a complaint of worsening difficulty swallowing over the last two months. He also has a long history of gastroesophageal reflux disease. He is now becoming concerned because he has lost 15 pounds in the last two weeks. What is the most likely diagnosis? A. Leiomyosarcoma B. Esophageal stricture C. Adenocarcinoma D. Achalasia E. Squamous cell carcinoma
C. Adenocarcinoma
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? A. Endoscopy B. Esophageal manometry C. Barium esophagram D. Esophageal pH monitoring E. CT scan of the abdomen
C. Barium esophagram
A 71-year-old woman comes to the office because her friends have noticed a slight yellowing of her skin over the past month. She says she has persistent "itching all over", had a recent weight loss of 6.8-kg (15-lb), and has a mild pain in the middle of her back after she eats a meal. On physical exam, there is round cystic mass in the upper abdomen that is non-tender to palpation. Which of the following specific serum markers is most likely to be abnormally elevated? A. Alpha fetoprotein (AFP) B. Beta human chorionic gonadotropin C. CA 19-9 D. CA-125 E. Carcinoembryonic antigen (CEA)
C. CA 19-9
Which of the following conditions is the most common cause of massive lower gastrointestinal bleeding? A. Hemorrhoids B. Colon cancer C. Diverticular disease D. Upper gastrointestinal hemorrhage E. Meckel diverticulum
C. Diverticular disease
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? A. Repeat endoscopy B. Barium esophagography C. Esophageal manometry D. Abdominal CT scan E. Urea breath test
C. Esophageal manometry
A 40-year-old man comes to the emergency department because of increasing upper abdominal pain that began two hours ago. He states the pain has been progressive, with associated nausea and several episodes of vomiting. Physical examination shows his temperature is 37.8ºC (100.2˚F), pulse is 105/min, respirations are 18/min, and blood pressure is 115/75 mmHg. He appears very pale and his abdomen is extremely tender to palpation. Laboratory studies show: Serum amylase: 725 U/L Serum lipase: 890 U/L Alanine aminotransferase: 175 U/L Aspartate aminotransferase: 120 U/L Which of the following is the most likely underlying cause of this patient's condition? A. Alcohol abuse B. Furosemide use C. Gallstone disease D. Hypercholesterolemia E. Hypoparathyroidism
C. Gallstone disease
A 55-year-old man comes to the office because of upper back pain for a month. He has lost 18-kg (40-lb) over the last 3 months. He has a history of hypertension and chronic lower back pain secondary to a construction accident 20 years prior. His current medications include lisinopril and hydrocodone. Physical examination shows scleral icterus. Laboratory analysis shows elevated carcinoembryonic antigen and CA 19-9. A CT scan is obtained and shows a mass contained in the head of the pancreas. The patient is referred to a surgeon for a Whipple procedure. Which of the following organs are removed in this procedure? A. Entire pancreas, CBD, stomach, duodenum, jejunum, and appendix B. Entire pancreas, gall bladder, proximal ileum, and left hepatic lobe C. Head of pancreas, duodenum, proximal jejunum, gall bladder, CBD, and distal stomach D. Head of the pancreas, gall bladder, and CBD E. Head of the pancreas, proximal jejunum, duodenum, and CBD
C. Head of pancreas, duodenum, proximal jejunum, gall bladder, CBD, and distal stomach
A patient presents with abdominal distension associated with nausea and vomiting. Which of the following findings is consistent with a paralytic ileus? A. Crampy abdominal pain B. Hyperactive bowel sounds C. Obstipation and failure to pass flatus D. Gas in small intestine only on KUB (kidney, ureter, bladder)
C. Obstipation and failure to pass flatus
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? A. Ranitidine B. Ondansetron C. Omeprazole D. Sucralfate E. Dicyclomine
C. Omeprazole
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? A. Gastric carcinoma B. Chronic pancreatitis C. Pancreatic carcinoma D. Choledocholithiasis
C. Pancreatic carcinoma
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? A. Oral proton pump inhibitors B. Resection of the entire duodenum C. Resection of the tumor D. Long term therapy with oral amoxicillin and an H2 antagonist E. Systemic chemotherapy
C. Resection of the tumor
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? A. Barium enema B. Barium upper GI series C. Ultrasonography of the abdomen D. CT scan of the abdomen E. Upper GI endoscopy
C. Ultrasonography of the abdomen
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? A. Barium upper GI series B. CT of abdomen C. Upper endoscopy D. PET scan E. Flexible sigmoidoscopy
C. Upper endoscopy
A 16-year-old girl is brought to the emergency department by ambulance after reportedly ingesting "a bottle of aspirin." Vital signs are temperature 37.8°C oral; pulse 94/min; respirations 30/min; blood pressure 100/68 mm Hg. What would you expect the blood gases to show that would confirm she had swallowed the aspirin? A. anion gap metabolic acidosis with respiratory acidosis B. nonanion gap metabolic acidosis with respiratory alkalosis C. anion gap metabolic acidosis with respiratory alkalosis D. nonanion gap metabolic acidosis with respiratory acidosis
C. anion gap metabolic acidosis with respiratory alkalosis
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
C. emulsification of triglycerides
Which of the following agents is a significant cause of pill-induced esophagitis? A. fluoxetine B. omeprazole C. ibuprofen D. Vitamin D E. ciprofloxacin
C. ibuprofen
Which of the following is indicated to confirm the diagnosis of celiac sprue in a patient with positive serologic testing? A. stool for fecal fat B. barium enema C. intestinal biopsy D. antimitochondrial antibodies E. food challenge
C. intestinal biopsy
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
C. lactulose
Which one of the following is a characteristic finding on computed tomography (CT) of the abdomen in a patient with acute diverticulitis? A. toxic megacolon B. air-fluid levels C. soft tissue inflammation of the pericolic fat D. thinning of the colon wall E. paucity of bowel gas in the colon
C. soft tissue inflammation of the pericolic fat
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? A. calcium B. iron C. vitamin B12 D. vitamin C E. vitamin K
E. vitamin K
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 laboratory finding is most consistent with the suspected diagnosis? A. Decreased hematocrit B. Elevated amylase C. Hyperkalemia D. Hypochloremic alkalosis E. Hyponatremia
D. Hypochloremic alkalosis
A nonpenetrating tear of the gastroesophageal junction in association with a history of vomiting is known as which of the following? A. Boerhaave syndrome B. Plummer-Vinson syndrome C. Peutz-Jeghers syndrome D. Mallory-Weiss syndrome E. Zollinger-Ellison syndrome
D. Mallory-Weiss syndrome
A 63 year old male is evaluated for midepigastric pain, weight loss and jaundice. On exam his skin is jaundiced and has scleral icterus. On palpation of the abdomen, you find a distended nontender gallbladder. Which of the following is the most likely diagnosis? A. Choledocholithiasis B. Chronic pancreatitis C. Gastric carcinoma D. Pancreatic carcinoma
D. Pancreatic carcinoma
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? A. peptic ulcer disease B. viral gastroenteritis C. Hirschsprung disease D. pyloric stenosis E. intussusception
D. pyloric stenosis
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? A. immediate referral to oncologist B. referral to GI for liver biopsy C. referral to surgeon for resection D. reassurance that no treatment is necessary E. repeat CT scan in 3 months
D. reassurance that no treatment is necessary
The best initial diagnostic study for a suspected perforated peptic ulcer is which of the following? A. abdominal ultrasound B. upper GI barium swallow C. esophagogastroduodenoscopy (EGD) D. upright/decubitus abdominal plain film E. colonoscopy
D. upright/decubitus abdominal plain film
A 58-year-old man presents with the acute onset of abdominal pain associated with fever and shaking chills. The patient is hypotensive and febrile with a temperature of 102.2°F. Although he is confused and disoriented, he complains of right upper quadrant pain during palpation of the abdomen. His sclerae are icteric and the skin is jaundiced. Which of the following is the most likely diagnosis? A. Acute cholecystitis B. Choledocholithiasis C. Acute pancreatitis D. Ascending cholangitis
D. Ascending cholangitis
A 56-year-old man is diagnosed with a carcinoma of the sigmoid colon by colonoscopy. Which of the following tests should be performed as part of the preoperative evaluation for distant metastasis? A. Carcinoembryonic antigen level B. CT of the chest C. Endorectal ultrasound D. CT scan of the abdomen E. Bone scan
D. CT scan of the abdomen
A 45-year-old woman comes to the emergency department because of the sudden onset of abdominal pain during the past hour. She reports occasional episodes of abdominal pain that radiates to the right shoulder, especially after eating greasy meals; however, her usual episodes are milder and shorter. She does not drink alcohol or use illicit drugs. Her temperature is 39.4°C (103°F). Physical examination shows scleral icterus. Which of the following is the most likely diagnosis? A. Pancreatitis B. Diverticulitis C. Cholecystitis D. Cholangitis E. Appendicitis
D. Cholangitis
A 23-year-old man, unrestrained driver, is brought to the emergency department by ambulance after having been involved in an automobile accident. His vitals are BP: 99/54 mm Hg, P: 112/min, R: 18/min, oxygen saturation: 99%, T: 99.8°F. Examination reveals mild abdominal tenderness with pain radiating to the right shoulder. What is the most appropriate diagnostic test to order initially? A. Computed tomography of the abdomen and pelvis B. Diagnostic peritoneal lavage C. Flat and upright abdominal radiographs D. Diagnostic ultrasound
D. Diagnostic ultrasound
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, flat ulcerations. Initial treatment consists of which of the following medications? A. Nystatin suspension B. Acyclovir C. Famciclovir D. Ganciclovir E. Fluconazole
D. Ganciclovir
A 65-year-old female presents to the primary care office with epigastric pain and nausea. Which of the following is a spiral gram-negative rod that resides beneath the gastric mucosa layer and causes gastric mucosal inflammation, with polymorphonuclear cells and lymphocytes? A. Treponema pallidum B. Borrelia burgdorferi C. Corynebacterium diphtheriae D. Helicobacter pylori E. Giardia lamblia
D. Helicobacter pylori
A 65-year-old woman comes to the emergency department because of mid-epigastric pain that radiates to the back. Despite attempts to alleviate the pain, it has persisted for the past 8 hours. She has not had any melena. She has a history of hyperparathyroidism. Examination shows temperature is 38°C (100.4°F), pulse is 102/min, and blood pressure is 100/70 mm Hg. Her abdomen is mildly distended, tender to palpation, with no guarding. Complete blood cell count shows no abnormalities. Serum lipase concentration is elevated. Which of the following is the greatest risk factor for the likely diagnosis? A. H. pylori B. Acinar cell loss C. Barrett esophagus D. Hypercalcemia E. Pancreatic pseudocyst
D. Hypercalcemia
A 74-year-old woman comes to the clinic because of stomach pain for the past 6 months. It used to only occur after meals, but has gotten progressively more frequent and wakes her up at night. She also notes that she has lost 20-lb (9.1kg) in the past 3 months, and attributes this to a decreased appetite. Her current medications include atorvastatin and metformin. Her temperature is 38.1°C (100.6°F), pulse is 84/min, respirations are 12/min, and blood pressure is 136/84 mm Hg. Physical examination shows a cachectic appearing woman with yellow-colored skin. A non-tender mass is palpated in the right upper quadrant of the abdomen. Laboratory studies show a direct bilirubin of 3.5 mg/dL. Abdominal ultrasound is shown below. A cholecystectomy is performed and histologic examination shows a primary malignancy. Which of the following disorders is associated with the development of this patient's condition? A. Irritable bowel syndrome B. Peptic ulcer disease C. Primary biliary cholangitis D. Primary sclerosing cholangitis E. Small intestine bacterial overgrowth
D. Primary sclerosing cholangitis
Your 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 physical 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 and calcified with a single, large gallstone. Of the following, what is the most appropriate next step? A. Counsel the patient on diet, exercise, and lifestyle changes and revisit the issue should symptoms reoccur. B. Refer the patient for an abdominal computed tomography (CT) scan. C. Refer the patient to a gastroenterologist. D. Refer the patient to a surgeon for a laparoscopic cholecystectomy due to the risk of gall bladder cancer. E. Re-evaluate the patient for symptomatology in four to six weeks.
D. Refer the patient to a surgeon for a laparoscopic cholecystectomy due to the risk of gall bladder cancer.
A 54-year-old man presents to the emergency department with abdominal pain. He has a two-day history of severe epigastric pain radiating to the back with associated nausea and vomiting. He is markedly obese. His medical history is significant for diabetes mellitus and a premature heart attack 10 years ago. He admits to having problems adhering to his medication regimen. He denies alcohol use. When questioned about his family's medical history he reports that his brother and mother also have known heart problems. CT scan shows diffuse parenchymal enlargement of the pancreas with indistinct margins and retroperitoneal fat stranding. The biliary tree has a normal calibre. He is diagnosed with acute pancreatitis. Which of the following most likely incited acute pancreatitis in this patient? A. Severe hypercholesterolemia B. Severe hyperglycemia C. Severe hypertension D. Severe hypertriglyceridemia E. Severe hypocalcemia
D. Severe hypertriglyceridemia
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
D. Smoking cigarettes
Which of the following diagnostic tests is the imaging study of choice in patients suspected of having Zollinger-Ellison syndrome? A. Transabdominal ultrasound B. Computed tomography of the abdomen C. Magnetic resonance imaging D. Somatostatin receptor scintography E. Endoscopic ultrasonography
D. Somatostatin receptor scintography
A 54-year-old man presents to the emergency department with crampy abdominal pain, nausea, and vomiting. The patient has not passed gas or had a bowel movement for at least 10 hours. On examination, the abdomen is distended and there are high-pitched bowel sounds with rushes. A plain radiograph of the abdomen reveals cecal distension to 12 cm. What is the most appropriate definitive management for this patient? A. Intravenous fluids B. Nasogastric suction C. Observation D. Surgical exploration
D. Surgical exploration
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? A. Upper endoscopy B. Increase the dose of the antacids C. Barium esophagography D. Treat empirically with a proton pump inhibitor E. Esophageal pH monitoring
D. Treat empirically with a proton pump inhibitor
35 year old obese female, 4 weeks post-partum, presents to ED with RUQ pain radiating to her back associated with nausea and vomiting that began after eating pizza. She has no past medical or surgical history. No pertinent family history. What initial imaging study would you order to evaluate this patient? A. CT scan of the abdomen B. Abdominal Xray C. MRI of the abdomen D. Ultrasound of the abdomen E. Upper endoscopy
D. Ultrasound of the abdomen
A 4-year-old child swallows several tablets of a medication that he found in his parent's bathroom cabinet underneath the sink. Approximately 2 to 3 hours after ingesting the tablets, there were no symptoms other than nausea and vomiting. Thirty hours after ingesting the tablets, elevated aminotransferase levels were detected followed by jaundice, hepatic encephalopathy, renal failure, and death. What did the child most likely swallow? A. diazepam B. aspirin C. oxycodone D. acetaminophen E. phenobarbital
D. acetaminophen
Administration of a drug that inhibits acetylcholinesterase would most likely lead to which of the following? A. bronchodilation B. decreased lacrimation C. decreased salivation D. increased gastric juice secretion E. increased heart rate
D. increased gastric juice secretion
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? A. pyloric stenosis B. mesenteric ischemia C. Crohn disease D. intussusception E. Hirschsprung disease
D. intussusception
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 relieve his symptoms for a few months, but they are not working well now. In discussing lifestyle modifications with this patient, to help reduce his symptoms, which of the following is recommended? A. Eating larger meals B. Increasing the intake of acidic foods C. Lying down within 30 minutes after eating D. Increasing the intake of fatty foods E. Elevating the head of the bed six inches
E. Elevating the head of the bed six inches
A 55-year-old man comes to the emergency room because of abdominal pain. The pain started the previous evening and is similar to abdominal pain he has experienced in the past. The patient has a history of hypertension, hyperlipidemia, obesity, alcohol use, osteoarthritis, and peripheral vascular disease. His medications include hydrochlorothiazide, pravastatin, metformin, and ibuprofen. His temperature is 37°C (98.6°F), pulse is 120/min, respirations are 18/min, and blood pressure is 135/85 mm Hg. Physical examination shows epigastric and right upper quadrant tenderness on palpation of his abdomen. Heme-occult stool test is negative. Serum lipase is normal. Which of the following is the most likely underlying cause of his condition? A. Acute inflammation of the pancreas B. Insufficient perfusion of small bowel C. Malignant transformation of the bile duct D. Mucosal erosion of the stomach E. Obstruction of the cystic duct
E. Obstruction of the cystic duct
What does a positive surface antibody for hepatitis B (anti-HBs) indicate? A. Reinfection B. Acute infection C. Chronic infection D. Carrier state E. Previous immunization
E. Previous immunization
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? A. Duodenal atresia B. Intestinal malrotation C. Intussusception D. Peptic ulcer disease E. Pyloric stenosis
E. Pyloric stenosis
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. Appropriate imaging is obtained and confirms the suspected diagnosis. What is the treatment of choice in this patient? A. Acid supression B. Dilatation of the lower esophageal sphincter C. Diverting colostomy D. Ladd procedure E. Pyloromyotomy
E. Pyloromyotomy
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? A. Platelets < 150,000 per microliter B. INR < 1.5 C. Patient remaining NPO for > 24 hours D. Hematocrit < 35% E. Respiratory failure requiring mechanical ventilation > 48 hours
E. Respiratory failure requiring mechanical ventilation > 48 hours
A 58-year-old male is diagnosed with a gastrin-secreting gut neuroendocrine tumor. What is the medical term for this condition? A. Ascending cholangitis B. Celiac disease C. Clostridium difficile colitis D. Irritable bowel syndrome E. Zollinger-Ellison syndrome
E. Zollinger-Ellison syndrome
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? A. hepatitis A B. hepatitis B C. hepatitis C D. hepatocellular carcinoma E. autoimmune hepatitis
E. autoimmune hepatitis
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? A. keep a food diary for the next 2 weeks B. flexible sigmoidoscopy C. increase dietary fiber and increase daily water intake D. refer for psychologic evaluation to help with stress of her divorce E. colonoscopy
E. colonoscopy
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? A. acute hepatitis B B. alcoholic hepatitis C. chronic hepatitis A D. Gilbert's syndrome E. hepatocellular carcinoma
E. hepatocellular carcinoma
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. An enema is attempted which is unsuccessful in relieving the impaction. Which of the following should be selected as the next treatment for this patient? A. passing a nasogastric tube B. milk of magnesia C. opiate analgesics for pain D. oral sodium phosphate E. manual disimpaction
E. manual disimpaction
Which of the following antibiotics is the most appropriate treatment for antibiotic-associated colitis? A. oral ciprofloxacin B. intravenous vancomycin C. oral sulfasalazine D. intravenous penicillin E. oral metronidazole
E. oral metronidazole
A 52-year-old man recently underwent surgery for a hip replacement. Upon discharge, he is prescribed oxycodone 7.5 mg and acetaminophen 325 mg and told to take 1 to 2 tablets every 6 hours prn to help manage the pain he is expected to encounter as he recovers at home. Which of the following medications would you also recommend for the patient to help minimize potential side effects associated with his pain medication? A. esomeprazole B. diphenhydramine C. guaifenesin D. hydrocortisone 1% cream E. senna & docusate
E. senna & docusate
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
E. systemic lupus erythematosus