I&D Block 9 Question Bank

Two of the birth defects that can be caused by excessive vitamin A during pregnancy

Cleft palate and cardiac issues

Which of the following conditions is correctly matched to its causal antibody/antigen?

All: Post-strep glomerulonephritis - antibodies against the cell wall mucopeptide Systemic lupus erythematosus - anti-nuclear antibody Serum sickness - foreign antisera Polyarteritis nodosa - hepatitis B virus surface antigen

A 19-year-old male college student presents to the clinic in January with a 2-day history of watery diarrhea. The patient also complains of weakness, nausea, vomiting, and abdominal cramps. He has no significant past medical history. He does not take any medication. He drinks socially on the weekends but does not smoke cigarettes. He recently returned from a 3-day cruise off the Florida coast with his fraternity brothers. The blood pressure is 110/70 mm Hg, the heart rate is 104/min, the respiratory rate is 12/min and the temperature is 37.7°C (99.9°F). On physical examination his buccal mucosa is dry. The physician suggests oral rehydration therapy. Which of the following is the most likely causative agent?

A: Norovirus is the most common cause of viral gastroenteritis in the world. The virus transmission is via the fecal-oral route. Drinking water, contaminated food, shellfish from contaminated water, and food contaminated from infected food-handlers are common sources for the virus to spread. Symptoms begin 12-48 hours after exposure to the virus, and watery diarrhea lasts anywhere from 12-60 hours in immunocompetent individuals.

A 63-year-old woman presents with acute onset of abdominal pain that describes as a steady deep discomfort in the left lower quadrant. She was constipated initially, but she is now experiencing diarrhea. On physical examination, she has a temperature of 38°C. The abdomen is tender in the LLQ with guarding and rebound tenderness. She has positive fecal occult blood. What is the most appropriate test to determine the most likely diagnosis?

Abdominal CT

Which of the following is the main pathology in type III hypersensitivity reaction?

Accumulation of immune complexes

What is an example of a type II hypersensitivity reaction?

Autoimmune hemolytic anemia

A 35-year-old man presents with intense itching around his anus that has been worsening over the last several weeks. He states that he has noticed an increasingly severe and tearing pain in the anal area with each bowel movement. He would rank this pain as a 10/10. This intense pain makes him not want to have any bowel movements. He admits to only one episode of a small amount of bright red blood on the toilet paper and on the stool itself. The patient denies fever, diarrhea, or ever being diagnosed with inflammatory bowel disease.

Avoid spicy food

A 30-year-old man hates milk and says, "I get constipated, so I use laxatives." He picked up food from a take-out restaurant that was selling fried rice, which he consumed later. His father has Crohn's disease. He presents with nausea, vomiting, and voluminous diarrhea with no change in osmolar gap. What is the probable cause of diarrhea?

B. cereus-induced food poisoning

Vitamin that only naturally occurs in animal sources

B12

Vitamin that requires intrinsic factor for absorption

B12

Vitamin that is nique in that deficiency and toxicity can result in neuropathy

B6

A 52-year-old woman was noted on yearly examination to have a microcytic anemia. She has recently noted a change in bowel habits and rectal bleeding with bowel movement. She reports abdominal pain. She has no prior surgical history. Her only medical issue is an elevated cholesterol level that is controlled by diet. Her pulse is 92 BPM, blood pressure is 140/78 mm Hg, respiration rate is 14/min, and temperature is 98.7°F. Rectal exam is notable for guaiac positive stool without any masses. Neurological examination is normal. What test should be ordered to confirm the suspected diagnoses?

Colonoscopy

A 42-year-old man presents for evaluation of vitamin D deficiency with possible osteomalacia. The patient had a pathologic fracture three weeks ago and was found to have dangerously low levels of vitamin D, with normal serum calcium levels. Bone density has been drastically affected, leading to the fracture. The lack of what compound is most responsible for the development of this disease?

Calcitriol

A 33-year-old woman presents to the urgent care center because of 3 days of abdominal pain and diarrhea. The pain is described as crampy, and she points to the periumbilical area to show its location. She has diarrhea about 12 times a day and only started noting blood in the stool starting yesterday. Her symptoms started a couple of days after she went camping, and other people who ate the chicken they cooked also have been ill. Temperature is 98.6°F (37°C), blood pressure is 121/81 mm Hg, heart rate is 77/min, and respiratory rate is 14/min. Physical examination is unremarkable. Given the following options, what is the most likely pathogen responsible for her presentation?

Campylobacter is transmitted by ingesting contaminated food or water, typically in young children and adults. It is the most frequently implicated pathogen in patients with bacterial diarrhea, and foodborne disease is often related to poultry.

A 23-year-old man who was volunteering in rural Mexico presents to the urgent care center after returning from his trip with complaints of fever, body aches, stomach cramping, and frequent diarrhea for 3 days. Today, he noted blood in his stool. He reports eating food from the local markets where he stayed and is unsure if it was safe. Bismuth subsalicylate has given him mild relief from his symptoms. His medical history is otherwise normal. On examination, his temperature is 38.0°C (100.5℉), pulse rate is 104/min, respirations are is 14/min, blood pressure is 108/66 mm Hg, and oxygen saturation on room air is 95%. On examination, he appears to be slightly ill. His abdomen is mildly tender without point tenderness or rebound. A stool sample is examined and gram-negative "S"-shaped, motile bacteria are present. What is the client's most likely diagnosis?

Campylobacter jejuni

A 3-year-old girl presents with a 1-day history of irritability and weakness in her legs. Neurologic exam reveals an ascending symmetrical paralysis with cranial neuropathy. A lumbar puncture is performed and cerebrospinal fluid is found to have a normal glucose level, <10 leukocytes/mm3, and elevated protein. Medical history shows the child recently recovered from a mild diarrheal illness. Question: What organism is triggering this syndrome?

Campylobacter jejuni

A 35-year-old male patient presents with a groin mass. The patient says the mass is painless, and there is no known trauma to the region. The mass is present upon standing and disappears when lying flat. Past medical history includes chronic constipation, hypertension, and hyperlipidemia. Past surgical history includes lipoma removal from the left shoulder. The patient denies tobacco use; he drinks about 6 beers per week. Ultrasound confirms the diagnosis, and surgical repair is scheduled. Question What is the most significant risk factor for this patient's condition?

Chronic constipation

A 58-year-old man presents with a recent episode of rectal bleeding. A brief history reveals that his bowel patterns have been increasingly erratic over the past 6 weeks. He reports periods of 2-6 days without bowel movements followed by copious production of thin coils of stool. He has lost 10 lb over the last month. His family history is significant for the death of his cousin from colon cancer. Physical exam reveals the patient is pale and febrile (temperature 101°F); the rectal exam is heme-positive with scant stool, and his prostate is soft and moderately enlarged. What is the most appropriate evaluation method in the diagnosis of colorectal cancer?

Colonoscopy

A 5-month-old girl presents with a 3-day history of vomiting. She is exclusively breastfed, and her mother states that today she has vomited within 15 minutes of each feeding. Her last wet diaper was 10 hours ago. On physical examination, she is afebrile, tachycardic, and irritable, and she does not express tears when crying. She was a full-term vaginal delivery. She has no significant past medical history. Her 3-year-old sister has had gastroenteritis for the past few days. Question Based on the most likely diagnosis, what is the most likely laboratory finding?

Hypokalemia

Type I hypersensitivity is mediated by what Immunoglobin (Ig) Class?

IgE

Type II hypersensitivity reactions are mediated by

IgG and IgM

Which of the following regarding the phases of Type I hypersensitivity is true?

Immediate phase is IgE mediated

Which of the following regarding the phases of type I hypersensitivity reaction is most accurate?

Immediate phase reaction is IgE mediated.

Stevens-Johnson syndrome/toxic epidermal necrolysis is

T-cell mediated.

A 15-year-old boy presents with bloody diarrhea and abdominal cramping. A double contrast barium enema shows fine serrations and narrowing of the rectum and sigmoid. Stool contains mucus, blood, and white blood cells, but no parasites or bacterial pathogens. Endoscopy shows inflamed mucosa and pseudopolyps. A biopsy finds an extensive inflammatory process in the mucosa and submucosa. The glands are filled with eosinophilic secretions; there is also mild involvement of the terminal ileum. Sulfasalazine treatment is attempted without improvement. What is the most appropriate next step in management?

Corticosteroids

What are the 4 D's of pellagra which is caused by vitamin B3 deficiency:

Diarrhea, death, dementia, dermatitis

A 28-year-old woman presents to your office with a chief complaint of abdominal discomfort, bloating, and constipation intermittently over the last 10 years. While her symptoms have waxed and waned, they have never worsened. She describes her abdominal pain as diffuse, dull, and crampy, and she often finds relief after a bowel movement. She denies radiation of pain, nausea, vomiting, fever, chills, weight loss, heartburn, hematemesis, hematochezia, or melena. Over the last 3 months, she reports abdominal cramping 12 to 15 times per month and has a hard bowel movement every 2 to 3 days with a sensation of incomplete evacuation. She has tried over-the-counter stool softeners and laxatives, with only minimal improvement. She has no significant past medical history and denies tobacco, alcohol, or illicit drugs. Her family history is negative for gastrointestinal (GI) disease, and she reports that her parents and siblings are healthy. She is currently engaged and reports moderate stress in preparing for the wedding. Her vital signs and general physical examination are unremarkable. Her abdomen has normal bowel sounds and mild tenderness on diffuse palpation without rebound, rigidity, or guarding. There is no hepatomegaly and no palpable masses. Pelvic examination is unremarkable, and anorectal examination reveals normal sphincter tone, no masses, and guaiac-negative stool. Most likely diagnosis? First steps in diagnosis? Treatment?

Dx: irritable bowel syndrome, constipation predominant 1st step: history and physical. Since they are negative for alarm signs, no additional diagnostic work up is needed Tx: education, reassurance, lifestyle modification with tracking of symptoms and food diary, elimination diet, regular exercise, minimize stressors.

Which of the following is used for the diagnosis of Clostridium difficile infection?

Enzyme immunoassay for Clostridium difficile toxin

Vitamins likely to cause toxicity if consumed in large amounts

Fat soluble

Vitamin that decreases neural tube defects

Folate

Too much ___ can make a diagnosis of ___ more difficult

Folate; bitamin B12 **No macrocytosis; HC levels will be normal, MMA will be normal

A 23-year-old woman presents to her doctor for nausea, fatigue, and amenorrhea. She had her first menarche at the age of 13, and her menstrual cycle became regular at the age of 15. She has been sexually active since the age of 20 but has had the same sexual partner since then. They stopped using birth control protection approximately 6 months ago. She does not smoke and consumes alcohol occasionally. Her blood pressure is 120/80 mm Hg, heart rate is 71/min, respiratory rate is 14/min, and temperature is 36.6℃ (98.2℉). Physical examination is significant only for slight breast engorgement and nipple pigmentation. Gynecologic examination reveals cervical softening and cyanosis. Which of the following drugs would be recommended for this patient?

Folic acid

A 38-year-old man presents with weakness, loss of appetite, headaches, and irritability. He developed these symptoms gradually over the past 4 months. He was diagnosed with Crohn's disease, which was moderate at the time of diagnosis 6 months ago. He takes methotrexate 15 mg, which effectively controls his symptoms. The patient's vital signs include: blood pressure 105/70 mm Hg, heart rate 102/min, respiratory rate 16/min, and temperature 36.4℃ (97.5℉). On physical examination, the patient is pale. His lungs are clear to auscultation. His heart sounds are rhythmic; a short early systolic murmur can be heard over the apex of the heart. The rest of the exam is unremarkable. Which of the following drugs should be prescribed to this patient?

Folic acid

A 14-year-old girl presents with a 4-day history of flatulence, foul-smelling stools, and abdominal distention. Her appetite has also been decreased. She has not seen any blood in her stools. She returned from a 2-week camping trip in the mountains of the western United States 1 week ago. Others in her expedition group are asymptomatic. Her physical examination reveals a well developed and well nourished adolescent with slight abdominal distention and tenderness; otherwise, everything is within normal limits. Question: What is the most likely cause of her symptoms?

Giardia lamblia

A 3-year-old boy is evaluated for a 24-hour history of diarrhea. His mother reports that he had five episodes of foul-smelling watery diarrhea associated with decreased appetite. A few other children at the same daycare center have presented with the same problem. On physical examination, the child is well hydrated and his abdomen is tender. Stool microscopy shows the presence of motile trophozoites representing the etiological agent. Question: What is most likely causing this patient's symptoms?

Giardiasis

You are performing an annual physical examination on a 14-year-old girl. In the last couple of years, she started having constipation "every other day or so," followed by loose stools. She still feels depressed because of her parents' recent divorce. She has no problems at school, her grades are good, and she participates in sports. Her mother is worried because she is so slim despite excellent appetite: that she has not grown enough. She still has not gotten her period. Her mother had her first period when she was 13. The rest of personal and family history is non-contributory. The patient's height is 5 ft, weight 79 lb (BMI 15.46; 3rd percentile); she is in Tanner stage 2 (the same as last year, according to her records); and her bone age is 12.5 years. The rest of physical examination is normal. Laboratory shows Hct of 31% and MCV of 73, low insulin-like growth factor (IGF), low FSH, positive anti-tissue transglutaminase antibodies. The rest of laboratory results are within normal limits, including TSH and prolactin.Question: What will restore normal puberty, growth, and weight in your patient?

Gluten-free diet

A structure composed an organized collection of macrophages with additional cells and matrix is best known as which of the following?

Granuloma

Which of the following is an example of a Type II hypersensitivity reaction?

Hashimoto's thyroiditis

A 20-year-old woman presents with 2 weeks of anorectal pain. She notes streaks of blood on her stool and toilet paper. She reports "a tearing pain during each bowel movement." She dreads having a bowel movement, and she attempts to hold it as long as she can. She broke her leg in a skiing accident 4 weeks ago and was prescribed oxycodone/acetaminophen (Percocet) for the first few days due to her pain. An anoscope reveals an acute anal fissure. What should be the next steps in treatment?

High Fiber diet and stool softeners

A 20-year-old woman presents with 2 weeks of anorectal pain. She notes streaks of blood on her stool and toilet paper. She reports "a tearing pain during each bowel movement." She dreads having a bowel movement, and she attempts to hold it as long as she can. She broke her leg in a skiing accident 4 weeks ago and was prescribed oxycodone/acetaminophen (Percocet) for the first few days due to her pain. An anoscope reveals an acute anal fissure. Question What should be the next step in treatment?

High-fiber diet and stool softeners

A 66-year-old man presents with a 2-month history of bone pain and weight loss. Lytic lesions were discovered on a routine X-ray. You order additional lab work. What electrolyte imbalance would you most likely find in this patient?

Hypercalcemia

Anorexia, headache, hepatosplenomegaly, irritability, scaly dermatitis, patchy loss of hair, bone pain, and hyperostosis are associated with

Hypervitaminosis A

A 67-year-old man is brought to the hospital by his relatives. He complains of early satiety, abdominal discomfort after food intake, and abdominal bloating. These symptoms have been present since the patient was 52, but they were milder at that time, so he has paid little attention to them since. Tingling and decreased sensation in both lower extremities began a few months ago. His relatives also note that he has become excessively somnolent and forgetful. The patient's medical history is significant for acute hepatitis B 20 years ago. He smokes a pack of cigarettes per day and drinks alcohol occasionally. His weight is 61 kg (134.5 lb), height is 181 cm (5 ft 11 in), and BMI is 18.6 kg/m2. His vital signs are temperature 36.1°C (96.9°F), heart rate 89/min, respiratory rate 13/min, and blood pressure 110/80 mm Hg. The patient's skin is pale, thin, and dry. There is no significant lymphadenopathy or thyromegaly. Lung and heart examinations are within normal limits. The patient's tongue is bright red with atrophic papillae. The abdomen is distended and tender to palpation in the epigastric area. Neurological examination shows symmetric decreased sensation and decreased muscle strength in both upper and lower extremities. On a mini-mental status examination, the patient scores 25 (slightly low) Which of the following options best explains the patient's neurological and psychiatric symptoms?

Impaired methylation of myelin phospholipids

A 35-year-old man presents with a painful perirectal lump. It began 6 days ago as a small firm mass and has gradually increased in size. As the mass has grown, it has become more tender. On examination, there is a 4 cm fluctuant red perirectal mass. Question What is the appropriate treatment?

Incision and drainage

Vitamin deficiency disease that presents with cardiomegaly, tachycardia, cyanosis, dyspnea, aphonic crying, vomiting, agitation, altered consciousness, and seizures

Infantile berber

A 45-year-old man presents with extreme asthenia and weight loss. He has been suffering from celiac disease for the past 12 years. He is at the highest risk of developing what type of intestinal malignancy?

Intestinal lymphoma

You get these nutrients when you eat salmon

Iron, Zinc, B12, B3, B1, Vitamin A, Folate

A 57-year-old man presents with 2 days of severe, generalized, abdominal pain that is worse after meals. He is also nauseated and reports occasional diarrhea mixed with blood. Apart from essential hypertension, his medical history is unremarkable. His temperature is 36.9°C (98.4°F), blood pressure is 145/92 mm Hg, and pulse is 105/min and irregularly irregular. Physical examination is only notable for mild periumbilical tenderness. Which of the following is the most likely diagnosis?

Ischemic bowel disease is classified into 3 main categories: acute mesenteric ischemia, chronic mesenteric ischemia, and ischemic colitis.

Which of the following statements regarding anaphylaxis is most accurate?

It is a serious hypersensitivity reaction that is rapid in onset and may cause death.

Which of the following statements regarding atopy/allergy is most accurate?

It is mainly a type 1 hypersensitivity reaction.

A 48-year-old female patient with a past medical history of obesity presents with a 2-month history of intermittent mild epigastric and right upper quadrant pain. The pain is intermittent and occurs in "waves." She notes nausea, vomiting, and radiation of pain to the right shoulder. Physical exam reveals unremarkable vital signs, but tenderness is noted in the right upper quadrant. There is no guarding or rebound. Bedside ultrasonography is obtained. Question What health maintenance advice is recommended for this patient?

Low-fat, low-cholesterol diet

The multinucleated 'giant cells' that can be present in a granuloma mainly consist of which type of cell?

Macrophages

A person who is vitamin deficient can become that way due to one or all of these three factors

Malabsorption, increased demand, decreased intake

A 22-year-old woman has had recurrent episodes of diarrhea, crampy abdominal pain, and slight fever over the last 2 years. At first the episodes, which usually last 1 or 2 weeks, were several months apart, but recently they have occurred more frequently. Other symptoms have included mild joint pain and sometimes red skin lesions. On at least one occasion, her stool has been guaiac-positive, indicating the presence of occult blood. Colonoscopy reveals several sharply delineated areas with thickening of the bowel wall and mucosal ulceration. Areas adjacent to these lesions appear normal. Biopsies of the affected areas show full-thickness inflammation of the bowel wall and several noncaseating granulomas. Most likely diagnosis: Common complications of this disease:

Most likely diagnosis: Crohn disease Common complications of this disease: Malabsorption and malnutrition, fibrous strictures of the intestine, and fistulae to other organs, such as from bowel to skin or bowel to bladder

Non-fortefied vegan source of vitamin D

Mushrooms

Excessive intake of this vitamin can cause flushing, nausea, rash, and tingling

Niacin (B3)

A 28-year-old male patient presents with rectal bleeding and three instances of a little bright-red blood with bowel movements. He reports severe rectal pain, especially with passing hard stools. Over-the-counter hemorrhoid creams have not provided relief. He admits episodic constipation for 2 years; he has eaten a high-fiber diet and taken over-the-counter stool softeners for 3 months. He denies dark tarry stools, easy bruising, and prior episodes of rectal bleeding. He has not noticed blood when urinating or brushing teeth. He denies nausea, vomiting, diarrhea, fevers, and weight loss. No known medical conditions. Family history is negative for gastrointestinal disorders. Social history reveals he is in a heterosexual relationship, denying anal intercourse. On physical exam, the abdomen is unremarkable. The anus has no visible protrusions or rash, but there is a very small, erythematous, tender "paper cut" area. Digital rectal exam (DRE) is painful. No masses in the rectal vault. Question In addition to treating constipation, what is the most appropriate prescription treatment for this patient's condition?

Nitroglycerin ointment

Do you wait until there is airway compromise before administering epinephrine?

No

What is the most common cause of acute diarrhea caused by foodborne infection?

Norovirus is the most common cause of infection caused by foodborne contamination. Poultry contamination is associated with the highest proportion of deaths, usually due to Salmonella or Listeria. Vibrio cholerae is less common, and is more often associated with contamination of seafood.

Which of the following is the best treatment option for fulminant Clostridium difficile infection?

Oral vancomycin and IV metronidazole

A 16-year-old female patient with a 2-year history of ulcerative colitis presents with signs of an acute exacerbation. There is abdominal pain and frequent passing of large quantities of blood and mucus from the rectum. She is treated with sulfasalazine, glucocorticoids, and intravenous alimentation. Diarrhea decreases markedly, but her status continues to deteriorate. Tachycardia, volume depletion, and electrolyte imbalance develop; temperature 38.77°C (101.8°F). Physical examination shows abdominal tenderness, but no mass is observed. Plain radiography shows the transverse colon is dilated up to 7 cm. Question: What is the most appropriate next step in management?

Perform Colectomy

A 16-year-old female patient with a 2-year history of ulcerative colitis presents with signs of an acute exacerbation. There is abdominal pain and frequent passing of large quantities of blood and mucus from the rectum. She is treated with sulfasalazine, glucocorticoids, and intravenous alimentation. Diarrhea decreases markedly, but her status continues to deteriorate. Tachycardia, volume depletion, and electrolyte imbalance develop; temperature 38.77°C (101.8°F). Physical examination shows abdominal tenderness, but no mass is observed. Plain radiography shows the transverse colon is dilated up to 7 cm. What is the most appropriate next step in management?

Perform colectomy.

A 28-year-old woman presents with weakness, fatigue, and headaches. She states that these symptoms began four months ago, and are gradually getting worse. Her past medical history is significant for epilepsy which was diagnosed four years ago. Initially, she was prescribed valproic acid, which, even at a maximum dose, did not control her seizures. She was then prescribed phenytoin, which she began six months ago, and is now seizure-free. She also takes omeprazole daily for gastroesophageal reflux disease, which was diagnosed several months ago. She also became a vegan two months ago. She does not smoke and consumes alcohol occasionally. Her blood pressure is 105/80 mm Hg, pulse is 98/min, respiratory rate is 14/min, and temperature is 36.8℃ (98.2℉). Her physical examination is significant only for pallor. Which of the following has most likely caused this woman's condition?

Phenytoin intake. The woman has macrocytic hyperchromic anemia, which is consistent with either B12 deficiency or folic acid deficiency. Phenytoin intake is the most likely cause of her condition because it is known to decrease folate absorption.

Which of the following is the main underlying mechanism in type IV hypersensitivity reaction?

Presensitized T cell activation upon contact with antigen

A 52-year-old man presents with rectal pain during bowel movements. He describes the pain as tearing. Physical examination reveals a tear in the anal mucosa. Question What is considered first-line treatment for the underlying cause of this patient's condition?

Psyllium

A 52-year-old man presents with rectal pain during bowel movements. He describes the pain as tearing. Physical examination reveals a tear in the anal mucosa. What is considered the first-line treatment for this condition?

Psyllium

What is the term used to describe the characteristic chest deformity associated with vitamin D deficiency?

Rachitic rosary

A 33-year-old man with no past medical history presents with groin mass. He denies pain and trauma to the region. When the patient stands, there is a round swelling in the inguinal area. If the patient is supine, the mass disappears. Question What is the appropriate intervention in this patient?

Referral to general surgeon

Disease results from vitamin D deficiency in children

Ricket's

In the winter, an 11-month-old male infant presents with a 2-day history of vomiting, diarrhea, and fever. He has not had routine medical care since birth. Mother reports no significant past medical history. His temperature is 102°F. Clinically, he appears dehydrated; his white blood cell count is 5400 cells/mm3 with a normal differential. His stool and urine are negative for white blood cells. Question: What is the most likely cause of gastroenteritis in this child?

Rotavirus

Vitamin deficiency disease due to poor collagen synthesis and is characterized by swollen, bleeding gums, poor wound healing, perifollicular hemorrhages and easy bruising

Scurvy

An elderly woman says that she is unable to pass stools unless she takes laxatives twice daily. What type of diarrhea is expected when laxatives are overused?

Secretory

Which of the following is an example of a Type III hypersensitivity reaction?

Serum sickness

A 5-year-old boy presents with a 4-day history of bloody diarrhea. He has had fever up to 104°F, abdominal pain, and painful defecation. His past medical history is unremarkable, and he has had no surgeries. He is on no medications and has no drug allergies. He attends a local daycare with nine other children. On physical examination, his abdomen is tender with hyperactive bowel sounds. While in the emergency department, he has a 5-minute generalized seizure. Question What pathogen is the most likely cause of the patient's diarrhea and seizure?

Shigella sonnei

A 35-year-old man presents with intense itching around his anus that has been worsening over the last several weeks. He states that he has noticed an increasingly severe and tearing pain in the anal area with each bowel movement. He would rank this pain as a 10/10. This intense pain makes him not want to have any bowel movements. He admits to only one episode of a small amount of bright red blood on the toilet paper and on the stool itself. The patient denies fever, diarrhea, or ever being diagnosed with inflammatory bowel disease. Question After confirming the suspected diagnosis via physical examination, you educate the patient to avoid what in order to help initiate healing?

Spicy foods

A 48-year-old man presents with a 2-day history of left-sided groin and scrotal pain. He has had similar pain episodically for several months, but it has recently become much worse after a weekend of helping his brother move furniture. He admits that he is not in good physical shape, and he thinks he may have pulled a groin muscle. He is in a monogamous relationship with his wife of 17 years. He has never had any testicular or scrotal conditions, and he has a negative surgical history. He denies fever and urinary symptoms. He has no allergies and takes no other medications. On physical exam, the patient has normal sexual development, with no edema, warmth or erythema present in the scrotum. No skin lesions are present. On palpation, there is mild tenderness on the left scrotum. However, with Valsalva, a small bulge is palpable in the left scrotum, and the patient's reported pain level increases. When he lies supine, the bulge is no longer palpable. Question What intervention is most appropriate for this patient's suspected condition?

Surgical referral

A 52-year-old man presents with a 3-day history of persistent diarrhea. He reports seven watery, non-bloody bowel movements daily. He has associated lower-abdominal cramping and mild nausea. He denies recent travel out of the country. He does not recall eating anything unusual, and none of his family members are sick. Past medical history is significant for GERD, for which he takes pantoprazole daily. He recently completed a course of oral levofloxacin for pneumonia. A stool sample is negative for ova and parasites, but PCR testing is positive for Clostridioides difficile. Question What is the appropriate first-line treatment?

Vancomycin

Vitamin given for prevention of hemorrhagic disease of newborns

Vitamin K

A 35-year-old man presents for medical care, but he is too embarrassed to tell the nurse his chief symptom. Eventually, he admits to severe, intense itching around his anus; it has been worsening the last several weeks. He further states that he has noticed increasingly severe and tearing pain in the anal area with each bowel movement. He ranks this pain as a 10/10 on a pain scale. This intense pain makes him try to avoid having bowel movements regularly. He admits to one episode of a small amount of bright red blood on the toilet paper and on the stool itself. Reviewing documentation on this patient reveals that this is the fourth similar episode in the last 14 months. The patient denies fever and diarrhea; according to him, he has never been diagnosed with inflammatory bowel disease. Question Considering the most likely diagnosis, what pharmaceutical intervention should be initiated?

Topical nitroglycerin 0.2-0.4%

Which of the following is an example of a Type IV hypersensitivity reaction?

Transplant rejection

10yo boy with fatigue, edema, dark red/brown urine 2 weeks after being treated for strep:

Type III hypersensitivity reaction

Which of the following types of hypersensitivity reaction is often referred to as delayed type hypersensitivity?

Type IV

Which type of hypersensitivity reaction is often referred to as delayed-type?

Type IV

18 yo female with red, itchy rash on abd near belt that has been worsening over the summer months?

Type IV hypersensitivity reaction to nickel and sweating.

A 28-year-old woman presents with bloody diarrhea for 1 week. After further questioning, she reveals that she had similar attacks in the past that subsided on their own. Her stool specimen is negative for ova and parasites. Stool culture did not grow any pathogens. A sigmoidoscopy is performed. There is friable erythematous mucosa extending from the rectum to the mid-descending colon, with broad-based ulcers in the descending colon. A biopsy taken from the rectum shows diffuse mononuclear inflammatory infiltrates in the lamina propria with crypt abscesses, but no granulomas are seen.Question: What is the most likely diagnosis?

Ulcerative colitis

A 22-year-old man presents with a right groin bulge. During physical assessment, a single sac is found protruding just lateral to the epigastric vessels. Although the clinical scenario is highly suggestive of a hernia, what initial imaging study would be the best choice to support this diagnosis?

Ultrasound

A 48-year-old man presents with a 2-day history of left-sided groin and scrotal pain. He has had similar pain episodically for several months, but it has recently become much worse after a weekend helping his brother move furniture. He admits that he is not in good physical shape, and he thinks he may have pulled a groin muscle. He is in a monogamous relationship with his wife of 17 years. He has never had any testicular or scrotal conditions, and he has a negative surgical history. He denies fever and urinary symptoms. He has no allergies and takes no other medications. On physical exam, the patient has normal sexual development with no edema, warmth, or erythema present in the scrotum. No skin lesions are present. On palpation, there is mild tenderness on the left scrotum. With the Valsalva maneuver, however, a small bulge is palpable in the left scrotum and the patient's reported pain level increases. When he lies supine, the bulge is no longer palpable. Question Based on this patient's history and physical what would be the most helpful test in establishing the suspected diagnosis?

Ultrasound

A 52-year-old man presents with a 3-day history of persistent diarrhea. He reports seven watery, non-bloody bowel movements daily. He has associated lower-abdominal cramping and mild nausea. He denies recent travel out of the country. He does not recall eating anything unusual, and none of his family members are sick. Past medical history is significant for GERD, for which he takes pantoprazole daily. He recently completed a course of oral levofloxacin for pneumonia. A stool sample is negative for ova and parasites, but PCR testing is positive for Clostridioides difficile. What is the appropriate first-line treatment?

Vancomycin

A 28-year-old woman presents to the emergency department due to a 3-hour history of nausea, abdominal cramping, vomiting, and watery diarrhea. She recounts her lunch approximately 8 hours ago, which consisted of a shrimp salad and a diet soda. She denies any neurological or other symptoms. She also denies any similar problems prior to this episode and was feeling well just before this incident. She denies fever or recent travel. Question What is the most likely organism responsible for her symptoms?

Vibrio parahaemolyticus

A 50-year-old woman with a family history of colon cancer underwent a total colonoscopy per screening guidelines for colon cancer. 2 polyps, 5 mm each, were noted on exam. The doctor advises the patient to repeat her colonoscopy in 3 years due to her polyp pathology. Which type of colon polyp does this patient likely have?

Villous adenoma

An 8-month-old female infant presents with a 2-day history of increasing irritability and decreased appetite. She has also had some diarrhea and low-grade fever. On exam, she is afebrile, fussy, and hard to console, but she appears alert and active. She lies with her hips and knees flexed, crying harder with any movement. A few petechiae are noted on her skin. Leg X-rays are done to look for a possible fracture that shows a pencil-thin cortex and a ground glass appearance of the bones. Further history reveals that she has been given evaporated milk since birth to save money, and she has not yet been started on solids.Question: What vitamin deficiency would most likely cause this infant's symptoms?

Vit. C

A 32-year-old female patient presents with a 1-month history of bleeding gums when brushing her teeth. She reports that her wounds are taking longer than usual to heal. She is a stay-at-home mother and is breastfeeding her 6-month-old twins. On examination, multiple splinter hemorrhages on the nails and ecchymoses over the lower limbs are noted. Question: What is the most likely diagnosis?

Vit. C Deficiency

A 3-year-old boy presents with his mother; she reports that he is unable to walk without support. He is an only child who rarely leaves his tenth-floor apartment home. On examination, he has a rachitic rosary and genu valgum. Question: What is the most likely diagnosis?

Vit. D Deficiency

A 20-year-old woman presents with intermittent nose bleeds for the past 2 weeks. She also reports that her menstrual periods have increased in number in the past 2 months. She recently underwent surgery for small bowel resection and eats only one meal a day. Laboratory investigations reveal prolonged prothrombin time, prolonged activated partial thromboplastin time, and a normal platelet count.Question: What is the most likely diagnosis?

Vit. K Deficiency

A 46-year-old man presents to the office complaining of dry, irritated eyes that have gotten worse over the past week. He states that he has also developed a red, bumpy rash on his arms. Physical examination reveals that his corneas and conjunctivae are dry and thickened. There are small ulcerations on his corneas. The skin on both arms has an erythematous rash characterized by small, white, raised lesions. He has a history of alcoholism but has no other significant medical history. Which of the following is most likely deficient, causing this man's symptoms?

Vitamin A

Vitamin that can cause hair loss and liver damage when taken excessively

Vitamin A

Water-soluble vitamin that is anti-oxidant

Vitamin C

A 16-year-old girl presents for continuing concerns about her weight. She has a family history of diabetes and has tried to lose weight before without success. Her BMI (body mass index) is at the 99th percentile for age, and she is given a trial of orlistat. Within 2 weeks, she returns to her pediatrician with bowel movement changes, flatulence, oily discharge, and mild abdominal pain. She lost 5 lb and would like to continue the treatment if the side effects could be eliminated. Question In addition to reducing fat consumption, what supplementation will she most likely require?

Vitamin D

A 16-year-old girl presents for continuing concerns about her weight. She has a family history of diabetes and has tried to lose weight before without success. Her BMI (body mass index) is at the 99th percentile for age, and she is given a trial of orlistat. Within 2 weeks, she returns to her pediatrician with bowel movement changes, flatulence, oily discharge, and mild abdominal pain. She lost 5 lb and would like to continue the treatment if the side effects could be eliminated. Question: In addition to reducing fat consumption, what supplementation will she most likely require?

Vitamin D

A 4-month-old girl has been gaining weight well and achieving normal milestones. She was a full-term infant born via vaginal delivery without complication. Her past medical history is significant only for a mild URI the previous month, and she is current with her vaccines. She has been exclusively breastfed since birth. Her mother eats a well-rounded diet that includes meat and dairy. Question What supplementation does the infant require?

Vitamin D

A 4-month-old girl has been gaining weight well and achieving normal milestones. She was a full-term infant born via vaginal delivery without complication. Her past medical history is significant only for a mild URI the previous month, and she is current with her vaccines. She has been exclusively breastfed since birth. Her mother eats a well-rounded diet that includes meat and dairy. Question: What supplementation does the infant require?

Vitamin D

Vitamin essential for maintaining proper levels of calcium and phosphorus in the body

Vitamin D

Vitamin that can cause calcium deposits in soft tissues, growth retardation, and kidney damage when taken excessively

Vitamin D

Vitamin that is technically a hormone because it is made in the body

Vitamin D

Fat soluble vitamin that serves as anti-oxidant

Vitamin E

Intake of what vitamin can effect INR levels

Vitamin K

A 7-day-old boy is brought to the emergency department due to blood in his stool. The mother says the baby was born by home birth at 38 weeks' gestation without complications. She refused the hepatitis B vaccine, erythromycin ointment, and intramuscular vitamin K shortly after birth. The mother denies fever, vomiting, or rash but says the baby has been fussier recently. The mother denies a family history of any similar problems. On exam, the patient is well-developed and meets all developmental milestones. He is tachycardic but with a regular rhythm. There is oozing blood from the umbilical site, which has not fully healed. A guaiac stool test is positive. What is the underlying cause of this presentation?

Vitamin K deficiency

A 35-year-old man presents with a painful perirectal lump. It began 6 days ago as a small firm mass and has gradually increased in size. As the mass has grown, it has become more tender. On examination, there is a 4 cm fluctuant red perirectal mass.

incision and drainage

A 45-year-old man comes to clinic with a history of excessive bloating, foul-smelling flatus, and loose stools for the past several months. He notes that about 30-60 minutes after breakfast each morning, he experiences cramping, bloating, passage of smelly flatus, and a very loose, watery bowel movement. He has not seen any blood or mucus in the stool and also denies any weight loss. This does not happen with lunch or dinner. Every day for breakfast, he eats a big bowl of cereal with milk and a yogurt smoothie. The physical exam is unremarkable with normal bowel sounds, no organomegaly, and no abdominal tenderness. He was advised to do a dietary trial of stopping dairy intake for 1 week. All his symptoms resolve, What is he diagnosed with?

lactose intolerance

Vegetarians and vegan have to watch for this deficiency because phytates in plant sources of this inhibit absorption

Zinc

A 48-year-old Caucasian woman with a chronic history of inability to tolerate oral intake is admitted to the hospital for J-tube placement. The patient also reports a rash that has developed on her upper extremities. Examination reveals diffuse petechiae and perifollicular hemorrhage.

ascorbic acid

Common causes of anaphylaxis include

bees

A 45-year-old man presents with a 24-hour history of severe anal pain and swelling. The pain started after straining at defecation and has worsened over the course of the day. There is no history of fever. Examination of the anal area reveals a swollen ecchymotic mass in the perianal skin, very close to the anal verge. What is the treatment of choice for this condition?

excision of thrombosed external hemorrhoid.

A 28-year-old male patient presents with rectal bleeding and three instances of a little bright-red blood with bowel movements. He reports severe rectal pain, especially with passing hard stools. Over-the-counter hemorrhoid creams have not provided relief. He admits episodic constipation for 2 years; he has eaten a high-fiber diet and taken over-the-counter stool softeners for 3 months. He denies dark tarry stools, easy bruising, and prior episodes of rectal bleeding. He has not noticed blood when urinating or brushing teeth. He denies nausea, vomiting, diarrhea, fevers, and weight loss. No known medical conditions. Family history is negative for gastrointestinal disorders. Social history reveals he is in a heterosexual relationship, denying anal intercourse. On physical exam, the abdomen is unremarkable. The anus has no visible protrusions or rash, but there is a very small, erythematous, tender "paper cut" area. Digital rectal exam (DRE) is painful. No masses in the rectal vault. In addition to treating constipation, what is the most appropriate prescription treatment for this patient's condition?

nitroglycerin ointment

A 60-year-old male patient with hypertension presents with constipation. He states that he often only has two bowel movements weekly. This has been an ongoing problem for months, but the situation has worsened since being released from the hospital after treatment for a myocardial infarction a few weeks ago. What is the most appropriate treatment?

oral psyllium

A 35-year-old man presents for medical care, but he is too embarrassed to tell the nurse his chief symptom. Eventually, he admits to severe, intense itching around his anus; it has been worsening the last several weeks. He further states that he has noticed increasingly severe and tearing pain in the anal area with each bowel movement. He ranks this pain as a 10/10 on a pain scale. This intense pain makes him try to avoid having bowel movements regularly. He admits to one episode of a small amount of bright red blood on the toilet paper and on the stool itself. Reviewing documentation on this patient reveals that this is the fourth similar episode in the last 14 months. The patient denies fever and diarrhea; according to him, he has never been diagnosed with inflammatory bowel disease. Considering the most likely diagnosis, what pharmaceutical intervention should be initiated?

topical nitroglycerin 0.2-0.4%

Which of the following types of hypersensitivities does NOT correctly match it's pathophysiology

type IV: Immunoglobulin G or M mediated. **Type IV hypersensitivity is mediated by T-cells.