PC2 Midterm
A 49-year-old man presents to the clinic with right upper quadrant pain and fever. Which of the following amounts of alcohol use may lead the clinician to suspect alcoholic hepatitis?
4 ounces of 80 proof per day
A 15-year-old boy presents to the clinic with RLQ abdominal pain, vomiting, and rebound tenderness. Which of the following diagnostic tests should the provider order to confirm the suspected diagnosis?
Abdominal ultrasound
An 80-year-old woman presents to the clinic to discuss the results of a barium esophagography that showed a bird beak distal esophagus. The patient continues to report difficulty with swallowing solids and liquids. Which of the following is the most likely explanation for these findings?
Achalasia
A 44-year-old obese diabetic woman presents with episodes of right upper quadrant and epigastric abdominal pain after meals for the past month. The pain is constant and steady, peaking in about one hour. During this latest episode, the pain lasted seven hours and radiated to her right shoulder. On examination, she is tender in the right upper quadrant of the abdomen; deep palpation during inspiration causes the patient to wince and pause to catch her breath. She also has fever and tachycardia, but no jaundice. Alkaline phosphatase, total bilirubin levels, and white blood cells are elevated. Aspartate aminotransferase, alanine aminotransferase, amylase, and lipase levels are slightly elevated. Which one of the following is your presumptive diagnosis?
Acute cholecystitis
A 52-year-old woman presents to your primary care office with sudden onset severe abdominal pain. Assessment reveals pain disproportionate to physical examination and slight tachycardia. Medical history significant for coronary artery disease. Which life-threatening condition is among the differential diagnoses?
Acute mesenteric ischemia
A 31-year-old man who was recently diagnosed with HIV presents to the clinic concerned for difficulty swallowing. During dinner last night, he had pain and trouble swallowing. This morning, his pain is still present, but he is able to tolerate eating and drinking. He has a past medical history of HSV-1 and currently has two herpetic sores visible on his oral mucosa. Which of the following is the appropriate course of treatment for this patient?
Acyclovir 400 mg PO five times per day for 14-21 days
A 57-year-old man presents with a change in stools over the last 4 months. His stools are intermittently bloody, and he has experienced a decline in his appetite associated with a 15-pound unintentional loss of weight. Which of the following is the most likely explanation for his symptoms?
Adenocarcinoma of the colon
Which lab marker elevation has the highest positive predictive value for a biliary etiology in patients diagnosed with acute pancreatitis?
Alanine aminotransferase
A 38-year-old man presents for his annual physical. He has no past medical history and takes no medications. He reports that his father was diagnosed with colon cancer at age 58 years. Based on current recommendations, when should this patient start colorectal cancer screening?
At age 40 years
What class of medication should be used for primary prophylaxis to prevent variceal hemorrhage?
Beta blocker
A 66-year-old man presents to the clinic for evaluation of odynophagia. He reports retrosternal pain that occurs with eating for the past 3 weeks. His medical history includes diabetes, gout, and osteoarthritis. He recently finished chemotherapy for thyroid cancer. He is currently pain-free, and all vital signs are normal. On exam, you note white, plaque-like lesions in the oropharynx. Which of the following is the best way to confirm the suspected condition?
Biopsy of esophageal lesions
A previously healthy 30-year-old woman presents to your office with complaints of abdominal pain and diarrhea for the past year. Her abdominal pain is located in the lower abdomen with relief after defecation. Her diarrhea symptoms include a small volume of loose stool, typically after meals. She has experienced some improvement in symptoms with dietary modifications, but overall is still having regular loose stools. Recently she has been feeling more fatigue than normal. Which of the following is the most appropriate initial laboratory test?
CBC
A 72-year-old man presents to the clinic for evaluation of abdominal pain. He reports a gradual worsening of pain over the past 2 days. Nausea, vomiting, and diarrhea are present. On exam, he is tender in the left lower quadrant. He is tender with a digital rectal exam, and fecal occult blood is positive. Temperature is elevated at 101.2°F, and all other vital signs are within normal range. Which of the following is used to diagnose the suspected condition?
CT of abdomen and pelvis
A 53-year-old man presents with weight loss, anorexia, abdominal pain, jaundice and early satiety. Which of the following is the most appropriate initial diagnostic test to diagnose and stage pancreatic cancer?
CT scan
A 48-year-old woman presents to the clinic complaining of abdominal pain, bloating, and flatulence for 5 days. Which of the following tests will confirm a diagnosis of small intestine bacterial overgrowth?
Carbohydrate breath test
Which of the following is a risk factor associated with the development of pancreatic cancer?
Cigarette smoking
A 34-year-old woman returns from travel outside of the US. Two days later, she presents with acute onset, frequent, green-colored and voluminous stooling. She has abdominal pain and a temperature of 101.9°F. A stool culture is positive for Shigella. Which of the following do you recommend?
Ciprofloxacin
A 23-year-old college student presents with 2 to 3 weeks of frequent stools that are mixed with blood and mucus. The frequent stools are associated with worsening tenesmus. Vital signs are within normal limits, and the physical examination is normal. The white blood cell count is also normal, and stool testing for infectious agents is negative. Which one of the following is the best next step in evaluating this patient for the presence of inflammatory bowel disease?
Colonoscopy with biopsies
A patient has been diagnosed via endoscopy with Barrett's esophagus following chronic gastroesophageal reflux disease (GERD). Which describes the most appropriate pharmacologic treatment for Barrett's esophagus?
Daily proton pump inhibitor dosed to control symptoms of gastroesophageal reflux disease
Which of the following physical exam findings is most consistent with a diagnosis of vitamin B12 deficiency?
Decreased proprioception
A nurse practitioner is caring for a 34-year-old man with a known history of intravenous drug use disorder and sexual intercourse with men. The patient presents to the clinic with a new onset of fatigue, ecchymosis, abdominal pain, and pruritus. The patient states that his symptoms have been present for the past month and are getting worse. On exam, the nurse practitioner notes the patient's sclerae are jaundiced. An enzyme-linked immunosorbent assay confirms a hepatitis C diagnosis. Which of the following is the best next step in treating hepatitis C?
Determine if patient is eligible for simplified treatment
A 30-year-old woman presents with complaints of watery diarrhea that is not bloody along with some nausea and no vomiting. She denies fever and chills. She has not traveled outside the country in the past 60 days, however, she was at a large family gathering two days ago. What is the most appropriate treatment for this patient?
Diet as tolerated with balanced electrolyte rehydration
Dysphagia can be either difficulty initiating the swallowing mechanism or difficulty completing the swallowing mechanism. Which best describes symptoms seen with dysfunction of the lower esophageal ring?
Difficulty completing swallowing with intermittent dysfunction only when eating solid foods
A 55-year-old woman presents with a complaint of left lower quadrant abdominal pain, constipation, and fever. On palpation, she is tender in the left lower quadrant with guarding and rebound tenderness. Which of the following is the most likely diagnosis?
Diverticulitis
A 70-year-old man presents to the clinic after hospitalization for new-onset atrial fibrillation. In the hospital, he was treated with intravenous amiodarone, and he has been discharged on amiodarone 400 mg daily. His other medications include metoprolol, lisinopril, and atorvastatin. Posthospitalization laboratory tests are unremarkable, except for an aspartate aminotransferase of 100 U/L (normal 0-35 U/L) and alanine aminotransferase of 95 U/L (normal 0-35 U/L). Prehospital aspartate aminotransferase and alanine aminotransferase were unremarkable. His vital signs are within normal limits, but he is experiencing fatigue posthospitalization. What is the most likely diagnosis based on his presentation?
Drug-induced liver injury
A 70-year-old man presents to the clinic for groin pain. Which of the following assessment findings may alert the provider to an incarcerated hernia?
Edema and erythema over the groin area
A 31-year-old woman presents with abdominal pain in the right upper quadrant that began after she ingested a fatty meal. Her symptoms are accompanied by nausea and vomiting that has persisted for 12 hours. Physical exam reveals a positive Murphy sign. Which of the following laboratory results would be expected?
Elevated WBC count and elevated ALT
Constipation is defined as unsatisfactory defecation characterized by infrequent stools, difficult passage of stools, excessive straining with stools, and hard stools. In patients with primary constipation, which conservative nonpharmacologic treatment is recommended?
Elimination of medications that cause or worsen constipation
A 45-year-old woman presents to your office with complaints of worsening heartburn and food regurgitation that occur several times every week. Treatment with a proton pump inhibitor has not relieved her symptoms. Which of the following diagnostic studies is used to confirm the diagnosis?
Endoscopy
A 63-year-old man with a 40-year history of alcohol and tobacco abuse presents with solid food dysphagia. The patient has also had a 21 lb weight loss over the past 7 months. Which of the following studies should be performed for a definitive diagnosis?
Endoscopy
An adult patient has recently been diagnosed with lactose intolerance after completing a lactose hydrogen breath test. They report experiencing chronic diarrhea. Which of the following would be appropriate anticipatory guidance to give to this patient?
Enzyme replacement preparations can be used to reduce symptoms
A 28-year-old man presents to the clinic due to progressive dysphagia and burning epigastric pain over the past 2 months. He previously tried famotidine and omeprazole for symptoms of acid reflux but experienced no relief. He has dysphagia to solid foods but can swallow liquids without difficulty. He has a history of moderate persistent asthma for which he takes combination budesonide-formoterol and albuterol. His mother has celiac disease, and his father has type 2 diabetes mellitus. The patient is not sexually active and does not use tobacco, drink alcohol, or use recreational drugs. Vital signs are within normal limits, and physical examination is unremarkable. Which of the following is the most likely diagnosis?
Eosinophilic esophagitis
A 54-year-old man presents for a follow-up visit to discuss a pending procedure. He has recently been diagnosed with Child-Pugh class B cirrhosis secondary to alcohol use disorder. He is scheduled for an upper endoscopy to evaluate for esophageal varices. He is upset, questioning the need for this procedure. You are his primary care provider and want to provide education to reinforce the gastroenterologist's recommendation. What is the most appropriate information to provide this patient?
Explain that scarring in the liver obstructs normal blood flow causing backup into the vessels of the esophagus
A 15-year-old boy, accompanied by his parents, presents to the clinic with complaints of abdominal pain and diarrhea. The patient states that he is a boy scout and had a recent hiking and camping trip. He explains that his group ran out of clean water and resorted to drinking stream water without boiling it. The patient's symptoms started after he returned home from his trip. He describes his stool as a greasy-like substance that floats on the top of the water. Which of the following organisms is the most likely cause of the patient's condition?
Giardia lamblia
While reviewing the medical history of a 16-year-old girl, you notice that she has had mildly elevated bilirubin levels in the past 2 to 3 years when she has had bloodwork done. Her complete blood count, blood smear, reticulocyte count, plasma aminotransferases, and alkaline phosphatase levels have all been normal. The patient has never had jaundice with any of these episodes. Family history reveals that her mother has a history of elevated bilirubin with illnesses. Which of the following is the most likely diagnosis?
Gilbert syndrome
A 65-year-old man presents with hematemesis. His past medical history includes heavy alcohol use, tobacco use, Helicobacter pylori infection, heavy intake of smoked fish, and diabetes mellitus. Endoscopic examination reveals a large pyloric mass. Which of the following is the most common cause of this type of gastric cancer?
Helicobacter pylori
A 75-year-old man with a history of recent bouts of constipation presents to the clinic with hematochezia with bowel movement and itching and pain around the perianal area. There is no abdominal pain or pain with bowel movements. Which of the following is the most likely diagnosis?
Hemorrhoid
Which viral etiology of hepatitis is most likely to result in chronic infection in adults?
Hepatitis C
A 32-year-old woman presents with abdominal pain, nausea, vomiting, and change in skin color for 6 days. She states that she had unprotected intercourse 4 weeks ago. Which one of the following tests indicates acute infection with hepatitis B as the cause of the patient's symptoms?
IgM antibody to B core antigen (Anti-HBc-IgM)
A 21-year-old woman presents to the clinic with abdominal pain for 2 months. She is a full-time college student and reports a significant amount of life stressors. Which of the following findings in the assessment is consistent with a diagnosis of irritable bowel syndrome?
Improvement of pain with defecation
In a patient with chronic abdominal pain, which additional finding suggests a diagnosis of irritable bowel syndrome?
Improvement with defecation
A 60-year-old woman with a history of well-controlled diabetes mellitus presents to your office with a complaint of constipation. She has a bowel movement about twice per week with straining and hard stools. She has had intermittent constipation for many years, but over the past four months it has been constant. Which of the following is the most appropriate initial management?
Increased fiber intake
A 43-year-old woman presents with a several year history of irregular bowel habits characterized by alternating diarrhea and constipation and associated with intermittent, occasional crampy abdominal pain and bloating. She denies loss of appetite, weight loss or vomiting, and she has never seen blood in her stools. The pain does not awaken her at night, and she has been unable to identify any particular dietary triggers. Her body mass index (BMI) is 24, she is afebrile, and her abdominal exam is unremarkable. A series of three fecal occult blood tests are all negative. What is the most likely diagnosis?
Irritable bowel syndrome
A 45-year-old man presents with intermittent diarrhea for the past six months that rarely occurs at night. He complains of an incomplete sense of bowel evacuation and states his stools have a lot of mucus. He is unable to identify anything that precipitates the diarrhea but states that it was better when he was on vacation. He denies travel outside of the U.S., exposure to any illness, recent antibiotic treatment, and unusual food intake. During the office visit, he is anxious to get back to work stating that he is in the midst of an important business deal. Physical examination reveals slight abdominal distension and tenderness to palpation. Which of the following is the most likely diagnosis?
Irritable bowel syndrome
A woman with a history of morbid obesity and type 2 diabetes mellitus presents to the clinic for a routine physical with no complaints. Her recent laboratory results show an AST of 55 U/L and an ALT of 60 U/L. She reports no alcohol or substance use, and her physical examination is unremarkable. What is the most appropriate next step to diagnose the suspected condition?
Laboratory testing
A 38-year-old man presents to the primary care clinic complaining of discomfort in his groin. He noticed the discomfort 3 weeks ago after lifting weights at the gym. He describes the sensation as aching or heaviness. He has stopped going to the gym because the discomfort is worse after exercise, and he is anxious to begin lifting again. On examination, a bulge is visible above his right inguinal ligament. The bulge is nontender, approximately 2 cm in diameter, and reducible. There is a positive cough impulse. There is no extension into the scrotum and no inguinal lymphadenopathy. What is the most appropriate treatment for this patient's suspected condition?
Laparoscopic surgical repair
Which of the following findings seen on rectal examination is most consistent with a concomitant systemic process?
Lateral anal fissure
A 15-year-old boy presents to the clinic with fever and watery diarrhea for 2 days. Which of the following necessitates a referral to the emergency department?
Lethargy
A 37-year-old woman presents to the clinic for follow-up on her laboratory work. At her annual check-up 2 weeks ago, she had no abnormal findings except a ferritin level of 300 ng/mL, so the provider ordered genetic testing. At the present visit, the provider diagnoses this patient with genetic hemochromatosis. Which of the following is most appropriate to include in the plan of care?
Limiting alcohol intake
What is the best advice to give a patient with gastroesophageal reflux disease on lifestyle management?
Losing weight
A 38-year-old woman presents with lower abdominal pain and bloating for the past year. She describes her abdominal pain as mild cramping that occurs 3-4 times per week and is partially relieved with a bowel movement. She reports having a bowel movement 2-3 times per week and describes the stool as hard and difficult to pass. She reports no blood in her stool. She reports no recent weight loss. She has no pertinent past medical history and takes no medications. She has been following a gluten- and lactose-free diet for the past 6 months with mild improvement in bloating and abdominal pain. She started taking a daily 17 g dose of polyethylene glycol with no improvement in the frequency or consistency of her bowel movements. Her grandfather had colon cancer diagnosed at the age of 67. She reports no other relevant family history. On physical examination, her vital signs are normal. Her abdominal examination is unremarkable. Results from a thyroid-stimulating hormone, complete blood count, and chemistry panel are normal. What would be the most appropriate next step in the management of this patient's condition?
Lubiprostone
A 61-year-old man presents with loss of appetite, unintentional weight loss, and dyspepsia. Endoscopy shows a gastric mass at the curvature of the stomach, and he is diagnosed with gastric carcinoma. Which of the following is true about his condition?
Men have a higher risk of developing this condition
Barrett's esophagus is a change in the mucosa of the distal esophagus from stratified squamous epithelium to abnormal columnar epithelium due to chronic gastroesophageal reflux disease (GERD). Endoscopic screening for Barrett's esophagus is indicated for which patient population?
Men with gastroesophageal reflux disease for more than five years whose symptoms are not controlled
You are evaluating a 73-year-old woman with a history of weakness, fatigue, and difficulty walking. She lives alone and unassisted. She has no past medical history and takes no medications. Physical examination shows an enlarged, smooth, and tender tongue. Pallor of the conjunctivae is also seen. Which of the following laboratory studies would be most likely to confirm the diagnosis?
Methylmalonic acid and homocysteine levels
A young woman suffers from chronic diarrhea. A detailed history provides no evidence of provocative medications as the cause. You send a stool sample to the laboratory and obtain the following results: Color: Yellow-brown Water: High Fat: Negative Blood: Negative WBCs: Negative Osmotic gap: Normal These results suggest which of the following as the most likely causative of this patient's diarrhea?
Motility
Which of the following physical exam findings is suggestive of the diagnosis of acute cholecystitis?
Murphy sign
Which of the following clinical presentations would be typical of an adolescent with undiagnosed celiac disease?
Nausea, vomiting, bloating, and diarrhea
Which of the following vitamin deficiencies causes the triad of dermatitis, diarrhea and dementia?
Niacin
A 60-year-old woman with a history of well-controlled diabetes mellitus presents to your office with a complaint of constipation. She has a bowel movement about twice per week with straining and hard stools. She has had intermittent constipation for many years, but over the past four months it has been constant. Which of the following is the most appropriate initial management?
Nitroglycerin
A 15-year-old girl presents to the clinic with symptoms of abdominal pain, vomiting, diarrhea, and flatulence after milk and cheese ingestion for the past 3 months. She says her symptoms resolve when she avoids dairy products. Her medical history is unremarkable. She is of Vietnamese descent. Examination is within normal limits. Which of the following is the best next step in making the diagnosis in this patient?
No further testing
A 58-year-old man presents with watery diarrhea and abdominal cramping. He reports three to four nonbloody, watery stools per day and loss of appetite for the past 3 days. He reports occasional nausea but no vomiting. He has recently been caring for his granddaughter's pet turtle, as she is gone to camp for the summer. He reports no recent hospitalization, antibiotic exposure, or travel. He has a 10-year history of hypertension and gastroesophageal reflux disease and takes lisinopril and omeprazole daily. On physical examination, his vital signs are normal aside from a temperature of 100.1°F. His bowel sounds are active throughout, and there is mild tenderness on deep palpation in all quadrants of his abdomen. What is the most likely cause for this patient's diarrhea?
Nontyphoidal Salmonella
A 60-year-old woman presents to the clinic for evaluation of abdominal pain. She reports a burning pain that worsens after eating. Nausea and lack of appetite are associated with the pain. She has a stressful, labor-intensive job, and she suffers from intermittent back pain, but she is otherwise healthy. She was taking naproxen daily for back pain for approximately 1 month but she discontinued daily use 2 weeks ago and is currently using the medication as needed. Which of the following is the best treatment for the suspected underlying condition?
Omeprazole
A 66-year-old man presents with nausea, intermittent abdominal cramping, and frequent diarrhea for the past three days. He was recently hospitalized for pneumonia and was discharged one week ago. He was feeling better until yesterday. Physical examination reveals mild lower abdominal tenderness but is otherwise unremarkable. Of the following choices, which is the most appropriate initial treatment?
Oral vancomycin
A 43-year-old woman presents with episodic epigastric pain that frequently follows a fatty meal and can last anywhere from 15 minutes to approximately two hours. At times the pain radiates toward her right shoulder. She has associated nausea without vomiting. Which of the following is the most appropriate next step in managing this patient?
Order a right upper quadrant abdominal ultrasound
A 72-year-old man presents with concerns of "looking yellow." He is asymptomatic but reports an unintentional 15-pound weight loss over the last two months. Physical examination reveals jaundice, mild epigastric tenderness, and palpable periumbilical nodules. Which of the following is the most likely diagnosis?
Pancreatic cancer
A 77-year-old man presents to his primary care provider with progressive jaundice for the past 2 weeks. He also reports a 15 lb unintentional weight loss. The man has a 50 pack-year smoking history. On physical exam, jaundice and hepatomegaly are noted. Additionally, his gallbladder is able to be palpated but is nontender. Which of the following is the most likely diagnosis?
Pancreatic cancer
A 68-year-old man presents to the clinic complaining of difficulty swallowing. He reports that this symptom started 3 months ago and has progressively worsened. He describes a feeling of food sticking in his throat after he eats solid foods, but he has no issue with liquids or soft foods, such as yogurt. He reports no recent weight loss, anorexia, chest pain, throat pain, nausea, or vomiting. Which of the following findings in this patient's history would increase suspicion for the likely cause of this patient's dysphagia?
Personal history of gastroesophageal reflux disease
A 25-year-old woman presents to your office with complaints of abdominal pain and constipation for the past year. She has seen a number of doctors and specialists with extensive testing revealing all normal results. She is following the dietary recommendations given to her previously, but is still only having bowel movements twice per week. Which of the following is the most appropriate next step in management?
Polyethylene glycol
A 65-year-old previously healthy man presents to the clinic with constant left lower abdominal pain for the last 3 days. He reports no nausea or vomiting. His vital signs are stable except for a low-grade fever, and the physical exam is largely unremarkable except for tenderness to palpation of the abdomen in the left lower quadrant. A basic metabolic panel, complete blood count, and C-reactive protein are ordered and show mild leukocytosis and a C-reactive protein at 65 mg/L (normal < 5 mg/L). A CT scan indicates the presence of colonic diverticula with inflammatory changes and localized bowel wall thickening without other complications. Which of the following is the most appropriate next step in management of this condition?
Prescribe pain reliever
An obese man presents with a 1-month history of dyspepsia. He denies dysphagia, odynophagia, vomiting, or weight loss. His exam reveals no concerning findings. You start him on antacids and order a fecal occult blood test (FOBT). He returns 1-month later unchanged. His FOBT is negative. Which of the following would be most likely used to aid in the clinical diagnosis of gastroesophageal reflux disease (GERD) in this patient?
Proton pump inhibitor trial
Which of the following categories of medicine used to treat gastroesophageal disease (GERD) in children needs to be closely monitored due to safety concerns for increased risk of infections, including Clostridium difficile and pneumonia?
Proton pump inhibitors
Which of the following would be the best advice to give to new parents whose bottle-fed infant is beginning to show signs of gastroesophageal reflux?
Provide smaller but more frequent feedings
A 3-week-old infant presents to the clinic with her mother for frequent vomiting. The mother states that she has an insatiable appetite but has lost 4 ounces since her 1-week check-up. The provider palpates an olive-like mass in the epigastrium. Which of the following is the most likely diagnosis?
Pyloric stenosis
A 2-year-old boy presents to the clinic with intermittent abdominal pain, vomiting, rectal bleeding, and fatigue for the last 2 days. His mother reports no similar symptoms in other family members or other systemic symptoms such as fevers. On physical examination, the abdomen is not tender, but a mass is palpated in the upper abdomen. What is the most appropriate next step for managing this patient's care?
Refer patient to the emergency department
A 66-year-old woman presents to the clinic with bloody stools for 2 days. She also states that after a meal, she has some abdominal discomfort. Her last colonoscopy was 6 years ago and was normal. The physical examination is unremarkable. Which of the following actions should the clinician take at this time?
Refer the patient to gastroenterology for a colonoscopy
A 55-year-old man who is overweight presents to the clinic to establish care. He has a history of smoking, hypertension, dyslipidemia, gastroesophageal reflux disease (GERD), and Barrett esophagus. He takes atorvastatin, hydrochlorothiazide, and pantoprazole. His vital signs are stable, and he has no significant complaints today. Which of the following is the first priority in caring for this patient?
Refer to gastroenterology for endoscopy
A 50-year-old man with a history of diabetes mellitus type 2, alcohol use disorder, and hypertriglyceridemia presents to the clinic with constant epigastric pain that radiates to the mid back with associated nausea and several episodes of vomiting for the last 48 hours. A physical exam reveals tenderness to palpation in the epigastric region as well as Cullen sign. Which of the following is the most appropriate next step in management?
Refer to the emergency department
A 40-year-old woman with a history of anemia presents to your office with complaints of abdominal bloating and pain with defecation. When she was younger she had daily bowel movements. Now she has a bowel movement every 3-4 days that is hard. She has to strain and has even had to use her finger to get the stool out. Which of the following historical factors is most important to discuss at this time?
Review of current medications
Celiac disease is an autoimmune condition caused by the response to dietary gluten. After diagnosis, education regarding avoidance of dietary gluten is essential. Which food is part of a gluten-free diet?
Rice and rice flour
A patient experiences painless bright-red blood per rectum after bowel movements. Perianal examination reveals no abnormalities. You diagnose non-strangulated, large internal hemorrhoids, and then prescribe topical anesthetics and stool softeners. Three weeks later, the patient reports no improvement. At this point in management, which of the following is the most recommended treatment for this patient's non-strangulated internal hemorrhoids?
Rubber band ligation
A 25-year-old woman with a new diagnosis of celiac disease presents to the clinic with abdominal pain and diarrhea. Which of the following foods should the patient remove from her diet completely?
Rye
For patients with lactose intolerance, in which of the following parts of the gastrointestinal tract does malabsorption of lactose occur?
Small intestine
A 65-year-old man presents for follow-up after an upper endoscopy. He has a 10-year history of cirrhosis. The upper endoscopy revealed small esophageal varices with red signs. There was no active bleeding seen and no band ligation was performed. Based on his history of cirrhosis and findings on endoscopy, what would be the most appropriate next step in the management of this patient?
Start nadolol
A 57-year-old man presents with upper abdominal pain that seems worse after eating. He reports the pain has been present for more than 6 months and has increased in severity the last 1 or 2 months. He says he tends to vomit if he overeats. Other pertinent history includes a decrease in appetite and a 15-pound weight loss. Which of the following gastrointestinal disorders is most consistent with his symptoms?
Stomach cancer
Osmotic diarrhea is one category of non-infectious diarrhea that occurs when fecal osmotic gap is over 125 mOsm/kg. What is one common cause of osmotic diarrhea?
Sugar substitutes such as sorbitol and sucralose
A 25-year-old man who was recently diagnosed with mild to moderate ulcerative colitis presents to the clinic for a wellness visit. Which of the following is true about potential complications of the disease progression in ulcerative colitis?
The risk of colon cancer is significantly increased
A 38-year-old woman presents with rectal pain and blood on the toilet paper when she wipes after bowel movements for the last two days. Physical examination reveals a mildly tender, external, non-thrombosed hemorrhoid without active bleeding. Which of the following is the most appropriate pharmacotherapy?
Topical hydrocortisone
A 28-year-old woman presents to the clinic with a 3-week history of bright red blood in her stool and a sensation of passing "shards of glass" with defecation. Physical examination reveals a midline anal fissure. In addition to fiber, sitz baths, stool softeners, and topical lidocaine, which of the following is the most appropriate next step in management?
Topical nitroglycerin
A 21-year-old man presents to the clinic complaining of abdominal pain, diarrhea, and bloody stools. For the past 2 months, he has had 6-8 loose bowel movements per day associated with urgency and crampy abdominal pain. He noticed 4 days ago that there was bright red blood in his stool, which prompted him to schedule the appointment. He reports no weight loss, fever, constipation, incontinence, or recent antibiotic use or travel. On examination, he has hyperactive bowel sounds and mild tenderness to palpation of his right and left lower quadrants. His vital signs are within normal limits. His laboratory tests reveal mild anemia, elevated erythrocyte sedimentation rate, and elevated fecal calprotectin. His stool culture is negative. Which of the following is the suspected diagnosis?
Ulcerative colitis
A 30-year-old man presents to the clinic with right upper quadrant pain for 2 days. He went to the emergency department 1 day ago with the same complaint and was discharged after a negative abdominal CT scan. Laboratory findings reveal an elevated AST, ALT, alkaline phosphatase, and bilirubin. Which of the following diagnostic tests will assist in the suspected diagnosis?
Ultrasound
A 35-year-old woman presents to the clinic with a chief complaint of dyspepsia and epigastric fullness. Which additional finding would warrant further testing for Helicobacter pylori infection?
Unexplained iron deficiency anemia
A 65-year-old man presents to the clinic with several weeks of dull, gnawing epigastric pain that is usually relieved by eating. He has been taking omeprazole for five weeks, but has had no improvement. His only other daily medication is ibuprofen for knee pain. An abdominal exam is normal and fecal occult blood testing is negative. The next best step in management includes which of the following diagnostic tests?
Upper endoscopy
Which of the following diagnostic tests has the highest sensitivity for diagnosing gastric ulcers?
Upper endoscopy
A 64-year-old woman presents to the clinic for ongoing epigastric pain that most often occurs a few hours after eating and in the middle of the night. She recently had an endoscopy performed, and the results show evidence of gastritis and peptic ulcer disease (PUD). No biopsies were completed during the endoscopy. Which of the following tests should be performed next to exclude or diagnose Helicobacter pylori as the possible cause of her PUD?
Urea breath test
A 42-year-old man presents to the clinic for diarrhea for 3 days. During the patient interview, the provider finds that the patient has been taking clindamycin for a staphylococcal infection for 7 days. Which of the following medications should the provider prescribe?
Vancomycin
Diarrhea caused by Clostridium difficile is an infectious disease that is treated with antibiotics. What is the first-line treatment for patients with non-severe Clostridium difficile?
Vancomycin
A 12-year-old girl with cystic fibrosis has been noncompliant with her vitamin and enzyme supplements. She presents with dry eyes and difficulty seeing at night. She is most likely deficient in which vitamin?
Vitamin A
A 17-year-old girl is brought by her mother to clinic for concerns for depression and irritability. She is generally a very health-conscious individual who plays tennis competitively and follows a strict vegan diet. Upon further questioning the girl reports chronic fatigue, diarrhea, and decreased sensation in her fingers. Her mother has also noticed that her gait has become uncoordinated. What vitamin is she most likely deficient in?
Vitamin B12
A 60-year-old missionary woman is being evaluated for dementia. She also has diarrhea. She was recently treated for tuberculosis with isoniazid. Physical examination shows a symmetric hyperpigmented rash on both arms. Deficiency of which of the following vitamins most likely resulted in this patient's condition?
Vitamin B3
A 38-year-old man who recently emigrated from Southeast Asia was treated several weeks ago at a local hospital for pulmonary tuberculosis. He was started on therapy including rifampin, isoniazid, pyrazinamide, and ethambutol. He now reports numbness in all of his extremities which began one week ago and has been progressing. On physical exam he has an uncoordinated gait and paresthesias on his hands and feet. What is the most likely cause of his symptoms?
Vitamin B6 deficiency
