Rosh 3. GI

_________________ is the most common surgical cause of abdominal pain. _____________________ occurs in up to 70% of patients diagnosed with this.

Appendicitis Leukocytosis (>10,000)

_____________________ is the most common surgical emergency in pregnant women?

Appendicitis!!!!!!!!!

A 17-month-old boy presents with bilious vomiting, fever, and abdominal distention for the past three days. The mother states she noticed blood in the last diaper she changed. What is the most likely diagnosis? A. Anal Fissure B. Intussusception C. Milk Protein Allergy D. Pyloric Stenosis

B. Intussusception

What is the number one treatment for cholera?

#1 Aggressive rehydration then FQs, Tetracyclines, Macrolides

Thiamine is vitamin B____

1

A __________ hernia goes through the inguinal canal, and a ____________ hernia does not.

A INDIRECT hernia=inguinal canal A direct hernia=pushes directly on the abdominal wall

A 35-year-old-man with a long history of occasional bloody diarrhea and abdominal pain presents with acute-onset severe abdominal pain. Vital signs are significant for a temperature of 102.2°F (39°C), heart rate 140 bpm, and blood pressure 82/55 mm Hg. On physical exam, his abdomen is distended and tympanitic. Which of the following diagnostic studies is indicated first at this time? A. Abdominal Radiograph B. Barium Enema C. CT scan of the abdomen pelvis with IV contrast D. Sigmoidoscopy

A. Abdominal Radiograph The patient's presentation is suspicious for toxic megacolon, a complication of inflammatory bowel disease. The hallmark of toxic megacolon is colonic dilatation in a patient with a known inflammatory condition of the colon who appears systemically toxic.

In the US, other than post op adhesions, what is most likely responsible for causing SBO? A. Adenocarcinoma B. CHRON disease C. Intussusception D. Volvulus

A. Adenocarcinoma

A 17-year-old girl presents to the ED complaining of lower abdominal pain over the past eight hours associated with a loss of appetite and mild nausea. She states she is sexually active and on oral contraceptives. Her last menstrual period was three weeks ago. Her temperature is 37.8°C. On exam, there is tenderness to palpation in the RLQ of the abdomen. Bowel sounds are absent. Pelvic exam reveals scant white discharge from the cervical os. There is no cervical motion tenderness, and the adnexa and ovaries appear normal. Which of the following is the most likely diagnosis? A. Appendicitis B. Ectopic Pregnancy C. PID D. Tubo-Ovarian Abscess

A. Appendicitis PID-needs cervical motion tenderness

Which of the following findings is most likely to occur with acute diverticulitis? A. Constipation B. Gross lower GI Bleeding C. Right lower quadrant tenderness D. Testicular pain

A. Constipation

A 54-year-old man with cirrhosis presents for evaluation of abdominal pain. The pain is diffuse throughout the abdomen and associated with subjective fever at home. He has no vomiting, diarrhea or change in mental status. His vital signs are T 100.6°F, HR 102, BP 140/88, RR 12, and oxygen saturation of 100% on room air. Bedside ultrasound demonstrates ascites. Which of the following is an indication for intravenous antibiotics? A. Ascitic fluid neutrophil count of 300 cells/mcL B. Ascitic fluid pH of 7.35 C. AST of 340 D. Peripheral WBC count of 15,000

A. Ascitic fluid neutrophil count of 300 cells/mcL The patient's presentation is concerning for spontaneous bacterial peritonitis (SBP), an acute bacterial infection in the ascitic fluid of patients with ascites in the setting of liver disease. Most commonly, gram negative enteric organisms are responsible for the infection and the treatment of choice is an intravenous third generation cephalosporin. Diagnosis is made based on an ascitic neutrophil count > 250 cells.

A 29-year-old pregnant patient presents with a three day history of diarrhea following a trip to Mexico. The patient describes having seven to eight loose, watery stools per day. She does not note any blood in the diarrhea and is otherwise asymptomatic. Vital signs are BP 116/72, HR 86, RR 15, T 38.7°C. Physical exam reveals mild dehydration, but is otherwise normal. After providing fluid replacement, what is the indicated treatment? A. Azithromycin B. Ciprofloxacin

A. Azithromycin Traveler's diarrhea is the most common illness affecting travelers to low-income parts of the world. Ciprofloxacin (B) is the antibiotic of choice for most destinations and is effective against most mucosally invasive pathogens, but is contraindicated in children and pregnancy.

Which of the following is the most common cause of acute pancreatitis? A. Biliary Tract pathology B. Endoscopic retrograde cholangiopancreatography C. Ethanol Ingestion D. Medication side effect

A. Biliary Tract pathology Biliary tract pathology (gallstones) is the leading cause of acute pancreatitis, accounting for approximately 45% of cases. The incidence may be as high as 66% in some regions. Stones from the bile duct, pancreatic duct, or common bile duct can obstruct the pancreatic duct, resulting in bile reflux, increased pancreatic secretions, and activation of pancreatic enzymes. Patients classically present following ingestion of a fatty meal or after binge drinking and complain of epigastric pain, nausea, and vomiting.

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? A. CBC B. Giardia antigen C. Stool Culture D. TSH

A. CBC IRRITABLE BOWEL SYNDROME (IBS)

Which of the following antibiotics is most appropriate to use in a 64-year-old man with a history of benign prostatic hyperplasia, glucose-6-phosphate dehydrogenase deficiency, and a recently diagnosed urinary tract infection? A. Cephalexin B. Nitrofurantoin C. Phenazopyridine D. Bactrim

A. Cephalexin Look at picture 10/27 at 4:24. In this patient with benign prostatic hypertrophy (BPH), glucose-6-phosphate dehydrogenase (G6PD) deficiency, and cystitis, care must be taken not to precipitate a hemolytic crisis. Oxidant drugs such as nitrofurantoin, phenazopyridine, dapsone, and sulfonamides can cause hemoglobin precipitation within the RBC, which leads to removal of the cell from circulation via the spleen. Patients with severe G6PD enzyme deficiency who ingest oxidant drugs can experience severe hemolysis and cardiovascular collapse. For those with more minor forms of the hereditary disease, the lengthy course of antibiotics required for this complex cystitis may be sufficient to cause symptomatic hemolytic anemia, jaundice, and splenomegaly. Cephalexin, a first-generation cephalosporin, is not associated with causing oxidative stress and is, therefore, an acceptable choice for this patient.

A 56-year-old man presents to the emergency room with a five-day history of constipation. He has a history of seasonal allergies, hypertension, and ulcerative colitis. His vital signs are within normal limits. Laboratory studies reveals microcytic, hypochromic anemia. Physical exam reveals an empty rectal vault. A fecal occult blood test is positive. Which of the following is the most likely diagnosis? A. Colorectal carcinoma B. Drug induced constipation C. Intestinal obstruction due to adhesions D. Toxic Megacolon

A. Colorectal Carcinoma This man most likely has obstructing colorectal carcinoma. Colorectal cancer is one of the most common malignancies in the world. Colorectal cancer is the most common cancer of the gastrointestinal tract. The most common type of colorectal cancer is adenocarcinoma.

A patient with irritable bowel syndrome complains mainly of lower abdominal pain. She denies diarrhea or constipation, and rarely has problematic flatulence. For this patient's abdominal pain, which of the following medications do you recommend? A. Desipramine B. Loperamide C. Lubiprostone D. Rifaxamin

A. Desipramine "I was IRRITABLE after my Brother and Sister (IBS) took the FODMaP with them to ROME, so I forgot to get GLUTEN, FRUITS, SUGAR, and LACTOSE at the BRISTOL market so VERINEs had to get MINES when she went to get the PEPPERMINT OIL."

You diagnose a 43-year-old man with alcohol withdrawal. Lab results reveal a hemoglobin of 12 g/dL and an MCV of 115 fL. Which of the following is the most likely cause of these findings? A. Direct Ethanol Toxicity B. Pyridoxine Deficiency C. Thiamine Deficiency D. Vitamin B12 Deficiency

A. Direct Ethanol Toxicity Ethanol affects practically every organ system in the body. This patient is suffering from a macrocytic anemia, most likely as a result of chronic alcohol abuse. Chronic ethanol intake directly suppresses bone marrow by impairing protein synthesis, causing anemia or even pancytopenia. Although patients who abuse alcohol often have concomitant nutritional deficiencies that contribute to the development of megaloblastic anemia, the most likely cause of macrocytic anemia is due to direct ethanol toxicity. Macrocytosis is present in the majority of alcoholics even before significant anemia appears. This is typically reversed after several months of abstinence from alcohol. In addition to the harmful effects of ethanol itself, its metabolite, acetaldehyde, is inherently toxic to biologic systems. Patients presenting with acute ethanol intoxication also commonly have decreased serum ionized magnesium concentrations. Total body magnesium may be depleted due to poor dietary intake, decreased GI absorption, and renal wasting. Vitamin B12 (D), or cyanocobalamin, is a water-soluble vitamin. Dietary deficiencies can cause megaloblastic anemia, pancytopenia, and neuropsychiatric symptoms. Because of the size of the B12 molecule, deficiencies typically result from issues with absorption (such as pernicious anemia), rather than from poor dietary intake.

A 51-year-old woman has been treated twice with appropriate therapy for documented Helicobacter pylori disease. She continues to complain of abdominal pain that is worse with eating. What is the next test that should be done for this patient? A. Endoscopic biopsy for culture and sensitivity testing B. Serum IgG antibody to helicobacter pylori C. Stool testing for H. Pylori antigen D. Urea Breath Test

A. Endoscopic biopsy for culture and sensitivity testing.

Gold standard for diagnosing peptic ulcer disease? A. Endoscopy B. H Pylori testing C. Upper GI series D. Urea breath test

A. Endoscopy

#14 picture A four-week-old baby boy presents to the Emergency Department with projectile vomiting over the past three days. On physical exam, he is found to have a palpable olive-like mass in the right upper quadrant. On laboratory analysis he has a hypochloremic metabolic alkalosis. Which of the following is a risk factor for development of this condition? A. Erythromycin use B. Female sex C. Full term birth D. Second born child

A. Erythromycin use The infant has pyloric stenosis, and erythromycin use is a risk factor. Pyloric stenosis occurs when there is hypertrophy of the pylorus, which causes a gastric outlet obstruction. It is most commonly seen between three to five weeks after birth. Risk factors include first born, male sex, prematurity, and macrolide antibiotic use. Infants will present as a "hungry vomiter" with forceful nonbilious vomiting with a desire to feed again. On physical exam, a palpable olive may be found in the right upper quadrant. Repetitive vomiting will lead to a hypochloremic metabolic alkalosis from loss of stomach acid. If this continues for a prolonged period, hypokalemia will occur due to stimulation of aldosterone from hypovolemia. Abdominal ultrasound will show a "target sign" that is characterized by an increased pyloric muscle thickness, length, and diameter. Definitive treatment is surgical management with a pyloromyotomy.

A man with a strangulated, indirect inguinal hernia undergoes hernia repair surgery. Three weeks later, he presents with a complaint of numbness about his "beltline." Examination reveals no recurrent hernia. During light touch testing, he reports partial numbness and paresthesias in the anterior L1 dermatome. Irritation of which of the following nerves is most likely causing these symptoms? A. Iliohypogastric nerve B. Lateral Femoral Cutaneous C. Obturator D. Pudendal

A. Iliohypogastric Number 145-see picture

Which one of the following is characteristic of Mallory-Weiss syndrome? A. Lacerations of the gastric cardia due to forceful vomiting B. Noniatrogenic traumatic injury to the esophagus

A. Lacerations of the gastric cardia due to forceful vomiting.

A 40-year-old man presents to the emergency department after an episode of blood-streaked vomiting. This happened following a night of excessive drinking and a few episodes of forceful vomiting. He presents with no other symptoms and is in otherwise good health. Which of the following is the most likely diagnosis? A. Mallory Weis Tear B. Boerhave syndrome

A. Mallory Weis Tear Boerhaave syndrome (B) is a full-thickness tear of the esophagus that can occur under similar circumstances of increased intra-gastric pressure and must be considered when patients present with symptoms such as fever, chest pain and shortness of breath.

A 26-year-old G1P1 woman with a history of peptic ulcer disease was recently placed on a daily nonsteroidal anti-inflammatory medication therapy to treat joint pain. A medication to reduce nonsteroidal anti-inflammatory medication induced ulcers was recommended. Which of the following medications carries a black box warning and should be avoided or used in extreme caution in this patient? A. Misoprostol B. Famotidine C. Omeprazole D. Pantoprazole

A. Misoprostol Misoprostol is not to be used to reduce nonsteroidal antiinflammatory medication induced ulcers in a woman of childbearing potential unless she is capable of complying with effective contraceptive measures and is at high risk of developing gastric ulcers and their complications.

Which of the following is true regarding elderly patients with abdominal pain? A. More likely to need an emergent surgical procedure B. More likely to present with an elevated WBC C> More likely to present with fever D. More likely to present with peritoneal signs

A. More likely to need an emergent surgical procedure (b/c they are more likely to present with life threatening causes requiring emergent surgery)

A previously healthy 30-year-old man presents to your clinic with questions about hepatitis C. He has no history of intravenous drug use, blood transfusions, or needlestick injury. Which of the following is the most appropriate next step in management? A. Screening with hepatitis C antibody test B. Screening with Hepatitis C RNA test

A. Screening with hepatitis C antibody test HEPATITIS C RNA TEST IS USED TO CONFIRM DIAGNOSIS.

Which one of the following groups of lab results is most consistent with a complication that commonly occurs 6 to 12 weeks after acute hepatitis? A. WBC/RBC/PLT decreased B. WBC increased, RBC decreased, Platelets decreased

A. WBC/RBC/PLT decreased Aplastic anemia is a known complication of acute hepatitis. This affects up to 2% of all patients after their initial illness. Hepatitis-associated aplastic anemia most often affects adolescent boys and young men, is most commonly seen 6-12 weeks after hepatitis, and can be fatal if untreated.

AST of 250 and ALT of 120 would be indicative of ________________ hepatitis and AST of 1000 and ALT of 1200 would be indicative of _____________ hepatitis

Alcoholic Hepatitis Viral hepatitis

A 59-year-old man presents to the ED with 12 hours of emesis and abdominal pain. Vital signs include a T 38.2°C, BP 110/79 mm Hg, and HR 109 bpm. On exam, you note a tender 2 x 2 cm bulge with erythema in the abdominal midline above the umbilicus. There is abdominal distension, and an occasional high-pitched bowel sound is heard. After placing an IV line and nasogastric tube, which of the following is the most appropriate course of management? A. Administer broad spectrum ABx and get a plain radiograph B. Administer broad spectrum antibiotics and obtain emergent surgical consultation

B. Administer broad spectrum antibiotics and obtain emergent surgical consultation

23. A 37-year-old woman presents with a one week history of increasing anal pain and swelling. The pain is throbbing and constant, even while not having a bowel movement. There is an area of swelling with erythema along a portion of the anus which is very tender to palpation on rectal exam. Which of the following is the most likely cause of this patient's condition? A. Anal fissure B. Anorectal Abscess C. Anorectal Fistula D. Pruritis Ani

B. Anorectal abscess Anorectal abscess presents with throbbing, constant pain around the rectal area and is identified on exam by erythema and swelling around the anus. If the abscess is in the intersphinteric space, it may not be visible externally, though is usually palpable on digital rectal exam. An anorectal abscess is thought to arise from an infected anorectal gland. The treatment is incision and drainage; antibiotics are not indicated unless the patient is immunosuppressed or there is a surrounding cellulitis

A 3-week-old infant presents with projectile vomiting. Mom reports he has vomited after each feed for the last 24 hours. What electrolyte abnormality do you expect to see? A. Hyperchloremic, hypokalemic metabolic alkalosis B. Hypochloremic, hypokalemic metabolic alkalosis

B. Hypochloremic, hypokalemic metabolic alkalosis

Which of the following is the most effective Initial treatment for a benign esophageal stricture? A. Balloon dilation B. Balloon dilation and PPI C. Esophageal stent D. Nissan fundoplication

B. Balloon dilation and PPI Balloon dilation and proton pump inhibitor is the most effective initial treatment for a benign esophageal stricture. An esophageal stricture is the narrowing of the esophagus caused by the buildup of acid and is one of the complications of gastrointestinal reflux disease.

A 16-month-old boy presents to the emergency department with a 12-hour history of severe, intermittent abdominal pain. Approximately every 20 minutes, the child draws his legs up to his chest and cries inconsolably. Between episodes, the child behaves normally. The child's vital signs are within normal limits. Physical exam is notable for a sausage-shaped mass on the right side of his abdomen. What is most common complication of the first-line treatment of his condition? A. Bowel Ischemia B. Bowel Perforation C. Dumping Syndrome D. Nutrient Malabsorption

B. Bowel Perforation Bowel perforation is the most common complication of a pneumatic enema, the first-line treatment of intussusception in stable children.

A patient complains of a change in bowel habits over the past 3 months. A fecal occult-blood test is positive. During a digital rectal examination, you palpate a solid 2cm by 2cm mass in the rectum. Which of the following serum tests would you order in the initial laboratory evaluation of a patient with suspected rectal neoplasia? A. AFP B. CEA

B. CEA Rectal cancer occurs most commonly as an adenocarcinoma. Other types are lymphoma, sarcoma and carcinoid. Symptoms include frank or occult bleeding, change in bowel habits, abdominopelvic pain, malaise, back pain and urinary symptoms. In addition to a thorough physical examination, evaluation usually requires a digital rectal examination and rigid proctoscopy. Lesions are biopsied for microscopic examination. If metastasis is suspected, further imaging is accomplished via ultrasound, CT and MRI modalities. Laboratory evaluation may include complete blood count, liver and kidney function tests, carcinoembryonic antigen (CEA) test and serum chemistries. AFP=Hepatocellular Carcinoma

A 63-year-old man with a history of a cholecystectomy and appendectomy presents with abdominal cramping, vomiting and decreased bowel movements. Bowel sounds are decreased. Which of the following is true regarding this patient? A. Abdominal x ray can be used to rule out the dx of SBO B. CT scan of the abdomen is highly specific in SBO C. Serum lactate is highly sensitive early on in patients with SBO D. Serum WBC is always elevated in SBO.

B. CT scan of the abdomen is highly specific in SBO

Which of the following increases symptoms of reflux? A. BB B. Caffiene C. Spearmint D. Testosterone supps

B. Caffiene

A 52-year-old man with a history of cirrhosis presents with worsening confusion. His wife reports he has been compliant with his lactulose at home. Which of the following is a common cause of worsening hepatic encephalopathy? A. Cardiac Ischemia B. Constipation C. Hyperkalemia D. Pancreatitis

B. Constipation There are many causes of acutely worsening hepatic encephalopathy including constipation due to an increase in intestinal ammonia production and subsequent absorption.

A 35-year-old man with a history of gastroesophageal reflux disease presents to the Emergency Department with chest pain and fever. An outpatient esophagogastroduodenoscopy was performed three days ago and revealed no gastric ulcers. On exam, he is ill-appearing and tachycardic. Which of the following is the next best step in management of this patient? A. Arrange for repeat emergent esophagogastroduodenoscopy B. Consult Thoracic surgery C. Order a barium esophogram D. Place an NG tube.

B. Consult Thoracic Surgery

A 3-year-old boy presents after swallowing a quarter. He was playing a game and was dared to swallow it. He now feels it stuck. At which location is an obstruction most likely to occur? A. Cricopharyngeus muscle B. Tracheal bifurcation

B. Cricopharyngeus muscle

Of the following, which is the most common infectious etiology of diarrhea in patients with AIDS? A. C Diff B. Cryptosporidium C. Cytomegalovirus D. Mycobacterium Avium Complex

B. Cryptosporidium

An 18-year-old man with schizophrenia presents after ingesting a razor blade. The patient indicates that he feels a foreign body sensation in his lower chest. The patient is tolerating secretions and appears to be in no acute distress. X-ray shows a metal foreign body in the distal esophagus. What management is indicated at this point? A. CT scan of the chest to further evaluate the location of the foreign body B. Emergent endoscopy C. Glucagon D. Observation

B. Emergent Endoscopy

A 33-year-old man presents with a painful, irreducible indirect inguinal hernia. You suspect strangulation. Which of the following is the most appropriate management step? A. Elective Hernia Repair B. Emergent Herniorrhaphy C. Hernia Truss D. Monitor for worsening symptoms

B. Emergent Herniorrhaphy

What is the most common cause of travelers diarrhea? A. ENTEROHEMORRHAGIC E Coli B. Enterotoxigenic E Coli

B. Enterotoxigenic E Coli

Which of the following is characterized by macrocytic anemia with increased reticulocytes and Heinz bodies? A. Alpha Thal B. G6PD C. Sickle Cell anemia D. Vitamin B12 deficiency

B. G6PD

What is the most common cause of acute pancreatitis worldwide? A. Alcohol B. Gallstones

B. Gallstones 45% of acute pancreatitis.

A 60-year-old woman presents with two days of right upper quadrant abdominal pain that is constant in nature and associated with subjective fever, nausea, and vomiting. Vital signs are significant for a temperature of 38.1°C, heart rate 87 bpm, blood pressure 140/80 mm Hg, respiratory rate 14 breaths/min, and oxygen saturation of 99% on room air. On physical examination, her abdomen is soft with right upper quadrant tenderness and a positive Murphy sign. Which of the following tests is most sensitive and specific in diagnosing this patient's condition? A. CT with IV contrast B. HIDA scan C. MRI with gadolinium D. US

B. HIDA scan Ultrasound (D) is most useful in the ED setting because it is a quick, noninvasive test. Its sensitivity and specificity, however, are lower than that of a HIDA scan for pathology-confirmed cholecystitis. Ultrasound findings and a clinical exam consistent with acute cholecystitis are highly predictive, and many such patients will undergo cholecystectomy without further diagnostic testing.

An 82-year-old nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of vascular dementia, hypertension, and hyperlipidemia. On examination he is afebrile, and a nasogastric aspirate is negative for evidence of bleeding. Which of the following is the most likely cause of this patient's bleeding? A. Diverticular Bleeding B. Ischemic Colitis C. PUD

B. Ischemic Colitis Ischemic colitis is a syndrome caused by inadequate blood flow through the mesenteric vessels, resulting in ischemia and possible gangrene of the bowel wall. Patients typically present with fairly acute onset crampy abdominal pain with tenderness over the affected bowel. Patients may have bloody diarrhea or passage of frank blood although it is not usually enough to warrant transfusion. The presentation with ischemic colitis differs from acute mesenteric ischemia which presents as pain that is disproportionate to physical examination findings. Risk factors include a history of atherosclerotic disease at other sites, such as coronary artery disease or cerebrovascular disease, advanced age, sepsis and extreme exercise. Bowel wall edema is the most common finding on CT imaging. All cases of ischemic colitis with signs of peritonitis or possible bowel infarction, generally warrant immediate surgical intervention for the resection of the ischemic or necrotic bowel, although this only occurs in about 20% of cases. Most cases resolve with supportive care (eg. IV fluids and bowel rest).

Which of the following findings best distinguishes cholangitis from acute cholecystitis? A. Fever B. Jaundice C. Leukocytosis

B. Jaundice (an elevated serum bilirubin level is characteristic of cholangitis.

A 52-year-old man with a long history of alcoholism presents with epigastric pain and vomiting. You diagnose him with pancreatitis. Which of the following laboratory values is associated with an increased risk of mortality on admission? A. ALT 350 B. LDH 400 C. Lipase 14,000 D. WBC 15,000

B. LDH 400 The Ranson criteria include a number of parameters which may be used in order to calculate a score predictive of mortality from pancreatitis. The criteria actually has two parts, the first score calculated at the time of admission and the second within 48 hours of admission. With a rising score, the risk of mortality increases and many sources advise consideration of admission to the ICU for a score of 3 or more. An LDH value of >350 IU/L on admission is part of the criteria.

Which of the following is considered the gold standard in the treatment of chronic anal fissures? A. Cryosurgery B. Lateral Internal Sphincterectomy C. Rubber Band ligation D. Sclerotherapy

B. Lateral Internal Sphincterectomy

A 40-year-old man presents with bloody stools for six months. He also reports a severe, tearing pain during defecation followed by throbbing discomfort. Medical history is significant for constipation. He has undergone multiple conservative treatments without improvement of his symptoms. He continues to have painful defecations. A fibrotic skin tag at the outermost edge of the anoderm is noted on physical exam. Which of the following is the most appropriate next step in management? A. Diltiazem B. Lateral Internal Sphincterectomy C. Silver Nitrate D. Sitz baths

B. Lateral internal sphincterectomy "He has undergone multiple conservative treatments."

Which of the following is most correct regarding appendicitis? A. An appendicolith is identified in the majority of cases. B. Leukocytosis is seen in the majority of cases C. Perforation is rare in patients younger than 2 years of age D. The presence of an appetitie makes the diagnosis unlikely

B. Leukocytosis is seen in the majority of cases.

A 70-year-old woman presents to your office with a complaint of difficulty having bowel movements. She tells you that she has a bowel movement every 2-3 days, the stool is hard and she has to strain. Which of the following is the most appropriate initial therapy? A. Docusate B. Methylcellulose C. Polyethylene Glycol D. Senna

B. Methylcellulose Initial management of constipation involves educating the patient, increasing fluid intake and dietary fiber, and bulk-forming laxatives such as methylcellulose or psyllium.

Which of the following is true regarding intestinal intussusception? A. Adults are more affected than children B. Most adult intussusception cases involve the small bowel C. Most children with intussusception have a pathologic lesion D. The classic triad of ab pain, mass, and heme-positive stools is usually seen in adults with intussusception

B. Most adults with intussusception cases involve the small bowel.

Which of the following vitamin deficiencies causes the triad of dermatitis, diarrhea and dementia? A. Ascorbic Acid B. Niacin C. Pyridoxine D. Thiamine

B. Niacin (B3)

A 53-year-old man with a history of atrial fibrillation and hypertension presents with severe abdominal pain. He states the pain has been there for 3 days but got more severe today. Over the last 3 days, he has been unable to eat because the pain occurs after eating. Vital signs are T 99.7°F, HR 123 bpm, BP 101/66 mm Hg, and RR 24/min. Examination reveals an uncomfortable patient with diffuse mild abdominal tenderness to palpation without rebound or guarding. Stool guaiac is positive, and serum lactate is 4.8 mmol/L. A surgical consultation is requested. Which of the following represents the appropriate management? A. Obtain abdominal X rays B. Obtain CT angiogram of the abdomen and pelvis C. Obtain CT scan of the abdomen and pelvis without IV contrast D. Obtain RUQ abdominal US

B. Obtain CT angiogram of the abdomen and pelvis This patient's presentation is highly suggestive of mesenteric ischemia, which is best diagnosed by CT angiogram. Once ischemia has progressed to infarction, mortality climbs to 70%, underscoring the need for rapid diagnosis and management. Mesenteric arterial embolism is the most common cause of mesenteric ischemia.

Treatment for SBO? A. Administer IV fluids and obtain a CT of the abdomen and pelvis B. Place an NG tube, begin antibiotics, and obtain a surgical consultation

B. Place an NG tube, begin antibiotics, and obtain a surgical consultation.

A 32-year-old man presents with a severe, tearing pain during defecation, followed by throbbing discomfort. His diet is low in fiber. He reports small bloody streaks on the toilet paper. On physical exam, a 4 mm linear lesion is noted along the anoderm. What is the most likely location of the lesion based on the suspected diagnosis? A. Anterior Midline B. Posterior Midline

B. Posterior midline Anal fissures

Sausage shaped abdominal mass on the right side of abdomen on 1 year old boy. What is the condition?

C. Intussceception

A 60-year-old woman with a history of congestive heart failure presents with substernal chest pain that awoke her from her sleep. She has dysphagia when swallowing solids and odynophagia when swallowing both solids and liquids. She reports a history of chest pain in the past but states that this pain is different in that it is sharp and occurs only after swallowing. Her medications include metoprolol succinate, furosemide, potassium chloride, simvastatin, isosorbide dinitrate, and levothyroxine. Which of the following is most likely to lead to the correct diagnosis? A. Barium Esophagram B. Questioning her about her med use

B. Questioning her about her med use Pill esophagitis is caused by a pill becoming trapped in a collapsed esophagus. Questioning the patient about when and how she takes her medication may elicit information suggesting pill esophagitis is the cause of her chest pain and would be the next step in determining a diagnosis. B: Bisphos K: KCl NSAID FeSO4 Vitamin C

Which of the following is one of the most common causes of bacterial food borne disease in the US? A. E Coli B. Salmonella C. Shigella D. Cholera

B. Salmonella

A 54-year-old man is unable to swallow after feeling a piece of steak "get stuck" while eating dinner. What is the most likely cause of his dysphagia? A. Achalasia B. Schatzki Ring

B. Schatzki Ring

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? A. Oral Docusate B. Topical Hydrocortisone C. Topical Lidocaine D. Topical Nifedipine

B. Topical Hydrocortisone A short course of a topical steroid cream (e.g. hydrocortisone) or suppositories used twice daily has been shown to improve pain and diminish swelling associated with external hemorrhoids.

Which of the following conditions is characterized by ataxia, oculomotor dysfunction, and altered mental status? A. KORSAKOFF Syndrome B. WERNICKE encephalopathy

B. WERNICKE encephalopathy Wernicke encephalopathy is characterized by oculomotor dysfunction (most commonly nystagmus), cerebellar dysfunction, and altered mental status. The result of thiamine deficiency, it is most frequently seen in chronic alcoholics Korsakoff syndrome (A), often seen in patients with Wernicke encephalopathy, is a disorder of anterograde and retrograde amnesia. It is also due to thiamine deficiency. Dementia, ataxia, and urinary incontinence are the hallmarks of normal pressure hydrocephalus (B). Vitamin B12 deficiency (C) can result in megaloblastic anemia, paresthesias, decreased proprioception, weakness, and altered mental status.

A 40-year-old man with a history of Glucose-6-phosphate dehydrogenase (G6PD) deficiency is diagnosed with a urinary tract infection. Which of the following medications should be avoided? A. Amoxacillin B. Ceftriaxone C. Gentamicin D. Bactrim

Bactrim Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked inherited hemolytic anemia that predisposes to hemolysis of RBCs in response to oxidative stress. Patients with G6PD deficiency are asymptomatic until exposed to agents that trigger oxidative stress. Patients may develop an acute hemolytic crisis, with development of jaundice, anemia, splenomegaly, and vascular collapse. Labs show decreased hematocrit, elevated unconjugated bilirubin, and decreased serum haptoglobin. Common triggers for hemolysis include viral and bacterial infections, metabolic acidosis, fava beans and medications, most notably antimalarial drugs, sulfonamides (sulfamethoxazole), nitrofurans (nitrofurantoin), methylene blue, vitamin K, and phenazopyridine. In this case, trimethoprim-sulfamethoxazole (TMP/SMX) should be avoided since it contains a sulfa moiety which could precipitate hemolysis.

A 55-year-old patient just had his first colonoscopy and uncomplicated polypectomy for 1-2 small (<10 mm) tubular adenomas. He has no family history of cancer. In the majority of patients, what is the time frame recommended for a repeat colonoscopy after an initial colonoscopy and polypectomy is performed? A. 1-3 years B. 3-5 years C. 5-10 Years D. 6 months-1 year.

C. 5 months-10 years

A 23-year-old man with a history of ulcerative colitis presents with abdominal pain and vomiting. On exam, he is febrile with a heart rate of 125 beats per minutes and blood pressure of 92/63 mm Hg. He has diffuse abdominal tenderness and distention. Which of the following imaging studies is most appropriate to diagnose toxic megacolon? A. Colonoscopy B. CT C. Plain radiography D. Ultrasound

C. Plain Radiography

A 40-year-old woman presents with acute onset right upper quadrant pain, nausea and vomiting. It began 18 hours ago after a fatty meal, and has progressively worsened. She is febrile and has tenderness in the right upper quadrant. She is not jaundiced. Blood tests are significant for a leukocytosis but only mildly elevated liver enzymes, bilirubin and amylase. Ultrasound examination reveals gallbladder wall thickening and pericholecystic fluid. The common bile duct is patent. Which of the following is the most likely diagnosis? A. Biliary Colic B. Cholangitis C. Cholecystitis D. Choledocholithiasis

C. Cholecystitis Cholangitis (B) is due to infection of the common bile duct (CBD). It may present similarly to cholecystitis, but is also associated with increased bilirubin leading to jaundice. Ascending cholangitis is characterized by Charcot's triad (right upper quadrant pain + jaundice + fever) and Reynold's pentad (Charcot's triad + shock + mental status changes).

Over the last 7 months a 13-year-old girl has had intermittent abdominal pain, which has made her quite irritable. The abdominal pain is associated with arthralgias and general malaise. Review of systems reveals that she has lost 5 kg (11 lb) and has painful bowel movements. Which one of the following is the most likely cause of these symptoms? A. IBS B. Celiac Disease C. Crohn' s Disease D. Ulcerative Colitis

C. Crohn' s disease Crohn's disease is the most common chronic inflammatory bowel disease which occurs during adolescence and young adulthood, with a second peak at 50-80 years of age. The manifestations of Crohn's disease are dependent on the site of involvement, but systemic signs and symptoms are more common than with ulcerative colitis. Crohn's disease presents with chronic diarrhea, crampy abdominal pain, fever, weight loss, and fatigue.

Which of the following is the most likely cause of Phenylketonuria? A. Conversion of phenylalanine to tyrosine B. Conversion of tyrosine to phenylalanine C. Deficiency of phenylalanine hydroxylase D. Excess of phenylalanine hydroxylase

C. Deficiency of phenylalanine hydroxylase

An 18-month-old boy is brought to his pediatrician's office by his parents with concern for developmental delays. The child was born at home and has had irregular healthcare. He has not started speaking and just started sitting upright unassisted. He also has unusual, musty smelling urine. On exam, the child has fair skin and hair. He has poor interaction with the pediatrician. After confirmation of the likely diagnosis, which of the following is the most appropriate management? A. Dietary restriction of branched chain amino acid B. Dietary restriction of lactose and galactose C. Dietary restriction of phenylalanine D. Vitamin C supplementation

C. Dietary restriction of phenylalanine This child most likely has phenylketonuria, which is managed with dietary restriction of phenylalanine. Phenylketonuria (PKU) is an inborn error of metabolism that impairs the body's ability to process the essential amino acid phenylalanine. PKU is the most common inborn error of amino acid metabolism. PKU is more common in Caucasians. In the United States, PKU is screened for at birth. In most cases, phenylketonuria is caused by phenylalanine hydroxylase deficiency, resulting in buildup of serum phenylalanine. Excessive levels of phenylalanine are thought to interfere with brain development. Newborn infants appear normal at birth. Intellectual disability is the hallmark symptom of untreated patients. The onset of PKU is typically insidious, but may worsen in early childhood as dietary exposure increases. Other signs and symptoms may include fair skin and hair, eczema, epilepsy, urine that smells musty, and severe behavioral disturbances. Diagnosis of PKU is based on serum phenylalanine levels. Magnetic resonance imaging typically shows white matter injury in the majority of patients with PKU. Dietary restriction of phenylalanine is the mainstay of treatment in PKU. Special supplements have been created that provide adequate protein requirements. Treatment should be started as soon as PKU is diagnosed to prevent significant neurologic sequelae. Serum phenylalanine concentrations should be measured often, particularly during infancy. Patients with PKU should be referred to a nutritionist and metabolic specialist.

Perforation of what GI structure is associated with the highest mortality? A. Cecum B. Duodenum C. Esophagus D. Stomach

C. Esophagus (often diagnosed late)

A 45-year-old woman comes to the urgent care clinic with a 5-hour history of right upper quadrant pain, fever, nausea, vomiting, and anorexia. She says the pain radiates to her shoulder and back. She says she began experiencing these symptoms shortly after eating a hot dog and chili cheese fries. She smokes 2 packs of cigarettes per day, drinks 2-3 alcoholic beverages every night, and occasionally smokes marijuana. The patient states that her two sisters both have had cholecystectomies. Her temperature is 38.8°C (101.8°F). Palpation of the abdomen shows voluntary guarding. An abdominal ultrasound shows a gallbladder wall of 6 mm. Which of the following contributed the most to the development of this patient's condition? A. Alcohol consumption B. Cigarette Smoking C. Family History D. Marijuana Smoking

C. Family History

A 24-year-old man with HIV was recently started on trimethoprim-sulfamethoxazole. He complains of two days of worsening fatigue and dyspnea. The patient appears pale with scleral icterus. Laboratory testing shows a marked anemia and elevated total and indirect bilirubin. What is the most likely diagnosis? A. Critter NAJJAR syndrome B. Gilbert's syndrome C. G6PD D Immune reconstitution syndrome

C. G6PD. Glucose-6-phosphate dehydrogenase deficiency (G6PD deficiency) is an X-linked inherited disorder causing the most common disease-producing enzymopathy in humans. There are more than 300 variants of the disease and some protection against malaria which likely contributes to its high frequency in the population. G6PD catalyzes two important reactions: the oxidation of G6P and also the reduction of NADP+ to NADPH. NADPH is a required co-factor in many enzymatic reactions in the body. In red cells, NADPH protects the cells against oxidative stress and therefore is heavily reliant on G6PD. In the presence of oxidative stress and oxidative pharmacologic agents, red blood cells begin to rapidly hemolyze. In crisis, patients present with jaundice, anemia depending on the degree of crisis and splenomegaly. Trimethoprim-sulfamethoxazole and other sulfonamides are oxidative drugs.

What is the most common cause of rectal bleeding in an adult? A. Colon Cancer B. Diverticulitis C. Hemorrhoids D. Inflammatory Bowel Disease

C. Hemorrhoids

What electrolyte most commonly causes an ileus? A. Hyperkalemia B. Hypernatremia C. Hypokalemia D. Hyponatremia

C. Hypokalemia

You examine a 17-year-old girl due to anorexia nervosa. She has low self-esteem with intense fear of gaining weight. She restricted her diet for the past three months. On physical exam, her BMI is 18 with heart rate of 35 beats per minute at rest. You decide to admit her for inpatient management. You plan to start nutritional therapy but worry about the risk of refeeding syndrome. Which laboratory finding is most consistent with refeeding syndrome? A. Hyperkalemia B. Hypermagnesemia C. Hypophosphatemia D. Thrombocytopenia

C. Hypophosphatemia

Which of the following is the most common cause of an esophageal perforation? A. Acid Ingestions B. Alkaline Ingestions C. Iatrogenic D. Vomiting

C. Iatrogenic

An 80-year-old man who presents to the emergency department with a complaint of sudden onset left-sided abdominal pain and bloody diarrhea. Abdominal CT demonstrates thickening of the bowel wall and free peritoneal fluid. What is the most likely diagnosis? A. Diverticulitis B. Infectious Colitis C. ischemic Colitis D. SBO

C. Ischemic Colitis Ischemic colitis is the sudden reduction of blood flow to the colon usually caused by an arterial occlusion, venous thrombosis, or hypoperfusion. Ischemic colitis is the most common form of ischemic bowel disease and most often affects the elderly. Blood to the colon is supplied by the mesenteric vasculature and when this is compromised, a reduction in blood flow occurs causing mesenteric and colonic ischemia. Patients with ischemic colitis present with sudden onset of mild to severe cramping, often on the left side of the abdomen, along with rectal bleeding or bloody diarrhea within 24 hours of symptom onset. An abdominal CT may demonstrate findings of thickening of bowel wall or free peritoneal fluid and colonoscopy is diagnostic. Treatment depends on the severity and complexity of the disease, ranging from supportive care to antithrombotic therapy to surgical exploration. Complications include necrosis of the bowel and gangrene, which are medical emergencies.

A nine-year-old girl is seen in the clinic for a well child visit and is found to have a body mass index in the 94th percentile. What additional studies should be ordered according to the American Academy of Pediatrics? A. Abdominal US to look for fatty liver disease B. Hemoglobin A1C and CMP C. Lipid Panel and CMP D. No additional studies recommended.

C. Lipid Panel and CMP According to the AAP guidelines, children with a body mass index (BMI) between 85th and 94th percentile should get a fasting lipid panel, ALT, AST, fasting glucose, and complete blood count to screen for diabetes, dyslipidemia, iron deficiency anemia, and other nutritional depletions.

A patient of yours with a history of diverticulosis develops acute diverticulitis. He is admitted to the hospital for inpatient care. He is successfully treated and discharged home. He follows up with you a few days later. Which of the following should you most likely recommend to him at this time? A. Colonoscopy within 3 days B. High fiber diet until 6 weeks of no symptoms C. Low fiber diet until 6 weeks of no symptoms D. Sigmoidoscopy within 3 days

C. Low fiber diet until 6 weeks of no symptoms. A low fiber diet is especially effective in cases of acute diverticulitis, because it helps reduce the frequency of stools and allows the affected portion of the colon to adequately heal.

A 21-year-old previously healthy man presents to clinic after several nights of partying. He complains of headache, nausea, and emesis that now contains blood. He also endorses a constant burning sensation in the left upper quadrant of his abdomen that started after the retching began. What is the most likely diagnosis? A. Esophageal Varices B. Esophagitis C. Mallory-Weis Tear D. PUD

C. Mallory Weis Tear

Which of the following is associated with pyloric stenosis? A. Bilious vomiting B. Elevated Lipase C. Metabolic Alkalosis D. Poor Feeding

C. Metabolic Alkalosis

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? A. Infectious B. Malabsorption C. Motility D. Osmotic

C. Motility An infectious cause (A) of chronic diarrhea would usually produce a stool that contains WBCs. The malabsorptive disorders (B) which lead to chronic diarrhea typically produce a fatty stool with an elevated osmotic gap. Osmotic disorders (D) result in an increased, not normal, stool osmotic gap.

Which of the following is true regarding diverticulitis A. All patients should have CT B. Complicated diverticulitis can be treated with PO antibiotics C. Oral Antibiotics should be given for 7-10 days in uncomplicated diverticulitis D. US is the imaging modality of choice.

C. Oral antibiotics should be given for 7-10 days in uncomplicated diverticulitis.

You are called to examine a 3-year-old boy in the emergency department for possible ingestion. He was found by his father drooling and playing with an opened drain cleaner. After suspecting a caustic ingestion, he immediately called poison control and was advised to bring the boy to the emergency department. The boy is irritable and drooling. His physical examination is otherwise normal. Which of the following is the most appropriate next step in management? A. Give activated charcoal B. Give PPX antibiotics C. Order an upper endoscopy D. Perform a gastric lavage

C. Order an upper endoscopy Caustic materials cause tissue injury. Caustic alkaline materials are found in drain cleaners, various cleaning agents, hair relaxers, dishwasher agents, and disk batteries. Alkalis produce liquefaction necrosis that allows further tissue penetration of the toxin and setting the stage for possible perforation. On the other hand, acids in household products include toilet bowl cleaners, swimming pool cleaners, and rust removers. Acids produce a coagulative necrosis that limits further tissue penetration, though perforation can still occur. Ingestion of caustic materials can produce injury to the oral mucosa, esophagus, and stomach. The symptoms include pain, drooling, vomiting, abdominal pain, and difficulty swallowing. Initial treatment of caustic exposures includes thorough removal of the product from the skin or eye by flushing with water. Endoscopy should then be performed within 12 to 24 hours of ingestion in symptomatic patients or those in whom injury is suspected in order to assess severity which will then guide the prognosis and treatment of the patient.

A woman with chronic constipation and poorly controlled diabetes mellitus presents with acute anal pain that is exacerbated by defecation. Inspection of the anal border reveals no abnormalities. Which of the following is the most likely diagnosis? A. Anal fistula B. Perianal Hematoma C. Perirectal abscess D. Thrombosed external hemorrhoid

C. Perirectal Abscess Anal fistula (A) is an abnormal connection between the epithelium of the anal canal and the perianal skin. Examination usually reveals the surface opening typical of a fistula, occurring with or without drainage. A perianal hematoma (B) occurs on the anal border. It typically can be seen during examination as a blue-tinged bulge, which is soft, smaller and mobile. If left untreated, it can progress to a thrombosed external hemorrhoid (D), which is hard and larger and is commonly visualized on physical exam.

A 32-year-old man presents with right upper quadrant pain that started earlier today. His symptoms initially included mild generalized abdominal discomfort and nausea before localizing to the right side of his abdomen. He has a low-grade fever but his vital signs are otherwise unremarkable. He has minimal tenderness in the right lower quadrant to palpation. Which of the following signs would be indicative of a retrocecal location of the appendix? A. Murphy Sign B. Obturator Sign C. Psoas Sign D. Rousing Sign

C. Psoas Sign

#117 An 85-year-old nursing home patient presents with diffuse abdominal pain and distension and nausea, but no vomiting. The above abdominal radiograph is obtained. What is the management of this patient?. It is determined that the patient has a sigmoid volvulus. What is the appropriate therapy? A. Enema B. NG tube and bowel rest C. Sigmoidoscopy D. Surgery

C. Sigmoidoscopy The radiograph demonstrates a markedly dilated single loop of colon consistent with a sigmoid volvulus. This is a closed-loop obstruction that results from twisting of a mobile segment of bowel. These occur almost entirely in two populations: (1) elderly, bedridden patients with debilitating comorbid disease and (2) patients of any age with profound neurologic or psychiatric illness. Almost all patients have a history of chronic severe constipation. Although spontaneous reduction of a sigmoid volvulus can occur, it is infrequent enough to mandate procedural intervention. Sigmoidoscopy is used to decompress and detorse the bowel.

A 12-month-old boy is brought to the emergency department by his mother for three days of intermittent episodes of inconsolable crying. This morning the boy became lethargic and difficult to awaken. He has had several episodes of nonbilious vomiting and grossly bloody stools. His vital signs are T 38.3°C, HR 140, BP 80/50, RR 22. On examination, he is lethargic but diffusely tender on abdominal palpation with involuntary guarding. His abdominal X-ray reveals free air under the diaphragm. Which of the following is the most appropriate definitive management of this patient's condition? A. Air contrast enema B. Administration of broad spectrum ABx C. Surgical Reduction D. Nasogastric suction

C. Surgical Resection Intussusception is the invagination of a bowel segment into a distal segment of bowel. It is the most common abdominal emergency in early childhood and is most common in males and in children under two years of age. The classic presentation of intussusception is intermittent abdominal pain, drawing up of the legs towards the abdomen, bloody "currant-jelly" stools mixed with mucus, and a right-sided sausage-shaped abdominal mass. Patients may also present only with progressive lethargy and altered consciousness, a presentation which is often mistaken for sepsis. The diagnostic modality of choice in suspected intussusception with uncertain presentation is ultrasound. In patients with high suspicion for intussusception air-contrast enema is both diagnostic and therapeutic. Contraindications to the use of air-contrast enema include hemodynamic instability with shock, free air under the diaphragm, and peritonitis. Children with these features need emergent surgical intervention.

A mother brings in her 2-week-old infant for a well child check. She reports that she is primarily breastfeeding him, with occasional formula supplementation. Which one of the following should you advise her regarding vitamin D intake for her baby? A. Breastfed infants do not. Need supplemental vitamin D B. Intake of vitamin D in excess of 200 IU/day is potentially toxic C. The baby should be given 400 IU of supplemental vitamin D daily D. Vitamin D supplementation should not be started until he is at least 6 months old

C. The baby should be given 400 IU of supplemental Vitamin D daily

"Apple core" lesion on barium enema x-ray

Colorectal cancer (usually left-sided)

The four Ds- Diarrhea, Dementia, Dermatitis, Death. What do these go with?

Crohns

Transmural involvement with cobblestone appearance

Crohns

An African American man is sent home with a prescription for an antibiotic after being diagnosed with a urinary tract infection. Two days later, he returns because his eyes are yellow. Which of the following antibiotics was most likely initially prescribed? A. Amoxicillin B. Cephalexin C. Doxycycline D. Bactrim

D. Bactrim Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked recessive hereditary disease that results in characteristically low levels of G6PD. This condition is present in 11% of African American men. Individuals with this deficiency may exhibit nonimmune hemolytic anemia in response to a variety of oxidant stressors such as exposure to particular medications or (more commonly) infection. Trimethoprim-sulfamethoxazole can cause an oxidative stress that leads to hemolytic anemia. Other medications associated with hemolysis in G6PD deficiency include the following:

A 10-month-old boy is being evaluated for bilious vomiting, diarrhea, and rectal bleeding. He appears to be in severe distress and is continuously crying. Which of the following should be used to both diagnose and treat this patient's condition? A. Abdominal CT B. Abdominal US C. Abdominal X Ray D. Contrast Enema

D. Contrast enema Based on the constellation of findings, this patient most likely has intussusception. Intussusception occurs when one portion of the intestine invaginates into another portion. The most common form is intussusception of the terminal ileum into the right colon (ileocolic intussusception). Intussusception is the most common abdominal emergency in early childhood. Patients with a typical presentation (eg, infant or toddler with sudden onset of intermittent severe abdominal pain with or without rectal bleeding), can proceed directly to nonoperative reduction using a contrast enema (using either barium or air). In these cases, the procedure is both diagnostic and therapeutic.

A mom brings in her 16-year-old daughter, with concerns of increasing weight loss. Over the past 3 months, her weight went from 60 kg to 55 kg, placing her at the 10th percentile for weight and BMI. She states she is just very conscious of her food choices and wants a regimented exercise routine, as she is training for High School track. She does admit to irregular scant menstrual periods. What constellation of signs and symptoms should you be concerned about in this patient? A. Anemia, Bradycardia, osteopenia B. Anemia, easy bruising, multiple fractures C. Discordered eating, amenorrhea, abnormal body image D. Disordered eating, amenorrhea, osteopenia

D. Disordered eating, amenorrhea, osteopenia FEMALE ATHLETE TIRAD 1. Amenorrhea 2. Disordered Eating 3. Osteopenia

Diet for a patient with phenylketonuria, life long strict adherence to a diet consisting of which of the following A. High in beans, low in veg B. High in meats, low in beans C. High in starches, low in frutis D. High in veg, low in meats

D. High in veg, low in meats.

Which of the following findings seen on rectal exam is most consistent with a concomitant systemic process? A. Anal fissure with bleeding B. Anal fissure with deep ulcer C. Anterior Midline Anal fissure D. lateral Anal fissure

D. Lateral Anal fissure

Which of the following is the most common form of liver disease in the US? A. Hep A B. Hep B C. Hep C D. NAFL

D. NAFL

A 66-year-old white woman presents to your office for a routine physical examination. Her medical problems include hypertension, diabetes mellitus, hypercholesterolemia, and gastroesophageal reflux, all controlled with medications. A bone density study is consistent with osteopenia. She is taking a multivitamin and calcium carbonate 1200 mg daily. Which of the following medications act to reduce calcium absorption? A. Atorvastatin B. HCTZ C. Metformin D. Omeprazole

D. Omeprazole

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? A. Esophagogastroduodenoscopy B. HIDA C. Manometry D. PPI trial

D. PPI Trial Esophagogastroduodenoscopy (EGD) (A) is used in diagnosing GERD if the patient fails to respond to an empiric trial of proton pump inhibition or if red flag features are present (dysphagia, odynophagia, weight loss, persistent vomiting, palpable mass or adenopathy or positive FOBT).

Which of the following is a contraindication to the use of air-contrast enema in the reduction of pediatric intussusception? A. Air contrast enema for a prior episode of intussusception in the last 24 hours B. Fever greater than 39 degrees C. Lethargy D. Peritonitis

D. Peritonitis Contraindications to the use of air-contrast enema include hemodynamic instability with shock, free air under the diaphragm, and peritonitis. Children with these features need emergent surgical intervention.

A 60-year-old man comes to the clinic complaining of difficulty swallowing, heartburn, chest pain, and mild weight loss. He has difficulty swallowing solids and liquids and often regurgitates undigested food. He has no past medical history and takes no medications. He denies any recent travel. Esophageal manometry reveals aperistalsis in the distal two-thirds of the esophagus and incomplete lower esophageal sphincter (LES) relaxation. Which of the following is the most likely diagnosis? A. Barret's esophagus B. infectious esophagitis C. Plummer-Vinson syndrome D. Primary Achalasia

D. Primary Achalasia Primary achalasia is a disease of unknown etiology in which there is a loss of peristalsis in the distal esophagus and a failure of lower esophageal sphincter (LES) relaxation with swallowing. These patients will typically present with difficulty swallowing (dysphagia to both solids and liquids), heartburn, substernal (or retrosternal) chest pain, and regurgitation of undigested food.

A 47-year-old man with a history of alcohol use disorder presents with severe abdominal pain, nausea, and vomiting for 1 day. Examination reveals marked epigastric tenderness to palpation. Labs show the following: Lipase: 4,300 U/L AST: 451 U/L ALT: 532 U/L Alkaline phosphatase: 313 U/L Total bilirubin: 5.3 µmol/L Which of the following is the best next step? A. CT scan of abdomen and pelvis B. Discharge home if patient tolerates oral fluids C. IV antibiotics and admission D. RUQ US

D. RUQ US This patient presents with pancreatitis caused by gallstones. Pancreatitis is a complicated disease with a relatively high associated mortality rate of 4-7%. The most common cause of pancreatitis is gallstones, with alcohol abuse as the number two cause in most populations. CT scan of the abdomen and pelvis (A) is the optimal modality in the emergency department for imaging the pancreas. However, the accuracy of ultrasound for biliary disease is superior to that of CT scan. If gallstones are suspected to be responsible for disease, ultrasound is preferred. When gallstones are not suspected, CT scan is recommended in severe pancreatitis or when there is acute deterioration, lack of improvement within 72 hours, or an uncertain diagnosis.

A 43-year-old woman presents with right upper quadrant abdominal pain for 3 weeks. She states that she intermittently gets sharp pain that occurs after eating and is associated with nausea and occasionally vomiting. The pain lasts for 10-15 minutes, and then spontaneously improves. Currently, she has no pain. Her vitals and bloodwork are normal. A right upper quadrant ultrasound is shown above. What management is indicated? A. Administer antibiotics B. Admit patient for cholescystectomy C> Obtain CT of abdomen and pelvis D. Referral for surgical consultation and pain medication as needed

D. Referral for surgical consultation and pain medication as needed. The decision for cholecystectomy (B) can be made with outpatient surgical consultation in patients with cholelithiasis.

A 46-year-old obese man presents to the clinic complaining of recurrent heartburn. He reports compliance with optimal medical management and dietary modifications and has been unsuccessful at losing weight. Which of the following is a contraindication to surgical intervention and should be ruled out before proceeding? A. Benign esophageal stricutres B. Gastroparesis C. Hiatal Hernia D. Scleroderma

D. Scleroderma Scleroderma presents a contraindication to surgery for gastroesophageal reflux disease due to the high incidence of postoperative dysphagia. One of the most serious complications of gastroesophageal reflux disease is Barrett esophagus, which manifests with alarm symptoms and undergoes malignant transformation into adenocarcinoma.

A 47-year-old man with chronic low back pain presents to the emergency department with epigastric pain for 3 weeks. The pain is burning, without radiation, and occurs 2-3 hours after eating. Vital signs are normal. He takes ibuprofen and naproxen for his back pain. What management is indicated? A. Admit for endoscopy B. Start esomeprazole and refer for outpatient evaluation C. Start ranitidine and refer for outpatient evaluation D. Stop ibuprofen and naproxen and refer for outpatient evaluation

D. Stop ibuprofen and naproxen and refer for outpatient evaluation The patient presents with clinical gastritis, likely secondary to the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Technically, gastritis is a histologic diagnosis indicating inflammation of the gastric mucosa and can only be definitively made after endoscopy and biopsy. Clinicians, however, refer to the symptoms of dyspepsia (pain in the upper abdomen that presents as bloating or heartburn) as gastritis. The most common cause of gastritis is Helicobacter pylori infection, but it also commonly results from medications, including salicylates and NSAIDs (ibuprofen, naproxen). Acute gastritis typically presents with abdominal pain located in the epigastric area that is burning in nature and can also have bloating or nausea associated with it. Treatment should begin with removal of any possible inciting agents including alcohol, smoking, steroids, or NSAIDs.

A 45-year-old woman presents to the ED with three hours of constant right upper quadrant abdominal pain that radiates to her right scapula. The pain was sudden in onset and awoke her from sleep. Vital signs are BP 130/70 mm Hg, HR 90, RR 16, T 98.8℉, and oxygen saturation 99% on room air. On exam, the patient is well appearing, with no pallor, jaundice or abdominal tenderness. Her AST, ALT, total bilirubin, alkaline phosphatase, and lipase are normal. Which of the following is the most likely diagnosis? A. Biliary Leak B. Cholangitis C. Cholecystitis D. Symptomatic Cholelithiasis

D. Symptomatic Cholelithiasis Biliary leak (A) should be considered in a post-cholecystectomy setting. Cholangitis (B) typically presents with physical exam findings (fever, abdominal tenderness, jaundice) and an ill-appearing patient. Cholangitis is associated with Charcot's triad of RUQ pain, jaundice, and fever. Cholecystitis (C) is characterized by RUQ pain and tenderness, often fever, and nausea and vomiting. Labs may show an elevated WBC and elevated total bilirubin and alkaline phosphatase. Ultrasound findings typically include a thickened gallbladder wall, pericholecystic fluid and a gallstone.

A 72-year-old man presents with progressive dysphagia. He initially had difficulty swallowing solid foods, but is now having difficulty swallowing liquids. An esophagogastroduodenoscopy reveals a fungating mass on the middle third of the esophagus. Biopsy of the lesion is positive for squamous cell carcinoma. Which of the following historical features does this man most likely have? A. Exposure to industrial dyes B. GERD C. Lynch Syndrome D. Tobacco use

D. Tobacco use Tobacco use is one of the most common risk factors for the development of squamous cell carcinoma of the esophagus. The most common types of esophageal cancer are squamous cell carcinoma (SCC) and adenocarcinoma. Barrett's metaplasia, from chronic, untreated gastroesophageal reflux disease (GERD), is the most common cause of esophageal adenocarcinoma. Tobacco smoking and alcohol consumption are the most common causes of esophageal SCC. Adenocarcinoma is most commonly seen in Caucasian males. SCC is most commonly seen in African Americans and Asians.

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? A. Abdominal CT B. Barium upper GI series C. H. Pylori Fecal Antigen Assay D. Upper Endoscopy

D. Upper Endoscopy

You are seeing in your office a four-week-old boy with vomiting. Which of the following findings is most concerning for pyloric stenosis as an underlying cause? A. Bilious emesis B. Hyperkalemia, Hypochloremic metabolic acidosis C. Vomitus with the appearance of "curdled milk" D. Weight loss

D. Weight loss Infantile pyloric stenosis should be considered in a neonate with vomiting and weight loss. The classic presentation of infantile pyloric stenosis is in a neonate one to three months of life with progressively forceful, non-bilious emesis. Males predominate over females in 5:1 ratio. A history of erythromycin exposure should also raise suspicion. Individuals with infantile pyloric stenosis typically display immediate hunger after vomiting. The classic exam reveals an olive-shaped mass in the epigastrium with peristaltic waves visible in the left upper quadrant. Classic presentation also includes dehydration and a hypochloremic, hypokalemic metabolic alkalosis.

A 22-year-old man who just returned from a trip to Scandinavia presents to the ED with complaints of severe cramping abdominal pain and diarrhea. The diarrhea was initially profuse and watery and is now bloody. His vital signs are a HR of 105 beats per minute, RR of 18 per minute, BP of 110/64 mm Hg, temperature of 101.84°F (38.8°C), and oxygen saturation of 99% on room air. He has right lower quadrant tenderness on exam. Fecal occult blood test is positive; wet mount of the stool shows fecal leukocytes. Which of the following is the most likely diagnosis? A. Salmonella B. Shigella C. Vibrio parahemolyticus D. YERSINIA Enterocolitis

D. YERSINIA enterocolitis Pseudoappendicitis

Define metabolic syndrome: 3 1. Waist circumference of >________ cm for men and >_______ cm for women 2. TG of >______ mg , HDL <______ for men and <___________ for women, BP of >______/______. 3. Fasting glucose>_________.

Define metabolic syndrome: 3 1. Waist circumference of >_102_ cm for men and >_88_ cm for women 2. TG of >_150_mg , HDL <_40_for men and <_50_ for women, BP of >_130_/_85_. 3. Fasting glucose>__120_.

A patient with alcohol abuse and cirrhosis presents with acute upper gastrointestinal bleeding, hypotension and tachycardia. His past medical history also includes portal hypertension. You suspect ruptured esophageal varices as the source of bleeding. In addition to cardiopulmonary stabilization and blood transfusion, which of the following is the most appropriate emergent interventional treatment? A. Distal splenorenal shunt B. Endoscopic band ligation C. Large volume paracentesis D. Trans jugular Intrahepatic portosystemic shunt

Endoscopic Band ligations Esophageal varices Acute-—Hemodynamic resuscitation, Octreotide, banding, sclerotherapy, PPX ABX Chronic—BB, ligation endoscopic

Which of the following is the most sensitive diagnostic study for diagnosing achalasia? A. Barium Swallow B. Esophageal manometry

Esophageal manometry Birds beak appearance.

Patient on cruise gets vomiting, nausea, and diarrhea. -Cause is ___________ virus Patient in day care cause is ____________ virus

Norovirus=cruise (I igNOROed my diarrhea on the cruise) Kids day care winter months=Rotavirus (ROTAte the baby so they can poop)

Patient is started on Isoniazid, what vitamin should they be concurrently started on? It is vitamin B___

Pyridoxine (B6)

SCC is #1 in the ______________ and the RF are _____________ and _____________ Adenoma is #1 in the _____________ and RF are _____________ and ______________.

SCC is #1 in the WORLD and the RF are ALCOHOL and TOBACCO Adenoma is #1 in the US and RF are GERD and BARRETS ESOPHAGUS.

What diarrheal toxin has the potential to cause extraintestinal manifestations such as hallucinations, confusion, and seizures

Shigella

imaging for intussusception

Ultrasound

the 3 Ds-Diarrhea, dermatitis, and dementia are associated with deficiency in vitamin ____________ Aka _______________. What is the name for a deficiency in this vitamin

Vitamin B3 aka Niacin Pellagra=B3 deficiency B3 (D3)

String sign

pyloric stenosis