GI continued
A 52-year-old obese man presents to your office with complaints of burning chest pain, food regurgitation and cough approximately once every week. He tells you that he likes to eat spicy foods and often eats a large meal shortly before bedtime to help him sleep. Which of the following is the most appropriate initial therapy? Bismuth subsalicylate FamotidineCorrect Answer Metoclopramide Omeprazole A 2-month-old child presents with projectile vomiting. The child initially remains hungry following the episodes of vomiting but, in time, loses interest in feeding and presents to the emergency department appearing wasted and severely dehydrated. On physical exam, the patient appears dehydrated, and a small olive-like structure can be palpated in the right upper quadrant. What is the most likely diagnosis? Formula intolerance Gastroesophageal reflux disease Hirschsprung disease Pyloric stenosis
Pyloric stenosis
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? Bilious emesis Hyperkalemic, hypochloremic metabolic acidosis Vomitus with the appearance of "curdled milk" Weight loss
Weight loss
A 23-year-old man presents with abdominal pain, vomiting and two loose, nonbloody stools. Physical examination reveals right lower quadrant tenderness to palpation. A CT is performed showing a normal appendix and some inflammation at the ileocecal junction. What pathogen is commonly implicated in this disorder? Aeromonas species Salmonella enterica Vibrio parahaemolyticus Yersinia enterocolitica
Yersinia enterocolitica
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? Salmonellosis Shigellosis Vibrio parahaemolyticus infection Yersinia enterocolitis
Yersinia enterocolitis
A 65-year-old man presents to the clinic after being hospitalized for a type B acute aortic dissection, which was managed medically. Which of the following is the primary goal of long-term management to reduce the risk of complications and recurrent dissection? Controlling blood pressure Initiating a supervised exercise program Lowering cholesterol Smoking cessation
Controlling blood pressure
A patient of yours becomes acutely jaundiced. She has had no contact with blood, body fluids, medical specimens or needles. She is currently sexually inactive. Which of the following is she most likely infected with? Hepatitis A Hepatitis B Hepatitis C Hepatitis D
Hepatitis A
Absorption of vitamin B12 requires intrinsic factor. Which of the following cells of the stomach secretes intrinsic factor? Chief cells G-cells Mucous cells Parietal cells
Parietal cells
Which of the following is classified as an esophageal motility disorder? Achalasia Esophageal web Schatzki ring Zenker diverticulum
Achalasia
A careful cardiac examination requires close attention to the heart sounds. The second heart sound, S2, is produced by which of the following structures? Aortic and pulmonic valves Mitral and tricuspid valves Pericardium and chest wall Posterior and anterior cusps of the mitral valve
Aortic and pulmonic valves
Which of the following organisms is the most common cause of traveler's diarrhea? Campylobacter jejuni Enterohemorrhagic Escherichia Coli Enterotoxigenic Escherichia Coli Giardia lamblia
Enterotoxigenic Escherichia Coli
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 nomedications. 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? Iron panel Mean corpuscular volume Methylmalonic acid and homocysteine levels Peripheral blood smear
Methylmalonic acid and homocysteine levels
Which of the following is a risk factor for developing Kawasaki disease? 4 years of age Congenital heart defect Female sex Preceding upper respiratory tract infection
4 years of age
A 45-year-old woman uses ibuprofen daily for the last 12 months to help with her chronic back pain. She comes to you with new onset epigastric pain. Endoscopic examination reveals a duodenal ulcer. Helicobacter pylori serologic testing is positive. She has no known drug allergies. In addition to stopping the ibuprofen, which of the following is the most appropriate therapy at this time? Clarithromycin plus amoxicillin plus a proton pump inhibitor Clarithromycin plus an H2-antagonsist Metronidazole plus amoxicillin plus bismuth subsalicylate Metronidazole plus bismuth subsalicylate
Clarithromycin plus amoxicillin plus a proton pump inhibitor
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? Colorectal carcinoma Drug-induced constipation Intestinal obstruction due to adhesions Toxic megacolon
Colorectal carcinoma
A 70-year-old man with a history of hypertension and hypercholesterolemia presents to the office with pain to the thigh and buttocks that has been getting increasingly worse over the past few months. He states that the pain is only present when he is walking his dog in his neighborhood but gets better when he sits down to rest. He is an active tobacco user and has been smoking a pack of cigarettes daily for the past 40 years. Based on the location of his pain, which of the following arteries is most likely affected by atherosclerosis? Common iliac artery Deep femoral artery Distal superficial femoral artery Popliteal artery
Common iliac artery
When considering the diagnosis of a patient with leg pain and swelling, you determine that the pretest probability of deep vein thrombosis is high. Which of the following is the most appropriate test in confirming this diagnosis? Compression ultrasonography D-dimer assay Factor V level Venography
Compression ultrasonography
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? Arrange for repeat emergent esophagogastroduodenoscopy Consult thoracic surgery Order a barium esophagogram Place a nasogastric tube
Consult thoracic surgery
A patient presents with "food getting stuck" for the past 6 months. She also is having trouble swallowing liquids, and reports regurgitation, chest pain and indigestion as well. Cardiac work-up is negative, and a chest radiograph shows no significant abnormalities. A barium swallow study reveals severe distal esophageal narrowing without any pharyngoesophageal junction abnormalities. Which of the following disorders is the most likely diagnosis? Achalasia Gastroesophageal reflux disease Hiatal hernia Zenker's diverticulum
Achalasia
A 42-year-old man presents to the Emergency Department with acute onset of severe shortness of breath. He was recently discharged from the hospital with endocarditis. Vital signs include temperature 37.6°C, HR 110, BP 110/50, RR 24, SpO2 93%. On examination, he is ill appearing with a new apical systolic murmur and bibasilar rales. Which of the following is the most likely diagnosis? Acute mitral regurgitation Aortic regurgitation Health care associated pneumonia Pulmonary embolism
Acute mitral regurgitation
A 53-year-old man presents with a distended abdomen. Examination reveals a protuberant abdomen without specific point tenderness. A fluid wave is appreciated. Right upper quadrant percussion demonstrates hepatomegaly. There is yellowing of the skin, reddening of the palms, and the proximal nail beds are rounded. Which of the following is most likely included in this patients past medical history? Alcohol abuse Asbestos exposure Crohn's disease Diverticulosis
Alcohol abuse
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? Anal fissure Anorectal abscess Anorectal fistula Pruritus ani
Anorectal abscess
Which of the following statements is true regarding giant cell arteritis? Aortic involvement can lead to valvular disease and dissection Corticosteroid therapy should be initiated only when biopsy confirms the disease Histologic findings of inflammation are irreversible It is associated with sudden, painful binocular vision loss
Aortic involvement can lead to valvular disease and dissection
A 30-year-old man with ankylosing spondylitis presents for a routine physical. This is the first encounter that you appreciate a murmur during cardiac auscultation. You appreciate a diastolic, high pitched, blowing murmur while listening with the diaphragm in the left sternal border. There is no palpable thrill. Which of the following is the most likely diagnosis? Aortic regurgitation Aortic stenosis Mitral regurgitation Tricuspid stenosis
Aortic regurgitation
Elective surgical repair should be offered to which of the following patients with asymptomatic abdominal aortic aneurysm? 22-year-old man with Ehlers-Danlos syndrome; aneurysm size 3.5 cm 42-year-old man with hypertension; aneurysm size 3.9 cm with 0.9 cm expansion in 6 months 52-year-old man with positive family history; aneurysm size 4.5 cm 62-year-old man with tobacco use; aneurysm size 4.5 cm with aneurysm growth 0.2 cm in two years
42-year-old man with hypertension; aneurysm size 3.9 cm with 0.9 cm expansion in 6 months
A 62-year-old man with a history of ongoing tobacco abuse, hypertension, dyslipidemia and erectile dysfunction complains of progressive aching pain in his right buttock and hip. The pain is worse with walking and is relieved with rest. Physical exam of the lower extremities reveals slightly diminished femoral, popliteal, and dorsalis pedis pulses. Which of the following is the most likely site of this patient's peripheral arterial disease? Aortoiliac segment Common femoral artery Popliteal artery Superficial femoral artery
Aortoiliac segment
A 54-year-old man presents complaining of epigastric pain that started several hours ago. The pain is moderate and sharp but does not radiate. He has a history of hypertension and an exploratory laparotomy 20 years ago. His vital signs on presentation include T 37°C, HR 95 bpm, and BP 136/80 mm Hg. His exam reveals a firm, mildly tender protruding mass in the epigastric region with no overlying skin changes. Which of the following is the best next step? Apply gentle steady pressure to the mass Obtain computed tomography scan of the abdomen Perform bedside abdominal aortic ultrasound Perform incision and drainage of the mass
Apply gentle steady pressure to the mass
A 42-year-old man presents to the Emergency Department with nausea, vomiting, and right upper quadrant abdominal pain. He drinks alcohol daily. Which of the following laboratory results would be most consistent with alcoholic hepatitis? Alkaline phosphatase 350 U/L Aspartate transaminase 1000 U/L and alanine transaminase 1200 U/L Aspartate transaminase 250 U/L and alanine transaminase 120 U/L Mean corpuscular volume 60 fL
Aspartate transaminase 250 U/L and alanine transaminase 120 U/L
A 69-year-old man with atherosclerosis presents with calf pain during ambulation. He notices a blanching of the leg skin when the pain is at its worst. If he stops walking, the pain ceases within 5 minutes. He has a 120 pack-year history of tobacco use. Examination of the toes reveals prolonged capillary refill but normal sensation. A recent work-up revealed normal cardiac function. Which of the following abnormalities would most likely be found during examination of this patient's lower extremities? Atrophic, shiny skin Intrinsic foot muscle weakness Pitting edema Varicose veins
Atrophic, shiny skin
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? Azithromycin Ciprofloxacin Symptomatic therapy with loperamide Trimethoprim-Sulfamethoxazole
Azithromycin
A 35-year-old man with a history of ulcerative colitis presents to the emergency department with complaints of fever, mild abdominal pain, vomiting and diarrhea. His temperature is 102F, pulse is 125/min, and blood pressure is 88/52 mm Hg. Abdominal X-ray reveals colonic dilatation. In addition to fluid resuscitation, which of the following is the most appropriate initial step in management? Bowel rest and nasogastric tube Initiation of total parenteral nutrition Obtain CT scan of abdomen and pelvis with intravenous contrast Pain control with intravenous morphine
Bowel rest and nasogastric tube
Which of the following is a risk factor associated with the development of pancreatic cancer? Alcohol consumption Cigarette smoking Diet high in red meats Sedentary lifestyle
Cigarette smoking
A 19-year-old Asian man presents with complaints of diarrhea, flatulence, and bloating that occur everyday after breakfast. His breakfast is usually fruit with cottage cheese and a glass of milk. He denies weight loss, constipation, steatorrhea, bloody stools, or tenesmus. Which of the following tests will most likely diagnose his condition? Colonoscopy Hydrogen breath test IgA endomysial antibody test Qualitative fecal fat assay
Hydrogen breath test
An overweight 29-year-old roofer presents with acute groin swelling after lifting an 80-pound sack of shingles. Examination reveals a minimally tender mass in the right scrotum. There is no mass in the proximal thigh or abdomen. Which of the following types of hernia do you most likely suspect? Direct inguinal Epigastric Femoral Indirect inguinal
Indirect inguinal
A 35-year-old man presents with intermittent rectal bleeding and mucoid discharge for two weeks. His diet is low in fiber. He reports some bright red bloody streaks on the toilet paper after each bowel movement. Rectal pain is absent. On physical exam, no nodules are initially seen. With Valsalva, a purple nodule covered by mucosa is seen protruding through the anus. Which of the following is the most likely diagnosis? Anal abscess Anal fissure External hemorrhoid Internal hemorrhoid
Internal hemorrhoid
A 58-year-old man presents with 3 months of headache and transient diplopia. He also reports that chewing tough foods has been progressively painful. Laboratory testing reveals a normocytic anemia and ESR of 88 mm/hour. A brain CT is normal. Biopsy reveals fragmented elastic lamina, CD4+ lymphocytes and macrophages. Which of the following is the best next step to manage this patient's condition? Intravenous methylprednisolone Oral methotrexate Oral prednisone Temporal artery resection
Intravenous methylprednisolone
Which of the following describes the correct management of aortic dissection? All aortic dissections eventually need surgical or endovascular repair Crystalloids are the preferred treatment of hypotension in the setting of aortic dissection Stanford type A dissections should be managed chronically with negative inotropes Vasodilators are the preferred treatment of hypertension in the setting of aortic dissection
Crystalloids are the preferred treatment of hypotension in the setting of aortic dissection
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? CT scan of the chest to further evaluate the location of the foreign body Emergent endoscopy Glucagon Observation
Emergent endoscopy
A 47-year-old woman with a history of human immunodeficiency virus infection, hypertension, and schizophrenia, presents with a 1-day history of epigastric abdominal pain, nausea and vomiting. Vital signs are notable for BP 135/86 mm Hg, pulse of 104 beats/minute, RR 14 breaths/minute, temperature of 37.9, and oxygen saturation of 98% on room air. On examination, she is exquisitely tender in the epigastrium. Lipase is elevated at 4,500 U/L. Which of the following of her medications is the most likely cause of her symptoms? Aripiprazole Enalapril Penciclovir Tenofovir
Enalapril
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? Erythromycin use Female sex Full-term birth Second born child
Erythromycin use
A 27-year-old woman presents to her primary care physician with dysphagia. Her symptoms began several months ago. She has trouble swallowing solids and liquids though liquids seem to make her choke and sputter the most; therefore, she has been unable to eat and has thus experienced significant weight loss. She has no significant past medical history apart from a 20-pack-per-year smoking history. She denies any recent travel. Physical examination is within normal limits. A barium esophagram reveals a "bird's beak" appearance. What is the next best step in diagnosis? Begin a calcium channel blocker Begin botulinum toxin injections Esophageal manometry Upper endoscopy
Esophageal manometry
A 52-year-old man comes to the clinic complaining of difficulty swallowing, upper abdominal pain, and heartburn. He says he has a difficult time swallowing solid foods and the food frequently gets "stuck" in his throat. He has a history of food allergies, asthma, and atopic dermatitis. Laboratory studies show markedly elevated serum IgE levels. Upper endoscopy shows stacked circular rings. Which of the following is the most likely diagnosis? Achalasia Esophageal stricture Esophagitis Gastroesophageal reflux disease (GERD)
Esophagitis
What is the most common cause of acute pancreatitis worldwide? Alcohol Gallstones Medications Trauma
Gallstones
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? Crigler-Najjar syndrome Gilbert's syndrome Glucose-6-phosphate dehydrogenase deficiency Immune reconstitution syndrome
Glucose-6-phosphate dehydrogenase deficiency
Which of the following laboratory results signifies acute hepatitis B? HBsAg +, anti-HBc IgG +, HBeAg -, HBV DNA + HBsAg +, anti-HBc IgM +, HBeAg +, HBV DNA + HBsAg -, anti-HBs +, HBeAg -, HBV DNA - HBsAg -, anti-HBs -, HBeAg -, HBV DNA -
HBsAg +, anti-HBc IgM +, HBeAg +, HBV DNA +
Which of the following is demonstrated on a peripheral blood smear of a patient with glucose 6-phosphate dehydrogenase deficiency? Heinz bodies Howell-Jolly bodies Rouleaux formation Target cells
Heinz bodies
A 32-year-old man develops malaise, anorexia, fever, nausea, vomiting, and abdominal discomfort. AST and ALT are markedly elevated. Which of the following hepatitis viruses is associated with the highest risk of progression to chronic infection in adults? Hepatitis A virus Hepatitis B virus Hepatitis C virus Hepatitis E virus
Hepatitis C virus
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? Computed tomography scan with intravenous contrast Hepatobiliary iminodiacetic acid (HIDA) scan MRI with gadolinium Ultrasound
Hepatobiliary iminodiacetic acid (HIDA) scan
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? Colonoscopy Computed tomography Plain radiography Ultrasound
Plain radiography
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? Anterior midline Circumferential Lateral Posterior midline
Posterior midline
A 16-year-old girl returns from a summer abroad volunteering at an HIV clinic in Zimbabwe. She is going to volunteer at her local hospital, which requires tuberculosis skin testing. Her skin test is read as 14 mm of induration. Chest X-ray is negative and she is asymptomatic so she is started on a 9-month course of isoniazid. What vitamin should she concurrently be started on? Cobalamin Niacin Pyridoxine Thiamine
Pyridoxine
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? Barium esophagram CT angiogram of the chest CElectrocardiogram Questioning her about her medication use
Questioning her about her medication use
Which of the following is a risk factor for the development of deep vein thrombosis? Alcohol consumption Female sex Recent major surgery Younger than 40 years old
Recent major surgery
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? Administer antibiotics and admit for observation Admit patient for cholecystectomy Obtain CT scan of the abdomen and pelvis Referral for surgical consultation and pain medication as needed
Referral for surgical consultation and pain medication as needed
What is the most common cause of tricuspid valve stenosis? Bacterial endocarditis Dilation and dissection of the aortic root Marfan syndrome Rheumatic heart disease
Rheumatic heart disease
A woman presents with dyspnea on exertion. Cardiac examination reveals an apical mid diastolic murmur. You also notice pitting edema in both her legs. She undergoes echocardiographic testing. Which of the following abnormalities would you most expect to see on the echocardiogram? Decreased trans-mitral mean pressure gradient Increased opening of the mitral valve leaflets Right atrial hypertrophy Right ventricular hypertrophy
Right ventricular hypertrophy
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? Enema Nasogastric tube and bowel rest Sigmoidoscopy Surgical intervention
Sigmoidoscopy
Which of the following cardiac auscultation findings is most consistent with mitral valve regurgitation? Harsh, crescendo-decrescendo systolic murmur Loud S1, opening snap, and a diastolic rumble Mid-systolic click and late systolic murmur Soft S1 and a loud, blowing holosystolic murmur
Soft S1 and a loud, blowing holosystolic murmur
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? Admit for endoscopy Start esomeprazole and refer for outpatient evaluation Start ranitidine and refer for outpatient evaluation Stop ibuprofen and naproxen and refer for outpatient evaluation
Stop ibuprofen and naproxen and refer for outpatient evaluation
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? Biliary leak Cholangitis Cholecystitis Symptomatic cholelithiasis
Symptomatic cholelithiasis
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? Abdominal CT Barium upper gastrointestinal series H. pylori fecal antigen assay Upper endoscopy
Upper endoscopy
A 66-year-old man presents with nausea and recurrent vomiting. His wife accompanies him and adds she thinks his voice has changed. His past medical history is significant for alcohol abuse, tobacco abuse, hypertension, COPD and celiac disease. During examination, his voice is raspy and hoarse. You order a chest and neck CT scan which reveals a mass. Which of the following is the most likely location of this mass? Gastric cardia Gastric pylorus Lower one-third of the esophagus Upper two-thirds of the esophagus
Upper two-thirds of the esophagus
An obese 45-year-old man works for the local electric company as a utility-pole lineman. He presents with painful, tortuous superficial veins on his lower legs. These areas are not associated with erythema, warmth or skin breaks. Which of the following initial plans is most appropriate at this time? Dangle your legs at night over the side of your bed for 30 minutes Increase your daily exercise routine Schedule an appointment with a vascular surgeon Use compressive stockings during the day
Use compressive stockings during the day
A 76-year-old man with a history of hypertension presents after a syncopal event. He also reports decreased exercise tolerance over the last two months. He is currently asymptomatic. His ECG is normal sinus rhythm with no changes. On examination, he has a harsh systolic murmur that radiates to the carotid arteries. Which of the following is true about the most likely cause of his syncope? Critical disease is defined by heart valve area less than 2 cm2 It typically results from rupture of the chordae tendinae The murmur increases with valsalva Vasodilators and diuretics should be used with caution
Vasodilators and diuretics should be used with caution
A 12-year-old boy is brought to the clinic for progressively worsening blurry vision and generalized headaches that are worse in the morning. On further questioning, he is also revealed to have nausea, joint pain, itchy and peeling skin, dizziness, and irritability. Historically, he has been a healthy child and his family follows an organic diet with additional supplements that include 2 tablespoons of cod liver oil and a multivitamin tablet a day. On exam, his weight dropped from the 50th percentile a year before to the 10th percentile currently. He has oily skin and hair and cracking at the corners of his mouth. Chronic overdose of which of the following most likely caused his symptoms? Vitamin A Vitamin C Vitamin D Vitamin E
Vitamin A
A 12-year-old girl with cystic fibrosis has been non-compliant 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 Vitamin D Vitamin E Vitamin K
Vitamin A
A 15-year-old girl presents to the emergency department complaining of headaches. The patient denies fever, sore throat, vomiting, and head trauma. Physical exam reveals facial acne, papilledema, and splenomegaly. Excess of which of the following vitamins is most likely causing her symptoms? Vitamin A Vitamin B3 Vitamin B6 Vitamin C Vitamin E
Vitamin A
A homeless man presents with difficulty walking and painful calves. He has a history of alcohol abuse and ulcerative colitis, both untreated. He denies a history of chronic diarrhea. A blood tox screen is negative for alcohol and illicit drugs. His examination is significant for several neurologic findings: altered proprioception, distal numbness, hyporeflexia, mental confusion and nystagmus. Perioral and tongue examination is normal. These symptoms are most likely related to a deficiency of which of the following vitamins? Vitamin B1 Vitamin B2 Vitamin B3 Vitamin C
Vitamin B1
A 85-year-old was found unconscious in his home by emergency medical services and was brought to the hospital. He lives by himself and appears emaciated on physical exam. Bleeding of his gums and multiple chronic appearing wounds on the extremities are also noted on physical exam. Which vitamin deficiency does this patient most likely have? Vitamin A Vitamin B Vitamin C Vitamin D
Vitamin C
A 28-year-old woman presents to her primary care provider complaining of abdominal bloating, cramping and diarrhea most days of the week for the last four months. The diarrhea commonly occurs in the morning or following meals. Episodes occur four or five times per day and are of moderate volume. She denies fever, nausea, vomiting, periods of constipation, or change in appetite. The diarrhea does not wake her from her sleep and she reports no blood or pus in her stool. She states the periods of diarrhea will last several months and then seem to resolve without explanation. In between diarrhea episodes, she has normal formed bowel movements once per day. A review of her symptom diary reveals no food associations. She denies any recent travel. What is the most likely diagnosis? Celiac disease Infectious diarrhea Inflammatory bowel disease Irritable bowel syndrome
Irritable bowel syndrome
A 58-year-old man with chronic hypertension presents to the ED with acute, 10/10 tearing substernal pain that radiates to the back. All you can gather from him is that he also has some type of "collagen disorder" and diabetes. A chest radiograph reveals a widened mediastinum. As you prepare for a transesophageal echocardiogram, you would most likely start which of the following medications as a first-line agent? Clonidine Labetalol Lisinopril Nitroprusside
Labetalol
A 4-year-old boy presents to your office with watery nonbloody diarrhea for the last three months. He has occasional abdominal pain prior to the onset of the diarrhea and his mother noted worsening flatulence, especially after meal times. Mom denies any recent travel or camping and the patient does not go to school or daycare. On exam, he is 60th percentile for weight and height (similar to his last well-child check), appears well, and has a normal abdominal exam. What is the most likely diagnosis? Celiac disease Inflammatory bowel disease Irritable bowel syndrome Lactase deficiency
Lactase deficiency
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? Diltiazem 2% ointment Lateral internal sphincterotomy Silver nitrate 2% Sitz baths
Lateral internal sphincterotomy
Which of the following is considered the gold standard in the treatment of chronic anal fissures? Cryosurgery Lateral internal sphincterotomy Rubber band ligation Sclerotherapy
Lateral internal sphincterotomy
A woman in her second trimester of pregnancy develops a left lower extremity deep vein thrombosis. Which of the following is the most appropriate choice of anticoagulation for this patient? Apixaban Dabigatran Low molecular weight heparin Warfarin
Low molecular weight heparin
An elderly patient presents to the office complaining of lower extremity skin changes and discomfort that is relieved with elevation. Which of the following would most likely be present on physical exam? Cold lower extremities Diminished pulses Lower extremity edema Palpable cord
Lower extremity edema
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? Esophageal varices Esophagitis Mallory-Weiss tear Peptic ulcer disease
Mallory-Weiss tear
Which of the following statements is true regarding prosthetic heart valves? Anticoagulation is optional with mechanical valves Mechanical valves are associated with less hemolysis and are less thrombogenic than bioprosthetic are Mechanical valves are more prone to paravalvular leaks than bioprosthetic valves are Mechanical valves make opening and closing sounds similar to, but louder than, those of native valves
Mechanical valves are more prone to paravalvular leaks than bioprosthetic valves are
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? Caucasians are at highest risk for developing this condition Chemotherapy and radiation are standard initial therapy for localized disease Five-year survival rate of advanced disease is 80% Men have a higher risk of developing this condition
Men have a higher risk of developing this condition
A 73-year-old woman with a history of hypertension presents with a unilateral headache for 3 weeks. She states she has a throbbing pain at her right temple and has pain in her jaw with opening and closing. The vision in her right eye has worsened over the previous day. Her blood pressure is 173/100 mm Hg. What treatment is indicated? Carbamazepine Labetalol Methylprednisolone Noncontrast head CT scan
Methylprednisolone
A 55-year-old woman presents to the office with progressive dyspnea, paroxysmal dyspnea, orthopnea, and fatigue over the last several months. On auscultation of her heart, you detect a low-pitched diastolic rumble best heard in the left lateral decubitus position along with a high-pitched opening snap. Which type of valvular abnormality is associated with these findings? Aortic regurgitaion Aortic stenosis Mitral regurgitation Mitral stenosis
Mitral stenosis
A 58-year-old previously healthy woman presents with complaints of dyspnea on exertion and fatigue for the past one month. She denies unexplained weight loss or weight gain, chest pain, or cough. Physical exam reveals a low pitched, diastolic murmur, heard best at the apex. There is an associated opening snap. Which of the following is the most likely diagnosis? Aortic regurgitation Aortic stenosis Mitral regurgitation Mitral stenosis
Mitral stenosis
A 52-year-old woman four days post myocardial infarction presents with a new murmur. On examination, the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspneic at rest and has rales throughout all her lung fields. Her blood pressure is 108/68 mm Hg, and her heart rate is 70 beats per minute. Which of the following would be the definitive clinical intervention? Coronary artery bypass surgery (CABG) Immediate fluid bolus Intra-aortic balloon counterpulsation Mitral valve replacement
Mitral valve replacement
A 62-year-old man with a history of hypertension and tobacco abuse presents with acute onset of sharp epigastric abdominal pain with radiation to his back. On arrival, his vitals signs are T 37.3°C, HR 100, BP 180/90 in the right arm and 80/40 in the left arm, RR 27. Which of the following agents is the first line management of this patient's condition? Diuretics Negative inotropes Vasodilators Vasopressors
Negative inotropes
A 67-year-old man with a history of hypertension presents to the emergency department complaining of the acute onset of severe tearing chest pain and a syncopal episode. Which of the following physical exam findings would support the most likely diagnosis? Ankle-brachial index of 1.0 Mydriasis New murmur of aortic regurgitation Positive Murphy sign
New murmur of aortic regurgitation
A young woman with Raynaud phenomenon presents with a three month history of cyclical short episodes of chest pain. Her social history is positive for intermittent cocaine use. The pain occurs most commonly after she wakes in the morning, lasts for 20 minutes, then resolves. This pain occurs at rest and is not worse with exercise or increased activity. Which of the following would you most expect to find during an evaluation of these symptoms? Coronary artery stenosis Normal exercise stress test Pain relief during ergonivine administration Persistent ST elevation
Normal exercise stress test
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? Atorvastatin Hydrochlorothiazide Metformin Omeprazole
Omeprazole
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? Obtain serum amylase and lipase levels Order a contrast-enhanced computed tomography scan Order a right upper quadrant abdominal ultrasound Prescribe oral omeprazole
Order a right upper quadrant abdominal ultrasound
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? Abdominal radiograph Barium enema CT scan of the abdomen pelvis with IV contrast Sigmoidoscopy
Abdominal radiograph
Which of the following is contraindicated in children with bloody diarrhea and no confirmatory infection by stool culture? Antibiotics Blood transfusion Hemodialysis Intravenous fluid hydration with normal saline
Antibiotics
A 15-year-old boy is brought by his mother to the Emergency Department due to nausea, multiple episodes of vomiting previously ingested food, and three loose bowel movements. His mother notes that the boy reheated the leftover rice stored in the refrigerator the night before. Physical examination reveals a tired child who is afebrile with dry mucous membranes. He has pink palpebral conjunctivae, clear breath sounds, a soft abdomen with mild tenderness at the epigastric area, and full pulses. Which of the following is the most likely causative agent? Bacillus cereus Campylobacter jejuni Clostridium botulinum Vibrio cholerae
Bacillus cereus
Which of the following is the most common cause of an esophageal perforation? Acid ingestions Alkaline ingestions CIatrogenic Vomiting
CIatrogenic
A 34-year-old man presents with "heartburn." His evaluation leads the provider to believe that gastroesophageal reflux disease is the etiology of his symptoms. Which of the following increases symptoms of reflux? Beta-blockers Caffeine Spearmint Testosterone supplements
Caffeine
Which of the following is the most common cause of esophageal varices in the United States? Cirrhosis Hepatic steatosis Parasitic infestation Prolonged standing
Cirrhosis
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? Desipramine Loperamide Lubiprostone Rifaximin
Desipramine
A patient presents with new onset odynophagia. Chest imaging reveals a lower esophageal stricture but rules out the possibility of neoplasia. Endoscopy shows mucosal inflammation and fibrosis. Which of the following is the most appropriate initial treatment? Dilation Diltiazem Famotidine Lactulose
Dilation
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? Distal splenorenal shunt Endoscopic band ligation Large volume paracentesis Transjugular intrahepatic portosystemic shunt
Endoscopic band ligation
A 57-year-old man with HIV complains of gradually increasing pain and difficulty with swallowing despite use of omeprazole that was prescribed for suspected gastroesophageal reflux. An endoscopy reveals yellow-whitish nodular plaques adherent to an erythematous mucosa. What is the next most appropriate step in management of this patient? Esophageal dilation Fluconazole Pantoprazole Prednisone
Fluconazole
Which of the following is characterized by macrocytic anemia with increased reticulocytes and Heinz bodies? Alpha thalassemia Glucose-6-phosphate dehydrogenase deficiency Sickle cell anemia Vitamin B12 deficiency
Glucose-6-phosphate dehydrogenase deficiency
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? Hyperchloremic, hyperkalemic metabolic alkalosis Hyperchloremic, hypokalemic metabolic alkalosis Hypochloremic, hyperkalemic metabolic alkalosis Hypochloremic, hypokalemic metabolic alkalosis
Hypochloremic, hypokalemic metabolic alkalosis
A 3-week-old boy presents with two days of non-bilious projectile vomiting. Examination reveals a mass in the infant's right upper quadrant. On a barium upper GI series report, the radiologist states a "string sign" is present. Which of the following is this infant at greatest risk of developing? Hyperchloremia Hyperkalemia Hypokalemia Hyponatremia
Hypokalemia
An 82-year-old man presents with acute symptoms of ischemic colitis. He subsequently undergoes emergent bowel resection surgery. The surgical report details an infarction of the descending colon and recto-sigmoid junction. Pathology in which of the following arteries is the most likely cause of this condition? Celiac trunk Inferior mesenteric artery Portal vein Superior mesenteric artery
Inferior mesenteric artery
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? Diverticulitis Infectious colitis Ischemic colitis Small bowel obstruction
Ischemic colitis
Which of the following findings best distinguishes cholangitis from acute cholecystitis? Elevated alkaline phosphatase Fever Jaundice Leukocytosis
Jaundice
Which of the following findings is classically associated with pyloric stenosis? Bilious vomiting Elevated lipase Metabolic alkalosis Poor feeding
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? Infectious Malabsorption Motility Osmotic
Motility
An obese 37-year-old woman is in the emergency room for right-sided abdominal pain and excessive flatulence. This episode has persisted for several hours. On physical exam you palpate her right upper quadrant while she takes a deep breath. The patient experiences pain and has a transient pause in inspiration. This physical exam finding is associated with which of the following signs? Levine sign McBurney's point tenderness Murphy's sign Psoas sign
Murphy's sign
Which of the following antibiotics may precipitate hemolysis in a patient with G6PD deficiency? Amoxicillin/Clavulanate Cephalexin Nitrofurantoin Streptomycin
Nitrofurantoin
In addition to stool softeners, which of the following can be used topically in the management of midline anal fissures? Fentanyl Mupirocin Nitroglycerin Sucrose
Nitroglycerin
A 35-year-old woman presents to your office to establish care as a new patient. She has a history of ulcerative colitis with multiple flare-ups. Which of the following is the most appropriate maintenance therapy? Hydrocortisone suppositories Oral mesalamine Oral metronidazole Oral prednisone
Oral mesalamine
A 7-year-old girl has a history of cerebral palsy, static encephalopathy, seizure disorder, and recent aspiration pneumonia. She completed treatment for pneumonia two days ago but now has developed foul-smelling, watery diarrhea and abdominal cramping. Her vital signs are within normal limits for age. What is the treatment of choice? Intravenous clindamycin Intravenous vancomycin Oral metronidazole Reassurance regarding antibiotic-associated diarrhea
Oral metronidazole
A 77-year-old man presents to his primary care provider with progressive jaundice for the past 2 weeks. He also admits to 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? Cholecystitis Cirrhosis Hepatocellular carcinoma Pancreatic cancer
Pancreatic cancer
A patient presents to the clinic complaining of a tearing pain with bowel movements and reports small streaks of blood on the toilet paper. A physical examination of the patient's anus reveals a lesion most likely in which of the following anatomic locations? Anterior midline Circumferentia Lateral Posterior midline
Posterior midline
Which of the following conditions most commonly results in symptomatic hemorrhoids? Pancreatitis Peptic ulcer disease Pregnancy Ulcerative colitis
Pregnancy
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? Barrett's esophagus Infectious esophagitis Plummer-Vinson syndrome Primary achalasia
Primary achalasia
Which of the following is one of the most common causes of bacterial foodborne disease in the United States? Enterotoxigenic Escherichia coli Salmonella Shigella Vibrio cholerae
Salmonella
Twenty-four hours after eating a salad containing bean sprouts, a 25-year-old man became ill with fever, abdominal pain and diarrhea. Which of the following organisms is the most likely cause of his symptoms? Clostridium perfringens Cryptosporidium parvum Enterotoxigenic Escherichia coli Salmonella enterica
Salmonella enterica
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? Achalasia Barrett esophagus Neoplasm Schatzki ring
Schatzki ring
A pediatric patient presents to your office for a new patient evaluation. He has a history of Hirschsprung's disease. Which of the following complications is associated with this congenital disease? Diverticulosis Fatty liver disease Fistula Toxic megacolon
Toxic megacolon
A 32-year-old man presents to clinic with worsening colicky stomach pains, and bloody, mucous streaked diarrhea. He reports he has no fever, nausea or vomiting. His symptoms began vaguely a week ago and have progressed in severity since then. He reports he is otherwise healthy, not on any medications and has not travelled recently. He has no family history of colon cancer and reports the symptoms are so bad he is no longer able to go out in public for fear of having to use the toilet. Stool studies are negative. Colonoscopy reveals edema, friability, mucous and erosions of the mucosal surface of the rectosigmoid region. Which of the following is the most likely diagnosis? Colon cancer Crohn's disease Irritable bowel syndrome Ulcerative colitis
Ulcerative colitis
A patient presents with hematemesis. What test is most likely to determine the etiology of the bleeding? CT scan of the abdomen and pelvis Nasogastric tube lavage Right upper quadrant ultrasound Upper endoscopy
Upper endoscopy
A 32-year-old man presents to your office with a new diagnosis of celiac disease. He wants to make sure that he is adhering to a gluten-free diet and is confused about what he can eat. Which of the following foods can he safely include on his diet? Fried chicken with gravy Spaghetti with marinara sauce Tuna fish sandwich on whole wheat bread Vegetables with brown rice
Vegetables with brown rice
A 3-week-old boy presents with nonbilious, forceful emesis for 2 days. On examination, the infant appears active and feeds vigorously, followed immediately by vomiting. Which of the following is the most appropriate diagnostic study? Abdominal radiograph Abdominal ultrasound CT scan of the abdomen and pelvis Urine dipstick
Abdominal ultrasound
Which of the following is the most appropriate diagnostic test in a patient with suspected infantile hypertrophic pyloric stenosis? Abdominal ultrasound CT of the abdomen MRI of the abdomen Plain X-ray of the abdomen
Abdominal ultrasound
A 42-year-old man with a history of human immunodeficiency virus infection presents to his primary care provider with complaints of odynophagia and dysphagia. He also admits to nausea and generalized chest pain. The man's last CD4 count was 90 cells/μL. Upper endoscopy reveals multiple, small ulcers in the distal esophagus. Which of the following is the most appropriate management? Acyclovir Fluconazole Ganciclovir Trimethoprim/sulfamethoxazole
Acyclovir
A 57-year-old man presents complaining of 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 Gastrointestinal carcinoid tumor Primary colorectal lymphoma Squamous cell carcinoma of the colon
Adenocarcinoma of the colon
A 35-year-old previously healthy man presents to your office with a complaint of diarrhea 24 hours after returning from a mission trip to Sierra Leone. He endorses hourly bouts of large volumes of stool that now have a white-colored liquid appearance. Physical exam findings include decreased skin turgor, dry buccal mucous membranes and a rapid, thready radial pulse. Which of the following is the most appropriate next step in management? Administer intravenous fluids Administer vitamin C Chloroquine Trimethoprim-sulfamethoxazole
Administer intravenous fluids
Which of the following findings on X-ray is suggestive of colorectal cancer? Apple core sign Bird's beak sign Egg-on-a-string sign String sign
Apple core sign
A 37-year-old obese woman presents with symptoms of biliary colic for the past 3 months. An ultrasound is negative for any gallstones. Which of the following is the most appropriate management for this patient? Cholecystectomy Cholecystokinin-HIDA scan CT scan Endoscopic Retrograde Cholangiopancreatography (ERCP)
Cholecystokinin-HIDA scan
A 43-year-old woman presents to the ED with abdominal pain. She reports that the pain is epigastric and worse with food. She denies any fevers, chills, vomiting, or diarrhea. She recently visited a gastroenterologist who told her she had a bacterial infection in her stomach, however, she did not follow up or receive treatment. On exam, her abdomen is soft and nontender. Which of the following is the most appropriate treatment regimen for this patient's condition? Amoxicillin 1 g bid, metronidazole 500 mg bid, lansoprazole 30 mg bid for 10-14 days Clarithromycin 500 mg bid, amoxicillin 1 g bid, lansoprazole 30 mg bid for 10-14 days Clarithromycin 500 mg bid, amoxicillin 1 g bid, metronidazole 500 mg bid for 10-14 days Clarithromycin 500 mg bid, amoxicillin 1 g bid, metronidazole 500 mg bid, lansoprazole 30 mg bid for 10-14 days
Clarithromycin 500 mg bid, amoxicillin 1 g bid, lansoprazole 30 mg bid for 10-14 days
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? Cardiac ischemia Constipation Hyperkalemia Pancreatitis
Constipation
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? Direct ethanol toxicity Pyridoxine deficiency Thiamine deficiency Vitamin B12 deficiency
Direct ethanol toxicity
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? Appendicitis Diverticulitis Inflammatory bowel disease Small bowel obstruction
Diverticulitis
A 24-year-old man with HIV presents with severe dysphagia and odynophagia for one week. Physical examination reveals the above image. What management is indicated? Acyclovir Clotrimazole troches CT scan of the neck Fluconazole
Fluconazole
A 43-year-old woman with a history of HIV (last CD4 count 231 cells/µL, viral load undetectable) presents with a sore throat that has progressively worsened over 1 week. She has been unable to tolerate solids for the last 3 days and also has pain with swallowing liquids. Her vital signs are normal. On exam, you note the findings seen in the image above. What management is indicated at this time? Acyclovir Clotrimazole troches Fluconazole Penicillin V potassium
Fluconazole
A 45-year-old man presents to his primary care provider with complaints of foul-smelling diarrhea, malaise, and abdominal pain for 1 week. The patient reports that the symptoms started about 2 weeks after his backpacking trip in the mountains. He does report that several of the other people in his group have experienced similar symptoms. On physical exam, the patient is ill appearing but in no acute distress. Physical exam is unremarkable. What is the most likely diagnosis? Clostridium difficile Cryptosporidium parvum Entamoeba histolytica Giardia lamblia
Giardia lamblia
A previously healthy 42-year-old man presents to your office with questions about screening for colon cancer. He has no family history of colon cancer, but heard that he should start getting a colonoscopy every 5 years starting at age 40. Which of the following recommendations do you provide? He does not need screening because he has no family history of colon cancer He should be scheduled for a colonoscopy as soon as possible He should start screening at age 50 and continue indefinitely He should start screening at age 50 and continue until age 75
He should start screening at age 50 and continue until age 75
A 4-week-old male presents to the pediatrician's office with his mother for projectile nonbilious vomiting just after being fed that started five days ago. The mother states that the child wants to be fed almost immediately after the vomiting occurs. She reports the child is having 5-6 wet diapers and 1-2 liquid yellow-brown stools per day. Other than the episodes of vomiting, the mother reports her infant to be very content. Physical exam reveals moist mucous membranes and a nondistended abdomen with a right upper quadrant olive-shaped mass on the lateral border of the rectus abdominus muscle. Bowel sounds are noted to be normoactive and of normal pitch. What is the most likely diagnosis? Cow-milk intolerance Gastroesophageal reflux Infantile hypertrophic pyloric stenosis Intussusception
Infantile hypertrophic pyloric stenosis
Which of the following findings seen on rectal examination is most consistent with a concomitant systemic process? Anal fissure with bleeding Anal fissure with deep ulcer Anterior midline anal fissure Lateral anal fissure
Lateral anal fissure
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? Colonoscopy within 3 days High fiber diet until 6 weeks of no symptoms Low fiber diet until 6 weeks of no symptoms Sigmoidoscopy within 3 days
Low fiber diet until 6 weeks of no symptoms
A 14-year-old girl with a 2-year history of bulimia nervosa presents to the emergency department with hematemesis. You suspect an upper gastrointestinal hemorrhage, and order an emergent endoscopy. Which of the following will most likely be found with this diagnostic test? H.pylori infection Hematochezia Mallory-Weiss tear Meckle's diverticulum
Mallory-Weiss tear
What is the most common cause of upper gastrointestinal bleeding? Aortoenteric fistula Boerhaave syndrome Esophogeal varices Peptic ulcer disease
Peptic ulcer disease
Which of the following supports the diagnosis of biliary colic? An ultrasound that shows an empty gallbladder and duct Pain that is relieved by eating food Radiation of abdominal pain to the lumbar region Steady abdominal pain localized in the right upper quadrant
Steady abdominal pain localized in the right upper quadrant
What diameter does an abdominal aortic aneurysm need to exceed for elective surgical repair to be generally recommended in asymptomatic patients? 2.5 cm 4.0 cm 5.0 cm 5.5 cm
5.5 cm
A 65-year-old Norwegian man presents with hematemesis. His past medical history includes alcohol abuse, 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? Diabetes mellitus Helicobacter pylori Smoked fish diet Tobacco use
Helicobacter pylori
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? Amoxicillin Cephalexin Doxycycline Trimethoprim-sulfamethoxazole
Trimethoprim-sulfamethoxazole
Which of the following is recommended in the treatment of an acute anal fissure? Antibiotics Antifungal cream Sitz bath Surgery
Sitz bath
In addition to benzodiazepines, which of the following should be administered to patients in alcohol withdrawal? Carbamazepine Haloperidol Propanolol Thiamine
Thiamine
A 32-year-old man presents with a 1-year history of frequent abdominal cramping, nonbloody diarrhea, and a 20-lb weight loss. He has no history of foreign travel, antibiotic use, or consumption of well water. He complains of a chronic, pruritic rash that is vesicular in nature. Which of the following is the most likely diagnosis? Celiac disease Collagenous colitis Crohn disease Irritable bowel syndrome
Celiac disease
What is the most commonly seen symptom or sign in patients with acute aortic dissection? Aortic insufficiency murmur Chest pain Pulse deficit Syncope
Chest pain
A 28-year-old south Asian immigrant who is in her second trimester of her first pregnancy presents to the emergency department complaining of worsening dyspnea, orthopnea and lower extremity edema. She has never experienced anything like this before. She has no past medical history; however, she admits to frequent sore throats and ear infections as a child. Which of the following is most likely to be heard on auscultatory exam? A diastolic decrescendo murmur heard at the left lower sternal border A diastolic low-pitched decrescendo murmur best heard at the cardiac apex A holosystolic murmur heard best at the cardiac apex A systolic crescendo-decrescendo murmur best heard at the right upper sternal border
A diastolic low-pitched decrescendo murmur best heard at the cardiac apex
Which of the following is the most common cause of acute pancreatitis? Biliary tract pathology Endoscopic retrograde cholangiopancreatography Ethanol ingestion Medication side effect
Biliary tract pathology
Which of the following is the most effective initial treatment for a benign esophageal stricture? Balloon dilation Balloon dilation and proton pump inhibitor Esophageal stent Nissen fundoplication
Balloon dilation and proton pump inhibitor
Which of the following is a risk factor for the condition shown above? Bicuspid aortic valve Chronic heroin use Fibromuscular dysplasia Tobacco use
Bicuspid aortic valve
A 76-year-old woman presents to her primary care physician due to increasing chest pain and shortness of breath at rest. She has a history of hypertension and states that she was told 3 months ago that she has a murmur but cannot recall any other information about this diagnosis. Which of the following is the most likely diagnosis in this patient? Bicuspid aortic valve Calcified aortic valve Mitral stenosis Tricuspid regurgitation
Calcified aortic valve
A 23-year-old man presents with rectal pain. He also reports yellow discharge and tenesmus. He is sexually active with men and has receptive anal intercourse. Which of the following is the most appropriate treatment? Ceftriaxone 1 gm IV and azithromycin 1 gm PO Ceftriaxone 250 mg IM and doxycycline 100 mg PO BID for 7 days Ciprofloxacin 500 mg PO BID for 7 days and metronidazole 500 mg PO TID for 7 days Metronidazole 500 mg PO TID for 7 days
Ceftriaxone 250 mg IM and doxycycline 100 mg PO BID for 7 days
A 43-year-old man is currently undergoing palliative radiation therapy for pancreatic cancer. He presents to the emergency department with a 4-day history of gradually worsening left lower extremity pain. Pain is localized to the calf and made worse with ambulation. Exam shows mild edema of the left calf without erythema or warmth. Which of the following is the most likely diagnosis? Cellulitis Deep venous thrombosis Peripheral artery disease Superficial thrombophlebitis
Deep venous thrombosis
A 55-year-old man with a past medical history of hypertension presents to the emergency department with two days of left lower quadrant pain and a fever of 38.2°C at home. He denies nausea or vomiting and has been able to tolerate oral intake at home. He endorses some intermittent painless hematochezia over the last year but states that he has never had a colonoscopy. His vitals are HR 89 beats per minute, RR 16, and BP 142/90. His abdominal exam is significant for moderate tenderness to palpation of the left lower quadrant without rebound or rigidity. His CBC shows a white blood cell count of 12,000. A CT scan confirms diverticulitis without perforation or abscess formation.Which of the following is the most appropriate next step in the management of this patient's diverticulitis? Admit for inpatient intravenous antibiotics Discharge home with oral antibiotics Surgery consult for colon resection Urgent colonoscopy to rule out colon cancer
Discharge home with oral antibiotics
A 32-year-old woman presents to the ED complaining of right calf swelling for one week. She is one week postpartum, following an uneventful full-term vaginal delivery. She denies any chest pain, dyspnea, or cough. On examination, her right calf is 16 inches in circumference, and her left calf is 10 inches. Which of the following is the most accurate test to confirm the diagnosis? Computed tomography D-dimer assay Duplex ultrasound DImpedance plethysmography
Duplex ultrasound
An elderly man presents with 6 months of progressive positional dyspnea. Nine months ago, he had a mild heart attack and was properly treated. Today, you appreciate a new loud, blowing holosystolic murmur heard at the apex. Which of the following color Doppler echocardiography findings would you most expect to find based on these signs and symptoms? During diastole, blood flows from the right ventricle into the right atrium During diastole, blood is seen flowing from the aorta into the coronary arteries During systole, blood flows from the left ventricle into the aorta During systole, blood is seen flowing from the left ventricle into the left atrium
During systole, blood is seen flowing from the left ventricle into the left atrium
A patient is found to have a low pitched rumbling diastolic apical murmur. Which of the following is the most frequent presenting complaint associated with this murmur? Chest pain Dyspnea with exertion Hemoptysis Palpitations
Dyspnea with exertion
Which of the following signs or symptoms is most likely to be associated with a patient with chronic venous insufficiency? Edema Hair loss Muscle atrophy Pallor
Edema
A 25-year-old truck driver presents with a 1-day history of throbbing rectal pain. Your examination shows a large thrombosed external hemorrhoid. Which one of the following is the preferred initial treatment for this patient? Elliptical excision of the thrombosed hemorrhoid Infrared coagulation Rubber band ligation of the hemorrhoid Stool softeners and a topical analgesic
Elliptical excision of the thrombosed hemorrhoid
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? Endoscopic biopsy for culture and sensitivity testing Serum IgG antibody to Helicobacter pylori Stool testing for Helicobacter pylori antigen Urea breath test
Endoscopic biopsy for culture and sensitivity testing
A 75-year-old woman with a history of hypertension presents to the ED with right upper quadrant pain that has been gradually worsening over the past day. Her vital signs are: T 103°F, BP 100/60, HR 100, RR 22, and oxygen saturation 97% on room air. Physical exam reveals scleral icterus and right upper quadrant tenderness without rebound or guarding. A bedside right upper quadrant ultrasound demonstrates a common bile duct measuring 1 cm. Laboratory results are pending. What is the definitive management of this condition? Broad spectrum antibiotics Cholecystectomy Endoscopic retrograde cholangiopancreatography Percutaneous transhepatic cholangiography
Endoscopic retrograde cholangiopancreatography
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? Computed tomography Endoscopy Magnetic resonance imaging Ultrasound
Endoscopy
A healthy 6-year-old boy presents to the ED with bloody diarrhea. He was in his usual state of health until one week ago when loose, watery stools (up to 10 per day) were noted. He was seen by his pediatrician four days ago but has since developed increasing amounts of blood and pus in his stools along with a low-grade fever. Mom states there is no recent travel, antibiotic use, or known sick contacts. His vitals are a heart rate 118 beats per minute, oxygen saturation 100% on room air, and rectal temperature of 100.94°F (38.3°C). Your physical exam reveals a mildly tender abdomen without localization, rebound, guarding, or peritoneal signs. You note grossly bloody stool on rectal exam. A brief discussion with his pediatrician confirms your suspicion of an invasive bacterial diarrhea; a stool culture was positive for Shigella. Which of the following statements is true regarding this condition? Antibiotics should be avoided because this is a severe case and the patient is at highest risk of developing hemolytic uremic syndrome Antidiarrheal agents (such as diphenoxylate and atropine) are indicated, given the frequency of loose stools Extraintestinal manifestations such as hallucinations, confusion, and seizures may occur Oral rehydration should be avoided; IV fluids should be initiated
Extraintestinal manifestations such as hallucinations, confusion, and seizures may occur
A 65-year-old woman presents to the emergency department in atrial fibrillation with rapid ventricular response for an unknown duration of time. She was started on heparin and no atrial thrombus was seen on transesophageal echocardiogram. She underwent successful direct current cardioversion and is now back in normal sinus rhythm. What is the minimum period of time she must remain on anticoagulation after cardioversion? Five days Four weeks One year Three months
Four weeks
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? Give activated charcoal Give prophylactic antibiotics Order an upper endoscopy Perform gastric lavage
Order an upper endoscopy
Which of the following is the most likely cause of the finding seen above? Pancreatitis Ruptured gastric ulcer Severe pyelonephritis Splenic rupture
Pancreatitis
You are caring for a patient who is diagnosed with pancreatic adenocarcinoma. The oncologist makes a note of a positive Trousseau syndrome in the documentation. Which of the following is she referring to? Nontender palpable gallbladder Palpable left supraclavicular lymph node Popliteal pain with abrupt ankle dorsiflexion Tender migratory thrombophlebitis
Tender migratory thrombophlebitis
A 19-year-old man with a previous history of abdominal pain and diarrhea presents to your office with complaints of fatigue, weight loss, sweats and malaise. He tells you that his mother has experienced similar symptoms, but doesn't like to go to the doctor so has never been evaluated. Which of the following is most suggestive of Crohn's disease rather than ulcerative colitis? Genetic predisposition Lesions affecting the colon Symptoms of diarrhea and abdominal pain Transmural inflammation
Transmural inflammation
You discover a blowing, holosystolic murmur in a newborn boy, heard loudest at the left sternal border. A pediatric cardiologist diagnoses Ebstein's anomaly. In addition to a malformed right atrium and ventricle, which of the following abnormalities would you most expect to see on this patient's echocardiogram? Left ventricular hypertrophy Overriding aorta Tricuspid insufficiency Tricuspid stenosis
Tricuspid insufficiency
Which of the following murmurs is associated with an increase in right atrial pressure? Aortic regurgitation Mitral regurgitation Mitral stenosis Tricuspid regurgitation
Tricuspid regurgitation
You are concerned with hearing a new diastolic, rumbling murmur in one of your patients. This murmur is best heard with the bell over the left sternal border at the fourth intercostal space and is louder during inspiration. Which of the following is the most likely diagnosis? Aortic regurgitation Aortic stenosis Tricuspid regurgitation Tricuspid stenosis
Tricuspid stenosis
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? Amoxicillin Ceftriaxone Gentamicin Trimethoprim-sulfamethoxazole
Trimethoprim-sulfamethoxazole
