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Flashcards in 10/16- Review Deck (15)
1

- A 48 year old man presents to clinic with epigastric pain and weight loss. His appetite is good and he has been eating well.

- He admits to drinking heavily for the past 15-20 years.

- He has recently been diagnosed with diabetes and despite treatment with insulin is still losing weight.

- His stools are large in volume and oily with a foul odor.

His diagnosis is most likely:

A. Celiac disease

B. Small bowel bacterial overgrowth

C. Large surgical resection that he has not told you about

D. Pancreatic insufficiency

E. Gluten allergy

A. Celiac disease

B. Small bowel bacterial overgrowth

C. Large surgical resection that he has not told you about

D. Pancreatic insufficiency

E. Gluten allergy

- Steatorrhea: large volume and oily with foul odor; indicates fat malabsorption

- Alcohol history supports pancreatic insufficiency as well

- Diabetes also indicates pancreatic issues

2 most common causes of pancreatitis:

- Acute pancreatitis (40%)

- Alcohol pancreatitis (30%): typ have to drink ~20 yrs to get to this level

2

Which of the following colon polyps has the highest potential to progress to malignancy?

A. Hyperplastic polyp

B. Adenomatous polyp

C. Juvenile polyp

D. Fundic gland polyp

E. Hamartomatous polyp

A. Hyperplastic polyp- no malignant potential; don't need another colonocopy for 10 yrs

B. Adenomatous polyp- tubular type is most commonly malignant

C. Juvenile polyp

D. Fundic gland polyp- stomach

E. Hamartomatous polyp

- Adenoma -> carcinoma transformation takes ~ 10 yrs

- There are differnent types of the adenomatous polyps (tubular are highest risk for malignancy)

3

- A 31-year-old HIV + male presents with dysphagia and odynophagia.

- On endoscopy white plaques are seen in the esophagus. Biopsy of one of these plaques is performed.  Microscopic exam showed a possible organism.  This is a picture from the PAS stain that was performed on the tissue. 

What is the BEST diagnosis?

A. Normal esophageal flora

B. Contamination from mouth flora

C. Candida esophagitis

D. Aspergillous infection

E. Invasive mucor infection

A. Normal esophageal flora

B. Contamination from mouth flora

C. Candida esophagitis

D. Aspergillous infection

E. Invasive mucor infection

- White plaques point toward esophagitis; think Candida (especially in elderly, HIV, or otherwise immunocompromised)

- Also CMV esophagitis (possibility)

4

- 52 year old woman with severe epigastric pain presents to the emergency room with melena.

- She denies taking nsaids and has no other major medical problems. 

- Her acute abdominal series reveals this: 

This is most likely a complication of:

A. Irritable bowel syndrome

B. Diverticulosis

C. Duodenal ulcer

D. Appendicitis

E. Cholecystitis

 

A. Irritable bowel syndrome- could potentiall cause epigastric pain, but won't result in perforation

B. Diverticulosis- this occurs lower in the GIT (sigmoid colon, LLQ); not going to cause this perforation. Pain will be lower

C. Duodenal ulcer

D. Appendicitis

E. Cholecystitis

- Can see air bubble below diaphragm

- NSAIDs asked because they're a risk factor for ulcers and presentation of gastric pain

- Another common cause of ulcers is H. pylori; want to ask history about this (higher in developed areas, Peurto Rico...)

5

Describe melena. What causes it?

A. Black and formed

B. Dark, Oily and voluminous

C. Red with clots

D. Black, sticky, like “tar”

E. Unclear, waiting for her to text you a picture

A. Black and formed

B. Dark, Oily and voluminous

C. Red with clots

D. Black, sticky, like “tar”

E. Unclear, waiting for her to text you a picture

Melena is caused by blood entering the GIT relatively high in the process

- Heme -> hematin (by bacteria in GIT)

6

Which of the following would suggest Ulcerative Colitis rather than Crohn’s disease?

A. Transmural inflammation

B. Terminal ileum stricture

C. Enterocutaneus fistula

D. Proctitis

A. Transmural inflammation

B. Terminal ileum stricture

C. Enterocutaneus fistula

D. Proctitis

Ulcerative Colitis:

- Starts in rectum and moves up proximally

- Remains in colon (nowhere else in GIT)

Crohn's Disease:

- Transmural inflammation (all layers)

- Terminal ileum stricture: due to muscles being affected 9back to the transmural inflammation)

- Enterocutaneous fistula

7

46 year old man presents to the clinic with 2 weeks of diarrhea.  It seemed to start after taking his son camping in the Rocky Mountains.  His stools are voluminous and foul smelling with oily appearance. 

What type of diarrhea is he most likely having?

A. Factitious diarrhea

B. Osmotic diarrhea

C. Diabetic diarrhea

D. Infectious diarrhea

A. Factitious diarrhea

B. Osmotic diarrhea

C. Diabetic diarrhea

D. Infectious diarrhea

8

46 year old man presents to the clinic with 2 weeks of diarrhea.  It seemed to start after taking his son camping in the Rocky Mountains.  His stools are voluminous and foul smelling with oily appearance

Duodenal biopsies are most likely to reveal:

A. H. Pylori

B. Shigella

C. E. Coli

D. Giardia

E. Celiac sprue

A. H. Pylori

B. Shigella

C. E. Coli

D. Giardia

E. Celiac sprue

9

A 62 year old woman presents to the clinic with several months of difficulty with swallowing.  Upon taking her history, which of the following suggests oropharyngeal dysphagia?

A. Difficulty initiating the swallow

B. Nocturnal regurgitation

C. Sensation of the bolus being stuck behind the breastbone

D. Odynophagia

E. Heartburn symptoms

A. Difficulty initiating the swallow

B. Nocturnal regurgitation

C. Sensation of the bolus being stuck behind the breastbone

D. Odynophagia

E. Heartburn symptoms

- If it feels like food is getting stuck, think stricture

- Consider neurological disease as well: stroke, Parkinson's...

10

- 58 year old woman who recently migrated from Mexico presents to the emergency department with 3 days of melena and weakness. 

- Family history is notable for a brother who had a perforated duodenal ulcer. 

What is the most important initial step in treating this patient?

A. Evaluating vital signs and resuscitating her with IV fluids and blood if needed

B. Stat Helicobacter pylori serologies and treat if positive

C. Oral proton pump inhibitor twice daily

D. Call surgical consult for urgent evalaution

A. Evaluating vital signs and resuscitating her with IV fluids and blood if needed

B. Stat Helicobacter pylori serologies and treat if positive

C. Oral proton pump inhibitor twice daily

D. Call surgical consult for urgent evalaution

- History from Mexico is a hint towards H. pylori

11

What is the most common cause of severe hematochezia (bright red blood per rectum)?

A. Peptic ulcer disease

B. Celiac disease

C. Solitary rectal ulcer syndrome

D. Constipation

E. Diverticulosis

A. Peptic ulcer disease

B. Celiac disease

C. Solitary rectal ulcer syndrome

D. Constipation

E. Diverticulosis

12

- A 28 year old woman is seeing you in clinic for constipation that she has had as long as she can remember. 

- You have investigated for metabolic disturbances and mechanical obstruction and no cause of the constipation has been found. 

- She has no alarm symptoms. 

A reasonable next step in the management/evaluation of this patient is:

A. Anorectal manometry

B. Colectomy

C. Anotrectal ultrasound

D. Therapeutic trial

E. Colonoscopy

A. Anorectal manometry

B. Colectomy

C. Anotrectal ultrasound- 

D. Therapeutic trial

E. Colonoscopy

- Young and otherwise healthy; no alarm symptoms

13

47 year old obese woman presents with constant epigastric pain radiating to the shoulder.  This started as intermittent post-prandial pain but has progressed to being constant. Her 5 devoted children have brought her to the emergency room for the pain. 

Which is the following is most likely to be found?

A. Cholelithiasis on abdominal ultrasound

B. Appenciditis on CT scan

C. Retroperitoneal abcess on CT scan

D. Dilated loops of small bowel on abdominal Xray (KUB)

E. Omega sign on KUB

A. Cholelithiasis on abdominal ultrasound

B. Appenciditis on CT scan

C. Retroperitoneal abcess on CT scan

D. Dilated loops of small bowel on abdominal Xray (KUB)

E. Omega sign on KUB- indicative of sigmoid lobulous

- Fat, Female, over Forty

- Shoulder pain is referred from diaphragm area

- Expect to see Murphy's sign with this as well (recall: McBurney's is appendicitis)

14

A 50 year old man has his first screening colonoscopy today.  He had no polyps.  He has no family history of colon cancer or polyps and no other risk factors. 

The appropriate recommendation for the next screening colonoscopy is:

A. 1 year

B. 5 years

C. 10 years

D. None. He should have a FIT test for his next screening interval

E. None since no cancer was found

A. 1 year

B. 5 years

C. 10 years

D. None. He should have a FIT test for his next screening interval

E. None since no cancer was found

- Normal doesn't mean we didn't miss something!

- FIT/FOBT test done once/yr > 50 yo if never had a colonoscopy

- After colonoscopy, don't need FIT/FOBT testing, just follow up as indicated by colonoscopy

- Want to start screening testing at least 10 yrs before family member experienced problems in someone with positive family history

15

Which of the following is a feature of Crohn’s disease?

A.  Bloody diarrhea

B.  Surgery can be curative

C.  Villous atrophy on duodenal biopsies

D.  Fistulae can develop

E.  Extraintestinal manifestations are uncommon

A.  Bloody diarrhea- true, but not as specific as some other features; classic bloody diarrhea is more characteristic of UC

B.  Surgery can be curative- true for ulcerative colitis; Crohn's, however, can occur anywhere in patches along GIT

C.  Villous atrophy on duodenal biopsies- Common finding in Celiac disease

D.  Fistulae can develop

E.  Extraintestinal manifestations are uncommon