Exam 2 - GI packrat Flashcards
(151 cards)
1
Q
Which of the following is a common physical examination finding in early intestinal obstruction?
A. high fever.
B. profuse flatulence.
C. rebound tenderness
D. hyperactive, high-pitched bowel sounds
A
(c) D. Abdominal distention and high-pitched, hyperactive bowel sounds are common in early intestinal obstruction.
2
Q
Which of the following studies is most appropriate to diagnose celiac disease? A. Urinary D-xylose test B. Small bowel biopsy C. Barium contrast x-ray D. Schilling test
A
(c) B. Definitive diagnosis of celiac disease is made by small bowel biopsy.
3
Q
Which of the following tumor markers is useful in monitoring a patient for recurrence of colorectal cancer after surgical resection? A. CA-125 B. Carcinoembryonic antigen C. 5-hydroxindoleacetic acid D. Alpha-1-fetoprotein
A
(c) B. Carcinoembryonic antigen can be used to monitor a patient for the return of colorectal cancer after treatment.
4
Q
A 14 month-old male who attends day care presents with a two-day history of frequent watery stools. His mother states that he had a fever and vomiting the day before but these have resolved. His mother denies pain in the child. The child is mildly dehydrated but otherwise appears well. Stool samples are free of blood and white blood cells. The lab reports no ova or parasites noted in the stool samples. Which of the following is the most likely diagnosis? A. Intussusception B. Viral gastroenteritis C. Shigella D. Lactase insufficiency
A
(c) B. Rotavirus is the most common cause of gastroenteritis in children and this is frequently passed in the daycare setting.
5
Q
A patient develops abdominal cramps and watery diarrhea 10 to 12 hours after eating a plate of unrefrigerated meat and vegetables. The patient denies vomiting. The causative agent is most likely A. Staphylococcus aureus. B. Clostridium perfringens. C. Escherichia coli. D. Salmonella.
A
(c) B. Food poisoning caused by Clostridium perfringens
has an incubation period of 8 to 14 hours and results from poorly refrigerated cooked meat.
6
Q
The most common initial presenting symptom of primary biliary cirrhosis is A. jaundice B. palmar erythema C. pruritus D. xanthomas
A
(c) C. Pruritus is the most common initial symptom in primary biliary cirrhosis due to the accumulation of bile salts.
7
Q
Which of the following medications used in the treatment of peptic ulcer disease is classified as a proton pump inhibitor? A. Cimetidine (Tagamet) B. Sucralfate (Carafate) C. Omeprazole (Prilosec) D. Misoprostol (Cytotec)
A
(c) C. Omeprazole is a proton pump inhibitor.
8
Q
Which of the following is the therapy of choice for long-term management of esophageal varices in a patient who cannot tolerate beta blocker therapy?
A. Octreotide (Sandostatin)
B. Sclerotherapy
C. Transjugular intrahepatic portosystemic shunt
D. Sengstaken-Blakemore tube
A
(c) B. Sclerotherapy is effective in decreasing the risk for rebleeding in a patient with esophageal varices.
9
Q
A 3 year-old presents with profuse watery diarrhea for the past three days. The child vomited twice yesterday, but not today. On exam, the child is febrile, with pulse of 142, respiratory rate of 18, and blood pressure of 60/40 mmHg. On exam, the child is alert and responsive, with no focal findings. Which of the following is the most appropriate intervention? A. Antibiotic therapy B. Begin soft diet C. IV fluids D. Oral rehydration
A
(c) D. The goal of therapy for a child with severe gastroenteritis and dehydration is to restore fluid loss. Oral rehydration with an appropriate electrolyte solution is the best option if the child is not actively vomiting and is alert enough to take oral fluids. IV fluids should be reserved for those who are unable to take fluids orally.
10
Q
Initial pharmacologic treatment of acute hepatic encephalopathy consists of A. lactulose. B. omega-3-fatty acids. C. neomycin. D. mannitol.
A
(c) A. Lactulose acts as an osmotic laxative decreasing ammonia absorption and decreases ammonia production by directly affecting bacterial metabolism.
11
Q
A 72 year-old male presents to the ED complaining of acute onset of severe diffuse abdominal pain of four hours duration. He states that he has vomited twice since the onset of pain. He also complains of three days of constipation. He is afebrile and the physical examination is noteworthy for a distended, diffusely tender abdomen with normoactive bowel sounds. His rectal exam reveals hemoccult positive brown stool.Medications include omeprazole (Prilosec) for GERD, digoxin and warfarin (Coumadin) for atrial fibrillation,OTC multivitamins and stool softeners. The abdominal and chest x-rays show no abnormalities. Which of the following is the most likely diagnosis? A. Acute cholecystitis B. Mesenteric infarction C. Perforated duodenal ulcer D. Small bowel obstruction
A
(c) B. Acute onset of severe diffuse abdominal pain in a person with atrial fibrillation warrants the suspicion of mesenteric infarction. Vomiting and constipation may be seen, along with occult blood in the stool. Bowel sounds may be normal.
12
Q
An asymptomatic 50 year-old person has no risk factors for colorectal cancer. In addition to yearly hemoccult screening of the stool, how often should flexible sigmoidoscopy be performed? A. Every year B. Every other year C. Every 5 years D. Every 10 years
A
(c) C. In a person with no risk factors for colorectal cancer, screening should include annual Hemoccult testing and flexible sigmoidoscopy every 5 years.
13
Q
Which medication is considered the mainstay of therapy for mild to moderate inflammatory bowel disease? A. Prednisone B. Sulfasalazine C. Metronidazole D. Azathioprine (Imuran)
A
(c) B. Sulfasalazine and other 5-aminosalicylic acid drugs are the cornerstone of therapy in mild to moderate inflammatory bowel disease as they have both anti-inflammatory and antibacterial properties.
14
Q
Which of the following treatments is the most appropriate for a patient with an acutely tender, fluctuant perirectal mass? A. Fistulectomy B. Drainage of an abscess C. Antibiotic therapy D. Removal of an anal fissure
A
(c) B. Perirectal abscesses should be treated by drainage as soon as a diagnosis is established.
15
Q
Congenital absence of ganglionic nerve cells innervating the bowel wall is seen in which of the following conditions? A. Hirschsprung's disease B. Meckel's diverticulum C. Chagas disease D. Hashimoto's hypothyroidism
A
(c) A. Hirschsprung disease, also termed congenital aganglionic megacolon, results from a lack of ganglion cells in the bowel wall.
16
Q
A middle-aged patient is being treated for recurrent diarrhea and peptic ulcer disease that is refractory adequate standard therapy. Which of the following is the most likely diagnosis? A. Achlorhydria B. Drug resistant H. pylori infection C. Zollinger-Ellison syndrome D. Giardiasis
A
(c) C. Zollinger-Ellison syndrome is the result of unregulated release of gastrin resulting in gastric acid hypersecretion. Up to 50% of patients complain of diarrhea along with peptic ulcer disease.
17
Q
Which of the following is suggestive of thiamine deficiency? A. Ataxia B. Bleeding C. Cheilosis D. Diarrhea
A
A. Ataxia, mental deficits, horizontal nystagmus, muscle weakness and atrophy, and cardiomegaly are all clinical findings in thiamine deficiency.
18
Q
Which of the following would be consistent for a person who has a successful response to the hepatitis B immunization series?
A. HBsAg positive; anti-HBc positive; anti-HBs negative
B. HBsAg negative; anti-HBc positive; anti-HBs positive
C. HBsAg negative; anti-HBc negative; anti-HBs positive
D. HBsAg negative; anti-HBc negative; anti-HBs negative
A
(c) C. A person immunized against hepatitis B would have a positive anti-HBs with negative HBsAg and negative anti-HBc.
19
Q
Which of the following presents the greatest risk factor for the development of pancreatic cancer? A. Alcohol abuse B. Coffee consumption C. Cigarette smoking D. Lean body mass
A
(c) C. Cigarette smoking is the most consistent risk factor for the development of pancreatic cancer.
20
Q
The parents of a 16 year-old male presents to the clinic with their son asking that you examine him. Over the past 9-12 months he has developed behavioral problems and emotional lability. Physical examination reveals a well-developed male who is cooperative with exam but tends to be easily distracted. It is noteworthy for dysarthria, a resting tremor and the presence of gray-green pigmentation surrounding each pupil. The most likely diagnosis is A. drug abuse. B. hemochromatosis. C. Wilson's disease. D. Parkinsonism.
A
(c) C. Wilson’s disease results in the excessive deposition of copper in the liver and brain. Kayser-Fleisher rings are the result of granular deposits in the eye and are pathognomonic for Wilson’s disease.
21
Q
The drug of choice in an adult for empirical treatment of an ill-appearing patient with infectious diarrhea who has recently returned from Mexico is A. amoxicillin. B. ceftriaxone (Rocephin). C. ciprofloxacin (Cipro). D. doxycycline.
A
(c) C. Fluoroquinolones like Ciprofloxacin are the class of drugs used in the empirical treatment of infectious diarrhea. Alternatives include trimethoprim/sulfamethoxazole or erythromycin.
22
Q
Which of the following is consistent with acute cholangitis?
A. Jaundice
B. Caput medusa
C. Bilateral flank bruising
D. An enlarged, palpable nontender gallbladder
A
(c) A. Jaundice is part of Charcot’s triad associated with cholangitis along with fever and biliary colic.
23
Q
A severely dehydrated child with gastroenteritis who is unable to tolerate oral rehydration should receive which of the following intravenous therapies? A. 10 mg/kg normal saline B. 20 mg/kg normal saline C. 10 mg/kg D5W D. 20 mg/kg D5W
A
(c) B. In a severely dehydrated child, restoring intravascular volume to insure adequate tissue perfusion is the immediate objective. This is best done with either Ringers lactate or normal saline. The addition of potassium would only be done after initial fluid boluses and after insuring adequate kidney function. The addition of glucose to the IV solution may result in an osmotic diuresis worsening the dehydration.
24
Q
A 52 year-old female comes to the office because of black stools for the past 3 days. She is afebrile and she has no
pertinent physical examination abnormalities. Which of the following is the most appropriate initial diagnostic study?
A. Stool for occult blood
B. Stool cultures
C. Sigmoidoscopy
D. Abdominal CT scan
A
(c) A. Occult bleeding, as evidenced by the patient’s history of black stools, is initially verified by a positive fecal occult blood test.
25
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A newborn weighs 8 pounds at birth. On average, what should the infant weigh at 1 year of age?
A. 16 pounds
B. 20 pounds
C. 24 pounds
D. 28 pounds
```
(c) C. An infant will triple birth weight within the first year of life. A newborn that weighs 8 pounds at birth will weigh approximately 24 pounds at 1 year of age.
26
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Which of the following is an indication for vaccination against hepatitis A?
A. Illicit drug users
B. Health care workers
C. Renal dialysis patients
D. Routine vaccination starting at birth
```
(c) A. Hepatitis A vaccine is recommended for illicit drug users, anyone living or traveling to endemic areas, sewage workers, food handlers, homosexual and bisexual men, animal handlers, patients with a history of chronic liver disease or a clotting factor disease as well as children and workers in day care settings and institutions.
27
```
Which of the following is the most common indication for operative intervention in patients with chronic pancreatitis?
A.Weight loss
B. Intractable pain
C. Exocrine deficiency
D. To decrease risk of cancer
```
(c) B. Indications for surgical treatment of chronic pancreatitis include severe pain that limits the patient's functioning or intractable pain despite the use of non-narcotic analgesics and absence of alcohol intake.
28
A 45 year-old male presents with abdominal pain and one episode of mild hematemesis, which happened days ago. On physical examination, vital signs are stable and he is in no acute distress. Hemoglobin and hematocrit are unremarkable; endoscopy reveals non-bleeding small superficial ulceration of the duodenal bulb. Rapid urease test is positive. Which of the following is the most appropriate treatment at this time?
A. Schedule for a selective vagotomy and antrectomy
B. Start an antacid along with omeprazole (Prilosec)
C. Schedule elective ulcer excision and start sucralfate (Carafate)
D. Start omeprazole (Prilosec) and antibiotic therapy against H. pylori
(c) D. Treatment goals of H. pylori associated ulcers include eradicating the infection with appropriate antibiotics as well as use of a proton pump inhibitor, such as omeprazole, to promote ulcer healing.
29
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A 20 year-old male presents with a mass in the groin. On examination with the patient standing, a mass is noted that extends into the scrotum. The patient denies any trauma. The most likely diagnosis is
A. an indirect inguinal hernia.
B. a direct inguinal hernia.
C. an obturator hernia.
D. a femoral hernia.
```
(c) A. An indirect inguinal hernia is caused by a patent processus vaginalis and the hernial contents may be felt in the ipsilateral scrotum.
30
```
Which of the following can be a very serious consequence of using antidiarrheals in a patient with inflammatory bowel disease?
A. Lymphoma
B. Toxic megacolon
C. Bone marrow suppression
D. Delayed serum sickness-like reaction
```
(c) B. Antidiarrheals may cause the development of toxic megacolon when used by patients with active severe
inflammatory bowel disease.
31
```
A patient presents complaining of periumbilical pain. Which of the following anatomical sites is this finding associated with?
A. Bladder
B. Stomach
C. Pancreas
D. Small bowel
```
(c) D. Small bowel. Pain from the small intestine, appendix, or proximal colon causes periumbilical pain.
32
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Which of the following pathophysiological processes is believed to initiate acute appendicitis?
A. Obstruction
B. Perforation
C. Hemorrhage
D. Vascular compromise
```
(c) A. Obstruction of the appendiceal lumen by lymphoid hyperplasia, a fecalith or foreign body initiates most cases of appendicitis.
33
```
Gallstones usually result in biliary symptoms by causing inflammation or obstruction following migration into the
common bile duct or
A. cystic duct.
B. pancreatic duct.
C. duodenal ampulla.
D. common hepatic duct.
```
(c) A. Obstruction of the cystic duct by gallstones causes the typical symptom of biliary colic. Once obstructed the gallbladder distends and becomes edematous and inflamed. Gallstones can also migrate into the common bile duct through the cystic duct leading to a condition known as choledocholithiasis.
34
A 3 week-old male infant presents with recurrent regurgitation after feeding that has progressed to projectile vomiting in the last few days. The mother states that the child appears hungry all of the time. She denies any diarrhea in the child. Which of the following clinical findings is most likely?
A. Bile-stained vomitus
B. Hemoccult positive stools
C. Olive-sized mass in the right upper abdomen
D. Sausage-shaped mass in the upper-mid abdomen
(c) C. An olive-sized mass may be palpated in the right upper abdomen in pyloric stenosis and if found, is
pathognomonic for pyloric stenosis.
35
To further assess ascites in a patient, the physician assistant instructs the patient to turn onto one side while performing percussion. Which of the following is the reason for this maneuver?
A. Testing for shifting of dullness on percussion
B. Shifting of internal organs making percussion easier
C. Trying to elicit any pain while moving
D. Trying to produce a caput medusa
(c) A. In ascites, dullness shifts to the more dependent side as the fluid relocates into dependent space, while
tympany shifts to the top as the gas-filled organs float to the top of the ascitic fluid.
36
Which of the following clinical findings would be seen in a patient with food poisoning caused by Staphylococcus aureus?
A. Ingestion of mayonnaise-based salads 48 hours earlier
B. Bloody diarrhea with mucus for one week
C. Abdominal cramps and vomiting for 48 hours
D. High fever for 1 week
(c) C. Abdominal cramps, nausea, vomiting, and watery diarrhea typically last 1-2 days with staphylococcal food
poisoning.
37
A 42 year-old male with a history of constipation presents with complaints of severe pain with defecation described as feeling like he is "tearing apart." He has also noted occasional small amounts of blood on toilet paper. External examination of the rectum is unremarkable and an internal rectal exam cannot be performed due to severe pain when
attempted. Which of the following is the most likely diagnosis?
A. Proctitis
B. Anal fissure
C. Rectal prolapse
D. Internal hemorrhoids
(c) B. Anal fissures are easily diagnosed from history alone with the classic finding of severe pain upon defecation.Constipation is also a common cause of the trauma that leads to development of a fissure.
38
Which of the following typical findings would be revealed during a sigmoidoscopy on a patient with Crohn's disease of the intestine?
A. Rectal pseudopolyps
B. Diffuse ulceration and bleeding
C. Sheets of WBCs with inflamed mucosa
D. Intermittent longitudinal mucosal ulcers and fissures
(c) D. Ulcerations tend to be linear with transverse fissures in Crohn's disease. These skip lesions are common with Crohn's disease.
39
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A 48 year-old male presents with complaints of heartburn that occurs approximately 45 minutes after eating about three times a week that is relieved by antacids. He claims to have followed advice about elevating the head of the bed, avoiding spicy foods, and losing weight, but continues to have heartburn. Which of the following is the most appropriate next step?
A. Ranitidine (Zantac)
B. Sucralfate (Carafate)
C. Metoclopramide (Reglan)
D. Misoprostol (Cytotec)
```
(c) A. Ranitidine, an H2 receptor blocker, is indicated for the treatment of mild, intermittent symptoms of
gastroesophageal reflux disease.
40
Which of the following is the laboratory test that marks recovery from Hepatitis B infection and non-infectivity?
A. Hepatitis B surface antibody(anti-HBs)
B. Hepatitis B surface antigen (HBsAg)
C. Hepatitis B core antigen (HBcAg)
D. Hepatitis A antibody (anti-HAV)
(c) A. Specific antibody to HBsAg appears in most individuals after clearance of HBsAg which indicates recovery from hepatitis B infection, non-infectivity, and immunity.
41
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A 32 year-old presents with a 3-day history of diarrhea. The patient denies blood, mucus, or night awakening with diarrhea. He recently returned from a business trip to Canada. On physical examination, the patient is afebrile and vital signs reveal BP 115/80, pulse is 76, and respirations are 14. The abdominal examination reveals hyperactive bowel sounds, but is otherwise unremarkable. Which of the following is the most appropriate initial intervention?
A. Stool for culture, ova, and parasites
B. Proctosigmoidoscopy
C. Metronidazole (Flagyl)
D. Supportive treatment
```
(c) D. Symptomatic treatment, including dietary management and over-the-counter antidiarrheals, is indicated for afebrile patients with watery diarrhea of less than 5 days duration.
42
A 62 year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwise
unremarkable. Which of the following is the most likely diagnosis?
A. Viral hepatitis
B. Pancreatic cancer
C. Acute cholecystitis
D. Gilbert's syndrome
(c) B. Pancreatic cancer is suggested by the vague epigastric pain with the jaundice resulting from biliary obstruction due to cancer involving the pancreatic head. The presence of a palpable non-tender gallbladder (Courvoisier's sign) also indicates obstruction due to the cancer.
43
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A 25 year-old man presents with odynophagia and dysphagia. On endoscopic examination, small, white, patches with surrounding erythema are noted. Silver stain is positive for hyphae. The best treatment option for this patient is
A. acyclovir (Zovirax).
B. omeprazole (Prilosec).
C. fluconazole (Diflucan).
D. penicillin G.
```
(c) C. The patient has Candida esophagitis and the treatment of choice is fluconazole.
44
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A 53 year-old man who had previously been in good health presents to the emergency department with a history of passing approximately 300 cc of bright red blood from the rectum 45 minutes ago. From which of the following anatomical sites is the bleeding most likely originating?
A. rectosigmoid
B. duodenum
C. stomach
D. esophagus
```
(c) A. Rectosigmoid is the most common site leading to hematochezia.
45
A 40 year-old female complains of acute right upper quadrant pain radiating to the back and low grade fever. Laboratory evaluation indicates the presence of urinary bilirubin and an elevation of serum alkaline phosphatase.
Which of the following is the most likely diagnosis?
A. cholecystitis
B. viral hepatitis
C. Gilbert's syndrome
D. Dubin-Johnson syndrome
(c) A. Cholecystitis. The presence of urinary bilirubin indicating conjugated hyperbilirubinemia coupled with the elevation of serum alkaline phosphatase suggests biliary obstruction that may lead to cholecystitis.
46
```
Which of the following signs is positive in the presence of ascites?
A. shifting dullness
B. CVA tenderness
C. ballottment sign
D. cutaneous hypersensitivity
```
(c) A. Shifting dullness or the presence of a fluid wave is noted in patients with ascites.
47
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A patient presents with a concern about an upcoming trip. He states he is traveling to Mexico and has a question about how to treat diarrhea should it develop. In addition to promoting fluid intake which of the following is
recommended?
A. kaolin-pectin
B. ciprofloxacin
C. simethicone
D. doxycycline
```
(c) B. Ciprofloxacin is indicated in the treatment of traveler's diarrhea.
48
A patient presents complaining of vague anal discomfort. On examination, the patient is noted to have a few small external hemorrhoids and edema in the anal region. Which of the following is the most appropriate intervention?
A. proctoscopy followed by a hemorrhoidectomy
B. increased dietary fiber and sitz baths
C. hemorrhoidal banding
D. inject a sclerosing agent
(c) B. Most hemorrhoids respond well to conservative treatment such as fiber and sitz baths.
49
```
Which of the following subtypes of viral hepatitis requires the presence of the hepatitis B virus for replication?
A. hepatitis A
B. hepatitis C
C. hepatitis D
D. hepatitis E
```
(c) C. In the United States, hepatitis D is most commonly seen in persons exposed frequently to blood or blood
products, such as drug addicts. It requires the presence of hepatitis B virus for its replication and expression.
50
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A 62 year-old patient with arthritis is on daily naproxen therapy. Which of following medications is used to protect against GI complications?
A. diphenoxylate (Lomotil)
B. sulfasalazine (Azulfidine)
C. metoclopramide (Reglan)
D. misoprostol (Cytotec)
```
(c) D. Misoprostol is an analog of prostaglandins and used in the treatment of NSAID induced ulcer disease.
51
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The initial manifestation of acute pancreatitis is often
A. generalized pruritus.
B. epigastric pain.
C. epigastric mass.
D. anorexia.
```
(c) B. The typical findings in acute pancreatitis include nausea, vomiting, and abdominal pain. Epigastric pain,
generally abrupt in onset, is steady and severe.
52
Which of the following is the mechanism of action of infliximab (Remicade)?
A. block lymphocyte proliferation
B. direct effect on smooth muscle
C. monoclonal antibody that binds to tumor necrosis factor
D. 5-HT antagonist
(c) C. Infliximab is a monoclonal antibody that binds to tumor necrosis factor.
53
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Ulcerative colitis usually presents with which of the following?
A. bloody diarrhea
B. toxic megacolon
C. fever and left quadrant pain
D. alternating constipation and diarrhea
```
(c) A. Ulcerative colitis typically presents with episodic bloody diarrhea, lower abdominal cramps, and urgency to defecate.
54
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A 65 year-old patient with adenocarcinoma of the colon in remission presents for follow-up. Which of the following tumor markers should be monitored?
A. AFP
B. CEA
C. CA 19-9
D. CA-125
```
(c) B. CEA is used to monitor recurrence of colon carcinoma.
55
The main complication with the use of transjugular intrahepatic portosystemic shunt (TIPS) procedure is which of the following?
A. increased portal pressures resulting in further esophageal varices
B. increased portal pressures resulting in a worsening of cirrhosis
C. Budd-Chiari syndrome
D. increased risk of encephalopathy
(c) D. TIPS procedures involve the placement of a stent in the liver in order to shunt blood away from the portal vein into the hepatic vein which bypasses the cirrhotic liver parenchyma. Its main complication is encephalopathy from the accumulation of toxic substances in the brain since the liver no longer acts as a filter.
56
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A 42 year-old patient who is being treated for colon cancer with chemotherapy develops nausea and vomiting. Which of the following drugs would be the most effective in controlling the nausea and vomiting?
A. scopolamine (Scopace)
B. meclizine (Antivert)
C. ondansetron (Zofran)
D. loperamide (Imodium)
```
(c) C. Ondansetron selectively blocks 5-HT3 receptors in the periphery (visceral afferent fibers) and in the brain
(chemoreceptor trigger zone). It is indicated for use in chemotherapy induced nausea and vomiting.
57
A 45 year-old female presents with a ten pound weight loss and recurrent greasy stools mixed with diarrhea. The patient notes that these symptoms are worse with certain foods. Which of the following laboratory tests should initially be ordered?
A. anti-endomysial antibodies
B. anti-mitochondrial antibodies
C. anti-glomerular basement membrane antibodies
D. anti-phospholipid antibodies
(c) A. Patients with celiac sprue disease are likely to have anti-endomysial antibody formation.
58
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Which of the following is used to screen for malabsorption disorders of the intestines?
A. serum gastrin level
B. urea breath test
C. fecal eosinophils
D. stool fecal fat
```
(c) D. Stool fecal fat is the gold standard test for the evaluation of patients with malabsorption of the intestine.
59
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A patient presents with abdominal pain. On deep palpation of the left lower quadrant the patient notes increased pain in the right lower quadrant. This is noted as a positive
A. Psoas sign.
B. Murphy's sign.
C. Rovsing's sign.
D. Obturator sign.
```
(c) C. A Rovsing's sign is positive when the patient experiences right lower quadrant pain with deep palpation of the left lower quadrant.
60
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The first step in the treatment of a patient with an intestinal obstruction and no comorbid diseases is
A. nasogastric decompression.
B. invasive hemodynamic monitoring.
C. abdominal exploration.
D. administration of antibiotics.
```
(c) A. Nasogastric decompression is indicated in all but mild cases of obstruction to prevent distal passage of
swallowed air and minimize distension.
61
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A 65 year-old patient with known history of alcohol and tobacco abuse presents with solid food dysphagia. The patient also has a 24 lb weight loss over the past 6 months. Which of the following is the most appropriate
intervention?
A. endoscopy with biopsy
B. chest x-ray
C. barium esophagogram
D. CT scan of the thorax
```
(c) A. Endoscopy with biopsy establishes the diagnosis of esophageal cancer with a high degree of reliability.
62
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A patient is hospitalized with a change in mental status. Examination reveals that he is unable to maintain dorsiflexion of the wrists after pronating his arms in front of his body. Which of the following is the most likely diagnosis?
A. cocaine overdose
B. hyperthyroidism
C. hepatic encephalopathy
D. Parkinson's disease
```
(c) C. This is the description for asterixis that is seen with hepatic encephalopathy, uremia, and carbon dioxide narcosis.
63
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A 23 year-old female presents with a 24-hour history of watery diarrhea, nausea and vomiting after returning from a cruise. On exam, the vitals reveal HR 120, BP 90/60, and RR 20. The abdomen is soft and non-tender, with hyperactive bowel sounds. Which of the following is the most appropriate management at this time?
A. loperamide (Imodium)
B. IV hydration
C. bismuth sulfate (Pepto bismol)
D. ciprofloxacin (Cipro)
```
(c) B. This is most likely a self-limiting viral gastroenteritis and is treated with hydration and supportive care.
64
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A 3 year-old presents with a 24-hour history of diarrhea. The patient is afebrile and the stool is noted to be loose and watery. No blood is noted in the stool. Fecal WBC is negative. Which of the following is the most likely diagnosis?
A. viral gastroenteritis
B. toxic megacolon
C. ulcerative colitis
D. intussusception
```
(c) A. Patients with viral gastroenteritis are afebrile and noted to have loose, watery, non-bloody diarrhea. Fecal WBC is negative.
65
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A 16 day-old male presents in the office with a history of vomiting after feeding for the past 2 days. The vomiting has become progressively worse and the mother describes it as very forceful, sometimes hitting the floor 6 feet away. She says the neonate is always hungry. On physical examination, it is noted that he is 2 ounces below birth weight, and has a small palpable mass (about 1.5 cm) in the epigastrium. The most likely diagnosis is
A. achalasia.
B. tracheoesophageal fistula.
C. pyloric stenosis.
D. Meckel's diverticulum.
```
(c) C. Pyloric stenosis begins between 2 to 4 weeks of age with vomiting that becomes projectile after each feeding. An olive-size mass can often be felt in the epigastrium.
66
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A 30 year-old patient presents with weight loss, diarrhea, and steatorrhea. Labs reveal that the antiendomysial antibody (AEA) is positive. What is the most likely diagnosis?
A. Celiac sprue
B. Ulcerative colitis
C. Whipple's disease
D. Zollinger-Ellison syndrome
```
(c) A. Celiac sprue is not only characterized by these classic symptoms. The antiendomysial antibody has a 90-95% sensitivity and 90-95% specificity for celiac sprue.
67
```
Which of the following is the most important intervention in acute pancreatitis?
A. IV fluid administration
B. Antibiotic administration
C. Calcium replacement
D. Antiemetics
```
(c) A. The mainstay of management in acute pancreatitis is fluid resuscitation. Isotonic solutions are best to maintain renal perfusion and urine output > 100 ml/hour.
68
```
As a rule, solid foods such as cereal and fruits are best introduced into an infant's diet at approximately
A. 1 to 3 weeks.
B. 4 to 8 weeks.
C. 4 to 6 months.
D. 10 to 14 months.
```
(c) C. The inclusion of solid foods in the diet is best done at approximately 4-6 months. Before 4 to 6 months of age does not contribute significantly to the infant's health and it increases their risk of allergies and atopy.
69
Which of the following laboratory tests, if positive, would be most indicative of Crohn's disease?
A. Antineutrophil cytoplasmic antibodies (ANCA)
B. Antiendomysial antibodies (AEA)
C. Antinuclear antibodies (ANA)
D. Anti-Saccharomyces cerevisiae antibodies (ASCA)
(c) D. Anti-Saccharomyces cerevisiae antibodies (ASCA). About 60-70% of patients with Crohn's disease are positive for these antibodies which are directed at the cell walls of S. cerevisiae while only 10-15% of ulcerative colitis is found to be positive.
70
```
In a patient with metabolic acidosis due to ingestion of methanol, which substance below is considered therapeutic?
A. Salicylates
B. Paraldehyde
C. Ethylene glycol
D. Ethanol
```
(c) D. Ethanol, along with hemodialysis and supportive measures, is indicated for metabolic acidosis caused by
methanol ingestion.
71
```
What is the term for blue discoloration about the umbilicus?
A. Cullen's sign
B. Murphy's sign
C. Rovsing's sign
D. Turner sign
```
(c) A. Cullen's sign is a blue discoloration about the umbilicus and can occur in hemorrhagic pancreatitis and results from hemoperitoneum.
72
```
Which of the following medications decreases the exchange of hydrogen for potassium by inhibiting hydrogen, potassium-ATPase?
A. Ranitidine (Zantac)
B. Misoprostol (Cytotec)
C. Sucralfate (Carafate)
D. Omeprazole (Prilosec)
```
(c) D. Omeprazole, a proton pump inhibitor, works by inhibiting hydrogen, potassium-ATPase.
73
```
A patient presents to the emergency department with right upper quadrant pain over eight hours, nausea, and vomiting. On exam there is a fever of 101.2 degrees F. Ultrasound shows a distended gallbladder. What is the most
appropriate management of this patient?
A. Oral analgesics
B. Diagnostic peritoneal lavage
C. Proton pump inhibitors
D. Laparoscopic cholecystectomy
```
(c) D. The proper treatment for acute cholecystitis is IV fluids, antibiotics, pain control, and surgery. Cholecystectomy is the definitive treatment for acute cholecystitis and laparoscopic cholecystectomy is the procedure of choice.
74
```
A patient presents uncertain as to whether he has completed the Hepatitis B vaccination series. What laboratory test would be most helpful in determining his immunization status?
A. Anti-HBs
B. HBeAg
C. HBsAg
D. Anti-HBc
```
(c) A. Anti-HBs is the circulating antibody that develops to surface antigen in response to either past Hepatitis B
infection or to Hepatitis B immunization. It represents immunity to the Hepatitis B virus in otherwise
immunocompetent patients.
75
```
A patient with a history of severe peptic ulcer disease is 5 weeks status post Billroth I surgery. One week ago he restarted his normal diet and has had the onset of severe nausea, abdominal cramping, and light-headedness that occur approximately thirty minutes after eating. The abdominal exam reveals a healing surgical scar without areas of unusual tenderness or any palpable masses. Which of the following is the most likely diagnosis?
A. Anxiety disorder
B. Celiac sprue
C. Dumping syndrome
D. Irritable bowel syndrome
```
(c) C. Dumping syndrome typically occurs after Billroth type I surgeries as well as gastric bypass surgeries when the patient attempts to eat a large amount of simple sugars.
76
```
A patient presents with abdominal pain in the right lower quadrant, examination reveals increased pain in the right lower quadrant on deep palpation of the left lower quadrant. This commonly known as which of the following?
A. Psoas sign
B. Murphy's sign
C. Rovsing's sign
D. Obturator sign
```
(c) C. A positive Rovsing's sign can be elicited in a patient with appendicitis when increased pain occurs in the right lower quadrant upon palpation of the left lower quadrant.
77
```
A 45 year-old male presents with a long history of ulcerative colitis and recent progressive complaints of right upper quadrant pain, weight loss, fever and most recently, a rapid onset of jaundice with pruritus. Labs revealed elevated bilirubin and alkaline phosphatase. Viral serologies were negative. An endoscopic cholangiogram showed areas of stenosis and dilation throughout the bile duct system. What is the most likely diagnosis?
A. Choledocholithiasis
B. Hepatic carcinoma
C. Portal hypertension
D. Primary sclerosing cholangitis
```
(c) D. Primary sclerosing cholangitis (PSC) results in diffuse intra- and extrahepatic duct sclerosing with dilatation proximal to these areas.
78
```
Which of the following is the most effective prophylaxis for traveler's diarrhea?
A. Metronidazole
B. Ciprofloxacin
C. Tetracycline
D. Ampicillin
```
(c) B. Ciprofloxacin. Options for prophylaxis of traveler's diarrhea include norfloxacin, ciprofloxacin, ofloxacin, or
trimethoprim/sulfamethoxazole.
79
```
A 30 year-old female presents with a one to two year history of daily bouts of mid-abdominal crampy pain and bloating that are briefly relieved with defecation. Loose to watery bowel movements occur four to five times daily. She denies any nocturnal symptoms. Previous laboratory studies, abdominal CT scans and a colonoscopy have all been normal. Attempted dietary changes, exercise and probiotics have provided no relief. What is the next step in
treatment for this patient?
A. Nortriptyline (Pamelor)
B. Omeprazole (Prilosec)
C. Polyethylene glycol (Miralax)
D. Promethazine (Phenergan)
```
(c) A. Nortriptyline, and other tricyclic antidepressants (TCAs), is an appropriate choice for someone with diarrhea predominant irritable bowel syndrome due to their numerous mechanisms of action.
80
A male patient presents for a routine physical examination. He denies chronic health problems, regular medication use or previous surgeries. He exercises 4-5 times weekly, does not use tobacco products, and consumes alcohol in moderation. His last intake of alcohol was two weeks ago while on a trip to Mexico. His review of systems and physical examination are both negative. Routine labs were drawn which were significant for the following:
Total serum bilirubin 3.5 mg/dL (0.3-1.0 mg/dL),
direct bilirubin 0.2 mg/dL (0.1-0.3 mg/dL),
AST 35 U/L (0-35 U/L),
ALT 30 U/L (0-35 U/L),
Alkaline Phosphatase 48 U/L (30-120 U/L)
GGT 12 U/L (1-94 U/L).
What is the most likely diagnosis in this patient?
A. Alcoholic hepatitis
B. Crigler-Najjar syndrome
C. Gilbert's syndrome
D. Wilson's disease
(c) C. Gilbert's syndrome is a relatively common cause of mild isolated elevations in indirect serum bilirubin.
81
What is the pathologic mechanism of Hirschsprung's disease?
A. Pyloric circular muscle hypertrophy causing gastric outlet obstruction
B. Absence of ganglion cells in the mucosal and muscular layers of the colon
C. A defect in the diaphragm leading to protrusion of the abdominal viscera into the thoracic cavity
D. Absence of relaxation of the lower esophageal sphincter and lack of peristalsis in the esophageal body
(c) B. Hirschsprung's disease results from an absence of ganglion cells in the mucosal and muscular layers of the
colon.
82
```
A pregnant female presents at 32 weeks gestation with painless rectal bleeding and a bulging perianal mass when straining which goes away. Which of the following is the most appropriate management of this patient?
A. Hemorrhoidectomy
B. Metronidazole (Flagyl)
C. Psyllium (Metamucil)
D. Sclerotherapy
```
(c) C. Dietary fiber or psyllium bulk laxatives can be used to decrease straining with defecation.
83
```
A patient presents with a long history of dyspepsia refractory to maximum appropriate therapy. A recent upper GI series revealed multiple gastric and duodenal ulcerations with prominent mucosal folds. What diagnostic study would be confirmatory of this patient's suspected diagnosis?
A. EGD with duodenal biopsy
B. Serum gastrin level
C. Helicobacter pylori serology
D. Abdominal CT scan
```
(c) B. Serum gastrin levels can be elevated for many reasons; however significant elevations in a fasting state as well as with the secretin stimulation test are confirmatory for Zollinger-Ellison syndrome which is highly suspect in this case.
84
```
Which of the following is best described as a hard nodule in the periumbilical region?
A. Hodgkin's lymphoma
B. Gastric bezoar
C. Sister Mary Joseph nodule
D. Virchow's node
```
(c) C. The Sister Mary Joseph nodule can occur with metastatic gastric and pancreatic cancers. The nodule is
generally minimally to non-tender to palpation.
85
```
A person presenting with bleeding esophageal varicies should be treated with which of the following while awaiting arrival of endoscopy?
A. Carafate (Sucralfate)
B. Octreotide (Sandostatin)
C. Omeprazole (Prilosec)
D. Enoxaparin (Lovenox)
```
(c) B. Octreotide is a vasoactive drug used in the treatment of GI bleeding as well as somatostatin, vasopressin, and terlipressin. Somatostatin and octreotide are preferred due to safety and less incidence of serious side effects.
86
```
What is considered the most common physical examination finding for intestinal obstruction?
A. Distention
B. Fluid wave
C. Rigidity
D. Tenderness
```
(c) A. Abdominal distention is the most common hallmark of all kinds of intestinal obstructions though its presence can be variable depending on the duration and exact location of the obstruction.
87
```
A 33 year-old patient returns from a community picnic that was held on a hot July day. The patient developed severe explosive diarrhea, nausea, vomiting and abdominal cramps six hours after having homemade potato salad and hot dogs. Multiple people who ate at this picnic have similar symptoms. There is no associated fever. What is the most likely causative organism for these symptoms?
A. Clostridium perfringens
B. Campylobacter jejuni
C. Shigella
D. Staphylococcus aureus
```
(c) D. Staphylococcus aureus is an acute illness caused by the ingestion of enterotoxin-producing organism. It is the only common acute ingestion of a preformed toxin. The clinical picture in the question is the classic presentation for this illness. Foods most responsible for this infection are ham, cream, custard pastries, and mayonnaise-based salads.
88
```
A 62 year-old male is brought to the emergency department with acute hematemesis. The patient denies a previous history of vomiting. His wife states he has chronic liver disease. Physical examination reveals a distended abdomen without rebound, guarding or organomegaly. There is a fluid wave. Which of the following is the most likely diagnosis?
A. Esophageal varices
B. Mallory-Weiss tear
C. Arteriovenous malformation
D. Perforated duodenal ulcer
```
(c) A. Esophageal varices are dilated submucosal veins that develop in a patient with underlying portal
hypertension. The most common cause of portal hypertension is cirrhosis.
89
```
Which of the following medications is most useful in maintaining remission in a patient with ulcerative colitis?
A. Oral corticosteroids
B. Corticosteroid enemas
C. Sulfasalazine
D. Macrodantin
```
(c) C. Sulfasalazine, olsalazine, and mesalamine are effective in maintaining remission in patients with ulcerative colitis.
90
```
A 50 year-old male with history of alcohol abuse presents with acute, severe epigastric pain radiating to the back. The patient admits to an episode of coffee ground emesis. On examination he is ill-appearing with a rigid, quiet abdomen and rebound tenderness. Which of the following is the most likely diagnosis?
A. Abdominal aortic aneurysm
B. Perforated duodenal ulcer
C. Acute myocardial infarction
D. Cholecystitis
```
(c) B. Perforation of a duodenal ulcer causes sudden, severe pain, with rebound tenderness and rigid abdomen on physical examination. It is often associated with coffee ground emesis.
91
A patient presents with nausea, vomiting, and fever for one day. She describes periumbilical abdominal pain which has settled in her right lower quadrant. On examination she has right lower quadrant pain with deep left lower
quadrant palpation. This finding is known as which of the following?
A. Psoas sign
B. Rebound tenderness
C. Rovsing's sign
D. Obturator sign
(c) C. Right lower quadrant pain with deep left lower quadrant palpation is Rovsing's sign.
92
```
Which of the following is the study of choice to diagnose upper gastrointestinal malignancy?
A. Abdominal CT
B. Upper endoscopy
C. Barium swallow
D. Abdominal ultrasound
```
(c) B. Upper endoscopy is the study of choice to diagnose gastroduodenal ulcers, erosive esophagitis and upper gastrointestinal malignancy.
93
An 18 month-old female presents to the Emergency Department having possibly swallowed a hearing aid battery within the past hour. She is drooling and appears anxious but parents have noticed no stridor or dyspnea. She has no history of previous esophageal injury. Physical examination is unremarkable. Chest radiograph reveals a radiopaque
round object at the distal esophagus. Which of the following is the most appropriate treatment option?
A. Observation for 24 hours
B. Esophagoscopy for removal
C. Barium swallow
D. Bronchoscopy
(c) B. Esophagoscopy is the procedure of choice for acutely ingested foreign bodies.
94
A 40 year-old male presents with several months of abdominal pain and nausea. Endoscopy reveals an irregular 1 x 2 cm area of loss of rugal folds near the antrum. Biopsies show extensive mucosal and submucosal infiltration by B-lymphocytes.
The patient is given appropriate treatment and the lesion resolves. Which infectious agent is most likely to be associated with these findings?
A. Aspergillus fumigatus
B. Helicobacter pylori
C. Human papilloma virus
D. Salmonella typhi
(c) B. H. Pylori causes gastric mucosal inflammation with PMN's and lymphocytes. Infection causes nausea and
abdominal pain. Inflammation may be confined to the superficial gastric epithelium or may extend deeper
resulting in varying degrees of gland atrophy. Eradication of H. Pylori with appropriate therapy leads to
resolution of the chronic gastritis.
95
```
A 3 year-old presents with profuse watery diarrhea for the past three days. The child vomited twice yesterday, but not today. On examination, the child is febrile, with pulse of 142, respiratory rate of 18, and blood pressure of 60/40 mmHg. The child is alert and responsive, with no focal findings. Which of the following is the most appropriate
intervention?
A. Antibiotic therapy
B. Loperamide (Imodium)
C. 3% normal saline IV infusion
D. Oral rehydration
```
(c) D. The goal of therapy for a child with severe gastroenteritis and dehydration is to restore fluid loss. Oral rehydration with an appropriate electrolyte solution is the best option if the child is not actively vomiting and is alert enough to take oral fluids.
96
```
A 66 year-old female presents to your office complaining of progressive difficulty swallowing over the last 6 months. Initially she had difficulty only with meats, but now she has dysphagia with other foods as well. Which of the following is the most appropriate initial diagnostic study?
A. Barium swallow
B. Endoscopy
C. CT scan
D. Urea breath test
```
(c) B. Endoscopy is the diagnostic study of choice in a patient with progressive dysphagia because of its ability to obtain tissue for diagnosis.
97
```
Which of the following is considered to be the treatment of choice for the pruritus that occurs with primary biliary cirrhosis?
A. Colchicine (Colzalide)
B. Atorvastatin (Lipitor)
C. Cholestyramine (Questran)
D. Enalapril (Vasotec)
```
(c) C. Cholestyramine, a bile salt sequestrant, is able to decrease the pruritus that occurs from the bile stasis and granulomas.
98
```
A patient diagnosed with Barrett's esophagus is at an increased risk for the development of what type of cancer?
A. Squamous cell
B. Transitional cell
C. Adenocarcinoma
D. Atypical carcinoid
```
(c) C. The most serious complication of Barrett's esophagus is esophageal adenocarcinoma.
99
```
An otherwise healthy 23 year-old female presents to the student health office complaining of 3 days of frequent, watery, non-bloody stools. She denies significant abdominal pain, vomiting, fever or dark urine. Others on campus have been seen with the same presentation this week. Initial choice of treatment includes which of the following?
A. Fluid intake and bowel rest
B. Ciprofloxacin
C. Hospital admission with IV fluids
D. Atropine
```
(c) A. Most mild diarrhea will not lead to dehydration with adequate fluids and comfort with rest to the bowel.
100
```
A 72 year-old man presents with acute left lower quadrant abdominal pain. He has nausea, vomiting, and constipation. He has a fever of 101° F and guarding and rebound tenderness in his left lower quadrant. His white blood cell count is elevated. He has no prior history of gastrointestinal disease. Which of the following is the most likely diagnosis?
A. Inflammatory bowel disease
B. Irritable bowel syndrome
C. Viral gastroenteritis
D. Acute diverticulitis
```
(c) D. Acute abdominal pain, fever, left lower abdominal tenderness, and leukocytosis are hallmark signs of acute
diverticulitis.
101
```
A 25 year-old man presents with odynophagia and dysphagia. On endoscopic examination, small, white, patches with surrounding erythema of the esophagus are noted. Silver stain is positive for hyphae. The best treatment option for this patient is
A. acyclovir (Zovirax).
B. omeprazole (Prilosec).
C. fluconazole (Diflucan).
D. penicillin G.
```
(c) C. The patient has Candida esophagitis and the treatment of choice is fluconazole.
102
A 41 year-old female presents to you for medical screening advice. Her 44 year-old sister passed away recently 18 months after diagnosis of metastatic colon cancer. Which of the following is the most appropriate advice for this
patient?
A. Double contrast barium enema now and repeat every 5 years if normal
B. Rectal occult blood testing annually until age 50 then sigmoidoscopy every 3 years
C. Rectal occult blood testing annually until age 50 then screening colonoscopy every 5 years
D. Screening colonoscopy now and repeat every 3-5 years if normal
(c) D. Hereditary factors are believed to contribute to up to 30% of colorectal cancers. Relative risk is 3.8 times if the family member's cancer was diagnosed at less than 45 years of age. Recommended screening in a single first degree relative with colorectal cancer diagnosed before age 60 is beginning colonoscopy at age 40 or ten
years younger than age at diagnosis of youngest affected first-degree relative. Then if negative, every 5 years.
103
```
A 65 year-old homeless male with a history of pancreatitis is seen in the emergency department for vomiting, upper abdominal pain, back pain and weakness. He is cachetic, pale and jaundiced. A 4-5 cm mass is palpable in the mid to right hypochondrium. What is the most likely diagnosis?
A. Chronic cholecystitis
B. Carcinoma of head of pancreas
C. Fibrolipoma
D. Primary biliary cirrhosis
```
(c) B. Seventy-five percent of pancreatic cancers are in the head. Risk factors include age, tobacco use, obesity,
chronic pancreatitis, family history and previous abdominal radiation.
104
```
Which of the following is the treatment of choice for patients with celiac disease?
A. Gluten-free diet
B. Small bowel resection
C. Clindamycin
D. Whipple procedure
```
(c) A. Removal of all gluten from the diet is essential to therapy in celiac disease.
105
```
A 45 year-old type 2 diabetic female with history of cholelithiasis presents to the clinic with 2-3 episodes of sudden, severe epigastric pain that radiates to her shoulder. She has associated nausea and vomiting. Temperature is 101 degrees F and she is experiencing chills. Today her eyes appear yellow in color. Which of the following is the most likely diagnosis for this patient
A. Postcholecystectomy syndrome
B. Cholangitis
C. Gastroesophageal reflux disease
D. Pancreatic cancer
```
(c) B. Cholangitis is characterized by a history of biliary pain, fever, chills, and jaundice associated with episodes of abdominal pain.
106
```
Which of the following is the most appropriate study for diagnosing Hirschsprung disease?
A. Rectal biopsy
B. Stool leukocyte test
C. CT of the abdomen and pelvis
D. Fecal occult blood test
```
(c) A. A rectal biopsy showing the absence of ganglion cells in both the submucosal and muscular layers of the
involved bowel is the most appropriate diagnostic study for Hirschsprung disease.
107
A 32 year-old male with history of tobacco abuse presents with an intermittent burning sensation in his chest for six months, worsening over the past 2 weeks. His wife has noticed episodes of coughing at night. He denies dysphagia, weight loss, hematemesis, or melena. His vital signs are all normal and physical examination is unremarkable. Which
of the following is the most likely diagnosis?
A. Peptic ulcer disease
B. Acute gastritis
C. Gastroesophageal reflux disease
D. Esophageal stricture
(c) C. Gastroesophageal reflux disease presents with at least weekly episodes of heartburn and typically occurs
after meals and upon reclining. Patients may complain of regurgitation, chronic cough, laryngitis, or sore
throat.
108
An afebrile 22 year-old female presents with 2 days of a painful rectal mass which worsens with defecation. She denies any blood with bowel movements. She admits to ongoing constipation and generally poor diet of fast food. She is otherwise healthy. On examination there is a tender, swollen, bluish, ovoid mass visible at the anal margin.
Which of the following is the most likely diagnosis?
A. Rectal prolapse
B. Thrombosed hemorrhoid
C. Internal Hemorrhoid
D. Rectal polyp
(c) B. A thrombosed hemorrhoid causes acute pain increased with defecation and sitting.
109
A cirrhotic patient presents with progressive drowsiness and delirium. Physical examination reveals asterixis and tremor. Which of the following medications would you initiate?
A. Empiric antibiotic therapy
B. Lactulose (Kristalose)
C. Bolus fluid challenge with sodium chloride
D. Hydrochlorothiazide (Diuril)
(c) B. This patient has hepatic encephalopathy. Increased ammonia levels contribute to the mental status changes
associated with hepatic encephalopathy. Lactulose leads to a change in bowel flora so that fewer ammonia
forming organisms are present and also helps in the acidification of colon contents which leads to a
nonabsorbable ammonium ion creation.
110
```
A 24 year-old female presents with complaints of abdominal pain, bloating, and chronic diarrhea. She says she felt worse last month while on vacation in Italy. Despite eating well she lost weight. What would be the most appropriate treatment for this patient?
A. Gluten-free diet
B. Small bowel resection
C. Ciprofloxacin (Cipro) therapy
D. Pancreatic enzymes
```
(c) A. Celiac disease is a diffuse disease of the small bowel that is caused by immunologic malfunction. This
disease is active only in the presence of gluten, a constituent of wheat. Avoidance of gluten-containing foods is the treatment of choice.
111
```
Which of the following diagnostic studies is indicated in the evaluation of an upper gastrointestinal bleed?
A. Esophageal manometry
B. Bleeding scan
C. Upper endoscopy
D. Barium swallow
```
(c) C. Endoscopy is the evaluation modality of choice in patients with upper GI bleeding. The advantage of this
technique is that it can be used for both diagnostic and therapeutic purposes.
112
```
A 68 year-old male presents with jaundice, weight loss, and boring abdominal pain which radiates to the back. The gallbladder is palpable on physical examination. This finding is most consistent with which of the following?
A. Pancreatic tumor
B. Hemorrhagic pancreatitis
C. Cholecystitis
D. Cholelithiasis
```
(c) A. A large palpable gallbladder resulting from pressure from a tumor in the pancreatic head is known as Courvoisier's sign.
113
```
Which of the following treatments is used to reduce the hepatic complications of hemochromatosis?
A. Penicillamine
B. Paracentesis
C. Albumin
D. Phlebotomy
```
(u) B. Paracentesis may be performed in patients with tense ascites which can symptomatically improve the
patient but does not alter long-term prognosis.
114
```
A 62 year-old male presents with complaints of dyspepsia, early satiety, and dysphagia. What diagnostic study would be indicated in his initial workup?
A. PET CT scan
B. Abdominal ultrasound
C. Gastric emptying studies
D. Upper endoscopy
```
(c) D. Upper endoscopy is indicated for patients over the age of 55 presenting with new-onset symptoms of
dyspepsia in order to evaluate for gastric cancer or other serious organic disease. Upper endoscopy is the
diagnostic study of choice to diagnose gastroduodenal ulcers, erosive esophagitis, and upper GI malignancy.
115
A 32 year-old female presents with an 8-week history of a burning sensation deep in the chest, which starts about 30 minutes after she eats and worsens when she lays down at night. She has had some relief with an antacid and denies dysphagia. Which of the following interventions would be beneficial for this patient?
A. Raising the foot of the bed
B. Taking Cimetidine (Tagamet) 30 minutes after a meal
C. Eating 3 large meals per day
D. Avoiding mint
(c) D. Both peppermint and chocolate are substances known to aggravate reflux.
116
```
A 72 year-old woman presents to your clinic complaining of constipation. Which of the following presentations would be most concerning?
A. Fewer than one stools per week
B. Weight loss
C. Recurrent hemorrhoids
D. Scybala
```
(c) B. Alarm symptoms are concerning for colorectal malignancy and include weight loss, anemia, hematochezia, or positive fecal occult blood test. These symptoms are particularly worrisome in a patient with a family history of colorectal cancer.
117
```
Which of the following is the most common cause of ascites?
A. Nephrotic syndrome
B. Portal hypertension
C. Bacterial peritonitis
D. Uterine malignancy
```
(c) B. Over 80% of patients with ascites have portal hypertension secondary to chronic liver disease. Infection, malignancy, and nephrotic syndrome are common causes of non-portal hypertensive ascites.
118
```
A 45 year-old male nonsmoker presents with a 3-month history of difficulty swallowing. He describes the gradual onset of dysphagia for solids and liquids; he now complains of substantial discomfort after eating. What is his most likely diagnosis?
A. Achalasia
B. Schatzki ring
C. Esophageal carcinoma
D. Zenkers diverticulum
```
(c) A. Achalasia is by far the most common cause of dysmotility. This is particularly true in a non-smoker (less likely to be esophageal carcinoma or a lung cancer causing a paraneoplastic syndrome) and someone who
has not been to an area endemic for Chagas disease.
119
A patient was treated for community acquired pneumonia with amoxicillin-clavulanate (Augmentin). On day 7 of therapy he develops fulminate diarrhea. The diarrhea is described as greenish and foul-smelling. He admits to
associated abdominal cramps. Which of the following is the treatment of choice for this patient?
A. Metronidazole (Flagyl)
B. Diphenoxylate/atropine (Lomotil)
C. Clindamycin (Cleocin)
D. Ciprofloxacin (Cipro)
(c) A. Patients with C. difficile colitis should be treated with Flagyl for 10-14 days following cessation of the
diarrhea-inducing antibiotics.
120
```
A 31 year-old female complains of diarrhea. She admits to associated weight loss and steatorrhea, but denies melena or hematochezia. Which of the following is the most likely diagnosis?
A. Celiac disease
B. Lactose intolerance
C. Short bowel syndrome
D. Irritable bowel syndrome
```
(c) A. Greater than 10 grams of fecal fat in 24 hours is most consistent with a malabsorption syndrome such as
celiac sprue.
121
```
A 56 year-old diabetic male with a three-month history of epigastric pain after eating says he gets full really fast now. His test for Helicobacter pylori is negative. Which of the following is the recommended medication to treat this patient?
A. Calcium carbonate (Tums)
B. Ranitidine (Zantac)
C. Omeprazole (Prilosec)
D. Metoclopramide (Reglan)
```
(c) D. Metoclopramide accelerates gastric emptying and is the treatment of choice for this patient.
122
```
What nail finding is most consistent with cirrhotic liver disease?
A. Clubbing
B. Pitting
C. Terry's nails
D. Beau's lines
```
(c) C. Terry's nails occur when the nail plate turns white with a ground glass appearance, a distal band of reddish
brown, and obliteration of the lunula. Terry's nails are seen in liver disease, usually cirrhosis.
123
```
What is the initial treatment of choice for inflammatory bowel disease?
A. Ondansetron (Zofran)
B. Sulfasalazine (Azulfidine)
C. Metronidazole (Flagyl)
D. Azothioprine (Imuran)
```
(c) B. Sulfasalazine and other 5-aminosalicylic acid drugs are the cornerstone of therapy in mild to moderate inflammatory bowel disease as they have both anti-inflammatory and antibacterial properties.
124
```
A 68 year-old male with a history of alcohol abuse presents with coffee-ground emesis. He denies vomiting prior to this episode. What is the most likely cause of his bleeding?
A. Erosive gastritis
B. Gastric neoplasm
C. Mallory-Weiss tear
D. Zenker diverticulum
```
(c) A. Drugs and alcohol are the most common causes of upper gastrointestinal bleeding.
125
```
Prolonged use of a proton pump inhibitor can lead to low levels of which of the following nutrients?
A. Folic acid
B. Magnesium
C. Vitamin B6
D. Vitamin B12
```
(c) D. Vitamin B12 requires gastric acid for absorption in the stomach. Prolonged use of a proton pump inhibitor
suppresses gastric acid production.
126
```
What physical examination finding is most specific for acute cholecystitis?
A. Psoas sign
B. Rovsing's sign
C. Murphy's sign
D. Cullen's sign
```
(c) C. A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a postive Murphy's sign
and is most specific for cholecystitis.
127
```
For patients undergoing highly emetogenic chemotherapy regimens, which of the following would be the first-line antiemetic medication?
A. Ondansetron (Zofran)
B. Lorazepam (Ativan)
C. Dronabinol (Marinol)
D. Prochlorperazine (Compazine)
```
(c) A. A 5HT3 receptor blocker such as ondansetron is the agent of choice, given its high efficacy and low risk of side effects (headache being the major, and usually easily manageable, one).
128
```
Which of the following complications of Crohn's disease most frequently requires surgery?
A. Hemorrhage
B. Intra-abdominal abscess
C. Malabsorption
D. Perforation
```
(c) B. Surgery is the treatment of choice for an abscess, which is a common complication of Crohn's disease.
129
```
A 22 year-old graduate student presents with a six-month history of abdominal pain relieved with defecation which seems to coincide with her starting PA school. She describes alternating constipation and diarrhea as well as bloating. She denies any recent weight changes. Her only medication is citalopram (Celexa) What is the most likely diagnosis for this patient?
A. Crohn's disease
B. Irritable bowel syndrome
C. Thyroid storm
D. Celiac disease
```
(c) B. The patient's symptoms are consistent with irritable bowel syndrome. More than 50% of patients who seek medical attention for symptoms of IBS also have a diagnosis of depression, anxiety, or somatization.
130
Which of the following is the diagnostic study of choice in the evaluation of Zollinger-Ellison syndrome?
A. D-xylose absorption test
B. Gastrin level
C. 5-hydroxyindoleacetic acid assay (5-HIAA)
D. Urea breath test
(c) B. Zollinger-Ellison Syndrome (ZES) is characterized by elevated levels of serum gastrin resulting from gastrin secreting tumors usually located in the duodenum or pancreas.
131
```
An elderly man who recently emigrated from a war-torn area of Africa is brought to the clinic by his daughter. She explains that her father's diet was very limited in calories and protein and that he mostly ate corn and very little fresh foods. He has chronic diarrhea and examination reveals pigmented regions on hands, arms, and face and mild dementia. His tongue is smooth and shiny. This patient most likely has a deficiency of which of following vitamins?
A. Folate
B. Niacin
C. Thiamine
D. Vitamin K
```
(c) B. This patient's syndrome known as pellagra is due to niacin (vitamin B3) deficiency. It is often seen in people where corn is the major source of energy and is still endemic in parts of Africa. The syndrome includes glossitis, pigmented dermatitis, dementia, and diarrhea.
132
A 68 year-old woman presents with intermittent crampy abdominal pain and vomiting of 6 hours' duration. She feels bloated but denies rectal bleeding. Examination of the abdomen reveals no palpable mass and you note an upper midline scar from previous abdominal surgery. An abdominal radiograph demonstrates dilated loops of small bowel
with air-fluid levels. Which of the following is the most likely cause of this patient's symptoms?
A. Adhesions
B. Sigmoid volvulus
C. Incisional hernia
D. Intussusception
(c) A. The patient's surgical history, presenting symptoms and abdominal imaging are consistent with small bowel obstruction. Peritoneal adhesions are the most common cause of small bowel obstruction.
133
```
A 36 year-old truck driver presents with a very tender mass that has developed between his buttocks over the past 4days. Examination shows a small pit-like opening in the midline near the coccyx which is surrounded by an erythematous halo. The area is exquisitely tender and pressure produces purulent drainage from the opening. Which of the following is the most likely diagnosis?
A. Anorectal fistula
B. Hidradenitis suppurativa
C. Perirectal abscess
D. Pilonidal cyst
```
(c) D. Pilonidal cyst presents with a tender draining abscess or chronic sinus over the sacrococcygeal or perianal region. It is thought to be due to distended and obstructed hair follicles and rupture into subcutaneous tissues with inspissated hair. On exam the patient will have midline pits near the coccyx or sacrum.
134
```
A 34 year-old female 3 days status-post appendectomy complains of mild diffuse abdominal pain with associated nausea and vomiting. On examination you note diminished bowel sounds. There is generalized abdominal distension with mild tenderness on palpation. There are no signs of peritoneal inflammation. Abdominal radiographs show distended gas-filled loops of the small and large intestine. Abdominal CT scan shows no mechanical obstruction. Which of the following is the most appropriate management for this patient?
A. Docusate sodium (Colace)
B. Colonoscopic decompression
C. Restrict oral intake
D. Exploratory laparoscopy
```
(c) C. Most adynamic ileuses respond to restriction of oral intake and gradual advancement of diet as bowel function returns.
135
A 48 year-old male with a history of AIDS presents with complaints of odynophagia and dysphagia for 1 week. The patient denies nausea, vomiting, diarrhea, constipation or melena. Endoscopic evaluation reveals diffuse, linear plaques which are yellowish-white in color and adhere to the esophageal mucosa. Which of the following is the treatment of choice for this patient?
A. Nystatin (Mycostatin) suspension
B. Oral acyclovir (Zovirax)
C. Oral fluconazole (Diflucan)
D. Inhaled triamcinolone acetonide (Azmacort)
(c) C. Oral fluconazole is the treatment of choice for a patient with candidal esophagitis.
136
```
A 42 year-old male with chronic complaints of heartburn and regurgitation presents for follow-up after undergoing endoscopic evaluation which shows evidence of Barrett's esophagus. Which of the following is the most serious potential complication in this patient?
A. Peptic stricture
B. Esophageal adenocarcinoma
C. Esophageal web formation
D. Mallory-Weiss tear
```
(c) B. Esophageal carcinoma is the most serious complication of Barrett's esophagus.
137
A 50 year-old female presents with constipation following an episode of tearing pain associated with bleeding while defecating 4 days ago. She admits to a residual throbbing pain and she is afraid to have a bowel movement. On examination you note what appears to be a crack in the epithelium of the anal verge. Which of the following is the most appropriate initial management for this patient?
A. Anal sphincter strengthening exercises
B. Injection sclerotherapy
C. Fiber supplementation and sitz baths
D. Analgesics with incision and drainage
(c) C. This patient has signs and symptoms consistent with an anal fissure. Most patients will respond to fiber supplementation and sitz baths.
138
```
Which of the following symptoms most commonly indicates diarrhea of an inflammatory etiology?
A. Bloody stools
B. Large volume stools
C. Fatty stools
D. Watery stools
```
(c) A. Bloody diarrhea occurs due to mucosal inflammation and/or erosions/ulcerations and may be caused by infection, inflammation, or ischemic enterocolitis.
139
```
A 43 year-old female calls the office stating that her husband was recently diagnosed with Hepatitis A. She denies a past history of or immunization for this disease and specifically denies recent jaundice, fever, nausea, or abdominal pain. Which of the following is the most appropriate next step in the care of this patient?
A. Prednisone
B. Ribavirin (Virazole)
C. Immune globulin
D. Lamivudine (Epivir)
```
(c) C. Immune globulin is indicated in close contacts of patients with Hepatitis A who have not previously had the disease or been immunized against it.
140
A 65 year-old woman is admitted to the hospital for severe abdominal pain and vomiting over the last 6 hours. Her laboratory findings
WBC Count - 19,000
Serum triglyceride level - 1100 mg/dL
Glucose - 280 mg/dL
```
Which of the following is the most likely diagnosis?
A. Acute cholecystitis
B. Acute pancreatitis
C. Hepatitis
D. Diabetic ketoacidosis
```
(c) B. This patient has acute pancreatitis. Typical symptoms include abdominal pain and nausea and vomiting. Significant hypertriglyceridemia is present. Transient hyperglycemia is common, in addition to elevation of lipase and amylase, serum amino-transferase and alkaline phosphatase are elevated in 50% of patients with acute pancreatitis.
141
```
A 3 week-old infant is evaluated for persistent projectile vomiting described as breast milk without bile or blood. The abdomen is distended before vomiting and a small, mid-epigastric mass is palpable after vomiting. Which of the following is the most appropriate diagnostic study for the evaluation of this patient?
A. Barium enema
B. Esophageal manometry
C. H. pylori stool antigen
D. Upper GI contrast radiographs
```
(c) D. This infant has pyloric stenosis and an upper GI series will reveal a narrowed distal stomach with double tract of barium.
142
```
An 80 year-old woman with a 40 pack-year history of smoking presents with progressive dysphagia for solids over the past 6 months. She states that she has often had to regurgitate her food because it "gets stuck." She has had an unintentional weight loss of 20 pounds. Which of the following is the initial diagnostic test of choice?
A. Barium esophagography
B. Esophageal manometry
C. Esophageal motility studies
D. Esophageal pH monitoring
```
(c) A. This patient's history of smoking, unintentional weight loss, and progressive dysphagia for solids makes esophageal neoplasm most likely. The initial less invasive diagnostic test is barium swallow which will detect lumen narrowing (mechanical) lesions such as cancer.
143
```
A 45 year-old female presents with bowel movements associated with bright red blood after being diagnosed with a stage II hemorrhoid 1 month ago. She has used increased fiber and fluid intake as her primary treatment up to this point. Which of the following is the most appropriate next step in managing this patient's condition?
A. Rubber band ligation
B. Hemorrhoidectomy
C. Diltiazem (Cardizem) therapy
D. Iron supplementation
```
(c) A. Patients who have a stage I, II or III hemorrhoid with recurrent bleeding not responsive to conservative therapy should have injection sclerotherapy, rubber band ligation or application of electrocoagulation. Rubber band ligation is easy to use and has a high efficacy rate.
144
```
A 10 year-old African immigrant presents 2 weeks after arriving in the US describing dry eyes and difficulty with night vision. Examination reveals numerous, small white conjunctival patches bilaterally. This patient's symptoms are most likely due to which of the following deficiencies?
A. Vitamin B6
B. Vitamin C
C. Vitamin D
D. Vitamin A
```
(c) D. Vitamin A deficiency is one of the most common causes of blindness in developing countries. It is also seen secondary to malabsorption disorders and frequent mineral oil laxative use. Night blindness is one of the earliest symptoms.
145
```
An asymptomatic 30 year-old male with no significant past medical history presents to the office. He is concerned about his father being diagnosed with colon cancer at the age of 60. Which of the following is the most appropriate health counseling for this patient?
A. Flexible sigmoidoscopy now
B. Colonoscopy at age 40
C. Flexible sigmoidoscopy age 35
D. Colonoscopy age 50
```
(c) B. It is recommended that patients with a single first-degree relative with colon cancer diagnosed at or after age 60 should begin screening at age 40 preferably with a colonoscopy.
146
```
A 41 year-old female presents with RUQ pain. She is febrile and slightly tachycardic. Examination demonstrates abdominal tenderness and abrupt cessation of inspiration with palpation under the right costal margin during deep inspiration. Ingestion of which of the following is most likely to have proceeded the onset of this condition?
A. Alcoholic beverage
B. Dairy product
C. High-fiber meal
D. Fatty meal
```
(c) D. Cholecystitis presents with complaint of RUQ pain and on exam there may be a positive Murphy's sign. It is associated with meals high in fat. Alcohol, dairy products and high fiber meals are not associated with cholecystitis and would not present as fever, tenderness and positive Murphy's sign
147
```
A 56 year-old male with a history of hypertension and alcohol use presents with mid-epigastric pain and coffee-ground emesis since early this morning. The patient denies diarrhea, constipation or blood in his stools. Endoscopic evaluation done after admission revealed peptic ulcer disease with active bleeding. Which of the following is the most appropriate therapy to reduce the risk of rebleeding in this patient?
A. IV pantoprazole (Protonix)
B. Oral hyoscyamine sulfate (Levsin)
C. IV famotidine (Pepcid)
D. Oral metoclopramide (Reglan)
```
(c) A. IV proton pump inhibitors reduce the risk of rebleeding after endoscopic treatment in patients with peptic ulcers that have high risk features such as active bleeding.
148
```
A 35 year-old female 2 months status-post gastric bypass surgery develops abdominal cramps, diarrhea, palpitations, sweating and nausea shortly after eating. Which of the following is the most likely diagnosis?
A. Dumping syndrome
B. Inflammatory bowel disease
C. Surgical adhesions
D. Zollinger-Ellison syndrome
```
(c) A. Gastric bypass puts this patient at risk for dumping syndrome. Her symptoms represent both cardiovascular and gastrointestinal reactions which occur after eating. The underlying effect is due to the stomach's inability to regulate its rate of emptying.
149
```
A 19 year-old female presents with intermittent episodes of loose stools over the past 6 to 8 months. She admits to crampy abdominal pain and bloating that seems to be more associated with her stress level than with food intake. She denies fever, melena, or nocturnal symptoms. Examination reveals normoactive bowel sounds and mild lower abdominal tenderness on palpation without rebound tenderness or organomegaly. Which of the following is the treatment of choice in this patient?
A. Cimetidine (Tagamet)
B. Metronidazole (Flagyl)
C. Metoclopramide (Reglan)
D. Dicyclomine (Bentyl)
```
(c) D. Dicyclomine (Bentyl) and other anticholinergic agents can help relieve abdominal symptoms of cramping and bloating associated with irritable bowel syndrome.
150
```
A 33 year-old male returns from an extended camping trip and complains of 5 weeks of mild diarrhea, mostly after breakfast. The stool is described as bulky, greasy, frothy, and malodorous; it is free of blood or pus. He is afebrile and has upper abdominal discomfort, cramps, distention, and excessive flatus. he has lost several pounds. Which of the following is the most likely diagnosis?
A. Amebiasis
B. Giardiasis
C. Schistosomiasis
D. Trypanosomiasis
```
(c) B. This is a classic presentation of diarrheal illness due to Giardia and in its chronic state can cause malabsorption and therefore be associated with foul smelling, oily or greasy stools with weight loss.
151
```
A 25 year-old woman complains of bloating, abdominal cramps, and loose stools with flatulence. Her symptoms seem to occur 1-2 hours after meals containing any dairy products. Which of the following would be the most appropriate diagnostic test to confirm your suspicion?
A. Colonoscopy
B. Fecal smear for leukocytes
C. Hydrogen breath test
D. Serum IgA endomysial antibody
```
(c) C. This woman most likely has lactase deficiency as her symptoms occur after dairy ingestion. Hydrogen breath test after administration of lactose will confirm the diagnosis.
