VII-37. A patient with a diagnosis of scleroderma who has diffuse cutaneous involvement presents with malignant hypertension, oliguria, edema, hemolytic anemia, and renal failure. You make a diagnosis of scleroderma renal crisis
(SRC). What is the recommended treatment?
VII-38. Your patient with end-stage renal disease on hemodialysis has persistent hyperkalemia. He has a history of total bilateral renal artery stenosis, which is why he is on hemodialysis. He only has electrocardiogram changes when his potassium rises above 6.0 meq/L, which occurs a few times per week. You admit him to the hospital for
further evaluation. Your laboratory evaluation, nutrition counseling, and medication adjustments have not impacted his serum potassium. What is the next reasonable step to undertake for this patient?
A. Adjust the dialysate.
VII-39. A 63-year-old male is brought to the emergency department after having a seizure. He has a history of an unresectable lung mass treated with palliative radiation therapy. He is known to have a serum sodium of 128 meq/L chronically. The patient's wife reports that on the night before admission he was somnolent. This morning,
while she was trying to awaken him, he developed a generalized tonic-clonic seizure lasting approximately 1 min. In the emergency room he is unresponsive. Vital signs and physical examination are otherwise normal. Serum sodium is 111 meq/L. He is treated with 3% saline and transferred to the intensive care unit. One day later serum
sodium is 137 meq/L. He has had no further seizures since admission and is awake but is barely able to move his extremities and is dysarthric. Which of the following studies is most likely to explain his current condition?
D. MRI of the brainstem showing demyelination
VII-40. A 25-year-old female with nephrotic syndrome from minimal-change disease is seen in the emergency department with increased right leg swelling. Ultrasound of the leg shows thrombosis of the superficial femoral vein. Which of the following is not a mechanism of hypercoagulability in this disorder?
C. Chronic disseminated intravascular coagulation
VII-41. It is hospital day 5 for a 65-year-old patient with prerenal azotemia secondary to dehydration. His creatinine was initially 3.6 mg/dL on admission, but it has improved today to 2.1 mg/dL. He complains of mild lower back pain, and you prescribe naproxen to be taken intermittently.
By what mechanism might this drug further impair his renal function?
A. Afferent arteriolar vasoconstriction
VII-42. A 63-year-old male with a history of diabetes mellitus is found to have a lung nodule on chest radiography. To stage the disease further he undergoes a contrastenhanced CT scan of the chest. One week before the CT scan, his BUN is 26 mg/dL and his creatinine is 1.8 mg/ dL. Three days after the study he complains of dyspnea, pedal edema, and decreased urinary output. Repeat BUN
is 86 mg/dL and creatinine is 4.4 mg/dL. The most likely mechanism of the acute renal failure is
A. acute tubular necrosis
VII-44. A 35-year-old female presents with complaints of bilateral lower extremity edema, polyuria, and moderate left-sided flank pain that began approximately 2 weeks ago. There is no past medical history. She is taking no medications and denies tobacco, alcohol, or illicit drug use. Examination shows normal vital signs, including
normal blood pressure. There is 2+ edema in bilateral lower extremities. The 24-h urine collection is significant for 3.5 g of protein. Urinalysis is bland except for the proteinuria. Serum creatinine is 0.7 mg/dL, and ultrasound examination shows the left kidney measuring 13 cm and the right kidney measuring 11.5 cm. You are concerned
about renal vein thrombosis. What test do you choose for the evaluation?
C. Magnetic resonance venography
VII-45. The posterior pituitary secretes arginine vasopressin (antidiuretic hormone) under which of the following stressors?
D. A and B
VII-46. A 29-year-old man is admitted to the hospital with a severe asthma exacerbation. He is taken to the intensive care unit (ICU) and treated with continuous aerosolized β-adrenergic agonists and glucocorticoids. He requires bilevel positive airway pressure mechanical respiration. After 18 h of this therapy, his respiratory status begins to improve. He begins to complain of fatigue and myalgias
in his legs. He has difficulty ambulating and on neurologic examination he has three out of five symmetric weakness in the lower extremities. On the cardiac monitor, you notice flattened T waves, ST depression, and a prolonged QT interval. What is the cause of this patient's neurologic and cardiac findings?
C. Medication effect
VII-47. A 33-year-old male is brought for medical attention after completing an ultramarathon. Upon finishing he was disoriented and light-headed. His normal weight is 60 kg. Physical examination reveals a body temperature of 38.3°C (100.9°F), blood pressure of 85/60 mmHg, and heart rate of 125/min. The patient's neck veins are flat,
and skin turgor is poor. Laboratory studies are notable for a serum sodium of 175 meq/L. The patient's estimated free water deficit is
C. 7.5 L
VII-48. A 66-year-old woman is being treated with penicillin for mitral valve endocarditis due to Streptococcus viridans. She initially improved with resolution of her fever after 7 days, but now comes to the emergency room complaining of fever and rash during week 4 of her treatment. She continues to receive penicillin IV via a central line
equipped with an infusion system. She has had no drainage from the site of her central line and has otherwise been feeling well until she developed a diffuse pruritic rash over her entire body, beginning on her trunk. She also has had a fever to as high as 38.3°C at home. On examination, she has an erythematous maculopapular rash over her trunk and legs. In many areas, it has coalesced to form raised plaques. She currently has a temperature of
39°C. Her laboratory values shows a white blood cell count of 12,330/μL with 72% polymorphonuclear cells, 12% lymphocytes, 5% monocytes, and 11% eosinophils. Her BUN is 65 mg/dL, and creatinine is 2.5 mg/dL. At the
time of her hospital discharge, the patient's BUN was 24 mg/dL and creatinine was 1.2 mg/dL. Which test is most likely to yield the diagnosis of her acute renal failure?
E. Hansel's stain for eosinophils in the urine
VII-52. You are consulting to advise on another antihypertensive agent for a patient with difficult-to-control hypertension. Despite high doses of a beta blocker, the patient remains hypertensive. The estimated glomerular filtration rate (GFR) is 75 mL/min per 1.73 m2. On physical examination, there is no exophthalmos and no thyroid
bruit. The great vessels are without bruit as well. Abdominal examination reveals bruits loudest in bilateral flanks as well as a left femoral bruit. Peripheral pulses are intact. An ultrasound confirms the presence of bilateral renal artery stenosis. Which medication class would not be a good choice to add to this patient's regimen?
C. Angiotensin II receptor blocker
VII-53. Which of the following patients in need of dialysis would receive the greatest benefit from placing a peritoneal dialysis catheter rather than a hemodialysis catheter?
B. Patients in developing countries
VII-54. A patient with a history of Sjögren's syndrome hasthe following laboratory findings: plasma sodium 139 meq/L, chloride 112 meq/L, bicarbonate 15 meq/L, and potassium 3.0 meq/L; urine studies show a pH of 6.0, sodium
of 15 meq/L, potassium of 10 meq/L, and chloride
of 12 meq/L. The most likely diagnosis is
A. type I renal tubular acidosis (RTA)
VII-55. The condition of a 50-year-old obese female with a 5-year history of mild hypertension controlled by a thiazide diuretic is being evaluated because proteinuria was noted during her routine yearly medical visit. Physical examination disclosed a height of 167.6 cm (66 in.), weight of 91 kg (202 lb), blood pressure of 130/80 mmHg, and
trace pedal edema. Laboratory values are as follows: Serum creatinine: 106 μmol/L (1.2 mg/dL)
BUN: 6.4 mmol/L (18 mg/dL) Creatinine clearance: 87 mL/min Urinalysis: pH 5.0; specific gravity 1.018; protein 3+; no glucose; occasional coarse granular cast Urine protein excretion: 5.9 g/d
A renal biopsy demonstrates that 60% of the glomeruli have segmental scarring by light microscopy, with the remainder of the glomeruli appearing unremarkable (see following figure). The most likely diagnosis is
B. focal and segmental sclerosis
VII-56. A 20-year-old college student seeks medical attention for light-headedness. He just completed a rigorous tennis match and did not drink any water or fluids. Supine blood pressure is 110/70 mmHg, and heart rate is 105/min. Upright, the blood pressure is 95/60 mmHg with a heart rate of 125/min. Temperature and mental status are normal. Which of the following laboratory results is most likely in this patient?
D. Urine sodium <20 meq/L
VII-57. A 50-year-old male is admitted to the hospital with pneumonia. He does well after the administration of antibiotics, but his sodium is noted to rise from 140 to 154 meq/L over 2 days. He reports thirst and has had a urine output of
approximately 5 L per day. Which of the following is the most appropriate next step to evaluate the patient's disorder?
B. Measurement of serum vasopressin level
VII-58. A 16-year-old female star gymnast presents to your office complaining of fatigue, diffuse weakness, and muscle cramps. She has no previous medical history and denies tobacco,
alcohol, or illicit drug use. There is no significant
family history. Examination shows a thin female with normal blood pressure. Body mass index (BMI) is 18 kg/m2. Oral examination shows poor dentition. Muscle tone is normal, and neurologic examination is normal. Laboratory studies show hematocrit of 38.5%, creatinine of 0.6 mg/dL, serum bicarbonate of 30 meq/L, and potassium of 2.7 meq/ L. Further evaluation should include which of the following?
D. Urine toxicology screen for diuretics
VIII-1. A 46-year-old man is admitted to the hospital for upper gastrointestinal (GI) bleeding. He has a known history of peptic ulcer disease, for which he takes a protonpump inhibitor. His last admission for upper GI bleeding was 4 years ago. After fluid resuscitation, he is hemodynamically stable and his hematocrit has not changed in the past 8 h. Upper endoscopy is performed. Which of the following findings at endoscopy is most reassuring that
the patient will not have a significant rebleeding episode within the next 3 days?
B. Clean-based ulcer
VIII-2. Which of the following statements about alcoholic liver disease is not true?
C. Serum aspartate aminotransferase levels are often
greater than 1000 U/L.
VIII-3. A 47-year-old woman presents to the emergency room with severe mid-abdominal pain radiating to her back. The pain began acutely and is sharp. She denies cramping or flatulence. She has had two episodes of emesis of bilious material since the pain began, but this has not lessened the pain. She currently rates the pain as a 10 out of 10 and feels the pain is worse in the supine position. For the past few months, she has had intermittent episodes of right upper and mid-epigastric
pain that occur after eating but subside over a few
hours. These are associated with a feeling of excess gas. She denies any history of alcohol abuse. She has no medical history of hypertension or hyperlipidemia. On physical examination, she is writhing in distress and slightly diaphoretic. Vital signs are: hear rate 127 beats/min, blood pressure 92/50 mmHg, respiratory rate 20 breaths/min, temperature 37.9°C, SaO2 88% on room air. Her body mass index is 29 kg/ m2. The cardiovascular examination reveals a regular tachycardia. The chest examination shows dullness to percussion at bilateral bases with a few scattered crackles. On abdominal examination, bowel sounds are hypoactive. There is no rash or bruising evident
on inspection of the abdomen. There is voluntary
guarding on palpation. The pain with palpation is
greatest in the periumbilical and epigastric area without rebound tenderness. There is no evidence of jaundice, and the liver span is about 10 cm to percussion. Amylase level is 750 IU/L, and lipase level is 1129 IU/L. Other laboratory values include: aspartate amino transferase (AST) 168 U/L, alanine aminotransferase (ALT) 196 U/L, total bilirubin 2.3 mg/dL, alkaline phosphatase level 268 U/L, lactate dehydrogenase LDH 300 U/L, and creatinine 1.9 mg/dL. The hematocrit is 43%, and white blood cell (WBC) count is 11,500/μL with 89% neutrophils. An arterial blood gas shows a pH of 7.32, PaCO2 32 mmHg, and a PaO2 of 56 mmHg. An ultrasound confirms a dilated common bile duct with evidence of pancreatitis manifested as an edematous and enlarged pancreatitis. A CT scan shows no evidence of necrosis. After 3 L of normal saline,
her blood pressure comes up to 110/60 mmHg
with a heart rate of 105 beats/min. Which of the following statements best describes the pathophysiology of this disease?
A. Intrapancreatic activation of digestive enzymes with
autodigestion and acinar cell injury
B. Chemoattraction of neutrophils with subsequent
infiltration and inflammation
C. Distant organ involvement and systemic inflammatory
response syndrome related to release of activated
pancreatic enzymes and cytokines
D. All of the above
VIII-4. In the case vignette presented above, which of the following factors at presentation predicts a poor outcome and increased risk of death in acute pancreatitis?
D. PaO2 <60 mmHg
VIII-5. A 22-year old woman presents to the emergency department with abdominal pain and malaise. Her symptoms began about 8 h prior to presentation, and she has no diarrhea. The pain is mostly in the right flank currently but began in the periumbilical area. She has nausea and vomiting. Temperature is 100.3°C, blood pressure 129/90 mmHg, heart rate 101 beats/min. Physical examination shows only mild diffuse abdominal tenderness. The abdomen is soft and bowel sounds are diminished. She is tender in the right flank without costovertebral angle tenderness. The genitourinary and pelvic examinations are normal. White blood cell count is 10,000/μL. Urine analysis shows 2 white blood cells per high powered
field, no epithelial cells, and 1 red blood cell per high
powered field. A serum pregnancy test is negative. She has no past medical history and has never had similar symptoms. She is not sexually active. Which of the following is the most likely diagnosis?
B. Acute appendicitis
VIII-6. A 28-year-old male with HIV and a CD4 count of 4/μL is admitted to the hospital with several days of epigastric boring abdominal pain radiating to the back with associated nausea and bilious vomiting. He has a history of disseminated mycobacterial disease, cryptococcal pneumonia, and injection drug use. His current medications include fluconazole, trimethoprim-sulfamethoxazole,
clarithromycin, ethambutol, and rifabutin. On physical examination he has normal vital signs, decreased bowel sounds, and tender epigastrium without rebound or guarding. Rectal exam is guaiac-negative. The remainder of the examination is normal. Amylase and lipase are elevated.
The patient is treated conservatively with intravenous fluids and bowel rest, with resolution of symptoms. Right upper quadrant ultrasound is normal, and calcium and triglycerides are normal. Which of the following changes to his medical regimen should be recommended on discharge?
C. Substitute dapsone for trimethoprim-sulfamethoxazole.
VIII-7. All of the following necessitate sending bacterial stool cultures in patients with diarrhea for 2 days severe enough to keep them home from work except
VIII-8. While doing rounds in the intensive care unit,
you see a 70-year-old male patient with multisystem organ failure who is postoperative day 3. Review of his history reveals that he had a perforated appendix due to a delay in the diagnosis of acute appendicitis. Prior to his surgical intervention, he was noted to be delirious. His preoperative laboratory results showed: sodium,
133 meq/dL, potassium, 5.2 meq/dL, chloride, 98 meq/ dL, bicarbonate, 14 meq/dL, blood urea nitrogen 85 mg/dL, creatinine, 3.2 mg/dL. Urine analysis had no red cells, white cells, and trace protein. An electrocardiogram showed ST-segment depression in an area of an old myocardial infarct. Preoperative troponin I level was 0.09 mg/dL. He had no history of chronic renal insufficiency.
What is the most likely etiology of this patient's
E. Volume depletion
VIII-10. A 55-year-old white male with a history of diabetes presents to your office with complaints of generalized weakness, weight loss, nonspecific diffuse abdominal pain, and erectile dysfunction. The examination is significant for hepatomegaly without tenderness, testicular atrophy, and gynecomastia. Skin examination shows a diffuse slate-gray hue slightly more pronounced on the face and neck. Joint examination shows mild
swelling of the second and third metacarpophalangeal joints on the right hand. What is the recommended test for diagnosis?
D. Genetic screen for HFE gene mutation (C282Y and
VIII-11. All the following are associated with an increased risk for cholelithiasis except
C. high-protein diet
VIII-12. A 28-year-old man is admitted to the hospital with a large perianal abscess. He is taken to the operating room for incision and drainage, which he tolerates well, and he is discharged home with a 2-week course of antibiotics. He returns to the hospital 2 months later for a rash on his
shins. On examination, he has discrete red swollen nodules on both of his shins without fluctuance. They measure ~2 cm in diameter. He has no respiratory complaints, and the rest of his skin examination is normal. Laboratory data
show a white blood cell count of 12,000 with a normal differential. Erythrocyte sedimentation rate is 64 mm/h. A chest radiograph is normal. Thyroid-stimulating hormone is 3.27 mU/L, and a glycosylated hemoglobin is 5.3%. Which of the following conditions is he also likely to have?
VIII-13. A 55-year-old male with cirrhosis is seen in the clinic to follow up a recent hospitalization for spontaneous bacterial peritonitis. He is doing well and finishing his course of antibiotics. He is taking propranolol and lactulose; besides complications of end-stage liver disease, he has well-controlled diabetes mellitus and had a basal cell carcinoma resected 5 years ago. The cirrhosis is
thought to be due to alcohol abuse, and his last drink of alcohol was 2 weeks ago. He and his wife ask if he is a liver transplant candidate. He can be counseled in which of the following ways?
B. He is not a transplant candidate now, but may be after
a sustained period of proven abstinence from alcohol.
VIII-14. A 16-year-old woman had visited your clinic 1 month ago with jaundice, vomiting, malaise, and anorexia. Two other family members were ill with similar symptoms. Based on viral serologies, including a positive anti-hepatitis A virus (HAV) IgM, a diagnosis of hepatitis A was made. The patient was treated conservatively, and 1 week after
first presenting, she appeared to have made a full recovery. She returns to your clinic today complaining of the same symptoms she had 1 month ago. She is jaundiced, and an initial panel of laboratory tests returns elevated transaminases.
Which of the following offers the best explanation of
what has occurred in this patient?
E. Relapsing hepatitis
VIII-15. A male patient with inflammatory bowel disease (IBD) comes to your office as a new patient. Reviewing the medical records, you note that he has had primarily rectal disease. Macroscopic photographs from his most recent
colonoscopy show a lumpy, bumpy, hemorrhagic mucosa with ulcerations. Histology shows a process that is limited to the mucosa, with the deep layers unaffected. There are crypt abscesses. Which historic feature would be surprising in a patient with this form of IBD?
B. Current smoker
VIII-16. A 26-year-old male presents with persistent perianal pain for 2 months that is worse with defecation. The patient notes that he occasionally sees small amounts of red blood on the toilet tissue. He never has had blood staining the toilet bowl. He reports persistent constipation but has not had any incontinence. He denies anal trauma.
On physical examination there is a linear ulceration with raised edges with a skin tag at the distal end. Circular fibers of the hypertrophied internal sphincter are visible. What is the most appropriate treatment of this disease?
D. Nitroglycerin ointment
VIII-17. A 76-year-old man complains of frequent small stools that are not abnormally liquid or hard. There is some pain with passing the stool. He has no abdominal pain, nausea, melena, vomiting, or fever. He has approximately eight to ten bowel movements per day, which interferes with his
quality of life, though there is no fecal incontinence. What is a possible diagnosis to explain his complaints?
VIII-19. A 62-year-old female has a 3-month history of diffuse crampy abdominal pain and watery diarrhea and has lost 14 lb over this period. There is no prior history of abdominal or gynecologic disease. She is on no regular medications,
is a nonsmoker, and does not consume alcohol.
Colonoscopy reveals normal colonic mucosa. Biopsies of the colon reveal inflammation with extensive subepithelial collagen deposition and lymphocytic infiltration of the epithelium.
Which of the following is the most likely diagnosis?
A. Collagenous colitis
VIII-20. A 29-year-old woman who recently immigrated to the United States from South America presents to a local emergency room with severe abdominal pain, jaundice, and fever. No one else at home is ill. She is unsure how long her symptoms have been going on, but describes a sudden worsening over the past 3 days. She
has been unable to get out of bed and has not been eating well over that period of time. She has had nausea and vomiting. She denies alcohol or illicit drug use. She is rapidly triaged and on initial laboratory studies is found to have an ALT and AST in the thousands. She is to be admitted for inpatient management, and viral hepatitis serologies are sent. In a patient with acute hepatitis B, which of the following would be the first indication of infection?
D. HBsAg (hepatitis B surface antigen)
VIII-21. The patient described above has the following laboratory results: HBsAg is positive, Anti-HBc IgM is positive, and HBeAg is positive. All other serologies are negative. She is diagnosed with acute hepatitis B. When interpreting hepatitis B serology results, the term "window period" refers to the time between which of the following?
C. HBsAg and anti-HBs positivity
VIII-22. A 57-year-old man with peptic ulcer disease experiences transient improvement with Helicobacter pylori eradication. However, 3 months later, symptoms recur despite acid-suppressing therapy. He does not take nonsteroidal anti-inflammatory agents. Stool analysis for H. pylori antigen is negative. Upper GI endoscopy reveals prominent gastric folds together with the persistent ulceration in the duodenal bulb previously detected and the beginning of new ulceration 4 cm proximal to the initial ulcer. Fasting gastrin levels are elevated and basal acid secretion is 15 meq/h.
What is the best test to perform to make the diagnosis?
C. Blood sampling for gastrin levels following secretin
VIII-23. A 29-year-old woman comes to see you in clinic because of abdominal discomfort. She feels abdominal discomfort on most days of the week, and the pain varies in location and intensity. She notes constipation as well as diarrhea, but
diarrhea predominates. In comparison to 6 months ago, she has more bloating and flatulence than she has had before. She identifies eating and stress as aggravating factors, and her pain is relieved by defecation. You suspect irritable bowel
syndrome (IBS). Laboratory data include: white blood cell (WBC) count 8000/μL, hematocrit, 32%, platelets, 210,000/ μL, and erythrocyte sedimentation rate (ESR) of 44 mm/h. Stool studies show the presence of lactoferrin but no blood. Which intervention is appropriate at this time?
VIII-24. After a careful history and physical and a cost-effective workup, you have diagnosed your patient with IBS. What other condition would you expect to find in this patient?
E. Psychiatric diagnosis
VIII-25. Which of the following statements about cardiac cirrhosis is true?
B. AST and ALT levels may mimic the very high levels
seen in acute hepatitis infection or acetaminophen
VIII-26. A patient with known peptic ulcer disease presents with sudden abdominal pain to the emergency department. She is thought to have peritonitis but refuses an abdominal examination due to the discomfort caused by previous examinations. Which of the following maneuvers
will provide reasonably specific evidence of peritonitis without manual palpation of the abdomen?
B. Forced cough elicits abdominal pain.
VIII-27. In chronic hepatitis B virus (HBV) infection, presence of hepatitis B e antigen (HBeAg) signifies which of the following?
D. Ongoing viral replication
VIII-28. A 42-year-old male presents for evaluation of recurrent sharp substernal chest pain that occurs primarily at rest and radiates to both arms and the sides of the chest. He notes that the pain is worse with eating and emotional stress. The pain lasts approximately 10 min before resolving entirely. He has undergone a full cardiac evaluation, including negative exercise echocardiography
for inducible ischemia. You suspect diffuse esophageal spasm and order a barium swallow for further evaluation. Which of the following findings would best correlate with your suspected diagnosis?
B. Uncoordinated distal esophageal contractions resulting
in a corkscrew appearance of the esophagus
VIII-29. A 26-year-old woman presents to your clinic and is interested in getting pregnant. She seeks your advice regarding vaccines she should obtain, and in particular asks about the hepatitis B vaccine. She works as a receptionist for a local business, denies alcohol or illicit drug use, and
is in a monogamous relationship. Which of the following is true regarding hepatitis B vaccination?
C. Pregnancy is not a contraindication to the hepatitis
VIII-30. A 41-year-old female presents to your clinic with a week of jaundice. She notes pruritus, icterus, and dark urine. She denies fever, abdominal pain, or weight loss. The examination is unremarkable except for yellow discoloration of the skin. Total bilirubin is 6.0 mg/dL, and direct bilirubin is 5.1 mg/dL. AST is 84 U/L, and ALT is 92 U/L. Alkaline phosphatase is 662 U/L. CT scan of the abdomen
is unremarkable. Right upper quadrant ultrasound
shows a normal gallbladder but does not visualize
the common bile duct. What is the most appropriate next management step?
B. Endoscopic retrograde cholangiopancreatography
VIII-31. A 46-year-old woman with a past medical history of osteoporosis presents to the hospital because of hematemesis. She reports having bright-red bloody emesis for 2 h as well as seeing "coffee-grounds" in her emesis. However, you do not witness any vomiting in the emergency
department. She takes calcium, vitamin D, and
alendronate. Blood pressure is 108/60 mmHg, heart rate 93 beats/min, and temperature 37.6°C. Her hematocrit is 30% (baseline 37%). You request an emergent upper endoscopy and resuscitate the patient with fluids. What is the role for immediate IV proton-pump inhibitor (PPI) therapy in this patient?
C. It should be initiated only if high-risk ulcers are
identified at the time of endoscopy.
VIII-32. While waiting for endoscopy, you recheck her hematocrit 2 h later and it remains 30%. Vital signs are unchanged. You perform a gastric lavage, which returns clear fluid. Test of occult blood in the lavage is negative. What is the most appropriate intervention at this time?
B. Continue current management and plan.
VIII-33. A 34-year-old male reports "yellow eyes" for the last 2 days during a routine employment examination. He states that since his early twenties he has had similar episodes of yellow eyes lasting 2 to 4 days. He denies nausea, abdominal pain, dark urine, light-colored stools, pruritus, or weight loss. He has not sought prior medical attention because of finances, lack of symptoms, and the
predictable resolution of the yellow eyes. He takes a multivitamin and some herbal medications. On examination he is mildly obese. He is icteric. There are no stigmata of chronic liver disease. The patient's abdomen is soft and nontender, and there is no organomegaly. Laboratory examinations
are normal except for a total bilirubin of 3
mg/dL. Direct bilirubin is 0.2 mg/dL. AST, ALT, and alkaline phosphatase are normal. Hematocrit, lactate dehydrogenase (LDH), and haptoglobin are normal. Which of the following is the most likely diagnosis?
D. Gilbert's syndrome
VIII-35. A 45-year-old male says that for the last year he occasionally has regurgitated particles from food eaten several days earlier. His wife complains that his breath has been foul-smelling. He has had occasional dysphagia for solid foods. The most likely diagnosis is
D. Zenker's diverticulum
VIII-37. A 38-year-old male presents to his physician with 4 to 6 months of weight loss and joint complaints. He reports that his appetite is good, but he has had diarrhea with six to eight loose, foul-smelling stools each day. He has also had migratory pain in the knees and shoulders.
Stool studies demonstrate steatorrhea. Which of the following diagnostic tests is most likely to be positive in this patient?
C. Serum PCR for Tropheryma whippelii
VIII-38. Inflammatory bowel disease (IBD) may be caused by exogenous factors. Gastrointestinal flora may promote an inflammatory response or may inhibit inflammation. Probiotics have been used to treat IBD. Which of the following organisms has been used in the treatment of IBD?
D. Lactobacillus spp.
VIII-39. A 61-year-old male is admitted to your service for swelling of the abdomen. You detect ascites on clinical examination and perform a paracentesis. The results show a white blood cell count of 300 leukocytes/μL with 35% polymorphonuclear cells. The peritoneal albumin
level is 1.2 g/dL, protein is 2.0 g/dL, and triglycerides are 320 mg/dL. Peritoneal cultures are pending. Serum albumin is 2.6 g/dL. Which of the following is the most likelydiagnosis?
A. Congestive heart failure
VIII-40. A 78-year-old female nursing home resident complains of rectal pain and profuse watery diarrhea for 2 days. Her nurse reports 2 weeks of constipation prior to this. A physician sent a Clostridium difficile stool antigen test that returned negative. What is the next step in establishing
B. Digital rectal examination
VIII-41. Which of the following is the most common cause of acute pancreatitis in the United States?
VIII-42. A 24-year-old woman with a history of irritable bowel syndrome (IBS) has been treated with loperamide, psyllium, and imipramine. Because of continued abdominal pain, bloating, and alternating constipation/diarrhea, she is started on alosetron, 0.5 mg bid. Five days later she
is brought to the emergency department with severe abdominal pain. On examination she is in severe discomfort. Her temperature is 39°C, blood pressure 90/55 mmHg, heart rate 115 beats/min, respiratory rate 22 breaths/min, and oxygen saturation normal. Abdominal examination is notable for hypoactive bowel sounds, diffuse
tenderness, and guarding without rebound tenderness. Her stool is heme positive. Laboratory studies are notable for a white blood cell count of 15,800 with a left shift and a slight anion gap metabolic acidosis. Which of the following is the most likely diagnosis?
D. Ischemic colitis
VIII-43. An 88-year-old woman is brought to your clinic by her family because she has become increasingly socially withdrawn. The patient lives alone and has been reluctant to visit or be visited by her family. Family members, including seven children, also note a foul odor in her apartment and on her person. She has not had any weight loss. Alone in the examining room, she only complains of hemorrhoids. On mental status examination,
she does have signs of depression. Which of
the following interventions is most appropriate at this
C. Physical examination including genitourinary and
VIII-44. You are asked to consult on a 62-year-old white female with pruritus for 4 months. She has noted progressive fatigue and a 5-lb weight loss. She has intermittent nausea but no vomiting and denies changes in her bowel habits. There is no history of
prior alcohol use, blood transfusions, or illicit druguse. The patient is widowed and had two heterosexual partners in her lifetime. Her past medical history is
significant only for hypothyroidism, for which shetakes levothyroxine. Her family history is unremarkable.
On examination she is mildly icteric. She has spider angiomata on her torso. You palpate a nodular liver edge 2 cm below the right costal margin. The remainder of the examination is unremarkable. A right upper quadrant ultrasound confirms your suspicion
of cirrhosis. You order a complete blood count and a comprehensive metabolic panel. What is the most appropriate next test?
B. Antimitochondrial antibodies (AMA)
VIII-45. Your 33-year-old patient with Crohn's disease (CD) has had a disappointing disease response to gluco- corticoids and 5-ASA agents. He is interested in steroid- sparing agents. He has no liver or renal disease. You pre- scribe once-weekly methotrexate injections. In addition to monitoring hepatic function and complete blood count, what other complication of methotrexate therapy do you advise the patient of?
VIII-46. Which of the following is potentially associated with constipation?
A. B. C. D. E. F. G. Colon cancer Depression Eating disorder Hypothyroidism Irritable bowel syndrome Pharmaceutical agents All of the above
VIII-47. A 23-year-old Turkish female presents to the emergency department for evaluation of acute abdominal pain. She reports that she has had multiple episodes of se- vere abdominal pain since age 15. These episodes have been very severe, once prompting exploratory laparot- omy at age 18 with removal of the appendix, which was histologically benign. She reports that the pain lasts ap- proximately 2 or 3 days and then resolves entirely without intervention. There are no clear triggers for the pain. Past evaluation has included normal upper and lower endos- copy, normal small bowel series, and multiple CT scans that have shown only small amounts of free ﬂuid in the abdominal cavity. In addition, the patient recently devel- oped a migratory arthritis affecting her knees and ankles. The patient is currently on no medications. Multiple other family members have similar complaints. On physi- cal examination the patient appears in moderate distress, lying very still. Temperature is 39.8°C (103.6°F). Heart rate is 130, and blood pressure is 112/66. She has evidence of a pleural effusion on the right with decreased breath sounds and dullness to percussion of half the lung ﬁeld. She has a regular tachycardia without murmurs. Bowel sounds are hypoactive, and there is moderate diffuse ab- dominal tenderness. There is mild rebound tenderness diffusely throughout the abdomen without guarding. Her left knee is swollen and erythematous with an effusion. Laboratory studies show a white blood cell count of 15,300/mm3 (90% neutrophils). Erythrocyte sedimenta- tion rate is 110 s. Arthrocentesis reveals a white blood cell count of 68,000 with 98% neutrophils. Culture is negative at 1 week. The patient's symptoms resolve over the course of 72 h. What is the best therapy for prevention of the pa- tient's symptoms?
VIII-48. An 18-year-old man presents to a rural clinic with nausea, vomiting, anorexia, abdominal discomfort, myal- gias, and jaundice. He describes occasional alcohol use and is sexually active. He describes using heroin and co- caine "a few times in the past." He works as a short-order cook in a local restaurant. He has lost 15.5 kg (34 lb) since his last visit to clinic and appears emaciated and ill- appearing. On examination he is noted to have icteric sclerae and a palpable, tender liver below the right costal margin. In regard to acute hepatitis, which of the follow- ing is true?
A. A distinction between viral etiologies cannot be made using clinical criteria alone.
VIII-49. A 22-year-old pregnant woman presents to the emergency department with abdominal pain and malaise. Her symptoms began about 8 h prior to presentation and she has no diarrhea. Her pain is mostly in the right ﬂank currently but began in the periumbilical area. She has nausea and vomiting. She has had an uncomplicated pregnancy and she is at 24 weeks' gestation. She receives regular obstetric care, and her last examination, including an echo, was normal 1 week ago. Temperature is 100.3°C, blood pressure 129/90 mmHg, and heart rate 105 beats/ min. Physical examination shows only mild abdominal tenderness. The abdomen is soft and bowel sounds are di- minished. She is tender in the right lower quadrant with- out costovertebral angle tenderness. The genitourinary examination is normal, and she has a closed os. Fetal monitoring shows a normal fetal heart rate. White blood cell count is 10,000/µL. Urine analysis shows 2 white blood cells per high powered ﬁeld, no epithelial cells, and 1 red blood cell per high powered ﬁeld. What is the most likely diagnosis?
A. Acute appendicitis
VIII-50. A 54-year-old male presents with 1 month of diar- rhea. He states that he has 8 to 10 loose bowel movements a day. He has lost 8 lb during this time. Vital signs and physical examination are normal. Serum laboratory stud- ies are normal. A 24-h stool collection reveals 500 g of stool with a measured stool osmolality of 200 mosmol/L and a calculated stool osmolality of 210 mosmol/L. Based on these ﬁndings, what is the most likely cause of this pa- tient's diarrhea?
D. Vasoactive intestinal peptide tumor
VIII-51. All the following are risk factors for developing cholangiocarcinoma except
VIII-52. A 34-year-old female presents to your clinic with 5 weeks of right upper quadrant pain. She denies nausea, changes in bowel habits, or weight loss. Her past medical history is unremarkable. Her only medications are a mul- tivitamin and oral contraceptives. The examination is no- table for a palpable liver mass 2 cm below the right costal margin. Serum α fetoprotein is normal. An abdominal CT scan shows two 3-cm hypervascular lesions in the right hepatic lobe that are suggestive of hepatocellular ad- enoma. What is the most appropriate next management step?
B. Discontinuation of oral contraceptives
VIII-53. A 50-year-old male without a signiﬁcant past medical history or recent exposure to alcohol presents with midepigastric abdominal pain, nausea, and vomit- ing. The physical examination is remarkable for the ab- sence of jaundice and any other speciﬁc physical ﬁndings. Which of the following is the best strategy for screening for acute pancreatitis?
C. Measurement of both serum amylase and serum lipase
VIII-54. A 43-year-old man with alcohol dependence pre- sents with a sharp epigastric pain radiating to the back. He also has had nausea with bilious emesis on three occa- sions in the past 24 h. He has had no bright red blood or coffee-ground material in his vomitus, nor has he had melena. His last alcohol intake was yesterday, and he nor- mally drinks a gallon of whiskey on a daily basis. He has a history of acute pancreatitis due to alcohol. On physical examination, he appears uncomfortable, writhing in bed. His vital signs are: heart rate 112 beats/min, blood pres- sure 156/92 mmHg, temperature 37.8°C, respiratory rate 24 breaths/min, and SaO2 96% on room air. The abdomi- nal examination reveals decreased bowel sounds and is tympanitic to percussion. There is diffuse tenderness to palpation in the midepigastrium without rebound. Vol- untary guarding is present. The liver span is 15 cm to per- cussion, and a smooth liver edge is palpated 5 cm below the right costal margin. No spleen tip is palpable. The amylase is 580 U/L, and lipase is 690 U/L. Liver function testing reveals an AST of 280 U/L, ALT 184 U/L, alkaline phosphatase 89 U/L, and albumin 2.6 g/dL. Fecal occult blood testing is negative. Which of the following best re- ﬂects the current recommendations on treatment of acute pancreatitis in this patient?
E. Treatment with analgesia, IV ﬂuid resuscitation, and avoidance of oral feeding will result in improvement in 3-7 days.
VIII-55. A 38-year-old male is seen in the urgent care cen- ter with several hours of severe abdominal pain. His symptoms began suddenly, but he reports several months of pain in the epigastrium after eating, with a resultant 10-lb weight loss. He takes no medications besides over- the-counter antacids and has no other medical problems or habits. On physical examination temperature is 38.0°C (100.4°F), pulse 130/min, respiratory rate 24/min, and blood pressure 110/50 mmHg. His abdomen has absent bowel sounds and is rigid with involuntary guarding dif- fusely. A plain ﬁlm of the abdomen is obtained and shows free air under the diaphragm. Which of the following is most likely to be found in the operating room?
C. Perforated duodenal ulcer
VIII-57. A 37-year-old female presents with a chief com- plaint of difﬁculty swallowing. She reports that she feels as if food gets stuck in her midchest. She notices no dif- ference between liquids or solids but does note that the symptoms worsen when she eats hurriedly. She has had a 15-lb weight loss and reports regurgitation of undigested food after eating. The patient undergoes barium swallow. What is the most likely diagnosis?
VIII-58. Which of the following extraintestinal manifesta- tions of inﬂammatory bowel disease typically worsens with exacerbations of disease activity?
VIII-59. A 62-year-old male is evaluated in the emergency department for a complaint of vomiting and inability to tolerate oral intake. These symptoms have gradually pro- gressed from occasional episodes of emesis after meals to an extent where the patient has not been able to tolerate solid foods for the last week. He notes no signiﬁcant sen- sation of nausea before the emesis. Instead, the patient describes vomiting partially digested foods within a half hour of eating. The patient notes no abdominal pain. He has experienced an unintentional 30-lb weight loss over 6 months. The patient has a history of diabetes mellitus that is poorly controlled, with a glycosylated hemoglobin level of 8.9%. The patient underwent partial gastrectomy for peptic ulcer disease at age 52. His only medication is insulin therapy. On physical examination the patient is cachectic with a body mass index (BMI) of 17. He has temporal wasting. The abdominal examination reveals no masses and is nontender. The bowel sounds are normoac- tive, and the patient's stool is hemoccult-negative. An ab- dominal ﬁlm shows an enlarged gastric bubble with decompressed small intestinal loops. What is the most likely diagnosis?
D. Gastric outlet obstruction
VIII-60. The patient in Question VIII-59 undergoes upper endoscopy for further evaluation, and a large mass is seen in the fundus of the stomach. Biopsy shows gastric ade- nocarcinoma. All the following are risk factors for the de- velopment of this disease except
E. juvenile hamartomatous polyps
VIII-61. A 25-year-old female with cystic ﬁbrosis is diag- nosed with chronic pancreatitis. She is at risk for all of the following complications except
D. niacin deﬁciency
VIII-62. All of the following statements regarding fat mal- absorption are true except
Nutritional deﬁciencies are uncommon. C.
VIII-63. A 64-year-old man seeks evaluation from his primary care physician because of chronic diarrhea. He reports that he has two or three large loose bowel movements daily. He describes them as markedly foulsmelling, and they often leave an oily ring in the toilet. He also notes that the bowel movements often follow heavy meals, but if he fasts or eats low-fat foods, the stools are more formed. Over the past 6 months, he has lost about 18 kg (40 lb). In this setting, he reports intermittent
episodes of abdominal pain that can be quite se-vere. He describes the pain as sharp and in a midepigastric location. He has not sought evaluation of the pain previously, but when it occurs, he will limit his oral intake and treat the pain with nonsteroidal antiinflammatory drugs. He notes the pain has not lasted for >48 h and is not associated with meals. His past medical history
is remarkable for peripheral vascular disease and tobacco use. He currently smokes one pack of cigarettes daily. In addition, he drinks two to six beers daily. He has stopped all alcohol intake for up to a week at a time in the past without withdrawal symptoms. His current medications are aspirin, 81 mg daily, and albuterol metered dose inhaler (MDI) on an as-needed basis. On physical examination, the patient is thin but appears well. His body mass index is 18.2 kg/m2. Vital signs are normal. Cardiac and pulmonary examinations are normal. The abdominal examination shows mild epigastric
tenderness without rebound or guarding. The liver span is 12 cm to percussion and palpable 2 cm below the right costal margin. There is no splenomegaly or ascites present. There are decreased pulses in the lower extremities
bilaterally. An abdominal radiograph demonstrates
calcifications in the epigastric area, and CT scan confirms that these calcifications are located within the body of the pancreas. No pancreatic ductal dilatation is noted. An amylase level is 32 U/L, and lipase level is 22 U/L. What is the next most appropriate step in diagnosing and managing this patient's primary complaint?
A. Advise the patient to stop all alcohol use and prescribe
VIII-64. A 52-year-old male with chronic hepatitis C presents to your clinic with worsening right upper quadrant pain. Examination shows a palpable right upper quadrant mass. CT scan shows a large 5 × 5 cm mass in the right lobe of the liver. Serum α fetoprotein is elevated. A CTguided liver biopsy confirms the suspected diagnosis of hepatocellular carcinoma. All the following are appropriate management steps except
D. systemic chemotherapy