USMLE Step 3 Question of the Week #495

495.  A 49-year-old obese female presents with abdominal pain.  Patient states the pain acutely onset several hours ago and describes it as constant, severe, localized around the umbilicus and radiating to her back.  She says the pain feels better if she is sitting up and bending slightly forward.   Patient also says she feels nauseous and vomited once after the pain began.  No relevant past medical or surgical history.  No current medications or allergies.  Review of systems is significant for several recent episodes of abdominal pain after eating.

On exam, the patient is in distress, sitting upright, and leaning slightly forward.  Vitals are temperature 38.3 °C (101.1 °F), blood pressure 110/78 mm Hg, pulse 105/min, respirations 25/min, and oxygen saturation 98% on room air.  Cardiac exam is normal.  Lungs are clear to auscultation.  Abdominal exam reveals tenderness to palpation in the periumbilical region.  Bowel sounds are diminished.

Laboratory values are:

Sodium                                                            140 mEq/L

Potassium                                                        4.0 mEqL

Chloride                                                          100 mEq/L

Bicarbonate                                                    25 mEq/L

BUN                                                                 35 mg/dL

Creatinine                                                       1.1 g mg/dL

Glucose (fasting)                                             90 mg/dL

Calcium                                                           7.0 mg/dL

Phosphorous                                                    4.1 mg/dL

Bilirubin, conjugated                                      1.5 mg/dL

Bilirubin, total                                                 3.0 mg/dL

AST (SGOT)                                                      325 mU/mL

ALT (SGPT)                                                      175 mU/mL

Alkaline Phosphatase                                      295 U/L

Amylase                                                          250 U/L

Lipase                                                              89 U/L

TSH                                                                  1.1 mIU/L

PTH                                                                  30 pg/mL

Troponin I (cTnI)                                             <0.02 ng/mL

Lactate Deydrogenase (LDH)                          750 U/L

C-reactive protein                                           45 mg/L

b-hCG                                                              <1 mIU/mL

 

WBC                                                                19,000 / mm3

RBC                                                                 4 x 106/mm3

Hematocrit                                                      45%

Hemoglobin                                                    13.0 g/dL

Platelet Count                                                 275,000 / mm3

Differential

Neutrophils (%)                                               85

Lymphocytes (%)                                             10

Monocytes (%)                                                5

Eosinophils (%)                                                3.5

Basophils (%)                                                   1.5

Chest and KUB x-rays, and EKG are unremarkable.

Aggressive fluid resuscitation and supplemental 100% oxygen are given.  Meperidine 150 mg intramuscularly is administered.  Abdominal ultrasound reveals the presence of a gallstone in the common bile duct (CBD).  Patient is kept NPO.

What is the next best step in management?


A. Contrast CT of the abdomen

B. Endoscopic retrograde cholangiopancreatography (ERCP)

C. Administer meropenem 1 g IV every 8 hours

D. Laparoscopic cholecystectomy

E. Magnetic resonance cholangiopancreatography (MRCP)

@hagemanGIstep2

USMLE Step 2CK Question #1

A 48-year-old homeless man presenting with severe abdominal pain. He has been hospitalized 6 times in the past year for similar complaints. Hospital records indicate multiple admissions with alcohol intoxication. The pain radiates to his back, and is accompanied by nausea and vomiting. The patient has a temperature of 103F, but does not permit an abdominal exam. Laboratory analysis indicates elevated gamma glutamyl transpeptidase and an AST/ALT ratio > 2. What is the most likely diagnosis?

A – Cholecystitis

B – Pancreatitis

C – Choledocholithiasis

D – Duodenal peptic ulcer

E – Gallbladder cancer

Question of the Week #482

A 63-year-old woman comes to the emergency department complaining of severe midabdominal pain. She reports that the pain has increased in intensity over the past few days. There has been no associated nausea or vomiting, no change in bowel habits, and no relief afforded by position changes. She is postmenopausal and does not take hormone replacement therapy. She has a 30-year history of hypertension, and has been noncompliant with her therapy of calcium channel blocker and thiazide diuretic. On examination her abdomen is obese but there is a suggestion of a nontender, pulsatile mass in the epigastric region. The remainder of the physical examination is normal. Which of the following is the best next step in management?

A. Abdominal ultrasound
B. Abdominal CT scan without contrast
C. Abdominal CT scan with contrast
D. Angiography
E. Observation

Question of the Week # 471

A 14-year-old girl with a history of Crohn’s disease presents with 2-day history of feeling ‘feverish’, malaise, lower abdominal pain and non-bloody diarrhea. She has about 10 episodes of diarrhea daily. She has had three similar episodes in the past 7 years. She denies any recent travel or sick contacts, rush, cough or other symptoms of infection. She has no known allergies and does not take any medications currently. She has been taking 5-ASA, but stopped 6 months ago as she had been asymptomatic for 10 months before that. On presentation, the patient is afebrile with a body temperature of 101.0 F and appears ill. Her blood pressure is 120/80 mmHg and heart rate of 90 beats/minute.  Abdominal examination is remarkable for abdominal tenderness in the lower abdomen, but no rebound or guarding. A subsequent CT scan shows dilatation of the left colonic lumen, as well as a thickened colon wall with pericolic fat stranding, particularly in the left colon. The admitting team determines the patient’s presentation is due to exacerbation of her disease. The patient is started on 5-ASA, metronidazole and prednisone and her condition improves within 10 days when she is symptom-free. What is the most appropriate plan after her symptoms have resolved?

A)     Continue 5-ASA, taper prednisone and discontinue metronidazole
B)      Continue 5-ASA and prednisone, discontinue metronidazole
C)      Discontinue ASA-5 and metronidazole and continue prednisone for 4 weeks, followed by taper
D)     Recommend therapy with infliximab an instruct to take 5-ASA when she starts experiencing symptoms, discontinue prednisone and metronidazole
E)      Continue 5-ASA and metronidazole for at least 4 weeks, taper prednisone

Question of the Week # 464

464) A 68 year old man with history of Diabetes Mellitus type II and diabetic gastroparesis  is evaluated in your office for lack of appetite, nausea, vomiting, weight loss and a feeling full after eating small amounts of food material. He has lost 10 lbs weight in past 2 months. He denies any rectal bleeding or melena. He does report some epigastric discomfort. On examination, he appears in no distress, blood pressure is at 120/80. Abdomen is mildly distended with slight tenderness in upper abdomen. Patient is admitted and started on IV hydration. A plain X-ray abdomen is shown below. Gastroenterology is consulted and an upper endoscopy is pending. What is the most appropriate evidence-based next step?

gastric

A) Arrange for Laparoscopy
B) Endoscopic removal
C) Give Coca-Cola
D) Give Pepsi or any other soda
E) Metoclopramide

Question of the Week # 462

462) A 39 year old man is seen in your office for swelling of the abdomen and shortness of breath of several months’ duration. He is an active smoker and smoked about 1 pack per day for 20 years. He drinks alcohol occasionally. He denies any cough or fever. On examination, he is afebrile with a temperature of 98.1F , respiratory rate of 18/min, pulse 88/min and blood pressure at 120/70 mm Hg. Cardiac examination reveals regular heart sounds and no S3 gallop. Chest examination shows decreased breath sounds, increased antero-posterior diameter and hyper-resonance to percussion.  Abdominal exam is significant for fluid wave and shifting dullness. Liver is enlarged. No splenomegaly.

Labs reveal :

Hemoglobin : 14.2gm%

Serum creatinine 1.0mg%

Albumin 3.2gm%

Total bilirubin 1.0 mg%

Alkaline phosphatase 90 U/L

AST ( Aspartate aminotransferase) 160 U/L

ALT (Alanine aminotransferase) 190 U/L

Which of the following is most helpful in establishing the diagnosis

A. Serum Ferritin

B. Serum Ceruloplasmin leve

C. Anti-Actin and Smooth muscle antibodies

D. 2D Echocardiogram

E. Serum Alpha-1 anti-trypsin level.

Question of the Week # 458

458) A 65-year-old man is brought to the emergency department after having two large bowel movements over the past hour that consisted of bright red blood and no stool in the past 3 hours. He denies any abdominal pain or nausea, but does recall having crampy abdominal discomfort after eating over the last several days. His past medical history is significant for hypertension and diabetes and his medications include lisinopril, metoprolol and metformin. He had a colonoscopy at the age of 55 which was unremarkable. On presentation, his temperature is 37.0°C (98.6°F), blood pressure is 80/60 mm Hg, and pulse is 110/min. His abdomen is soft and nontender. There is no guarding or rebound tenderness. There is fresh red blood in the rectum, but there are no palpable masses. Intravenous fluid boluses are started. Which of the following is the most appropriate next step in the management of this patient?
A. Perform upper gastrointestinal endoscopy
B. Order a CT scan of the abdomen
C. Order a nuclear bleeding scan of the colon
D. Perform a colonoscopy
E. Perform nasogastric aspiration

Question of the Week # 455

You are evaluating a 63-year-old female with a complaint of abdominal pain radiating to her back. She has diminished appetite and pruritus. Her past history is significant for a 40-year history of tobacco use. She has three glasses of wine once a week.

The patient is afebrile, with blood pressure of 123/85, and her heart rate is 74. She appears jaundiced, with scleral icterus. Her abdomen is tender to palpation in the epigastric region, and her liver is palpable 2 cm below the right costal margin. Laboratory tests reveal total bilirubin of 6.0. direct bilirubin of 4.8, alkaline phosphatase of 1000, and AST is 42, with and ALT of 40. Which of the following initial diagnostic test will you order?

A. Abdominal ultrasound

B. Percutaneous liver biopsy

c. Percutaneous transhepatic cholangiography

D. CT abdomen and pelvis

E. Endoscopic retrograde cholangio-pancreatography.

Question of the Week # 447

447) A 54 year old caucasian man is seen in your office for initial visit examination. He recently moved from Texas to your town and would like to establish care with you. He has no significant past medical problems except for Gastro-Esophageal Reflux Disease for twenty years. He previously suffered hearburn symptoms that were controlled with over the counter ranitidine . Later, his symptoms became refractory and he was started on omeprazole by his previous physician. He currently takes 20 mg of Omeprazole and is very happy that he has been asymptomatic for the past 1 year.  He has had colonoscopy 2 years ago and this was normal. His father died of Colon cancer at the age of 70. He does not smoke.

Which of the following is the most appropriate action at this time ?

A) Instruct him to continue Omeprazole and follow up in 1 year.

B) Refer to gastroenterology for Upper Endoscopy

C) 24 hour Esophageal pH monitoring

D) Stool Guaic test and Flexible Sigmoidoscopy

E) Stool test for H.Pylori antigen

Question of the Week # 443

443 ) A 38 year old man is evaluated in your office for a chronic rash on his elbows. He reports this has been worsening over the last 6 months and is intensely itchy. He lost about 8lbs weight in the past 6 months. Review of systems is normal except for 4 to 5 episodes of loose stools every day. Laboratory investigations reveal moderate microcytic anemia. On examination, he is afebrile. There is a vesicular rash on the extensor aspects of his bilateral elbows as shown below:

elbows

Which of the following is most helpful in diagnosing this condition?

A) Fecal occult blood testing and Sigmoidoscopy

B) Anti-nuclear antibodies

C) Anti-Endomysial antibodies

D) Small bowel follow through

E) Anti-Sacharomyces Cerviseae antibodies ( ASCA)

Question of the Week # 424

424)  A 30 year old man presents to the emergency room with complaints of  right lower extremity swelling and pain over the past two days. He has had recurrent diarrhea with loose, watery bowel movements for several weeks without any blood in it. He also reports developing a red, scaly rash around his nose, mouth , genital area and on the buttocks.  He has itching and pain in the areas affected by the rash. He denies any fever or night sweats or weightloss.  He does not drink alcohol. He is sexually active with his girl friend and always uses condoms. On examination, his vitals are stable. Cardiac and respiratory examination is normal. There is  angular cheilitis.  Laboratory investigations reveals a normocytic, normochromic anemia. Stool analysis does not show any leucocytes or blood and is negative for ova and parasites. Venous doppler reveals right lower extremity deep vein thrombosis extending up to common femoral vein. Skin examination shows findings as below:

 

In addition to starting anticoagulation, which of the following should be performed next?

A) Serum Zinc Level

B) CT scan of the abdomen

C) Protein C and S levels

D) Serum Glucagon Levels

E) Factor V leiden mutation

Question of the Week # 422

422) A 54-year-old man with history of Diabetes Mellitus and End-Stage Renal Disease is evaluated in your office during a follow up visit after undergoing hemo-dialysis in the morning. He has been dependent on Hemo-Dialysis  for past four years and undergoes dialysis thrice a week. He reports recurrent epigastric abdominal pain that is burning in quality which is relieved by taking over the counter antacids. He denies any pain at this time. He denies any nausea or vomiting. He has no history of alcohol use or smoking. On examination, he is afebrile and vitals are stable. Abdominal examination is benign. Laboratory investigations are as follows:

WBC  8.0K/µL

Hemoglobin 10.5gm%

Serum amylase 200 IU/L ( N =  25 to 160 U/L)

Serum Lipase 150 IU/L (Normal = 25 to 80U/L)

AST  30 IU/L

ALT 40 IU/L

Total bilirubin 0.6gm%

Alkaline Phosphatase 80IU/L .

Which of the following is indicated in this patient at this time?

A) Ultrasound of the Gall Bladder

B) Nothing by mouth and IV hydration

C) No further investigations or treatment

D) Endoscopic Retrograde Cholangio Pancreatography

E) CT scan of the Abdomen

Question of the Week # 379 & 380

379)  A 38  year old man from India presents to out-patient clinic with complaints of abdominal pain and bloating. He also reports having intermittent diarrhea. His symptoms are worse upon eating and have progressively worsened over the past 6 months. He has lost about 6 lbs weight over the same period. He has come to visit his sister in the United States and she forced him to seek medical attention. Upon review of systems, he reports intermittent cough associated with mild shortness of breath and wheezing. His past medical history includes frequent episodes of sinus infections. On examination, he appears comfortable. Chest, Cardiac and Abdominal examination is benign. Chest X-ray is normal. Laboratory investigations are shown below:

WBC : 9.0k/µl

Differential : Neutophils 42%, Lymphocytes 30%, Monocytes 8%, Eosinophils 18%

Hemoglobin 13.5gm%

Platelet count 280k/µl

HIV serology : Negative

Stool for ova and parasites : Negative

Liver function Tests: Normal

Serum Creatinine : 1.0mg%

Urinalysis : normal

Which of the following  is the most likely diagnosis?

A) Chagas Disease

B) Eosinophilic Gastroenteritis

C) Churg Strauss Syndrome

D) Wegener’s Granulomatosis

E) Tropical Pulmonary Eosinophilia ( Microfilariasis)

380) Which of the following is the most appropriate next step?

A) Upper GI Endoscopy

B) Pulmonary Function Tests

C) Trypanosoma Cruzi Antibodies

D) Di-ethyl carbazine therapy

E) Anti-Proteinase -3 antibodies ( C-ANCA)

Question of the Week # 378

378)  A 34  year old caucasian woman comes for re-evaluation of her chronic epigastric pain and burning.  She feels bloated and full even after eating small amounts of food. She denies any chest pain or shortness of breath. She failed several courses of treatment with h2-blockers and proton pump inhibitiors. She has had two endoscopies in the past which were normal, most recent endoscopy was three months ago.  There was no evidence of gastric stasis on endoscopies after overnight fast.  She was tested for H.pylori infection in the past and was negative. She denies dysphagia, weightloss, nausea, vomiting, dark colored stools or rectal bleeding. There is no family history of gastric malignancy. She does not smoke or drink alcohol.   A ultrasound of the abdomen did not reveal any evidence of gall stones. Amylase and Lipase levels have been normal on several occassions. She has been anxious and unable to sleep at night.  On examination, she is slightly under-weight for her age. Abdominal examination does not reveal any tenderness or palpable masses. Stool guaiac is negative. A complete blood count as well as comprehensive metabolic panel are normal. Which of the following  is the most appropriate next step?

A) Antidepressants

B) Repeat Endoscopy

C) Recommend to take Antacid therapy as needed

D) Scintigraphic gastric emptying study

E) Observation

Question of the Week # 377

377)  A 42  year old man with no significant past medical is evaluated in your office for complaints of burning epigastric pain in his abdomen for the past 2 months. The pain is worse after eating and it is worse at night. He denies any chest pain or shortness of breath.  He takes over the counter antacids when the pain occurs and that seems to relieve the pain temporarily. He lives in New York City and has never traveled outside the United States.  He denies dysphagia, weightloss, nausea, vomiting, dark colored stools or rectal bleeding. There is no family history of gastric malignancy. He does not smoke or drink alcohol.   On examination, he is athletic. Abdominal examination does not reveal any tenderness or palpable masses. Stool guaiac is negative and complete blood count does not show any anemia. Which of the following  is the most appropriate next step?

A) Obtain Upper GI Endoscopy

B) Obtain H.Pylori Serology by ELISA

C) Start Empiric trial with Omeprazole

D) Reassure because his dyspepsia is functional

E) Obtain H.Pylori Stool Antigen

Question of the Week # 376

376)  A 56  year old Hispanic man with no significant past medical history presents to community health center with complaints of burning pain in his abdomen and bloating for the past 2 months. The pain is more is more in the epigastric area and is worse after eating and it is worse at night. He denies any chest pain or shortness of breath.  He takes over the counter antacids when the pain occurs and that seems to relieve the pain temporarily. He denies dysphagia, weightloss, nausea, vomiting, dark colored stools or rectal bleeding. There is no family history of gastric malignancy. He does not smoke or drink alcohol.   On examination, he is well-built. Abdominal examination does not reveal any tenderness or palpable masses. Stool guaiac is negative and complete blood count does not show any anemia. Which of the following  is the most appropriate next step?

A) H.Pylori antibodies

B) Trial of Proton Pump Inhibitors

C) Empiric therapy for H.Pylori

D) Ultrasound Gall Bladder

E) Endoscopy

Question of the Week # 375

375)  A 65 year old woman is evaluated in your office for weight-loss of 20lbs over the past 6 months. She thinks she has lost weight because she is scared of eating since food causes her to have significant abdominal pain. Pain is particularly worse when she takes a fatty meal and is associated with nausea and early satiety. She has a history of coronary artery disease for which she underwent percutaneous coronary intervention 2 years ago.  She denies any chest pain, palpitations or irregular heart beat. She smoked 1 pack cigarettes per day for the past 40 years. On examination, her vitals are stable. Cardiac and abdominal examination are benign. Stool occult blood is negative. Which of the following is the most likely etiology of her symptoms?

A) Mesenteric vein thrombosis

B) Mesenteric atherosclerosis

C) Gastric Malignancy

D) Cholelithiasis

E) Mesenteric arterial thrombosis

Question of the Week # 373 and 374

373)  A 70 year old woman presents to the emergency room with complaints of abdominal pain for the past one day. The pain is in in lower abdomen and is mild to moderate. It has started suddenly and is persistent. She also reports  having had two episodes of  loose and bloody stools this morning. Her past medical history is significant for coronary artery disease, hypertension and chronic kidney disease. On examination, she is afebrile, blood pressure is 130/80 mm Hg, pulse 90/min and respiratory rate 18/min. Cardiac examination reveals normal and regular heart sounds without murmurs. There is tenderness in the left lower quadrant of the abdomen. There is no rebound tenderness or rigidity. The patient is started on intravenous fluids. Stool studies reveal blood but no leukocytes. Clostridium difficle toxin is negative. Stool cultures are sent. Complete blood count shows White blood cell count at 20,000/µl with left shift. She is started on IV hydration. Which of the following is the most likely diagnosis?

A) Mesenteric Infarction

B) Acute Diverticulitis

C) Acute Mesenteric Ischemia

D) Ischemic Colitis

E) Inflammatory Bowel Disease

374) The patient in the above question undergoes appropriate diagnostic work up and the diagnosis is confirmed. Which of the following is the most appropriate next step in management ?

A) Broad spectrum antibiotics

B) Mesenteric angiography

C) Obtain Surgery Consult

D) Percutaneous Transluminal Angioplasty and Mestenteric stent

E) Start Methylprednisolone and Mesalmaine

Question of the Week # 372

372)  A 65 year old man presents to the Emergency room with complaints of severe abdominal pain that began 30 minutes ago while at rest. He reports diffuse pain that all over his abdomen, the lower back as well as in the flanks. His past medical history is significant for diabetes mellitus and peripheral vascular disease. He denies any abdominal trauma. He smokes about 1 pack cigarettes per day . On examination, he is in severe distress secondary to pain. He is afebrile, blood pressure is 80/40 mm Hg, pulse 120/min and respiratory rate 24/min. Abdomen is mildly distended with mild tenderness and a palpable pulsatile mass. Femoral and dorsalis pedis pulses are diminished.  An electrocardiogram reveals sinus tachycardia. The patient is started on intravenous fluids and is placed on a cardiac monitor. Which of the following  is the most appropriate next step?

A) CT scan of the abdomen

B) Exploratory laporotomy

C) Cardiac enzymes

D) Focused Abdominal Sonography in Trauma ( FAST)

E) Start Insulin Drip.

Question of the Week # 371

371)  A 45 year caucasian man is evaluated in your office prior to surgery for refractory heartburn symptoms. He was diagnosed with Gastro-esophageal reflux disease 2 years ago. Initially, his disease was mild and was responsive to over the counter antacids. He was started on PPI ( proton pump inhibitor trial 6 months ago and has not responded. He switched physicians and tried different brands of proton pump inhibitors with no benefit. An endoscopy was performed a year ago and repeat endoscopy 3 months ago revealed erosions and inflammations consistent with reflux esophagitis with out any background of barrett’s esophagus. The patient is scheduled for fundoplication surgery and is here for pre-operative evaluation. Which of the following should be performed at this time ?

A) 24 hour esophageal pH monitoring

B) Barium esophagogram

C) Esophageal motility studies

D) No additional tests needed , clear patient  for surgery

E) H.Pylori Urea Breath Test

Question of the Week # 337

337) A 62 year old man with past medical history of hypertension is admitted with bright red bleeding per rectum. He has no pain.  He had four other episodes of bright red bleeding in the past one year. All the episodes were painless. He refused colonoscopy at that time. He denies any constipation or diarrhea. He reports no weight-loss. He denies any chest pain or shortness of breath. On physical examination, his vitals are stable. Cardiovascular examination reveals a 4/6 early peaking systolic murmur that radiates to his neck and the carotids. Reminder of his exam is benign. The patient agrees for endoscopic evaluation and is scheduled for Colonoscopy. Which of the following is most likely to be diagnosed on Colonoscopy?

A) Ischemic Colitis

B) Colon cancer

C) Diverticulosis

D) Arterio-Venous Malformations

E) Internal Hemorrhoids

Question of the Week # 335

335) A 75 year old hispanic man presents with right upper quadrant abdominal pain for past two weeks. He reports that the pain is excruciating and sharp when he takes a deep breath. He denies any recent trauma or fever or night sweats or cough. He reports lack of appetite and 30 lbs weight loss in the past 3 months. He immigrated to United States from Mexico about 15 years ago. He has no significant medical problems and has never been to a doctor in the past 25 years. A chest x-ray does not reveal any significant abnormalities. An ultrasound of the abdomen shows normal appearing gall bladder with gall stones but no evidence of cholecystitis. Common bile duct is within normal limits. Murphy’s sign is negative. Laboratory investigations reveal:

Total Protein : 7.5gm%

Albumin : 4.0gm%

Total bilirubin : 0.4 mg% ( N = 0.3 to 1.0 mg%)

AST : 30U/L (  N= 5 to 40U/L

ALT : 28 U/L (  N= 8  to 55U/L)

Alkaline Phosphastase ( ALP) : 750 U/L (  N= 4 to 130U/L)

GGTP : 40U/L (  N= 3 to 60U/L)

Which of the following is the most appropriate next step in management ?

A) Laparoscopic Cholecystectomy

B) HIDA scan

C) Bone Scan and Prostate Specific Antigen

D) Quantiferon Gold Test

E) MRI of the Pancreas

 

Question of the week # 301

301) A five month old male infant is brought to the out patient department for evaluation of one month history of recurrent vomiting, diarrhea and skin rash . The baby was delivered normally at term with out any complications. Mother reports that she breastfed him for four months and recently has been feeding him exclusively with formula. Mother reports that the baby vomits intermittently after each feed and develops raised, red welts on his skin after each feeding. There is no blood or bile in the vomitus. Vomiting  occurs within 30 minutes after feeding. Suckling is normal. He also has mucousy, loose stools for the past three weeks with no blood.  There is no history of cough, cold or fever. On examination, the infant in no apparent distress and vitals are normal. Abdominal examination is benign with out any palpable masses or peristaltic waves. Rest of the physical is  normal. Laboratory investigations reveal Hb: 13.2 gm%; Haematocrit: 35%; WBC: 9,200/μl ; Platelets: 225,000/μl, Na 132 meq/L; K 3.8 meq/L; Cl 92 meq/L; albumin 4.6g%. Urinalysis is normal. Which of the following is the most appropriate next step in managing this condition?

A) Abdominal ultrasound

B) Lactose free formula

C) Start hydrolyzed formula feeds

D) IgE Radio-allergosorbent test

E) Observation

Question of the week # 299

299) A 10 month old male infant  is brought by his concerned mother to the Emergency room with complaints of vomiting and bloody diarrhea. Mother reports that he suffered from “stomach flu” symptoms about 1 week ago which resolved spontaneously.  He had 4 episodes of vomiting since yesterday and has been crying intermittently every 15 minutes. There is no blood or bile in the vomitus. He had four loose stools with blood in it. There is no history of fever or cough or cold. His past medical history is unremarkable. On examination, temperature is 98.4F,  pulse 112, respiratory rate 30/min and blood pressure at 80/50 mm hg. Oral mucosa appear moist and skin turgor is adequate. Abdomen is soft with no palpable masses. Bowel sounds are present. Stool guaiac is strongly positive. Stool is sent for cultures and abdominal x-rays are obtained. An x-ray image is shown below:

Which of the following is the most appropriate next step in managing this condition?

A) Abdominal ultrasound

B) Gastrograffin enema

C) Surgery

D) Rectal tube placement

E) Flexible sigmoidoscopy

Question of the week # 294

294) A 71 year old woman presents to the emergency room with complaints of bright red bleeding per rectum. She denies any abdominal pain, nausea or vomiting. She has a history of paroxysmal atrial fibrillation. Her medications include aspirin and beta blocker. About 10 days ago, she had a screening colonoscopy. She had a 3cm polyp in the sigmoid colon which was removed at that time.  She reports that she did not experience any bleeding immediately after polyp removal and is concerned about this episode that occured so many days after the procedure. On physical examination she is afebrile . Abdominal examination is benign. Rectal examination reveals bright red blood and no palpable hemorrhoids. Patient is anxious about her diagnosis.  Which of the following is the most appropriate statement?

A) ” Your bleeding is mostly secondary to ischemic colitis”

B) ” Bleeding can occur up to two weeks after polypectomy”.

C) ” Your bleeding is related to Aspirin use”.

D)  ” We will have to repeat colonoscopy to confirm that a cancer has not been missed”

E) ” You will need diagnostic laporoscopy to evaluate the cause”

Question of the week # 293

293) A 70 year old man is evaluated in the emergency room for abdominal pain , fever, nausea and vomiting that began 8 hours after he underwent a screening colonoscopy. The pain is severe and is mostly in the left lower quadrant of the abdomen. He reports that his colonoscopy procedure was uneventful except that he had a 2cm sessile polyp which was removed during the procedure. He denies any rectal bleeding. On examination, temperature is 102 F, blood pressure 100/60 mmHg, pulse 120, respiratory rate 28/min. Abdominal examination reveals severe tenderness,  guarding and rigidity in the left lower quadrant. Laboratory investigations show:

WBC 28k/µl with left shift

Hemoglobin 13.5 g/dL

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Which of the following is most important next step in management?

A) Obtain urgent surgical consult

B) Rectal tube placement

C) Serum amylase level

D) Supportive care alone

E) Barium enema

Question of the week # 292

292) A 66 year old man is evaluated in the emergency room for abdominal pain and fever. The patient underwent a screening colonoscopy in the outpatient Gastroenterology clinic 8 hours ago and had a 3cm sessile polyp removed. He complains of moderate pain in left lower quadrant that started one hour ago. He denies nausea or vomiting or rectal bleeding. On examination, temperature is 100.8F, blood pressure 140/90 mmHg, pulse 102, respiratory rate 20 bpm. Abdominal examination reveals tenderness and guarding in the left lower quadrant. There is no rigidity or rebound tenderness. His laboratory investigations including complete blood count and comprehensive metabolic panel are within normal limits. Which of the following is the most appropriate next step in managing this patient?

A) Exploratory Laporotomy

B) Rectal tube placement

C) Flexible sigmoidoscopy

D) CT Scan of the Abdomen

E) Conservative management

Question of the Week # 265

265 )  A 52 year old woman presents to your office with complaints of increased thirst and increased urinary frequency. Her other medical problems include Hypertension and Dyslipidemia. Blood pressure has been under control on enalapril. Her family history is significant for diabetes mellitus and Hypertension.  Physical examination reveals an obese woman in no apparent distress. Blood pressure is at 135/80 mm Hg. Velvety thickened skin is noted in bilateral axillae. Which of the following results will establish the diagnosis that could explain the symptoms and physical examination findings in this patient?

A) Random plasma glucose > 180mg%

B) Hemoglobin A1c > 6.5%

C) Fasting Blood Sugar > 110 mg%

D)  Oral Glucose Tolerance Test  , plasma glucose ≥120 mg% at 2 hours

E)  Urine glucose > 300 mg%

Question of the Week # 264

264 )  A 52 year old woman presents to your office with complaints of increased thirst and increased urinary frequency. Her family history is significant for diabetes mellitus and Hypertension. A glucometer reading obtained in the office shows 260mg%. Hemoglobin A1C is 7.0% . The patient is subsequently started on Metformin. Three days after starting Metformin, she presents with nausea and diarrhea. She denies any fever or abdominal pain. Physical examination is within normal limits. Random glucometer reading shows 130mg%. Comprehensive metabolic panel is within normal limits. Which of the following is the most appropriate next step in managing this patient’s symptoms?

A) Discontinue Metformin

B) Check lactic acid level

C) Recommend Metformin to be taken with meals.

D)  Check serum ketones

E) Insulin drip

Question of the Week # 263

263 )  A 69 year old man with history of metastatic prostate cancer is admitted with nausea, vomiting and constipation of three days duration. He denies any abdominal pain. He was seen in the oncology clinic for severe bone pain and was started on sustained release Oxycodone as well as short acting oxycodone one week ago. His pain is well-controlled but he is distressed by his  newly developed symptoms.  On examination, his temperature is 98F, Heart rate is 130/min, Respiratory rate 20/min and Blood pressure 120/80 mm Hg. Chest is clear to auscultation and abdominal examination is benign. Obstructive series is negative for bowel obstruction. A CT scan of the adbomen does not reveal any small bowel obstruction. The patient is given promethazine and metoclopromide for vomiting. Which of the following opiod-induced adverse effects are expected to be persistent despite continued use of opiod analgesics ?

A) Nausea

B) Drowsiness

C) Constipation

D) Respiratory depression

E) Itching

Question of the Week # 233

233 )  A 36 year old man is evaluated in the emergency room for nausea, vomiting and diarrhea. He also reports fever of one day duration. He denies any rash. He has had 4 to 5 watery bowel movements in the last 24 hours. The diarrhea started 3 days ago and is progressively worse. He feels extremely weak.  His last sexual activity was 6 months ago and he always uses condoms. He denies any fever or  using any recent medications. He works in tourism industry and returned from a business trip to Mexico one week ago.  On examination, temperature is 101F, blood pressure 90/50 mm hg, his oral mucosa are dry. Abdominal examination is benign. The patient has been adequately hydrated and feels better now though, he continues to have diarrhea. Which of the following is the most appropriate next step in management?

A) Observation

B) Rifaximin

C) Amoxicillin

D) Trimethoprim-Sulfamethoxazole

E) Metronidazole

Question of the Week # 216

216 )  A 75 year old woman with past medical history of hypertension and diabetes is evaluated in your office for 20 lb weight loss. She reports decreased appetite and depressed mood for the past 6 months. Her history is significant for chronic smoking 1 pack per day for last 50 years. She lives alone and does all her daily activities by herself.  She has no known cardiac problems. She denies shortness of breath or cough. On examination, scleral icterus is noted. Lab studies show total bilirubin elevated at 10gm% with predominantly direct component. A subsequent CT of the abdomen shows a heterogeneous mass of about 4cm in diameter. A triphasic CT with pancreatic protocol shows invasion of the portal vein and encasement of superior mesenteric artery by the mass. There are no distant metastases. A chest X-Ray is normal. CA 19-9 level 1400U/ml.  Which of the following is the most appropriate next  step ?

A) Hospice Evaluation

B) Surgical resection

C) Fine needle aspiration biopsy

D) Chemotherapy

E) Radiation therapy

Question of the Week # 215

215 )  A 65 year old woman with past medical history of chronic smoking is evaluated in the office for painless jaundice. She has noticed yellow coloring of her skin about 3 weeks ago and it has been progressively increasing. She denies abdominal pain, fever or altered bowel movements. On examination, she has profoundly icteric sclerae. Lab studies show total bilirubin elevated at 5gm% with predominantly direct component. A subsequent CT of the abdomen shows a heterogeneous mass of about 4cm in diameter. A triphasic CT with pancreatic protocol shows no involvement of portal vein or superior mesenteric artery. No lymphadenopathy is evident. CA 19-9 level 400u/ML. Which of the following is the most appropriate next step?

A) Fine needle aspiration biopsy

B) Surgical resection

C) Radiation therapy

D) Chemotherapy

E) Hospice evaluation

 

Question of the Week # 214

214 )  A 58 year old woman presents to the office because  her friend noticed that she looked yellow and asked her to seek medical attention. Lately, her urine has turned dark yellow but she thought it was because of reduced fluid intake. She has lost 10lb weight in the last 3 months. She denies any abdominal pain, nausea or vomiting. She denies any fever. She smoked about 2 packs per day for the past 30 years. She quit smoking 1 month ago. Physical examination reveals profound scleral icterus. Laboratory investigations reveal a Hemoglobin 10gm%, MCV 88, Total Bilirubin 17gm% , Direct bilirubin 13gm%, AST 120U/L, ALT 110U/L and ALP 600U/L. A CT scan of the abdomen does not show any mass in the pancreas. Ultrasound of the abdomen reveals common bile duct diameter of 12mm. Which of the following is the most appropriate next step in management?

A) CA 19-9 level

B) Endoscopic Retrograde Cholangiopancreatography

C) CT guided biopsy of Pancreatic Head

D) Percutaneous Biliary Stent

E) Haptoglobin level

Question of the Week # 193

193)  A 22 year old woman is evaluated in the office for recurrent attacks of colicky abdominal pain that resolve spontaneously. During the episodes, the pain lasts about 8 to 10 hours and resolves spontaneously. Several clinical examinations, laboratory investigations and imaging studies in the past have failed to reveal any clear etiology. She also reports recurrent swelling of her hands and feet, the last episode being 2 weeks ago. Physical examination is benign. A complete blood count and comprehensive metabolic panel are with in normal limits. Which of the following is most helpful in confirming the suspected diagnosis?

a)      Urinary Porphobilinogen

b)      Radio Allergosorbent Test ( RAST)

c)       Anti-nuclear antibodies

d)      C1-Inhibitor

e)      24 hour delta-aminolevulinic acid

Question of the Week # 181

181) A 35 year-old man with history of ulcerative colitis is seen in your office for nodular, tender skin lesions on both of his anterior legs. He was diagnosed with ulcerative colitis about 6 months ago when he first presented with severe bloody diarrhea. He was initially managed with steroids and is now, being maintained on Mesalamine. A colonoscopy at the time of diagnosis revealed pancolitis. He has no diarrhea now. There is no evidence of weight-loss.  Physical examination reveals tender erythematous lesions on the  anterior aspect of his bilateral lower extremities. Laboratory investigations reveal leucocytosis and elevated C-reactive protein. Which of the following is a poor prognostic factor in Inflammatory Bowel Disease?

A) Proctitis

B) Erythema nodosum

C) Albumin of 4.1 gm/dl

D) Lymphocytosis

E) Elevated ANCA (anti-neutrophilic cytoplasmic antibodies) level.

Question of the Week # 172

172)  A 44 year old obese woman presents with complaints of abdominal pain in the right upper quadrant that started 4 hours ago and is persistent. She has mild nausea. On physical examination, there is tenderness in right upper quadrant which increases with deep breath. Her liver function tests are normal; WBC count is 24,000/µl with neutrophilic predominance. Amylase and Lipase are with in normal limits. An ultrasound of the gall bladder reveals gall stones but there is no pericholecystic fluid or any other sonographic evidence of acute cholecystitis. Sonographic murphy’s sign is absent. The most appropriate next step in managing this patient:

A)     Percutaneous Cholecystostomy

B)      Laparoscopic Cholecystectomy

C)      HIDA scan

D)     Endoscopic Retrograde Cholangiopancreatography (ERCP)

E)     Magnetic Resonance CholangiOpancreatography ( MRCP)

 

Question of the Week # 171

171)  A 54 year old woman presents with complaints of abdominal pain in the right upper quadrant that started 4 hours ago and is persistent. She denies any fever, nausea or vomiting.

On physical examination, there is mild tenderness in right upper quadrant. Her liver function tests reveal an AST (SGOT) 160U/L ( N= 5 to 40U/L) , ALT (SGPT) 240U/L( N= 8 to 55U/L)  , Alkaline phosphatase 110 U/L ( 40 TO 130U/L) , Total Bilirubin 1.2mg%.  An ultrasound of the gall bladder does not reveal any gall stones or pericholecystic fluid and shows a common bile duct diameter of 9mm (normal 6mm). The most appropriate next step in managing this patient:

A)     Hepatitis Serology

B)      Laparoscopic Cholecystectomy

C)      HIDA scan

D)     Endoscopic Retrograde Cholangiopancreatography (ERCP)

E)      Magnetic Resonance CholangiOpancreatography ( MRCP)

Question of the Week #88

Q88) A 75 year old woman is sent from the nursing home for evaluation of fever and altered mental status. The patient’s past medical history is significant for moderate Alzheimer’s dementia. On examination, she is confused. Her vitals reveal Temperature of 102F, Blood pressure 80/60 and a HR of 102/min. Chest and cardiovascular examination is benign. On abdominal examination, the patient moans upon palpation of right upper quadrant. Cholecystitis is suspected and ultrasound is obtained that reveals very distended gall bladder with pericholecystic fluid, a normal caliber common bile duct and a gall stone in the cystic duct. The patient is started on IV Normal saline and broad spectrum antibiotics. Her blood pressure despite initial hydration is still 80/40. She is started on Norepinephrine drip. The next most important step in managing this patient ?

A. Urgent Cholecystectomy

B. Endoscopic Retrograde Cholangiopancreatography

C. Percutaneous Cholecystostomy

D. 2D echocardiogram

E. Exploratory Laporotomy

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