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

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