Clinical Medicine

Question 1

Fluid wave is highly indicative of which disease process?

Answer 1

Ascites

Question 2

How do you test for Murphy’s sign?

What constitutes a postive Murphy’s Sign?

Answer 2

Push in the RUQ

Hold pressure while you ask the patient to take a breath in

If the patient takes a sharp breath in and stops abruptly, they have a positive Murphy’s sign

Suggestive of Acute Cholecystitis

Sensitivity 97% Specificity 48%

Question 3

Answer 3

E

Remember, that tenderness at McBurney’s Point is highly suggestive of appendicitis

Question 4

A postive Murphy’s sign is suggestive of…

Answer 4

Cholecystitis

Question 5

Which physical exam finding has the highest likelihood ratio for detecting peritonitis?

Answer 5

Rigidity

Question 6

What are the most likely causes of RUQ pain?

Answer 6

• Biliary Disease
• Cholecystitis (inflamed gallbladder/galstones)
• Renal Colic
• Pancreatitis

Question 7

What is the most likely cause of ascites?

What will you find on exam?

Answer 7

Cirrhosis of the liver

Positive fluid wave, positive shifting dullness

Question 8

Which blood tests would be abnormal in the setting of hepatocyte damage?

Answer 8

ALT
AST
GGT

(All elevated)

Question 9

Which tests would be abnormal in the setting of cholestasis?

Answer 9

Alk-phos
GGT
Bilirubin

Question 10

Which tests would be abnormal in the setting of impaired synthetic or metabolic function of the liver?

Answer 10

Albumin
Bilirubin
Prothrombin time

Question 11

What kind of cells are hepatocytes?

Answer 11

Epithelial

• Tumors derived from hepatocytes are adenomas (benign) or adenocarcinomas (malignant)

Question 12

What color is AST?

What is the significance of its location in the hepatocyte?

Answer 12

Purple (cytosolic) or blue (mitochondrial)

In the cytosol => elevated when hepatocytes die

Question 13

What color is ALT?

What is the significance of its location in the hepatocyte?

Answer 13

Red

In the cytosol => elevated when hepatocytes die

Question 14

What color is Alk-phos?

Answer 14

Green

• Hangs out with GGT near the bile canaliculus = both are elevated in bile duct pathologies

Question 15

What color is GGT?

What is the significance of its location in the hepatocyte?

Answer 15

Yellow

• Hangs out with Alk-Phos near the canaliculus => both are released if anything is wrong with the bile ducts

Question 16

What kind of liver injury will cause the largest elevation in GGT?

Under what conditions do we usually check GGT?

Answer 16

Intrahepatic cholestasis

(mild elevation in extrahepatic cholestais)

Usually GGT is checked when alk-phos is high; elevated GGT in the setting of elevated alk-phos confirms bile duct issue

Question 17

A 59 year old male presents with ALT of 44 IU/L (1.3xULN) and AST of 92 IU/L

Which of the following would be most predictive of alcoholic liver disease?

1. Elevated GGT
2. Clinical history of alcohol use disorder
3. Liver biopsy with fatty change
4. Elevated alkaline phosphatase

Answer 17

b. Clinical history of alcohol use disorder

• No test/assay is specific for alcoholic liver disease
  
  • AST:ALT > 2:1 wtih elevated GGT is suggestive, but may be present in other late-stage liver disease
• Biopsy cannot distinguish

Question 18

Which image shows a normal liver?

What is wrong with the one that isn’t normal?

Answer 18

Left is normal

Right is a fatty liver (more pixelated)