Exam 2 - GI packrat Flashcards
Which of the following is a common physical examination finding in early intestinal obstruction?
A. high fever.
B. profuse flatulence.
C. rebound tenderness
D. hyperactive, high-pitched bowel sounds
(c) D. Abdominal distention and high-pitched, hyperactive bowel sounds are common in early intestinal obstruction.
Which of the following studies is most appropriate to diagnose celiac disease? A. Urinary D-xylose test B. Small bowel biopsy C. Barium contrast x-ray D. Schilling test
(c) B. Definitive diagnosis of celiac disease is made by small bowel biopsy.
Which of the following tumor markers is useful in monitoring a patient for recurrence of colorectal cancer after surgical resection? A. CA-125 B. Carcinoembryonic antigen C. 5-hydroxindoleacetic acid D. Alpha-1-fetoprotein
(c) B. Carcinoembryonic antigen can be used to monitor a patient for the return of colorectal cancer after treatment.
A 14 month-old male who attends day care presents with a two-day history of frequent watery stools. His mother states that he had a fever and vomiting the day before but these have resolved. His mother denies pain in the child. The child is mildly dehydrated but otherwise appears well. Stool samples are free of blood and white blood cells. The lab reports no ova or parasites noted in the stool samples. Which of the following is the most likely diagnosis? A. Intussusception B. Viral gastroenteritis C. Shigella D. Lactase insufficiency
(c) B. Rotavirus is the most common cause of gastroenteritis in children and this is frequently passed in the daycare setting.
A patient develops abdominal cramps and watery diarrhea 10 to 12 hours after eating a plate of unrefrigerated meat and vegetables. The patient denies vomiting. The causative agent is most likely A. Staphylococcus aureus. B. Clostridium perfringens. C. Escherichia coli. D. Salmonella.
(c) B. Food poisoning caused by Clostridium perfringens
has an incubation period of 8 to 14 hours and results from poorly refrigerated cooked meat.
The most common initial presenting symptom of primary biliary cirrhosis is A. jaundice B. palmar erythema C. pruritus D. xanthomas
(c) C. Pruritus is the most common initial symptom in primary biliary cirrhosis due to the accumulation of bile salts.
Which of the following medications used in the treatment of peptic ulcer disease is classified as a proton pump inhibitor? A. Cimetidine (Tagamet) B. Sucralfate (Carafate) C. Omeprazole (Prilosec) D. Misoprostol (Cytotec)
(c) C. Omeprazole is a proton pump inhibitor.
Which of the following is the therapy of choice for long-term management of esophageal varices in a patient who cannot tolerate beta blocker therapy?
A. Octreotide (Sandostatin)
B. Sclerotherapy
C. Transjugular intrahepatic portosystemic shunt
D. Sengstaken-Blakemore tube
(c) B. Sclerotherapy is effective in decreasing the risk for rebleeding in a patient with esophageal varices.
A 3 year-old presents with profuse watery diarrhea for the past three days. The child vomited twice yesterday, but not today. On exam, the child is febrile, with pulse of 142, respiratory rate of 18, and blood pressure of 60/40 mmHg. On exam, the child is alert and responsive, with no focal findings. Which of the following is the most appropriate intervention? A. Antibiotic therapy B. Begin soft diet C. IV fluids D. Oral rehydration
(c) D. The goal of therapy for a child with severe gastroenteritis and dehydration is to restore fluid loss. Oral rehydration with an appropriate electrolyte solution is the best option if the child is not actively vomiting and is alert enough to take oral fluids. IV fluids should be reserved for those who are unable to take fluids orally.
Initial pharmacologic treatment of acute hepatic encephalopathy consists of A. lactulose. B. omega-3-fatty acids. C. neomycin. D. mannitol.
(c) A. Lactulose acts as an osmotic laxative decreasing ammonia absorption and decreases ammonia production by directly affecting bacterial metabolism.
A 72 year-old male presents to the ED complaining of acute onset of severe diffuse abdominal pain of four hours duration. He states that he has vomited twice since the onset of pain. He also complains of three days of constipation. He is afebrile and the physical examination is noteworthy for a distended, diffusely tender abdomen with normoactive bowel sounds. His rectal exam reveals hemoccult positive brown stool.Medications include omeprazole (Prilosec) for GERD, digoxin and warfarin (Coumadin) for atrial fibrillation,OTC multivitamins and stool softeners. The abdominal and chest x-rays show no abnormalities. Which of the following is the most likely diagnosis? A. Acute cholecystitis B. Mesenteric infarction C. Perforated duodenal ulcer D. Small bowel obstruction
(c) B. Acute onset of severe diffuse abdominal pain in a person with atrial fibrillation warrants the suspicion of mesenteric infarction. Vomiting and constipation may be seen, along with occult blood in the stool. Bowel sounds may be normal.
An asymptomatic 50 year-old person has no risk factors for colorectal cancer. In addition to yearly hemoccult screening of the stool, how often should flexible sigmoidoscopy be performed? A. Every year B. Every other year C. Every 5 years D. Every 10 years
(c) C. In a person with no risk factors for colorectal cancer, screening should include annual Hemoccult testing and flexible sigmoidoscopy every 5 years.
Which medication is considered the mainstay of therapy for mild to moderate inflammatory bowel disease? A. Prednisone B. Sulfasalazine C. Metronidazole D. Azathioprine (Imuran)
(c) B. Sulfasalazine and other 5-aminosalicylic acid drugs are the cornerstone of therapy in mild to moderate inflammatory bowel disease as they have both anti-inflammatory and antibacterial properties.
Which of the following treatments is the most appropriate for a patient with an acutely tender, fluctuant perirectal mass? A. Fistulectomy B. Drainage of an abscess C. Antibiotic therapy D. Removal of an anal fissure
(c) B. Perirectal abscesses should be treated by drainage as soon as a diagnosis is established.
Congenital absence of ganglionic nerve cells innervating the bowel wall is seen in which of the following conditions? A. Hirschsprung's disease B. Meckel's diverticulum C. Chagas disease D. Hashimoto's hypothyroidism
(c) A. Hirschsprung disease, also termed congenital aganglionic megacolon, results from a lack of ganglion cells in the bowel wall.
A middle-aged patient is being treated for recurrent diarrhea and peptic ulcer disease that is refractory adequate standard therapy. Which of the following is the most likely diagnosis? A. Achlorhydria B. Drug resistant H. pylori infection C. Zollinger-Ellison syndrome D. Giardiasis
(c) C. Zollinger-Ellison syndrome is the result of unregulated release of gastrin resulting in gastric acid hypersecretion. Up to 50% of patients complain of diarrhea along with peptic ulcer disease.
Which of the following is suggestive of thiamine deficiency? A. Ataxia B. Bleeding C. Cheilosis D. Diarrhea
A. Ataxia, mental deficits, horizontal nystagmus, muscle weakness and atrophy, and cardiomegaly are all clinical findings in thiamine deficiency.
Which of the following would be consistent for a person who has a successful response to the hepatitis B immunization series?
A. HBsAg positive; anti-HBc positive; anti-HBs negative
B. HBsAg negative; anti-HBc positive; anti-HBs positive
C. HBsAg negative; anti-HBc negative; anti-HBs positive
D. HBsAg negative; anti-HBc negative; anti-HBs negative
(c) C. A person immunized against hepatitis B would have a positive anti-HBs with negative HBsAg and negative anti-HBc.
Which of the following presents the greatest risk factor for the development of pancreatic cancer? A. Alcohol abuse B. Coffee consumption C. Cigarette smoking D. Lean body mass
(c) C. Cigarette smoking is the most consistent risk factor for the development of pancreatic cancer.
The parents of a 16 year-old male presents to the clinic with their son asking that you examine him. Over the past 9-12 months he has developed behavioral problems and emotional lability. Physical examination reveals a well-developed male who is cooperative with exam but tends to be easily distracted. It is noteworthy for dysarthria, a resting tremor and the presence of gray-green pigmentation surrounding each pupil. The most likely diagnosis is A. drug abuse. B. hemochromatosis. C. Wilson's disease. D. Parkinsonism.
(c) C. Wilson’s disease results in the excessive deposition of copper in the liver and brain. Kayser-Fleisher rings are the result of granular deposits in the eye and are pathognomonic for Wilson’s disease.
The drug of choice in an adult for empirical treatment of an ill-appearing patient with infectious diarrhea who has recently returned from Mexico is A. amoxicillin. B. ceftriaxone (Rocephin). C. ciprofloxacin (Cipro). D. doxycycline.
(c) C. Fluoroquinolones like Ciprofloxacin are the class of drugs used in the empirical treatment of infectious diarrhea. Alternatives include trimethoprim/sulfamethoxazole or erythromycin.
Which of the following is consistent with acute cholangitis?
A. Jaundice
B. Caput medusa
C. Bilateral flank bruising
D. An enlarged, palpable nontender gallbladder
(c) A. Jaundice is part of Charcot’s triad associated with cholangitis along with fever and biliary colic.
A severely dehydrated child with gastroenteritis who is unable to tolerate oral rehydration should receive which of the following intravenous therapies? A. 10 mg/kg normal saline B. 20 mg/kg normal saline C. 10 mg/kg D5W D. 20 mg/kg D5W
(c) B. In a severely dehydrated child, restoring intravascular volume to insure adequate tissue perfusion is the immediate objective. This is best done with either Ringers lactate or normal saline. The addition of potassium would only be done after initial fluid boluses and after insuring adequate kidney function. The addition of glucose to the IV solution may result in an osmotic diuresis worsening the dehydration.
A 52 year-old female comes to the office because of black stools for the past 3 days. She is afebrile and she has no
pertinent physical examination abnormalities. Which of the following is the most appropriate initial diagnostic study?
A. Stool for occult blood
B. Stool cultures
C. Sigmoidoscopy
D. Abdominal CT scan
(c) A. Occult bleeding, as evidenced by the patient’s history of black stools, is initially verified by a positive fecal occult blood test.
A newborn weighs 8 pounds at birth. On average, what should the infant weigh at 1 year of age? A. 16 pounds B. 20 pounds C. 24 pounds D. 28 pounds
(c) C. An infant will triple birth weight within the first year of life. A newborn that weighs 8 pounds at birth will weigh approximately 24 pounds at 1 year of age.
Which of the following is an indication for vaccination against hepatitis A? A. Illicit drug users B. Health care workers C. Renal dialysis patients D. Routine vaccination starting at birth
(c) A. Hepatitis A vaccine is recommended for illicit drug users, anyone living or traveling to endemic areas, sewage workers, food handlers, homosexual and bisexual men, animal handlers, patients with a history of chronic liver disease or a clotting factor disease as well as children and workers in day care settings and institutions.
Which of the following is the most common indication for operative intervention in patients with chronic pancreatitis? A.Weight loss B. Intractable pain C. Exocrine deficiency D. To decrease risk of cancer
(c) B. Indications for surgical treatment of chronic pancreatitis include severe pain that limits the patient’s functioning or intractable pain despite the use of non-narcotic analgesics and absence of alcohol intake.
A 45 year-old male presents with abdominal pain and one episode of mild hematemesis, which happened days ago. On physical examination, vital signs are stable and he is in no acute distress. Hemoglobin and hematocrit are unremarkable; endoscopy reveals non-bleeding small superficial ulceration of the duodenal bulb. Rapid urease test is positive. Which of the following is the most appropriate treatment at this time?
A. Schedule for a selective vagotomy and antrectomy
B. Start an antacid along with omeprazole (Prilosec)
C. Schedule elective ulcer excision and start sucralfate (Carafate)
D. Start omeprazole (Prilosec) and antibiotic therapy against H. pylori
(c) D. Treatment goals of H. pylori associated ulcers include eradicating the infection with appropriate antibiotics as well as use of a proton pump inhibitor, such as omeprazole, to promote ulcer healing.
A 20 year-old male presents with a mass in the groin. On examination with the patient standing, a mass is noted that extends into the scrotum. The patient denies any trauma. The most likely diagnosis is A. an indirect inguinal hernia. B. a direct inguinal hernia. C. an obturator hernia. D. a femoral hernia.
(c) A. An indirect inguinal hernia is caused by a patent processus vaginalis and the hernial contents may be felt in the ipsilateral scrotum.
Which of the following can be a very serious consequence of using antidiarrheals in a patient with inflammatory bowel disease? A. Lymphoma B. Toxic megacolon C. Bone marrow suppression D. Delayed serum sickness-like reaction
(c) B. Antidiarrheals may cause the development of toxic megacolon when used by patients with active severe
inflammatory bowel disease.
A patient presents complaining of periumbilical pain. Which of the following anatomical sites is this finding associated with? A. Bladder B. Stomach C. Pancreas D. Small bowel
(c) D. Small bowel. Pain from the small intestine, appendix, or proximal colon causes periumbilical pain.
Which of the following pathophysiological processes is believed to initiate acute appendicitis? A. Obstruction B. Perforation C. Hemorrhage D. Vascular compromise
(c) A. Obstruction of the appendiceal lumen by lymphoid hyperplasia, a fecalith or foreign body initiates most cases of appendicitis.
Gallstones usually result in biliary symptoms by causing inflammation or obstruction following migration into the common bile duct or A. cystic duct. B. pancreatic duct. C. duodenal ampulla. D. common hepatic duct.
(c) A. Obstruction of the cystic duct by gallstones causes the typical symptom of biliary colic. Once obstructed the gallbladder distends and becomes edematous and inflamed. Gallstones can also migrate into the common bile duct through the cystic duct leading to a condition known as choledocholithiasis.
A 3 week-old male infant presents with recurrent regurgitation after feeding that has progressed to projectile vomiting in the last few days. The mother states that the child appears hungry all of the time. She denies any diarrhea in the child. Which of the following clinical findings is most likely?
A. Bile-stained vomitus
B. Hemoccult positive stools
C. Olive-sized mass in the right upper abdomen
D. Sausage-shaped mass in the upper-mid abdomen
(c) C. An olive-sized mass may be palpated in the right upper abdomen in pyloric stenosis and if found, is
pathognomonic for pyloric stenosis.
To further assess ascites in a patient, the physician assistant instructs the patient to turn onto one side while performing percussion. Which of the following is the reason for this maneuver?
A. Testing for shifting of dullness on percussion
B. Shifting of internal organs making percussion easier
C. Trying to elicit any pain while moving
D. Trying to produce a caput medusa
(c) A. In ascites, dullness shifts to the more dependent side as the fluid relocates into dependent space, while
tympany shifts to the top as the gas-filled organs float to the top of the ascitic fluid.
Which of the following clinical findings would be seen in a patient with food poisoning caused by Staphylococcus aureus?
A. Ingestion of mayonnaise-based salads 48 hours earlier
B. Bloody diarrhea with mucus for one week
C. Abdominal cramps and vomiting for 48 hours
D. High fever for 1 week
(c) C. Abdominal cramps, nausea, vomiting, and watery diarrhea typically last 1-2 days with staphylococcal food
poisoning.
A 42 year-old male with a history of constipation presents with complaints of severe pain with defecation described as feeling like he is “tearing apart.” He has also noted occasional small amounts of blood on toilet paper. External examination of the rectum is unremarkable and an internal rectal exam cannot be performed due to severe pain when
attempted. Which of the following is the most likely diagnosis?
A. Proctitis
B. Anal fissure
C. Rectal prolapse
D. Internal hemorrhoids
(c) B. Anal fissures are easily diagnosed from history alone with the classic finding of severe pain upon defecation.Constipation is also a common cause of the trauma that leads to development of a fissure.
Which of the following typical findings would be revealed during a sigmoidoscopy on a patient with Crohn’s disease of the intestine?
A. Rectal pseudopolyps
B. Diffuse ulceration and bleeding
C. Sheets of WBCs with inflamed mucosa
D. Intermittent longitudinal mucosal ulcers and fissures
(c) D. Ulcerations tend to be linear with transverse fissures in Crohn’s disease. These skip lesions are common with Crohn’s disease.
A 48 year-old male presents with complaints of heartburn that occurs approximately 45 minutes after eating about three times a week that is relieved by antacids. He claims to have followed advice about elevating the head of the bed, avoiding spicy foods, and losing weight, but continues to have heartburn. Which of the following is the most appropriate next step? A. Ranitidine (Zantac) B. Sucralfate (Carafate) C. Metoclopramide (Reglan) D. Misoprostol (Cytotec)
(c) A. Ranitidine, an H2 receptor blocker, is indicated for the treatment of mild, intermittent symptoms of
gastroesophageal reflux disease.
Which of the following is the laboratory test that marks recovery from Hepatitis B infection and non-infectivity?
A. Hepatitis B surface antibody(anti-HBs)
B. Hepatitis B surface antigen (HBsAg)
C. Hepatitis B core antigen (HBcAg)
D. Hepatitis A antibody (anti-HAV)
(c) A. Specific antibody to HBsAg appears in most individuals after clearance of HBsAg which indicates recovery from hepatitis B infection, non-infectivity, and immunity.
A 32 year-old presents with a 3-day history of diarrhea. The patient denies blood, mucus, or night awakening with diarrhea. He recently returned from a business trip to Canada. On physical examination, the patient is afebrile and vital signs reveal BP 115/80, pulse is 76, and respirations are 14. The abdominal examination reveals hyperactive bowel sounds, but is otherwise unremarkable. Which of the following is the most appropriate initial intervention? A. Stool for culture, ova, and parasites B. Proctosigmoidoscopy C. Metronidazole (Flagyl) D. Supportive treatment
(c) D. Symptomatic treatment, including dietary management and over-the-counter antidiarrheals, is indicated for afebrile patients with watery diarrhea of less than 5 days duration.
A 62 year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwise
unremarkable. Which of the following is the most likely diagnosis?
A. Viral hepatitis
B. Pancreatic cancer
C. Acute cholecystitis
D. Gilbert’s syndrome
(c) B. Pancreatic cancer is suggested by the vague epigastric pain with the jaundice resulting from biliary obstruction due to cancer involving the pancreatic head. The presence of a palpable non-tender gallbladder (Courvoisier’s sign) also indicates obstruction due to the cancer.
A 25 year-old man presents with odynophagia and dysphagia. On endoscopic examination, small, white, patches with surrounding erythema are noted. Silver stain is positive for hyphae. The best treatment option for this patient is A. acyclovir (Zovirax). B. omeprazole (Prilosec). C. fluconazole (Diflucan). D. penicillin G.
(c) C. The patient has Candida esophagitis and the treatment of choice is fluconazole.
A 53 year-old man who had previously been in good health presents to the emergency department with a history of passing approximately 300 cc of bright red blood from the rectum 45 minutes ago. From which of the following anatomical sites is the bleeding most likely originating? A. rectosigmoid B. duodenum C. stomach D. esophagus
(c) A. Rectosigmoid is the most common site leading to hematochezia.
A 40 year-old female complains of acute right upper quadrant pain radiating to the back and low grade fever. Laboratory evaluation indicates the presence of urinary bilirubin and an elevation of serum alkaline phosphatase.
Which of the following is the most likely diagnosis?
A. cholecystitis
B. viral hepatitis
C. Gilbert’s syndrome
D. Dubin-Johnson syndrome
(c) A. Cholecystitis. The presence of urinary bilirubin indicating conjugated hyperbilirubinemia coupled with the elevation of serum alkaline phosphatase suggests biliary obstruction that may lead to cholecystitis.
Which of the following signs is positive in the presence of ascites? A. shifting dullness B. CVA tenderness C. ballottment sign D. cutaneous hypersensitivity
(c) A. Shifting dullness or the presence of a fluid wave is noted in patients with ascites.
A patient presents with a concern about an upcoming trip. He states he is traveling to Mexico and has a question about how to treat diarrhea should it develop. In addition to promoting fluid intake which of the following is recommended? A. kaolin-pectin B. ciprofloxacin C. simethicone D. doxycycline
(c) B. Ciprofloxacin is indicated in the treatment of traveler’s diarrhea.
A patient presents complaining of vague anal discomfort. On examination, the patient is noted to have a few small external hemorrhoids and edema in the anal region. Which of the following is the most appropriate intervention?
A. proctoscopy followed by a hemorrhoidectomy
B. increased dietary fiber and sitz baths
C. hemorrhoidal banding
D. inject a sclerosing agent
(c) B. Most hemorrhoids respond well to conservative treatment such as fiber and sitz baths.
Which of the following subtypes of viral hepatitis requires the presence of the hepatitis B virus for replication? A. hepatitis A B. hepatitis C C. hepatitis D D. hepatitis E
(c) C. In the United States, hepatitis D is most commonly seen in persons exposed frequently to blood or blood
products, such as drug addicts. It requires the presence of hepatitis B virus for its replication and expression.
A 62 year-old patient with arthritis is on daily naproxen therapy. Which of following medications is used to protect against GI complications? A. diphenoxylate (Lomotil) B. sulfasalazine (Azulfidine) C. metoclopramide (Reglan) D. misoprostol (Cytotec)
(c) D. Misoprostol is an analog of prostaglandins and used in the treatment of NSAID induced ulcer disease.
The initial manifestation of acute pancreatitis is often A. generalized pruritus. B. epigastric pain. C. epigastric mass. D. anorexia.
(c) B. The typical findings in acute pancreatitis include nausea, vomiting, and abdominal pain. Epigastric pain,
generally abrupt in onset, is steady and severe.
Which of the following is the mechanism of action of infliximab (Remicade)?
A. block lymphocyte proliferation
B. direct effect on smooth muscle
C. monoclonal antibody that binds to tumor necrosis factor
D. 5-HT antagonist
(c) C. Infliximab is a monoclonal antibody that binds to tumor necrosis factor.
Ulcerative colitis usually presents with which of the following? A. bloody diarrhea B. toxic megacolon C. fever and left quadrant pain D. alternating constipation and diarrhea
(c) A. Ulcerative colitis typically presents with episodic bloody diarrhea, lower abdominal cramps, and urgency to defecate.
A 65 year-old patient with adenocarcinoma of the colon in remission presents for follow-up. Which of the following tumor markers should be monitored? A. AFP B. CEA C. CA 19-9 D. CA-125
(c) B. CEA is used to monitor recurrence of colon carcinoma.
The main complication with the use of transjugular intrahepatic portosystemic shunt (TIPS) procedure is which of the following?
A. increased portal pressures resulting in further esophageal varices
B. increased portal pressures resulting in a worsening of cirrhosis
C. Budd-Chiari syndrome
D. increased risk of encephalopathy
(c) D. TIPS procedures involve the placement of a stent in the liver in order to shunt blood away from the portal vein into the hepatic vein which bypasses the cirrhotic liver parenchyma. Its main complication is encephalopathy from the accumulation of toxic substances in the brain since the liver no longer acts as a filter.
A 42 year-old patient who is being treated for colon cancer with chemotherapy develops nausea and vomiting. Which of the following drugs would be the most effective in controlling the nausea and vomiting? A. scopolamine (Scopace) B. meclizine (Antivert) C. ondansetron (Zofran) D. loperamide (Imodium)
(c) C. Ondansetron selectively blocks 5-HT3 receptors in the periphery (visceral afferent fibers) and in the brain
(chemoreceptor trigger zone). It is indicated for use in chemotherapy induced nausea and vomiting.
A 45 year-old female presents with a ten pound weight loss and recurrent greasy stools mixed with diarrhea. The patient notes that these symptoms are worse with certain foods. Which of the following laboratory tests should initially be ordered?
A. anti-endomysial antibodies
B. anti-mitochondrial antibodies
C. anti-glomerular basement membrane antibodies
D. anti-phospholipid antibodies
(c) A. Patients with celiac sprue disease are likely to have anti-endomysial antibody formation.
Which of the following is used to screen for malabsorption disorders of the intestines? A. serum gastrin level B. urea breath test C. fecal eosinophils D. stool fecal fat
(c) D. Stool fecal fat is the gold standard test for the evaluation of patients with malabsorption of the intestine.
A patient presents with abdominal pain. On deep palpation of the left lower quadrant the patient notes increased pain in the right lower quadrant. This is noted as a positive A. Psoas sign. B. Murphy's sign. C. Rovsing's sign. D. Obturator sign.
(c) C. A Rovsing’s sign is positive when the patient experiences right lower quadrant pain with deep palpation of the left lower quadrant.
The first step in the treatment of a patient with an intestinal obstruction and no comorbid diseases is A. nasogastric decompression. B. invasive hemodynamic monitoring. C. abdominal exploration. D. administration of antibiotics.
(c) A. Nasogastric decompression is indicated in all but mild cases of obstruction to prevent distal passage of
swallowed air and minimize distension.
