T-notes-mixte Flashcards
32F presents with two months of dysphagia to solids that occurs 3-5x per week. She has had to visit the emergency room for a food impact once in the past. She sometimes forces himself to vomit to resolve obstruction. She is otherwise healthy except for allergic rhinoconjunctivitis for which he takes sublingual immunotherapy and nasal spray. Physical exam is normal. What diagnostic test would you order?
A. CT chest
B. Endoscopy
C. Esophageal manometry D. Cine esophagram
B
This is most likely EoE and diagnosis is made on biopsy.
A 51F born in Canada is admitted to with a 3 day history of melena and is suspected to have liver disease based upon clinical examination revealing mild edema, scleral icterus, palmar erythema. She is on no medications. She has no family history of liver or autoimmune disease. No viral hepatitis risk factors. Vaccines up to date. She does not drink alcohol. She has been feeling unwell with weight loss, anorexia and fatigue for the past 12 months.
Vitals: BMI: 24 BP 102/68, HR 90, afebrile. She is fatigued but oriented, attentive, ambulatory in ER.
Labs available show Hgb 109 WBC 10 Plt 102 Na 128 Cr 72
AST 927 ALT 1034 ALP 168 INR 1.5 Alb 32 Bili 49. Quantitative immunoglobulins show elevated IgG.
Ultrasound reveals normal appearing liver with perihepatic and pelvic ascites, no obvious masses in liver. No portal venous thrombus. CT abdomen reveals evidence of portal hypertensive gastropathy and esophageal varices on CT.
Which of the following should be initiated most urgently?
a) Ultrasound guided paracentesis to rule out SBP b) Carvedilol 6.25 mg once daily
c) Nadolol 40 mg po and endoscopic variceal ligation d) Prednisone 50 mg po daily
e) Ceftriaxone 1g IV
f) Octreotide 50mg IV
E
The only option with mortality benefit for patients with cirrhosis who have GI
bleeding. Low likelihood that this is variceal bleed given hemodynamic stability therefore CTX takes priority over octreotide (in reality you would do CTX + octreotide + PPI). No role for NSBB prior to hemostasis.
67F with a recent STEMI was started on clopidogrel and ASA. She had been on ranitidine 150 mg PO for years after a remote UGIB related to an H. pylori positive ulcer. She remembers receiving antibiotics for her H. pylori. She has had no recent GI bleeding. Which of the following do you recommend for her therapy?
A. Continue ranitidine
B. Double ranitidine dose to 300 mg
C. Change ranitidine to a pantoprazole
D. Treat for H pylori with PBMT
C
A 53F presents with 3 months of epigastric pain and 2 weeks of intermittent loose stools and melena. EGD shows diffuse gastric antrum and duodenal bulb ulcers. What would be the next best test?
A. Secretin stimulation test B. Gastrin level
C. H. Pylori IgG
D. Therapeutic endoscopy
B
Suspect Zollinger-Ellison syndrome with numerous ulceration, especially in the duodenal bulb.
48M with a 15-year history of ileocolonic Crohn’s disease is admitted with a flare. He is not responsive to high dose IV steroids and plan to start infliximab as he does not want surgery. He had his normal vaccinations in childhood and has not had any vaccinations since then. What would you do in regards to vaccinations?
A.Provide an MMR booster Now
B. Provide the TdAP booster when steroids tapered to<20mg/d pred
C. Provide a varicella booster when steroids tapered to <20mg/d pred
D. Provide the intranasal influenza vaccine Now
B
