Vignette Questions

Question 1

A 45-year-old woman presents with right upper quadrant pain, fever, and nausea. The pain started after eating a fatty meal. On physical examination, she has a positive Murphy’s sign. What is the most likely diagnosis?

A. Acute pancreatitis
B. Acute cholecystitis
C. Peptic ulcer disease
D. Hepatitis

Answer 1

Acute Cholecystitis

Question 2

Which of the following imaging studies is considered the gold standard for diagnosing acute cholecystitis?

A. Abdominal X-ray
B. Abdominal ultrasound (transabdominal)
C. CT scan
D. HIDA scan (cholescintigraphy)

Answer 2

Abdominal Ultrasound (Transabdominal)

Question 3

In a patient with acute cholecystitis, which of the following lab findings is most commonly elevated?

A. Amylase
B. Lipase
C. Alkaline phosphatase
D. Hemoglobin

Answer 3

Alkaline phosphatase

Question 4

A 52-year-old woman presents with a 6-month history of intermittent right upper quadrant pain, particularly after eating fatty foods. She reports nausea and occasional bloating but denies fever or jaundice. Physical examination reveals mild tenderness in the right upper quadrant without rebound or guarding. Ultrasound shows a thickened gallbladder wall with multiple gallstones. What is the most likely diagnosis, and what is the definitive treatment?

Answer 4

Chronic cholecystitis; definitive treatment is cholecystectomy

Question 5

A 60-year-old man undergoes a cholecystectomy for chronic right upper quadrant pain. Histopathological examination of the removed gallbladder shows chronic inflammation, fibrosis, and the presence of Rokitansky-Aschoff sinuses. What is the histological diagnosis, and what is the most common underlying cause?

Answer 5

Chronic cholecystitis; most common underlying cause is repeated episodes of acute cholecystitis or chronic irritation by gallstones

Question 6

A 65-year-old woman with a history of chronic cholecystitis presents with sudden onset of severe abdominal pain, nausea, and vomiting. Physical examination reveals signs of peritonitis, and an abdominal X-ray shows air in the biliary tree.

What is the most likely complication of her chronic condition?

A. Gallstone ileus
B. Gallbladder cancer
C. Pancretitis
D. Small Bowel Obstruction

What is the next immediate step in management?

Answer 6

Gallstone ileus

Stabilization and surgical removal of gallbladder

Question 7

A 58-year-old man with chronic right upper quadrant discomfort undergoes an abdominal ultrasound, which shows a thickened gallbladder wall, multiple gallstones, and no pericholecystic fluid. Lab tests are unremarkable. Given these findings, what is the next best step in management?

Answer 7

This patient has chronic cholecystitis he needs an elective cholecystectomy

Question 8

A 45-year-old woman with chronic cholecystitis is advised to modify her diet while awaiting elective surgery. What dietary changes should she be advised to make to minimize her symptoms?

Answer 8

Reduce intake of fatty foods

Question 9

A 68-year-old woman with diabetes presents with vague upper abdominal discomfort and fatigue. She has a history of gallstones. Physical examination is unremarkable except for mild right upper quadrant tenderness.

What is the best diagnostic test for the suspected diagnosis?

Answer 9

Abdominal Ultrasound

This patient has chronic cholecystitis

Question 10

A 65-year-old man presents with unintentional weight loss, early satiety, and persistent epigastric pain over the past three months. He has a history of chronic gastritis and smoking. On physical examination, there is a palpable mass in the epigastrium. An upper endoscopy reveals an ulcerated lesion in the antrum of the stomach. Biopsy confirms adenocarcinoma. What are the risk factors for gastric cancer in this patient, and what is the next step in management?

What is the most common cancer type of gastric cancer?

Answer 10

Risk factors include chronic gastritis and smoking. The next step in management is staging with a CT scan of the abdomen and pelvis to assess the extent of the disease and plan treatment.

Adenocarcinoma

Question 11

A 70-year-old woman undergoes a gastrectomy for a mass found in the stomach. Histological examination shows signet ring cells. What type of gastric cancer is most likely present?

Answer 11

Adenocarcinoma

*This finding is significant because it indicates diffuse-type gastric adenocarcinoma which is associated with a poorer outcome

Question 12

A 55-year-old man reports progressive dysphagia, nausea, and vomiting. He also mentions feeling weak and tired. Physical examination reveals pallor and a left supraclavicular lymph node enlargement. What diagnostic test should be performed next?

What is the name for the finding of enlarged supraclavicular lympth node

Answer 12

Upper endoscopy with biopsy to confirm the presence of malignancy

Question 13

A 35-year-old woman presents with fatigue, nausea, and jaundice for the past week. She reports dark urine and pale stools. She recently returned from a trip to Southeast Asia. On examination, she has hepatomegaly and tenderness in the right upper quadrant. Laboratory tests reveal elevated ALT and AST levels, and positive IgM anti-HAV. What is the most likely diagnosis?

What is the recommended management?

Answer 13

Acute Hepatitis A

Supportive care and pt should avoid alcohol and hepatic toxic meds

Question 14

A 28-year-old man presents with fever, malaise, and jaundice. He reports a history of intravenous drug use. Laboratory tests show markedly elevated ALT and AST levels, and positive HBsAg and IgM anti-HBc. What is the most likely diagnosis?

Answer 14

Acute Hepatitis B

A positive HBsAg indicates an active infection
and
Postive IgM anti-HBc suggests a recent (acute) infection

Question 15

A 40-year-old man with acute hepatitis C presents with confusion, asterixis, and jaundice. His INR is elevated, and he has a markedly elevated ALT and AST. What complication is he likely experiencing, and what is the initial management?

Answer 15

Acute liver failure (fulminant hepatitis); initial management includes hospitalization, supportive care, monitoring for hepatic encephalopathy, and consideration for liver transplant evaluation.

Question 16

A 55-year-old woman with a history of blood transfusion in the 1980s presents with fatigue and right upper quadrant discomfort. Laboratory tests reveal elevated ALT and AST, and positive HCV RNA.

What are some potential complications of this condition?

Answer 16

This patient has chronic hepatitis C; potential complications include cirrhosis, hepatocellular carcinoma, and liver failure

Question 17

A 10-year old child presents with periumbilical pain that later localizes to the right lower quadrant. What is the most likely diagnosis?

Answer 17

Appendicitis

Question 18

A 9-year-old female presents with a 24-hour history of abdominal pain that initially started around the navel but has now localized to the right lower quadrant. She has vomited twice and reports a decrease in appetite. On examination, she has a fever of 37.8°C (100°F) and tenderness in the right lower quadrant with guarding. What is the next best step in management?

A. Administer IV fluids and observe
B. Order an ultrasound of the abdomen
C. Schedule for immediate surgery
D. Start broad-spectrum antibiotics

Answer 18

Order an ultrasound of the abdomen

Question 19

Parents of a 2-month-old boy report that their child has been crying excessively for the past month. The episodes last up to 4 hours, usually occurring in the late afternoon and evening. The infant is feeding well, gaining weight appropriately, and has no other symptoms. Physical examination is unremarkable. What would be the most appropriate advice for the parents?

A. Prescribe an antispasmodic medication.
B. Recommend dietary changes for the breastfeeding mother.
C. Advise on various soothing techniques and reassure that this condition generally resolves by 4 months of age.
D. Order abdominal x-rays to rule out any abnormalities.

Answer 19

Advise on various soothing techniques and reassure that this condition generally resolves by 4 months of age.

Colic typically resolves around 4 months of age

Question 20

A 3-month-old infant presents with episodes of intense crying lasting more than 3 hours per day, occurring at least three days a week for the past three weeks. The infant appears healthy with normal growth and no signs of disease. What is the most likely diagnosis?

A. Gastroesophageal reflux disease
B. Colic
C. Intestinal obstruction
D. Urinary tract infection

Answer 20

Colic

Question 21

Which of the following is the most common cause of constipation in children?

A. Intestinal obstruction
B. Hypothyroidism
C. Functional constipation
D. Electrolyte imbalances

Answer 21

Functional Constipation

Question 22

A 4-year-old child presents with a history of passing hard, pellet-like stools every 3-4 days with occasional episodes of painful defecation. There is no history of gastrointestinal disease or developmental delays. What is the most likely diagnosis?

A. Irritable bowel syndrome
B. Functional constipation
C. Anal fissure
D. Hirschsprung disease

Answer 22

Functional Constipation

Question 23

Which dietary recommendation is most appropriate for a child suffering from constipation?

A. Increase intake of high-fat foods
B. Increase fluid and fiber intake
C. Decrease carbohydrate intake
D. High-protein diet

Answer 23

Increase fluid and fiber intake

Question 24

What is the first-line pharmacologic treatment for children with constipation?

A. Stimulant laxatives
B. Osmotic laxatives
C. Bulk-forming agents
D. Enemas

Answer 24

Osmotic laxatives

Polyethylene glycol 3350 (MiraLAX) 1.5 per kg per day

Question 25

A newborn presents with bilious vomiting within the first 24 hours of life. An abdominal x-ray shows a “double bubble” sign. What is the most likely diagnosis?

A. Pyloric stenosis
B. Intussusception
C. Duodenal atresia
D. Necrotizing enterocolitis

Answer 25

Duodenal atresia

Question 26

Which of the following is associated with an increased risk of duodenal atresia?

A. Maternal diabetes
B. Maternal use of folic acid supplements
C. Paternal age over 50 years
D. Maternal obesity

Answer 26

Maternal Diabetes

Question 27

What is the most appropriate initial management for a newborn diagnosed with duodenal atresia?

A. Immediate surgical correction
B. Pharmacological closure of the patent ductus arteriosus
C. Placement of a nasogastric tube and fluid resuscitation
D. Initiation of enteral feeding

Answer 27

Placement of a nasogastric tube and fluid resuscitation

Question 28

A 4-month-old infant presents to the clinic with symptoms of frequent regurgitation, irritability, and poor weight gain. The mother reports that the baby seems to be in pain during and after feedings. Physical examination shows no respiratory symptoms or signs of esophagitis. What is the most appropriate initial management for this patient?

A. Start an empirical trial of a proton pump inhibitor.
B. Recommend thickening of feedings and positioning changes.
C. Perform an upper gastrointestinal series.
D. Prescribe an antibiotic for suspected bacterial infection.

Answer 28

Recommend thickening of feddings and positioning changes as this child has GERD

Question 29

A 3-year-old boy is brought to the pediatric clinic by his parents who noticed a bulge in his groin that becomes more apparent when he cries. The bulge is reducible and the child does not appear to be in discomfort while you examine him. Based on this presentation, what is the most likely diagnosis and the recommended management?

A. Inguinal hernia; refer for surgical evaluation.
B. Umbilical hernia; reassure and observe.
C. Hydrocele; schedule a follow-up in six months.
D. Testicular torsion; immediate surgical intervention.

Answer 29

Inguinal hernia; refer for surgical evaluation.

Question 30

A 3-day-old full-term newborn is observed to have jaundice during a routine postnatal visit. The infant is breastfeeding well, with 6-8 wet diapers a day and appears otherwise healthy. What is the most likely type of jaundice in this case, and what is the appropriate initial management?

A. Physiologic jaundice; continue to monitor bilirubin levels and ensure effective breastfeeding.
B. Breast milk jaundice; switch to formula feeding temporarily.
C. Hemolytic jaundice; order a Coombs test immediately.
D. Cholestasis; refer for liver function tests and ultrasound.

Answer 30

Physiologic jaundice; continue to monitor bilirubin levels and ensure effective breastfeeding.

Question 31

A 2-day-old neonate, born at 35 weeks gestation via emergency cesarean delivery due to fetal distress, presents with jaundice. The mother’s blood type is O+ and the infant’s blood type is B+. The infant appears lethargic and the bilirubin level is rising. What is the most appropriate next step?

A. Initiate phototherapy and perform a direct Coombs test.
B. Continue to observe as the jaundice is likely physiologic.
C. Begin exchange transfusion immediately.
D. Advise the mother to stop breastfeeding until jaundice resolves.

What rise in biliribin levels requires treatment?

Answer 31

Initiate phototherapy and perform a direct Coombs test

faster than 0.2 mg/dL per hour or 5 mg/dl per day

Question 32

A 7-week-old infant with a history of projectile vomiting is diagnosed with pyloric stenosis based on clinical findings and confirmed by ultrasound. Prior to any surgical intervention, which complication must be corrected?

A. Hypernatremia
B. Hypoglycemia
C. Metabolic alkalosis
D. Respiratory acidosis

How should it be corrected?

Answer 32

Metabolic alkalosis

Pyloric stenosis leads to projectile vomiting, which is typically non-bilious. This condition often results in significant loss of gastric acid (hydrochloric acid). The stomach’s continual production and subsequent loss of hydrochloric acid through vomiting leads to a state where there is an abnormal increase in blood pH, known as metabolic alkalosis.

IV fluids

Question 33

A 32-year-old man with a history of gastroesophageal reflux disease presents to his primary care physician with concerns for progressive dysphagia of both solids and liquids which is not improved with treatment. He reports he has been belching more and feels epigastric burning after meals. He undergoes an upper endoscopy which is negative, but a barium esophagram shows a dilated esophagus with a “bird beak” appearance at the lower esophageal sphincter concerning for achalasia. Which of the following elements of his history is most consistent with a diagnosis of achalasia?

What is the best test to diagnose achalasia?

Answer 33

Progressive dysphagia of both solids and liquids

Esophageal Monometry

Question 34

A 35-year-old man presents to his primary care physician with complaints of abdominal pain, chronic diarrhea, and heartburn for the last month. His father was previously diagnosed with peptic ulcer disease, and his uncle has Zollinger-Ellison syndrome, so he would like to be tested for these conditions. What is the best test to diagnose Zollinger-Ellison syndrome?

What is the most common site of Zollinger-Ellison syndrome metastases?

Answer 34

Serum Gastrin Concentration

Zollinger-Ellison syndrome (ZES) is caused by duodenal or pancreatic gastrinomas (a type of neuroendocrine tumor) which secrete excessive gastric acid leading to severe peptic ulcer disease and diarrhea.

The liver

Question 35

A 35-year-old man with a history of heavy alcohol use presents with sudden onset of severe epigastric pain and vomiting for the past six hours. He is tender to palpation in the epigastrium on abdominal exam without peritoneal signs. Lipase is elevated more than three times the upper limit of normal. A computed tomography scan of the abdomen is pending. What is the most likely diagnosis?

Answer 35

Acute Pancreatitis

Question 36

An 80-year-old man with a history of moderate dementia is brought in by ambulance to the emergency department from his long-term care facility for abdominal pain and distension for the past hour. His caregiver is present and states that he has not had a bowel movement for several days. Physical exam reveals a largely distended abdomen that sounds hollow with percussion. Abdominal radiograph was obtained and shows a U-shaped, distended sigmoid colon. What is the most likely diagnosis?

What are some risk factors?

Answer 36

Colonic Volvulus

Long-term care facility, bedridden, chronic constipation, elderly

Question 37

A 65-year-old woman presents to the clinic with constant abdominal pain in the left lower quadrant for the past two days. She also reports being slightly constipated recently. Vital signs are T 100.4°F, HR 83, BP 116/76 mm Hg, and RR 20. On abdominal exam, she is tender to palpation in the left lower quadrant but has no peritoneal signs or palpable masses. Which of the following is the most likely diagnosis?

Answer 37

Acute Diverticulitis

Question 38

A 35-year-old man presents to establish care with a primary care provider. When reviewing his family history, he states that his mother was diagnosed with colorectal cancer at the age of 61. At what age should he undergo his first colonoscopy?

Answer 38

40

Question 39

Which of the following is a patient with undiagnosed colorectal cancer most likely to present with?

A. Abdominal pain
B. Change in bowel habits
C. Iron deficiency anemia
D. Proctalgia fugax

Answer 39

Change in Bowel Habits

Question 40

A 37-year-old man presents to his primary care physician for follow-up of complaints of dysphagia. He reports when he swallows large boluses of food, he initially feels like he can swallow, but then feels like it gets stuck. When he takes more time to chew his food, his symptoms improve. He does not have any problems swallowing liquids. A barium swallow is significant for a symmetric narrowing near the gastroesophageal junction. Which of the following is the most likely diagnosis?

Answer 40

Schatzki ring (fibrous esophageal ring)

Question 41

A 17-year-old girl presents to the office with reports of abdominal pain, diarrhea, and weight loss over the past 6 months. The patient is well developed and well nourished. On physical exam, her temperature is 98.6°F, blood pressure is 112/64 mm Hg, heart rate is 84 bpm, oxygen saturation is 98% on room air, and respiratory rate is 18/minute. She has a slightly distended abdomen that is nontender to palpation and has normoactive bowel sounds. She has a hemoglobin level of 11.8 g/dL and an elevated anti-tissue transglutaminase immunoglobulin A. You suspect celiac disease. What will most likely be found on a duodenal biopsy?

Answer 41

Atrophic mucosa with complete loss of villi

Question 42

A 38-year-old man presents to the clinic to discuss chest pain. The pain has been present about once weekly for the past 3 weeks, and the patient describes it as a burning sensation in the center of his chest. He has noticed that the pain is worse after meals. Vital signs are a blood pressure of 122/82 mm Hg, heart rate of 68 bpm, respiratory rate of 16/min, oxygen saturation of 98% on room air, temperature of 98.7°F, and BMI of 32 kg/m2. A cardiac examination reveals a regular rate and rhythm with no murmurs, gallops, or rubs. The patient’s lungs are clear to auscultation bilaterally. Upon abdominal examination, he reports pain to palpation in the epigastric region. The remainder of the physical examination is within normal limits. An ECG is obtained and is unremarkable. What is the best next step in management?

Answer 42

Lifestyle modifications and an H2-Receptor Antagonist (Cimetidine, Famotidine, Nizatidine, Ranitidine)

Question 43

A 55-year-old woman, who is otherwise healthy, presents to the clinic with abdominal pain. She notes pain intermittently over the past 2 weeks. She also notes feelings of fullness and bloating. She feels it is worse after eating. She reports no chest discomfort or burning, cough, nausea, vomiting, diarrhea, or constipation. She has no significant weight loss or weight gain. The patient states she drinks one to two glasses of wine per night. Vital signs show a heart rate of 80 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 118/75 mm Hg, temperature of 98°F, and oxygen saturation of 100% on room air. Abdominal exam reveals normoactive bowel sounds and mild tenderness to palpation in the epigastric region and right upper quadrant without rebound tenderness, guarding, or rigidity. Urine shows negative leukocytes or nitrites. There is no hematuria. CBC and CMP results are within normal limits. What is the most likely diagnosis?

Answer 43

Acute Gastritis

Question 44

A 57-year-old man with a medical history of hypertension treated with losartan 25 mg daily presents to the clinic with rectal bleeding and a few episodes of mild fecal incontinence gradually worsening over the past 3 months. He describes the blood as bright red and notices it on the toilet paper after wiping and also notes a small amount of blood in the toilet bowl after having a bowel movement. He reports one bowel movement per day recently, compared to his usual two to three per day. Vital signs include a heart rate of 76 bpm, blood pressure of 132/82 mm Hg, respiratory rate of 18/minute, oxygen saturation of 98% on room air, and temperature of 98.4°F. On physical exam, normal-appearing perianal skin is observed with no erythema or protrusions. A digital rectal examination is performed and no abnormalities are palpated. Anoscopy shows bulging purple-blue veins in the anal canal and distal rectum. What is the most likely diagnosis?

Answer 44

Internal Hemmorhoid

Question 45

A 15-year-old boy presents with bloody diarrhea and abdominal cramping. A double contrast barium enema shows fine serrations and narrowing of the rectum and sigmoid. Stool contains mucus, blood, and white blood cells, but no parasites or bacterial pathogens. Endoscopy shows inflamed mucosa and pseudopolyps. A biopsy finds an extensive inflammatory process in the mucosa and submucosa. The glands are filled with eosinophilic secretions; there is also mild involvement of the terminal ileum. Sulfasalazine treatment is attempted without improvement. What is the most likely diagnosis, and what would be the next step in management.

Answer 45

This patient has ulcerative colitis not responsive to treatment with sulfasalazine, next step in management would be to prescribe corticosteroids.

Question 46

A 33-year-old man presents with a 2-day history of severe diarrhea and vomiting. He had been on a business trip to Asia 3 days ago, and he reports eating food bought from street vendors. He describes his stools as watery and not bloodstained. He is allergic to seafood, and he takes antacids for peptic ulcers. On examination, he is moderately dehydrated; temperature is 37°C, PR is 100, and BP is 120/60 mm Hg.

What pathogenic organism is most likely causing his symptoms?

Answer 46

Vibrio cholera

Question 47

A 5-year-old boy presents with a 4-day history of bloody diarrhea. He has had fever up to 104°F, abdominal pain, and painful defecation. His past medical history is unremarkable, and he has had no surgeries. He is on no medications and has no drug allergies. He attends a local daycare with nine other children. On physical examination, his abdomen is tender with hyperactive bowel sounds. While in the emergency department, he has a 5-minute generalized seizure.

What pathogen is the most likely cause of the patient’s diarrhea and seizure?

Answer 47

Shigella sonnei

Question 48

A 36-year-old patient presents with a 24-hour history of sudden severe diarrhea described as profuse, gray, cloudy, watery stools without blood or fecal odor. The patient was recently in Bangladesh for work and returned yesterday. They are experiencing a mildly elevated temperature with a very dry mouth, headache, and severe fatigue.

What is most likely offending organism?

Answer 48

Vibrio cholera

Question 49

A 70-year-old man presents to the emergency department with a 3-day history of crampy abdominal pain, vomiting, and abdominal distension. He has not passed gas or had a bowel movement in 48 hours. He has a history of abdominal surgery for a previous hernia repair. On physical examination, his abdomen is distended with high-pitched bowel sounds.

What is the most likely diagnosis?

What is the initial management?

Answer 49

Small Bowel Obstruction

NPO status, nasogastric tube insertion for decompression, and IV fluids

Question 50

A 65-year-old woman presents with abdominal pain, vomiting, and constipation. An abdominal X-ray shows multiple air-fluid levels and dilated loops of small bowel. What additional imaging study can be performed to confirm the diagnosis and assess for complications?

Answer 50

Abdominal CT to assess for complications such as ischemia or perforation

Question 51

A 55-year-old man with a known history of Crohn’s disease presents with severe abdominal pain, vomiting, and fever. His abdomen is distended and tender with rebound tenderness. A CT scan shows dilated loops of small bowel with a transition point and signs of free air under the diaphragm. What is the likely complication, and what is the immediate management?

Answer 51

Bowel perforation; immediate management includes emergency surgery, IV antibiotics, and supportive care

Question 52

A 9-month-old infant is brought to the emergency department with intermittent episodes of severe crying and drawing up of the legs, followed by periods of lethargy. The mother reports seeing blood and mucus in the stool. On examination, there is a palpable mass in the right upper quadrant.

What is the most likely diagnosis?

Answer 52

Intussesception

Question 53

A 2-year-old child presents with abdominal pain and vomiting. The parents report episodes of screaming and pulling the legs to the chest, followed by periods of quietness. You suspect intussesception. What are you likely to see on ultrasound?

Answer 53

Target or “dounut” sign

Question 54

A 3-year-old boy with intussusception has persistent abdominal pain and distension despite an air enema reduction attempt. He develops fever and tachycardia. What complication should be suspected, and what is the next step in management?

Answer 54

Suspect bowel perforation or ischemia; the next step in management is surgical intervention

Question 55

A 45-year-old man presents to the clinic with complaints of burning epigastric pain that improves with eating but worsens a few hours later. He reports occasional nausea but denies vomiting or weight loss. His medical history is significant for chronic NSAID use for osteoarthritis. On physical examination, he has mild tenderness in the epigastric region.

What is the most likely diagnosis?
A. GERD
B. Gastric Ulcer
C. Duodenal Ulcer
D. Acute pancreatitis

Answer 55

Duodenal Ulcer

The pain associated with a duodenal ulcer is classically described as improving with food and worsening a few hours after eating, whereas pain from a gastric ulcer typically worsens with food intake.

Question 56

A 32-year-old woman presents with fatigue, malaise, and jaundice. She reports dark urine and clay-colored stools over the past week. She recently returned from a trip to South Asia. On physical examination, she has icteric sclera and mild hepatomegaly. Liver function tests show elevated AST and ALT, with a positive hepatitis A IgM antibody.

What is the most likely mode of transmission for this patient’s condition?

A. Blood transfusion
B. Fecal-oral route
C. Sexual contact
D. Intravenous drug use

Answer 56

Fecal-oral route

Question 57

A 24-year-old woman presents with chronic diarrhea, abdominal pain, and weight loss. She reports having intermittent fevers and a history of perianal fistulas. On examination, she has tenderness in the right lower quadrant. Colonoscopy reveals skip lesions and a cobblestone appearance of the mucosa.

Which of the following is the most likely diagnosis?

A. Ulcerative colitis
B. Irritable bowel syndrome (IBS)
C. Crohn’s disease
D. Celiac disease

Answer 57

Crohn’s Disease

Question 58

A 55-year-old man with a history of alcohol use disorder presents to the emergency department with severe, constant epigastric pain radiating to his back. He reports nausea and vomiting. Laboratory tests reveal elevated serum amylase and lipase. An abdominal ultrasound shows no evidence of gallstones.

Which of the following is the most likely cause of his symptoms?

A. Gallstone pancreatitis
B. Alcohol-induced pancreatitis
C. Peptic ulcer disease
D. Acute cholecystitis

Answer 58

Alcohol-induced pancreatitis

Question 59

A 35-year-old woman presents with chronic diarrhea, bloating, and unintentional weight loss. She has a history of iron deficiency anemia and reports that her symptoms improve when she avoids gluten-containing foods. Serological testing reveals positive anti-tissue transglutaminase (tTG) antibodies.

What is the next step in confirming the diagnosis?

A. Colonoscopy with biopsy
B. Small bowel biopsy via endoscopy
C. Stool culture
D. Genetic testing for HLA-DQ2 and HLA-DQ8

Answer 59

Small bowel biopsy via endoscopy

Question 60

A 60-year-old man presents with left lower quadrant abdominal pain, fever, and a change in bowel habits. He reports that the pain has been worsening over the past two days. On examination, he has tenderness in the left lower quadrant with guarding. A CT scan of the abdomen shows inflammation of the sigmoid colon with the presence of diverticula.

What is the most appropriate initial treatment for this condition?

A. High-fiber diet
B. Broad-spectrum antibiotics and bowel rest
C. Immediate surgical intervention
D. Colonoscopy

Answer 60

Broad-spectrum antibiotics and bowel rest

Question 61

A 22-year-old man presents to the emergency department with acute onset of periumbilical pain that later localized to the right lower quadrant. He reports associated nausea and vomiting. On physical examination, there is tenderness at McBurney’s point and a positive Rovsing’s sign.

What is the next best step in management?

A. Observation and repeat examination
B. Abdominal ultrasound
C. Laparoscopic appendectomy
D. CT scan of the abdomen and pelvis

Answer 61

Laparoscopic appendectomy

Given the classical presentation, surgery is the definitive treatment. However, imaging such as a CT scan may be performed to confirm the diagnosis if there is any uncertainty

Question 62

A 65-year-old man with a history of cirrhosis presents with confusion and altered mental status. He has asterixis on examination. Laboratory tests reveal elevated serum ammonia levels.

What is the most appropriate initial treatment?

A. Intravenous antibiotics
B. Lactulose
C. Hemodialysis
D. Corticosteroids

Answer 62

Lactulose

Hepatic encephalopathy is a neuropsychiatric syndrome associated with liver dysfunction, most commonly seen in patients with cirrhosis. It occurs due to the accumulation of toxic substances in the bloodstream that the liver is unable to detoxify, with ammonia being one of the primary toxins involved. Lactolose reduces the production and absorption of ammonia in the intestines.

Question 63

A 50-year-old man presents with recurrent peptic ulcers that are refractory to treatment. He reports episodes of diarrhea and significant weight loss. Laboratory tests reveal elevated fasting serum gastrin levels.

Which of the following is the most likely diagnosis?

A. Peptic ulcer disease
B. Zollinger-Ellison syndrome
C. Cushing’s syndrome
D. Carcinoid syndrome

Answer 63

Zollinger-Ellison syndrome

Question 64

A 60-year-old man with a history of alcohol use disorder presents with increasing abdominal distension and discomfort. On physical examination, you note a fluid wave and shifting dullness. His liver function tests are elevated, and he has hypoalbuminemia.

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

A. Endoscopy
B. Abdominal paracentesis
C. Colonoscopy
D. Ultrasound of the liver

Answer 64

Abdominal paracentesis

Question 65

A 25-year-old woman presents with acute onset of nausea, vomiting, and watery diarrhea. She reports that she recently ate at a local seafood restaurant. She has no significant medical history and is otherwise healthy. Her vital signs are stable, and she is mildly dehydrated.

Which of the following is the most likely causative agent?

A. Escherichia coli
B. Norovirus
C. Helicobacter pylori
D. Giardia lamblia

Answer 65

Norovirus

This is one of the most common causes of acute gastroenteritis worldwide, particularly in settings like restaurants, cruise ships, and other places where people gather in close quarters. Norovirus is highly contagious and is often associated with outbreaks linked to contaminated food or water, particularly shellfish and other seafood. It typically causes a rapid onset of symptoms, including nausea, vomiting, watery diarrhea, and abdominal pain. The illness is usually self-limiting and resolves within 1-3 days.

Question 66

A 28-year-old woman presents with chronic diarrhea, abdominal bloating, and weight loss. She also has a history of iron deficiency anemia. She reports that her symptoms improve when she avoids gluten-containing foods.

Which of the following serological tests is most appropriate to confirm the diagnosis?

A. Anti-nuclear antibody (ANA)
B. Anti-tissue transglutaminase (tTG) antibody
C. Anti-mitochondrial antibody (AMA)
D. Anti-Smith antibody

Answer 66

Anti-tissue transglutaminase (tTG) antibody

Question 67

A 65-year-old man with a history of chronic gastroesophageal reflux disease (GERD) presents with progressive difficulty swallowing solid foods. He reports that liquids are easier to swallow. He denies weight loss or regurgitation.

Which of the following is the most likely diagnosis?

A. Esophageal carcinoma
B. Achalasia
C. Esophageal stricture
D. Zenker’s diverticulum

Answer 67

Esophageal stricture

Chronic GERD can lead to esophageal inflammation and, over time, can cause scarring and narrowing of the esophagus, resulting in an esophageal stricture. Patients with an esophageal stricture typically experience progressive dysphagia, initially to solid foods and later possibly to liquids as the stricture worsens. The history of chronic GERD and the specific pattern of dysphagia (solids more than liquids) are strongly suggestive of an esophageal stricture.

Question 68

A 3-week-old male infant presents with non-bilious, projectile vomiting after feedings. The parents report that the baby is constantly hungry and feeds vigorously. On physical examination, an olive-shaped mass is palpated in the right upper quadrant.

Which of the following is the most likely diagnosis?

A. Gastroesophageal reflux
B. Intussusception
C. Pyloric stenosis
D. Hirschsprung disease

Answer 68

Pyloric stenosis

Question 69

A 55-year-old man with a history of chronic hepatitis B presents with unintentional weight loss, jaundice, and abdominal pain. On examination, he has hepatomegaly and a palpable liver mass. Alpha-fetoprotein (AFP) levels are elevated.

Which of the following is the most likely diagnosis?

A. Hepatic adenoma
B. Hepatocellular carcinoma
C. Cholangiocarcinoma
D. Metastatic colon cancer

Answer 69

Hepatocellular carcinoma

The patient’s history of chronic hepatitis B, combined with the symptoms of unintentional weight loss, jaundice, abdominal pain, hepatomegaly, and elevated AFP levels, strongly indicates a diagnosis of hepatocellular carcinoma (HCC)