Question 1

A 38-year-old woman comes to the office due to persistent cough for the past several months. The patient says that at first she was awakened occasionally at night or in the early morning by severe bouts of coughing, but lately this has occurred every 3-4 days. The cough is often accompanied by wheezing and clear sputum; she has no cough during the daytime but has had occasional hoarseness and throat irritation. She has also noticed that her symptoms are worse when she drinks wine with dinner or eats a large meal. The patient began jogging regularly a month ago in an attempt to lose weight and has not noticed any symptom exacerbation or shortness of breath with exercise. She went to the emergency department 2 months ago due to squeezing chest pain, but all workups were normal. The patient has a 2-year history of hypertension, which is well controlled with lisinopril, and also has a history of seasonal allergy. She does not use tobacco or illicit drugs and drinks alcohol socially. Temperature is 36.8 C (98.2 F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 16/min. Pulse oximetry is 99% on room air. BMI is 30 kg/m². Nasal and pharyngeal mucosae appear normal and there is no jugular venous distension. The lungs are clear to auscultation, and heart sounds are normal with no murmur. The abdomen is soft and nontender. Which of the following is most likely to improve this patient's cough?

Accepted Answer

Explanation: 11ec2b69_c155_0ebc_8f63_9d7cd3a714fa_MD0005_00 This patient likely has gastroesophageal reflux disease (GERD). Chronic cough is a common presenting symptom of GERD and may be caused by stimulation of cough receptors in the upper or lower respiratory tract (due to aspiration of gastric contents), or through an esophageal-tracheobronchial cough reflex triggered in the distal esophagus. In some cases, cough may be the only presenting symptom of GERD; however, this patient also has hoarseness, throat irritation, and an episode of chest pain (sometimes mimicking ischemic chest pain) that suggests the diagnosis. Alcohol causes a decrease in lower esophageal sphincter tone, and a worsening of symptoms with wine intake is also consistent with GERD. The initial diagnosis of cough-predominant GERD is based on symptomatic presentation, and initial management consists of lifestyle modifications (eg, weight loss, avoidance of alcohol intake) and an 8-week course of proton-pump inhibitor therapy (eg, omeprazole); a trial of histamine blocker, which is an appropriate initial therapy for mild GERD, is typically foregone in patients with significant cough. For patients in whom the cough does not respond to proton-pump inhibitor treatment, 24-hour esophageal pH monitoring is recommended to reevaluate the diagnosis. (Choices A and C) Inhaled beta-2 agonists (eg, albuterol) are used in the management of intermittent asthma, and leukotriene inhibitors (eg, montelukast) are sometimes used in patients with cough-variant asthma when the cough is refractory to other treatment. However, this patient's lack of cough exacerbation with exercise makes asthma less likely. Wheezing, commonly associated with asthma, may also occur in GERD due to aspiration of gastric contents. (Choice B) Intranasal glucocorticoids (eg, fluticasone) are used to treat allergic rhinitis, which is commonly associated with upper airway cough syndrome (UACS). However, in patients with UACS, inflammation of the nasal mucosa and oropharyngeal cobblestoning are expected on physical examination, and worsening of the cough with alcohol intake is not typical. (Choice D) ACE inhibitors (eg, lisinopril) are a common cause of chronic cough and should be considered in the differential diagnosis of cough for any patient taking these medications. However, this patient's hoarseness and throat irritation make GERD a more likely cause of the cough. Educational objective: Chronic cough is a common presenting symptom of gastroesophageal reflux disease (GERD), and in some cases may be the only presenting symptom. The initial management of suspected cough-predominate GERD involves lifestyle modification and 8 weeks of proton-pump inhibitor therapy. References: Chronic cough and gastroesophageal reflux disease: experience with specific therapy for diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/12628862)

Question 2

A 65-year-old man comes to the emergency department after 2 episodes of bloody bowel movements.  The patient felt well until approximately 3 hours ago when he had a sudden urge to defecate, followed by passage of a large amount of bright red blood.  He had another small amount of bloody stool several minutes later, but has had no bleeding since then.  The patient has never had similar symptoms before and reports no fever, nausea, vomiting, hematemesis, abdominal pain, or weight loss.  Medical history includes hypertension, for which he takes lisinopril.  His most recent colonoscopy was 5 years ago, which revealed diverticulosis and 2 colonic polyps that were removed.  The patient is a former smoker and drinks alcohol socially.  Temperature is 37.2 C (99 F), blood pressure is 116/70 mm Hg without orthostatic changes, and pulse is 94/min.  Lungs are clear to auscultation, and heart sounds are normal.  The abdomen is nondistended, soft, and nontender without masses or hepatosplenomegaly.  Rectal examination reveals bright red blood in the rectal vault and internal hemorrhoids, but no palpable mass or tenderness.  Which of the following is the most likely source of this patient's rectal bleeding?

Accepted Answer

Explanation: 11ec2b69_c152_76a7_8f63_f5a00871ef55_MD0005_00 This patient with 2 episodes of hematochezia and a history of diverticulosis most likely has diverticular bleeding (DB). Colonic diverticulosis results from outpouching of the colon wall at points of weakness where the vasa recta penetrate the circular muscle layer of the colon. As the mucosa and submucosa herniate through the muscular layer, the penetrating artery that predisposed the diverticula becomes increasingly exposed. The exposed artery is no longer protected by the muscular layer, and DB occurs as the artery is injured from erosion or trauma to the mucosal layer. DB usually manifests as painless hematochezia; however, right-sided DB, which is more common than left-sided, may sometimes present with melena. Other common symptoms include bloating and cramping due to the cathartic effect of blood in the gastrointestinal tract. The bleeding is usually self-limited, but management involves fluid resuscitation and, if necessary, transfusion of blood products. Patients should undergo colonoscopy for cauterization or tamponade of visible bleeding vessels, although angiography with embolization is an alternate management strategy. Surgical management should be considered for patients who continue to bleed despite endoscopic and angiographic management. (Choice A) Colonic angiodysplasia (arteriovenous malformation) describes the development of dilated, tortuous submucosal vessels and is a common cause of hematochezia. However, DB is more likely in this patient with a history of diverticulosis and no predisposing risk factors for colonic angiodysplasia (eg, end-stage kidney disease, von Willebrand disease, aortic stenosis). (Choice B) Dilation of the submucosal venous plexus occurs in both internal and external hemorrhoids. Although this patient has evidence of internal hemorrhoids, hemorrhoidal bleeding is usually characterized by small-volume bright red blood that covers the stool. Patients may also report mucus, perianal itching, and mild fecal leakage. (Choice D) Diverticulitis results when a colonic diverticulum becomes inflamed and perforates. Microperforation can result in uncomplicated diverticulitis whereas macroperforation can result in complications such as abscess formation or fistulization into adjacent organs (eg, urinary bladder). Patients commonly present with fever, abdominal pain, nausea, and vomiting, but hematochezia is rare. (Choice E) Colorectal cancer may ulcerate and present with hematochezia or melena, but patients also frequently report abdominal pain, weight loss, and a progressive change in bowel habits. Educational objective: Colonic diverticulosis, which commonly presents with painless hematochezia, results from outpouching of the colon walls at points of weakness where the vasa recta penetrate the circular muscle layer of the colon. Bleeding occurs as the exposed artery is injured, usually from erosion or trauma. References: Diverticular bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/19873964) Endoscopic management of diverticular bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/25548554)

Question 3

A 56-year-old man comes to the physician due to several months of difficulty in swallowing.  At first, meat would stick in his throat, and now he has difficulty swallowing all solid food and occasionally liquids.  The patient coughs and sometimes aspirates food particles when eating.  He has no shortness of breath, chest pain, or heartburn and has lost several pounds in the last 2 months.  The patient was evaluated for persistent right ear pain 4 weeks ago, but no diagnosis could be made.  His past medical history is significant for hypertension.  He smokes 2 packs of cigarettes daily and consumes 6-8 bottles of beer on weekends.  The patient is not sexually active.  Lungs are clear to auscultation.  Neck palpation shows no lymph node enlargement or thyromegaly. Endoscopy performed on this patient identifies an upper-esophageal mass with irregular contours that partially obstructs the lumen of the esophagus.  Which of the following is the most likely histopathologic type of this tumor?

Accepted Answer

Explanation: The 2 main histopathologic types of esophageal carcinoma are adenocarcinoma (AC) and squamous cell carcinoma (SCC). The location in the esophagus of each type determines its incidence. AC is generally found in the distal to mid-esophagus and usually occurs in patients with chronic gastroesophageal reflux and Barrett's esophagus (Choice A). SCC is far more likely to cause upper-esophageal lesions, as seen in this patient. Chronic alcohol and tobacco use are risk factors for esophageal SCC and other squamous cell cancers of the head and neck. In recent years, the incidence of SCC has decreased as the incidence of AC has increased. (Choice B) Esophageal melanoma is much rarer than esophageal SCC or AC. (Choice D) Gastrointestinal stromal tumors are uncommon subendothelial malignancies. They occur primarily in the stomach and small intestine and are rare in the esophagus. Educational objective: Esophageal adenocarcinoma is found primarily in the lower esophagus and is associated with chronic gastroesophageal reflux and Barrett's esophagus. Squamous cell carcinoma is often seen in patients who use alcohol and tobacco chronically and is usually located in the upper esophagus. References: A survey of oesophageal cancer: pathology, stage and clinical presentation. (http://www.ncbi.nlm.nih.gov/pubmed/16480397)

Question 4

A 34-year-old previously healthy man was admitted to the intensive care unit after a motor vehicle collision 3 days ago in which he was the unrestrained driver.  The patient sustained traumatic brain injury and blunt chest trauma, which are being managed nonoperatively.  He has had episodes of hypotension, which improved after fluid resuscitation and packed red blood cell transfusion.  He is mechanically ventilated and is receiving enteral feeding via the nasogastric tube.  Today, the patient is noted to have black liquid stool that is heme-positive.  He has had no fever or high gastric residuals.  The abdomen is nondistended and soft with normal bowel sounds.  Laboratory results are as follows:  Which of the following would have been most effective at preventing this patient's current condition?

Accepted Answer

Explanation: 11ec2b69_c157_0a90_8f63_e9e133fd03e9_MD0005_00 This mechanically ventilated patient with recent head trauma has developed an upper gastrointestinal (GI) bleed, as evidenced by the melenic bowel movements and anemia. This is most likely from gastric or esophageal stress ulcers. Critically ill patients may have uremic toxins and reflux of bile salts into the stomach; both can disrupt the protective glycoprotein layer, which can lead to increased permeability of the gastric mucosa, predisposing to ulcer formation. Head trauma causes increased gastrin secretion, leading to parietal cell stimulation and acid secretion. Shock is associated with mucosal ischemia leading to ulcerations. Most of these ulcerations occur within the first 72 hours and tend to be located in the proximal stomach. Ulcerations occurring later in the hospital course tend to be located in the duodenum. Proton pump inhibitors (PPIs) as well as H₂ antagonists are used to increase the pH in the stomach by lowering gastric acid formation, which prevents the gastric injury associated with ulcer formation. PPI may have increased efficacy in acid suppression. Both PPIs and H₂ antagonists may be associated with increased risk of Clostridium difficile infection (CDI) and pneumonia. (Choice A) The addition of probiotics is sometimes used to prevent CDI; however, efficacy remains controversial. This treatment would not decrease risk of ulcer formation. CDI would cause leukocytosis and diarrhea, not melena. (Choice B) Avoidance of hypotensive episodes is beneficial in preventing end-organ damage, including gastric mucosal ischemia and ischemic colitis. However, ischemic colitis causes lower GI bleed with hematochezia, not melenic stools. In this intubated patient with multiple risk factors, stress ulcers would likely form despite normotension. (Choice C) Enteral feeding introduces higher pH tube feeds into the acidic environment of the stomach and may be protective from ulcer formation and bleeding. In critically ill patients, early initiation (eg, within 72 hours of ICU admission) is also associated with lower risk of infection. (Choice E) Fresh frozen plasma (FFP) is used to correct coagulopathies due to vitamin K antagonists or deficiencies and is generally not indicated unless INR >2.0. This patient's INR is 1.5 and is unlikely to improve with infusion of FFP. Educational objective: Prophylaxis for stress ulcers is recommended for intensive care unit (ICU) patients with coagulopathy, gastrointestinal (GI) bleeding in the last year, mechanical ventilation >48 hours, head trauma, spinal cord injury, or major burns; or for patients with 2 of the following: sepsis, ICU stay >1 week, occult GI bleeding >6 days, or glucocorticoid therapy. Proton pump inhibitors (PPI) or H₂ blockers may be used to decrease risk of stress ulcer formation, but PPIs may have increased efficacy. References: A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. (http://www.ncbi.nlm.nih.gov/pubmed/9504939) Proton pump inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23318494)

Question 5

A 52-year-old woman is hospitalized because of shortness of breath on exertion, abdominal distention, and a 25-pound weight loss in the past three months.  The symptoms have been progressively getting worse over the past four weeks.  Her other medical problems include chronic obstructive pulmonary disease, coronary artery disease, cholelithiasis, and hepatitis-C.  She has smoked two packs of cigarettes daily for 30 years.  She has drunk four to six 12-ounce beers daily for >20 years.  Her mother has a history of breast cancer.  Her vital signs are within normal limits.  Physical examination is unremarkable except for the presence of massive ascites on abdominal examination.  Diagnostic paracentesis and serum chemistries reveal:  Which of the following is the most likely cause of the ascites?

Accepted Answer

Explanation: Abdominal paracentesis and ascitic fluid analysis is the most reliable way to differentiate between the different causes of ascites. The most common cause of ascites in the United States is hepatic cirrhosis. The differential diagnosis of ascites can be narrowed down by calculating the serum-ascites albumin gradient (SAAG), which is equal to the serum albumin value minus the ascitic fluid albumin value (not the ratio of the two). The SAAG value is useful in identifying the presence or absence of portal hypertension and has replaced the old transudative-exudative model of classifying ascitic fluid. A SAAG value >1.1 g/dL is known as high albumin-gradient ascitic fluid and indicates portal hypertension, while a value < 1.1 g/dL is known as low albumin-gradient ascitic fluid and indicates that the patient does not have portal hypertension. Clinical conditions associated with high SAAG (>1.1 g/dL) include congestive heart failure (Choice B), cirrhosis (Choice C), and alcoholic hepatitis (Choice E). Conditions associated with low (< 1.1 g/dL) albumin gradient include peritoneal carcinomatosis, peritoneal tuberculosis, nephrotic syndrome, pancreatitis, and serositis. This patient has a SAAG of 0.6 g/dL (2.8 minus 2.2), which indicates nonportal hypertensive etiology of her ascites. Given her clinical presentation, carcinomatosis from malignancy, such as ovarian cancer, would be a likely etiology. She should have further investigation to confirm the diagnosis. (Choice D) Budd-Chiari syndrome is one of the postsinusoidal noncirrhotic causes of portal hypertension and is caused by thrombosis of the hepatic veins and/or suprahepatic inferior vena cava. The SAAG value in patients with Budd-Chiari syndrome is >1.1 g/dL. Educational objective: A serum-ascites albumin gradient value of >1.1 g/dL indicates the presence of portal hypertension, while a value of <1.1 g/dL indicates the absence of portal hypertension. References: The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites (http://www.ncbi.nlm.nih.gov/pubmed/1616215)

Question 6

A 54-year-old man comes to the emergency department due to worsening epigastric and retrosternal chest pain, nausea, and vomiting.  The patient started having severe nausea, retching, and forceful vomiting after eating some spicy food and consuming a small amount of alcohol with dinner several hours ago.  The vomitus contained ingested food particles, but the most recent episode included a small amount of bright red blood.  The pain has progressively worsened, and he now has pain while swallowing and mild shortness of breath.  The patient has had dyspeptic symptoms in the past, which he self-treated with over-the-counter antacids.  He does not use tobacco or illicit drugs.  He appears pale, diaphoretic, and in moderate distress.  Temperature is 38 C (100.4 F), blood pressure is 140/90 mm Hg, pulse is 120/min, and respirations are 24/min.  Neck veins are flat.  Dullness to percussion and decreased breath sounds are present over the left basal area.  Abdominal examination reveals epigastric tenderness and decreased bowel sounds.  Stool occult blood is positive.  Upright chest x-ray reveals a small pleural effusion of the left lung, and ECG shows sinus tachycardia; the imaging results are otherwise unremarkable. The patient continues to have chest pain that radiates to the back and worsens during deep breaths.  He appears restless and dyspneic.  Blood pressure is now 110/60 mm Hg and pulse is 130/min.  Intravenous fluids are administered.  Laboratory results are as follows:
 Which of the following is the most appropriate test for confirming this patient's diagnosis?

Accepted Answer

Explanation: The best initial diagnostic test for esophageal perforation is an esophagogram with water-soluble contrast (eg, diatrizoate). This test provides a definitive diagnosis in 90% of cases. If the test is negative but clinical suspicion is high, barium contrast can be used. Water-soluble contrast is preferred as barium can produce further mediastinal irritation and injury in patients with Boerhaave syndrome. (Choice B) CT scan of the chest, not the abdomen, can be of value if the diagnosis is unclear after esophagogram or if the patient cannot tolerate the procedure. However, it is not the test of choice as it may fail to detect small tears. (Choice C) Esophageal manometry and pH studies are useful in patients with symptoms of gastroesophageal reflux disease (GERD) unresponsive to therapy with proton pump inhibitors. GERD typically presents with a sensation of heartburn with occasional dysphagia or regurgitation, not hematemesis, fevers, and hemodynamic instability. (Choice D) Lateral soft tissue neck radiography may be able to detect subcutaneous air or a soft tissue defect associated with a proximal esophageal tear, but the patient has evidence of a distal tear with a pleural effusion. Regardless, x-ray is a poorly sensitive technique for diagnosing Boerhaave syndrome. (Choice E) Upper gastrointestinal endoscopy is used to evaluate hematemesis due to a variety of causes, but is generally avoided in patients in whom Boerhaave syndrome is suspected as it can worsen pneumomediastinum due to insufflation of the esophagus prior to passing the scope. It should be reserved for patients who require esophageal repair but are unable to tolerate surgery. Educational objective: The best diagnostic test for esophageal perforation is an esophagogram with water-soluble contrast. CT scan of the chest is helpful but may not detect small tears or ruptures. Upper gastrointestinal endoscopy may worsen pneumomediastinum and should generally be avoided in patients with suspected Boerhaave syndrome. References: Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. (http://www.ncbi.nlm.nih.gov/pubmed/22035338)

Question 7

A 33-year-old Caucasian male presents to your office and complains that solid food 'sticks in the chest.'  He says that he has to chew food more carefully, take more liquids with meals, and swallow small portions.  He recalls having a similar episode several months ago that got better after 'following a diet', but it was much less severe.  He has had periodic chest pain behind the sternum for the last several years.  He denies any recent significant weight loss, abdominal pain, nausea, vomiting, diarrhea/constipation, black stools and neck lumps.  He smokes one pack of cigarettes daily and consumes alcohol occasionally.  He is currently not taking any medications.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Explanation: It is important to identify the non-classical presentations of GERD, including periodic retrosternal chest pain that can mimic angina. The resulting erosive esophagitis may cause transitory dysphagia, which may result in a peptic stricture if left untreated. Peptic stricture formation is a well-known complication of GERD that can cause obstructive dysphagia. In this case, the typical clinical picture of obstructive dysphagia is given: difficulty swallowing solid food, prolonged and careful chewing, and swallowing small portions. (Choices A and B)Malignancies can cause obstructive dysphagia; however, the following information from the patient's history do not support this diagnosis: (1) young age, (2) absence of weight loss, and (3) previous history of GERD and GERD-induced stricture. (Choice C)Achalasia usually causes dysmotility-type dysphagia that is characterized by a difficulty in swallowing both solids and liquids. (Choice D)Barrett's esophagus is a pre-malignant complication of GERD. It does not cause dysphagia. Educational Objective: Peptic stricture is a well-known complication of GERD that results from the healing process of ulcerative esophagitis. Dysphagia usually starts with solids followed by liquids. Young age and lack of alarming symptoms argue against a diagnosis of malignancy.

Question 8

A 25-year-old woman comes to the physician with 2 months of progressively increasing pain in both lower extremities.  The pain is localized over both shins and is worse with ambulation.  She reports a 2-kg (4.5-lb) weight loss, but no fever, night sweats, chest pain, or abdominal pain.  Her past medical history is unremarkable and she is currently on no medications.  Family history is significant for a mother and sister with hypothyroidism.  The patient has a 5-pack-year smoking history and drinks 2 glasses of beer on weekends.  She has a nutritious diet with regular intake of vegetables, meats, whole-grain foods, and dairy products.  Examination shows tenderness at both shins and vitiligo over her back. Laboratory results are as follows:
 The red blood cells are hypochromic and microcytic.  Basic metabolic chemistry panel is otherwise normal.  The serum ferritin level is low.  Plasma 25-hydroxy vitamin D level is undetectable.  Which of the following blood tests is likely to indicate the diagnosis?

Accepted Answer

Explanation: 11ec2b69_c14f_6962_8f63_29b9df9b167d_MD0005_00 This patient has iron and vitamin D deficiencies despite consuming a nutritious diet, suggesting a malabsorption disorder. In a young patient with multi-nutrient malabsorption, the most likely explanation is celiac disease (gluten-sensitive enteropathy). The likelihood of celiac disease is even higher in this patient with vitiligo and a family history of hypothyroidism (associated autoimmune disorders). Although celiac disease is classically associated with prominent gastrointestinal symptoms such as diarrhea, a substantial subset of patients develops malabsorption with minimal or no gastrointestinal symptoms. Screening for celiac disease is performed by checking the anti-endomysial antibody and anti-tissue transglutaminase antibody levels. Simultaneously checking both antibody levels increases the sensitivity for diagnosing the disease. The gold standard for diagnosis is small intestinal biopsy. (Choice B) Alkaline phosphatase is a marker of bone turnover (bone fraction) as well as biliary tract disease (liver fraction). In the setting of vitamin D deficiency, the elevated serum alkaline phosphatase level is most likely related to high bone turnover. In the absence of other features suggesting concurrent liver disease, fractionation of alkaline phosphatase is not needed. (Choice C) Circulating 25-hydroxyvitamin D is converted to the active form, 1,25-hydroxyvitamin D, primarily in response to parathyroid hormone. Although 25-hydroxyvitamin D levels are very sensitive markers for vitamin D intake, 1,25-dihydroxy-vitamin D levels may remain normal until late stages of vitamin D deficiency due to upregulation of 1-alpha-hydroxylase in the kidneys. In this patient with vitamin D deficiency confirmed by a low 25-hydroxyvitamin D level, measuring 1,25-hydroxyvitamin D would be unlikely to add any additional useful information. (Choice D) Hypocalcemia in hypoparathyroidism is associated with increased serum phosphorus levels. This patient has hypophosphatemia, making hypoparathyroidism unlikely. In addition, bone pain is not a typical feature of hypoparathyroidism. Parathyroid hormone level in this patient may be elevated due to secondary hyperparathyroidism; however, measurement will not be helpful in delineating the diagnosis. (Choice E) Multiple myeloma (MM) is a potential cause of bone pain in older patients. Patients with MM can also show anemia, hypercalcemia, and renal insufficiency as well as systemic symptoms such as fatigue and weight loss. It is strongly suggested by a monoclonal protein on serum or urine protein electrophoresis. However, MM is unlikely in young patients such as this. In addition, alkaline phosphatase is not usually elevated in MM as the lytic bone lesions are characterized by bone resorption rather than bone turnover with new bone formation. Educational objective: Celiac disease is a common cause of multi-nutrient malabsorption. Iron deficiency anemia and vitamin D deficiency can develop even in the absence of classic gastrointestinal malabsorption symptoms such as diarrhea. References: Metabolic and nutritional features in adult celiac patients. (http://www.ncbi.nlm.nih.gov/pubmed/18431062)

Question 9

A 56-year-old man comes to the physician due to several months of difficulty in swallowing.  At first, meat would stick in his throat, and now he has difficulty swallowing all solid food and occasionally liquids.  The patient coughs and sometimes aspirates food particles when eating.  He has no shortness of breath, chest pain, or heartburn and has lost several pounds in the last 2 months.  The patient was evaluated for persistent right ear pain 4 weeks ago, but no diagnosis could be made.  His past medical history is significant for hypertension.  He smokes 2 packs of cigarettes daily and consumes 6-8 bottles of beer on weekends.  The patient is not sexually active.  Lungs are clear to auscultation.  Neck palpation shows no lymph node enlargement or thyromegaly.  Which of the following is the best initial step in management of this patient?

Accepted Answer

Explanation: Dysphagia (difficulty swallowing) is categorized into 2 main types: Oropharyngeal dysphagia is characterized by difficulty initiating a swallow, often accompanied by coughing, drooling, or aspiration Esophageal dysphagia is characterized by delayed sensations of food sticking in the upper or lower chest This patient's symptoms include recent ear pain (referred from a hypopharyngeal lesion), and coughing and aspiration during swallowing, which are all consistent with an oropharyngeal or proximal esophageal disorder. Dysphagia initially involving both solids and liquids would suggest a neuromuscular disorder, but dysphagia that occurs initially for solids and later includes liquids is characteristic of a mechanical obstruction. A number of his clinical features (eg, progressive symptoms, weight loss, history of alcohol and tobacco use) suggest a malignant cause of dysphagia. This patient has a structural lesion most likely located in the pharynx or proximal esophagus. The most reasonable first step would be to perform nasopharyngeal laryngoscopy, a minimally invasive test that can visualize this likely location. This pattern of dysphagia also can be evaluated using a standard barium esophagram, which will often identify upper esophageal disorders (eg, Zenker's diverticulum) and should be ordered prior to upper gastrointestinal endoscopy (esophagogastroduodenoscopy [EGD]). An esophagram is also indicated when there is suspicion for achalasia or a long-segment stricture (seen in patients with prior radiation exposure or caustic ingestion). If no diagnosis is made on laryngoscopy or barium esophagram, an EGD may be needed to visualize the esophageal mucosa fully. (Choice A) A CT chest scan may eventually be necessary to stage a malignancy found in the oropharynx/esophagus or to rule out extrinsic compression if other tests are nondiagnostic. However, CT chest scan has poor sensitivity for detecting small lesions or mucosal abnormalities in the pharynx and upper esophagus. (Choice B) Manometry may be helpful if an esophageal motility disorder is suspected. A mechanical obstruction is suggested due to this patient's pattern of dysphagia (initially beginning with solids and progressing to involve liquids). (Choice C) EGD is most helpful when a patient has lower-esophageal symptoms. EGD is not recommended as an initial evaluation for patients with possible upper-esophageal lesions as the upper esophagus is often not visualized well during scope insertion and perforation is possible. (Choice E) Videofluoroscopic barium swallow is a functional test providing visualization of the pharynx and upper esophagus as the patient swallows. This test assesses neuromuscular disorders but is less useful for identifying structural lesions than the direct visualization that laryngoscopy offers. Educational objective: Oropharyngeal dysphagia is characterized by difficulty initiating a swallow and often involves coughing, drooling, or aspiration. Esophageal dysphagia is characterized by delayed sensations of food sticking in the upper or lower chest. Structural lesions that lead to dysphagia in the pharynx and upper esophagus may be visualized with nasopharyngeal laryngoscopy. References: Diagnostic evaluation of dysphagia. (http://www.ncbi.nlm.nih.gov/pubmed/18542115)

Question 10

A 70-year-old woman comes to the emergency department due to abdominal pain and bloody diarrhea.  Last night, the patient experienced mild cramping with abdominal pain and an urgent desire to defecate, but when she went to the bathroom, she did not have a bowel movement.  The patient attributed her symptoms to the spicy food she had for lunch and took some antacids, but the pain persisted.  This morning she had large-volume diarrhea containing bright red blood.  She has had no nausea or vomiting and has never had similar symptoms.  The patient was found to have diverticulosis during a colonoscopy 2 years ago, so a high-fiber diet was advised.  Other medical problems include hypertension, type 2 diabetes mellitus, coronary artery disease, and end-stage renal disease from diabetic nephropathy.  She receives intermittent maintenance hemodialysis (most recently yesterday) and has had several occasions of hypotension during dialysis, requiring intravenous fluid replacement.  The patient does not use tobacco, alcohol, or illicit drugs.  She has taken no antibiotics or nonsteroidal analgesics recently.  The patient lives with her husband and has not recently traveled.  Temperature is 37.2 C (99 F), blood pressure is 119/81 mm Hg, pulse is 90/min, and respirations are 16/min.  The abdomen is mildly distended and soft with moderate left-sided tenderness.  There is no rebound tenderness and bowel sounds are decreased.  Rectal examination reveals bloody stool but no tenderness or mass.  Laboratory results are as follows:  Upright abdominal radiography reveals a dilated transverse colon with no free air.  Flexible sigmoidoscopy shows mucosal edema.  Which of the following is the most likely cause of this patient's current symptoms?

Accepted Answer

Explanation: 11ec2b69_c150_f004_8f63_65b90a3c47c4_MD0005_00 This patient has several risk factors for underlying atherosclerosis (eg, hypertension, diabetes mellitus, end-stage renal disease), which increases the risk of developing colonic ischemia (CI). CI most commonly occurs in the setting of nonocclusive disease, when a mismatch between oxygen demand and supply results from diffuse mesenteric atherosclerosis combined with a state of low blood flow (eg, hypovolemia during hemodialysis). The most vulnerable colonic regions are those with limited collateral blood flow (eg, splenic flexure, rectosigmoid junction). Less commonly, occlusive disease can occur due to an embolic event or atherosclerotic plaque rupture. CI frequently presents with acute, crampy abdominal pain and fecal urgency, which may be followed by an episode of bloody diarrhea. In some patients, the presentation can be more chronic than acute. Unlike the pain of mesenteric ischemia of the small bowel, which is typically severe and periumbilical in location, the pain of CI is usually relatively mild and located more peripherally in the abdomen. Leukocytosis and lactic acidosis are common laboratory findings. Radiography may show colonic distension or pneumatosis (gas in the bowel wall), and lower endoscopy can confirm the diagnosis by demonstrating friable, edematous mucosa; erythema; and scattered pale patches. pneumatosis (Choice B) Acute diverticulitis also presents with abdominal pain and leukocytosis; however, patients also frequently report fever, nausea, vomiting, and nonbloody diarrhea. In addition, diverticulitis would not explain this patient's imaging or endoscopy findings. (Choice C) Angiodysplasia is an uncommon cause of gastrointestinal bleeding and is characterized by painless hemorrhage. Risk factors include aortic stenosis, von Willebrand disease, and chronic kidney disease. (Choice D) Pseudomembranous colitis due to Clostridium difficile or Salmonella infection is also commonly associated with diarrhea, abdominal pain, leukocytosis, bowel dilation on imaging, and edematous mucosa on endoscopy. However, diarrhea is typically watery, and although occult blood may be present in the stool, evidence of frank hemorrhage is rare. In addition, this patient's lack of recent travel or antibiotic exposure further decreases this likelihood. (Choice E) Ulcerative colitis commonly presents with the subacute onset of bloody diarrhea, abdominal pain, urgency, tenesmus, and incontinence. In addition to mucosal edema, endoscopy commonly shows loss of vascular markings, exudates, and spontaneous hemorrhage. Educational objective: Colonic ischemia most commonly occurs due to nonocclusive disease in the setting of underlying atherosclerosis and a state of low blood flow. Patients typically have abdominal pain, bloody diarrhea, and fecal urgency as well as leukocytosis, lactic acidosis, and colonic distension or pneumatosis shown on abdominal x-rays. References: Ischemic colitis: clinical practice in diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/19109863)

Question 11

A 62-year-old man comes to the office due to a 2-month history of progressive exertional dyspnea and fatigue.  The patient says, "I feel tired all the time and take frequent naps during the day."  He consumes a balanced diet and does not use tobacco, alcohol, or illicit drugs.  Physical examination shows mucosal pallor.  Stool testing for occult blood is positive.  Laboratory results are as follows:  Colonoscopy reveals several small, flat, cherry-red lesions in the right colon but is otherwise normal.  Esophagogastroduodenoscopy and capsule endoscopy are normal.  The likely cause of this patient's anemia is most strongly associated with which of the following?

Accepted Answer

Explanation: 11ec2b69_c155_d20e_8f63_df11490ac0dc_MD0005_00 Angiodysplasias (vascular ectasias or arteriovenous malformations) are vascular anomalies composed of multiple aberrant blood vessels located in the gastrointestinal (GI) tract. A frequent cause of occult GI bleeding, angiodysplasias are most common in patients age >60 and are often discovered incidentally on endoscopy, appearing as small, cherry-red lesions. The pathogenesis may be due to chronic occlusions of submucosal veins, resulting in vascular congestion and the formation of dysplastic arteriovenous collaterals. Only a small percentage of angiodysplasias bleed; however, bleeding rates are higher with end-stage renal disease (ESRD), aortic stenosis, and von Willebrand disease (vWD) as these conditions most likely cause a bleeding diathesis that leads to more frequent GI bleeding from malformed vessels. Uremia associated with ESRD causes platelet dysfunction, and both aortic stenosis (which leads to acquired vWD due to mechanical disruption during valvular flow) and hereditary vWD cause decreased levels of vW factor, which is required for platelet aggregation. (Choice A) Dermatomyositis, an inflammatory myopathy with a characteristic heliotrope rash and Gottron papules, is associated with multiple malignancies, including lung, colon, and ovarian cancers. This patient has evidence of a GI bleed and microcytic (mean corpuscular volume <80/μm³) anemia (likely due to iron deficiency), which are concerning for colon cancer; however, colonoscopy would likely reveal a protruding endoluminal neoplasm. heliotrope rash Gottron papules (Choices C and D) Primary sclerosing cholangitis causes scarring of the biliary ducts, eventually leading to cirrhosis; it is strongly associated with ulcerative colitis (UC). Seronegative spondyloarthropathy (eg, ankylosing spondylitis) can be seen with UC or Crohn disease. However, UC typically causes bloody diarrhea, tenesmus, and abdominal pain, and colonoscopy reveals characteristic colitis with inflammation and friable mucosa. Crohn disease typically causes prolonged diarrhea, abdominal pain, and weight loss, and colonoscopy reveals focal ulcerations alongside normal mucosa (cobblestone with skip lesions). (Choice E) Tricuspid valve regurgitation can be associated with carcinoid syndrome, which causes flushing and diarrhea but not bleeding. Educational objective: Angiodysplasias are frequent causes of gastrointestinal bleeding, particularly in patients with end-stage renal disease, von Willebrand disease, and aortic stenosis.

Question 12

A 34-year-old woman comes to the emergency department due to a 12-hour history of sudden-onset, upper abdominal pain. She describes the pain as intense, constant, and radiating to the back. The pain is relieved by leaning forward and worsens with eating. The patient also reports nausea and has vomited several times. She has no previous episodes of abdominal pain, fever, chills, weight loss, fatigue, or night sweats. The patient has no known medical conditions and takes no prescription or over-the-counter medications. She does not use alcohol, tobacco, or illicit drugs. Her last menstrual period was 2 weeks ago and was normal. The patient is sexually active with a male partner and uses condoms. Temperature is 36.7 C (98.1 F), blood pressure is 134/72 mm Hg, pulse is 72/min, and respirations are 14/min. BMI is 24 kg/m². Physical examination shows moist mucous membranes and anicteric sclera. Lung fields are clear, and S1 and S2 are normal. The abdomen is soft and tender in the upper abdomen but without rebound, involuntary guarding, or rigidity. Bowel sounds are normal. Neither hepatomegaly nor splenomegaly is present. Bimanual examination reveals no adnexal masses or tenderness. Neurologic examination is within normal limits. The patient is diagnosed with hypertriglyceridemia-induced acute pancreatitis, and intravenous insulin is started. Although the triglyceride levels improve in response to therapy, her abdominal pain remains unchanged by day 8 of hospitalization. The patient tolerates minimal nutritional intake despite the use of a nasogastric tube. Temperature is 38.6 C (101.5 F), blood pressure is 90/50 mm Hg, pulse is 107/min, and respirations are 22/min. Oxygen saturation is 98% on room air. Physical examination reveals tenderness in the upper abdomen to deep palpation without involuntary guarding, rebound, or rigidity. Repeat laboratory analysis reveals leukocytosis with a left shift, whereas hemoglobin and liver function tests remain unchanged. Which of the following would be the best next step in management of this patient?

Accepted Answer

Explanation: Despite appropriate treatment for hypertriglyceridemia-induced acute pancreatitis (AP) with intravenous insulin and supportive care, this patient's condition is deteriorating (eg, fever, leukocytosis, hypotension), and she has ongoing abdominal pain. She should be evaluated for infected pancreatic necrosis. Mild to moderate AP usually resolves with supportive management, but pancreatic necrosis can develop in severe cases. The necrosis is initially sterile but can become secondarily infected (usually gram-negative enteric bacteria) typically >7 days after initial presentation. Infected pancreatic necrosis should be considered in patients with persistent abdominal pain and in those whose condition initially improves but then deteriorates (eg, leukocytosis, fever, unstable vital signs). Gas within pancreatic necrosis is diagnostic, which is best identified by an abdominal CT scan with intravenous contrast. Initial management requires the use of intravenous antibiotics capable of penetrating pancreatic necrosis (eg, meropenem, fluoroquinolone + metronidazole). Debridement of the necrotic material is sometimes considered for patients whose condition fails to improve with conservative management. (Choice A) Corticosteroids can be used to treat autoimmune pancreatitis but not hypertriglyceridemia-induced AP or infected pancreatic necrosis, so they would not be recommended in this patient. (Choice C) Patients whose condition fails to improve with antibiotics are sometimes treated with antifungals (eg, fluconazole), but these agents would not be administered before confirming the diagnosis with CT scan. (Choice D) MR cholangiopancreatography is more time-consuming and costly than CT scan. Infected pancreatic necrosis is a life-threatening condition, and rapid diagnosis with CT scan is preferred. (Choice E) Nasogastric (NG) or nasojejunal (NJ) tube feedings are used for patients who cannot tolerate oral nutrition for an extended time. This patient's NG tube feeding has already failed, and she is unlikely to benefit from an NJ tube; instead, parenteral nutrition should be considered. Educational objective: Infected pancreatic necrosis should be considered in patients with acute pancreatitis who have persistent abdominal pain or have initial improvement followed by clinical deterioration (eg, leukocytosis, fever). CT scan showing gas within pancreatic necrosis is diagnostic. Management includes intravenous antibiotics. References: Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. (http://www.ncbi.nlm.nih.gov/pubmed/23100216) American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/29409760) Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23786708)

Question 13

A 37-year-old man comes to the office for a routine preventive visit.  He is healthy and asymptomatic and has no significant medical history.  The patient has a 5-pack-year smoking history but quit 10 years ago.  He drinks 1 or 2 beers daily.  The patient works as a sales manager for a manufacturing company.  His father had colon cancer that was diagnosed at age 53, but there is no other family history of cancer.  Vital signs are within normal limits.  No abnormalities are noted on examination.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c151_8c45_8f63_716380bb0090_MD0005_00 Colon cancer screening is recommended beginning at age 45 for individuals at average risk. However, those who have a first-degree relative with colon cancer are at increased risk and therefore warrant screening beginning at an earlier age (Choice A). Patients who have a first-degree relative with sporadic (ie, not related to a hereditary colon cancer syndrome) colon cancer or advanced adenoma (eg, ≥10 mm, high-grade dysplasia) should be offered screening beginning at age 40 or 10 years before the age at which the relative's colon cancer was diagnosed, whichever comes first (Choices C and D). This patient, whose father was diagnosed with colon cancer at age 53, should be offered colonoscopy at age 40. If the patient's initial colonoscopy is normal, repeat colonoscopy should be offered every 5 years (routine 10-year intervals can be considered for those who have only 1 first-degree relative with colon cancer if the diagnosis was made after age 60). (Choice E) Genetic testing for hereditary colon cancer syndromes (eg, familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer [Lynch syndrome]) is usually recommended for patients with a stronger family history (eg, multiple relatives with cancer at a young age or at multiple sites). Having 1 relative with sporadic colon cancer does not warrant genetic testing. Educational objective: Patients at average risk for colon cancer should start colon cancer screening at age 45. For those with a first-degree relative with colon cancer or advanced adenoma, screening colonoscopy is recommended beginning at age 40 or 10 years before the relative's age at diagnosis, whichever comes first. References: Screening for colorectal cancer: US Preventive Services Task Force recommendation statement (http://www.ncbi.nlm.nih.gov/pubmed/34003218)

Question 14

A 34-year-old woman comes to the emergency department due to a 12-hour history of sudden-onset, upper abdominal pain. She describes the pain as intense, constant, and radiating to the back. The pain is relieved by leaning forward and worsens with eating. The patient also reports nausea and has vomited several times. She has no previous episodes of abdominal pain, fever, chills, weight loss, fatigue, or night sweats. The patient has no known medical conditions and takes no prescription or over-the-counter medications. She does not use alcohol, tobacco, or illicit drugs. Her last menstrual period was 2 weeks ago and was normal. The patient is sexually active with a male partner and uses condoms. Temperature is 36.7 C (98.1 F), blood pressure is 134/72 mm Hg, pulse is 72/min, and respirations are 14/min. BMI is 24 kg/m². Physical examination shows moist mucous membranes and anicteric sclera. Lung fields are clear, and S1 and S2 are normal. The abdomen is soft and tender in the upper abdomen but without rebound, involuntary guarding, or rigidity. Bowel sounds are normal. Neither hepatomegaly nor splenomegaly is present. Bimanual examination reveals no adnexal masses or tenderness. Neurologic examination is within normal limits. Laboratory results are as follows: Pregnancy testing is negative. Abdominal ultrasound reveals a normal-appearing gallbladder and a nondilated biliary tree. The patient is admitted to the hospital; intravenous fluid, antiemetics, and pain medications are started. Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: This patient meets diagnostic criteria for acute pancreatitis (AP) based on characteristic abdominal pain and a lipase level ≥3 times the upper limit of normal. Once a diagnosis of AP is made, the etiology must be determined. Gallstones and alcohol account for >65% of cases but have been excluded in this patient by ultrasound and a detailed history. Hypertriglyceridemia causes up to 14% of AP cases and usually occurs in patients with triglyceride levels >1,000 mg/dL; therefore, a lipid panel, including a serum triglyceride level, should be ordered in this patient. Other causes (eg, autoimmune pancreatitis, medications [eg, furosemide, didanosine], infections [eg, HIV, Ascaris]) are less common but should be considered in select circumstances. (Choices A and D) Clinical findings to suggest gallstone-induced pancreatitis include abnormal liver chemistries (eg, elevated alanine aminotransferase, bilirubin, and alkaline phosphatase) and dilated biliary ducts (suggesting obstruction at the ampulla of Vater). Endoscopic retrograde cholangiopancreatography (ERCP) and MR cholangiopancreatography should be considered in such patients but are not necessary in this woman. In addition, ERCP can worsen pancreatitis. (Choice B) Intravenous antibiotics are not indicated in the routine management of AP but are needed in patients with extrapancreatic infections (eg, pneumonia) and in those who develop infected pancreatic necrosis. An infection warranting antibiotics is unlikely because this patient is afebrile and does not have leukocytosis. (Choice E) Although certain infections (eg, Salmonella, Cryptosporidium, Ascaris) can cause AP, they are significantly less common than hypertriglyceridemia, and stool studies would not be ordered until more common causes have been eliminated. Educational objective: When alcohol or gallstones do not cause acute pancreatitis, patients should be evaluated for hypertriglyceridemia with a serum lipid panel. References: American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/29409760) Acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/25368923) Early phase of acute pancreatitis: assessment and management. (http://www.ncbi.nlm.nih.gov/pubmed/25133018)

Question 15

A 51-year-old man comes to the emergency department due to abdominal cramping, nausea, and bloody diarrhea.  The patient reports having 2 episodes of large-volume, red- to maroon-colored, liquid stool over the past hour.  He has also been feeling lightheaded but has had no vomiting, chest pain, or dyspnea.  He sprained his ankle while playing racquetball 2 weeks ago and has been taking ibuprofen.  He reports no chronic health issues and has never had similar symptoms in the past.  Screening colonoscopy a year ago revealed scattered diverticulosis but was otherwise unremarkable.  He smokes a pack of cigarettes daily and drinks a 6-pack of beer every week.  Temperature is 37.3 C (99.1 F), pulse is 112/min, and blood pressure is 116/70 mm Hg while supine and 90/60 mm Hg while standing.  The patient appears anxious and diaphoretic.  Cardiopulmonary examination is normal with the exception of tachycardia.  The abdomen is nondistended and soft with mild generalized tenderness.  There is no guarding or rebound tenderness, and bowel sounds are hyperactive.  Rectal examination reveals maroon-colored stool.  Fingerstick hemoglobin is 12 g/dL.  Blood samples for cell counts, serum chemistry, and type and crossmatch are obtained.  Intravenous access is established and intravenous fluids are administered.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: This patient presents with hematochezia (bright red or maroon-colored stool), which is most commonly due to bleeding from the lower gastrointestinal (GI) tract (eg, diverticulosis, hemorrhoids). However, rapid, large-volume bleeding from an upper GI source (eg, peptic ulcer) can lead to hematochezia rather than the more classic melena (black and tarry stool) typically associated with an upper GI bleed; up to 15% of cases of hematochezia are due to upper GI bleeding. In patients with hematochezia and hemodynamic instability, it should be initially assumed that there is an upper GI source of bleeding if there is no strong suggestion of a lower GI source (eg, passage of large clots, known recent diverticular bleed). This patient has orthostatic hypotension as well as risk factors for upper GI bleeding (eg, ibuprofen use); therefore, following initial volume resuscitation, esophagogastroduodenoscopy (EGD) for identification and treatment (eg, hemostatic clipping) of a suspected upper GI source is most appropriate. If EGD fails to identify a source, colonoscopy should then be pursued. For patients who remain hemodynamically unstable despite initial volume resuscitation, interventional radiology procedures (eg, angiography with embolization) are often the best alternative to EGD. (Choices A and D) Both abdominal CT angiography and radionuclide bleeding scanning (using tagged red blood cells) can be helpful in localizing active GI bleeding. However, because these tests are only diagnostic and not therapeutic, EGD is preferred. (Choice B) Initial intervention with colonoscopy is appropriate in patients with hemodynamically stable hematochezia or strong suggestion of a lower GI source. However, EGD is the most appropriate initial intervention in patients with hemodynamic instability and reasonable suspicion for an upper GI source of bleeding. (Choice E) Wireless video capsule endoscopy makes use of a capsule that is swallowed by the patient and transmits images as it passes through the bowel. It is typically reserved for when both EGD and colonoscopy fail to localize bleeding and the source is thought to be in the small intestine. Educational objective: Although hematochezia is most commonly associated with lower gastrointestinal (GI) bleeding, large-volume, upper GI bleeding can also present with hematochezia. Patients with hematochezia and hemodynamic instability (eg, orthostatic hypotension) should generally be assumed to have an upper GI source of bleeding. Following initial volume resuscitation, they should undergo initial evaluation with esophagogastroduodenoscopy. References: A prospective characterization of upper gastrointestinal hemorrhage presenting with hematochezia. (http://www.ncbi.nlm.nih.gov/pubmed/9040197)

Question 16

A 43-year-old woman comes to the emergency department due to midepigastric abdominal pain.  The pain is sharp, radiates to her back, and is accompanied by nausea, vomiting, and malaise.  Her symptoms started approximately 24 hours earlier.  For the past 6 months she has had intermittent, colicky abdominal pain that occurs after meals.  The patient's medical problems include hypertension, depression, and recurrent urinary tract infections.  Medications include lisinopril, amlodipine, and fluoxetine.  She has no known drug allergies and does not use tobacco, alcohol, or illicit drugs.  Family history is notable for ovarian cancer in her mother.  Temperature is 37.1 C (98.8 F), blood pressure is 146/92 mm Hg, pulse is 85/min, and respirations are 14/min.  Physical examination reveals moist mucous membranes, no lymphadenopathy, clear lung fields, and normal S1 and S2.  The abdomen is soft and tender in the midepigastrium without rigidity or rebound tenderness.  Bowel sounds are normoactive.  The remainder of the examination is normal.  Laboratory results are as follows:  The patient is hospitalized and treated with supportive care.  Abdominal ultrasound reveals multiple gallstones that are 3-5 mm in diameter, but no abnormalities are seen in the common bile duct.  Lipid panel shows triglycerides of 150 mg/dL.  On the third day of hospitalization, the patient is symptom-free, she tolerates oral feeding, and liver enzymes have normalized.  Which of the following treatment options is most appropriate to prevent further episodes of pancreatitis?

Accepted Answer

Explanation: This patient with acute-onset epigastric pain radiating to the back, nausea, vomiting, and an elevated lipase has acute pancreatitis. The patient lacks a history of alcohol use and has normal triglycerides and calcium levels. Given this and evidence of cholelithiasis with elevation of alkaline phosphatase, gallstone pancreatitis (GP) is the most likely diagnosis. The management of GP depends on its severity. Patients with mild disease, which is characterized by the lack of both organ failure and local or systemic complications (eg, acute necrotic collection, heart failure), should undergo cholecystectomy within 7 days of clinical improvement; this is usually performed during the same hospitalization (eg, this patient could be scheduled for surgery the next day). Patients who do not have their gallbladders removed have a 25%-30% risk of recurrent acute pancreatitis, cholecystitis, or cholangitis during the next 6-18 weeks. Delayed cholecystectomy should be considered for patients with severe GP, which is characterized by persistent failure of one or more organ systems (eg, hypotension not responsive to fluid resuscitation) (Choice B). Waiting allows for the resolution of active inflammation and complications (eg, walled-off necrosis), facilitating surgical management. In addition to having a cholecystectomy, patients should also undergo evaluation of the biliary system to ensure no gallstones remain. This can be performed through intraoperative cholangiogram in low-risk patients; alternatively, endoscopic retrograde cholangiopancreatography can be obtained prior to cholecystectomy in patients with evidence of persistent biliary obstruction (eg, elevated alkaline phosphatase, hyperbilirubinemia) (Choice C). (Choice D) Although a low-fat diet is recommended for patients with acute pancreatitis, cholecystectomy is the most important intervention to decrease the risk of recurrent pancreatitis, cholecystitis, and cholangitis. (Choice E) Ursodeoxycholic acid treatment can be considered as a second-line option for patients with symptomatic cholelithiasis (eg, biliary colic) who do not desire surgery, but it does not have a role in the treatment of patients with GP. Educational objective: The management of gallstone pancreatitis depends on its severity. Patients with mild disease should undergo cholecystectomy within 7 days of clinical improvement. Those with more severe disease should delay cholecystectomy until the resolution of inflammation and complications. References: Gallstone disease: diagnosis and management of cholelithiasis, cholecystitis and choledocholithiasis. (http://www.ncbi.nlm.nih.gov/pubmed/25473723) Acute biliary pancreatitis: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/19636174)

Question 17

A 40-year-old woman comes to the office due to intermittent dysphagia for the past several months.  The patient says, "I frequently have a sensation of food getting stuck in my chest several seconds after swallowing along with pain behind the sternum.  I have noticed no specific triggers and have had several episodes after swallowing liquids also."  The patient reports no weight loss, nausea, vomiting, hematemesis, abdominal pain, or melena.  She has a history of iron deficiency anemia due to menorrhagia from uterine fibroids.  The patient has not been taking oral iron supplements due to associated constipation.  She does not use tobacco, alcohol, or illicit drugs.  Family history is notable for systemic sclerosis in the patient's sister.  Vital signs are within normal limits and physical examination shows no abnormalities.  Barium esophagogram is normal.  Manometry after a test swallow demonstrates premature and simultaneous contractions of the distal esophagus.  Lower esophageal sphincter relaxation is normal.  Hemoglobin is 10.8 g/dL.  Which of the following is the most accurate response to the patient regarding her current symptoms?

Accepted Answer

Explanation: 11ec2b69_c151_da66_8f63_5b1f3c6c537d_MD0005_00 This patient with dysphagia and retrosternal chest pain that occur within seconds of eating likely has diffuse (or distal) esophageal spasm (DES). Patients frequently experience a sensation of both solids and liquids getting stuck; this sensation may be triggered by the ingestion of hot or cold foods. Because DES is associated with gastroesophageal reflux disease, some patients with DES who present with heartburn may initially be misdiagnosed. DES may be due to impairment of the inhibitory neurons that innervate the esophagus, causing disordered and premature simultaneous contractions of the distal esophagus. The gold standard for diagnosis is esophageal manometry, which would show premature contractions with normal distal esophageal sphincter relaxation. Barium swallow may show a corkscrew appearance of the esophagus; however, this is neither sensitive nor specific for diagnosis. Current first-line therapy is calcium channel blockers. Tricyclic antidepressants are also suggested for patients who present primarily with chest pain. (Choice A) Systemic sclerosis causes progressive collagen deposition and fibrosis of multiple tissues, including the smooth muscle integral for gastrointestinal motility. Patients may present with dysphagia and heartburn, but esophageal manometry would show evidence of hypomotility with low amplitude contractions and low sphincter pressure. (Choice B) Eosinophilic esophagitis frequently presents with similar symptoms of dysphagia, odynophagia, and heartburn. However, this condition is seen more frequently in men and is highly associated with other allergic conditions (eg, asthma, allergic rhinitis, food allergy). Esophageal manometry findings are nonspecific. (Choice D) Achalasia is caused by failure of the lower esophageal sphincter to relax due to degeneration of the ganglia in the Auerbach plexus. Secondary achalasia can be caused by infection with Trypanosoma cruzi (Chagas disease). An esophagogram typically reveals a dilated esophagus with a "bird's beak" narrowing of the distal esophagus. (Choice E) Plummer-Vinson syndrome is the triad of iron deficiency anemia, dysphagia, and esophageal web. The webs would be seen on barium esophagram (or upper endoscopy), and manometry would not show simultaneous contractions. The webs generally improve with iron repletion. Educational objective: Diffuse esophageal spasm is a motility disorder characterized by disordered and premature simultaneous contractions of the distal esophagus with normal distal esophageal sphincter relaxation as demonstrated by manometry. Patients may present with chest pain and dysphagia. First-line treatment is with calcium channel blockers.

Question 18

A 55-year-old man comes to the emergency department due to a 3-day history of abdominal cramps and diarrhea.  He has had 5-7 watery stools a day, including at night.  Three weeks ago, the patient was hospitalized for a perforated peptic ulcer that was complicated by peritonitis; he received antibiotics and underwent abdominal washout and distal gastrectomy.  The initial postoperative course was uncomplicated.  Temperature is 38.3 C (100.9 F), blood pressure is 116/74 mm Hg, and pulse is 96/min.  Abdominal examination shows mild distension and diffuse tenderness.  Bowel sounds are normal.  The surgical wounds are clean, intact, and without discharge.  Which of the following is the most likely cause of this patient's diarrhea?

Accepted Answer

Explanation: This patient who recently received antibiotics during hospitalization for a perforated peptic ulcer now has a low-grade fever, abdominal cramping and tenderness, and profuse watery diarrhea, most likely due to Clostridioides difficileinfection (CDI). Profuse watery diarrhea (≥3 loose stools/24 hr) is the hallmark symptom of CDI, which is suspected when major risk factors (eg, recent antibiotic use, recent hospitalization) are present. C difficile is a spore-forming, gram-positive, anaerobic bacterium transmitted via the fecal-oral route. After being ingested, the hardy, antibiotic-resistant spores germinate in the colon to become fully functional bacilli. Typically, normal colonic flora (eg, Bacteroides) suppresses the overgrowth of C difficile bacilli, but antibiotics can disrupt the normal colonic flora, leading to unchecked C difficileproliferation. Pathology is mediated by the release of C difficile exotoxins (ie, toxin A, toxin B) that cause inflammation and mucosal injury. (Choice A) Some distal gastrectomy procedures (eg, Billroth II) create a blind loop of small intestine that can experience bacterial overgrowth, especially if partial obstruction (eg, due to intraabdominal adhesion) subsequently develops. Small intestinal bacterial overgrowth can cause abdominal discomfort and watery diarrhea; however, the abdomen is usually normal (vs diffusely tender) on examination, and fever is unexpected. Billroth II (Choice B) Colonic ischemia may occur if a perforated ulcer leads to peritonitis, hemodynamic instability, and hypoperfusion of the mesenteric vasculature. Although acute colonic ischemia can cause abdominal cramping and diarrhea, the diarrhea is typically bloody (vs watery), and symptoms usually occur within hours of the hypoperfusion episode (vs 3 weeks later). (Choice D) Pyloric sphincter bypass or resection (eg, distal gastrectomy) may result in rapid emptying of gastric contents (hyperosmolar chyme) into the small intestine. The resulting fluid shifts (intravascular → intraluminal) can cause dumping syndrome presenting with abdominal cramps and diarrhea. However, symptoms typically occur shortly after meals, not during the night, and include vasomotor manifestations (eg, diaphoresis, palpitations). (Choice E) Injury to the vagus nerve during gastric surgery (eg, distal gastrectomy) can result in gastroparesis. The resulting delayed gastric emptying can cause abdominal pain and distension, but early satiety, nausea, and vomiting are commonly also present. Fever is unexpected. Educational objective: Clostridioides difficile is transmitted via the fecal-oral route. Ingested spores germinate in the colon to become fully functional bacilli and may proliferate unchecked when the normal colonic flora is disrupted (eg, antibiotic use). Profuse watery diarrhea (≥3 loose stools/24 hr) is the hallmark of C difficile infection. References: Clostridioides difficile biology: sporulation, germination, and corresponding therapies for C. difficile infection. (http://www.ncbi.nlm.nih.gov/pubmed/29473021)

Question 19

A 54-year-old man comes to the emergency department due to worsening epigastric and retrosternal chest pain, nausea, and vomiting.  The patient started having severe nausea, retching, and forceful vomiting after eating some spicy food and consuming a small amount of alcohol with dinner several hours ago.  The vomitus contained ingested food particles, but the most recent episode included a small amount of bright red blood.  The pain has progressively worsened, and he now has pain while swallowing and mild shortness of breath.  The patient has had dyspeptic symptoms in the past, which he self-treated with over-the-counter antacids.  He does not use tobacco or illicit drugs.  He appears pale, diaphoretic, and in moderate distress.  Temperature is 38 C (100.4 F), blood pressure is 140/90 mm Hg, pulse is 120/min, and respirations are 24/min.  Neck veins are flat.  Dullness to percussion and decreased breath sounds are present over the left basal area.  Abdominal examination reveals epigastric tenderness and decreased bowel sounds.  Stool occult blood is positive.  Upright chest x-ray reveals a small pleural effusion of the left lung, and ECG shows sinus tachycardia; the imaging results are otherwise unremarkable.
Which of the following is the most likely cause of this patient's current condition?

Accepted Answer

Explanation: 11ec2b69_c153_fd49_8f63_c5f304dc0e1f_MD0005_00 This patient's presentation with retrosternal chest pain after repeated episodes of vomiting is classic for spontaneous esophageal perforation (Boerhaave syndrome) complicated by acute mediastinitis. Other associated symptoms are dyspnea, odynophagia, epigastric pain, and shoulder pain. Boerhaave syndrome is characterized by a full-thickness tear of the esophagus due to sudden elevation in esophageal pressure (eg, vomiting) allowing gastric contents to enter previously sterile sites, in this case the mediastinum (resulting in mediastinitis). Most tears occur in the distal third of the esophagus, and the negative intrathoracic pressure within the chest results in an influx of esophageal contents into the pleural cavity, causing inflammation and pleural effusion (typically on the left). The effusion can be accompanied by pneumomediastinum (free air within the chest), pneumothorax, or both. Fever due to mediastinitis often takes >4 hours to develop, which can delay diagnosis. Urgent management is needed as mediastinitis carries a high mortality rate that doubles if it is not properly treated within 24 hours of diagnosis. In contrast to Boerhaave syndrome, a Mallory-Weiss tear is a mucosal (ie, partial thickness) tear of the esophagus. A Mallory-Weiss tear can also present with hematemesis following nausea and vomiting; however, perforation does not occur, so fever, chest pain, mediastinitis, left pleural effusion (which is due to fluid leakage), and hemodynamic instability would be unlikely (Choice D). (Choice A) Aspiration pneumonitis can be seen after episodes of vomiting; however, it most commonly occurs during emesis in patients with a decreased level of consciousness or an inability to protect the airway. This patient has not described changes in mental status, and pleural effusion or gastrointestinal bleeding would not be expected in aspiration pneumonitis. (Choice B) Erosive esophagitis is frequently caused by direct esophageal injury due to medication ingestion. Common offenders include bisphosphonates and tetracyclines. Typical presentation is with burning chest pain, but the fever and clinical instability associated with Boerhaave syndrome are not expected in erosive esophagitis. (Choice E) Perforated gastric ulcers are another surgical emergency causing marked hemodynamic instability; however, acute-onset, severe abdominal pain is expected, and upright chest x-ray often reveals free air under the diaphragm. In addition, gastric ulcers are not associated with repetitive vomiting. Educational objective: Esophageal perforation, also known as Boerhaave syndrome, usually presents as acute retrosternal chest pain following episodes of repeated vomiting. Most tears occur in the distal third of the esophagus and are associated with left-sided pleural effusion. Pneumomediastinum and/or pneumothorax can occur as well. A delay in surgical management is associated with mediastinitis and a high mortality rate. References: Spontaneous esophageal rupture as the underlying cause of pneumothorax: early recognition is crucial. (http://www.ncbi.nlm.nih.gov/pubmed/25589955)

Question 20

A 65-year-old woman comes to the emergency department due to the sudden onset of severe periumbilical pain, nausea, and vomiting.  She has no fever, diarrhea, constipation, or urinary complaints.  Her last menstrual period was 14 years ago.  The patient has a history of coronary artery disease, a recent acute anterior myocardial infarction, hypertension, and hyperlipidemia.  She had an appendectomy at age 18.  She has a 20-pack-year smoking history.  The patient drinks alcohol occasionally.  Her temperature is 36.7 C (98 F), blood pressure is 120/76 mm Hg, pulse is 120/min and irregular, and respirations are 16/min.  The abdomen is soft, nondistended, nontender, and has normoactive bowel sounds.  There is no rebound tenderness or rigidity.  Pelvic examination is within normal limits.  ECG shows atrial fibrillation without other abnormal findings.  Laboratory results are as follows:  The other studies show normal serum lipase, slightly elevated serum amylase, and normal liver function tests.  Urinalysis is normal.  Fecal occult blood test is negative.  Plain abdominal x-ray shows no abnormalities.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Explanation: 11ec2b69_c14e_7f00_8f63_89d339c17b67_MD0005_00 This patient's presentation is concerning for acute mesenteric ischemia likely due to atrial fibrillation leading to embolic phenomenon. Acute mesenteric ischemia is typically due to sudden occlusive or nonocclusive obstruction of intestinal blood flow (arterial or venous). Occlusive ischemia is most commonly due to embolic or thrombotic involvement of the superior mesenteric system (artery or vein), segmental intestinal strangulation, or volvulus. Emboli typically are due to a dislodged cardiac thrombus (eg, underlying atrial fibrillation) that occludes the superior mesenteric artery. Superior mesenteric venous occlusion is typically due to conditions such as hypercoagulable states, portal hypertension, and abdominal infections. Nonocclusive ischemia is usually due to hypoperfusion (eg, low cardiac output) leading to splanchnic hypoperfusion and vasoconstriction. Patients usually develop sudden onset of periumbilical abdominal pain with nausea and vomiting. The pain is often out of proportion to the examination findings; the initial abdominal examination is often normal (eg, soft, nontender, and nondistended) without peritoneal signs (eg, rebound tenderness, guarding). Progression of small-bowel ischemia to infarction leads to a grossly distended abdomen, absent bowel sounds, peritoneal signs, and blood in the stools (eg, positive fecal occult blood test). As a result, diagnosis requires a high index of clinical suspicion, especially in elderly patients with risk factors (eg, atrial fibrillation, peripheral vascular disease). Marked leukocytosis, hemoconcentration, and elevated lactate resulting in metabolic acidosis are common. CT of the abdomen shows signs of small-bowel ischemia (eg, focal or segmental bowel wall thickening, intestinal pneumatosis with portal vein gas, dilated bowel, mesenteric stranding) and is helpful in excluding other causes of abdominal pain. However, the diagnosis is best established with CT angiogram. Treatment involves fluid resuscitation, correction of metabolic acidosis, broad-spectrum antibiotics, and nasogastric tube for decompression. Surgical consultation is required. (Choice A) Acute colonic ischemia is usually due to transient reduction in blood flow to the colon due to hypovolemic states or transient ischemia to the bowel. It affects primarily the watershed areas (eg, splenic flexure, rectosigmoid). Patients usually have a more lateralized abdominal pain followed by bloody diarrhea. Pain is mild to moderate (as compared to the severe pain seen with acute mesenteric ischemia) because colonic ischemia is usually not due to obstructed blood flow to the colon. (Choice B) Acute diverticulitis usually causes a more localized pain, and physical examination would show left lower-quadrant tenderness. Patients may also develop diarrhea. (Choice C) Acute intermittent porphyria is a rare disease that usually presents with recurrent episodes of abdominal pain worsened by factors including medications (eg, phenytoin), menstruation, systemic illness, and surgery. Other findings can include peripheral neuropathy, tachycardia, and hyponatremia. However, porphyria more commonly occurs earlier in life, usually after puberty. (Choice E) Patients with intestinal obstruction usually have a history of absolute constipation. Examination usually shows a distended abdomen with hyperactive bowel sounds. As the distension worsens, the bowel sounds can become hypoactive. Plain abdominal radiographs typically show dilated loops of bowel with air fluid levels. Educational objective: Acute mesenteric ischemia is typically due to sudden occlusive or nonocclusive obstruction of intestinal blood flow (arterial or venous). Risk factors include older age, atrial fibrillation, congestive heart failure, and peripheral vascular disease. Sudden onset of periumbilical abdominal pain (out of proportion to examination), normal abdominal examination without peritoneal signs, and metabolic acidosis are early clues. References: Acute mesenteric ischemia. (http://www.ncbi.nlm.nih.gov/pubmed/24267504) The role of radiology in the diagnosis and treatment of mesenteric ischaemia. (http://www.ncbi.nlm.nih.gov/pubmed/23243151)

Exam 2: Foundations of Independent Practice