Gastroenterology — MCQs

A 35-year-old man presents with acute-onset right flank pain. He says that his symptoms began suddenly 6 hours ago and have not improved. He describes the pain as severe, colicky, and ‘coming in waves’. It is localized to the right flank and radiates to the groin. He says he has associated nausea. He denies any fever, chills, dysuria, or hematuria. His past medical history is significant for asymptomatic nephrolithiasis, diagnosed 9 months ago on an upright abdominal radiograph, which has not yet been treated. The patient’s vital signs include: temperature 37.0°C (98.6°F), blood pressure 145/90 mm Hg, pulse 119/min, and respiratory rate 21/min. On physical examination, the patient is constantly moving and writhing with pain. There is severe right costovertebral angle tenderness. The remainder of the physical examination is unremarkable. A urine dipstick shows 2+ blood. A noncontrast CT of the abdomen and pelvis reveals a 4-mm-diameter radiopaque stone at the right ureteropelvic junction. Several nonobstructing small-diameter stones are noted in the left kidney. Mild hydronephrosis of the right kidney is noted. Intravenous fluids are started and ondansetron is administered. Which of the following is the next best step in the management of this patient?

A 44-year-old woman comes to the physician because of a 2-year history of progressive dysphagia. She initially had symptoms only when consuming solid foods, but for the past 2 months she has also had difficulty swallowing liquids. She describes a feeling of food “getting stuck” in her throat. She was diagnosed with gastroesophageal reflux disease 2 years ago and has had episodic pallor of her fingers since adolescence. She has smoked half a pack of cigarettes daily for 24 years. Her only medication is omeprazole. Her pulse is 65/min, respirations are 12/min, and blood pressure is 127/73 mm Hg. Examination shows thickening of the skin of her fingers, with small white papules on her fingertips. There are small dilated blood vessels on her face, lips, and tongue. Cardiopulmonary examination shows no abnormalities. Which of the following is the most likely cause of this patient's dysphagia?

A previously healthy 30-year-old woman comes to the physician because of a 6-month history of a recurring rash that typically occurs on exposure to the sun and affects only the face. She also has noticed several nonpainful ulcers on the roof of her mouth. She is sexually active with one male partner and they use condoms inconsistently. Her mother has end-stage renal disease. The patient does not smoke or drink alcohol. Her vital signs are within normal limits. Physical examination shows an erythematous rash across the cheeks that spares the nasolabial folds. There are three small ulcers on the hard palate. Laboratory studies show: Leukocyte count 3,000/mm3 Platelet count 70,000/mm3 Erythrocyte sedimentation rate 80 mm/h Serum Antinuclear antibodies 1:320 Anti-Smith antibodies positive Urine Protein 3+ RBC casts negative RBCs none WBCs 10–15/hpf Which of the following is the most appropriate next step in management?

A 56-year-old woman presents to the emergency department with muscle weakness. She reports her symptoms have progressively worsened over the course of 2 weeks and are most significant in her lower extremities. She also notices increased urinary frequency. Approximately 1 month ago she was diagnosed with a calcium phosphate nephrolithiasis. Medical history is significant for rheumatoid arthritis diagnosed approximately 10 years ago treated with methotrexate, and type II diabetes mellitus treated with metformin. Her temperature is 98.6°F (37°C), blood pressure is 138/92 mmHg, pulse is 92/min, and respirations are 17/min. On physical exam, there is mild tenderness to palpation of the metacarpophalangeal and proximal interphalangeal joints. There is 4/5 power throughout the lower extremity. Laboratory testing is shown. Serum: Na+: 137 mEq/L Cl-: 106 mEq/L K+: 2.9 mEq/L HCO3-: 18 mEq/L Glucose: 115 mg/dL Creatinine: 1.0 mg/dL Urine pH: 5.6 Which of the following is the best next step in management?

A 23-year-old man complains of lower back pain that began approximately 6 months ago. He is unsure why he is experiencing this pain and notices that this pain is worse in the morning after waking up and improves with physical activity. Ibuprofen provides significant relief. He denies bowel and bladder incontinence or erectile dysfunction. Physical exam is notable for decreased chest expansion, decreased spinal range of motion, 5/5 strength in both lower extremities, 2+ patellar reflexes bilaterally, and an absence of saddle anesthesia. Which of the following is the most appropriate next test for this patient?

A 46-year-old woman presents to the emergency department complaining of abdominal pain, nausea, and vomiting approximately 4 hours after a fatty meal. She reports that this has happened before, but this episode is worse. The vomit was non-bilious and did not contain any blood. She recalls frequent episodes of vague epigastric pain that often wakes her up during the night. Over the counter omeprazole and a small meal or snack would provide some relief in the past. The patient also mentions recent anorexia and early satiety. She takes over the counter ibuprofen several times a week for headaches. Blood pressure is 125/82 mm Hg, pulse is 102/min, and respiratory rate is 19/min. On physical examination, she has hypoactive bowel sounds, and her abdomen seems grossly distended and tympanic on percussion. Which of the following is most consistent with a duodenal ulcer?

A 32-year-old man comes into your office because of pain in his right knee, left elbow, and left wrist. It started about a week ago but has particularly localized to his wrist. The patient states that he has 2 sexual partners. He states he has also had some white discharge from his penis with pruritis and pain during urination. His temperature is 97.6°F (36.4°C), blood pressure is 124/84 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam reveals pain upon palpation of the patient's left wrist which also appears erythematous and swollen. What is the best next step in management for this patient?

A 47-year-old woman comes to the physician because of a 2-week history of gradually worsening facial and lower extremity swelling. She has had a 4-kg (8.8-lb) weight gain during this time. Her blood pressure is 150/88 mm Hg. Examination shows periorbital edema and 2+ pretibial edema bilaterally. A 24-hour collection of urine shows 4.0 g of proteinuria. Microscopic examination of a kidney biopsy specimen shows thickening of the glomerular basement membrane. Electron microscopy shows dense subepithelial deposits. Further evaluation is most likely to show which of the following?

A 72-year-old man presents to his primary care physician complaining of increasing difficulty sleeping over the last 3 months. He reports waking up frequently during the night because he feels an urge to move his legs, and he has a similar feeling when watching television before bed. The urge is relieved by walking around or rubbing his legs. The patient’s wife also notes that she sometimes sees him moving his legs in his sleep and is sometimes awoken by him. Due to his recent sleep troubles, the patient has started to drink more coffee throughout the day to stay awake and reports having up to 3 cups daily. The patient has a past medical history of hypertension and obesity but states that he has lost 10 pounds in the last 3 months without changing his lifestyle. He is currently on hydrochlorothiazide and a multivitamin. His last colonoscopy was when he turned 50, and he has a family history of type II diabetes and dementia. At this visit, his temperature is 99.1°F (37.3°C), blood pressure is 134/81 mmHg, pulse is 82/min, and respirations are 14/min. On exam, his sclerae are slightly pale. Cardiovascular and pulmonary exams are normal, and his abdomen is soft and nontender. Neurologic exam reveals 2+ reflexes in the bilateral patellae and 5/5 strength in all extremities. Which of the following is most likely to identify the underlying etiology of this patient's symptoms?

A 38-year-old man comes to the physician because of upper abdominal discomfort for 2 weeks. He has had 3–4 episodes of vomiting during this period. Over the last year, he has had frequent episodes of abdominal pain at night that were relieved by eating. He underwent a right shoulder surgery 6 weeks ago. He has no history of serious illness. He has smoked one pack of cigarettes daily for 14 years. He drinks one to two beers daily. He has a history of illicit drug use, but has not used for the past 15 years. He is sexually active with three female partners and uses condoms inconsistently. His only medication is daily naproxen. He returned from a 2-week vacation to Mexico one month ago. He appears uncomfortable. His temperature is 39.5°C (103.1°F), pulse is 90/min, and blood pressure is 110/70 mm Hg. Examination shows a soft abdomen with mild tenderness to palpation in the right upper quadrant. Bowel sounds are normal. Rectal examination is unremarkable. Test of the stool for occult blood is positive. His hemoglobin concentration is 13.1 g/dL, leukocyte count is 23,100/mm3, and platelet count is 230,000/mm3. Abdominal ultrasound shows a 2-cm hypoechoic lesion with some internal echoes in an otherwise normal looking liver. Which of the following is the most likely cause for the sonographic findings?