Liver disease — MCQs

A 53-year-old woman presents to your office with several months of fatigue and abdominal pain. The pain is dull in character and unrelated to meals. She has a history of type 2 diabetes mellitus and rheumatoid arthritis for which she is taking ibuprofen, methotrexate, and metformin. She has 2-3 drinks on the weekends and does not use tobacco products. On physical examination, there is mild tenderness to palpation in the right upper quadrant. The liver span is 15 cm at the midclavicular line. Laboratory results are as follows: Serum: Na+: 135 mEq/L Cl-: 100 mEq/L K+: 3.7 mEq/L HCO3-: 24 mEq/L BUN: 13 mg/dL Creatinine: 1.0 mg/dL Alkaline phosphatase: 100 U/L AST: 70 U/L ALT: 120 U/L Bilirubin (total): 0.5 mg/dL Bilirubin (conjugated): 0.1 mg/dL Amylase: 76 U/L What is the most likely cause of her clinical presentation?

A 44-year-old man comes to the physician because of a 2-week history of lower extremity swelling and frothy urine. He has a history of chronic hepatitis C infection. Physical examination shows 3+ pitting edema of the lower legs and ankles. Further evaluation of this patient is most likely to show which of the following?

A 71-year-old man is brought to the emergency department by his daughter after she found him to be extremely confused at home. She says that he appeared to be fine in the morning; however, upon returning home, she found that he was slumped in his chair and was hard to arouse. She was worried that he may have taken too many medications and rushed him to the emergency department. His past medical history is significant for bipolar disorder and absence seizures. He does not smoke and drinks 4 alcoholic beverages per night on average. On physical exam, he is found to have a flapping tremor of his hands, pitting ankle edema, and gynecomastia. He does not appear to have any focal neurologic deficits. Which of the following lab findings would most likely be seen in this patient?

A 20-year-old man, who was previously healthy, is taken to the emergency department due to agitation during the past 24 hours. During the past week, his family members noticed a yellowish coloring of his skin and eyes. He occasionally uses cocaine and ecstasy, and he drinks alcohol (about 20 g) on weekends. The patient also admits to high-risk sexual behavior and does not use appropriate protection. Physical examination shows heart rate of 94/min, respiratory rate of 13/min, temperature of 37.0°C (98.6°F), and blood pressure of 110/60 mm Hg. The patient shows psychomotor agitation, and he is not oriented to time and space. Other findings include asterixis, jaundice on the skin and mucous membranes, and epistaxis. The rest of the physical examination is normal. The laboratory tests show: Hemoglobin 16.3 g/dL Hematocrit 47% Leukocyte count 9,750/mm3 Neutrophils 58% Bands 2% Eosinophils 1% Basophils 0% Lymphocytes 24% Monocytes 2% Platelet count 365,000/mm3 Bilirubin 25 mg/dL AST 600 IU/L ALT 650 IU/L TP activity < 40% INR 1.5 What is the most likely diagnosis?

A 52-year-old man presents to his primary care physician for generalized pain. The patient states that he feels like his muscles and bones are in constant pain. This has persisted for the past several weeks, and his symptoms have not improved with use of ibuprofen or acetaminophen. The patient has a past medical history of alcohol abuse, repeat episodes of pancreatitis, constipation, and anxiety. He has a 22 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 140/95 mmHg, pulse is 70/min, respirations are 15/min, and oxygen saturation is 99% on room air. On physical exam, you note generalized tenderness/pain of the patient's extremities. Abdominal exam reveals normoactive bowel sounds and is non-tender. Dermatologic exam is unremarkable. Laboratory values are ordered as seen below. Hemoglobin: 12 g/dL Hematocrit: 36% Leukocyte count: 7,500/mm^3 with normal differential Platelet count: 147,000/mm^3 Serum: Na+: 138 mEq/L Cl-: 100 mEq/L K+: 4.2 mEq/L HCO3-: 24 mEq/L BUN: 20 mg/dL Glucose: 99 mg/dL Creatinine: 1.0 mg/dL Ca2+: 10.2 mg/dL Alkaline phosphatase: 252 U/L Lipase: 30 U/L AST: 12 U/L ALT: 10 U/L Which of the following is associated with this patient's condition?

A 32-year-old man comes to the physician for a follow-up examination. He has a 2-month history of increasing generalized fatigue and severe pruritus. He has hypertension and ulcerative colitis which was diagnosed via colonoscopy 5 years ago. Current medications include lisinopril and rectal mesalamine. He is sexually active with 2 female partners and uses condoms inconsistently. His temperature is 37.3°C (99.1°F), pulse is 86/min, and blood pressure is 130/84 mm Hg. Examination shows scleral icterus and multiple scratch marks on the trunk and extremities. The lungs are clear to auscultation. The abdomen is soft and nontender. The remainder of the examination shows no abnormalities. Laboratory studies show: Hemoglobin 11.5 g/dL Leukocyte count 7500/mm3 Platelet count 280,000/mm3 Serum Na+ 138 mEq/L Cl- 101 mEq/L K+ 4.7 mEq/L Urea nitrogen 18 mg/dL Glucose 91 mg/dL Creatinine 0.8 mg/dL Bilirubin Total 1.5 mg/dL Direct 0.9 mg/dL Alkaline phosphatase 460 U/L AST 75 U/L ALT 78 U/L Anti-nuclear antibody negative Antimitochondrial antibodies negative Abdominal ultrasound shows thickening of the bile ducts and focal bile duct dilatation. Which of the following is the most likely diagnosis?

A 48-year-old man is brought to the emergency department by his wife 20 minutes after she witnessed him vigorously shaking for about 1 minute. During this episode, he urinated on himself. He feels drowsy and has nausea. He has a history of chronic alcoholism; he has been drinking 15 beers daily for the past 3 days. Before this time, he drank 8 beers daily. His last drink was 2 hours ago. He appears lethargic. His vital signs are within normal limits. Physical and neurologic examinations show no other abnormalities. On mental status examination, he is confused and not oriented to time. Laboratory studies show: Hematocrit 44.0% Leukocyte count 12,000/mm3 Platelet count 320,000/mm3 Serum Na+ 112 mEq/L Cl- 75 mEq/L K+ 3.8 mEq/L HCO3- 13 mEq/L Urea nitrogen 6 mEq/L Creatinine 0.6 mg/dL Albumin 2.1 g/dL Glucose 80 mg/dL Urgent treatment for this patient's current condition puts him at increased risk for which of the following adverse events?

A 50-year-old woman presents with esophageal varices, alcoholic cirrhosis, hepatic encephalopathy, portal hypertension, and recent onset confusion. The patient’s husband does not recall her past medical history but knows her current medications and states that she is quite disciplined about taking them. Current medications are spironolactone, labetalol, lactulose, and furosemide. Her temperature is 38.3°C (100.9°F), heart rate is 115/min, blood pressure is 105/62 mm Hg, respiratory rate is 12/min, and oxygen saturation is 96% on room air. On physical examination, the patient is disoriented, lethargic, and poorly responsive to commands. A cardiac examination is unremarkable. Lungs are clear to auscultation. The abdomen is distended, tense, and mildly tender. Mild asterixis is present. Neurologic examination is normal. The digital rectal examination reveals guaiac negative stool. Laboratory findings are significant for the following: Basic metabolic panel Unremarkable Platelet count 95,500/µL Leukocyte count 14,790/µL Hematocrit 33% (baseline is 30%) Which of the following would most likely be of diagnostic value in this patient?

A 46-year-old man comes to the emergency department because of a 10-day history of right upper quadrant abdominal pain. He has also been feeling tired and nauseous for the past 6 weeks. On examination, scleral icterus is present. Abdominal examination shows tenderness to palpation in the right upper quadrant. The liver edge is palpated 2 cm below the right costal margin. Laboratory studies show: Aspartate aminotransferase 1780 U/L Alanine aminotransferase 2520 U/L Hepatitis A IgM antibody Negative Hepatitis B surface antigen Negative Hepatitis B surface antibody Negative Hepatitis B core IgM antibody Positive Hepatitis C antibody Positive Hepatitis C RNA Negative Which of the following is the best course of action for this patient?

A 48-year-old woman comes to the emergency department because of a photosensitive blistering rash on her hands, forearms, and face for 3 weeks. The lesions are not itchy. She has also noticed that her urine has been dark brown in color recently. Twenty years ago, she was successfully treated for Coats disease of the retina via retinal sclerotherapy. She is currently on hormonal replacement therapy for perimenopausal symptoms. Her aunt and sister have a history of a similar skin lesions. Examination shows multiple fluid-filled blisters and oozing erosions on the forearms, dorsal side of both hands, and forehead. There is hyperpigmented scarring and patches of bald skin along the sides of the blisters. Laboratory studies show a normal serum ferritin concentration. Which of the following is the most appropriate next step in management to induce remission in this patient?