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1 | |
A 24-year-old patient known to be infected with HIV- 1 presents with a 2-week history of intermittent bloody diarrhea, urgency, abdominal pain, and malaise. Stool culture for enteropathogenic organisms is negative, and analysis for ova and parasites is similarly unrevealing. The patient is taking no medication. The diarrheal symptoms do not respond to a course of trimethoprim-sulfamethoxazole. Colonoscopic examination reveals multiple areas of ulceration and mucosal erosion. Biopsy reveals the presence of cells containing a large, densely staining nucleus and abundant intracytoplasmic inclusions. The most appropriate therapy for this patient is |
| | A) | pentamidine |
| | B) | pyrimethamine |
| | C) | ganciclovir |
| | D) | acyclovir |
| | E) | isoniazid |
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2 | |
A 48-year-old woman develops fevers, chills, and icteric sclera. In addition to a fever of 39.2°C (102.5°F), the physical examination is remarkable for an ill-appearing jaundiced female with right upper quadrant pain. Ultrasonography reveals a dilated common bile duct with stones in the gallbladder and in the duct itself. The patient is placed on broad-spectrum antibiotics to cover organisms known to infect the biliary tract. The procedure most appropriate now is |
| | A) | laparotomy to canulate the common bile duct, remove the stone, and perform a cholecystectomy |
| | B) | laparoscopic cholecystectomy |
| | C) | placement of an external stent for bilary drainage |
| | D) | endoscopic retrograde cholangiopancreatography |
| | E) | antibiotics for several days |
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3 | |
A 45-year-old man says that for the past year he occasionally has regurgitated food particles eaten several days earlier. His wife complains that his breath has been foul-smelling. He has had occasional dysphagia for solid foods. The most likely diagnosis is |
| | A) | gastric outlet obstruction |
| | B) | scleroderma |
| | C) | achalasia |
| | D) | Zenker's diverticulum |
| | E) | diabetic gastroparesis |
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4 | |
A 57-year-old man seeks attention in the emergency department for weakness and melena, which he has had for 3 days. He says he has not had significant abdominal pain and had no prior gastrointestinal bleeding. On examination he is disheveled and unshaven, appears older than his stated age, and has a 20 mmHg orthostatic drop in blood pressure. Findings include bilateral temporal wasting, anicteric and pale conjunctivae, spider angiomas on his upper torso, muscle wasting, hepatosplenomegaly, and hyperactive bowel sounds without abdominal tenderness to palpation. Stool is melenic. Nasogastric aspiration reveals "coffee-grounds" material, which quickly clears with lavage. Hematocrit is 30 percent, and mean corpuscular volume is 105 fL. Saline gastric lavage is initiated. The appropriate next step in the management of this man's illness would be to |
| | A) | perform gastroscopy |
| | B) | pass a Sengstaken-Blakemore tube and begin an intravenous infusion of vasopressin (Pitressin) |
| | C) | order an upper gastrointestinal series |
| | D) | order immediate visceral angiography |
| | E) | insert a large-bore intravenous line and type and cross-match the man's blood |
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5 | |
A 42-year-old woman presents with a complaint of watery diarrhea and abdominal pain that has occurred intermittently over the past 4 years. After the passage of three or four loose stools in the morning, she feels well for the rest of the day and never has nocturnal diarrhea. Physical examination reveals an anxious woman with a tender left lower abdominal quadrant and no fecal material in the rectum; the results are otherwise normal. Sigmoidoscopic examination discloses excess mucus, but the mucosa appears normal. Barium enema is normal except for sigmoid spasticity, and examination of a stool specimen reveals well-formed feces that are negative for blood, pathogenic bacteria, and parasites. Results of thyroid studies are normal. A trial of milk restriction results in no change in symptoms. At this point the physician should |
| | A) | consider a trial of diphenoxylate or loperamide to control symptomatic diarrhea |
| | B) | tell the patient that her symptoms are largely emotional in origin |
| | C) | consider a trial of psyllium to increase stool bulk |
| | D) | obtain stool electrolytes and osmolality |
| | E) | perform a jejunal aspirate and analyze the fluid for parasites |
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6 | |
Which of the following statements about achalasia is correct? |
| | A) | The underlying abnormality appears to be defective innervation of the esophageal body and lower gastric sphincter |
| | B) | Dysphagia, chest pain, and regurgitation are the predominant symptoms |
| | C) | Chest x-rays often reveal a large gastric air bubble |
| | D) | Manometry reveals a normal or elevated pressure of the lower gastric sphincter |
| | E) | Omeprazole is effective in controlling the symptoms in many patients |
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7 | |
A 75-year-old woman with a history of aspirin-induced gastritis 5 years ago now has severe knee and hip pain that is thought to be due to osteoarthritis. She requires treatment with nonsteroidal anti-inflammatory agents. Which of the following agents would be most helpful for prophylaxis against recurrent gastrointestinal bleeding? |
| | A) | Omeprazole |
| | B) | Misoprostol |
| | C) | Nizatidine |
| | D) | Sucralfate |
| | E) | Atropine |
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8 | |
Which of the following statements regarding eosinophilic enteritis is correct? |
| | A) | Peripheral blood eosinophilia is rare. |
| | B) | It affects only the small intestine. |
| | C) | The majority of patients have a history of food allergies or asthma. |
| | D) | Treatment with glucocorticoids is not indicated. |
| | E) | It may be difficult to distinguish from regional enteritis. |
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9 | |
A 50-year-old man without significant past medical history or recent exposure to alcohol presents with midepigastric abdominal pain, nausea, and vomiting. The physical examination is remarkable for the absence of jaundice and any other specific physical findings. Which of the following is the best strategy for screening for acute pancreatitis? |
| | A) | Measurement of serum amylase |
| | B) | Measurement of serum lipase |
| | C) | Measurement of both serum amylase and serum lipase |
| | D) | Isoamylase level analysis |
| | E) | Magnetic resonance imaging |
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10 | |
Which of the following statements regarding primary biliary cirrhosis (PBC) is correct? |
| | A) | A positive anti-pus antibody test is present in more than 90 percent of these patients. |
| | B) | Glucocorticoid treatment is helpful. |
| | C) | The majority of these patients are men. |
| | D) | Administration of D-penicillamine appears to be an effective treatment. |
| | E) | Rheumatoid arthritis, CREST syndrome, and scleroderma occur with increased frequency in patients with PBC. |
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11 | |
A 19-year-old female exchange student from London has had bouts of jaundice, fever, malaise, arthralgias, and marked elevation of hepatic transaminases over the past 6 months. The patient was not exposed to hepatotoxic drugs. Hypergammaglobulinemia has been noted. Serologic evaluation for infection with hepatitis A, B, and C has been negative, as have tests for systemic lupus. Liver biopsy now reveals bridging necrosis. Which of the following tests will be most helpful in confirming the diagnosis? |
| | A) | Rheumatoid factor |
| | B) | Hemoglobin electrophoresis |
| | C) | Antibodies to liver and kidney microsomal antigens |
| | D) | Antibodies to hepatitis D virus |
| | E) | Antibodies to hepatitis E virus |
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12 | |
Which of the following is an important physiologic function of bile acids? |
| | A) | Conjugation with toxic substances, thus allowing their excretion |
| | B) | Allowing the excretion of hemoglobin breakdown products |
| | C) | Aiding the absorption of vitamin B12 |
| | D) | Facilitating absorption of dietary fats |
| | E) | Maintaining appropriate intestinal pH |
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13 | |
A 37-year-old man with chronic alcoholism is admitted to the hospital with acute pancreatitis. On the third hospital day sudden, complete blindness develops in the left eye. The most likely explanation is |
| | A) | alcohol withdrawal symptoms |
| | B) | transient ischemic attack (transient monocular blindness) |
| | C) | occlusion of the retinal vein |
| | D) | acute glaucoma |
| | E) | Purtscher's retinopathy |
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14 | |
In which one of the following situations would therapy with oral chenodeoxycholic acid be most effective in dissolving gallstone(s)? |
| | A) | A 27-year-old Asian woman with thalassemia |
| | B) | A 49-year-old woman with two 2-cm stones |
| | C) | A 60-year-old man with gallstones visible on chest x-ray |
| | D) | A 45-year-old woman with a history of gallstone pancreatitis and a residual 1-cm radiolucent gallstone |
| | E) | A 55-year-old man with a history of biliary colic, several small gallstones seen on ultrasonography, and a poorly opacified gallbladder after oral cholecystography |
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15 | |
Which of the following could falsely depress the serum amylase level in a patient suspected of having acute pancreatitis? |
| | A) | Hypertriglyceridemia |
| | B) | Hypercholesterolemia |
| | C) | Hypocalcemia |
| | D) | Associated pleural effusion |
| | E) | Associated intestinal infarction |
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16 | |
Mechanical obstruction of the colon is most commonly caused by |
| | A) | adhesions |
| | B) | carcinoma |
| | C) | volvulus |
| | D) | hernia |
| | E) | sigmoid diverticulitis |
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17 | |
In which of the following causes of fatty liver is microvesicular fat seen in biopsy specimens of liver? |
| | A) | Jejunoileal bypass for morbid obesity |
| | B) | Acute fatty liver of pregnancy |
| | C) | Total parenteral nutrition |
| | D) | Prolonged intravenous hyperalimentation |
| | E) | Carbon tetrachloride poisoning |
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18 | |
A 35-year-old woman complains of right upper quadrant pain, which occurs after she eats a large meal. Occasionally the episodes are accompanied by nausea and vomiting. A plain x-ray of the abdomen discloses gallstones. Ultrasonography reveals gallstones and a normal- sized common bile duct. The patient's blood chemistry and CBC are normal. The most therapeutic maneuver at this time would be |
| | A) | observation |
| | B) | laparoscopic cholecystectomy |
| | C) | ursodeoxycholic acid |
| | D) | shock wave lithotripsy |
| | E) | ursodeoxycholic acid and shock wave lithotripsy |
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19 | |
A 22-year-old woman with a history of ulcerative colitis presents with jaundice, pruritus, and intermittent right upper quadrant abdominal pain. The most likely finding on ERCP is |
| | A) | malignant stricture of the common bile duct |
| | B) | stones in the common bile duct |
| | C) | normal findings |
| | D) | diffuse strictures |
| | E) | blocked ampula of vater |
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20 | |
Chronic active hepatitis is most reliably distinguished from chronic persistent hepatitis by the presence of |
| | A) | extrahepatic manifestations |
| | B) | hepatitis B surface antigen in the serum |
| | C) | antibody to hepatitis B core antigen in the serum |
| | D) | a significant titer of anti-smooth-muscle antibody |
| | E) | characteristic liver histology |
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