USMLE Step 2CK Question #1

A 48-year-old homeless man presenting with severe abdominal pain. He has been hospitalized 6 times in the past year for similar complaints. Hospital records indicate multiple admissions with alcohol intoxication. The pain radiates to his back, and is accompanied by nausea and vomiting. The patient has a temperature of 103F, but does not permit an abdominal exam. Laboratory analysis indicates elevated gamma glutamyl transpeptidase and an AST/ALT ratio > 2. What is the most likely diagnosis?

A – Cholecystitis

B – Pancreatitis

C – Choledocholithiasis

D – Duodenal peptic ulcer

E – Gallbladder cancer

Question of the Week #482

A 63-year-old woman comes to the emergency department complaining of severe midabdominal pain. She reports that the pain has increased in intensity over the past few days. There has been no associated nausea or vomiting, no change in bowel habits, and no relief afforded by position changes. She is postmenopausal and does not take hormone replacement therapy. She has a 30-year history of hypertension, and has been noncompliant with her therapy of calcium channel blocker and thiazide diuretic. On examination her abdomen is obese but there is a suggestion of a nontender, pulsatile mass in the epigastric region. The remainder of the physical examination is normal. Which of the following is the best next step in management?

A. Abdominal ultrasound
B. Abdominal CT scan without contrast
C. Abdominal CT scan with contrast
D. Angiography
E. Observation

Question of the Week # 471

A 14-year-old girl with a history of Crohn’s disease presents with 2-day history of feeling ‘feverish’, malaise, lower abdominal pain and non-bloody diarrhea. She has about 10 episodes of diarrhea daily. She has had three similar episodes in the past 7 years. She denies any recent travel or sick contacts, rush, cough or other symptoms of infection. She has no known allergies and does not take any medications currently. She has been taking 5-ASA, but stopped 6 months ago as she had been asymptomatic for 10 months before that. On presentation, the patient is afebrile with a body temperature of 101.0 F and appears ill. Her blood pressure is 120/80 mmHg and heart rate of 90 beats/minute.  Abdominal examination is remarkable for abdominal tenderness in the lower abdomen, but no rebound or guarding. A subsequent CT scan shows dilatation of the left colonic lumen, as well as a thickened colon wall with pericolic fat stranding, particularly in the left colon. The admitting team determines the patient’s presentation is due to exacerbation of her disease. The patient is started on 5-ASA, metronidazole and prednisone and her condition improves within 10 days when she is symptom-free. What is the most appropriate plan after her symptoms have resolved?

A)     Continue 5-ASA, taper prednisone and discontinue metronidazole
B)      Continue 5-ASA and prednisone, discontinue metronidazole
C)      Discontinue ASA-5 and metronidazole and continue prednisone for 4 weeks, followed by taper
D)     Recommend therapy with infliximab an instruct to take 5-ASA when she starts experiencing symptoms, discontinue prednisone and metronidazole
E)      Continue 5-ASA and metronidazole for at least 4 weeks, taper prednisone

Question of the Week # 464

464) A 68 year old man with history of Diabetes Mellitus type II and diabetic gastroparesis  is evaluated in your office for lack of appetite, nausea, vomiting, weight loss and a feeling full after eating small amounts of food material. He has lost 10 lbs weight in past 2 months. He denies any rectal bleeding or melena. He does report some epigastric discomfort. On examination, he appears in no distress, blood pressure is at 120/80. Abdomen is mildly distended with slight tenderness in upper abdomen. Patient is admitted and started on IV hydration. A plain X-ray abdomen is shown below. Gastroenterology is consulted and an upper endoscopy is pending. What is the most appropriate evidence-based next step?

gastric

A) Arrange for Laparoscopy
B) Endoscopic removal
C) Give Coca-Cola
D) Give Pepsi or any other soda
E) Metoclopramide

Question of the Week # 462

462) A 39 year old man is seen in your office for swelling of the abdomen and shortness of breath of several months’ duration. He is an active smoker and smoked about 1 pack per day for 20 years. He drinks alcohol occasionally. He denies any cough or fever. On examination, he is afebrile with a temperature of 98.1F , respiratory rate of 18/min, pulse 88/min and blood pressure at 120/70 mm Hg. Cardiac examination reveals regular heart sounds and no S3 gallop. Chest examination shows decreased breath sounds, increased antero-posterior diameter and hyper-resonance to percussion.  Abdominal exam is significant for fluid wave and shifting dullness. Liver is enlarged. No splenomegaly.

Labs reveal :

Hemoglobin : 14.2gm%

Serum creatinine 1.0mg%

Albumin 3.2gm%

Total bilirubin 1.0 mg%

Alkaline phosphatase 90 U/L

AST ( Aspartate aminotransferase) 160 U/L

ALT (Alanine aminotransferase) 190 U/L

Which of the following is most helpful in establishing the diagnosis

A. Serum Ferritin

B. Serum Ceruloplasmin leve

C. Anti-Actin and Smooth muscle antibodies

D. 2D Echocardiogram

E. Serum Alpha-1 anti-trypsin level.

Question of the Week # 458

458) A 65-year-old man is brought to the emergency department after having two large bowel movements over the past hour that consisted of bright red blood and no stool in the past 3 hours. He denies any abdominal pain or nausea, but does recall having crampy abdominal discomfort after eating over the last several days. His past medical history is significant for hypertension and diabetes and his medications include lisinopril, metoprolol and metformin. He had a colonoscopy at the age of 55 which was unremarkable. On presentation, his temperature is 37.0°C (98.6°F), blood pressure is 80/60 mm Hg, and pulse is 110/min. His abdomen is soft and nontender. There is no guarding or rebound tenderness. There is fresh red blood in the rectum, but there are no palpable masses. Intravenous fluid boluses are started. Which of the following is the most appropriate next step in the management of this patient?
A. Perform upper gastrointestinal endoscopy
B. Order a CT scan of the abdomen
C. Order a nuclear bleeding scan of the colon
D. Perform a colonoscopy
E. Perform nasogastric aspiration

Question of the Week # 455

You are evaluating a 63-year-old female with a complaint of abdominal pain radiating to her back. She has diminished appetite and pruritus. Her past history is significant for a 40-year history of tobacco use. She has three glasses of wine once a week.

The patient is afebrile, with blood pressure of 123/85, and her heart rate is 74. She appears jaundiced, with scleral icterus. Her abdomen is tender to palpation in the epigastric region, and her liver is palpable 2 cm below the right costal margin. Laboratory tests reveal total bilirubin of 6.0. direct bilirubin of 4.8, alkaline phosphatase of 1000, and AST is 42, with and ALT of 40. Which of the following initial diagnostic test will you order?

A. Abdominal ultrasound

B. Percutaneous liver biopsy

c. Percutaneous transhepatic cholangiography

D. CT abdomen and pelvis

E. Endoscopic retrograde cholangio-pancreatography.

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