Pancreatitis Diagnosis and Management, Exams of Nursing

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AAFP Board Review – GI questions with correct

answers

A 49-year-old male brings you a copy of his laboratory results obtained during an insurance examination. The patient says he feels fine, but his bilirubin level was 2.5 mg/dL (N <1.0). He says he averages 5 alcoholic beverages per week and takes no medications other than occasional ibuprofen. On examination he is not jaundiced and has no scleral icterus, and the remainder of the examination is within normal limits, including palpation of the liver and spleen. Laboratory testing reveals a normal CBC, normal liver enzyme levels, and normal serum haptoglobin. Bilirubin fractionation reveals an indirect level of 2.0 mg/dL and a direct level of 0.5 mg/dL (N <0.4). The most likely diagnosis is (check one) A. asymptomatic cholecystitis B. alcoholic liver disease C. Gilbert's syndrome D. hemolytic anemia CORRECT ANSWER C. Gilbert's syndrome Gilbert's syndrome is a hereditary condition associated with unconjugated hyperbilirubinemia (usually with

a bilirubin level <5.0 mg/dL). The bilirubin level increases with infection, exertion, and fasting. Patients are asymptomatic and have otherwise normal liver function studies. Not hemolytic anemias, which cause a decrease in serum haptoglobin, an increase in lactate dehydrogenase and/or CBC abnormalities, particularly on the peripheral smear. A 68-year-old female with diabetes mellitus, coronary artery disease, fibromyalgia, and dyspepsia presents for follow-up. She has been taking omeprazole (Prilosec) for 10 years. It was started during a hospitalization, and her symptoms have returned with previous trials of discontinuation. Which one of the following adverse events is this patient at risk for as a result of her omeprazole use? (check one) A. Hypermagnesemia B. Urinary tract infections C. Nephrolithiasis D. Hip fractures CORRECT ANSWER D. Hip fractures Which one of the following is a significant risk factor for esophageal adenocarcinoma? (check one) A. Aspirin therapy B. Ibuprofen therapy C. Helicobacter pylori infection D. Obesity E. Crohn's disease CORRECT ANSWER D. Obesity Esophageal adenocarcinoma has become the predominant type of esophageal cancer in North America and Europe, and gastroesophageal reflux and obesity are the main risk factors.

A 55-year-old female has severe symptoms of gastroesophageal reflux disease. Upper endoscopy with a biopsy shows severe esophagitis and Barrett's esophagus. Which one of the following is true regarding this patient? (check one) A. The severity of her symptoms is due to the presence of Barrett's esophagus B. Follow-up screening endoscopy will reduce her risk of death from esophageal cancer C. Her risk of developing esophageal adenocarcinoma is >90% D. Her risk of developing esophageal adenocarcinoma is <1% CORRECT ANSWER C. Her risk of developing esophageal adenocarcinoma <1% The actual risk of adenocarcinoma from Barrett's esophagus is less than 1%. Endoscopy does nothing to reduce the risk of death. Patients with Barrett's esophagus can have minimal symptoms. A 34-year-old white male letter carrier has developed progressively worsening dysphagia for liquids and solids over the past 3 months. He says that he has lost about 30 lb during that time. On examination, you note that he is emaciated and appears ill. His pulse rate is 98 beats/min, temperature 37.8°C (100.2°F), respiratory rate 24/min, and blood pressure 95/60 mm Hg. His weight is 45 kg ( lb) and his height is 170 cm (67 in). His dentition is poor, and there is evidence of oral thrush. His mucous membranes are dry. You palpate small posterior cervical and axillary nodes. The heart, lung, and abdominal examinations are normal. You promptly consult a gastroenterologist, who performs upper endoscopy, which reveals numerous small ulcers scattered throughout the esophagus with otherwise normal mucosa. As you continue to investigate, you take a more detailed history. Which one of the following is most likely to be related to the patient's problem?

(check one) A. Intravenous drug use B. A family history of esophageal cancer C. Chest pain relieved by nitroglycerin D. Recent travel to Russia CORRECT ANSWER A. IV drug use

• young man with weight loss, oral thrush, lymphadenopathy, and ulcerative esophagitis is likely to have HIV infection.
• Intravenous drug use is responsible for over a quarter of HIV infections in the United States.
• Esophageal disease develops in more than half of all patients with advanced infection during the course of their illness.
• The most common pathogens causing esophageal ulceration in HIV-positive patients include Candida, herpes simplex virus, and cytomegalovirus
• Identifying the causative agent through culture or tissue sampling is important for providing prompt and specific therapy. When considering a diagnosis of pancreatitis, amylase levels (check one) A. can help determine the severity of the disease B. are less likely to be elevated in alcoholics C. are more sensitive and specific than serum lipase levels D. are less likely to be affected by nonpancreatic conditions such as renal insufficiency CORRECT ANSWER B. Amylase and lipase levels are used to help make the diagnosis of acute pancreatitis.
• amylase is less sensitive & specific Which one of the following nutritional management strategies is associated with better outcomes in patients with mild acute pancreatitis whose pain and nausea have resolved?

(check one) A. Waiting until lipase has normalized before beginning oral intake B. Early initiation of a clear liquid diet C. Early initiation of a low-fat diet D. Early initiation of tube feeding E. Early initiation of total parenteral nutrition 70 CORRECT ANSWER D. Early low-fat diet

• bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from the gut
• patients who are provided oral feeding early in the course of acute pancreatitis have a shorter hospital stay, decreased infectious complications, decreased morbidity, and decreased mortality. You are covering the inpatient service and following up on a 67-year-old female admitted 3 days ago for severe pancreatitis. CT on admission showed edema and mild inflammation. Currently the patient is receiving intravenous fluids, daily laboratory evaluations, and pain medications. She is NPO and afebrile, with a blood pressure of 130/78 mm Hg and a pulse rate of 88 beats/min. Which one of the following therapies should be initiated to lower complication rates and shorten the patient's hospital stay? (check one) A. Enteral nutrition

B. Parenteral nutrition C. Surgical debridement D. Prophylactic antibiotics CORRECT ANSWER A. Enteral nutrition

• Prophylactic antibiotics should only be used when there is significant necrosis (SOR C).
• surgical debridement is indicated only if there is infected necrosis or persistent fluid collections (SOR C). Total parenteral nutrition is most appropriate for patients: (check one) A. With poorly functioning gastrointestinal tracts who cannot tolerate enteral feeding B. Who cannot swallow because of an esophageal motility problem C. Who refuse to eat D. In whom maintenance nutrition is desired for a short period following recovery from surgery CORRECT ANSWER A. with poorly functioning gastrointestinal tracts who cannot tolerate other means of nutritional support Tube feeding
• Patients who cannot swallow because of an esophageal motility problem and those who are resistant to feeding can be managed with tube feedings Peripheral alimentation
• short term in patients recovering from surgery A 25-year-old female presents with abdominal pain localized to the right lower quadrant. Which one of the following would be most helpful in diagnosing acute appendicitis? (check one) A. A CBC B. Urinalysis C. Plain abdominal films

D. Abdominal/pelvic ultrasonography E. Abdominal/pelvic CT CORRECT ANSWER E. Abd & pelvic CT

• all others are not as specific or sensitive A 44-year-old obese female complains of intermittent right upper quadrant pain that is worse after fatty meals. Which one of the following is the preferred initial imaging modality for evaluating her complaint and confirming the diagnosis? (check one) A. A plain radiograph B. Ultrasonography C. Cholescintigraphy D. Contrast-enhanced CT E. Contrast-enhanced MRI CORRECT ANSWER B. Ultrasonography - cholecystitis or cholelithiasis A 78-year-old white male is scheduled to undergo CT with contrast. His current diagnoses include type 2 diabetes mellitus, heart failure, anemia of chronic disease, and renal insufficiency. Evidence supports the use of which one of the following to reduce the risk of contrast-induced nephropathy in this patient? (check one) A. Intravenous furosemide B. Ascorbic acid C. Calcium antagonists D. Isotonic bicarbonate infusion E. High osmolar contrast media CORRECT ANSWER D. Isotonic bicarb infusion
• Low-osmolar or iso-osmolar contrast media should be used to prevent contrast- induced nephropathy in at-risk patients.

• hydration before the procedure, preferably with isotonic saline or isotonic sodium bicarbonate solution is best A 34-year-old female with newly diagnosed diarrhea-predominant irritable bowel syndrome (IBS) presents with worsening abdominal discomfort. Her abdominal discomfort is not severe but it is constant. She has tried dicyclomine (Bentyl) without relief and is interested in trying a different approach. The patient has had negative testing for inflammatory bowel disease and celiac disease, along with normal blood tests. She asks about specific dietary modifications or medications that may be helpful for her abdominal discomfort. Which one of the following interventions would you recommend? (check one) A. Amitriptyline B. Clarithromycin (Biaxin) C. Loperamide (Imodium) D. Increased intake of insoluble dietary fiber CORRECT ANSWER A. Amitriptyline ricyclic antidepressants (TCAs) such as amitriptyline have shown benefit in patients with irritable bowel syndrome (IBS), as have SSRIs. Because of the anticholinergic properties of TCAs it is thought that TCAs may be more beneficial than SSRIs in patients with diarrhea-predominant IBS

A 45-year-old female has ultrasonography of her kidneys as part of an evaluation for uncontrolled hypertension. The report notes an incidental finding of stones in the gallbladder, confirmed on right upper quadrant ultrasonography. She has no symptoms you can relate to the gallstones. Other than hypertension she has no chronic medical problems. Which one of the following should you recommend to her at this time regarding the gallstones? (check one) A. Expectant management B. Oral dissolution therapy C. Extracorporeal lithotripsy D. Endoscopic retrograde cholangiopancreatography (ERCP) E. Laparoscopic cholecystectomy CORRECT ANSWER A. Expectant management A 61-year-old female tells you that her brother was recently diagnosed with hereditary hemochromatosis and his physician suggested that she get tested. She feels well and has no significant health problems. Which one of the following would be most appropriate for initial screening? (check one) A. Serum transaminases B. A CBC and a serum iron level C. Testing for the HFE gene

D. Ferritin and transferrin saturation E. Total iron binding capacity CORRECT ANSWER D. Ferritin and transferrin saturation The transferrin saturation is calculated by dividing the serum iron level by the total iron binding capacity. If the serum ferritin level is elevated (>200 ng/mL in women) or the transferrin saturation is ³45% the HFE gene should be checked. A 62-year-old female with numbness in the lower extremities and macrocytosis has a normal serum folate level and a serum B12 level of 200 pg/mL (N 150-800). Which one of the following laboratory findings would confirm the diagnosis of B12 deficiency? (check one) A. Elevated angiotensin converting enzyme B. Elevated methylmalonic acid C. Elevated free erythrocyte protoporphyrin D. Low haptoglobin E. Low homocysteine CORRECT ANSWER B. Elevated methylmalonic acid

• Vitamin B12 is a cofactor in the synthesis of both methionine and succinyl coenzyme A, and vitamin B12 deficiency leads to the accumulation of methylmalonic acid and homocysteine, which are the precursors of these compounds.
• Homocysteine is also elevated in folic acid deficiency, check methylmalonic acid if serum vitamin B12 levels are 150-400 pg/mL. Not reduced haptoglobin level
• hemolytic anemia. Not elevated free erythrocyte protoporphyrin level
• lead poisoning or iron deficiency. Not elevated angiotensin converting enzyme
• sarcoidosis.

A 67-year-old male with moderate macrocytosis complains of paresthesias of his feet. If the patient has a borderline low vitamin B12 level, elevated levels of which one of the following would suggest vitamin B12 deficiency? (check one) A. Serum gastrin B. Reticulocytes C. Methylmalonic acid D. Serum ferritin E. Serum folate CORRECT ANSWER C. Methylmalonic acid

• also homocysteine levels Not Gastrin: high in pernicious anemia, but are not diagnostic alone. Not High ferritin levels: increased iron stores in the liver Not ferritin levels: hemochromatosis. A 39-year-old male with a history of alcoholism presents to your office with complaints of abdominal pain, vomiting, and nausea following a recent binge. He has eaten little since the onset of his symptoms 3 days ago. Laboratory findings suggest alcoholic ketoacidosis. His serum bicarbonate level is 16.3 mEq/L (N 22.0- 26.0). In addition to thiamine, what other treatment should be provided for this patient? (check one) A. Bicarbonate and insulin B. Glucagon (GlucaGen) and hydrocortisone C. Normal saline and glucose

D. N-acetylcysteine and pyridoxine (vitamin B6) CORRECT ANSWER C. Normal saline and glucose - Alcoholic ketoacidosis

• Blood glucose levels are usually low or normal, and volume depletion associated with nausea, vomiting, and abdominal pain
• high osmolal and anion gaps
• insulin usu low, but pt not usu hypoglycemic
• Treatment: vigorous volume repletion, thiamine and glucose Not Bicarb: Only in marked acidemia (pH <7.10) is the administration of bicarbonate thought to be necessary. Not N-acetylcysteine and pyridoxine: Not the treatment of alcoholic ketoacidosis Not glucagon and hydrocortisone: levels are typically high An elevation of serum methylmalonic acid is both sensitive and specific for a cellular deficiency of which vitamin? (check one) A. Vitamin A B. Vitamin B 6 C. Vitamin B 12 D. Vitamin D E. Folate CORRECT ANSWER C. Vitamin B 12 An 80-year-old male presents with a 10-day history of intermittent colicky abdominal pain. The pain is low and central and seems to be worse after eating. He has no associated fever or vomiting but does feel nauseated when the pain is present. He says that prior to this episode he had hard stools once or twice a week that were difficult to pass. For the past several days he has

had only watery stools, several times a day. On examination there is fullness in his left lower quadrant with nonspecific tenderness diffusely and no guarding or rebound. A urine dipstick is normal. Which one of the following is the most likely diagnosis? (check one) A. Viral gastroenteritis B. Acute colitis C. Constipation D. Urinary tract infection E. Nephrolithiasis CORRECT ANSWER C. constipation

• Rome criteria define constipation as the presence of two or more of the following:

1. straining on defecation
2. hard stools
3. incomplete evacuation
4. less than three bowel movements per week. This patient has multiple symptoms on this list. The presence of watery bowel movements does not rule out the diagnosis of constipation, as it is common for liquid stool to pass an obstructive source. A 59-year-old male with known cirrhosis is beginning to show some lower abdominal distention. Ultrasonography confirms your suspicion that he has developed moderate ascites for the first time. Which one of the following is recommended as the initial treatment of choice for this condition? (check one)

A. Chlorthalidone B. Spironolactone (Aldactone) C. Furosemide (Lasix) D. Ramipril (Altace) E. Large-volume paracentesis CORRECT ANSWER B. Spironolactone (Aldactone)

• grade 2 ascites (visible clinically by abdominal distention)
• the initial treatment: diuretics along with salt restriction
• Aldosterone antagonists such as spironolactone are more effective than loop diuretics (SOR A)
• Chlorthalidone, a thiazide diuretic, is not recommended
• Large-volume paracentesis is the recommended treatment of grade 3 ascites (gross ascites with marked abdominal distention), and is followed by salt restriction and diuretics. Which one of the following is a physiologic difference between males and females that can affect the pharmacokinetics of medications with a narrow therapeutic index? (check one) A. A consistently higher glomerular filtration rate in women B. The typically higher BMI in women C. Smaller fat stores in women D. Greater gastric acid secretion in women E. Slower gastrointestinal transit times in women CORRECT ANSWER E. Slower GI transit in women - lower the absorption of medications e.g. metoprolol, theophylline, and verapamil.
• women should wait longer after eating before taking medications that should be administered on an empty stomach e.g. ampicillin, captopril, levothyroxine, loratadine, and tetracycline.

• Women secrete less gastric acid than men, need an acidic beverage to aid in absorption of medications that require an acidic environment e.g. ketoconazole.
• Women usually have lower BMIs than men, and may need smaller loading or bolus dosages of medications to avoid unnecessary adverse reactions.
• Women typically have higher fat stores than men, so lipophilic drugs e.g. benzodiazepines and neuromuscular blockers have a longer duration of action
• Women also have lower GFR than men, resulting in slower clearance of medications that are eliminated renally, e.g. digoxin and methotrexate. 56-year-old female with well-controlled diabetes mellitus and hypertension presents with an 18-hour history of progressive left lower quadrant abdominal pain, low-grade fever, and nausea. She has not been able to tolerate oral intake over the last 6 hours. An abdominal examination reveals significant tenderness in the left lower quadrant with slight guarding but no rebound tenderness. Bowel sounds are hypoactive. Rectal and pelvic examinations are unremarkable. Which one of the following is recommended as the initial diagnostic procedure in this situation? (check one) A. CT of the abdomen and pelvis B. Abdominal and pelvic ultrasonography C. A barium enema D. Colonoscopy E. Laparoscopy CORRECT ANSWER A. CT of the abdomen and pelvis - acute diverticulitis.
• Ultrasonography may be helpful in suggesting other diagnoses, but it is not as specific or as sensitive for diverticulitis as CT. A 69-year-old male presents with a 2-week history of fever, fatigue, weight loss, and mild diarrhea. He is found to have a mildly tender mass in the left lower quadrant of the abdomen.

The most likely diagnosis is: (check one) A. Crohn's disease B. ulcerative colitis C. celiac disease D. diverticulitis E. lymphoma CORRECT ANSWER D. Diverticulitis

• left lower quadrant in the elderly and may present as an abscess Crohn's disease
• distal small intestine (regional enteritis)
• most typically in a young person
• usually in the second or third decade of life. Ulcerative colitis
• usually presents with a longer history
• does not typically present with a mass Lymphoma 2-week history of a palpable mass is not a typical presentation Celiac disease
• does not cause a palpable left lower quadrant mass. An 82-year-old male nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of multi-infarct dementia, hypertension, and hyperlipidemia. On examination he is afebrile, and a nasogastric aspirate is negative for evidence of bleeding. Which one of the following is the most likely cause of this patient's bleeding? (check one) A. Peptic ulcer disease

B. Ischemic colitis C. Diverticular bleeding D. Angiodysplasia E. Infectious colitis CORRECT ANSWER B. Ischemic colitis Diverticular bleeding and angiodysplasia are painless Infectious colitis is associated with fever. A 64-year-old white male presents to the emergency department with a 48-hour history of left lower quadrant pain. After a thorough history and a physical examination you conclude that the patient has diverticulitis. The patient is allergic to metronidazole (Flagyl). You recommend a clear-liquid diet, a follow-up visit with his primary care physician in 48 hours, and treatment with: (check one) A. amoxicillin B. amoxicillin/clavulanate (Augmentin) C. ciprofloxacin (Cipro) D. doxycycline E. azithromycin (Zithromax) CORRECT ANSWER B. An accepted regimen for outpatient treatment of diverticulitis is amoxicillin/clavulanate, 875 mg every 12 hours.

• The other regimens are not optimal treatments because they do not include anaerobic coverage. A 52-year-old female with morbid obesity is incidentally noted to have mildly elevated AST

(SGOT) levels. She does not consume alcohol and denies using recreational drugs. A workup for chronic viral hepatitis and hemochromatosis is negative. Which one of the following is most likely to improve her hepatic condition? (check one) A. Pentoxifylline B. Simvastatin (Zocor) C. L-carnitine D. Vitamin E E. Weight loss CORRECT ANSWER E. Weight loss A healthy diet, weight loss, and exercise are first-line therapeutic measures to reduce insulin resistance in patients with nonalcoholic fatty liver disease. Which one of the following nutritional interventions should be recommended to accelerate pressure ulcer healing in the elderly? (check one) A. Supplemental arginine B. Oral vitamin C and zinc C. High-dose multivitamins D. Adequate protein intake CORRECT ANSWER D. Adequate protein intake

• Very few nutritional interventions have been shown to accelerate pressure ulcer healing in the elderly. p Maintaining a protein intake of at least 1.2-1.5 g/kg/day is recommended, and some authorities recommend 2 g/kg/day with stage III or IV ulcers.
• Increased caloric intake is also necessary to promote healing

A 70-year-old white male with hypertension has several abnormal liver function tests on routine testing. He says he does not drink alcohol, and the prescription medications he is taking are unlikely to cause hepatotoxicity. However, during more extensive history taking, he tells you that he does use some over-the-counter medications. Which one of these is most likely responsible for the abnormal laboratory findings? (check one) A. Aspirin, used occasionally for headache B. A fiber supplement taken to promote regular bowel habits C. One long-acting niacin tablet per day D. One 250-mg vitamin C tablet daily E. Chewable simethicone after meals, almost daily CORRECT ANSWER C. Niacin Hepatotoxicity resulting from timed-release formulations of niacin has been reported in elderly individuals Patients may be taking this supplement without their physician's knowledge, feeling it is safe because it is a vitamin Not Aspirin and vitamin C

• gastrointestinal iron loss and anemia In a patient with chronic hepatitis B, which one of the following findings suggests that the infection is in the active phase? (check one) A. A normal liver biopsy B. Detectable levels of HBeAb C. Detectable levels of HBsAb D. Elevated levels of ALT E. Undetectable levels of HBV DNA CORRECT ANSWER D. Elevated levels of ALT - also HBeAg, indicating high levels of HBV DNA anti-HBeAg, Carrier Stat

• Anti-HBe
• normalization of liver enzymes
• greatly reduced levels of hepatitis B virus in the bloodstream. An otherwise healthy 40-year-old male comes to your office for follow-up of elevated liver enzymes on an insurance examination. He is 173 cm (68 in) tall and weighs 113 kg (250 lb) (BMI 37.7 kg/m2). He says he drinks about two beers per week. Findings are normal on a physical examination, except for a slightly enlarged liver. AST and ALT levels are twice the upper limits of normal. Which one of the following would be the most appropriate next step? (check one) A. A liver biopsy B. Ultrasonography of the liver C. Colonoscopy D. Testing for viral hepatitis E. Repeat AST and ALT levels in 3 months CORRECT ANSWER D. Testing for viral hepatitis - hep B & hep C should be ruled out; even if Nonalcoholic fatty liver disease is the most likely diagnosis
• pt's alcohol consumption of less than two drinks per week makes alcoholic fatty liver disease unlikely
• A liver biopsy would not be appropriate at this time
• Liver ultrasonography should be considered after hepatitis B and C are ruled out.
• The patient is younger than the recommended screening age for colonoscopy. Which one of the following is found most consistently in patients diagnosed with irritable bowel syndrome? (check one) A. Passage of blood per rectum B. Passage of mucus per rectum

C. Abdominal pain D. Constipation E. Diarrhea CORRECT ANSWER C. Abdominal pain abdominal pain as the most consistent feature found in irritable bowel syndrome (IBS), and its absence makes the diagnosis less likely. A 26-year-old female presents with a 1-year history of recurring abdominal pain associated with intermittent diarrhea, 5-7 days per month. Her pain improves with defecation. There has been no blood in her stool and no weight loss. Laboratory findings are normal, including a CBC, chemistry profile, TSH level, and antibodies for celiac disease. Which one of the following would be most appropriate at this point? (check one) A. Colonoscopy B. An upper GI series with small-bowel follow-through C. Abdominal CT with contrast D. A gluten-free diet E. Loperamide (Imodium) CORRECT ANSWER E. Loperamide Rome criteria

• 3 days per month of abdominal pain for the past 3 months
• a change in the frequency of stool
• and improvement with defecation. According to current clinical guidelines IBS can be diagnosed by history, physical examination, and routine laboratory testing, as long as there are no warning signs.
• Warning signs include rectal bleeding, anemia, weight loss, fever, a family history of colon cancer, onset of symptoms after age 50, and a major change in symptoms. Colonoscopy, CT, and GI contrast studies are not indicated.
• A gluten-free diet would not be indicated since the antibody tests for celiac disease are negative

A 65-year-old asymptomatic female is found to have extensive sigmoid diverticulosis on screening colonoscopy. She asks whether there are any dietary changes she should make. In addition to increasing fiber intake, which one of the following would you recommend? (check one) A. Limiting intake of dairy products B. Limiting intake of spicy foods C. Limiting intake of wheat flour D. Limiting intake of nuts E. No limitations on other intake CORRECT ANSWER E. No limitations on other intake Patients with diverticulosis should increase dietary fiber intake or take fiber supplements to reduce progression of the diverticular disease. Avoidance of nuts, corn, popcorn, and small seeds has not been shown to prevent complications of diverticular disease A 43-year-old female presents to your office for evaluation of a chronic cough that has been present for the past 6 months. She is not a smoker, and is not aware of any exposure to environmental irritants. She does not have any systemic complaints such as fever or weight loss, and does not have any symptoms of heartburn or regurgitation. She is not on any regular medications. Auscultation of the lungs and a chest radiograph show no evidence of acute disease. A trial of an inhaled bronchodilator and antihistamine therapy does not improve the patient's symptoms. Which one of the following would be the most appropriate next step? (check one) A. A methacholine inhalation challenge test B. Pulmonary function testing

C. CT of the chest D. A trial of a proton pump inhibitor E. 24-hour pH monitoring CORRECT ANSWER D. trial of a proton pump inhibitor - Gastroesophageal reflux disease (GERD) is one of the most common causes of chronic cough.

• Aggressive acid reduction using a proton pump inhibitor twice daily before meals for 3-4 months is the best way to demonstrate a causal relationship between GERD and extra-esophageal symptoms (SOR B). Methacholine inhalation testing
• not necessary since symptomatic asthma has been ruled out by the lack of response to bronchodilator therapy. Chest CT and pulmonary function tests
• are not indicated given the lack of findings from the history, physical examination, and chest film to suggest underlying pulmonary disease A 62-year-old male on hemodialysis develops a pruritic rash on his arms and chest, with erythematous, thickened plaques and edema. He had brain imaging with a gadolinium-enhanced MRI for neurologic symptoms 10 days ago. Which one of the following is true regarding this problem? (check one) A. A skin biopsy is diagnostic B. The problem is limited to the skin C. Immediate treatment is critical D. The disease is more common in males E. Death from the disease is unusual CORRECT ANSWER A. A skin biopsy is diagnostic - gadolinium-associated nephrogenic systemic fibrosis
• after use of gadolinium-based contrast material in patients with severe renal dysfunction, often on dialysis.

• Associated proinflammatory states e.g. surgery, malignancy, and ischemia, are often present as well
• Dermatologic manifestations are usually seen, but multiple organ systems may be involved.
• There is no effective treatment, and mortality is approximately 30%. A deep biopsy of the affected skin is diagnostic. Over the last 6 months a developmentally normal 12-year-old white female has experienced intermittent abdominal pain, which has made her quite irritable. She also complains of joint pain and general malaise. She has lost 5 kg (11 lb) and has developed an anal fissure. Which one of the following is the most likely cause of these symptoms? (check one) A. Celiac disease (gluten enteropathy) B. Irritable bowel syndrome C. Hepatitis A D. Crohn's disease E. Giardiasis CORRECT ANSWER D. Crohn's disease
• The most common age of onset: adolescence then 50-80 years of age
• systemic signs and symptoms are more common than with ulcerative colitis
• Perianal disease is also common IBS & viral gastroenteritis
• no weight loss and anal lesions are extremely uncommon
• historical and epidemiologic findings in this case are not consistent with either of these infections Celiac disease and giardiasis
• can have diarrhea and weight loss
• no anal fissures.

Which one of the following is a frequent cause of cross-reactive food-allergy symptoms in latex-allergic individuals? (check one) A. Avocadoes B. Goat's milk C. Pecans D. Pastrami E. Peppermint CORRECT ANSWER A. Avocadoes Latex allergy has IgE antibodies that cross-react with some proteins in plant- derived foods. A 70-year-old Asian male presents with hematochezia. He has stable vital signs. Lower endoscopy is performed, but is unsuccessful due to active bleeding. Which one of the following would be most appropriate at this point? (check one) A. Abdominal CT B. A barium enema C. A technetium-99m blood pool scan D. Exploratory laparotomy E. A small-bowel radiograph CORRECT ANSWER C. A technetium-99m blood pool scan

• localizing the bleeding site, rather than diagnosing the cause of the bleeding, is the most important task Lower GI series
• usually nondiagnostic during heavy, active bleeding Blood pool scan