Gastroenterology
An 80-year-old woman is hospitalized for a 1-day history of abrupt-onset, mild, diffuse lower abdominal cramping and discomfort, followed several hours later by initially loose, nonbloody stools that evolved into hematochezia. She has subsequently passed six bloody stools. She has no fever, chills, nausea, or melenic stool. She reports no recent exposure to sick persons, antibiotic use, travel, or NSAID use.
On physical examination, blood pressure is 150/85 mm Hg. Other vital signs are normal. Abdominal examination shows mild mid-abdominal tenderness to deep palpation, no distention, and no rebound or guarding. Rectal examination reveals a small amount of bright red blood on the examining finger.
Laboratory studies:
Leukocyte count
14,000/μL (85% neutrophils)
Hemoglobin 12.5 g/dL (125 g/L)
Platelet count 205,000/μL
CT scan of the abdomen and pelvis with intravenous contrast shows marked wall thickening of the transverse and descending colon with patent arterial and venous vessels. There are no mass lesions or diverticula.
What is the cause of the bleeding?
Ischemic Colitis
A 72-year-old man is evaluated in the emergency department for acute chest and back pain. Medical history is remarkable for hypertension, type 2 diabetes mellitus, and cigarette smoking. Medications are losartan, hydrochlorothiazide, metoprolol succinate, and metformin.
On physical examination, blood pressure is 200/100 mm Hg in the left upper extremity and 170/100 mm Hg in the right upper extremity, and pulse rate is 102/min; other vital signs are normal. Cardiac examination is unremarkable other than the tachycardia.
ECG shows sinus tachycardia but is otherwise normal. Chest radiograph shows a widened mediastinum. CT angiogram of the chest shows an aortic dissection extending from the aortic root to the distal abdominal aorta with extension into the proximal brachiocephalic artery.
Name the medication you start
Iv beta blocker
A 71-year-old patient is evaluated during a follow-up visit. They were recently evaluated for dysphagia. Upper endoscopy identified a nonobstructing mass in the middle third of the esophagus, and biopsy revealed squamous cell carcinoma.
Does he need immunotherapy and biopsy to confirm for it's use? Why or why not
Yes. Studies show that adding the PD-1 checkpoint immune inhibitor nivolumab to chemotherapy improved overall survival in patients with metastatic esophageal squamous cell cancer, including those without increased PD-1 expression.
68-year-old man is evaluated in the ICU after being admitted 1 day ago for community-acquired pneumonia. . On admission, he was intubated for acute respiratory failure. He has a history of hypertension, hyperlipidemia, and COPD with carbon dioxide retention.
pH7.49
Pco2 46 mm Hg
Blood urea nitrogen 18 mg/dL
Creatinine
1.2 mg/dL
Sodium
136 mEq/L
Potassium 4.9 mEq/L
Chloride
98 mEq/L
Bicarbonate 32 mEq/L
What is his acid base disorder?
Posthypercapnic metabolic alkalosis
A 52-year-old man is evaluated in the emergency department for abdominal pain and an associated 4.5-kg (10-lb) weight loss during the past 2 months. Painful sores on his legs appeared 1 month ago.
On physical examination, blood pressure is 165/100 mm Hg and pulse rate is 105/min; other vital signs are normal. Abdominal examination discloses diffuse tenderness without peritoneal signs or organomegaly. There are a tender 3-cm ulcer with central necrosis on the left shin and two similar-appearing 1-cm ulcers on the right lateral ankle.
Laboratory studies:
Erythrocyte sedimentation rate
88 mm/h H
C-reactive protein 4.0 mg/dL H
ALT 45 U/L H
AST 55 U/L H
Creatinine 1.3 mg/dL
6 months ago: 0.9 mg/dL (79.6 μmol/L)
Urinalysis results are unremarkable.
Abdominal CT angiogram demonstrates saccular microaneurysms and areas of narrowing in the mesenteric, celiac, and right renal arteries.
What is the diagnosis and virus associated?
polyarteritis nodosa (PAN)/hepatitis B
Name the two types of microscopic colitis
Name the treatment
Name a medication associated with causing it
Microscopic colitis has two subtypes: lymphocytic colitis and collagenous colitis
Budesonide
NSAIDS, SSRI's, proton pump inhibitors
Name two reasons for endocarditis prophylaxis
AND
name two drugs, one must be for PCN allergy
amoxicillin
cephalexin, azithromycin, clarithromycin, or doxycycline
A 69-year-old man is evaluated in the emergency department for a 1-week history of abdominal pain and concomitant nausea with no vomiting, fevers, or chills. Medical history is significant for hypertension and COPD. Medications are losartan and inhaled tiotropium.
On physical examination, the patient appears uncomfortable. Blood pressure is 136/90 mm Hg, pulse rate is 84/min, and respiration rate is 16/min. Oxygen saturation is 98% breathing ambient air. Abdominal examination reveals mild tenderness in the periumbilical area without rebound tenderness or guarding.
Laboratory studies:
Hemoglobin 13.9 g/dL
Leukocyte count 5600/μL
Platelet count 278,000/μL
A comprehensive metabolic panel is normal.
CT scan of the abdomen shows a portal vein thrombosis; the liver is normal in size and appearance.
What test to order next?
JAK-2
A 27-year-old woman is evaluated in the emergency department for protracted diarrhea, nausea, and inability to tolerate liquids or solid food
On physical examination, blood pressure is 86/58 mm Hg, and pulse rate is 114/min. The patient is alert and oriented. Mucous membranes are dry. There is poor skin turgor.
Blood urea nitrogen
30 mg/dL H
Creatinine 1.1 mg/dL (97.2 µmol/L)
Sodium 126 mEq/L
Chloride 98 mEq/L (98 mmol/L)
Bicarbonate 18 mEq/L (18 mmol/L)
Urine sodium 5.0 mEq/L (5.0 mmol/L)
Urine osmolality 600 mOsm/kg H2O
What treatment do you order first?
Isotonic fluids
An 18-year-old man is evaluated in the emergency department for 3 days of worsening abdominal and knee pain, as well as a rash. He completed an antibiotic course for streptococcal pharyngitis 2 weeks ago. Medical history is otherwise noncontributory, and he takes no medications.
On physical examination, vital signs are normal. There are petechiae and palpable purpura over the buttocks and on both lower extremities. Abdominal examination reveals diffuse tenderness without peritoneal signs. Warmth and swelling in both knees are present; knees are tender along the joint lines. The remainder of the examination is normal.
Laboratory studies show a normal complete blood count with differential, complete metabolic panel, venous lactate level, prothrombin time, and partial thromboplastin time.
CT scan of the abdomen shows multifocal areas of bowel wall thickening and mesenteric lymphadenopathy
what is the disease/what test to order next?
urinalysis, IgA vasculitis (henoch-Schönlein purpura)
Name a medication for treatment of MASH other than GLP-1
Name the drug's mechanism
Name a relative contraindiction to it's use
Rezdiffa (resmetirom)
thyroid hormone receptor-beta agonist
Cirrhosis
A 58-year-old woman is evaluated for daily heart palpitations. She has no chest pain, shortness of breath, syncope, or presyncope, but she finds the palpitations uncomfortable. Medical history is significant for hypertension and sleep apnea. Her only medication is lisinopril.
On physical examination, vital signs are normal. Cardiac examination detects occasional ectopy.
Results of routine laboratory studies, including thyroid-stimulating hormone level, are within normal ranges.
ECG shows sinus rhythm and is otherwise normal. Forty-eight–hour ambulatory ECG monitoring shows occasional premature atrial contractions (~5%) and 10 runs of atrial tachycardia (longest, 10 beats; fastest, 150/min) that correlate with symptoms of palpitations. Transthoracic echocardiogram is normal.
Name a medication to start
Beta blocker (or CCB)
A 42-year-old woman is evaluated before discharge following hospitalization for alcohol withdrawal. She has had alcohol use disorder for many years but says she is now willing to do whatever it takes to quit. She does not use opioids or other nonprescribed substances. She also has hypertension and chronic kidney disease. Medications are amlodipine and chlorthalidone.
Physical examination, including vital signs, is normal.
Laboratory studies:
Estimated glomerular filtration rate
25 mL/min/1.73 m2
What medication do you start? Which medication is contraindicated?
Naltrexone
Acamprosate (GFR)
75 year old male with AKI
2-day history of swelling, pain, and redness of the left leg and low-grade fever
5-cm area of erythema and edema over the left shin with associated tenderness.
c3 43 (low)/ c4 normal
urinalysis: 3+ protein, 3+ blood
Urine protein-creatinine ratio
2600 mg/g
Kidney biopsy shows endocapillary proliferation on light microscopy, codominant granular staining for C3 complement and IgA on immunofluorescence microscopy, and subepithelial hump-like deposits on electron microscopy
what is the cause of the kidney injury and the most likely organism?
infection-related glomerulonephritis
staph aureus
A 31-year-old woman is hospitalized for markedly elevated blood pressure, preceded by 1 week of headache and visual blurring. She has a 2-year history of diffuse cutaneous systemic sclerosis with anti-RNA polymerase III antibody positivity. Medications are omeprazole and mycophenolate mofetil.
On physical examination, blood pressure is 215/105 mm Hg and pulse rate is 88/min. Skin thickening is noted from the forearms to the fingers and over the anterior chest, neck, and feet. Several fingers on both hands are cyanotic.
Laboratory studies:
Hematocrit 32% L
Leukocyte count 6000
Platelet count 120,000/µL L
Haptoglobin Undetectable
Creatinine 2.1 mg/dL (185.6 µmol/L) H
Urinalysis
2+ protein; trace blood
Peripheral blood smear shows schistocytes.
name the disease and medication to start
scleroderma renal crisis/captopril
44-year-old man is evaluated because of persistent abnormal liver test results. He is asymptomatic. He drinks five cans of beer daily. He is of northern European descent and has no known family history of liver disease. His only medical condition is obesity, and he takes no medications.
On physical examination, vital signs and other findings are normal.
Laboratory studies:
Platelet count 432,000/μL
Albumin 4.4 g/dL (44 g/L)
Alkaline phosphatase 98 U/L H
ALT 96 U/L H
AST 87 U/L H
Bilirubin 0.8 mg/dL (13.6 µmol/L)
Iron 229 µg/dL (40.9 µmol/L) H
Transferrin saturation 81.7% H
Ferritin 822 ng/mL H
HFE gene variant testing
C282Y heterozygous
Results of viral hepatitis, autoimmune hepatitis, and Wilson disease testing are negative.
Ultrasound of the abdomen shows increased liver echogenicity consistent with steatosis.
What is the cause of his liver disease?
MAFLD
64 yo male with EF of 30%, telemetry shows HR sinus rhythm 75-85, patient already on max dose coreg (carvedilol), farxiga, entresto, aldactone
what medication do you add next?
Ivabradine
A 62-year-old man is evaluated in the hospital for fever, joint pain, rash, and pancytopenia. Three years ago, he began to experience episodes of joint pain and swelling of the knees, elbows, wrists, and ankles. He has also experienced episodic rash and eruptions of tender red nodules on the legs. Additional symptoms include episodic fever and pain and erythema of the ears. He has not seen a physician in many years and does not have any known medical conditions.
On physical examination, temperature is 38.2 °C (100.1 °F); other vital signs are normal. Erythema is observed on the external ears bilaterally; the ear lobes are spared. Heart, lung, and abdominal examinations are normal. The elbows and wrists are warm and tender to palpation. Synovitis of the knees and ankles and modest knee effusions are observed. Multiple tender erythematous nodules and diffuse plaques are noted over the legs.
Laboratory studies:
Erythrocyte sedimentation rate 104 mm/h H
Hemoglobin
7.5 g/dL (75 g/L) L
Mean corpuscular volume 99 fL
Leukocyte count
2200/μL L
Platelet count
43,000/μL (43 × 109/L) L
Rheumatoid factor Negative
Antinuclear antibodies Negative
Anti–cyclic citrullinated peptide antibodies Negative
A skin biopsy specimen from a lesion reveals neutrophilic dermatosis. A bone marrow biopsy specimen demonstrates vacuolated granulocytic and erythroid precursors without evidence of tumor infiltration
What is the syndrome?
VEXAS syndrome
his inflammatory disorder develops in late adulthood and occurs almost exclusively in men; manifestations include fever, cytopenias, characteristic vacuoles in myeloid and erythroid precursors, dysplastic bone marrow, neutrophilic cutaneous and pulmonary inflammation, chondritis, ocular involvement, venous thrombosis, and vasculitis.
UBA1 gene
A 45-year-old man is evaluated in the hospital for worsening kidney function. He was admitted 2 days ago with hypertensive emergency (blood pressure, 228/124 mm Hg) and acute kidney injury, prompting initiation of intravenous nicardipine.
On physical examination, BP is 146/92 mm Hg; other vital signs are normal. Examination is remarkable only for 1+ bilateral lower extremity edema. Urine output in the past 24 hours is 1 L.
What is the cause of the AKI and name a test to prove it
thrombotic microangiopathy (TMA)
peripheral smear
A 35-year-old patient is hospitalized for recent hemoptysis in the setting of 6 months of progressive shortness of breath and cough. They also report 3 weeks of bilateral leg swelling and lower extremity rash. One week ago, right foot weakness developed.
On physical examination, blood pressure is 95/70 mm Hg and pulse is 105/min. Pulmonary examination reveals crackles at both lung bases. A palpable rash is shown. Right foot dorsiflexion is 3/5.
Laboratory studies:
Hemoglobin 10.5 g/dL L
C3 complement Normal
C4 complement Normal
Creatinine 3.2 mg/dL H
Anti–double-stranded DNA antibody titer
Negative
Antinuclear antibody titer
1:320
Antiglomerular basement membrane antibody titer
Negative
ANCA
Positive (p-ANCA pattern)
Cryoglobulin
Negative
Urinalysis
2+ blood; 3+ protein; 20-30 erythrocytes/hpf
Bronchoalveolar lavage reveals progressive bloody aliquots.
Kidney biopsy specimen shows pauci-immune crescentic glomerulonephritis.
what is the diagnosis?
Microscopic polyangitis
A 24-year-old woman is evaluated for intermittent abdominal pain associated with vomiting for the past 2 months. She has restricted her food intake because she fears that it will trigger her symptoms. As a result, she has lost 2.3 kg (5 lb). The patient reports no dysphagia, diarrhea, joint pain, or fever. She has asthma and is allergic to penicillin and shellfish. Her mother also has asthma. Her only medication is an albuterol inhaler.
Physical examination findings, including vital signs, are normal.
Laboratory studies:
Eosinophil differential count 11%
Erythrocyte sedimentation rate Normal
Hemoglobin Normal
Total IgE Normal
Upper endoscopy shows normal gastric mucosa. Duodenal aspirate is negative for parasites and Helicobacter pylori. Gastric biopsy specimens are negative for H. pylori.
Name another thing to look for on the biopsy for diagnosis and your diagnosis
Eosinophils
Eosinophilic gastritis
Name an anti-arrythmic medication you should avoid in structural heart disease or post MI?
Bonus: what was the name of the trial
1c flecainide
CAST trial
Name the immune mediated demyelinating disease characterized by positive aquaporin-4 anitbodies
Neuromyelitis Optica
50-year-old woman is evaluated for gross hematuria and severe bilateral flank pain that began 3 days ago, for which she has been taking ibuprofen and acetaminophen. Medical history is significant for hyperlipidemia, hypertension, and chronic kidney disease secondary to membranous nephropathy.
Albumin
1.9 g/dL (19 g/L) L
Creatine kinase 150 U/L
Creatinine
3.2 mg/dL
3 months ago:2.0 mg/dL
Lactate dehydrogenase 1550 U/L
Urine protein-creatinine ratio
12,000 mg/g
Urinalysis
Specific gravity 1.010; 3+ protein; large blood; positive leukocyte esterase; no nitrites; erythrocytes too numerous to count
What is the cause of the AKI?
Renal Vein Thrombosis
A 76-year-old man undergoes follow-up evaluation for acute gout of the left knee, which developed during hospitalization for heart failure exacerbation. He was diagnosed 4 days ago after synovial fluid analysis revealed needle-shaped, negatively birefringent intracellular crystals; Gram stain was negative. Intra-articular methylprednisolone followed by intravenous methylprednisolone, 60 mg/d for 3 days, have not relieved his pain. He previously developed a rash after receiving colchicine. He also has hypertension. Medications are furosemide, lisinopril, metoprolol, heparin, and morphine as needed.
On physical examination, vital signs are normal. The left knee is warm, swollen, and tender.
Blood and synovial fluid cultures are negative.
Name the medication to give
Canakinumab