A
B
Repeat from Part 1
100
A 66 yo man is evaluated for a several year history of 1 to 3 bulky, semisolid, foul-smelling bowel movements daily that are associated with excess flatulence. Associated symptoms are episodic epigastric pain, a ravenous appetite, and a 9.0 kg weight loss over the last year. Medical history is notable for alcoholism; he has not consumed alcohol since his last attack of pancreatitis 15 years ago. He has an 80 pack year history of smoking but currently does not smoke. He takes no medications.
On exam, temp is 37.0, BP 133/72, HR 77, RR 14. BMI is 21. He is thin with temporal wasting and poor dentition. Abdominal exam reveals mild epigastric tenderness with no masses. Liver and spleen are not enlarged. Borborygmi is audible without a stethoscope. There is no abdominal distension or jaundice.
Labs reveal a serum albumin of 3.3, serum lipase of 46, and tissue transglutaminase is negative.
Abdominal ultrasound shows pancreatic calcification but no masses. Fecal fat testing reveals a stool fat of 40 g/d.
What is the most appropriate treatment?
What are pancreatic enzymes?
100
A 63 yo man is evaluated for a 1 month history of painless jaundice. He has not had pancreatitis, weight loss, oily stools, or DM. He has never smoked cigarettes and has consumed alcohol only minimally and rarely. His medical and family history is unremarkable and he takes no medications.
On exam, his vitals are within normal limits. BMI is 27. Jaundice is noted. Abdominal exam reveals epigastric tenderness without guarding or rebound.
Labs:
ALT 132
AST 121
Alk Phos 353
Total bilirubin 4.2
Serum IgG4 Elevated
MRCP shows features of sclerosing cholangitis, focal enlargement of the head of the pancreas with a featureless border, and a non-dilated pancreatic duct.
What is the most appropriate management?
What is prednisone?
100
A 35 yo man is evaluated during a follow-up appointment for persistent heartburn with chronic cough. He has a 1-year history of gastroesophageal reflux disease and takes pantoprazole twice daily. He reports no nausea, vomiting, or dysphagia. Upper endoscopy performed 1 year earlier showed no abnormal findings.
His vital signs and physical examination are normal. Results of an ear, nose, and throat evaluation are noncontributory.
What is the most appropriate next diagnostic test?
What is ambulatory pH monitoring?
200
A 31 yo woman is evaluated for a 9 year history of episodic attacks of idiopathic pancreatitis. She previously had no pain between attacks; however, over the last 6 months, epigastric pain has become more constant and has increased in severity. The pain has not responded well to enzyme replacement, ibuprofen, and acetaminophen. She was recently started on tramadol with modest but not sufficient relief of her symptoms. Current medications include enteric-coated pancreatic enzymes, ibuprofen, and tramadol.
On exam, vital signs are normal; BMI is 24. Abdominal pain reveals epigastric and LUQ abdominal tenderness without guarding or rebound.
CT shows evidence of chronic pancreatitis. There is no pancreatic cyst, mass, enlargement, or pancreatic ductal dilation and no bile duct dilation or gallstones. Endoscopic US confirms findings of chronic pancreatitis.
What is the most appropriate additional treatment?
What is a gabapentinoid?
200
A 35 yo man is evaluated in the ED for a 6 hour history of epigastric abdominal pain that radiates to the back. he also has nausea and occasional bilious vomiting. he has consumed between 6-12 beers daily for 10-15 years.
On exam, temp is 99.0 F, BP 110/65, HR 105, RR 22. Exam reveals epigastric tenderness without guarding or rebound. Bowel sounds are present but hypoactive, and there is mild abdominal distention. No jaundice is noted.
Labs reveal a WBC of 14, BUN of 25, and lipase of 952.
Abd US shows a normal appearing gallbladder and no biliary distention. he is admitted to the hospital. Over the next 48 hours, he has ongoing abdominal pain and nausea, and poor appetite despite supportive therapy consisting of pain medication and aggressive IV fluid replacement. Subsequent CT of the abd shows nonenhancing areas of the head and body of the pancreas (consistent with necrosis) and several peripancreatic fluid collections.
What is the most appropriate next step in management?
What is enteral nutrition by NJ tube?
200
A 65 yo man is evaluated with upper endoscopy in follow-up for Barrett esophagus. He has had heartburn for more than 15 years, but his symptoms have been well controlled with daily omeprazole. He reports no weight loss or pain with swallowing and has no history of anemia. He stopped smoking 5 years earlier, but has a 40-pack-year history.
Vital signs and the remainder of the physical examination are normal.
On upper endoscopy, an area of salmon-colored mucosa is seen in the esophagus. Biopsies confirm evidence of Barrett esophagus with low-grade dysplasia. The pathology slides were reviewed by a second pathologist, confirming the presence of low-grade dysplasia.
Which of the following is the most appropriate next step in management?
What is endoscopic ablation therapy?
300
A 55 yo woman is evaluated during a routine examination. She underwent biliopancreatic diversion with duodenal switch 8 years ago for treatment of obesity related complications and lost 150 lb in the 1st year following surgery. Her weight has been relatively stable for the last year. She has had chronic nonbloody diarrhea since her bariatric surgery. She also has generalized fatigue, dry skin, dry and itchy eyes, and increased difficulty seeing road signs at night while driving. Her other medical problems are type 2 DM and HTN. She takes metformin and lisinopril as well as an OTC multivitamin with iron. Her last colonoscopy, performed 5 years ago, was normal.
On exam, BP is 140/79, HR 63. BMI is 25. Exam is otherwise unremarkable.
Labs show a Hgb of 10.5 with MCV of 95.
What deficiency best explains this patient's current findings?
What is vitamin A deficiency?
300
A 68 yo woman undergoes upper endoscopy for evaluation of dyspepsia. She has a history of pernicious anemia. She has no other medical problems and her only medication is oral b12.
On exam, vital signs are normal, as is the remainder of the exam.
Upper endoscopy discloses a 6 mm polyp in the body of the stomach, which is removed by polypectomy. Other endoscopic findings, including biopsy of the duodenum to evaluate for celiac disease, are normal. Pathologic examination of the polyp confirms a well differentiated neuroendocrine tumor.
The fasting serum gastrin level is 1025 pg/mL.
What is the most appropriate management?
What is observation?
300
A 25 yo man is evaluated for a sensation of solid food “sticking” several times per week. He reports that he sometimes forces himself to vomit when he feels food “stuck” in the esophagus, but he has never gone to the emergency department. He takes a multivitamin and is generally healthy.
On physical examination, vital signs and other findings, including those of an abdominal examination, are unremarkable.
Upper endoscopy findings are shown.
Biopsies of the esophagus show more than 18 eosinophils/hpf.
What is the most likely diagnosis?
What is EOE?
400
A 51 yo woman is evaluated in the ED after running her car into a stop sign several hours ago. EMS reported that she had confusion, tremulousness, and low blood glucose level, all which resolved after ingestion of glucose tablets. Her medical history is significant for a 1.5 year history of episodic confusion. She has no history of diabetes mellitus and has not used insulin or oral hypoglycemic agents. She has not had upper abdominal pain, pancreatitis, weight loss. She takes no medications.
In the ED, vital signs and exam are normal.
To further investigate the hypoglycemia, she is admitted to the hospital for a 72 hour fast. Confusion is observed after 10 hours of fasting, but the neuro exam is otherwise nonfocal. Blood samples are immediately drawn and the symptoms resolve with administration of glucose.
Labs show an elevated C-peptide level, plasma glucose of 45, and an elevated fasting insulin level.
CT shows a normal appearing pancreas?
What is the most appropriate diagnostic test to perform next?
What is endoscopic US?
400
A 55 yo man is evaluated in the ED for a 6 hour history of severe epigastric abdominal pain and n/v. In the previous 6 weeks, he had 2 episodes of postprandial right upper quadrant pain. He is otherwise healthy and takes no medications.
On exam, temp is 36.8, BP 130/75, HR 89, RR 17. BMI is 29. Scleral icterus is present. Abdominal exam reveals epigastric abdominal tenderness without guarding or rebound. Bowel sounds are present but hypoactive, and there is abdominal distention.
He is admitted to the hospital and fluid resuscitation is started.
Labs:
WBC 14,000 --> 12,000
ALT 350 --> 98
AST 310 --> 86
T bili 4.5 --> 1.6
Lipase 3250 --> 1220
Abdominal US shows cholelithiasis with no gallbladder wall thickening or pericholecystic fluid. The common bile duct is not dilated. There is no choledocholithiasis.
What is the most appropriate management prior to discharge?
What is cholecystecomy prior to hospital discharge?
400
A 25-year-old man is evaluated for worsening heartburn of 4 months' duration, despite treatment with twice-daily omeprazole. He has no pertinent personal or family medical history and takes no other medication.
On physical examination, vital signs and other findings are normal.
Upper endoscopy shows a normal esophagus with a normal gastroesophageal junction. The stomach has 30 small (<10 mm) sessile polyps seen in the fundus. The duodenum is normal. Pathology of a polyp shows it to be a fundic gland polyp.
What is the most appropriate next step in evaluation of this patient?
What is colonoscopy?