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B
C
Bonus
100
A 20-year-old man is evaluated for epigastric pain that has gradually increased in severity over 8 months. The pain worsens with eating and is not relieved by antacids. He reports no melena, diarrhea, or constipation. PMH is unremarkable and he takes no medication.
On examination, vital signs are normal. Epigastric tenderness to palpation is noted. Other findings are normal.
A complete blood count is normal.
What is the most appropriate next step?
What is H Pylori testing?
100
A 38 yo man is evaluated for epigastric discomfort and early satiety associated with an unintentional 4.5-kg (9.9-lb) weight loss over the preceding 5 months. His family history includes lobular breast cancer diagnosed in his mother at age 45 years, stomach cancer diagnosed in his maternal grandfather at age 48 years, and stomach cancer diagnosed in his maternal uncle at age 52 years. The patient's medical history is unremarkable, and he takes no medication.
On physical examination, vital signs are normal. Abdominal examination shows epigastric tenderness to palpation and normal bowel sounds.
What is the most appropriate diagnostic test to perform next?
What is EGD?
100
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?
100
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?
200
A 65 yo man is evaluated after a positive stool antigen test for Helicobacter pylori infection obtained to confirm eradication after therapy. H. pylori gastritis was diagnosed in the setting of a duodenal ulcer. Four weeks ago, he completed a 10-day course of eradication therapy consisting of amoxicillin, clarithromycin, and omeprazole. He reports taking all medications as prescribed during treatment and reports no upper gastrointestinal symptoms or melena. The patient does not smoke cigarettes or drink alcohol. He has no known drug allergies.
What is the most appropriate 14-day treatment regimen?
What is Bismuth, metronidazole, omeprazole, and tetracycline for 14 days?
200
A 45 yo man is evaluated for a 2-month history of a burning sensation starting in his stomach and radiating into his chest, usually occurring 4 to 5 times weekly. He says that he usually eats dinner late and then goes to sleep. He often wakes up with a sour taste in his mouth. He reports no dysphagia or unintentional weight loss. He takes no medication.
On physical examination, vital signs are normal; BMI is 34. The remainder of the examination, including abdominal examination, is unremarkable.
What is the most appropriate next step in management?
What is empiric treatment with a PPI?
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.
What is the most appropriate next step in management?
What is endoscopic ablation therapy?
300
A 66 yo man is evaluated for breakthrough symptoms of GERD despite once-daily pantoprazole. He has a 5-year history of GERD.
On physical examination, his blood pressure is 118/70 mm Hg, pulse rate is 76/min, and respiratory rate is 18/min; BMI is 30. The abdomen is soft, nontender, and nondistended. Bowel sounds are hyperactive. The remainder of the examination is unremarkable.
Upper endoscopy shows Barrett esophagus. Biopsy results are indefinite for dysplasia.
What is the most appropriate next step in management?
What is optimization of medical therapy followed by repeat upper endoscopy?
300
A 55 yo man is evaluated for progressive dysphagia of 2 years' duration. He reports dysphagia to both solid food and liquids. He has cardiomyopathy, with an ejection fraction of 15%. His medications are pantoprazole, furosemide, valsartan, digoxin, metoprolol, low-dose aspirin, and amiodarone. He is unable to walk up two flights of stairs without stopping. He does not drink or smoke.
On physical examination, his blood pressure is 100/65 mm Hg, pulse rate is 90/min, and respiratory rate is 22/min; BMI is 32. His examination is remarkable for fine crackles at the lung bases posteriorly, a third heart sound, and 2+ pitting edema to the knees.
Upper endoscopy shows no masses. A barium esophagram is shown.
What is the most appropriate treatment?
What is botulinum toxin injections?
300
A 45 yo woman is evaluated for episodic nausea, bloating, and epigastric pain of 5 years' duration. In the past 3 months, the nausea has been accompanied by occasional vomiting. She also reports near-daily heartburn symptoms that have not responded to daily omeprazole. She has a 10-year history of type 2 diabetes mellitus that is treated with metformin and glyburide.
On physical examination, vital signs are normal; BMI is 29. Abdominal examination shows diffuse tenderness to deep palpation with no guarding. Other findings are normal.
Laboratory studies show a blood hemoglobin A1c level of 7.5%. The basic metabolic panel is normal. A complete blood count and liver chemistry tests are normal.
Upper endoscopy shows a moderate amount of retained food in the stomach and patchy erythema of the gastric mucosa. Biopsies of the stomach are normal.
What is the most appropriate next step in management?
What is a gastric emptying scintigraphy?
400
A 75-year-old woman with longstanding GERD comes to the office with concerns related to her new diagnosis of osteopenia. Her GERD is well controlled with once-daily pantoprazole, which she has taken without side effects for 1 year. She also takes calcium and vitamin D supplements. Other than her age, she has no additional risk factors for osteoporosis.
Her vital signs and the remainder of the physical examination are normal.
What is the most appropriate next step in management?
What is try to decrease or discontinue Pantroprazole?
400
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 testing?
400
A 65 yo woman is reevaluated following an initial evaluation for anemia. Other than a gradually increasing sense of fatigue, she has no symptoms. Her only other medical problem is autoimmune thyroid disease, which is being treated with levothyroxine. Her last screening colonoscopy, done 4 years earlier, was normal.
Physical examination reveals normal vital signs. There is evidence of conjunctival rim pallor. The remainder of the examination, including thyroid and neurologic examinations, is normal.
At the time of her initial evaluation, laboratory studies showed a hemoglobin level of 10 g/dL (100 g/L) and mean corpuscular volume of 104 fL. Serum cobalamin and ferritin levels were low. An antiparietal cell antibody test was positive. Stool testing revealed no evidence of blood.
What is the most appropriate test to perform next?
What is EGD?