Gastroenterology
A 55-year-old man is evaluated for gastroesophageal reflux disease (GERD). He has a 20-year history of GERD, which is well controlled with medication. He is an active cigarette smoker with a 30–pack-year history. He does not drink alcohol. A chest radiograph obtained 2 years ago for the evaluation of fever and cough revealed a hiatal hernia. His only medication is omeprazole.
On physical examination, vital signs are normal. BMI is 37. Other than abdominal obesity, the physical examination is normal.
Which of the following is the most appropriate initial management?
A. Bariatric surgery
B. Esophageal motility study
C. Fundoplication
D. Upper endoscopy
D. Upper endoscopy
A 20-year-old woman is evaluated at a follow-up appointment for a 6-month history of disordered eating. She describes an intermittent uncontrollable urge to eat large amounts of food. When this occurs, she rapidly consumes substantially more food than most people would consume and eats until she is uncomfortably full, sometimes when she does not feel hungry. She reports feeling embarrassed and remorseful about these episodes. She does not vomit or self-induce vomiting. She is being treated with cognitive behavioral therapy, which has reduced the frequency of binge eating, but the symptoms persist. A trial of citalopram was only partially effective. She is concerned about her weight gain. She is otherwise healthy and takes no medications.
On physical examination, BMI is 29. Vital signs and other findings are normal.
Which of the following is the most appropriate next step in treatment?
A. Admission to an inpatient facility specializing in eating disorders
B. Fluoxetine
C. Lisdexamfetamine
D. Monitored dietary intake
C. Lisdexamfetamine
A 23-year-old man is evaluated for cough, rhinorrhea, and wheezing of 3 weeks' duration. He has no fevers, chills, or chest pain and no history of asthma or allergies. He is a pastry chef and notes that his symptoms improve on nonworking weekends.
On physical examination, vital signs are normal. Oxygen saturation is 94% with the patient breathing ambient air. Expiratory wheezing is noted.
Laboratory studies show a normal Aspergillus-specific IgE level.
Spirometry reveals moderate airflow obstruction that improves after inhaled albuterol.
Chest radiograph is normal.
Which of the following is the most likely diagnosis?
A. Acute bronchitis
B. Acute hypersensitivity pneumonitis
C. Allergic bronchopulmonary aspergillosis
D. Occupational asthma
D. Occupational asthma
A 27-year-old man is evaluated in the emergency department after three episodes of loss of consciousness and falling down that started 2 weeks ago. He has no memory of the events. The third event was witnessed by a coworker who noted that the patient cried out, had whole-body stiffening, and fell backward off his chair. While on the ground, the patient's whole body shook with synchronous limb jerking for 2 minutes. Afterward, the patient was very sleepy and had slow, snoring-like breathing. He remained in a state of impaired alertness for 8 minutes. He gradually awoke by the time he reached the emergency department 20 minutes later, and now has recovered to normal.
On physical examination, vital signs are normal. All other examination findings, including those from a neurologic examination, are unremarkable.
Which of the following is the most likely diagnosis?
A. Generalized convulsive status epilepticus
B. Generalized tonic-clonic seizure
C. Myoclonic seizure
D. Psychogenic nonepileptic spells/events
B. Generalized tonic-clonic seizure
A 21-year-old woman is evaluated in the hospital following cardiac arrest that occurred during a collegiate cross-country race. She received cardiopulmonary resuscitation at the scene and has recovered while at the hospital. She has no pertinent personal medical history. The patient takes no medications.
On physical examination, vital signs are normal. The remainder of the examination is unremarkable.
Laboratory studies are within normal limits.
Echocardiogram shows normal left ventricular function and right ventricular dilation and dysfunction. Results from cardiac catheterization are normal.
Metoprolol is initiated.
Which of the following is the most appropriate additional management before discharge?
A. Amiodarone
B. Genetic testing
C. Implantable cardioverter-defibrillator
D. Lisinopril
C. Implantable cardioverter-defibrillator
A 34-year-old woman is evaluated at routine follow-up after diagnosis of primary sclerosing cholangitis (PSC) earlier this month. The diagnosis of PSC was confirmed with magnetic resonance cholangiopancreatography showing multifocal intra- and extrahepatic bile duct strictures without evidence of a dominant stricture or mass. A carbohydrate antigen 19-9 measurement was normal. She has no other medical conditions and takes no medications.
Which of the following is the most appropriate management at this time?
A. Colonoscopy
B. Endoscopic retrograde cholangiopancreatography
C. Liver biopsy
D. Liver transplant
A. Colonoscopy
A 78-year-old woman is evaluated for a nonhealing venous ulcer on the medial aspect of the right ankle that has been present, unchanging, for 6 months. She reports no fever. She has no other medical problems and takes no medications.
On physical examination, vital signs are normal. BMI is 28. A shallow, exudative, nonpainful ulcer is located above the right medial malleolus. There is no surrounding erythema. Hyperpigmentation, varicosities, and edema are seen in both lower extremities.
Ankle-brachial index measurement on the right is 0.9.
Wound care is initiated.
Which of the following is the most appropriate additional treatment?
A. Cephalexin
B. Compression therapy
C. Honey
D. Topical hydrogen peroxide
B. Compression therapy
A 52-year-old man is evaluated after hospital discharge for total knee arthroplasty. In the recovery room following the procedure, he was reintubated because of hypoxemia, which was then completely resolved. The postintubation chest radiograph was normal. Hypoxemia did not return following extubation 24 hours later, and oxygenation was normal at discharge on hospital day 4. He also has hypertension. Medications are lisinopril and short-term apixaban for postarthroplasty venous thromboembolism prophylaxis.
On physical examination, vital signs are normal. BMI is 31. Neck circumference is 42 cm (16.5 in). He has a low-lying soft palate. Lung and heart examinations are normal.
Which of the following is the most likely cause of the hypoxemia?
A. Aspiration pneumonia
B. Obstructive sleep apnea
C. Pulmonary edema
D. Pulmonary embolism
B. Obstructive sleep apnea
A 25-year-old man is evaluated for a 1-year history of headaches. He recently returned from active military duty where he sustained a mild traumatic brain injury (TBI). A CT scan obtained after injury was normal. Headaches, which started soon after the TBI, typically occur three times weekly, last 24 hours, and are bifrontal, dull, and moderate in intensity. The patient also reports occasional photosensitivity accompanying the headaches but has had no nausea, phonophobia, visual disturbances, or neurologic symptoms. He takes ibuprofen as needed to relieve the pain.
On physical examination, vital signs and all other physical examination findings are normal.
Results of standard laboratory studies are normal.
Which of the following is the most appropriate diagnostic test to perform next?
A. Brain MRI
B. Depression screening
C. Electroencephalography
D. Erythrocyte sedimentation rate
E. Montreal Cognitive Assessment
B. Depression screening
A 72-year-old man is hospitalized with decompensated heart failure. Initial overnight treatment consisted of intravenous furosemide equal to his total oral outpatient dose (40 mg). Overnight urine output was 250 mL, with no change in his symptoms. Medical history is significant for hyperlipidemia and hypertension. Outpatient medications are lisinopril, metoprolol succinate, furosemide, and atorvastatin.
On physical examination, blood pressure is 122/82 mm Hg, pulse rate is 88/min, respiration rate is 26/min, and oxygen saturation is 95% with the patient breathing 2 L/min of oxygen by nasal cannula. He is alert, and his skin is warm and dry. Central venous pressure is elevated. Cardiac examination does not reveal an S3. There is pitting edema to his knees.
Serum electrolytes are normal, creatinine level is 1.5 mg/dL (132.6 μmol/L), and B-type natriuretic peptide level is elevated.
Which of the following is the most appropriate treatment?
A. Add intravenous milrinone
B. Add intravenous nitroglycerin
C. Discontinue metoprolol
D. Increase intravenous furosemide
D. Increase intravenous furosemide
A 45-year-old woman is evaluated at follow-up for abnormal alkaline phosphatase levels on three previous blood tests. She has mild pruritus. She has no family history of liver disease. She has no other medical concerns and does not take any medications.
Vital signs and other physical examination findings are normal.
Her complete blood count and alanine aminotransferase, aspartate aminotransferase, serum albumin, serum total bilirubin, and total protein are within normal limits. The alkaline phosphatase level is 212 U/L.
Which of the following is the most appropriate diagnostic test to perform next?
A. Antimitochondrial antibody
B. Anti–smooth muscle antibody
C. Liver biopsy
D. Serum IgG4
A. Antimitochondrial antibody
A 31-year-old man is evaluated for persistent difficulties at work related to intermittent flashbacks of a near-death experience during a tour of active duty. These flashbacks occur without warning during the day and at night, with associated palpitations, diaphoresis, and severe anxiety. The unpredictable nature of the flashbacks has caused generalized anxiety throughout the day, difficulty with sleep initiation, and a desire to avoid being at work because he is afraid of his response to having a flashback in public. He does not drink alcohol.
The patient is referred for psychotherapy and would also like to begin pharmacologic treatment.
Which of the following is the most appropriate treatment?
A. Lorazepam
B. Medical cannabis
C. Prazosin
D. Sertraline
D. Sertraline
A 48-year-old man is evaluated in the emergency department for an acute myocardial infarction. Medical history is significant for hyperlipidemia. His only medication is atorvastatin.
On physical examination, pulse rate is 56/min. Other vital signs are normal. Oxygen saturation is 96% with the patient breathing ambient air. Cardiac examination reveals an S4. Lungs are clear.
The initial serum troponin I level is elevated. An ECG shows ST-segment elevations in leads II, III, and aVF. A chest radiograph is normal.
Which of the following is the most appropriate oxygen management?
A. Oxygen by nonrebreather mask
B. Oxygen by Venturi mask
C. Oxygen, 3 L/min by nasal cannula
D. No additional oxygen management
D. No additional oxygen management
A 25-year-old woman is evaluated for a 3-month history of headaches that previously occurred weekly but now occur daily. She describes the headaches as holocranial, dull, and vice-like, and worsened by the Valsalva maneuver. The patient reports associated neck stiffness, intermittent visual blurring without diplopia, and nocturnal pulsatile tinnitus. She has had no other symptoms. She also has a history of acne and vitamin D deficiency. Medications are topical benzoyl peroxide, oral doxycycline, and vitamin D.
On physical examination, vital signs and BMI are within normal limits. Neurologic examination reveals bilateral papilledema. Physical examination findings are otherwise unremarkable.
Cerebral spinal fluid analysis shows an opening pressure of 280 mm H2O. Other laboratory studies are within normal limits.
A contrast-enhanced brain MRI shows a partially empty sella and widened optic nerve sheaths. Results of magnetic resonance venography are normal.
Which of the following is the most appropriate next step in treatment?
A. Administer prednisone
B. Administer topiramate
C. Discontinue doxycycline
D. Discontinue vitamin D
C. Discontinue doxycycline
A 70-year-old man is evaluated for recently diagnosed paroxysmal atrial fibrillation that is mildly symptomatic. Medical history is significant for hypertension and previous stroke. Medications are rivaroxaban and metoprolol. He has experienced no episodes of bleeding on anticoagulation therapy.
On physical examination, blood pressure is 128/74 mm Hg and pulse rate is 72/min and regular. The remainder of the examination is unremarkable.
An echocardiogram reveals an enlarged left atrium and normal left ventricle. Forty-eight–hour ambulatory ECG monitoring shows atrial fibrillation prevalence of 10% with a controlled ventricular rate less than 90/min and no other abnormalities.
Which of the following is the most appropriate treatment?
A. Left atrial appendage occlusion
B. Pacemaker implantation
C. Rhythm control
D. Switch rivaroxaban to warfarin
E. No additional therapy
C. Rhythm control
A 50-year-old man is evaluated for newly developed ascites. He has cirrhosis due to nonalcoholic steatohepatitis. Paracentesis confirms cirrhosis as a cause of the ascites and excludes infection, and a low-sodium diet is implemented. Medical history includes type 2 diabetes mellitus, hypertension, and dyslipidemia. Current medications are metformin, lisinopril, and atorvastatin.
On physical examination, vital signs are normal. The abdomen is nontender and mildly distended, with normal bowel sounds.
Serum creatinine level is 1.1 mg/dL (97.2 μmol/L). Random urine protein-creatinine ratio is 16 mg/g.
Which of the following is the most appropriate additional treatment?
A. Discontinue atorvastatin
B. Discontinue lisinopril
C. Initiate lactulose
D. Initiate low-protein diet
B. Discontinue lisinopril
A study evaluated the test characteristics of a new rapid diagnostic test for influenza. Polymerase chain reaction–based testing of nasal secretions was used as the gold standard for diagnosis. The study was performed during the summer, when influenza rates are at their nadir.
The sensitivity and specificity of the rapid diagnostic test are 70.6% and 92.8%, respectively. The positive and negative predictive values are 90.7% and 75.9%, respectively.
Which of the following reflects how the new test will perform at the peak of influenza season?
A. Negative predictive value will increase
B. Positive predictive value will increase
C. Sensitivity will increase
D. Specificity will increase
B. Positive predictive value will increase
A 62-year-old man is evaluated in follow-up examination for COPD. Despite smoking cessation, adherence to his medical regimen, good inhaler technique, and participation in pulmonary rehabilitation, he continues to experience breathlessness with mild exertion and has diminished quality of life. He has a minimal dry cough, and he has never required treatment for an acute exacerbation of COPD. Medications are fluticasone-umeclidinium-vilanterol and albuterol inhalers as needed. Immunizations are up to date.
On physical examination, vital signs are normal. Oxygen saturation is 93% with the patient breathing ambient air. There are diminished breath sounds.
A 6-minute walk test shows a minimum oxygen saturation of 90% with the patient breathing ambient air. Spirometry shows an FEV1 of 35% of predicted and a DLCO of 42% of predicted.
Chest imaging shows upper-lobe-predominant emphysema.
Which of the following is the most appropriate treatment?
A. Long-term azithromycin therapy
B. Lung volume reduction surgery
C. Roflumilast
D. Supplemental oxygen
B. Lung volume reduction surgery
A 44-year-old man is evaluated for a 15-year history of headaches that have become increasingly frequent over the past 6 months, now occurring between 15 and 20 days per month. He describes the headache pain as a global feeling of heaviness or tightness that seems to improve with exercise or distraction. Headaches are often preceded and accompanied by neck tightness. He has had no photophobia, phonophobia, nausea, aura, or neurologic symptoms. Acetaminophen, relaxation training, and cognitive behavioral therapy have been ineffective. NSAIDs caused gastroesophageal reflux symptoms.
All physical examination findings, including vital signs, are normal.
Which of the following is the most appropriate preventive treatment?
A. Amitriptyline
B. Butalbital
C. Cyclobenzaprine
D. Onabotulinum toxin A
E. Topiramate
A. Amitriptyline
A 57-year-old woman is evaluated in the emergency department for an acute anterior ST-elevation myocardial infarction.
Aspirin, ticagrelor, unfractionated heparin, and intravenous nitroglycerin are initiated. Emergent coronary angiography reveals an acutely occluded proximal left anterior descending (LAD) coronary artery and 70% stenosis of the mid right coronary artery. The LAD lesion is treated with drug-eluting stent placement, resulting in resolution of chest pain and improvement in the ST-segment elevation seen on ECG.
Following successful percutaneous coronary intervention, blood pressure is 138/82 mm Hg, pulse rate is 78/min, respiration rate is 18/min, and oxygen saturation is 94% with the patient breathing ambient air. The remainder of the examination is unremarkable.
Which of the following is the most appropriate additional management?
A. Glycoprotein IIb/IIIa inhibitor infusion
B. Predischarge exercise ECG
C. Right coronary artery revascularization
D. Supplemental oxygen
C. Right coronary artery revascularization
A 25-year-old woman is evaluated for watery, nonbloody diarrhea of 9 months' duration, occurring four times daily but not nocturnally. It is usually accompanied by abdominal pain in the periumbilical area or left lower quadrant. Pain usually diminishes after a bowel movement. She has had no weight loss.
On physical examination, vital signs are normal. BMI is 22. Abdominal examination reveals minimal tenderness in the left lower quadrant.
Laboratory studies show normal fecal calprotectin, thyroid-stimulating hormone, hematocrit, tissue transglutaminase IgA, and liver chemistries. The test result for Clostridioides difficile is negative.
Which of the following is the most appropriate diagnostic test?
A. Abdominal ultrasonography
B. Colonoscopy with biopsy of right and left colon
C. Stool testing for Escherichia coli O157:H7
D. Stool testing for Giardia
D. Stool testing for Giardia
A 53-year-old woman is evaluated for refractory chronic cough. She has had a bothersome dry cough for longer than 1 year. She has undergone empiric trials of glucocorticoid nasal sprays, decongestants, cough suppressants, prednisone, and omeprazole, alone and in combination, with no improvement in symptoms. Results of allergy skin testing, rhinoscopy, CT of the sinuses and chest, spirometry, ambulatory pH monitoring, and sputum testing have been normal. She currently takes no medications.
On physical examination, vital signs and other findings are unremarkable.
The patient is referred for a multimodal speech pathology intervention.
Which of the following is the most appropriate additional treatment?
A. Budesonide
B. Esomeprazole
C. Gabapentin
D. Morphine
C. Gabapentin
A 66-year-old man who is undergoing annual low-dose CT for lung cancer screening is evaluated following the discovery of a solitary 1.5-cm lung nodule in the right upper lobe. There is no lymphadenopathy or effusion seen on the CT scan. He has a chronic cough and a 90-pack-year smoking history. His medical history is otherwise unremarkable, and he takes no medications.
On physical examination, vital signs and the remainder of the physical examination are normal.
Laboratory studies, including liver chemistry tests and measurement of sodium and calcium levels, are normal.
Which of the following is the most appropriate test to perform next?
A. Endobronchial ultrasonography
B. High-resolution CT
C. Integrated PET/CT
D. Sputum cytology
C. Integrated PET/CT
A 70-year-old woman is hospitalized for progression of cognitive impairment to dementia and ataxia over the past 6 months. She has developed myoclonus, gait problems, and interruption of circadian rhythm.
On physical examination, vital signs are normal. She is alert but has difficulty with orientation to place and time. Cranial nerves and motor strength are normal. There are occasional myoclonic jerks of the trunk. Sensation is intact throughout; cerebellar ataxia is seen on finger-nose-finger, heel-to-shin, and gait testing. Deep tendon reflexes are increased throughout.
Diffusion-weighted MRI of the brain shows hyperintensity in the basal ganglia and several regions of the cortex.
A lumbar puncture is performed.
Which of the following is the most appropriate diagnostic test to perform on the cerebrospinal fluid?
A. 14-3-3 Protein assay
B. Polymerase chain reaction for herpes simplex virus
C. Real-time quaking-induced conversion assay
D. Total tau protein measurement
C. Real-time quaking-induced conversion assay
A 47-year-old man is evaluated for a heart murmur. He is asymptomatic and has no exercise limitations.
On physical examination, vital signs, including blood pressure, are normal. There is a grade 1/6 decrescendo diastolic murmur heard at the left sternal border. The remainder of the examination is normal.
Echocardiogram shows a left ventricular ejection fraction of 55%, a bicuspid aortic valve with mild aortic regurgitation, and a normal left ventricular end-systolic dimension. The ascending aorta is enlarged, with a dimension of 4.2 cm. Echocardiographic imaging quality of the aortic sinuses, sinotubular junction, and ascending aorta is excellent.
Which of the following is the most appropriate management?
A. Aortic valve replacement and repair of the ascending aorta
B. Cardiac magnetic resonance imaging
C. Echocardiographic surveillance
D. Initiation of losartan
C. Echocardiographic surveillance