Epigastric Pain Radiating To Inferior Angle Of Scapula

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DIRECTIONS: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question.

234. A 35-year-old alcoholic male is admitted for nausea, vomiting, and abdominal pain that radiates to the back. The laboratory value that suggests a poor prognosis in this patient is a. Elevated serum lipase b. Elevated serum amylase c. Leukocytosis of 20,000/^m d. Diastolic blood pressure greater than 90 mmHg

DIRECTIONS: Each group of questions below consists of lettered options followed by a set of numbered items. For each numbered item, select the one lettered option with which it is most closely associated. Each lettered option may be used once, more than once, or not at all.

Items 235-237

Match the patient described with the most likely diagnosis.

a. Acute diverticulitis b. Acute pancreatitis c. Acute cholecystitis d. Intestinal obstruction e. Irritable bowel syndrome

235. A 45-year-old moderately obese white woman presents with four episodes of severe epigastric and right upper quadrant pain, each episode lasting 30 to 60 min and accompanied by nausea and vomiting. Her most recent episode was very severe, with the pain radiating to the inferior angle of the scapula. (CHOOSE 1 DIAGNOSIS)

236. A 78-year-old white man presents with a 3-day history of gradually worsening left lower quadrant pain. He does not have rectal bleeding or weight loss but has noticed mild constipation in association with the pain. He has a temperature of 100.2°F, moderate left lower quadrant tenderness without evidence of peritoneal inflammation, and a white count of 14,200. (CHOOSE 1 DIAGNOSIS)

237. A 68-year-old woman who has had a previous open cholecystectomy presents with an 8-h history of cramping periumbilical pain. Each episode of pain lasts 3 to 5 min and then abates. Over several hours she develops nausea, vomiting, and abdominal distension. She has been unable to pass stool or flatus for the past 4 h. (CHOOSE 1 DIAGNOSIS)

Items 238-240

238. A 40-year-old cigarette smoker complains of epigastric pain, well localized, nonradiating, and described as burning. The pain is partially relieved by eating. There is no weight loss. He has not used nonsteroidal anti-inflammatory agents. The pain has gradually worsened over several months. The most sensitive way to make a specific diagnosis is a. Barium x-ray b. Endoscopy c. Serologic test for Helicobacter pylori d. Serum gastrin

239. The patient is found to have a duodenal ulcer by upper endoscopy. The likelihood of this patient having H. pylori in the gastric antrum is a. 5%

240. The best way to eradicate H. pylori in this patient is a. Omeprazole 20 mg PO daily for 6 weeks b. Ranitidine 300 mg PO qhs for 6 weeks c. Omeprazole 20 mg BID, amoxicillin 1000 mg BID, clarithromycin 500 mg BID for 14 days d. Pepto-Bismol and metronidazole BID for 7 days e. Sulcrafate 200 ^g QID for 6 weeks

Items 241-242

241. A 70-year-old male presents with a complaint of fatigue. There is no history of alcohol abuse or liver disease; the patient is on no medication. Scleral icterus is noted on physical exam. There is no evidence for chronic liver disease on physical exam, and the liver and spleen are nonpalpable. The patient is noted to have a normocytic, normochromic anemia. The first step in evaluation of this patient is a. CT scan of the abdomen b. Hepatitis profile c. Liver function tests, including direct versus indirect bilirubin and urine bilirubin d. Abdominal ultrasound

242. The patient above is noted to have conjugated hyperbilirubinema, with bilirubin detected in the urine. Serum bilirubin is 12 mg/dL, AST and ALT are in normal range, and alkaline phosphatase is 300 U/L (3 times normal). The next step in evaluation is a. Ultrasound or CT scan b. Hepatitis profile c. Reticulocyte count d. Family history for hemochromatosis

Items 243-245

243. A 40-year-old male with long-standing alcohol abuse complains of abdominal swelling, which has been progressive over several months. He has a history of gastrointestinal bleeding. On physical exam, there are spider angiomas and palmar erythema. Abdominal collateral vessels are seen around the umbilicus. There is shifting dullness, and bulging flanks are noted. An important first step in the patient's evaluation is a. Diagnostic paracentesis b. UGI series c. Ethanol level d. CT scan

244. A paracentesis is performed on the patient previously described. The serum albumin minus ascitic fluid albumin equals 1.4 g/dL. The most likely diagnosis is a. Portal hypertension b. Pancreatitis c. Tuberculous peritonitis d. Hepatoma

245. While hospitalized, the patient's mental status deteriorates. He has been having guaiac-positive stools and a low-grade fever. He has also received sedation for agitation. On physical exam, the patient is confused. He has no meningeal signs and no focal neurologic findings. There is hyperreflexia and a nonrhythmic flapping tremor of the wrist. The most likely explanation for the mental status change is a. Tuberculosis meningitis b. Subdural hematoma c. Alcohol withdrawal seizure d. Hepatic encephalopathy

246. A 50-year-old black male with a history of alcohol and tobacco abuse has complained of difficulty swallowing solid food for the past 2 months. More recently, swallowing fluids has also become a problem. He has noted black, tarry stools on occasion. The patient has lost 10 lb. Which of the following statements is correct?

a. The patient's prognosis is good b. Barium contrast study is indicated c. The most likely diagnosis is peptic ulcer disease d. The patient has achalasia

247. A 34-year-old male presents with substernal discomfort. The symptoms are worse after meals, particularly a heavy evening meal, and are sometimes associated with hot/sour fluid in the back of the throat and nocturnal awakening. The patient denies difficulty swallowing, pain on swallowing, or weight loss. The symptoms have been present for 6 weeks; the patient has gained 20 lb in the past 2 years. Your initial approach is a. A therapeutic trial of ranitidine b. Exercise test with thallium imaging c. Esophagogastroduodenoscopy d. CT scan of the chest

248. A 48-year-old woman presents with a change in bowel habits and 10-lb weight loss despite preservation of appetite. She notices increased abdominal gas, particularly after fatty meals. The stools are malodorous and occur 2 to 3 times per day; no rectal bleeding is noticed. The symptoms are less prominent when the patient follows a clear liquid diet. The most likely histological abnormality associated with this patient's symptoms is a. Signet ring cells on gastric biopsy b. Mucosal inflammation and crypt abscesses on sigmoidoscopy c. Villous atrophy and increased lymphocytes in the lamina propria on small bowel biopsy d. Small, curved gram-negative bacteria in areas of intestinal metaplasia on gastric biopsy

249. A nursing student has just completed her hepatitis B vaccine series. On reviewing her laboratory studies (assuming she has no prior exposure to hepatitis B), you expect a. Positive test for hepatitis B surface antigen b. Antibody against hepatitis B surface antigen (anti-HBS) alone c. Antibody against hepatitis core antigen (anti-HBC)

d. Antibody against both surface and core antigen e. Antibody against hepatitis E antigen

Items 250-252

Match the clinical description with the most likely disease process.

a. Primary biliary cirrhosis b. Sclerosing cholangitis c. Anaerobic liver abscess d. Hepatoma e. Hepatitis C

f. Hepatitis D

g. Hemochromatosis

250. A 40-year-old white female complains of pruritus. She has an elevated alkaline phosphatase and positive antimitochondrial antibody test. (CHOOSE 1 DISEASE PROCESS)

251. A 70-year-old male with a long history of diverticulitis has low-grade fever, elevated alkaline phosphatase, and right upper quadrant pain. (CHOOSE 1 DISEASE PROCESS)

252. A 30-year-old male with ulcerative colitis develops jaundice, pruritus, and right upper quadrant pain. Liver biopsy shows an inflammatory obliterative process affecting intrahepatic and extrahepatic bile ducts. (CHOOSE 1 DISEASE PROCESS)

253. A 40-year-old male has a history of three duodenal ulcers with prompt recurrence. Symptoms have been associated with severe diarrhea. One of the ulcers occurred close to the jejunum. Serum gastrin levels have been 200 pg/mL. The most useful test in this patient is a. Colonoscopy b. Endoscopic retrograde cholangiogram c. CT scan of abdomen d. Secretin injection test e. Upper gastrointestinal series

254. A 40-year-old white male complains of weakness, weight loss, and abdominal pain. On examination, the patient has diffuse hyperpigmenta-tion and a palpable liver edge. Polyarthritis of the wrists and hips is also noted. Fasting blood sugar is 185 mg/dL. The most likely diagnosis is a. Insulin-dependent diabetes mellitus b. Pancreatic carcinoma c. Addison's disease d. Hemochromatosis

Items 255-257

Match the clinical description with the most likely disease process.

a. Hemolysis secondary to G6PD deficiency b. Pancreatic carcinoma c. Acute viral hepatitis d. Crigler-Najjar syndrome e. Gilbert syndrome f. Cirrhosis of liver

255. An African American male develops mild jaundice while being treated for a urinary tract infection. Urine bilirubin is negative. Serum bilirubin is 3 mg/dL, all unconjugated. Hemoglobin is 7. (CHOOSE 1 DISEASE PROCESS)

256. A 60-year-old male is noted to have mild jaundice and weight loss. Alkaline phosphatase is very elevated. The patient has had very pale stools.


257. A young woman complains of fatigue, change in skin color, and dark brown urine. She has right upper quadrant tenderness and ALT of 1035 (normal is 8 to 20). (CHOOSE 1 DISEASE PROCESS)

258. A 32-year-old white woman complains of abdominal pain off and on since the age of 17. She notices abdominal bloating relieved by defecation as well as alternating diarrhea and constipation. She has no weight loss, GI bleeding, or nocturnal diarrhea. On examination, she has slight LLQ tenderness and gaseous abdominal distension. Laboratory studies, including CBC, are normal. Your initial approach should be a. Recommend increased dietary fiber, prn antispasmodics, and follow-up exam in 2 months b. Refer to gastroenterologist for colonoscopy c. Obtain antiendomysial antibodies d. Order UGI series with small bowel follow-through

259. A 55-year-old white woman has had recurrent episodes of alcohol-induced pancreatitis. Despite abstinence, the patient develops postprandial abdominal pain, bloating, weight loss despite good appetite, and bulky, foul-smelling stools. KUB shows pancreatic calcifications. In this patient, you expect a. Diabetes mellitus b. Malabsorption of fat-soluble vitamins D and K

c. Guaiac-positive stool d. Courvoisier's sign

260. A 34-year-old white woman is treated for a UTI with amoxicillin. Initially she improves, but 5 days after beginning treatment, she develops recurrent fever, abdominal bloating, and diarrhea with six to eight loose stools per day. You suspect antibiotic-associated colitis. The best diagnostic test is a. Identification of Clostridium difficile toxin in the stool b. Isolation of C. difficile in a stool culture c. Stool positive for white blood cells d. Detection of IgG antibodies against C. difficile in the serum

Items 261-264

For each case scenario, suggest the most likely diagnosis.

a. Gastric ulcer b. Aortoenteric fistula c. Mallory-Weiss tear d. Esophageal varices e. Hereditary hemorrhagic telangiectasia (HHT)

261. An 88-year-old white woman is taking naproxen for osteoarthritis. She has noticed mild epigastric discomfort for several weeks, but has continued the naproxen because of improvement in joint symptoms. She suddenly develops hematemesis and hypotension. (CHOOSE 1 DIAGNOSIS)

262. A 42-year-old white woman with a history of alcohol abuse develops nausea and vomiting without abdominal pain. After several bouts of retching, she vomits bright red blood. Physical exam is negative, without spider angiomata or splenomegaly. LFTs are normal. (CHOOSE 1 DIAGNOSIS)

263. A 76-year-old white man presents with painless hematemesis and hypotension. He has no previous GI symptoms but did have resection of an abdominal aortic aneurysm 12 years previously. EGD shows no bleeding source in the stomach or duodenum. (CHOOSE 1 DIAGNOSIS)

264. A 23-year-old man develops iron-deficiency anemia and heme-positive stools. His weight is stable. A few telangiectasias are present on the lips. Abdominal exam is negative without hepatosplenomegaly. (CHOOSE 1 DIAGNOSIS)

Items 265-268

For each case scenario, suggest the likeliest diagnosis.

a. Ulcerative colitis b. Crohn's disease c. Ischemic colitis d. Diverticulitis e. Amebic colitis

265. A 32-year-old white female presents with a 3-week history of diarrhea with the passage of blood and mucus. Sigmoidoscopy shows inflamed, friable mucosa from rectum to midsigmoid. Proximal involvement is not seen. Biopsy reveals inflammation with crypt abscesses. (CHOOSE 1 DIAGNOSIS)

266. A 35-year-old white man presents with diarrhea, weight loss, and RLQ pain. On exam, a tender mass is noted in the RLQ; the stool is guaiac-positive. Colonoscopy shows segmental areas of inflammation. SBFT shows nodular thickening of the terminal ileum. (CHOOSE 1 DIAGNOSIS)

267. A 75-year-old African American woman, previously healthy, presents with low-grade fever, diarrhea, and rectal bleeding. Colonoscopy shows continuous erythema from rectum to mid-transverse colon. The cecum is normal. (CHOOSE 1 DIAGNOSIS)

268. A 70-year-old white woman presents with LLQ abdominal pain, low-grade fever, and mild rectal bleeding. Examination shows LLQ tenderness. Unprepped sigmoidoscopy reveals segmental inflammation beginning in the distal sigmoid colon through the mid-descending colon. The rest of the exam is negative. (CHOOSE 1 DIAGNOSIS)

Items 269-272

For each of the following case scenarios, suggest the likeliest pathogen.

a. Staphylococcus aureus b. Shigella dysenteriae c. Entamoeba histolytica d. Giardia lamblia e. Yersinia enterocolitica

269. A 21-year-old white male presents with 10-lb weight loss, abdominal bloating, and bulky, loose stools. He has no history of travel, but he does drink from a surface water source. (CHOOSE 1 PATHOGEN)

270. A 44-year-old Hispanic man recently immigrated from Mexico. Beginning 2 weeks before the move, he developed lower abdominal pain, weight loss, and bloody, mucusy stools. (CHOOSE 1 PATHOGEN)

271. Two hours after ingesting potato salad at a picnic, a 50-year-old white woman develops severe nausea and vomiting. She has no diarrhea, fever, or chills. On exam, she appears hypovolemic, but the abdomen is benign.


272. A 30-year-old day care worker develops profuse bloody diarrhea, abdominal pain, and fever to 104°F Exam reveals mild lower abdominal tenderness without rebound. WBC is 23,000. Several schoolchildren have had a similar illness. (CHOOSE 1 PATHOGEN)

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Managing Diverticular Disease

Managing Diverticular Disease

Stop The Pain. Manage Your Diverticular Disease And Live A Pain Free Life. No Pain, No Fear, Full Control Normal Life Again. Diverticular Disease can stop you from doing all the things you love. Seeing friends, playing with the kids... even trying to watch your favorite television shows.

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