DIRECTIONS: Each of the numbered items or incomplete statements in this section is followed by answers or by completion of the statements. Select the one lettered answer or completion that is best in each case.

189. A 42-year-old woman presents to the emergency room complaining of the sudden onset of right upper abdominal pain. Her pain started after eating a hamburger for lunch. She is nauseated and vomited twice at home. She denies diarrhea. Her temperature is 102.2°F, blood pressure is 140/90 mm Hg, and pulse is 110/min. She appears anxious and distressed. She is not jaundiced. Abdominal examination reveals normal bowel sounds. While you are palpating under her right costal margin, the patient abruptly arrests her inspiration and pulls away because of sharp pain. Which of the following is the most appropriate next step in management?

a. Abdominal radiograph b. Ultrasound of the abdomen c. HIDA scan d. MRI of the abdomen e. Upper endoscopy

190. A 16-year-old boy presents to the emergency room with a history of a football injury to the left flank earlier that day while at practice. He reports that at the time of the injury he only had the "wind knocked out of him" and he recovered in a few minutes. About 1 h later he began to experience pain in the left upper quadrant and left shoulder. He also feels dizzy and light-headed on standing. Physical examination demonstrates orthostatic changes in blood pressure and heart rate. Heart and lung examinations are normal. Abdominal auscultation reveals normal bowel sounds, but the patient complains of tenderness when palpating the left upper quadrant. Rectal exam is normal. Which of the following is the most likely diagnosis?

a. Dislocation of the left shoulder b. Left rib fracture c. Left pneumothorax d. Ruptured spleen e. Contusion of the left kidney

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191. Which of the following is the proper sequence for examination of the abdomen?

a. Auscultation, percussion, inspection, palpation b. Auscultation, inspection, palpation, percussion c. Inspection, percussion, auscultation, palpation d. Inspection, auscultation, percussion, palpation e. Inspection, percussion, palpation, auscultation

192. A 40-year-old man presents to the emergency room complaining of severe abdominal pain that radiates to his back accompanied by several episodes ofvomiting. He drinks alcohol daily. On physical examination, the patient is found on the stretcher lying in the fetal position. He is febrile and appears ill. The skin of his abdomen has an area of bluish periumbilical discoloration. There is no flank discoloration. Abdominal examination reveals decreased bowel sounds. The patient has severe midepigastric tenderness on palpation and complains of exquisite pain when your hands are abruptly withdrawn from his abdomen. Rectal examination is normal. Which of the following is the most likely diagnosis?

a. Acute cholecystitis b. Pyelonephritis c. Necrotizing pancreatitis d. Chronic pancreatitis e. Diverticulitis f. Appendicitis

193. A 60-year-old man with a previous history of appendectomy 30 years ago presents to the emergency room complaining of abdominal pain. He describes the pain as colicky and crampy and feels it builds up, then improves on its own. He has vomited at least 10 times since the pain started this morning. He states that he has not had a bowel movement for 2 days and cannot recall the last time he passed flatus. The abdomen is slightly distended. Abdominal auscultation reveals high-pitched bowel sounds and peristaltic rushes. Percussion reveals a tympanic abdomen. The patient is diffusely tender with palpation but has no rebound tenderness. Rectal examination reveals the absence of stool. Which of the following is the most likely diagnosis?

a. Cholecystitis b. Diverticulitis c. Pancreatitis d. Gastroenteritis e. Intestinal obstruction

194. Which of the following statements is true regarding the term "scaphoid" abdomen?

a. An unremarkable abdomen should be called scaphoid b. It is a convex abdomen c. It is seen in patients who have ascites d. It is absent in obese patients e. It implies guarding f. It implies rigidity

195. Which of the following best describes the location of McBur-ney's point?

a. In the midclavicular line just under the right costal margin b. At the midpoint of a line connecting the symphysis pubis and the anterior superior iliac spine c. Midway along the right inguinal ligament d. One-third of the way along a line drawn from the right anterior superior iliac spine to the umbilicus e. One centimeter to the right of the umbilicus

196. A 32-year-old man presents with severe abdominal pain, which he describes as sharp and diffuse. He does not drink alcohol or take any medications. He has a past medical history significant for peptic ulcer disease over 5 years ago. He has stable vital signs and has no orthostatic changes. You observe the patient to be lying very still on the emergency room stretcher. On physical examination, he has a rigid abdomen and decreased bowel sounds. He has localized left upper quadrant guarding and rebound tenderness. He has referred rebound tenderness on palpation of the right upper quadrant. Rectal examination is FOBT negative. Which of the following is the best method of confirming the diagnosis in this patient?

a. Barium swallow b. Leukocytosis c. Upper endoscopy d. Abdominal radiograph e. Colonoscopy

197. A 74-year-old man presents with the abrupt onset of pain in the left lower abdomen, which has been progressively worsening over the last 2 days. He states that the pain is unremitting. He has some diarrhea but no nausea or vomiting. He has no dysuria or hematuria. His temperature is 102°F Bowel sounds are decreased. The patient has involuntary guarding. There is tenderness and rebound tenderness when the left lower quadrant is palpated. The referred rebound test is positive. A fixed sausage-like mass is palpable in the area of tenderness. There is no costovertebral angle (CVA) tenderness. Rectal examination reveals brown stool, which is fecal occult blood test (FOBT) positive. Blood-work demonstrates a leukocytosis. Which of the following is the most likely diagnosis?

a. Colon cancer b. Diverticulitis c. Pancreatitis d. Pyelonephritis e. Appendicitis

198. Abdominal pain upon vibration (the heel jar test) is commonly known as which of the following?

a. Markel sign b. Blumberg sign c. Rovsing sign d. Obturator sign e. Iliopsoas sign f. Courvoisier sign g. Dance sign

199. A 71-year-old woman with a history of chronic congestive heart failure presents to her family physician for a routine checkup. The physician notices that she has lost 20 lb since her last visit 6 mo ago. When questioned, the patient gives a history of intermittent periumbil-ical pain that begins 30 min after eating and lasts 2-3 h. She claims the pain is worse after large meals and so she has begun to eat less out of fear of precipitating the pain. Which of the following is the most likely diagnosis?

a. Pancreatitis b. Intestinal ischemia c. Cholecystitis d. Small bowel obstruction e. Peptic ulcer disease

200. A patient with a long history of cirrhosis presents with asterixis. He is alert and oriented to person, place, and time. His breath is positive for fetor hepaticus. His abdomen is significant for caput medusae and a positive fluid wave. He has no focal neurologic deficit. His wife states that the patient is very functional at home but is moderately confused and drowsy. Which is the most likely stage of hepatic encephalopathy in this patient?

a. Stage 1 hepatic encephalopathy b. Stage 2 hepatic encephalopathy c. Stage 3 hepatic encephalopathy d. Stage 4 hepatic encephalopathy

201. A 38-year-old man arrives at the emergency room with the chief complaint of hematemesis for 3 h. He does not drink alcohol and has no previous medical history. He spent the previous night vomiting approximately 10-12 times after eating some "bad chicken." The patient is squirming on the stretcher and is retching. He is afebrile with a heart rate of 120/min and a blood pressure of 90/60 mm Hg. Abdominal exam is positive for diffuse tenderness, but the patient has no rigidity, guarding, or rebound tenderness. There is no hepatospleno-megaly. Rectal exam is negative for occult blood. A nasogastric tube is inserted and reveals bright red blood. Which of the following is the most likely diagnosis?

a. Esophageal varices b. Mallory-Weiss tear c. Gastritis d. Peptic ulcer disease e. Boerhaave syndrome f. Dieulafoy lesion

202. A 24-year-old HIV-positive patient who has had AIDS for 3 years presents with painful swallowing and dysphagia to solids and liquids. He has no previous history of heartburn or reflux disease. His CD4 count is 41/^L and he recently required 3 wk of antibiotics for Pneumocystis carinii pneumonia. Examination of the pharynx reveals no oral thrush. Barium swallow demonstrates multiple nodular filling defects of various sizes that resemble a "cluster of grapes." Which of the following is the most likely diagnosis?

a. Candida esophagitis b. Reflux disease c. Barrett's esophagus d. Pneumocystis esophagitis e. Achalasia f. Plummer-Vinson syndrome g. Schatzki ring

203. Which of the following statements is true regarding the liver?

a. Macronodular cirrhosis is defined as liver nodules of <3 mm b. Micronodular cirrhosis is defined as liver nodules of >3 mm c. Normal liver size is 12 cm in the midclavicular line (MCL)

d. Macronodular cirrhosis is most likely due to alcohol use e. Micronodular cirrhosis is most likely due to viral infection

204. A 70-year-old woman with a 25-year history of diabetes mellitus presents with early satiety, bloating, and nausea after meals. She has had previous surgery for gallbladder stones and appendicitis. Her diabetes is complicated by retino-pathy and peripheral neuropathy. On physical examination, bowel sounds are normal. A succussion splash is audible. The abdomen is tympanic and there is no hepato-splenomegaly. There is no tenderness. Rectal examination is normal. Serum glucose is 310 mg/dL. Which of the following is the most likely diagnosis?

a. Celiac sprue b. Whipple's disease c. Gastroparesis d. Gluten-sensitive enteropathy e. Tropical sprue

205. Which of the following factors may cause a false-negative fecal occult blood test (FOBT) result?

a. Vitamin C

b. Turnips c. NSAIDs d. Red meat e. Aspirin f. Horseradish g. Poultry h. Fish

206. A 42-year-old morbidly obese woman complains of a nonproductive cough for 8 mo. She denies abdominal discomfort after eating and has never "suffered" from heartburn. Rarely, she has regurgitation, and when she does it has a sour taste to it. Abdominal examination is normal. Rectal examination is FOBT negative. Which of the following is the most likely diagnosis?

a. Carcinoma of the lung b. Gastroesophageal reflux disease c. Chronic obstructive lung disease d. Lactose deficiency e. Chronic cholestasis

207. A 16-year-old boy has had lifelong constipation. He requires suppositories and often enemas to initiate bowel movements. His abdomen is distended. Palpation reveals a tubular mass in the left lower quadrant. Rectal exam reveals no stool in the vault. Barium enema reveals a dilated colon above a normal-appearing rectum. Which of the following is the most likely diagnosis?

a. Colon carcinoma b. Gardner syndrome c. Peutz-Jeghers syndrome d. Hirschsprung's disease e. Volvulus

208. A 45-year-old patient presents with altered mental status. His wife states that over the last week her husband has been taking acetaminophen for some abdominal discomfort. He uses no illicit drugs but drinks 4-5 beers daily. Over the last 24 h, the patient has become progressively lethargic. Vital signs reveal a temperature of 97°F, a blood pressure of 100/70 mm Hg, a heart rate of 120/min, and a respiratory rate of 26/min. The patient is jaundiced with RUQ abdominal tenderness on palpation. He has no rebound tenderness or splenomegaly but has an enlarged liver. There is no ascites or peripheral edema. Heart and lung examinations are normal. The patient responds to painful stimuli and has asterixis. He has no focal neurologic deficit. Which of the following is the most likely diagnosis?

a. Alcohol intoxication b. Alcohol withdrawal c. Delirium tremens d. Acetaminophen toxicity e. Wilson's disease

209. A 19-year-old girl attending school in Massachusetts presents with the chief complaint of bloody diarrhea for 2 mo. She has abdominal discomfort and feels she has lost some weight. She also complains of tenesmus. Abdominal examination is normal. The rectal exam reveals stool containing blood and pus. Which of the following is the most likely diagnosis?

a. Irritable bowel syndrome b. Ulcerative colitis c. Giardiasis d. Hemorrhoids e. Diverticulosis

210. A 50-year-old man has a 10-year history of chronic active hepatitis from the hepatitis C virus. He is brought to the emergency room because of cachexia and disturbed mental status. On physical examination, the patient has palmar erythema and clubbing. He is jaundiced with massive ascites. He has asterixis. Laboratory data reveals severe hypoalbuminemia and hyperbilirubinemia. Which of the following is the most likely diagnosis?

a. Child's class A cirrhosis b. Child's class B cirrhosis c. Child's class C cirrhosis d. Child's class D cirrhosis e. Child's class E cirrhosis

211. A 44-year-old man with a history of peptic ulcer surgery presents with palpitations, tachycardia, light-headedness, and diaphoresis after eating a meal. The symptoms typically begin 30 min after eating. Which of the following is the most likely diagnosis?

a. Malabsorption b. Peptic ulcer recurrence c. Gastric carcinoma d. Gastritis e. Dumping syndrome f. Esophagitis

DIRECTIONS: Each set of matching items in this section consists of a list of lettered options followed by several numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more than once, or not at all. Each item will state the number of options to select. Choose exactly this number.

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