A 40-year-old man comes to the clinic after an abnormal hepatitis B test during a preemployment physical.  Test results are as follows:

Repeat testing yields the same results; in addition, anti-HBe is also negative.  What is the best next step in management?

A 53-year-old man comes to the office due to intermittent abdominal pain for the past 6 months.  He describes the pain as sharp, located across his mid-abdomen, and relieved with sitting upright.  The patient also describes postprandial bloating and discomfort during these episodes.  He has observed that the pain is more noticeable shortly after meals.  The painful episodes last minutes to hours at a time and then spontaneously resolve.  His symptoms are becoming progressively more severe and frequent, but currently he is not experiencing pain.  The patient has frequent large, loose stools that require multiple flushes.  He reports being hospitalized multiple times in the past for abdominal pain but does not recall a specific diagnosis, and no records of these hospitalizations are available.  The patient has no dysphagia, odynophagia, vomiting, black stools, or blood in the stool.  He reports a 6.8-kg (15-lb) weight loss over the last 6 months.  The patient drinks 4 or 5 bottles of beer daily and occasionally liquor.  He does not smoke or use illicit drugs.  Medications include over-the-counter antacids and acetaminophen.  Temperature is 36.4 C (97.5 F), pulse is 86/min, blood pressure is 122/78 mm Hg, and respirations are 12/min.  BMI is 21 kg/m².  The lungs are clear to auscultation.  The abdomen is tender to palpation, but soft and nondistended.  There is no rebound tenderness, rigidity, hepatomegaly, or splenomegaly.  The remainder of the physical examination is normal.  Laboratory results are as follows:

Item 1 of 2

Which of the following tests is most likely to provide the diagnosis?

Item 2 of 2

The patient’s magnetic resonance cholangiopancreatography reveals scattered calcifications within the pancreas without a duct obstruction, pseudocyst, or tumor.  The fecal elastase-1 level is low.  He is counseled to cease alcohol use and continue to avoid tobacco use.  A low-fat diet with small, frequent meals is also recommended.  Supplementation of fat-soluble vitamins is prescribed.  The patient confirms his strong intention to follow all recommendations.  Which of the following is the most appropriate next step in management of this patient’s abdominal pain?

A 53-year-old man comes to the emergency department due to sudden onset of nausea, vomiting, and severe epigastric pain radiating to the back.  He has no constipation, diarrhea, or black stools.  His medical history includes epilepsy, hypertension, and depression.  The patient was recently treated for cellulitis.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.8 C (100 F), blood pressure is 130/80 mm Hg, pulse is 118/min, and respirations are 20/min.  The abdomen is tender in the epigastric region.  Laboratory results are as follows:

FluoxetineWhich of the following is the most likely cause of this patient’s symptoms?

A 45-year-old woman comes to the office to discuss elevated hepatic transaminases found on routine and repeated laboratory testing.  The patient has no symptoms.  She does not use tobacco, alcohol, or recreational drugs.  She is sexually monogamous with her husband of 20 years.  There is no liver disease in her family.  BMI is 32 kg/m².  Blood pressure is 130/80 mm Hg and pulse is 87/min.  Physical examination is notable for a soft, palpable liver edge below the costal margin; there is no splenomegaly.  The remainder of the examination is normal.  Laboratory results are as follows:

Results of iron studies are normal, and viral hepatitis serologies are negative.  If a liver biopsy is performed, which of the following will most likely be seen?

A 45-year-old man is brought to the emergency department by his wife due to progressive lethargy, confusion, and abdominal pain.  He has had no hematemesis, melena, or hematochezia.  The patient has a history of alcoholic cirrhosis.  He had a variceal hemorrhage 2 months ago and has been treated previously for hepatic encephalopathy.  The patient takes nadolol, furosemide, spironolactone, and lactulose at home.  There have been no changes in his dietary intake, and he has not used any over-the-counter medicines or herbal supplements.  He still occasionally drinks alcohol but does not use tobacco or illicit drugs.  Temperature is 38 C (100.4 F), blood pressure is 104/60 mm Hg, and pulse is 96/min.  The patient is cachectic and somnolent, and he wakes up with painful stimuli.  He has a flapping tremor of both hands, and the speech is slurred and incomprehensible.  Mucous membranes are dry, and he has scleral icterus.  Several spider angiomata are present on the upper torso.  The lungs are clear to auscultation, and heart sounds are normal with no murmur.  The abdomen is distended and tense with large abdominal wall collaterals.  There is a fluid wave and diffuse tenderness but no rebound tenderness.  Bowel sounds are decreased.  Stool occult blood is negative.  Laboratory results are as follows:

A diagnostic paracentesis is performed, and the ascitic fluid results are as follows:

Item 1 of 2

Which of the following is the best next step in management of this patient?

Item 2 of 2

The patient is hospitalized, and appropriate therapy is started.  The patient’s wife inquires about his overall prognosis.  Which of the following is the most useful indicator for 90-day mortality in this patient?

A 48-year-old man with cirrhosis is brought to the emergency department due to 2 days of progressive drowsiness and lethargy.  Several months ago, the patient had similar symptoms that improved after treatment with lactulose.  He has had no nausea, vomiting, hematemesis, or melena.  The patient was diagnosed with alcohol-associated cirrhosis a year ago and required endoscopic ligation of esophageal varices at that time.  He has been abstinent from alcohol for the past year.  Home medications include furosemide, spironolactone, and lactulose.  The patient is adherent with medications and has 2 or 3 bowel movements daily.  Temperature is 36.7 C (98.1 F), blood pressure is 102/55 mm Hg, and pulse is 106/min.  The patient is somnolent but wakes up to voice and follows instructions.  Physical examination shows mild scleral icterus, dry mucous membranes, and several spider angiomas on the upper chest.  The abdomen is distended with shifting dullness, and there are dilated veins around the umbilicus.  No abdominal tenderness is present.  Stool occult blood is negative.  A flapping tremor of both hands is present, but no other focal neurologic deficits exist.  Laboratory results are as follows:

Diagnostic paracentesis is planned.  Which of the following is the best next step in management of this patient?

A 30-year-old woman comes to the emergency department due to 12 hours of severe abdominal pain, which radiates to her back and is associated with nausea and vomiting.  She has no chronic medical conditions.  There is no family history of premature coronary artery disease.  She does not use tobacco or alcohol.  Temperature is 37.7 C (99.9 F), blood pressure is 120/90 mm Hg, pulse is 85/min, and respirations are 18/min.  BMI is 34 kg/m².  The abdomen is tender to palpation but without rebound or involuntary guarding.  Laboratory results are as follows:

Ultrasound of the right upper quadrant shows pancreatic edema but is otherwise unrevealing.  In addition to an infusion of lactated Ringer solution and pain medication, the patient is treated with intravenous insulin and dextrose solution.  Her symptoms and laboratory studies improve after 3 days.  Which of the following is recommended to prevent recurrence in this patient?

A 25-year-old woman comes to the physician with 2 months of progressively increasing pain in both lower extremities.  The pain is localized over both shins and is worse with ambulation.  She reports a 2-kg (4.5-lb) weight loss, but no fever, night sweats, chest pain, or abdominal pain.  Her past medical history is unremarkable and she is currently on no medications.  Family history is significant for a mother and sister with hypothyroidism.  The patient has a 5-pack-year smoking history and drinks 2 glasses of beer on weekends.  She has a nutritious diet with regular intake of vegetables, meats, whole-grain foods, and dairy products.  Examination shows tenderness at both shins and vitiligo over her back.

Laboratory results are as follows:

The red blood cells are hypochromic and microcytic.  Basic metabolic chemistry panel is otherwise normal.  The serum ferritin level is low.  Plasma 25-hydroxy vitamin D level is undetectable.  Which of the following blood tests is likely to indicate the diagnosis?

A 38-year-old woman comes to the office for follow-up after recent hospitalization.  The patient went to the emergency department 2 weeks ago after several episodes of coffee-ground emesis.  She had intermittent, burning, epigastric pain over the past several months prior to hospitalization.  At that time, upper gastrointestinal endoscopy revealed a duodenal ulcer, and the patient was discharged on pantoprazole therapy.  The patient reports improvement in abdominal pain and has had no further hematemesis, hematochezia, or melena.  She has no other medical problems and in the past has taken only ibuprofen for occasional aches and pains.  The patient does not use tobacco, alcohol, or illicit drugs and has no allergies.  Family history is notable for gastric cancer in her father.  Temperature is 36.5 C (97.7 F), blood pressure is 124/78 mm Hg, and pulse is 82/min.  Cardiopulmonary examination is normal.  The abdomen is nondistended, soft, and nontender.  Gastric and duodenal biopsies performed during the endoscopy show chronic antral gastritis with presence of Helicobacter pylori but no evidence of malignancy.

Item 1 of 2

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 2

The patient returns to the office a month after completing the prescribed treatment.  She reports that she initially felt better but has had intermittent recurrence of the abdominal pain.  She also has had occasional nausea but no vomiting, hematemesis, hematochezia, or melena.  Which of the following is the best next step in management of this patient?

An 82-year-old woman is brought to the office due to new-onset fecal incontinence.  The patient has a history of Alzheimer disease and lives with her daughter but is able to perform most of the activities of daily living independently.  Her daughter states that the patient has had several incidents of involuntary stool leakage over the past week.  She also has had mild abdominal discomfort but no fever, nausea, vomiting, or blood in stools.  Other medical issues include hypertension and osteoarthritis.  The patient has delivered 4 children vaginally.  She does not use tobacco or alcohol.  Temperature is 37 C (98.6 F), blood pressure is 140/80 mm Hg, and pulse is 78/min.  The abdomen is nondistended and soft with mild generalized tenderness.  There is no guarding or rebound tenderness.  Bowel sounds are active.  Rectal examination shows mildly decreased anal sphincter tone and a copious amount of hard stool.  Perineal sensation is normal.  Stool testing for occult blood is negative.  Abdominal imaging shows no air-fluid levels or free intraperitoneal air.

Item 1 of 2

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 2

After appropriate interventions, the patient’s fecal incontinence resolves and the stool in the rectum clears.  Which of the following is the best step to prevent recurrence?

A 36-year-old woman comes to the office due to worsening nausea, postprandial fullness, and a bloating sensation over the past several months.  The patient says, “In the beginning, my symptoms were mild and infrequent, but lately I have had severe nausea after each meal, and I feel full very quickly.  I also vomit frequently several hours after meals and see undigested food in the vomit.”  The patient is afraid to eat due to the abdominal discomfort and has lost 4 kg (8.8 lb) over the past 3 months.  She has a 15-year history of type 1 diabetes mellitus previously controlled with basal-bolus insulin.  The patient frequently takes ibuprofen for tension headaches.  She does not use tobacco, alcohol, or recreational drugs.  Blood pressure is 126/77 mm Hg and pulse is 88/min.  BMI is 22 kg/m².  The abdomen is mildly distended, soft, and nontender.  Bowel sounds are normoactive in all quadrants, and there is an audible splashing sound in the epigastric region during sudden movement of the patient.  Neurological examination shows decreased vibration and position sensation in both feet.  Blood cell counts and serum chemistry studies are within normal limits, and hemoglobin A1c is 8.4%.

Item 1 of 2

Which of the following is the most appropriate next step in management of this patient’s current symptoms?

Item 2 of 2

Further evaluation shows no gastrointestinal obstruction, but gastric emptying is delayed.  In addition to optimization of glycemic control, which of the following is the best initial therapy for this patient?

A 62-year-old female is being evaluated for vague epigastric discomfort which she has had for the past two months.  She denies having nausea, vomiting, diarrhea, flank pain or urinary symptoms, but says she might have lost 2-3 pounds during this time.  Her past medical history is significant for hypertension.  Her daily medications are hydrochlorothiazide and lisinopril.  She does not use tobacco or alcohol.  Her family history is significant for breast cancer in her mother at age 72.  On physical examination, the patient’s blood pressure is 133/87 mmHg and heart rate is 73/min.  Her BMI is 22 kg/m².  The remainder of the examination is unremarkable.  Her laboratory test results are as follows:

CT scan of the abdomen shows a 3.6 cm loculated cystic lesion in the head of the pancreas with some wall calcifications.  What is the best next step in the management of this patient?

A 56-year-old man comes to the physician due to several months of difficulty in swallowing.  At first, meat would stick in his throat, and now he has difficulty swallowing all solid food and occasionally liquids.  The patient coughs and sometimes aspirates food particles when eating.  He has no shortness of breath, chest pain, or heartburn and has lost several pounds in the last 2 months.  The patient was evaluated for persistent right ear pain 4 weeks ago, but no diagnosis could be made.  His past medical history is significant for hypertension.  He smokes 2 packs of cigarettes daily and consumes 6–8 bottles of beer on weekends.  The patient is not sexually active.  Lungs are clear to auscultation.  Neck palpation shows no lymph node enlargement or thyromegaly.

Item 1 of 2

Which of the following is the best initial step in management of this patient?

Item 2 of 2

Endoscopy performed on this patient identifies an upper-esophageal mass with irregular contours that partially obstructs the lumen of the esophagus.  Which of the following is the most likely histopathologic type of this tumor?

A 54-year-old man comes to the emergency department with a 2-week history of exertional dyspnea and nonproductive cough.  He has no known medical problems and does not use any medications.  The patient has a long history of alcohol abuse and currently consumes a half-pint of vodka a day, although he is “trying to cut down.”  He smokes a pack of cigarettes a day and does not use illicit drugs.  Temperature is 36.8 C (98.2 F), blood pressure is 123/78 mm Hg, heart rate is 114/min and regular, and oxygen saturation is 96% on room air.  Lung examination shows decreased breath sounds on the right with dullness to percussion.  The patient’s abdomen is distended with flank dullness and a positive fluid shift sign.  There is 1+ bilateral pitting lower-extremity edema.  His hands are flushed over the palmar aspects, and small dilated blood vessels are visible over his upper chest.  Laboratory results are as follows:

Chest x-ray demonstrates a large right-sided pleural effusion.  A thoracentesis is performed, and 1.2 L of straw-colored fluid is removed.  The fluid shows a protein concentration of 1.2 g/dL and lactate dehydrogenase concentration of 60 U/L.  Gram stain and cultures are negative.  The patient’s symptoms improve after the procedure, and counseling regarding cessation of alcohol and tobacco use is provided.  Which of the following is the best next step in management of this patient’s pleural effusion?

A 35-year-old Caucasian man is seen in the emergency department for the evaluation of fever, weakness, generalized abdominal pain, and bloody stools.  He denies any vomiting but his appetite has been poor.  He was diagnosed with ulcerative colitis six months ago and he has been on and off sulfasalazine treatment.  His flare-up started four days ago, and rapidly progressed to his having multiple bloody bowel movements and severe abdominal pain.  He is a current smoker, but he has been trying to quit.  He has not been taking any antibiotics recently and he denies recent travel.  His temperature is 100 F (37.8 C), heart rate is 124/min, and blood pressure is 106/72 mmHg.  His mucous membranes appear dry.  Bowel sounds are hypoactive.  There is generalized abdominal tenderness and distension without any rebound tenderness or guarding.  The percussion note is tympanitic.

Item 1 of 2

Which of the following is the best initial step for managing this patient?

Item 2 of 2

Imaging studies show the presence of colonic dilatation with some air-fluid levels.  There is no pneumoperitoneum.  Initial evaluation shows:

Stool studies are negative for C.  difficile toxin.  At this point, the patient is most likely to benefit from which of the following?