Gastrointestinal System Question Set 2

A 42-year-old woman presents with exertional dyspnea and fatigue. Past history includes episodes of mild diarrhea for many years which was earlier diagnosed as irritable bowel syndrome. She has no current significant gastrointestinal symptoms. Examination reveals oral aphthous ulcers and pallor. Abdominal examination is normal and findings on the peripheral extremities are given below. Investigations reveal the presence of microcytic hypochromic anemia and results of fecal testing for occult blood are negative. What is the most likely diagnosis?

A 35-year-old male presents to the outpatient department with loose stools and lower abdominal pain. He is having 8 – 10 stools per day. The volume is small in quantity and mucoid with occasional blood. Examination shows a mild to moderate tenderness in the left iliac fossa. Perianal examination shows the presence of perianal skin ulcers .Vitals show the presence of BP of 120/76mmHg, pulse 74/min, temp 97.8deg F. He is a smoker and smokes about a pack a day. Travel history involves a trip to Egypt 3 weeks ago. What is the most likely diagnosis?

A 35 year old male presents to the outpatient department with a chief complaint of erectile dysfunction. Examination shows increased hyper pigmentation on the dorsal side of the arms. Past history includes diabetes mellitus. He is a non smoker and a non alcoholic. He has donated his blood once in the last 6 months. Nocturnal penile tumescence is negative. Labs show moderate increase in glycosylated hemoglobin and hepatic enzymes. What is the most likely diagnosis?

A 38 year old male was worried after finding that his father was diagnosed with colon cancer. His grandfather also had colon cancer. On screening, colonoscopy a polyp is found on the ascending (proximal) colon which on biopsy showed adenocarcinoma. What is the most likely type of gene mutation responsible for this disease?

A 38 year old female presents with dysphagia. The dysphagia was initially more predominantly for solids than liquids and is progressive in its severity. She complains of weakness, fatigue, and dyspnea, but no history of any recent weight loss. Investigations reveal Hb of 8.7 gm% and peripheral smear with microcytic hypochromic anemia. The most likely cause for her dysphagia is:

A 35-year female visits a clinic with abdominal pain and fullness with alternating increase and decrease in frequency of bowel movements for 1 month. The symptoms are not related to any specific diet or allergy. There is no family history of similar complaints in the family. She denies blood staining on toilet paper. FOBT is Negative. On colonoscopy and small intestinal biopsy, no abnormal findings are seen. What is the pathophysiology of this disease?

A 2 -year old boy was rushed to ED in early morning by her mother who is unresponsive to deep pain stimuli. On history taking mother told that he was suffering from cough and fever for last 3 days with a runny nose. She also had similar symptoms last week. She visited a free clinic and received medication. She had given medicine to him yesterday. Afterwards, he had 3 episodes of vomiting and since then his condition worsened. He did not wake up this morning after multiple attempts. On examination, his pulses are feeble, he is hypotensive, pupils are equal and slowly reactive to light. Liver is enlarged. Which of the following is responsible for patient symptoms?

A 32-year old man visits your clinic for mild intermittent epigastric pain for past 6 months, and lethargy for past 1 month. He denies any alcohol and smoking use, there is no family history of any such problem in the family. On examination, he is pallor, BP 144/86 mm of Hg, and PR 98/min with no other significant abnormalities. On lab investigation, Hb is 10 gm/dl, TLC is 7000/cmm, and MCV 94 microns. Urease test is Negative. Endoscopy was planned and it showed redness in the stomach and fundus, and absence of any bleeding points. Gastric antrum appeared to be hypertrophied. Which type of cells play a predominant role in the pathogenesis of this patient?

A 10-year old boy developed runny nose, fever and watery eyes. His parents gave him aspirin. Over the next few days, the boy developed jaundice, became irritable, lethargic and had seizures. The hepatic transaminases were significantly raised. The blood ammonia levels were also increased. The histological specimens will reveal:

68-year-old postmenopausal female presents at the clinic with left sided lower abdominal pain that worsens on defecation. Her body temperature is 37.8°C. She also complains of a mild headache. The disease history shows that she had been suffering from constipation over the past 12 years. Her weight is steady and there are no urinary symptoms. Her last menstruation was 16 years ago. What is the most likely diagnosis?

A 38-year-old female presents with dryness and foreign body sensation in the eyes. On further examination, oral cavity shows mucosal ulceration and atrophy. Biopsy of the lower lip shows marked lymphocytic infiltration in the minor salivary glands. Which of the following is most likely seen in this patient?

A 13-year-old boy presented with short stature, chronic diarrhoea and iron deficiency anemia. Serum anti-tissue transglutaminase (anti-tTG) antibodies were present. Hence upper gastrointestinal endoscopy along with small-intestinal biopsy was planned as next step in his evaluation. Which of the following changes is least likely to be present mucosa of the sample obtained by duodenal biopsy, if the boy has celiac disease?

A 25-year-old woman comes to her doctor’s office because she noticed slightly yellow color of her skin. Upon closer examination, it is clear that her sclera is also slightly icteric. She claims to have had similar episodes before. She always feels well, without nausea, fatigue or fever; her urine and stool are of normal color. Her blood tests show unconjugated hyperbilirubinemia without any other disorders, complete blood count shows values expected at her age and sex. Her liver enzymes and other parameters of liver function are normal. There is no bilirubin in her urine. What is the most likely diagnosis?

A 3-day-old male newborn is brought in because the parents noticed that his skin is becoming yellow. The baby is awake, calm and looks healthy except for the yellow tone of the skin and sclera. The mother said that the boy eats well, has normal stool and urine color. It’s her first child from first healthy pregnancy, the baby is born on time and delivered vaginally without any complications. Blood test shows a higher value of unconjugated bilirubin, complete blood count, and other routine biochemical blood tests are within expected range at her age. She mentioned that her sister died as an infant, but doesn’t know the diagnosis. The only thing she knows is that her sister had exchanged transfusion. Baby is treated with phototherapy, but jaundice only becomes more apparent and unconjugated hyperbilirubinemia persists well into the second week of life. What is the most likely diagnosis in this case?

A 42-year-old man that suffers from chronic obstructive pulmonary disease (COPD) for 4 years comes to his GP because of sudden onset of jaundice. Other than COPD, he had pancreatitis once, but other than that he is healthy. He also revealed that he didn’t smoke in his life. What could be a reason for development of liver damage in this patient?

A 55-years-old woman complained of severe pruritus and fatigue. She reported that she doesn’t suffer from any chronic diseases and was always healthy. Upon examination, a light yellow color of her sclera is visible and hepatosplenomegaly is found. She also has mild peripheral edema. Her blood reports showed elevated levels of bilirubin, aminotransferases, alkaline phosphatase (ALP), γ-glutamyl transpeptidase (GGTP), immunoglobulins, as well as cholesterol (especially HDL fraction). Antiviral antibodies are not present. Erythrocyte sedimentation rate is also elevated. Anti-mitochondrial antibodies are found and after liver biopsy is performed, microscopy shows bile duct injury, cholestasis, and granuloma. What is the most likely diagnosis?

A 35-years-old man comes to his GP because of jaundice, pain in right upper quadrant of the abdomen, fatigue, and pruritus. He was diagnosed with ulcerative colitis two years before and the disease is currently under control. Upon examination, hepatosplenomegaly is also noted. He is vaccinated against hepatitis A and B and claims to have not traveled abroad. Which of the following is the correct diagnosis in this case?

A 28-year-old man comes to his GP as he noticed a yellow coloration of his skin. Upon closer examination, it is clear that her sclera is also slightly icteric. He already has had similar episodes before. He always feels well, without nausea, fatigue or fever, his urine and stool are of normal color. Blood report showed unconjugated hyperbilirubinemia without any other disorders, complete blood count showed values expected for his age and sex. Liver enzymes are normal, as are other parameters of liver function. There is no bilirubin in his urine. He reports his father to have had similar episodes. What is a suggested treatment for the diagnosis this patient appears to have?

A 4-day-old female newborn is brought in as the parents have been noticing jaundice for the last two days. They were told that it is probably neonatal jaundice and that would pass on its own. However, the yellow color of the skin appears to be more obvious. The baby is awake, calm and looks healthy except for the yellow tone of the skin and sclera. The mother reported that the girl eats well, has normal stool and urine color. It’s her first child from first healthy pregnancy; the baby was born on time and delivered vaginally without any complications. Blood test shows a higher value of unconjugated bilirubin, complete blood count, and other routine biochemical blood tests are within expected parameters for age. Father revealed that his aunt had two babies died as infants but doesn’t know why; the mother mentioned that her uncle has unexplained jaundice. Baby is treated with phototherapy, but hyperbilirubinemia becomes severe. Which of the following is the most appropriate drug/ treatment in the present case?

A 39-years-old woman that suffers from chronic obstructive pulmonary disease (COPD) for two years comes to her GP because of sudden onset of jaundice. Other than COPD, she had pancreatitis twice, but other than that is healthy. She said she is a non-smoker. Her family history is unremarkable. What is the way through which the genetic disorder is passed in this patient?

A 38-year-old man comes to his GP because of pruritus and jaundice. He was diagnosed with ulcerative colitis two years ago and the disease is currently under control. Upon examination, hepatosplenomegaly is also noted. He is vaccinated against hepatitis A and B and claimed to have not traveled abroad. Which of the following is the most important in the diagnosis of the disease we are expecting the patient to have?

A 36-year-old man comes to his GP because of pain in right upper quadrant of the abdomen, fatigue, and pruritus. Upon examination, mild jaundice is noticeable as hepatosplenomegaly. He was diagnosed with ulcerative colitis 5 years ago and the disease is currently under control. He is vaccinated against hepatitis A and B and claimed to have not traveled abroad. What is the expected histological finding on liver biopsy in this patient?

A 25-years old lady visits the doctor with complains of irritable bowel syndrome (IBS). She is talking medication for her IBS that include imipramine, psyllium and loperamide. The female also suffers from alternating diarrhea/constipation, bloating and abdominal pain and treated with alosetron 0.5 mg bid. After five days, a GP attends her in the state of extreme discomfort and abdominal pain. Her detail examinations are: Heart rate: 115 beats/min, Respiratory rate: 22 breaths/min and Oxygen saturation: normal, Temperature: 39°C, Blood pressure: 90/55 mmHg, Stool test: heme positive, White blood cell count: 15,800, Diffuse tenderness, guarding (without rebound tenderness) and hypoactive bowel sounds are significant manifestations shown upon abdominal examination. Laboratory tests revealed presence of metabolic acidosis. What is the most appropriate diagnosis in this case?

A 50-years old lady presents to you with complaints of esophageal varices, alcoholic cirrhosis, hepatic encephalopathy, portal hypertension and confusion (in last few days). She is disoriented and extremely drowsy. It is hard for her to answer your questions smoothly. You are told that she is quite discipline in taking her medicines. Her husband also informs you about her medications that include aldactone, labetalol, lactulose and furosemide. Your examination and laboratory tests reveal following information: Her temperature: 38.3°C, Heart rate: 115 bpm, Blood pressure: 105/62 mmHg, Respiratory rate: 12 breaths/minute, Oxygen saturation: 96% (on room air), Slight asterixis & clear lungs, Cardiac examination: unremarkable Abdomen: swell & tense but not tender, Guaiac: negative. Results for extremity strength and cranial nerves are normal and symmetric. Basic metabolic panel: unremarkable. Platelet count: 95,500/µL, Leukocyte count: 4790/µL,. Hematocrit = 33% (baseline is 30%). Which of the following is an essential factor in diagnostic workup in this case?

You are attending a 40-year old male in emergency room with complains of acute abdominal pain. He is a hepatitis C–associated ascites patient. His lungs are clear, he is alert, lying still with moderate discomfort. His physical examination, cardiac examination and laboratory evaluations are as follows: Temperature: 38.3°C, Heart rate: 115 beats per minute, Blood pressure: 88/48 mmHg, Respiratory rate: 16 breaths/minute, - Oxygen saturation: 99% (on room air), Cardiac examination: unremarkable, Distant Bowel sounds; mild guarding, Diffusely tender abdomen: with no rebound tenderness, Leukocyte count: 11,630/µL (with 94% neutrophils), Rectal examination: normal, Pelvic examination: unremarkable, Platelets: 24000/µL, Hematocrit: 29%%, Paracentesis: 658 PMNs/µL, Total protein: 1.2 g/dL, glucose: 24 mg/dL. Gram stain demonstrates: gram-positive rods, gram-positive cocci in chains, gram-negative rods and yeast forms. All below mentioned therapeutic approaches are indicated in this case except?

You are attending a 43-years old female patient who has been suffering from jaundice for a week now. Her symptoms include dark urine, icterus and pruritus. There is no abdominal pain, fever or weight-loss. Her examination shows following results: Unremarkable: but yellowish skin, Bilirubin: 5.1mg/dL, Total bilirubin: 6.0 mg/dL, AST: 84 U/L, & ALT: 92 U/L, Alkaline phosphatase: 662 U/L, CT scan of abdomen: unremarkable, Right upper quadrant ultrasound: a normal gallbladder (but common bile duct is not visible). What do you suggest would be the best next management step in this scenario?

A 33-years old man is admitted with complains of “yellow eyes”. The patient is experiencing this symptom over the last three days. His medical history reveals that he is suffering from this disorder for more than a decade now. The episodes of yellow eyes are self-healing and last for no more than 3 to 5 days at a time. There is no medical history of nausea, weight loss, abdominal pain, light-colored stools, dark urine and pruritus. His only medications were some herbal products and multivitamins without any professional diagnosis and prescription respectively. Results from laboratory and physical examinations are: Slightly obese with no signs of chronic liver disease, Abdomen: soft & non-tender (with no organomegaly), Total bilirubin: 3 mg/dL, Direct bilirubin: 0.2 mg/dL, AST/ALT/Alkaline phosphatase: normal, Hematocrit/lactate dehydrogenase (LDH)/haptoglobin: normal, All of these patients’ results are normal except for total and direct bilirubin. What do you suggest this patient is suffering from?

A 35-years old male patient of yours complains about his feeling of fatigue and dark colored (tea-like) urine for 5 days. His physical is unremarkable except presence of tender hepatomegaly and jaundice. His laboratory results are: Aspartate aminotransferase (AST): 2490 U/L; Alanine aminotransferase (ALT): 2630 U/L; Alkaline phosphatase: 210 U/L; and Total bilirubin: 8.5 mg/dL Which of the following medical disorder has the lowest degree of relevance to cause above abnormalities?

A 50-years old lady experiences emergent abdominal pain with the past medical history of peptic ulcer. The lady visits the emergency department but refuses to undergo abdominal examination because of her present abdominal pain. The attending GP suggests peritonitis. Following is a list of possible maneuvers that may not require manual palpation of abdomen but still provides enough evidence of the presence of peritonitis in this patient. Please specify the right maneuver.

A 5-years old boy is admitted and evaluated to have bilateral conjunctivitis and pharyngitis. Other symptoms include itchy red eyes, fevers (at low grades) and sore throat. The boy has recently attended a camp where other kids were also ill. He was completely healthy before the incident. Which etiologic agent you suggest is the most likely cause of this boy illness?

A 28-year-old African American man presents with a draining abscess on his left jaw. He states that he had a “bad tooth” a few weeks ago which has progressed to his current condition. Vitals include blood pressure of 110/80, heart rate of 85 and a temperature of 100.3 °F. On physical exam, the patient has a 4cm abscess on the left maxillary line that is draining a granulous, purulent material. What is the most likely etiology of this abscess?

A 23-year-old female medical student presents to your office complaining of a painful lesion in her mouth. The patient denies tooth pain, bleeding from the gums, nausea, vomiting, diarrhea or previous episodes similar to this in the past. The patient states her last normal menstrual period was 12 days ago and that she has not been sexually active since starting medical school 2 years ago. On exam, the patient has good dentition with no signs of infection, with the exception of an ulcerated lesion on the oral mucosa. The non-vesicular lesion has a gray-white base and is surrounded by erythema. Which of the following explanations should you give the patient?

An infant of an unknown age is dropped off in the Emergency Department. There is no known medical history. The infant appears lethargic, accompanied by a large protruding tongue. Besides signs of neglect, the child is in no apparent distress. Heart rate is 70 bpm, respiratory rate is 30, temperature is 96.2 °F. Which of the following is the most likely cause of the patient’s macroglossia?

A 46-year-old woman presents to your office complaining of “feeling tired”. The patient states that she has been having some trouble eating because her “tongue hurts,” but she has no other complaints. On exam the patient has pale conjunctiva and skin and appears tired. She has a smooth, red tongue that is tender when you touch it with a tongue depressor. The patient’s hands and feet feel cold. Which of the following diagnoses is most likely?

A 60-year-old man presents to your office because he noticed a “weird patch” on the floor of his mouth. He states that he noticed it a few months ago but didn’t think anything of it because it didn’t hurt. However, he is concerned because it has not regressed and seems to have changed shape. On exam, you notice the patient has poor dentition at which point he admits to using chewing tobacco daily. The patch in question is red with irregular borders. Which of the following would be an appropriate way to counsel this patient on his current condition?

A 42-year-old man presents to your office complaining of right sided facial swelling that has gotten progressively worse over the last month after returning from a trip to India. On exam, the patient has obvious distortion of the facial features on the right without erythema or lymphadenopathy. A short neurological exam reveals no deficits. His blood pressure is 115/80 mmHg, heart rate is 65 bpm, and temperature is 98.9 °F. The patient states that he has been having trouble chewing his food but is not experiencing any pain. The patient is up to date on all of his immunizations. Which of the following is the most likely cause of his facial swelling?

A 52-year-old African-American woman presents to the office complaining of a feeling of “things getting stuck” in her throat that started a week ago. She states that when she tries to swallow it is uncomfortable. Her discomfort is mainly for solid foods while she does not have any problem with liquids. She further adds that she has lost 5 pounds in the last month because of this discomfort, as well as the fact that she gets frequent heartburn. She sometimes takes Antacids which relieves her heartburn. Past medical history is insignificant. She is an occasional drinker and smokes a half pack of cigarettes a day. On exam, her skin is shiny and taut, especially around her lips and fingertips. A barium swallow study is ordered. Which of the following is the most likely diagnosis?

A 54-year-old man presents to the emergency department after 'throwing up blood' an hour ago. He says this happens to him every once in a while but denies any pain with these episodes. The man is disheveled and has a slurred speech as he describes his symptoms. He is reluctant to give further history and wants immediate treatment of his condition. On exam, the patient has evidence of tortuous veins visible on his abdomen and his sclerae have a yellow tinge. Suddenly he begins vomiting copious amounts of blood and soon becomes unresponsive. His blood pressure drops to 70/40 mmHg. He is given 3 units of whole blood but passes away shortly after the incident. Which of the following was the most likely cause of his vomiting of blood?

A 68-year-old man presents to the office with his wife complaining of difficulty in swallowing that has gotten progressively worse over the past month. He has difficulty in initiating swallowing and often has to drink water with solid foods. He has no problems swallowing liquids. His wife is concerned about her husband's bad breath. Adding to his wife, the patient mentions about a recent episode of vomiting where the vomit smelled ‘really bad’ and contained the food that he ate two days before. On exam, the patient’s blood pressure is 110/70 mmHg, pulse is 72 bpm, with normal bowel sounds and no abdominal tenderness to palpation. A barium swallow radiograph is taken which reveals a localized collection of contrast material in the cervical region suggestive of an outpouching. Which of the following statements best describes the lesion seen on the radiograph?

A 35-year-old obese male presents to the office complaining of chronic heartburn and nausea for the past 6 months. The patient states that he has been taking 20mg of omeprazole twice per day with relief. The patient admits that he was prompted to come to the doctor when he recently started experiencing difficulty breathing and shortness of breath that he thinks are associated with any serious health condition. The patient has no cardiac history but is concerned because his father recently died of a heart attack. Imaging of the patient’s chest and abdomen would most likely reveal which of the following?

A 45-year-old obese woman presents to the office complaining of intermittent chest pain for the past 3 days. She states that the pain worsens when she lays down and after she eats her meals. She thinks that she has experienced similar pain before but does not remember it lasting this long. She also complaints of a bitter taste in her mouth but is otherwise in no apparent distress. She has a history of asthma, a partial hysterectomy 4 years ago, and hypothyroidism that was diagnosed 7 years back. She admits to drinking 5-6 cans of beer on weekend nights. Her blood pressure is 130/90 mmHg and her heart rate is 105/min. An EKG is performed that shows no abnormal findings. Which of the following is the most likely cause of her pain?

A 34-year-old male visits a gastroenterologist for an endoscopic evaluation after being referred by his primary care physician for a long history of gastroesophageal reflux disease. Past medical history is significant for diabetes mellitus that was diagnosed 3 years ago and his medications include metformin, metoclopramide, omeprazole. Although he is compliant with his medications he still continues to have heartburn and reflux which is the main reason for this referral today. Which of the following best describes this patient's endoscopic findings?

A 32-year-old HIV positive male presents to the office complaining of difficulty swallowing and bad breath for the past couple of months. Upon further questioning, he says, “it feels like there’s something in my throat”. He says the difficulty is sometimes severe enough that he has to skip meals and occurs with solid foods mainly. He is concerned about his bad breath as he has to attend meetings with his clients. Although he is on antiretroviral medications he admits that he is noncompliant. On exam, the patient is cachectic with pale conjunctiva. On lab evaluation, the patient’s CD4+ count is 70/mm^3. What is the most likely cause of his symptoms?

A 25-year-old man presents to the emergency department after numerous episodes of vomiting. The patient states that he thinks he “ate something weird” and has been vomiting for the past 48 hours. He says he came to the hospital because the last few times he “threw up blood.” He is hypotensive with a blood pressure of 90/55 mm Hg and a pulse of 120/min. After opening an intravenous line a physical examination is performed which is normal except for mild epigastric tenderness. An immediate endoscopy is performed and a tear involving the mucosa and submucosa of the gastroesophageal junction is visualized. Which of the following is the most likely diagnosis?

An 85-year-old man from Indonesia who recently moved to the US presents to your office complaining of hoarseness of voice for the past 2 months. He also has difficulty in swallowing for the same period of time. He expresses concerns about the swallowing difficulty as he can not eat well and has even lost 20 lbs since his last visit which was 3 months. He denies any shortness of breath, coughing of blood and chest pain. His bowel and bladder habit are normal. Past medical history is insignificant. He has a 60-pack-year history of smoking tobacco and drinks alcohol occasionally. Which of the following is the most likely cause of his symptoms?

A 47-year-old man visits the outpatient clinic with the complaints of heartburn and chest pain for the past six months. His pain is retrosternal and was associated with intake of only solid foods initially but now occurs with liquids as well. Antacids do not relieve his pain anymore. He is worried about the pain as it is getting worse with time. He also had an unintentional weight loss of 6 lbs during this period.. Physical examination including the abdominal examination is normal. Lab investigations reveal: Hb %: 10 mg/dL White blood cell total count: 5 x 109/L Platelet count: 168 x 109/ L Hematocrit: 38 % Red blood cell count: 4.2 x 1012/ L Esophagogastroduodenoscopy reveals an exophytic mass in the lower third of esophagus with ulcerations and mucous plugs. Which of the following is the most likely diagnosis in this patient?

A 5-week-old male infant is rushed to the Emergency Room due to severe vomiting and lethargy for past three days. His mother describes the vomiting as forceful and projectile and contains undigested breast milk but she did not notice any green fluids. He has not gained much weight in the past three months and looks very thin. He has a pulse of 144/min, temperature of 37.5° C and respirations of 18/min. Mucous membranes are dry and the boy is lethargic. Abdominal examination reveals a palpable mass in left upper quadrant that becomes more prominent after vomiting with visible peristaltic movements over epigastrium. Barium-contrast studies show double channel appearance of the pylorus. What is the best immediate step in management of this patient’s condition?

A 51-year-old woman visits her physician with the complaints of upper abdominal pain, nausea and early satiety for last six months. She has type 1 Diabetes for past 10 years and is on subcutaneous insulin along with metformin. She also complains of occasional heartburn and lost 10 lbs pounds in past six months without any changes in her diet. Past medical history is significant for long QT syndrome. Her vitals include a pulse of 74/min, respirations of 18/min, temperature of 37.7° C and a blood pressure of 140/84 mmHg. Abdominal examination is negative for organomegaly or any palpable mass but there is presence of succussion splash. She has slightly decreased vision in both her eyes and fundoscopy reveals diabetic changes in the retina. Esophagogastroduodenoscopy is performed which is negative for any obstruction but a small ulcer is seen near the cardiac end of stomach with some food particles. Which of the following drugs would be inappropriate in the management of this patient’s condition?

A 32-year-old male patient comes to the office requesting a screening for colorectal cancer. He currently has no symptoms and his main concern is that his father was diagnosed with colorectal cancer at the age of 55. What screening strategy would be the most appropriate in this case?

A 60-year-old patient comes to the urgent care clinic with the complaints of pain and abdominal distention for the past couple of weeks. He says it all started with a change in bowel habits three months ago and progressively started to defecate less until he was completely constipated, which led to the increasing pain and distention. He also mentions that he has lost weight during this period, even though he has not changed his diet. When asked about his family history, the patient reveals that his brother was diagnosed with colorectal cancer at the age of 65. An abdominal radiography and CT scan were done which confirm the diagnosis of obstruction. In which portion of the digestive tract is the lesion responsible for his bowel obstruction most likely to be found?

A 12-year old boy is brought to the Emergency Room by his mother with the complaints of abdominal pain and fever which started 24 hours ago. on further questioning, the mother says that her son vomited twice and has constipation that started about a day and a half ago. He has no relevant past medical history. His vitals are heart rate 103/min, respiratory rate 20/min, temperature 38.7 °C (101.66 °F) and blood pressure 109/69 mmHg. On physical examination, there is severe right lower quadrant abdominal tenderness on palpation. Which of the following is the most likely cause for this patient’s diagnosis?

A baby is delivered at 39 weeks without complications. Upon delivery, there are obvious cranio-facial abnormalities, including micrognathia, cleft lip and cleft palate. On further inspection downward slanting eyes and malformed ears. The child has an APGAR score of 9 and has no sign of cyanosis or heart murmur. Which of the following is the most likely underlying cause of this patient’s presentation at birth?

A 28-year-old man presents to the office complaining of sore throat, difficulty swallowing, and difficulty opening his mouth for the past 5 days. He states he has had symptoms like this before and “was given some antibiotics that made him feel better.” He is up to date on his immunizations. On exam, his temperature is 103.2°F and he has cervical lymphadenopathy bilaterally. Oropharyngeal exam is difficult because the patient finds it painful to fully open his mouth. However, you are able to view an erythematous pharynx as well as a large, unilateral lesion superior to the left tonsil. A rapid antigen detection test was negative. Which of the following is a serious complication of the most likely diagnosis?

A 22-year-old man from Nepal presents to the emergency department complaining of swelling and pain in his right testicle. The patient states that he just arrived in the United States to live with his wife, with whom he is monogamous. The patient denies painful urination or urethral discharge, but admits that 10 days ago he “felt like he had a fever” and the right side of his face was swollen and painful. Which of the following is characteristic of the most likely diagnosis?

A mother brings her 2 year old to your office. She states her son had a fever and was complaining of a throat pain 2 days ago but was prompted to bring him in because she noticed “sores on the back of his throat.” The child has been fussy and eating poorly. On exam, the child has reached all appropriate developmental milestones and appears well nourished. He has submandibular and anterior cervical lymphadenopathy. On oral exam, less than 10 lesions are visible on bilateral tonsillar pillars and soft palate with surrounding erythema. Four days later the lesions disappear without treatment. Which of the following is the most likely causative agent?

A 5-year-old boy presents to your office with his mother. The boy has been complaining of sore throat and headache for the past 2 days. His mother states that he had a fever of 102.7°F and has had difficulty eating. On exam, the patient has cervical lymphadenopathy and erythematous tonsils with exudates. A Streptococcal rapid antigen detection test is negative. Which of the following is the most likely causative agent?

A 26-year-old male comes to the Emergency Room with the complaint lower abdominal pain that started about five hours ago. The pain initially was located in around the umbilicus but later shifted to the right lower abdomen. It is a continuous dull aching pain that does not radiate. He rates the severity of his pain as 7/10. He denies any previous history of similar symptoms. His vital signs are: heart rate 100/min, respiratory rate 20/min, temperature is 38 °C (100.4 °F) and blood pressure 114/77 mmHg. On physical examination, there is severe right lower quadrant tenderness on palpation. Deep palpation of the left lower quadrant produces pain in the right lower quadrant. Rebound tenderness is present. Complete blood count result is given below: Hemoglobin: 16.2 mg/dL Hematocrit: 48 % Leukocyte count: 15000/mm^3 Neutrophils: 69 % Bands: 3 % Eosinophils: 1 % Basophils: 0 % Lymphocytes: 2 4% Monocytes: 3 % Platelet count: 380,000/mm^3 Which of the following is the most severe complication of this patient’s condition?

A 45-year-old woman comes to the office with a two-week history of rectal bleeding that occurs every day with her bowel movements. She denies any pain during defecation. Apart from this, she does not have any other complaints. Her past medical history is insignificant except for five normal vaginal deliveries. Her vitals are heart rate 72/min, respiratory rate 15/min, temperature 36.7 °C (98.06 °F) and blood pressure 115/85 mmHg. On rectovaginal examination, there is a palpable, non-painful, prolapsed mass that can be pushed back by the examiner's finger into the anal sphincter. What is the most likely diagnosis?

A four-month-old girl is brought to the office by her parents because they noticed a mass protruding from her rectum and she has been vomiting greenish vomit for the past 24 hours. Her parents noticed the mass when the child was being toilet trained and she strained to have a bowel movement 24 hours back, shortly after (about 20 hours ago) she had three episodes of greenish vomiting. She has a past medical history of failure to pass meconium for two days after birth. Her vital signs are heart rate 190/min, respiratory rate 44/min, temperature 37.2 °C (98.96 °F) and blood pressure 80/50 mmHg. On physical examination, the abdomen is distended. Rectal examination produces an explosive expulsion of gas and stool. The abdominal radiograph shows bowel distention and absence of distal gas. What is the most likely cause?

A 32-year-old woman comes to the office with the complaints of intense anal pain every time she has a bowel movement and mild bright red bleeding per rectum. The pain has been present for the past four weeks and it is too intense during defecation. It is dull and throbbing pain and is associated with slight bright red bleeding. She has no relevant past medical history. When asked about sexual history, she admits practicing anal intercourse. Her vital signs are heart rate 98/min, respiratory rate 16/min, temperature 37.6 °C (99.68 °F) and blood pressure 110/66 mmHg. On physical examination, the anal sphincter tone is markedly increased and it’s impossible to introduce the finger due to the patient's pain. What is the most common etiology of the patient’s condition?

A 57-year-old patient comes to the office with the complaints of perianal pain during defecation and perineal heaviness for one month. He also complains of discharge around his anus and bright red bleeding during defecation. The patient gives a history of having sexual relationship with other men without using any methods of protection. On physical examination, edematous verrucous anal folds are seen which are of hard consistency and painful to the touch. A proctosigmoidoscopy reveals an anal canal ulcer with well defined, indurated borders in a white background. A biopsy is taken and the results are pending. What is the most likely diagnosis?

A 25-year-old male construction worker comes to the office due to a yellowish discoloration of his skin and eyes for the past two weeks. He also complains of nausea and loss of appetite for the same duration. His past medical history is insignificant. He is a smoker but recently has grown a distaste for smoking. His vitals are heart rate 83/min, respiratory rate 13/min, temperature 36.5 °C (97.70 °F) and blood pressure 111/74 mmHg. On physical examination, there is mild hepatomegaly. His hepatitis viral panel is given below: Anti-HAV IgM: positive HBsAg: negative IgM anti-HBc: negative Anti-HCV: negative HCV-RNA: negative Anti-HDV: negative Anti-HEV: negative What is the most common mode of transmission for this patient’s diagnosis?

A 25-year-old male visits the office for a three-day history of fever and fatigue. Upon further questioning he says that he also had constant muscular pain, headaches, and fever during these days. He adds by giving a history of regular unprotected sexual relationship with multiple partners. He is a nonsmoker and drinks alcohol occasionally. Vital signs: heart rate 102/min, respiratory rate 18/min, temperature 38 °C (100.40 °F) and blood pressure 120/80 mmHg. On physical examination, he is icteric and hepatosplenomegaly is evident with diffuse muscular and abdominal tenderness particularly in the right upper quadrant. The serologic markers show the following pattern: anti-HAV IgM: negative HBsAg: negative anti-HBs: positive IgM anti-HBc: positive anti-HCV: negative anti-HDV: negative What is the most likely diagnosis?

A 25-year-old African-American male comes to the office due to extreme fatigue for the past 2 days. He also worries about his skin looking yellow. He does not have any other complaints and denies fever and headache. He admits to using illicit intravenous drugs in the past. He does not have any immunization records as he moved to the US from Africa at the age of 18. His vital signs are heart rate 72/min, respiratory rate 14/min, temperature 37.9 °C (100.22 °F) and blood pressure 100/74 mmHg. Physical examination is insignificant except for a mild diffuse abdominal tenderness. His blood is drawn for routine tests and shows an Alanine Aminotransferase (ALT) level of 2000 IU/L. Hepatitis viral panel is ordered which shows: Anti-HAV IgM: negative HBsAg: negative Anti-HBs: negative IgM anti-HBc: positive Anti-HCV: negative Anti-HDV: negative What is the most likely diagnosis?

A 73-year-old woman visits an urgent care clinic with the complaint of fever for the past 48 hours. She has been having frequent chills and increasing abdominal pain since her fever spiked to 103° F(measured at home). Abdominal pain is constant without any radiation and she rates the pain as a 4/10 pain. She also complains of malaise and fatigue. She does not have any significant past medical history. Her vitals are a heart rate of 110/min, respiratory rate of 15/min, temperature of 39.2 °C (102.5 °F) and blood pressure of 120/86 mmHg. On physical examination, she is icteric and there is severe tenderness on palpation of the right hypochondrium. Ultrasound is ordered which shows a dilated bile duct and calculus in the bile duct. Blood cultures are pending and antibiotic therapy is started. What is the most likely cause of her symptoms?

A 22-year-old woman comes to the office with the complaints of dark urine and low-grade fever for three months. She also expresses her concerns about feeling fatigued most of the time. She says that she thought her dark urine was from dehydration and started to drink more water but it showed minimal improvement. She denies sweating, recent change in her bowel movements and change in her appetite. She does not smoke nor does she drink alcohol. Her vitals are a heart rate 99/min, respiratory rate 18/min, temperature 38.5 °C (101.30 °F) and blood pressure of 100/60 mmHg. On physical examination, telangiectasias on anterior thorax are noted. The liver is palpable 4 cm below the costal border in the right midclavicular line and is tender on palpation. The spleen is palpable 2 cm below the costal border. Liver function results show: Aspartate Aminotransferase (AST): 780 U/L Alanine Aminotransferase(ALT): 50 U/L Total bilirubin: 10 mg/dL Direct bilirubin: 6 mg/dL Alkaline phosphatase(ALP): 150 U/L Serum Albumin: 2.5 g/dL Serum Globulins: 6.5 g/dL Prothrombin Time: 14 s Agglutinations: negative Serology for hepatitis C and D: negative Anti-smooth muscle antibodies: positive What is the most likely cause?

A 43-year-old man presents to the office with the complaints of mild abdominal pain, yellowish discoloration of eyes and itching all over his body for a year. He recently lost 5 lbs over a period of one month. He says that his urine is dark and stool appears clay colored. He doesn't give any history of hematemesis, melena or fever but mentions about his travel to Europe six months back. His past history includes a coronary angiography for anginal chest pain 2 years ago which showed 75% blockage in the Left Anterior Descending (LAD) artery and takes some pills but is unable to mention the names. On physical exam, there is a mass palpable in the right upper abdomen which is non-tender. Lab examination show: Alkaline phosphatase: 387 IU/L Total bilirubin: 18 mg/dL Aspartate transaminase: 191 IU/L Alanine transaminase: 184 IU/L CA 19-9: positive Serology is negative for hepatotropic viruses. Computed Tomography(CT) with contrast shows multifocal short segmental stricture of the bile duct outside the liver and mild dilation along with hypertrophy of the caudate lobe and atrophy of the left lateral and right posterior segments. Biopsy of the bile duct reveals periductal fibrosis with atypical bile duct cells in a desmoplastic stroma. Which of the following predisposing factors is responsible for this patient’s condition?

A 49-year-old female presents to the primary care physician with the complaints of recurrent episodes of right upper abdominal pain for the past 2 years. She is currently symptom-free. She mentions that the pain often occurs after a heavy fatty meal and radiates to her right shoulder. On examination, the patient has no tenderness in the abdomen and all other systemic examination is normal. Blood work shows: Leukocyte count: 8000/ mm^3 Total Bilirubin: 1.2 mg/dL Prothrombin time: 12 second Aspartate transaminase: 58 IU/L Alanine transaminase: 61 IU/L Serum Albumin: 4.1 g/dL Stool Occult blood: negative Ultrasonography of the abdomen shows thickened gallbladder wall with few gallstones. A hydroxy iminodiacetic acid (HIDA) scan was done which showed non-filling of the gallbladder and a minimal amount of tracer in common bile duct.Which of the following best describes the histopathological feature in this case?

A 37 year old man is rushed to the emergency department at night with the complaint of rapid onset of epigastric pain radiating to the back which started 4 hours ago. It is partially relieved on leaning forward. He admits to binge drinking this evening at a friend’s party. He is nauseated but hasn’t vomited. Vital signs include: blood pressure 90/60 mmHg, pulse: 110/min, temperature: 99° F and respiratory rate: 16/min. Physical exam shows tenderness over the epigastric region with decreased bowel sounds on auscultation. Blood investigation shows: Leukocyte: 18000/mm^3 with 81% neutrophils Serum Amylase: 415 U/L and Serum Lipase: 520 U/L. Which of the following can be best used to determine the prognosis in this case?

A 62-year-old man presents to his primary care physician after his wife and his friends noticed that he ‘looked yellow’. The patient has no complaints except for occasional mid upper abdominal pain relieved with Tylenol. Upon questioning, he recalls that he has lost some weight over the past several months but can not quantify the amount. His past medical history is significant for type 2 diabetes mellitus. He is known smoker and smokes 2 packs of cigarettes per day and has had this habit for 30 years.Vital signs are within normal limits and physical exam reveals mild jaundice and palpable gall bladder. Blood work shows: Total bilirubin - 13 mg/dL (normal 0-1.5 mg/dL), Direct bilirubin - 10 mg/dL (normal 0-0.3 mg/dL), and Alkaline phosphatase (ALP) - 560 IU/L (normal 39-117 IU/L) Ultrasonography did not demonstrate biliary stones or any mass in liver but a hypoechoic mass in the epigastric region is noted. The patient is prepared for Computed Tomography angiography for further evaluation.Which of the following best describes this patient’s disease?

A 41 year-old female presents to the urgent care clinic with the complaint of severe epigastric pain radiating to the back that began acutely a few hours ago. She additionally complains of nausea and vomited twice in the past hour. She denies any history of similar symptoms or trauma in the past. She is diabetic and was diagnosed with HIV infection 6 months back. She also has mild intermittent asthma and anxiety. She is on multiple medications but says she left the list of her medications at home. She is a non-smoker but drinks socially. Her vital signs are temperature: 99.6 °F, pulse: 95/min, blood pressure: 110/74 mmHg and respiratory rate:12/min. Her Body Mass Index (BMI) is 21 kg/m2 . Laboratory results show: Serum amylase: 415 U/L Serum lipase: 520 U/L Imaging studies show edematous pancreas with peripancreatic fluid collection with a normal gallbladder. Which of the following is the most likely etiology of her condition?

A 15-year-old girl is brought to the physician by her mother because she has not started menstruating yet. Her elder sister started menstruating at the age of 13 and her mother, at the age of 14. The patient is more concerned about her poor performance in sports. She says she can not participate in sports like before and gets tired very soon. During her last training session she had to walk out while performing a squatting exercise due to severe pain in her legs. She does not have a significant past medical or surgical history. Physical examination reveals pulsatile blood vessels within the intercostal spaces and diminished femoral pulses relative to brachial pulses. She also has a short neck with excessive skin in the lateral neck. This patient's symptoms are most likely associated with which of the following conditions?

A 25-year-old girl is brought to the emergency room after a suicide attempt. Her mother states that she found a large empty pill bottle next to her. The patient is conscious and tearful. She is currently complaining of severe abdominal pain but refuses to give any other history. On exam, her abdomen is exquisitely tender with evidence of crepitus in the epigastric region. Abdominal CT reveals a gastric perforation. Which of the following is the most likely cause?

A 52-year-old woman presents to her doctor complaining of mild epigastric pain and persistent heartburn for the past 2 months. An endoscopy is performed and reveals inflammation of the stomach mucosa without evidence of ulceration. A biopsy is performed and reveals intestinal metaplasia with destruction of a large number of parietal cells. She is diagnosed with chronic gastritis. Which of the following is characteristic of her diagnosis?

You are on your first day of a pathology rotation and your pathologist gives you a biopsy specimen to examine. She says it is from the antrum of the stomach of a 32-year-old man from Mexico who has been complaining of abdominal pain for the past 6 months. The patient states the pain is getting worse, especially when he eats. On endoscopy, there was a single ulcerated lesion with a “punched out” appearance. What are the most likely histologic findings in this biopsy specimen?

A family doctor in rural area is treating a patient for dyspepsia. The patient has had chronic heartburn and abdominal pain for the last 2 months and peptic ulcer disease due to H. pylori infection is suspected. Due to cost and access, the doctor decides to perform a diagnostic test in office that is less invasive and most convenient. Which of the following is the most likely test used?

A 53-year-old man presents to the office complaining of persistent abdominal pain. He states that he’s gained 10 lbs because the pain is only relieved by eating. The patient admits that he has numerous loose, foul smelling stools over the last few weeks with associated nausea. He has taken some over the counter antacids without relief or change in symptoms. Which of the following is the most likely diagnosis?

A 48-year-old woman with a history of osteoarthritis and hypertension presents to the office complaining of persistent abdominal pain for the last 2 months. She describes the pain as “burning and achy” that is worse when she eats- which has lead to a weight loss of 10lbs. The patient is currently taking Lisinopril and Atenolol for her blood pressure and Ibuprofen as needed for her osteoarthritis. Her temperature is 98.7°F, her heart rate is 75 bpm, and her blood pressure is 120/80 mmHg. An endoscopy is performed and a gastric ulcer is visualized and biopsied. The biopsy reveals H. pylori infection. Which of the following is the most likely predisposing factor to this patient’s diagnosis?

A 57-year-old female presents to the hospital complaining of 4 months of persistent abdominal pain that has recently gotten worse. The patient says that she was prompted to come to the emergency department because she had several episodes of vaginal bleeding. Her last menstrual period was approximately 8 years ago. The patient is sexually active with her husband and denies vaginal discharge and dysuria. The patient states that she has also been experiencing nausea and weight loss associated with the abdominal pain. Which of the following would be pathognomonic of this patient’s most likely diagnosis?

A 70-year-old man presents to the emergency department after several episodes of bloody stools that started 6 hours ago. The patient denies nausea, vomiting or diarrhea. On exam he is pale and cachectic. The patient’s abdomen is nontender to palpation on exam. His heart rate is 120 bpm and his blood pressure is 80/60 mmHg. A hemoccult test is grossly positive. Stool sample from the patient shows stools with gross blood. Which of the following is the most likely location of his intestinal bleeding?

A 26-year-old man presents to the office complaining of persistent epigastric pain. He states the pain is especially worse a few hours after he eats. The patient states that his father had similar symptoms when he was younger. A metabolic panel reveals the following: Sodium: 136 mEq/L Potassium: 4.2 mEq/L Calcium: 13.2 mg/dL Bicarbonate: 26 mEq/L Endoscopy reveals multiple duodenal ulcers. Which of the following is the most likely diagnosis?

A 57 year old female with a long standing history of liver cirrhosis presents to her primary care provider with the complaint of unintended weight loss of 18 pounds within the last month. She has a history of right upper quadrant pain in her abdomen on and off with decreased appetite for a few years and occasional shortness of breath. Past medical history is significant for Hepatitis E infection during her first pregnancy when she was 28 years old and history of blood transfusion after an accident 8 years ago. She drinks about 2-3 pints of beer every week on average and does not use tobacco. Her vital signs include a blood pressure of 110/68 mmHg, pulse rate of 82/min, Respiratory rate 11/min and a temperature of 37.7 °C. Physical exam is normal except for moderate icterus and tender hepatomegaly. Blood tests show mild anemia with decreased iron stores. Serum electrolytes, blood sugar and renal function are normal. Chest X-ray is normal. An ultrasound of the abdomen revealed a mass in liver which was confirmed with a biopsy to be hepatocellular carcinoma. Which of the following is the strongest causative factor that can linked to her diagnosis?

A 40-year-old woman comes to the office with the complaint of abdominal pain and yellow coloration of her skin for the past four days. She refers that the pain and skin coloration started gradually, increasing every day, but now she decided to consult the doctor skin color looks abnormal. She has been taking oral contraceptive pills for four years. Her vitals are: heart rate 102/min, respiratory rate 15/min, temperature 37.5 °C (99.5 °F) and blood pressure 116/76 mmHg. Physical examination shows abdominal pain on palpation, hepatomegaly 4 centimeters below the right costal border, and shifting abdominal dullness. Hepatitis viral panel is ordered which shows: Anti-HAV IgM: Negative HBsAg: Negative Anti-HBs: Negative IgM anti-HBc: Negative Anti-HCV: Negative Anti-HDV: Negative Anti-HEV: Negative An abdominal ultrasound shows hepatic vein thrombosis. A liver biopsy is performed which reveals congestion and necrosis in the central zones. What is the most likely cause of this patient’s condition?

A 57-year-old man visits the office with the chief complaints of fever and yellow discoloration of the skin for the past few days. He denies any change in his urine and stool color. He admits to drinking about 130 d/day of alcohol and has been doing so for the past 25 years. His wife who is accompanying him during this visit adds that once he drank 15 cans of beer at a funeral. His past medical history is unremarkable. He smokes 10 cigarettes every day. His vitals signs are heart rate 98/minute, respiratory rate 13/minute, temperature 38.2 °C (100.76 °F), and blood pressure 120/90 mmHg. On physical examination, he is icteric, there is right upper quadrant tenderness and hepatomegaly 3 centimeters below the right costal border. Laboratory studies show the following: Sodium: 135 mEq/L Potassium: 3.5 mEq/L ALT: 240 mEq/L AST: 500 mEq/L Liver biopsy is obtained but the results are pending. Which of the following would most likely be seen in his biopsy result?

A 36-year-old woman visits the office with her lab reports showing serum alkaline phosphatase (ALP) level five times the upper limit of normal range during a pre-employment health assessment. She has been asymptomatic all this time and her annual physical exam eight months ago was normal. She is a nonsmoker and quit alcohol last year. She is health conscious and follows a healthy diet. A complete hepatic biochemistry panel is performed, which is normal regarding the other parameters but immunologic studies are positive for antimitochondrial antibodies. Hepatic biopsy shows inflammatory infiltration surrounding the biliary ducts. What is the most likely cause of her symptoms?

A 67-year-old man comes to the office due to progressive abdominal distention, yellow skin coloration for the past two weeks. He also complains of fatigue but denies fever or any other symptoms. He has a history of being a heavy drinker for several years but he quit recently. On physical examination, there is shifting dullness on abdominal percussion, no edema, yellow skin coloration also involves the sclera and mucosa and bilateral gynecomastia is present. Blood analysis shows the following: Hb: 13 g/dL Leukocytes: 4,500/mm^3 Platelets: 86,000/mm^3 Aspartate transaminase (AST): 108 UI/L Alanine transaminase (ALT): 55 UI/L GGT: 185 UI/L Urea: 23 mg/dL Iron: 120 μg/dL Ferritin: 180 μg/dL Transferrin saturation: 40 % What is the most likely cause of this patient’s diagnosis?

A 66-year-old man is brought to the Emergency Room by his wife due to abdominal distension and persistent somnolence for the past couple of weeks. The wife adds further that the patient has been sleeping much more than usual for the past five days. His bowel and bladder habit have not changed. His medical history is significant for cirrhosis of liver secondary to prolonged alcohol consumption. His vital signs are heart rate: 76/min, respiratory rate: 15/min, temperature: 37 °C (98.6 °F) and blood pressure: 122/75 mmHg. On physical examination, a fluid thrill can be elicited on his abdomen, he has an altered mental status, hyperreflexia, and asterixis are noted. Blood tests show the following: Sodium: 140 mEq/L Potassium: 3.5 mEq/L Chloride: 4 mEq/L Glucose: 90 mg/dL The arterial blood gas shows: pH: 7.4 pCO2: 40 mmHg pO2: 90 mmHg HCO3: 26 mEq/L An abdominal ultrasound shows surface nodularity compatible with cirrhosis but no other changes aside from ascites. An upper GI endoscopy is performed which shows gastric varices with no signs of active bleeding. MRI of the brain is insignificant. What is the most likely precipitating factor that led to this patient’s condition?

A 50-year-old male comes to the office for a routine check-up. He has a past medical history of cirrhosis for four years secondary to Hepatitis C virus infection and ascites for which he takes a diuretic. Aside from the ascites, he has no other clinical signs or symptoms. His labs show the following: Aspartate Aminotransferase (AST): 80 U/L Alanine Aminotransferase(ALT): 50 U/L Total bilirubin: 2.5 mg/dL Direct bilirubin: 1.8 mg/dL Alkaline phosphatase(ALP): 140 U/L International Normalized Ratio: 1.9 Serum creatinine: 1 mg/dL Urinalysis shows: Sodium: 200 mmol/24h Potassium: 60 mmol/24h Protein: Nil RBCs: Nil RBC casts: Nil WBCs: Nil Urea: 13 g/24h Creatinine: 6 mmol/24h His abdominal ultrasound shows no changes in the cirrhotic liver compared to his last one done six months back. This also applies to the kidneys which are seen normal on ultrasound. Only moderate ascites is seen. An upper GI endoscopy shows esophageal varices of small size. The hepatic venous pressure gradient measurement is 14 mmHg. A diagnostic paracentesis is done which finds clear liquid, with 2300 cells/mL, 30 % lymphocytes, 60 % PMN and 1% red blood cells. What is the etiology responsible for most of this patient’s findings?

A 32-year-old man from Thailand is visiting his family in the US. He presents to the emergency department complaining of diarrhea and fatigue for the past 6 days, beginning before he left Thailand. The patient denies use of laxatives, nausea, and vomiting. On exam, he is pale with dry mucous membranes, his blood pressure is 80/50 mmHg, his heart rate is 105 bpm, temperature is 99.8 °F. A stool sample is obtained for culture and appears watery and copious. Pathology requires a categorization of the diarrhea. Which of the following is the correct categorization of this diarrheal disease?

A 23-year-old man presents to the office complaining of weight loss and fatigue over the past 2 months. He has a history of cystic fibrosis which is well controlled. He denies shortness of breath, chest pain, abdominal pain, nausea, vomiting, and melena. He states that he has been experiencing foul smelling, light colored stools but thinks it is because he hasn’t been eating well recently. On physical exam his skin is pale and dry. You are concerned that he is presenting with a malabsorption syndrome. Which of the following would be the most likely cause of malabsorption in this patient?

An 82-year-old woman presents to your office complaining of 2 weeks of foul smelling, greasy diarrhea. The patient states that she has felt very tired recently but otherwise has no other complaints. She denies abdominal pain, nausea, and vomiting. She states she has experienced some bloating and flatus but denies melena and hematochezia. Which of the following tests would you perform in order to confirm your suspected diagnosis?

An 11-year-old boy presents to the office with his mother for evaluation of weight loss, rash, and several weeks of bloating and diarrhea. The mother states that the patient’s father had similar symptoms at his age. On physical exam, the patient is pale with dry mucous membranes. The patient has a vesicular rash on bilateral lower extremities that he states are “very itchy.” What laboratory findings would confirm your suspected diagnosis?

A 52-year-old man presents to the office complaining of 2 months of diarrhea, abdominal pain, and fatigue. The patient states that because of this he has lost 8 lbs. He states his joints have been hurting more recently as well. The patient seems lethargic and when asked says that he has had some problems with concentration and memory recently. An endoscopy is performed with biopsy of the small bowel. What is the most likely histologic finding?

A 73-year-old man presents to the emergency department complaining of abdominal pain with nausea and vomiting, stating that he “can’t keep anything down”. The patient states that the pain has been gradually getting worse over the past 2 months- at first it was present only an hour after he ate but now it is constant. He also says that he has been constipated recently, which has also been getting worse. His last bowel movement was 4 days ago and was of normal caliber and states that he cannot pass flatus. The patient’s history is significant for hypertension and an episode of pneumonia last year with no history of surgeries. On exam, the patient is uncomfortable, his heart has a regular rate and rhythm at 105 bpm and his lungs are clear to auscultation bilaterally. His abdomen is visibly distended and diffusely tender with tympany on percussion. A CT shows dilated loops of small bowel with collapsed large bowel. What is the most likely cause of this patient’s diagnosis?

A group of patients at the local hospital are diagnosed for chronic secretory diarrhea. Multiple reasons were noted to cause chronic secretory diarrhea in these patients. Among the following causes, which one is the most common to cause chronic secretory diarrhea in the US?

A 25-years aged young man is admitted to the hospital suffering from bloody diarrhea. The patient is diagnosed with more than one reason to cause him bloody diarrhea. All of the following conditions can be potential reasons to cause bloody diarrhea except one. Pick out the one that is not or is irrelevant.

A 38-year-old female presents to the emergency department complaining of nausea with progressive upper abdominal pain for one day. For the past one year, she has had occasional pain in her right upper quadrant which often relieved on its own after few hours from onset. She was diagnosed with multiple gallstones for which she underwent an elective Endoscopic Retrograde Cholangio-Pancreatography(ERCP) a couple of days back. The procedure was uneventful with no immediate complications. She doesn't have any major medical illness and currently is not taking any medication. There is no history of any abdominal surgery in the past. She is a non-alcoholic and does not smoke cigarettes. On examination, there is tenderness over the epigastrium. however, rebound tenderness can not be elicited. Vital signs are noted to be: blood pressure: 110/68 mm Hg, pulse: 98/min, temperature: 97.2oF and respiratory rate: 11/min. Blood is drawn and sent to the lab for investigation. An imaging study of the abdomen confirms the most likely diagnosis. Which of the following parameters is expected to be below the normal range in her blood due to her current condition?