Escolar Documentos
Profissional Documentos
Cultura Documentos
Gastrointestinal
and
Nutritional
Questions
based
on
Chapter
3
of
the
book
Pance
Prep
Pearls
and
the
upcoming
release
of
PANCE
AND
PANRE
QUESTION
BOOK.
Good
luck!!!
1. A
35-year-old
male
comes
to
the
clinic
for
a
routine
physical
examination.
During
obtaining
a
history,
he
tells
you
his
brother
was
diagnosed
with
colon
cancer
at
53-years-old.
Which
of
the
following
describes
the
appropriate
colon
cancer
screening
guidelines
for
this
patient?
a. Fecal
occult
blood
testing
now
and
colonoscopy
every
10
years
b. Fecal
occult
blood
testing
at
age
40
and
colonoscopy
every
10
years
c. Fecal
occult
blood
testing
at
age
50
and
colonoscopy
every
10
years
d. Fecal
occult
blood
testing
at
age
50
and
colonoscopy
every
5
years
e. Fecal
occult
blood
testing
at
age
40
and
colonoscopy
every
5
years
2. A
45-year-old
male
presents
with
non-bloody
diarrhea
and
crampy
abdominal
pain
especially
in
the
right
lower
quadrant.
Rovsing,
Obturator
and
Psoas
sign
are
negative.
He
undergoes
an
upper
GI
series
with
small
bowel
follow
through
and
a
string
sign
is
seen.
The
patient
is
saccharomyces
cerevisiae
antibody
positive.
Which
of
the
following
lab
findings
would
most
likely
be
seen
in
this
patient?
a. increased
alpha
fetoprotein
b. increased
perinuclear
anti-neutrophil
antibody
c. increased
smooth
muscle
antibody
d. increased
mean
corpuscular
volume
of
the
red
blood
cells
e. increased
endomysial
antibodies
3.
A
50-year-old
obese
female
is
complaining
of
multiple
episodes
of
sharp,
right
upper
quadrant
pain
that
is
worsened
with
fatty
and
fried
foods.
The
patient
states
the
pain
radiates
to
the
right
shoulder.
On
physical
examination,
there
is
right
upper
quadrant
tenderness,
causing
the
patient
to
hold
their
breath
in
mid-
inspiration.
There
is
no
fever
or
jaundice.
Which
of
the
following
is
the
most
appropriate
test
at
this
time?
a. HIDA
scan
b. Endoscopic
retrograde
cholangiopancreatography
c. Ultrasound
of
the
gallbladder
d. Abdominal
radiograph
e. Prothrombin
and
albumin
level
Which
of
the
following
is
the
most
likely
diagnosis?
a. Zenkers
diverticulum
b. Esophageal
cancer
c. Nutcracker
esophagus
d. Achalasia
e. Diffuse
esophageal
spasm
6. In
evaluating
a
patient
with
oral
thrush
and
odynophagia,
which
of
the
following
endoscopic
findings
would
be
most
likely
seen
in
this
patient?
a. Large
superficial
ulcers
b. Columnar
cells
in
the
lower
esophagus
c. Small
deep
ulcers
d. Linear
plaques
e. Multiple
corrugated
rings
Which
of
the
following
is
the
most
common
early
physical
exam
finding
in
this
patient?
a. Peritoneal
signs
b. Bowel
sounds
with
gurgles
at
about
5-15
per
minute
c. No
bowel
sounds
d. Hyperactive,
high-pitched
tinkling
abdominal
sounds
e. Sausage
shaped
mass
9. Which
of
the
following
is
the
classic
description
of
a
patient
with
an
ascorbic
acid
(Vitamin
C)
deficiency.
a. Diarrhea,
dementia
and
dermatitis
b. Ataxia,
oculomotor
palsies,
global
confusion
c. The
presence
of
looser
lines
(zones)
d. Hyperkeratosis
and
perifollicular
hemorrhages
e. Magenta
colored
tongue,
corneal
lesions
and
scrotal
dermatitis
10. A
46-year-old
male
with
a
longstanding
history
of
GERD
now
has
dysphagia
to
solids,
weight
loss
and
anemia.
He
does
not
smoke
or
drink
and
has
not
had
any
recent
episodes
of
vomiting
or
retching.
Which
of
the
following
is
the
most
likely
diagnosis?
a. Barretts
esophagus
b. Diffuse
esophageal
spasm
c. Adenocarcinoma
of
the
esophagus
d. Squamous
cell
carcinoma
of
the
esophagus
e. Mallory
Weiss
tears
QUESTION
1
Choice
E
is
correct.
A
first-degree
relative
is
a
parent,
sibling
or
offspring.
Because
his
brother
was
diagnosed
at
age
53,
recommended
age
is
to
begin
at
age
40
(or
10
years
before
the
person
was
diagnosed
which
would
have
been
43
so
you
use
the
lower
number).
The
10
number
comes
from
the
thought
it
takes
roughly
about
10
years
on
average
for
a
polyp
to
become
malignant.
Average
Risk
1st
degree
relative
>60y
1st
degree
relative
<60y
FOBT
COLONOSCOPY
Annually
@
50y
Colonoscopy
q10y
(flex
sig
q5y)
(up
to
80y)
Annually
@
40y
Colonoscopy
q10y
Annually
@
40y
Colonoscopy q5y
Choice
A
is
incorrect
Choice
B
(Fecal
occult
blood
testing
at
age
40
and
colonoscopy
every
10
years)
is
recommended
in
patients
whose
first
degree
relative
was
diagnosed
over
60y
of
age
Choice
C
(Fecal
occult
blood
testing
at
age
50
and
colonoscopy
every
10
years)
is
the
standard
recommended
guidelines.
Choice
D
is
incorrect
QUESTION
2
Choice
D
(increased
MCV)
is
the
correct
answer.
The
string
sign,
non-bloody
diarrhea
and
right
lower
quadrant
pain
is
highly
suggestive
of
Crohns
disease.
The
terminal
ileum
is
the
most
common
site
of
Crohns
disease
and
since
it
sits
in
the
right
lower
quadrant,
RLQ
pain
is
a
common
finding
in
patients
with
Crohns.
Both
inflammatory
bowel
diseases
(Crohns
and
Ulcerative
Colitis)
are
thought
to
arise
from
an
inappropriate
autoimmune
response
to
the
normal
GI
flora.
Antibodies
against
the
harmless
saccharomyces
cerevisiae
(most
likely
known
to
you
as
Bakers/Brewers
yeast
used
to
make
ethanol
and
to
allow
dough
to
rise)
is
seen
in
about
70%
of
patients
with
Crohns
(and
only
10-15%
of
those
with
ulcerative
colitis
so
that
also
leads
to
the
diagnosis
of
Crohns.
Because
Crohns
most
commonly
affects
the
terminal
ileum
(where
B12
is
absorbed),
patients
may
develop
a
B12
deficiency
and
a
subsequent
macrocytic
anemia
with
an
increased
mean
corpuscular
volume
(MCV)
of
the
red
blood
cell.
Choice
A
(increased
alpha
fetoprotein)
is
common
in
hepatocellular
carcinoma
and
germ
cell
tumors
like
nonseminomatous
testicular
cancer.
In
utero,
alpha
fetoprotein
is
the
a
dominant
serum
protein
in
the
fetus
(the
fetus
version
of
albumin
produced
by
the
yolk
sac
and
the
liver
(this
is
why
it
is
can
be
seen
in
germ
cell
tumors
&
remember
produces
our
serum
proteins).
Choice
B
(increased
perinuclear
anti-neutrophil
antibody)
is
commonly
seen
with
ulcerative
colitis
(commonly
associated
with
bloody
diarrhea
and
left
upper
quadrant
since
it
the
inflammation
has
contiguous
spread
from
the
rectum
proximally
so
the
left
side
is
affected).
Cross
reference:
P-ANCA
is
also
seen
in
Churg-Strauss,
Primary
Sclerosing
Cholangitis
&
microscopic
polyangiitis.
Choice
C
(increased
smooth
muscle
antibody)
is
classically
associated
with
autoimmune
hepatitis
(but
can
be
seen
in
chronic
hepatitis
and
cirrhosis).
There
was
no
mention
of
liver
symptoms
or
sequelae
in
this
question
to
suggest
those
disorders.
Choice
E
(endomysial
antibodies)
&
transglutaminase
antibodies
are
classically
associated
with
Celiac
disease
(which
can
cause
a
chronic
diarrhea)
but
would
be
related
to
the
consumption
of
gluten.
QUESTION
3
Choice
C
(ultrasound
of
the
gallbladder)
is
correct.
This
is
a
classic
presentation
of
acute
cholecystitis,
making
ultrasound
the
best
initial
test
in
the
evaluation
of
suspected
cholecystitis.
Ultrasound
findings
will
be
the
presence
of
stone,
thickened
gall
bladder
and
a
positive
sonographic
Murphys
sign
while
doing
the
test.
Although
afebrile
in
this
vignette,
patients
with
acute
cholecystitis
can
be
febrile
due
to
the
infection.
The
referred
pain
to
the
right
shoulder
is
known
as
Boas
sign
(not
to
be
confused
with
pain
that
radiates
the
left
shoulder
Kehrs
sign).
Both
are
caused
by
phrenic
nerve
irritation.
Boas
sign
is
associated
with
acute
cholecystitis
and
Kehrs
sign
is
usually
associated
with
splenic
injury
most
commonly,
ectopic
pregnancy,
or
kidney
stones
Choice
A
is
the
gold
standard
test
but
remember
often
gold
standard
tests
are
most
often
not
the
initial
test
done.
If
the
question
asked
for
gold
standard,
then
HIDA
would
have
been
correct.
Choice
B
(ERCP)
is
used
for
suspected
biliary
tract
disease.
In
acute
cholecystitis,
the
stone
is
in
the
cystic
duct
but
bile
is
still
able
to
flow
through
the
bile
ducts
(this
is
why
there
are
no
long-term
sequelae
in
patients
who
have
a
cholecystectomy
as
the
bile
can
still
flow
without
the
gall
bladder.
In
biliary
duct
diseases,
patients
usually
develop
jaundice
with
the
blocking
of
the
biliary
tract.
Choice
D
(abdominal
X
ray)
would
be
useful
for
other
disorders,
such
as
small
bowel
obstruction
but
most
stones
are
radiopaque
(since
they
are
made
of
cholesterol)
so
wont
show
up
often
on
abdominal
X
ray
and
radiographs
wont
show
the
details
that
can
be
seen
on
ultrasound.
Choice
E
(PT
and
albumin
levels)
is
helpful
if
end
stage
liver
disease
is
suspected.
QUESTION
4
Choice
A
(Lansoprazole
30mg
+
amoxicillin
500mg
+
clarithromycin
500mg)
triple
therapy
is
the
mainstay
of
H-pylori
peptic
ulcer
disease.
Choice
B
can
be
used
for
H.
pylori
negative
disease.
Proton
pump
inhibitors
(the
azoles)
are
the
most
effective
drugs
against
acid
production.
Choice
C
is
an
alternative
in
patients
who
are
penicillin
allergic
(Metronidazole
is
substituted).
Choice
E
can
also
be
not
to
treat
peptic
ulcers.
Misoprostol
can
be
used
to
prevent
recurrence
or
ulcers
particularly
in
patients
with
aspirin
or
NSAID-induced
ulcers.
Remember
gastric
ulcers
are
due
to
decreased
protective
factors
(mucous
and
bicarbonate).
Prostaglandins
are
responsible
for
those
protective
mechanisms
and
aspirin
and
NSAIDs
exhibit
their
anti-inflammatory
effects
via
prostaglandin
inhibition.
Misoprostol
is
a
prostaglandin
analogue.
QUESTION
5
Choice
D
(Achalasia)
is
correct.
Achalasia
is
a
disorder
that
causes
loss
of
Aurbachs
plexus
at
the
lower
esophageal
sphincter
area.
Auerbachs
plexus
secretes
nitric
oxide
(which
leads
to
relaxation
of
the
LES).
Without
Auerbachs
plexus,
there
is
an
increased
LES
pressure,
leading
to
dysphagia.
On
a
Barium
swallow
(esophagram),
the
increased
LES
tone
leads
to
narrowing
of
the
GE
junction
and
pre
narrowing
dilation,
leading
to
the
classic
bird
beak
appearance.
Choice
D
denotes
successful
Hepatitis
B
vaccination.
The
surface
antibody
is
the
only
positive
marker
in
vaccination.
People
often
confuse
this
with
someone
with
a
distant
resolved
infection.
But
think
of
it
this
way,
if
you
were
infected
with
hepatitis
B,
then
the
virus
would
be
destroyed
by
the
macrophages,
producing
antibodies
to
surface
proteins
but
also
the
viral
core,
so
the
core
would
be
positive.
Choice
E
is
the
classic
description
of
the
window
period.
In
someone
who
is
infected,
the
window
period
describes
the
point
where
the
surface
antigen
is
disappearing
(leading
to
a
negative
HBsAg)
but
the
antibodies
are
not
enough
yet
to
be
detected
by
testing
(even
though
they
will
eventually
increase).
So
the
core
IgM
antibody
is
often
the
sole
serologic
marker
in
the
window
period.
HBsAG
HBsAB
HBcAB
HBeAG
HBeAB
A.
NEGATIVE
POSITIVE
POSITIVE
NEGATIVE,
NEGATIVE
(IgG)
B.
POSITIVE
NEGATIVE,
POSITIVE
NEGATIVE
NEGATIVE
(IgG)
C.
POSITIVE
NEGATIVE,
Positive
POSITIVE,
NEGATIVE
(IGM)
D
NEGATIVE
POSITIVE
NEGATIVE
NEGATIVE
NEGATIVE
E.
NEGATIVE
NEGATIVE
POSITIVE
NEGATIVE
NEGATIVE
(IgM)
QUESTION
8
Choice
D
(hyperactive
bowel
sounds)
is
correct.
Crampy
abdominal
pain,
nausea
vomiting
and
constipation
are
classic
for
a
small
bowel
obstruction.
Besides,
the
abdominal
X
ray
shows
the
stepladder
appearance
as
fluid
and
air
builds
up
in
the
obstructed
bowel
since
it
cannot
go
forward.
In
the
early
stages
of
obstruction,
there
is
hyperactive
bowel
sounds
as
the
bowel
proximal
to
the
obstruction
fervently
contracts
to
overcome
the
obstruction.
Later
in
the
disease,
hypoactive
bowel
sounds
(choice
C)
will
prevail
but
the
question
specifically
states
early.
Choice
A
(peritoneal)
is
not
specific
to
small
bowel
obstruction
but
can
be
seen
if
bowel
ischemia
is
present
due
to
small
bowel
obstruction
or
other
reasons
and
can
be
seen
in
many
disorders
and
often
not
seen
in
early
obstruction.
Choice
B
(gurgles
about
5-15)
is
considered
normal
bowel
sounds
Choice
E
(sausage
shaped
mass)
is
classically
associated
with
intussusception
which
would
be
associated
with
a
bowel
that
contains
mucous
and
blood
(currant-jelly)
and
vomiting.
Which
is
almost
exclusively
seen
in
infants.
If
it
occurs
in
adults,
it
is
often
associated
with
a
lead
point
such
as
a
malignancy
that
then
causes
the
telescoping.
QUESTION
9
Choice
D
(hyperkeratosis
&
perifollicular
hemorrhages)
is
correct.
Vitamin
C
is
needed
for
collagen
synthesis.
Scurvy
(Vitamin
C
deficiency)
is
associated
with
loss
of
collagen
in
blood
vessels,
leading
to
perifollicular
hemorrhages
&
purpura
among
the
other
manifestations.
Choice
A
is
classic
for
pellagra
(Vitamin
B3/Niacin)
deficiency
Choice
B
is
classic
for
vitamin
B1/Thiamin
deficiency.
Ataxia
oculomotor
paralysis
and
global
confusion
is
the
triad
of
Wernickes
encephalopathy.
Choice
D
(Looser
Lines)
are
associated
with
adult
onset
vitamin
D
deficiency
(Osteomalacia).
Choice
E
ocular-oral-genital
involvement
is
classically
associated
with
riboflavin
(Vitamin
B2)
deficiency.
QUESTION
1O
Choice
C
(Esophageal
adenocarcinoma)
is
correct.
Chronic
acidic
contents
in
the
esophagus
of
someone
with
longstanding
GERD
will
develop
Barretts
esophagus
(Choice
A),
the
precursor
to
esophageal
carcinoma.
The
fact
that
he
had
dysphagia
especially
to
solids,
weight
loss
and
anemia
make
malignancy
the
likely
cause.
Choice
B
(diffuse
esophageal
spasm)
is
a
motility
disorder,
so
both
solids
and
liquids
will
cause
spasm
of
the
esophagus.
The
patient
will
often
complain
of
odynophagia,
classically
its
a
stabbing
chest
pain
that
is
worse
with
hot
or
cold
foods
AND
liquids.
Choice
D
(Squamous
cell
carcinoma)
is
usually
seen
not
in
the
context
of
GERD
but
more
so
in
patients
who
drink
or
smoke
(this
patient
does
neither),
making
Choice
C
the
better
answer.
Choice
E
(Mallory
Weiss
Tears)
are
due
to
repeated
vomiting
or
retching
causing
superficial
mucosal
tears.
The
usually
develop
signs
of
bleeding
if
they
are
symptomatic.
PHOTO
CREDIT
Achalasia:
By
Farnoosh
Farrokhi,
Michael
F.
Vaezi.
[CC-BY-2.0
(http://creativecommons.org/licenses/by/2.0)],
via
Wikimedia
Commons
Small
Bowel
obstruction:
By
James
Heilman,
MD
(Own
work)
[CC-BY-SA-3.0-2.5-
2.0-1.0
(http://creativecommons.org/licenses/by-sa/3.0)
or
GFDL
(http://www.gnu.org/copyleft/fdl.html)],
via
Wikimedia
Commons