A 48-year-old woman comes to the office after abnormal serum liver chemistry results were found during a life insurance medical evaluation.  She has no chronic medical conditions and takes no medications.  The patient says that she has felt excessively tired lately, which she attributes to menopause.  She has had no hot flashes, changes in sleep pattern, anorexia, or weight loss.  The patient does not use tobacco, alcohol, or recreational drugs.  Family history is unknown.  Vital signs are within normal limits.  BMI is 30 kg/m².  She has small bilateral xanthelasmas and no scleral icterus.  The thyroid is not enlarged.  Cardiopulmonary examination is unremarkable.  The abdomen is soft and nontender with no hepatosplenomegaly.  There is no rash.  Current laboratory results are as follows:

Abdominal ultrasonography reveals increased hepatic echotexture, no gallstones, and a normal common bile duct.

Item 1 of 3
Which of the following is most likely to help establish the diagnosis in this patient?

Item 2 of 3
Which of the following is the most appropriate initial management of this patient’s condition?

Item 3 of 3
This patient is at greatest risk for which of the following disorders associated with her current condition?

A 55-year-old man comes to the emergency department due to blood-tinged vomiting.  The patient was at a party the evening prior to presentation and consumed a large quantity of alcohol.  After leaving, he developed symptoms of nausea and retching, followed by vomiting several hours later.  The emesis was initially clear but then became intermixed with small amounts of blood.  He has no abdominal pain, weight loss, or changes in stool.  The patient has a history of alcoholism and was admitted for acute pancreatitis a few months ago.  He currently takes no medications or over-the-counter supplements.  The patient drinks 4 or 5 beers daily but does not use tobacco or illicit drugs.  Temperature is 36.7 C (98.1 F), pulse is 88/min, and respirations are 16/min.  Physical examination shows dry mucous membranes, flat jugular veins, clear lung fields, and normal S1 and S2.  The abdomen is soft and tender in the midepigastrium with no rebound tenderness or rigidity.  Bowel sounds are normal.  There is moderate splenomegaly without hepatomegaly.  No edema is present.  Laboratory results are as follows:

The patient undergoes an esophagogastroduodenoscopy that reveals several small, erythematous erosions at the gastroesophageal junction as well as hyperemia and petechiae throughout the gastric mucosa.  Incidentally, varices are seen in the fundus of the stomach but no esophageal varices are seen.  Which of the following is the most likely cause of this patient’s varices?

A 40-year-old man comes to the office for follow-up.  The patient has nonalcoholic fatty liver disease diagnosed a year ago based on elevated hepatic transaminases and confirmatory ultrasound examination.  He does not use tobacco, alcohol, or recreational drugs.  BMI is 38 kg/m², decreased from 40 kg/m² a year ago.  Vital signs are normal.  Examination is notable for hepatomegaly.  Today’s fasting laboratory results are as follows:

Liver biopsy is performed and reveals marked hepatic steatosis with hepatocyte ballooning degeneration, lobular inflammation, and perisinusoidal/pericellular fibrosis.  Which of the following features is the strongest predictor of liver-related death in this patient?

A 38-year-old man comes to the office due to new-onset constipation.  For the past month, he has had 2 or 3 hard stools per week associated with straining.  When he wipes, he occasionally sees bright red blood on the toilet paper.  The patient also experiences lower abdominal bloating and passes flatus frequently.  Medical history is unremarkable.  The patient takes no medications.  Vital signs are normal.  BMI is 35 kg/m².  No tenderness, mass, or organomegaly is noted on abdominal examination.  Rectal examination reveals multiple hemorrhoids.  Laboratory results are as follows:

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

A 34-year-old woman comes to the emergency department due to a 12-hour history of sudden-onset, upper abdominal pain.  She describes the pain as intense, constant, and radiating to the back.  The pain is relieved by leaning forward and worsens with eating.  The patient also reports nausea and has vomited several times.  She has no previous episodes of abdominal pain, fever, chills, weight loss, fatigue, or night sweats.  The patient has no known medical conditions and takes no prescription or over-the-counter medications.  She does not use alcohol, tobacco, or illicit drugs.  Her last menstrual period was 2 weeks ago and was normal.  The patient is sexually active with a male partner and uses condoms.  Temperature is 36.7 C (98.1 F), blood pressure is 134/72 mm Hg, pulse is 72/min, and respirations are 14/min.  BMI is 24 kg/m².  Physical examination shows moist mucous membranes and anicteric sclera.  Lung fields are clear, and S1 and S2 are normal.  The abdomen is soft and tender in the upper abdomen but without rebound, involuntary guarding, or rigidity.  Bowel sounds are normal.  Neither hepatomegaly nor splenomegaly is present.  Bimanual examination reveals no adnexal masses or tenderness.  Neurologic examination is within normal limits.

Item 1 of 3
Which of the following is the most appropriate immediate next step for establishing the diagnosis in this patient?

Item 2 of 3
Laboratory results are as follows:

Pregnancy testing is negative.  Abdominal ultrasound reveals a normal-appearing gallbladder and a nondilated biliary tree.  The patient is admitted to the hospital; intravenous fluid, antiemetics, and pain medications are started.  Which of the following is the best next step in management of this patient?

Item 3 of 3
The patient is diagnosed with hypertriglyceridemia-induced acute pancreatitis, and intravenous insulin is started.  Although the triglyceride levels improve in response to therapy, her abdominal pain remains unchanged by day 8 of hospitalization.  The patient tolerates minimal nutritional intake despite the use of a nasogastric tube.  Temperature is 38.6 C (101.5 F), blood pressure is 90/50 mm Hg, pulse is 107/min, and respirations are 22/min.  Oxygen saturation is 98% on room air.  Physical examination reveals tenderness in the upper abdomen to deep palpation without involuntary guarding, rebound, or rigidity.  Repeat laboratory analysis reveals leukocytosis with a left shift, whereas hemoglobin and liver function tests remain unchanged.  Which of the following would be the best next step in management of this patient?

A 46-year-old man is brought to the emergency department by the police after being found unresponsive on a nearby park bench.  The patient was brought to the hospital on several previous occasions due to alcohol intoxication; no other history can be obtained.  He appears disheveled and has a strong smell of alcohol.  Temperature is 36.1 C (97 F), blood pressure is 110/76 mm Hg, pulse is 84/min, and respirations are 14/min.  Pulse oximetry shows 98% on room air.  The patient is somnolent and withdraws all extremities to painful stimuli but is unable to follow verbal instructions.  The mucous membranes are dry, and there are several spider angiomas and bilateral gynecomastia.  The lungs are clear to auscultation, and heart sounds are normal without murmurs.  There is moderate abdominal distension with shifting dullness.  The liver edge cannot be palpated.  While being evaluated in the emergency department, the patient vomits a large amount of bright red blood.  Repeat vital signs show that blood pressure is 100/50 mm Hg and pulse is 110/min.

Item 1 of 3

In addition to obtaining intravenous access for fluid resuscitation, which of the following is the best next step in management of this patient?

Item 2 of 3

The initial appropriate steps are taken for this patient, and an upper gastrointestinal endoscopy is planned.  Repeat vital signs show that blood pressure is 109/62 mm Hg and pulse is 85/min.  Laboratory results are as follows:

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

Item 3 of 3

Upper endoscopy shows actively bleeding esophageal varices that are treated with band ligation.  There is no evidence of gastric or duodenal ulcers.  The patient also receives intravenous antibiotics while in the hospital.  The bleeding stops, and his clinical condition improves.  Abdominal ultrasonography shows a nodular, shrunken liver; a patent portal vein; mild splenomegaly; and moderate ascites.  The patient is counseled on alcohol abstinence.  At the time of discharge, initiation of which of the following is most appropriate for decreasing the risk of recurrent variceal bleeding in this patient?

A 38-year-old woman comes to the office due to jaundice, nausea, and abdominal discomfort.  Vital signs are within normal limits.  Scleral icterus and hepatomegaly are present.  Laboratory results are as follows:

Anti–smooth muscle antibody titers are elevated.  Which of the following histologic findings is most likely to be seen on biopsy of this patient’s liver?

A 42-year-old woman comes to the office due to increasing episodes of burning substernal pain and sour taste in her mouth over the past 2 years. Previously, symptoms occurred only after a large or high-fat meal, but recently they have occurred almost daily. She has had no difficulty or pain with swallowing and has had no bloody or black stools, vomiting, or weight loss. The patient has no other medical conditions and takes no medications. Vital signs are within normal limits. BMI is 28 kg/m2. Physical examination shows normal oropharyngeal mucosa. The abdomen is nontender with no hepatosplenomegaly. The remainder of the physical examination is unremarkable. Stool testing for occult blood is negative. The patient states that the symptoms are interfering with her life and she would like them to be controlled. Which of the following is the most appropriate response to the patient regarding the next step in management?

A 34-year-old previously healthy man was admitted to the intensive care unit after a motor vehicle collision 3 days ago in which he was the unrestrained driver.  The patient sustained traumatic brain injury and blunt chest trauma, which are being managed nonoperatively.  He has had episodes of hypotension, which improved after fluid resuscitation and packed red blood cell transfusion.  He is mechanically ventilated and is receiving enteral feeding via the nasogastric tube.  Today, the patient is noted to have black liquid stool that is heme-positive.  He has had no fever or high gastric residuals.  The abdomen is nondistended and soft with normal bowel sounds.  Laboratory results are as follows:

Which of the following would have been most effective at preventing this patient’s current condition?

A 36-year-old man comes to the office due to frequent “loose stools” for the past 10 months.  The patient describes stools that are large in volume, liquid to semisolid, occurring up to 3-4 times a day, and often foul-smelling.  He also reports excessive flatulence and occasional nausea and abdominal cramping.  The patient says he may have lost some weight because his clothes are much looser than before.  He has no prior medical problems and takes no medications.  Family history is notable for hypertension and coronary artery disease in his father.  The patient immigrated to the United States from Italy with his family when he was 2 years old and has not traveled out of the country since then.  He does not use tobacco or illicit drugs and drinks alcohol occasionally.  The patient works in a family-owned restaurant and has had no sick contacts.  He consumes a balanced diet and notes no specific association of diarrhea to food.  The patient has been in a monogamous relationship with his wife for the past 10 years.  Temperature is 36.6 C (97.9 F), blood pressure is 130/86 mm Hg, and pulse is 72/min.  Weight is 63.5 kg (140 lb).  The sclerae are anicteric, and mucous membranes are moist without any lesions.  Cardiopulmonary examination is unremarkable.  The abdomen is soft, nondistended, and nontender, with no organomegaly.  Bowel sounds are increased.  Rectal examination shows no masses or tenderness and an empty rectal vault.  Stool occult blood testing is negative.  Samples for blood count, erythrocyte sedimentation rate, TSH, and serum electrolytes are obtained.

Item 1 of 3

Which of the following additional interventions is most appropriate in management of this patient’s diarrhea?

Item 2 of 3

The patient comes for a follow-up visit 2 weeks later.  He continues to have large-volume, foul-smelling stools but has had no new symptoms.  The patient recollects that his weight was about 75 kg (165 lb) prior to the onset of symptoms, and he has lost more than 5 kg (11 lb).  Physical examination findings are unchanged.  Laboratory testing performed during the previous visit is notable for the following:

Stool studies revealed a high osmotic gap.  Further laboratory studies are ordered.  Gastrointestinal endoscopy with biopsy is most likely to reveal which of the following?

Item 3 of 3

This patient is most likely to respond to which of the following therapies?

A 64-year-old man comes to the office due to progressive fatigue and weakness over the past several months.  The patient says, “I have very little energy and can hardly walk a block without resting.”  He has had no chest pain, palpitations, or dyspnea at rest but has had mild breathlessness while walking.  His wife adds that he has lost his appetite, and she believes that he has lost some weight.  The patient was diagnosed with hypertension several years ago but does not take any medications.  He drinks a half-pint of whiskey a day.  Blood pressure is 148/86 mm Hg, pulse is 80/min, and respirations are 14/min.  Oxygen saturation is 98% while breathing ambient air.  Lung auscultation is normal and heart sounds are normal with no murmur.  The abdomen is nondistended, soft, and nontender on palpation.  Rectal examination shows occult blood-positive brown stool.  Laboratory results are as follows:

Which of the following is the best initial step in evaluation of this patient’s anemia?

A 52-year-old woman is brought to the emergency department due to a 2-day history of fever, chills, abdominal pain, nausea, and vomiting.  Her husband says that she has become progressively confused and lethargic today.  The patient has a history of dyspepsia and underwent laparoscopic cholecystectomy 2 years ago but still has occasional upper abdominal discomfort.  Medical history also includes hyperlipidemia and diet-controlled diabetes mellitus.  The patient recently started taking herbal supplements to help lose weight.  She drinks alcohol at social events but does not use tobacco or illicit drugs.  There is no history of recent travel, but the family had a barbecue lunch before her symptoms started.  Other family members who consumed the same food are asymptomatic.  Temperature is 39.4 C (103 F), blood pressure is 90/50 mm Hg, pulse is 126/min, and respirations are 20/min.  BMI is 34 kg/m².  The patient has scleral icterus and dry mucous membranes.  The lungs are clear to auscultation and cardiac examination is normal with the exception of tachycardia.  There is marked right upper quadrant and epigastric tenderness without rebound tenderness.  The patient has no rash or enlarged lymph nodes.  She is somnolent but wakes to touch; otherwise, her neurologic examination is unremarkable.  Laboratory results are as follows:

Abdominal ultrasonography reveals fatty infiltration of the liver, postcholecystectomy changes, and dilated biliary ducts and common bile duct.  Which of the following is the most likely cause of this patient’s current condition?

A 62-year-old man comes to the office due to a 2-month history of progressive exertional dyspnea and fatigue.  The patient says, “I feel tired all the time and take frequent naps during the day.”  He consumes a balanced diet and does not use tobacco, alcohol, or illicit drugs.  Physical examination shows mucosal pallor.  Stool testing for occult blood is positive.  Laboratory results are as follows:

Colonoscopy reveals several small, flat, cherry-red lesions in the right colon but is otherwise normal.  Esophagogastroduodenoscopy and capsule endoscopy are normal.  The likely cause of this patient’s anemia is most strongly associated with which of the following?

A 54-year-old man comes to the emergency department due to worsening epigastric and retrosternal chest pain, nausea, and vomiting.  The patient started having severe nausea, retching, and forceful vomiting after eating some spicy food and consuming a small amount of alcohol with dinner several hours ago.  The vomitus contained ingested food particles, but the most recent episode included a small amount of bright red blood.  The pain has progressively worsened, and he now has pain while swallowing and mild shortness of breath.  The patient has had dyspeptic symptoms in the past, which he self-treated with over-the-counter antacids.  He does not use tobacco or illicit drugs.  He appears pale, diaphoretic, and in moderate distress.  Temperature is 38 C (100.4 F), blood pressure is 140/90 mm Hg, pulse is 120/min, and respirations are 24/min.  Neck veins are flat.  Dullness to percussion and decreased breath sounds are present over the left basal area.  Abdominal examination reveals epigastric tenderness and decreased bowel sounds.  Stool occult blood is positive.  Upright chest x-ray reveals a small pleural effusion of the left lung, and ECG shows sinus tachycardia; the imaging results are otherwise unremarkable.

Item 1 of 2

Which of the following is the most likely cause of this patient’s current condition?

Item 2 of 2

The patient continues to have chest pain that radiates to the back and worsens during deep breaths.  He appears restless and dyspneic.  Blood pressure is now 110/60 mm Hg and pulse is 130/min.  Intravenous fluids are administered.  Laboratory results are as follows:

Which of the following is the most appropriate test for confirming this patient’s diagnosis?

A 41-year-old woman comes to the office for follow-up on elevated liver aminotransferases found during a routine life insurance evaluation.  The patient has no symptoms.  She has not seen a physician in many years and has no significant medical history.  She takes no medications.  The patient drinks 3 glasses of wine per week and does not use recreational drugs.  Blood pressure is 136/78 mm Hg and pulse is 68/min.  BMI is 31 kg/m².  The abdomen is nontender with no hepatosplenomegaly.  Today’s laboratory results are as follows:

Which of the following is the best next step in making the diagnosis?

A 62-year-old man comes to the emergency department due to periumbilical abdominal pain.  The patient says, “The pain suddenly began one hour ago and has been constant.  I never had such severe pain in my life, and nothing makes it better.  I also have nausea, and I vomited green-colored liquid once.”  Two weeks ago, the patient was hospitalized after experiencing chest and epigastric pain and was diagnosed with ST elevation myocardial infarction.  He underwent percutaneous coronary intervention with stenting to the left anterior descending artery.  He has been taking dual antiplatelet therapy since then.  The patient’s other medical conditions include hypertension, hyperlipidemia, and obstructive sleep apnea.  He is a former smoker with a 20-pack-year smoking history and does not use alcohol or illicit drugs.  On examination, the patient appears to be in significant pain.  Temperature is 37.2 C (99 F), blood pressure is 140/85 mm Hg, pulse is 90/min, and respirations are 22/min.  Lungs are clear to auscultation, and heart sounds are normal with no murmur.  The abdomen is nondistended and soft with mild generalized tenderness.  There is no guarding or rebound tenderness.  Bowel sounds are normal.  Stool testing for occult blood is negative.  Laboratory results are as follows:

ECG shows normal sinus rhythm with deep Q waves in the anterior leads.  Which of the following is most likely to establish the diagnosis in this patient?

A 35-year-old woman comes to the office for evaluation of episodic abdominal pain.  After dinner a day ago, she had intense epigastric pain that lasted 30-40 minutes.  The pain was dull and radiated to her back and right shoulder.  It was accompanied by nausea, and the patient had difficulty catching her breath.  The pain completely resolved on its own after an hour.  The patient has had 2 similar episodes of lesser intensity in the past 6 months that also resolved spontaneously.  She has a history of migraine headaches treated with sumatriptan as needed.  She does not use tobacco or recreational drugs.  The patient has consumed 1 or 2 glasses of wine daily for the past 10 years.  Her father died of pancreatic cancer at age 75, and her mother died of breast cancer at age 65.  Vital signs are within normal limits.  BMI is 35 kg/m².  Abdominal examination reveals normoactive bowel sounds and no tenderness or guarding.  The liver span is 8 cm; the spleen is not palpable.  The remainder of the examination is unremarkable.

Item 1 of 3

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

Item 2 of 3

Abdominal ultrasonography is performed and reveals a nondistended gallbladder with numerous gallstones.  The common bile duct is normal sized (0.5 cm), but the pancreas is not well visualized.  Results of a complete metabolic panel are normal.  Which of the following is the most appropriate next step in management of this patient?

Item 3 of 3

The patient declines the suggested therapy and does not follow up with a health care provider.  She returns to the emergency department 6 months later with recurrent abdominal pain that has waxed and waned for the past 30 hours.  She also has had nausea and an episode of vomiting.  Temperature is 36.7 C (98 F), blood pressure is 136/80 mm Hg, and pulse is 100/min.  Mild icterus is noted on examination.  The abdomen is tender in the right upper quadrant without guarding or rebound tenderness.  Laboratory results are as follows:

Abdominal ultrasonography reveals a mildly distended gallbladder with multiple stones, no pericholecystic fluid, and a 1.1-cm common bile duct (normal: <0.6).  Which of the following is the best next step in management of this patient?