CASE 25: Acute pancreatitis

1. A 43-year-old man who is an alcoholic is admitted to the hospital with acute pancreatitis. H e is
given intravenous hydration and is placed NPO. Which of the following findings is a predictor of
higher mortality
A. H is age
B. Initial serum glucose level of 60 mg/ dL
C. BUN of 18 mg/ dL
D. Disorientation, with Glasgow Coma Scale score of 10
E. Amylase level of 1000 IU/L

2. A 37-year-old woman is noted to have gallstones on ultrasonography. She is placed on a low-fat

diet. After 3 months she is noted to have severe right upper quadrant pain, fever to 102°F, and
nausea. Which of the following is the most likely diagnosis?
A. Acute cholangitis
B. Acute cholecystitis
C. Acute pancreatitis
D. Acute perforation of the gallbladder

3. A 45-year-old man was admitted for acute pancreatitis, thought to be a result of blunt
abdominal trauma. After 3 months he still has epigastric pain but is able to eat solid food. H is
amylase level is elevated at 260 IU/ L. Which of the following is the most likely diagnosis?
A. Recurrent pancreatitis
B. Diverticulitis
C. Peptic ulcer disease
D. Pancreatic pseudocyst

CASE 27: Biliary obstruction, most likely caused by malignancy

1. 27.1 A 38-year-old man with a 12 pack of beer per day alcohol history presents with jaundice, ascites, and
dark urine. H is laboratory results are AST 350 U/ mL, ALT 150 U/ mL, alkaline phosphatase 120 U/ mL,
total bilirubin 25 mg/ dL, direct bilirubin 12 mg/ dL, and albumin 2.1 g/ dL. ANS: B - Alcoholic hepatitis
2. A 40-year-old moderately obese woman presents with abdominal pain after eating and mild scleral
icterus. Her laboratory results are AST 200 U/ L, ALT 150 U/ L, alkaline phosphatase 355 U/ L, total
bilirubin 3.5 mg/ dL, direct bilirubin 1.8 mg/ dL, and albumin 3.5 g/ Dl
ANS: E - Gallstones
3. A 25-year-old man presents with 3 days of scleral icterus but has been otherwise feeling well. H is
laboratory results are AST 45 U/ L, ALT 48 U/ L, alkaline phosphatase 100 U/ L, total bilirubin 3.2 mg/ dL,
direct bilirubin 0.2 mg/ dL, and albumin 3.5 g/ dL. Complete blood count and lactate dehydrogenase
(LDH ) are normal. ANS: C- Gilbert disease
4. A 32-year-old man with a 5-year history of episodic bloody diarrhea and abdominal cramping pain
presents with scleral icterus and fever. H is laboratory results are AST 100 U/ L, ALT 125 U/ L, alkaline
phosphatase 550 U/ L, total bilirubin 5.5 mg/ dL, direct bilirubin 3.0 mg/ dL, and albumin 2.9 g/ dL.
ANS: F- Primary sclerosing cholangitis

CASE 28: Acute glomerulonephritis (GN )

1. An 18-year-old marathon runner has been training during the summer. H e is brought to the
emergency room disoriented after collapsing on the track. H is temperature is 102°F. A Foley
catheter is placed and reveals reddish urine with 3+ blood on dipstick and no cells seen
microscopically. Which of the following is the most likely explanation for his urine
A. Underlying renal disease
B. Prerenal azotemia
 C. Myoglobinuria
D. Glomerulonephritis

2. Which of the following laboratory findings is most consistent with poststreptococcal

glomerulonephritis?
A. Elevated serum complement levels
B. Positive antinuclear antibody titers
C. Elevated ASO titers
D. Positive blood cultures
E. Positive cryoglobulin titers

3. A 22-year-old man complains of acute hemoptysis over the past week. H e denies smoking or
pulmonary disease. H is blood pressure is 130/ 70 mm H g, and his physical examination is
normal. H is urinalysis also shows microscopic hematuria and red blood cell casts. Which of the
following is the most likely etiology?
A. Metastatic renal cell carcinoma to the lungs
B. Acute tuberculosis of the kidneys and lungs
C. Systemic lupus erythematosus
D. Goodpasture disease (antiglomerular basement membrane

CASE 30: Acute kidney injury (AKI)

1. A 63-year-old woman with a history of cervical cancer treated with hysterectomy and pelvic irradiation
now presents with acute oliguric renal failure. On physical examination, she has normal jugular venous
pressure, is normotensive without orthostasis, and has a benign abdominal examination. H er urinalysis
shows a specific gravity of 1.010, with no cells or casts on microscopy. Urinary FENa is 2% and the Na level
is 35 mEq/ L. Which of the following is the best next step?
A. Bolus of intravenous fluids
B. Renal ultrasound
C. Computed tomographic (CT ) scan of the abdomen with intravenous
contrast
D. Administration of furosemide to increase her urine output

2. A 49-year-old man with a long-standing history of chronic renal failure as a consequence of diabetic
nephropathy is brought to the emergency room for nausea, lethargy, and confusion. H is physical examination is
significant for an elevated jugular venous pressure, clear lung fields, and harsh systolic and diastolic sounds heard
over the precordium. Serum chemistries reveal K 5.1 mEq/ L, CO2 17 mEq/ L, BUN 145 mg/ dL, and creatinine 9.8
mg/ dL. Which of the following is the most appropriate therapy?

A. Administer IV insulin and glucose.

B. Administer IV sodium bicarbonate.
C. Administer IV furosemide.
D. Urgent hemodialysis

3. A 62-year-old diabetic man underwent an abdominal aortic aneurysm repair 2 days ago. H e is being
treated with gentamicin for a urinary tract infection. H is urine output has fallen to 300 mL over 24 hours,
and his serum creatinine has risen from 1.1 mg/ dL on admission to 1.9 mg/ dL. Which of the following
laboratory values would be most consistent with a prerenal etiology of his renal insufficiency?
A. FENa of 3%
B. Urinary sodium level of 10 mEq/ L
C. Central venous pressure reading of 10 mm H g
D. Gentamicin trough level of 4 µg/ mL
CASE 41: : Septic shock, most likely as a consequence of UTI
1. Which of the following asymptomatic patients would most benefit from treatment of the
finding of more than 105 CFU/ mL of Escherichia coli on urine culture?
A. A 23-year-old asymptomatic sexually active woman
B. A 33-year-old asymptomatic pregnant woman
C. A 53-year-old asymptomatic diabetic woman
D. A 73-year-old asymptomatic woman in a nursing home

2. Which of the following is the best treatment for a 39-year-old woman with fever of 103°F,
nausea, flank pain, and more than 105 CFU/ mL of E coli in a urine culture?
A. Oral trimethoprim-sulfamethoxazole for 3 days
B. Single-dose ciprofloxacin
C. Intravenous and then oral levofloxacin for 14 days
D. Oral ampicillin for 21 to 28 days

3. A 57-year-old man is noted to have a blood pressure of 68/ 50 mm H g, heart rate of 140
bpm, elevated jugular venous pressure, inspiratory crackles on examination, and cold
clammy extremities. Which of the following is the most likely etiology?
A. Septic shock
B. Adrenal crisis
C. Cardiogenic shock
D. H ypovolemic shock

4. A 45-year-old man is noted to have a blood pressure of 80/ 40 mm H g, heart rate of 142
bpm, and fever of 102°F. H is abdomen is tender, particularly in the right lower quadrant,
and acute appendicitis is diagnosed. Three liters of 0.9% saline are infused and intravenous
antibiotics are administered as he is prepared for surgery. H is blood pressure falls to 70/ 42
mm H g. Which of the following is the most appropriate next step?
A. Administer a beta-blocker to control his heart rate.
B. Check a cortisol level and administer corticosteroids.
C. Infuse fresh frozen plasma (FFP).
D. Initiate norepinephrine intravenous infusion.
E. IV morphine for pain control.