Dr.

Christa

A 26 years old man came to the Emergency Department with yellowish eyes 5 days ago. He also
had nausea and vomiting in every meal. He had poor appetite. He said that his urine was dark
like tea. A week ago he had diarrhea 5 times per day and unexplained fever. He never had this
symptoms before. Physical examination revealed icteric sclerae and extremities, epigastric
tenderness, liver and spleen were not palpable. Laboratorium examination revealed Hb 13.5
gr / dl, Ht 40 %, platelet 248.000 / dl, SGOT 594 mu/ml, SGPT 1.793 mu / ml, bilirubin direct
0.77 mg %, bilirubin indirect 8.36 %, total bilirubin 9.13 mg%. Widal S.typhii O 1 /80.
What is the most likely diagnosis of this patient?
A. Kolesistitis  SGOT SGPT tidak meningkat
B. Pancreatitis  tidak sampai ikterik
C. Hepatitis  SGOT SGPT meningkat, direct bilirubin meningkat + indirect  urin gelap
D. Kolelitiasis  SGOT SGPT tidak meningkat, belum pasti fever
E. Liver Cirrhosis  liver tidak teraba. SGOT SGPT meningkat karena hepatosit rusak.
Tapi kalau udah sirosis gitu harusnya bilirubin direct tidak meningkat karena hepatosit nya
rusak?

What is your further investigation to confirm the diagnosis?

A. Urinalisis
B. Amilase and lipase serum
C. HbsAg and IgM anti HAV
D. Gamma GT
E. Alkaline Phosphatase

A 29 years old woman presents with abdominal discomfort especially in epigastric area after
meal. She also have unproductive cough continuously since 3 months ago and dyspnea feeling.
She didn’t experience nausea and epigastric pain. She feels bloated after having spicy food and
noodle. She feels better after having dyspepsia drugs. Endoscopy revealed candidiasis in third
distally, medially, and proximally esophagus; hyperemic cardia, fundus, corpus antrum;
hyperemic pars descendent and transversum duodenum.
What is the most likely diagnosis?
A. Erosive gastroduodenitis and candidiasis esophagus
B. GERD and acute gastritis
C. Bile reflux and esofagitis
D. H.pylori gastritis and ulcer like dyspepsia
E. Reflux like dyspepsia and duodenitis

A 40 years old woman come to the Emergency Department with upper abdominal pain that lasts
for several hours. The pain gradually increases in severity, and localizes to the epigastrium and
hypochondrium, with radiation to the shoulder area. She also experiences nausea, vomiting,
anorexia, and low grade fever. The findings on physical examination are mild icteric sclerae,
epigastric and hypochondrium tenderness, inspiratory arrest on palpation of the right
upper quadrant.

What structure is the most involved from this patient?

A. Liver
B. Pancreas
C. Gall Bladder
D. Duodenum
E. Gaster

A 45 years old woman presents with colic abdominal pain suddenly and persist with severe
intensity for 3 hours. She feels steady ache and fullness in the epigastrium and right upper
quadrant with radiation to the right scapula. Colic is precipitated by eating a fatty meal.
What is the most appropriate laboratory examination?
A. Alkaline Phosphatase
B. SGOT and SGPT
C. Bilirubin
D. Amilase
E. Ca 19-9
 A 21 years old woman, a college student, presents with complaint of abdominal discomfort
in the upper abdomen since 2 weeks ago, everyday but it’s not all day long. It feels like her
stomach bloated. Unpleasant abdominal fullness after normal size meals. The pain centered
especially at epigastric region, without any radiation. The pain is not associated with change
of position, or rest. Sometimes the meal could relieve the abdominal discomfort. She said she
never experience heartburn, nausea, or vomits. She denies any dysphagia, odynophagia,
fever, or cough. She has no problem with urination and defecation. She had a regular period,
the last period was 3 weeks ago. Endoscopy reveals no abnormalities. What is the most
likely diagnosis?
A. Ulcer like dyspepsia
B. Reflux like dyspepsia  gaada heartburn di kasus nya
C. Dismotility like dyspepsia
D. Unspecific dyspepsia
E. Organic ulcer dyspepsia

A 49 years old man presents to the emergency room because of melena of 3 days' duration. He
denies abdominal pain. Vital signs reveal a resting pulse of 104 per minute and a 25-mm Hg
orthostatic drop in BP. Physical findings include bilateral temporal wasting, pale conjunctivae,
spider angiomas on his upper torso, muscle wasting, hepatosplenomegaly, and hyperactive
bowel sounds without abdominal tenderness to palpation. His stool is melenic. Nasogastric tube
aspiration reveals coffee grounds material. Hematocrit is 31%.
The appropriate next step in the management is
A. Pass a nasogastric tube.
B. Obtain an upper GI series.
C. Insert a transjugular intrahepatic portosystemic shunt (TIPS).
D. Obtain immediate visceral angiography.
E. Perform upper endoscopy.

A 45-year-old male executive comes to your office complaining of epigastric pain for 2 months.
His primary physician prescribed him H2-blockers 3 weeks ago, which have produced only
partial relief of his symptoms. His weight is stable. His physical exam is normal. An upper
endoscopy reveals a 1-cm duodenal ulcer.
Which of the following risk factors is not associated with the development of ulcer disease?
A. Daily use of nonsteroidal anti-inflammatory drugs (NSAIDs)
B. Gastric infection with H. pylori
C. Emotional stress
D. Cigarette smoking
E. Gastrin-secreting tumors  kalau kebanyakan gastrin, gastric emptying terlalu cepat
jadinya acid chyme terlalu sering dan cepat ke duodenum. Makanya buffering capability dari
duodenum ga sanggup overcome acidity nya

A 42-year-old man presents with intermittent dysphagia to solids and liquids and regurgitation of
food. He has lost 4 pounds in 2 months. His physical exam is normal. A barium swallow reveals
a dilated esophageal body, with the distal esophagus terminating in a narrow end.
Which one of the following options is the most appropriate long-term therapy?
A. Isosorbide dinitrate
B. Metoclopramide
C. Dilation with balloon
D. Nifedipine
E. Dilation with rubber tube

A 35-year-old man presents with diarrhea for 10 days, characterized by frequent, low-volume
stools with the presence of mucus. He also complained of subjective fever and lower
abdominal pain.
The presence of leukocytes in stool is consistent with which organism?
A. Clostridium perfringens
B. S. aureus
C. Giardia lamblia
D. Enterobius vermicularis  gatal, ga diare
E. Entamoeba histolytica  diare berdarah
An 18 years old man is rejected as a blood donor because his serum ALT is elevated at 160 U/L
but tests for HBsAg, anti-HBc, anti-HCV and HCV RNA were negative. He states that he has
been told that he had liver abnormalities at least one year earlier. He drinks moderately (half a
six-pack of beer daily). On exam he has cataracts, spider angiomata, and
hepatosplenomegaly. The ALT is 200, AST is 150, serum bilirubin is 1.6 mg/dL, and serum
albumin 3.2 g/dL.. The serum uric acid is low. Tests for ANA, alpha 1-antitrypsin level and
phenotype, and repeat tests for markers of viral hepatitis are negative or normal. The serum
ceruloplasmin level is at the lower limit of normal

The next step in diagnosis should be:

A. Slit-lamp examination of corneas
B. 12 week therapeutic trial with prednisone
C. Liver biopsy
D.12 week therapeutic trial with interferon plus ribavirin
E. CT Scan of abdomen? Mau cari tau kenapa fungsi liver terganggu? Soalnya ini bukan
hepatitis, terus dia minum alcohol jadi mau memeriksa takutnya HCC??

A 51-year-old woman presents with abdominal pain, weight loss, early satiety, and night sweats.
On physical exam she appears cachectic, multiple enlarged lymph nodes are present in her neck
(supraclavicular area), and a mass is palpated in the epigastrium. Laboratory data reveal a
hemoglobin of 8 g/dL and a normal WBC count.
Which of the following is the most appropriate next step in establishing the diagnosis?
A. Upper GI series
B. Peripheral blood smear
C. CT of the abdomen
D. Upper endoscopy with biopsy
E. Exploratory laparotomy
An 19 year-old beer-drinking college student develops nausea, vomiting and jaundice four
weeks after traveling abroad. He received no immunoprophylaxis prior to his travel. Serum
ALT is 1400 U/L, serum bilirubin is 9 mg/dL, and IgM anti-HAV is detected. He recovers
over the next 6 weeks with nearly normal ALT levels (48 U/L) and serum bilirubin of 1.8 mg/dL.
Four weeks later he is referred to you because of increasing jaundice, bilirubin 7 mg/dL, re-
elevation of serum ALT (420 U/L). The patient reports symptoms similar to those at the outset of
his illness. Serologic studies reveal persistent presence of IgM anti-HAV. Additional studies
include absence of markers of active HBV or HCV infection. IgG level and albumin are normal
as is prothrombin time and alkaline phosphatase. ANA is negative.
What is the most likely diagnosis?
A. Reccurent acute alcoholic hepatitis
B. Autoimmune hepatitis
C. Acute hepatitis E
D. Relapsing hepatitis A
E. Hepatitis fulminan

A 53 years old female with past medical history of gallstones came to the ER complaining of
diffuse abdominal pain for 2 days and a generalized fatique for several monts. On physical
examination, her vital signs were stable and afebrile. She was morbidly obese and had a non
distented abdomen. She demonstrated diffuse abdominal pain. The laboratorium revealed ALT
50 U / L and AST 67 U / L. CT of her abdomen revealed a collapsed gallbladder and in the
right upper quadrant there was multiple shadowing gallstones, dilated common bile duct,
and intraluminal gallbladder air. The patient underwent open cholecystectomy. Pathology results
showed chronic calculous cholecystitis with mild chronic inflammatory changes of connective
tissue.
What is the most likely complication of this patient?
A. Malignancy
B. Biliary-enteric fistula
C. Cholangitis
D. Biliary obstruction
E. Gallstone ileus
Dr. Stefanus

WEEK 1

1. How many phases are there that can stimulate gatric acid secretion ?
a. 1
b. 2
c. 3
d. 4
e. 5

2. What kind of H. pylori’s product that can breakdown the glycoprotein lipid complex of
the mucous gel ?
a. proteases + cytokinases
b. proteases + phospolipases
c. phospolipases + cytokinases
d. cytokinase + amylases
e. none is correct

WEEK 2

1. 35 years old man came to a clinic with diarrheae, then the doctor told him that he had to
stay at the clinic and got infused. And the doctor told his nurse to get sample from his
stool and checked to the lab. And the result indicated that the man suffered from
secretory diarrhea. So which answer that suitable with this condition ?
a. Reducting Substances from the stool : -
b. K+ in the stool increase
c. Na + in the stool decrease
d. pH < 5
e. a+b+c+d are correct

2. 10 years old boy came to hospital his mom. And her mom said to the doctor that her son
had diarrhea since 2 days ago. From Physical Examination the doctor classified this boy :
mild to moderate dehydration. Which one from below that match to his condition ?
a. Skin fold : recoil in > 2 seconds
b. Eyes : deeply sunken
c. Mouth and tongue : dry
d. None is correct

WEEK 3
 1. A 55 years old man came with yellow color in his eyes since 5 days ago. From physical
examination: his conjungtiva pale, sclera : icteric. Blood pressure : 120 / 80 mmHg,
pulse 72x/min. So which one that match to his blood test ?
a. Direct bilirubin : Increase ; Indirect bilirubin : Decrease
b. Direct bilirubin : Decrease , Indirect bilirubin : Decrease
c. Direct bilirubin : Normal , Indirect bilirubin : Increase
d. Direct bilirubin : Normal , Indirect bilirubin : Normal
e. Direcy bilirubin : Increase , Indirect bilirubin : Normal

2. A 60 years old man diagnosed with Cirroshis hepatis and from the USG they found that
the spleen was enlarged and the portal splenic vein was also enlarged. So what else we
can find according to the USG result ?
a. spider nevi
b. ascites
c. Palmar erythema
d. Gynecomastia
e. none is correct

week 4

1. A 55 years old man, complained that his stool : blood (+), pain on his abdominal, fever (39 C)
and looking from his appearance, seems that his consciousness slightly decrease, nausea (+),
vomit (+). Abdominal examination : tenderness (+). Then the doctor thought that endoscopy
should be done with this patient, but suddenly he realized something that changed his mind
about doing endoscopy with his patient. Cause of the patient’s:
a. nausea
b. Abdominal tenderness
c. Blood in stool
d. Vomit

2. A patient diagnosed with Colon Carcinoma and the staging : T2, N1, M1. Meaning:
a. Tumor invades muscularis propria, metastasis to 1-3 pericolic lymph nodes ,and distant
metastasis present
b. Tumor invades submucosa, metastasis to 4 pericolic lymph nodes ,and distant metastasis
present
c. Tumor invades through muscularis propria into subserosa, metastasis any lymph along
vascular trunk and distant metastasis present
d. Tumor invades through muscularis propria, metastasis to 1-3 pericolic lymph nodes ,and
distant metastasis present
e. Tumor invades muscularis propria, metastasis to 4 pericolic lymph nodes ,and distant
metastasis present

Case Week 5
 1. A woman , 43 years old, felt that every time she ate fat food , she woud feel uncomfortable in
her stomach expecially on epigastric area, sometimes diarrhea. Blood in stool (-), Nausea (+),
Alcohol(+), smoking(-).
Then she went to see a doctor. Then the doctor said that she had a problem with her pancreas.
The doctor said that the enzyme Pancreatic lipase cannot work normally. And the doctor
explain the function of pancreas lipase :
a. Split off amino acids from the carboxyl end of the peptide chains
b. Neutralization of the acidic chime
c. Breaks down triglycerides into monoglycerides and free fatty acids
d. Stimulate the production of the bile in the liver

2. A 49 years old woman, visited her doctor and brought her lab result.
Hb : 14 gr/dl WBC:17.000/mm3
Po2 : 50 mmHg BUN: increase 3.5 mg/dl after IV fluid hydration
RBS: 230 mg/dl Ht: 37 %
Base excess: deficit 3 mEq/L
Serum AST : 180 IU/L
Serum LDH : 330 IU/L
From the lab we can resume that :according to Ranson’s criteria this patient’s mortality:
a. 1 %
b.10 – 20%
c. 5%
d.> 50%

Soal gastro Nico

1. A patient has severe gastroesophageal reflux disease (GERD). In addition to providing

some immediate symptom relief, you will prescribe an OTC combination antacid
product to suppress gastric acid as fully as possible. Which of the following drug is
most likely to meet that criterion:
A. atropine C. famotidine E. misoprostol
B. calsium carbonate D. omeprazole  gabisa bareng antasida

2. A patient come to your clinic with severe abdominal pain and a ‘burning’ sensation in the
upper abdomen. Endoscopy reveals several benign ulcers in the anthral mucosa of the
stomach. Which of the following drugs is most likely to provide the fastest relief of the
discomfort with just a single dose ?
A. antacid C. cimetidine E. propantheline
B. belladonna alkaloids D. misoprostol

3. On your first day as general practitioner you encounter a patient who is taking a proton
pump inhibitor, bisthmuth, metronidazole and tetracycline. Which of the following
is the most likely purpose for administering this drug combination ?
 A. antibiotic-associated pseudomembranous colitis
B. irritable bowel syndrome (IBS)
C. recurrent gastric and duodenal ulcers secondary to H.pylori
D. traveler’s diarrhea, E.coli-induced from drinking contaminated water
E. ulcers that occur in respons too long term, high dose NSAID therapy for arthritis

4. A patient presents in the general medicine clinic is treated with a number of prescription
drugs, one of which is misoprostol. Which of the following is the most likely purpose for
for which this drug is being administered?
A. routine management of gastroesophageal reflux disease (GERD)
B. profilaxis ulcers during long-term therapy with some NSAIDs
C. eradicating H.pylori in patients with acute and recurrent gastric ulcers
D. prevention of acute stress ulcers
E. managing ulcers that tend to develop during pregancy  justru bisa bikin keguguran

5. On your way to an examination, you experience that vulnerable feeling of an attack of

diarrhea. If you stopped at a drugstore , which one of the following antidiarrheal drugs
could you buy without prescription eventhough it is related chemically to strong opioid-
analgesic meperidine ?
A. aluminium hydroxide C. loperamide
B. codein D. magnesium hydroxide
E. metoclopramid

6. Which of the following drugs is most appropriate for the treatment of patient who
presents with Zollinger-Ellison syndrome resulting from a gastrinoma ?
A. cimetidin C. aluminium hydroxide E. ondansetron
B. cisaprid D. omeprazole

7. A 55-year-old woman with insulin-dependent diabetes of 40 years duration complains of

severe bloating and abdominal distress, especially after meals. Evaluation is consistent
with diabetic gastroparesis. The drug you would be most likely to recommend is :
A. atropine C. loperamide E. sucralfate
B. dopamine D. metoclopramide

8. A 52-year-old man with peptic ulcer disease has been on drug therapy for 3 months. While
on this regimen, he noticed changes in his bowel habits, increasing headaches, dizziness,
skin rashes, loss of libido, and gynecomastia.
Which drug is the most likely responsible for these effects?
A. cimetidine
B. famotidine
C. misoprostol
D. omeprazole
E. ranitidine

9. A 78-year-old man with chief complain nausea,vomiting, and epigastric pain. He was given
stomach medication, three hour later, he had dyskinesia and rigidity (extra pyramidal
 symptoms).
Which of the following drug is the most appropriate that can cause this situation?
A. domperidone
B. metoclopramide
C. ondansetrone
D. omeprazole
E. sucralfate

10. A 48-year-old man presents with a complaint of chronic no bloody diarrhea and right
lower quadrant pain with a palpable mass and tenderness. He states that this "flare-up" is one of
the worst he has ever experienced. Radiographic exam reveals evidence of ulceration,
stricturing, and fistula development of the colon and small bowel.
Which of the following drugs would be the most appropriate for treating this patient?
A. Diphenoxylate
B. Loperamide
C. Hyoscyamine
D. Mesalamine
E. Prednisone

11. A 51-year-old man comes to your private practice with a history of mid epigastric upper
abdominal pain that diminished by eating or taking antacid tables. He drinks 2-3 glasses of
beer every night, also taking 2-3 tablets of aspirin frequently for his stress related headache.
PE reveals no evidence for blood in the stool. You advised him to replace the aspirin with
acetaminophen and stop his drinking of beer; you give him a prescription of famotidine 20
mg bid.
Which of the following is the mechanism of action of famotidine?
A. Eradication of H.pylori
B. Increase of motility
C. Inhibit acid secretion
D. Neutralized gastric acid
E. Protect gastric mucous

12. A 48-year-old woman recently diagnosed with an adenocarcinoma. The oncologist schedules
her for radiation and chemotherapy. Because nausea and vomiting are common
complications, you recommend antiemetic premedication with dexamethasone.
Which of the following antiemetic drugs would be the most appropriate for this condition?
A. Chlorpromazine
B. Dimenhydrinate
C. Ondansetron
D. Prometazine
E. Scopolamine

13. A 24 year old woman comes to your private practice because of experiencing heartburn after
meals, especially when reclining on her sectional at home. Her symptoms are typically
relieved by antacids. In addition to an H2 blockers or PPI drugs, what additional agent could
help treat her esophagitis by coating necrotic tissue with a protective barrier, and thereby
 promote healing of the ulcer?
A. Attapulgite
B. Calcium carbonate
C. Loperamide
D. Mg-Al hydroxide
E. Sucralfate

14. A 42 year old, came to emergency department with a mild fever, followed by malaise,
fatigue, nausea and vomiting for 5 days. Acholic stool and darkening urine are also
appeared. Sclera and the skin looked yellow. The liver is palpable 2 cm below the costal
margin, tender and the spleen is enlarged. The patient was unconscious. No prior history of
the disease.
Those symptoms above could be found in the impairment mechanism of :
A. Albumin
B. Bilirubin
C. Glucose
D. Lipid
E. Urea

15. What is the mechanism of the darkening urine through the above case?
A. The unconjugated bilirubin filtered by the glomerulus
B. The red blood cells filtered by the glomerulus and appears in the urine
C. It is appears due to inflammation reaction in the renal
D. The unconjugated bilirubin is water soluble so it can appears in the urine
E. The conjugated bilirubin increase in plasma,readily filtered by the glomerulus

16. A 45-year-old obese woman with cholelithiasis presents to the emergency room complaining
of nausea and vomiting for 2 days, along with severe continuous midabdominal pain. She has
a low – grade fever and the physician finds that she has a slightly elevated WBC count
( 12.000) and an elevated serum amylase. The most likely diagnosis is
A. Ruptured abdominal aortic aneurysm
B. Hepatitis
C. Peptic ulcer disease
D. Early phase of acute appendicitis
E. Acute pancreatitis

17. A 2-year-old boy presents with recurrent and severe paroxysmal colicky pain accompanied
by straining efforts, loud cries, and vomiting. A stool with red blood mixed with mucus is
passed. An oblong mass is palpated in the mid-epigastrium.
What is the most likely diagnosis in this patient?
 A. A Meckel’s diverticulum
B. Meconium ileus
C. Necrotizing enterocolitis
D. An intussuseption
E. Congenital pyloric stenosis

18. A 37 years old man comes to your office with complaints of fatigue, anorexia nausea, and vomiting.
He does not have fever. His urine is dark. On physical examination, his liver is slightly enlarged and
minimally tender. He does not have edema or spider angiomata. Laboratory test show the following:
negative HBsAg, negative IgM anti HAV, positive IgM anti Hbc, and negative anti-HCV. The most
likely diagnosis;
A. Acute hepatitis A
B. Acute hepatitis B
C. Acute hepatitis A and B
D. Chronic hepatitis B  ini harusnya HBsAg positif karena kan masih hepatitis
E. Acute hepatitis C

19. A patient in your office tells you that he had an episode of vomiting bright red blood twice in 1 day
about 1 week ago, followed the next day by three or four episodes of vomiting material that looked
like coffee grounds. He could not afford to seek medical help then. The past 3 days he noticed black
‘sticky’ stools and he finally came to see you. What is your first concern
A. Bleeding colon cancer.
B. Bleeding from lung cancer
C. Crohn’s disease
D. Cirrhosis
E. Bleeding peptic ulcer

20.