SECTION VII

Disorders of the Gastrointestinal System

QUESTIONS

VII-1. All of the following are true about specific functions A. Diarrhea from malabsorption usually improves with
of the gut EXCEPT: fasting, whereas secretory diarrhea persists without
oral intake.
A. Gastric acid sterilizes the upper gut.
B. Sudden awakening from a sound sleep by pain sug-
B. Most nutrient absorption occurs in the small
gests functional rather than organic disease.
intestine.
C. Symptoms from mechanical obstruction, ischemia,
C. The pancreas secretes bicarbonate, which optimizes
inflammatory bowel disease, and functional bowel
the pH in the intestine for enzyme activation.
disorders are alleviated by meals.
D. The stomach secretes intrinsic factor which is neces-
D. Ulcer pain is typically acute in onset.
sary for vitamin B12 absorption.
E. Ulcer symptoms are usually made worse by eating.
E. The terminal ileum is primarily responsible for stool
dehydration, decreasing volumes from 1000–1500 mL VII-5. A 57-year-old female wishes to undergo a screening
to 100–200mL. colonoscopy for colon cancer. She has no family history
of colon cancer and currently has no symptoms referable
VII-2. All of the following diseases are associated with gas-
to the gastrointestinal tract. Which of the following state-
tric acid hypersecretion EXCEPT:
ments is true about colonoscopy as a screening test for
A. Duodenal ulcers colon cancer?
B. G-cell hyperplasia
A. Barium enema is as sensitive as colonoscopy for
C. Pernicious anemia
detecting colitis.
D. Retained antrum syndrome
B. Colonoscopy remains the gold standard for imaging
E. Zollinger-Ellison syndrome
the colonic mucosa.
VII-3. Which of the following gastrointestinal conditions is C. CT colonography has replaced traditional colonos-
characterized by noninflammatory visceral pain? copy for many younger patients because of its ability
to detect serrated polyps with greater sensitivity.
A. Appendicitis D. Flexible sigmoidoscopy would be as effective as colo-
B. Cholecystitis noscopy for detecting colon cancer in this patient.
C. Inflammatory bowel disease E. The cecum can only be reached in 75% of
D. Mesenteric ischemia colonoscopies.
E. Peptic ulcer

VII-4. Which of the following statements regarding gastro-

intestinal symptoms is TRUE?

481
 VII-6. Which of the following endoscopic procedures would past 3 years, but none as severe as this event. He denies
warrant antibiotic prophylaxis? food regurgitation outside of these episodes or heartburn
SECTION VII

symptoms. He is able to swallow liquids without difficulty

A. Endoscopic procedures in patients with prosthetic
and has not had any weight loss. Which of the following is
joints
the most likely diagnosis?
B. Endoscopic procedures in patients with synthetic
vascular grafts A. Achalasia
C. Endoscopic ultrasound with fine-needle aspiration B. Adenocarcinoma of the esophagus
in a patient with a lower gastrointestinal tract lesion C. Esophageal diverticula
D. Endoscopic retrograde cholangiopancreatography D. Plummer-Vinson syndrome
Disorders of the Gastrointestinal System

with anticipated complete drainage in a patient with E. Schatzki ring

biliary obstruction in the absence of cholangitis
E. Percutaneous endoscopic feeding tube placement VII-11. A 36-year-old woman with AIDS and a CD4 count
of 35/μL presents with odynophagia and progressive
VII-7. All of the following are indications for urgent endos- dysphagia. The patient reports daily fevers and a 20-lb
copy for acute upper gastrointestinal bleeding EXCEPT: weight loss. The patient has been treated with clotrima-
zole troches without relief. On physical examination, she
A. Bloody nasogastric aspirate that does not clear with
is cachectic with a body mass index of 16 and a weight of
large volume lavage
86 lb. Her temperature is 38.2°C (100.8°F). She is noted to
B. Large volume initial bleed
be orthostatic by blood pressure and pulse. Examination of
C. Orthostatic hypotension
the oropharynx reveals no evidence of thrush. The patient
D. Resting hypotension
undergoes esophagogastroduodenoscopy, which reveals
E. Severe pain
serpiginous ulcers in the distal esophagus without vesicles.
VII-8. Mr. Tyler, a 45-year-old male with known chronic No yellow plaques are noted. Multiple biopsies are taken
alcohol use, presents with two episodes of hematemesis. that show intranuclear and intracytoplasmic inclusions
He recently sustained a fall and injured his knee. He has in large endothelial cells and fibroblasts. What is the best
been taking ibuprofen several times a day for the last week treatment for this patient’s esophagitis?
for pain control. His initial hemoglobin is 10 g/dL. He A. Ganciclovir
receives 2 L of IV fluid and undergoes an urgent upper B. Glucocorticoids
endoscopy. All of the following are true about his risk of C. Fluconazole
rebleeding without intervention EXCEPT: D. Foscarnet
A. A clean-based ulcer is associated with a low risk E. Thalidomide
(3–5%) of rebleeding.
VII-12. A 43-year-old man presents with 6 months of
B. Adherent clots covering the ulcer base have a 90%
worsening dysphagia and postprandial regurgitation. He
risk of rebleeding.
reports difficulty and pain with swallowing both liquids
C. Flat pigmented spots covering the ulcer base have a
and solids; he has no difficulty with the initial components
10% risk of rebleeding.
of swallowing but reports pain in the mid-chest region.
D. When a fibrin plug is seen protruding from a vessel
He frequently regurgitates undigested food 20–60 minutes
wall in the base of an ulcer, (so-called sentinel clot or
after eating or drinking. In the past 2 months, he has lost
visible vessel), the risk of rebleeding from the ulcer is
15 lb. He also has had one episode of presumed pneumonia
40%.
4 months ago notable for a right lower lobe infiltrate. He
E. When active spurting from an ulcer is seen, there is a
has no significant past medical history, takes no medica-
90% risk of ongoing bleeding without therapy.
tions, and does not smoke cigarettes. He works as a service
VII-9. The advantages of endoscopy over barium radiogra-
phy in the evaluation of dysphagia include all of the fol-
lowing EXCEPT:
A. Ability to assess function and morphology
B. Ability to intervene as well as diagnose
C. Ability to obtain biopsy specimens
D. Increased sensitivity for the detection of abnormali-
ties identified by color, e.g., Barrett metaplasia
E. Increased sensitivity for the detection of mucosal
lesions

VII-10. A 47-year-old man is evaluated in the emergency

department for chest pain that developed at a restaurant
after swallowing a piece of steak. He reports intermittent
episodes of meat getting stuck in his lower chest over the
FIGURE VII-12

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 representative at a major electronics store and has never currently requiring treatment. He undergoes an esophago-
left the United States. Other than signs of recent weight gastroduodenoscopy, which is shown in Figure VII-14A.

SECTION VII
loss, his physical examination is unremarkable. A barium The biopsy is shown in Figure VII-14B.
swallow is performed and shown in Figure VII-12. Which
of the following is the most likely cause of his disease?
A. Autoimmune reaction to latent herpes virus
B. Diffuse spasm on smooth muscle
C. Infection by Trypanosoma cruzi
D. Malignant growth of columnar epithelial cells

QUESTIONS
E. Malignant growth squamous epithelial cells

VII-13. A 64-year-old man with a long history of abdomi-

nal pain, heartburn, and dyspepsia has an esophagogas-
troduodenoscopy to evaluate for peptic ulcer disease. No
gastric or duodenal ulcers are found, but there are tongues
of reddish mucosa extending proximally from the gastroe-
sophageal junction into the esophagus. Biopsies of these
areas demonstrate columnar metaplasia. All of the follow-
ing statements regarding this diagnosis are true EXCEPT:
A. Finding high-grade dysplasia mandates further
intervention.
B. High-dose proton pump inhibitor therapy will likely
cause regression of the mucosal abnormalities.
C. The incidence of these lesions has increased in the
era of potent acid suppression.
D. The patient has a high risk of coexisting cancer.
E. The patient is at significant risk of esophageal
adenocarcinoma.

VII-14. A 35-year-old man presents with progressive dys-

phagia over a 2-month period. He has noted that food has
been getting stuck more frequently in the last 2 weeks. He FIGURE VII-14B
has a history of intermittent gastroesophageal reflux dis-
ease for which he takes over-the-counter antacids every
few weeks. He has a history of eczema as a child but is not Which of the following is the most appropriate first step
in management?
A. Elimination diet
B. IV methylprednisolone
C. Mepolizumab
D. Trial of a proton pump inhibitor
E. Topical corticosteroids

A B

C D
FIGURE VII-14A

483
 VII-15. Ms. Pole is a 54-year-old woman who presents with
recurrent episodes of chest discomfort at rest. She denies
SECTION VII
exertional dyspnea and reports that occasionally her pain
is relieved with antacids. She works as a health care con-
sultant and has frequent stressful battles with doctors and
hospitals. An exercise cardiac stress test does not reveal any
evidence of inducible ischemia. She has a barium swallow,
which is shown in Figure VII-15. You suspect that she has
diffuse esophageal spasm. Which of the following findings
Disorders of the Gastrointestinal System
on esophageal manometry would support that diagnosis?
FIGURE VII-15
A. Contractions in the distal esophagus with short
latency relative to the time of the pharyngeal
contraction
B. Hypertensive peristalsis
C. Impaired lower esophageal sphincter (LES) contrac-
tion and absent peristalsis with substantial fluid pres-
surization of the esophageal body
D. Impaired LES contraction and absent peristalsis with
no fluid pressurization of the esophageal body
E. Impaired LES contraction and absent peristalsis with
spastic esophageal contractions
VII-16. Which of the following statements regarding ther-
apy for gastroesophageal reflux (GERD) therapy is TRUE?
A. Clostridium difficile infection rates are decreased in
patients receiving proton pump inhibitors.
B. Histamine-2 receptor antagonists are more effective
than proton pump inhibitors.
C. The effectiveness of proton pump inhibitors increases
substantially with increased dose.
D. Proton pump inhibitors are a rare cause of interstitial
nephritis.
E. Weight loss has been proven in randomized con-
trolled trials to ameliorate the symptoms of GERD.
VII-17. A 58-year-old man is evaluated for abdominal pain
by his primary care physician. He reports severe stress at
the job for the last 3 months and has since noted that he
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has epigastric pain that is relieved by eating and drinking
milk. He has not had food regurgitation, dysphagia, or
bloody emesis or bowel movements. He denies any symp-
toms in his chest. Peptic ulcer disease is suspected. Which
of the following statements regarding noninvasive testing
for Helicobacter pylori is true?
A. There is no reliable noninvasive method to detect
H. pylori.
B. Stool antigen testing is appropriate for proof of cure
after therapy for H pylori.
C. Plasma antibodies to H. pylori offer the greatest
sensitivity for diagnosis of infection.
D. Exposure to low-dose radiation is a limitation to urea
breath test.
E. False-negative test results using the urea breath test
may occur with recent use of nonsteroidal anti-
inflammatory drugs.
VII-18. A 44-year-old woman complains of 6 months of epi-
gastric pain that is worst between meals. She also reports
symptoms of heartburn. The pain is typically relieved by
over-the-counter antacid medications. She comes to the
clinic after noting her stools darkening. She has no signifi-
cant past medical history and takes no medications. Her
physical examination is normal except for diffuse mid-
epigastric pain. Her stools are heme positive. She under-
goes esophagogastroduodenoscopy, which demonstrates a
well-circumscribed, 2-cm duodenal ulcer that is positive
for Helicobacter pylori. Which of the following is the rec-
ommended initial therapy given these findings?
A. Lansoprazole, clarithromycin, and metronidazole for
14 days
B. Pantoprazole and amoxicillin for 21 days
C. Pantoprazole and clarithromycin for 14 days
D. Omeprazole, bismuth, tetracycline, and metronida-
zole for 14 days
E. Omeprazole, metronidazole, and clarithromycin for
7 days
VII-19. A 57-year-old man with peptic ulcer disease expe-
riences transient improvement with Helicobacter pylori
eradication. However, 3 months later, symptoms recur
despite acid-suppressing therapy. He does not take non-
steroidal anti-inflammatory drugs. Stool analysis for
H. pylori antigen is negative. Upper gastrointestinal (GI)
endoscopy reveals prominent gastric folds together with
the persistent ulceration in the duodenal bulb previously
detected and the beginning of a new ulceration 4 cm prox-
imal to the initial ulcer. Fasting gastrin levels are elevated,
and basal acid secretion is 15 mEq/h. What is the best test
to perform to make the diagnosis?
A. No additional testing is necessary.
B. Blood sampling for gastrin levels following a meal.
C. Blood sampling for gastrin levels following secretin
administration.
D. Endoscopic ultrasonography of the pancreas.
E. Genetic testing for mutations in the MEN1 gene.
VII-20. Which of the following are side effects of therapies
directed at peptic ulcer disease?
A. Famotidine may have weak anti-androgenic side
effects resulting in reversible gynecomastia and
impotence, primarily in patients receiving high doses
for prolonged periods of time (months to years).
B. Long-term acid suppression, particularly with proton
pump inhibitors, has been associated with a higher
incidence of community-acquired pneumonia as well
as community- and hospital-acquired Clostridium
difficile–associated disease.
C. Magnesium hydroxide can produce constipation and
phosphate depletion.
D. Rebound gastric acid hypersecretion has been
described in H. pylori–negative individuals after
discontinuation of H2 blockers. It occurs even after
relatively short-term usage (2 months) and may last
for up to 2 months after the medication has been
discontinued.
E. The long-term use of aluminum hydroxide can lead
to milk-alkali syndrome (hypercalcemia, hyperphos-
phatemia with possible renal calcinosis and progres-
sion to renal insufficiency).
VII-21. Which of the following statements regarding gastric
acid secretion is true?
A. Basal acid production occurs in a circadian pattern,
with highest levels occurring during the morning
and lowest levels during the night.
B. Distention of the stomach wall directly activates acid
secretion by parietal cells.
C. Sight, smell, and taste of food are the components of
the cephalic phase, which stimulates gastric secretion
via the phrenic nerve.
D. The gastric phase is activated once food enters the
stomach. This component of secretion is driven by
nutrients (amino acids and amines) that directly (via
peptone and amino acid receptors) and indirectly
(via stimulation of intramural gastrin releasing pep-
tide neurons) stimulate the G cell to release gastrin,
which in turn activates the parietal cell via direct and
indirect mechanisms.
VII-22. A 23-year-old woman is evaluated by her primary
care physician for diffuse, crampy abdominal pain. She
reports that she has had abdominal pain for the last sev-
eral years, but it is getting worse and is now associated with
intermittent diarrhea without flatulence. This does not
wake her at night. Stools do not float and are not hard to
flush. She has not noted any worsening with specific foods,
but she does have occasional rashes on her lower legs. She
has lost about 10 lb over the last year. She is otherwise
healthy and takes no medications. Which of the following
SECTION VII
is the most appropriate recommendation at this point?
A. Increased dietary fiber intake
B. Measurement of antiendomysial antibody
C. Measurement of 24-hour fecal fat
D. Referral to gastroenterologist for endoscopy
E. Trial of lactose-free diet
QUESTIONS
VII-23. A 54-year-old man is evaluated by a gastroenterolo-
gist for diarrhea that has been present for approximately
1 month. He reports stools that float and are difficult to
flush down the toilet; these can occur at any time of day
or night but seem worsened by fatty meals. In addition, he
reports pain in many joints lasting days to weeks and not
relieved by ibuprofen. His wife notes that the patient has
had difficulty with memory for the last few months. He
has lost 30 lb and reports intermittent low-grade fevers. He
takes no medications and is otherwise healthy. Endoscopy
is recommended. Which of the following is the most likely
finding on small bowel biopsy?
A. Dilated lymphatics
B. Flat villi with crypt hyperplasia
C. Mononuclear cell infiltrate in the lamina propria
D. Normal small bowel biopsy
E. Periodic acid–Schiff-positive macrophages contain-
ing small bacilli
VII-24. A 54-year-old man presents with 1 month of diar-
rhea. He states that he has 8 to 10 loose bowel movements
a day. He has lost 8 lb during this time. Vital signs and
physical examination are normal. Serum laboratory stud-
ies are normal. A 24-hour stool collection reveals 500 g
of stool with a measured stool osmolality of 200 mOsm/L
and a calculated stool osmolality of 210 mOsm/L. Based
on these findings, which of the following is the most likely
cause of this patient’s diarrhea?
A. Celiac sprue
B. Chronic pancreatitis
C. Lactase deficiency
D. Vasoactive intestinal peptide tumor
E. Whipple disease
VII-25. All of the following are direct functions of the intes-
tinal epithelium EXCEPT:
A. Barrier and immune defense
B. Fluid and electrolyte absorption and secretion
C. Production of several bioactive amines and peptides
D. Secretion of bile acids
E. Synthesis and secretion of apolipoproteins
485
 VII-26. A 40-year-old male with multiple prior admissions
for alcoholic pancreatitis presents for evaluation of several
SECTION VII
months of diarrhea. A 24-hour stool analysis confirms that
he has steatorrhea. Which of the following mechanisms
likely explains the elevation in stool fat content and result-
ing diarrhea?
A. Abnormalities of intestinal lymphatics (e.g., intesti-
nal lymphangiectasia)
B. Decreased enterohepatic circulation of bile acids
Disorders of the Gastrointestinal System
C. Decreased hydrolysis of triglycerides to free fatty
acids, monoglycerides, and glycerol
D. Impaired lipid absorption as a result of mucosal
inflammation
E. Increased dietary intake of medium chain triglycerides
VII-27. A 24-year-old woman is admitted to the hospital
with a 1-year history of severe abdominal pain and chronic
diarrhea that has been bloody for the past 2 months. She
reports a 20-lb weight loss, frequent fevers, and night
sweats. She denies vomiting. Her abdominal pain is
crampy and primarily involves her right lower quadrant.
She is otherwise healthy. Examination is concerning for an
acute abdomen with rebound and guarding present. CT
shows free air in the peritoneum. She is urgently taken to
the operating room for surgical exploration, where she is
found to have multiple strictures and a perforation of her
bowel in the terminal ileum. The rectum was spared, and a
fissure from the duodenum to the jejunum was found. The
perforated area is resected and adhesions lysed. Which of
the following findings on pathology of her resected area
confirms her diagnosis?
A. Crypt abscesses
B. Flat villi
C. Noncaseating granulomas throughout the bowel wall
D. Special stain for Clostridium difficile toxin
E. Transmural acute and chronic inflammation
VII-28. A 45-year-old man with ulcerative colitis has been
treated for the last 5 years with infliximab with excellent
resolution of his bowel symptoms and endoscopic evi-
dence of normal colonic mucosa. He is otherwise healthy.
He is evaluated by a dermatologist for a lesion that initially
was a pustule over his right lower extremity but has since
progressed in size with ulceration. The ulcer is moderately
painful. He does not recall any trauma to the area. On
examination, the ulcer measures 15 × 7 cm, and central
necrosis is present. The edges of the ulcer are violaceous.
No other lesions are identified. Which of the following is
the most likely diagnosis?
A. Erythema nodosum
B. Metastatic Crohn disease
C. Psoriasis
D. Pyoderma gangrenosum
E. Pyoderma vegetans
VII-29. Which of the following statements regarding the epi-
demiology of inflammatory bowel disease (IBD) is true?
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A. Children who receive frequent antibiotics in child-
hood are at lower risk of developing IBD.
B. IBD appears with decreasing incidence in countries
that are becoming more westernized.
C. Patients who have had an appendectomy with con-
firmed appendicitis have a lower risk of developing
ulcerative colitis.
D. Peak incidence of ulcerative colitis and Crohn dis-
ease is in the 6th–7th decades of life.
E. The highest incidence rates of ulcerative colitis and
Crohn disease have been reported in Asia, the Mid-
dle East, and Northern Africa.
VII-30. A 36-year-old male has had Crohn disease for 5 years.
His disease was initially managed with occasional tapers
of oral prednisone, followed by use of oral budesonide.
Over the last 6 months he has required two courses of oral
prednisone and was hospitalized for worsening abdominal
pain and fevers requiring IV antibiotics and corticoster-
oids. He has not had evidence of fistulizing disease. How
should his Crohn disease be managed at this time?
A. Begin IV cyclosporine A
B. Provide intermittent infusions of infliximab each
time he has a disease flare
C. Start azathioprine orally at 2–3mg/kg with the poten-
tial addition of infliximab
D. Start maintenance prednisone at 0.5mg/kg for 3
months
E. Start monthly infusions of IV golimumab
VII-31. Which of the following patients requires no further
testing before making the diagnosis of irritable bowel syn-
drome and initiating treatment?
A. A 76-year-old woman with 6 months of intermittent
crampy abdominal pain that is worse with stress and
associated with bloating and diarrhea.
B. A 25-year-old woman with 6 months of abdominal
pain, bloating, and diarrhea that has worsened stead-
ily and who now wakes from sleep at night to move
her bowels.
C. A 30-year-old man with 6 months of lower abdomi-
nal crampy pain relieved with bowel movements,
usually loose. Symptoms are worse during the day-
time at work and better on the weekend. Weight loss
is not present.
D. A 19-year-old female college student with 2 months
of diarrhea and worsening abdominal pain with
occasional blood in her stool.
E. A 27-year-old woman with 6 months of intermittent
abdominal pain, bloating, and diarrhea without asso-
ciated weight loss. Crampy pain and diarrhea persist
after a 48-hour fast.
VII-32. A 29-year-old woman comes to see you in the clinic
because of abdominal discomfort. She feels abdominal
discomfort on most days of the week, and the pain var-
ies in location and intensity. She notes constipation as
 well as diarrhea, but diarrhea predominates. Compared A. Air-fluid levels are commonly seen on plain abdomi-
with 6 months ago, she has more bloating and flatulence nal films.

than she has had before. She identifies eating and stress as B.
aggravating factors, and her pain is relieved by defecation.
You suspect irritable bowel syndrome. Laboratory data C.
include white blood cell count 8000/μL, hematocrit 32%,
platelets 210,000/μL, and erythrocyte sedimentation rate D.
44 mm/h. Stool studies show the presence of lactoferrin
but no blood. Which of the following interventions is most E.
SECTION VII
Less than 25% of patients present with peritoneal
signs.
Lower gastrointestinal bleeding will likely be visual-
ized on CT angiography.
Thickened colonic wall is not required on CT for the
diagnosis of her likely condition.
Ultrasound of the pelvis is the best modality to visu-

appropriate at this time?
A. Antidepressants
B. Ciprofloxacin
C. Colonoscopy
D. Reassurance and patient counseling
E. Stool bulking agents
VII-33. Which of the following statements regarding the
pathophysiology of irritable bowel syndrome (IBS) is true?
A. Abdominal distention, belching, and flatulence are
most commonly due to increased amounts of gas in
the gastrointestinal tract of patients with IBS.
B. Compared with patients without IBS, IBS patients
frequently exhibit blunted sensory responses to vis-
ceral stimulation.
C. Gut dysbiosis acting in concert with genetic and
environmental factors may alter intestinal permea-
bility, increase antigen presentation resulting in mast
cell activation.
D. Almost all patients with IBS display persistent signs
of low-grade mucosal inflammation with activated
lymphocytes, mast cells, and enhanced expression of
proinflammatory cytokines.
E. The majority of IBS patients report a bout of gastro-
enteritis at the onset of their symptoms.
VII-34. A 34-year-old female with known irritable bowel
syndrome has severe bouts of postprandial pain that have
prevented her from being able to enjoy regular meals with
her family. Which of the following therapies would be
most likely to improve her discomfort?
A. Activated charcoal taken immediately after eating a
meal.
B. An anticholinergic drug, such as dicyclomine,
administered 30 minutes prior to eating.
C. Citalopram administered once daily.
D. Fiber supplementation with psyllium.
E. Small doses of loperamide prior to meals.
VII-35. A 78-year-old woman is admitted to the hospital with
fever, loss of appetite, and left lower quadrant pain. She
is not constipated but has not moved her bowels recently.
Laboratory examination is notable for an elevated white
blood cell count. These symptoms began approximately 3
days ago and have steadily worsened. Which of the follow-
ing statements regarding her likely condition is true?
QUESTIONS
alize the likely pathologic process.
VII-36. A 67-year-old man is evaluated by the emergency
department for blood in the toilet bowl after moving his
bowels. Blood was also present on the toilet paper after
wiping. He does report straining and recent constipation.
He has a history of systemic hypertension and hyperlipi-
demia. Vital signs are normal, and he is not orthostatic.
Anoscopy shows external hemorrhoids, hematocrit is nor-
mal, and bleeding does not recur during his 6-hour emer-
gency department stay. Which of the following is the most
appropriate management?
A. Ciprofloxacin and metronidazole
B. Cortisone suppositories and fiber supplementation
C. Hemorrhoidal banding
D. Operative hemorrhoidectomy
E. Upper endoscopy
VII-37. An 88-year-old woman is brought to your clinic by
her family because she has become increasingly socially
withdrawn. The patient lives alone and has been reluc-
tant to visit or be visited by her family. Family members,
including seven children, also note a foul odor in her
apartment and on her person. She has not had any weight
loss. Alone in the examining room, she only complains
of hemorrhoids. On mental status examination, she does
have signs of depression. Which of the following interven-
tions is most appropriate at this time?
A. Head CT scan
B. Treatment with an antidepressant medication
C. Physical examination including genitourinary and
rectal examination
D. Screening for occult malignancy
E. Serum thyroid-stimulating hormone
VII-38. A 59-year-old female develops acute diverticulitis
and requires hospitalization for IV antibiotics. She has a
CT scan that does not show evidence of abscess perfora-
tion, stricture, or fistula, and she improves in about a week.
Which of the following should be undertaken to prevent
further symptomatic disease?
A. Annual colonoscopy
B. Avoidance of nuts
C. Daily mesalamine therapy
D. Initiation of a high-fiber diet
E. Subtotal colectomy to reduce the risk of perforation
during a subsequent bout

487
 VII-39. A 63-year-old man with poorly controlled type 2 abdominal discomfort and distension. She received a dose
diabetes presents to his primary care physician with 3 days of cefazolin prior to surgery but no other antibiotics. On
SECTION VII

or perianal pain, fever, and difficulty voiding. He has a his-
tory of uncomplicated stage 1 hemorrhoids, which have
been treated in the past with cortisone suppositories and a
high-fiber diet. On examination, he is febrile and there is
a 2-cm fluctuant mass at the anal verge. Which of the fol-
lowing would be the most appropriate management?
A. Excision and drainage of the mass
Disorders of the Gastrointestinal System
physical examination, she is afebrile with a blood pressure
of 140/80, heart rate of 110 beats/min, respiratory rate of
16 breaths/min, and oxygen saturation of 100% on 2 L of
nasal oxygen. She has a distended tympanic abdomen with
absent bowel sounds. There is no rebound tenderness. Her
upright abdominal film is shown in Figure VII-42. Which
of the following is the most likely diagnosis?

B. Infrared anticoagulation
C. Oral antibiotics and follow-up in 2 days
D. Rubber band ligation
E. Sclerotherapy

VII-40. A 63-year-old man with a history of diabetes and

myocardial infarction was admitted to the medical inten-
sive care unit 1 day ago with sepsis due to pneumococcal
pneumonia with bacteremia. He was started on antibiot-
ics immediately, but he initially required high doses of
noradrenaline and fluids to stabilize his blood pressure.
The noradrenaline was weaned off approximately 12 hours
ago. Over the past 2 hours, he has had increasing abdominal
pain, distension, and bloody stools. His physical examina-
tion is notable for blood pressure of 100/50, regular heart
rate of 100 beats/min, respiratory rate of 22 breaths/min,
and oxygen saturation of 93% on high-flow nasal oxygen.
He has a diffusely tender abdomen with no audible bowel
sounds. An abdominal radiograph shows multiple small
bowel air-fluid levels. Which of the following is the most
likely diagnosis?
A. Arterial embolism
B. Clostridium difficile colitis FIGURE VII-42 Reproduced with permission from Bongard
C. Inflammatory bowel disease FS et al: Current Critical Care Diagnosis & Treatment. New York:
D. Nonocclusive mesenteric ischemia McGraw Hill, 1994.
E. Venous thrombosis

VII-41. A 79-year-old female with known coronary artery A. Acalculous cholecystitis

disease requiring previous percutaneous coronary inter-
vention with stent placement presents to her primary care
physician’s office with 3 months of cramping abdominal
pain after meals. She denies any change in the pain with
defecation, and does not report increased flatulence or
belching. She has had more frequent, loose stools but
denies constipation. She has lost 15 lb during this time
period. Which of the following would be the most appro-
priate next step in management?
A. Noncontrast CT scan of the abdomen and pelvis
B. Electrocardiogram to look for the presence of atrial
fibrillation
C. Initiation of a high fiber diet
D. Initiation of an selective serotonin reuptake inhibitor
medication for possible depression
E. Mesenteric angiography
VII-42. A 74-year-old woman is 2 days post hip surgery for
a fracture after a fall. Her only medication prior to admis-
sion was a calcium supplement, and she has no prior surgi-
cal history. Over the past 24 hours, she has had increasing
B. Colonic pseudo-obstruction
C. Perforated duodenal ulcer
D. Small bowel obstruction
E. Small bowel ileus
VII-43. A 52-year-old man presents to the emergency
department with acute-onset abdominal pain that awoke
him from sleep. He has a history of paroxysmal atrial
fibrillation but has not had any recent episodes of atrial
fibrillation on remote monitoring. He has no prior history
of abdominal surgeries. His pain is 7/10 in severity, and
comes in intense waves. He has vomited twice and each
time his pain was improved for a few minutes afterward,
but then it returned. He is afebrile, with a heart rate in the
120s that is confirmed to be sinus tachycardia by electro-
cardiogram. He is afebrile. His abdomen is tender and
distended. He has high-pitched “musical” bowel sounds.
CT of the abdomen is shown in Figure III-43. He has no
evidence of gallstones or ductal dilatation on right upper
quadrant ultrasound, and the pancreas appears normal on

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 VII-46. A 38-year-old man is seen in the urgent care center
with several hours of severe abdominal pain. His symptoms

SECTION VII
began suddenly, but he reports several months of pain in
the epigastrium after eating, with a resultant 10-lb weight
loss. He takes no medications other than over-the-counter
antacids and has no other medical problems or habits. On
physical examination, temperature is 38.0°C (100.4°F),
pulse is 130 beats/min, respiratory rate is 24 breaths/min,
and blood pressure is 110/50. His abdomen has absent

QUESTIONS
bowel sounds and is rigid with involuntary guarding dif-
fusely. A plain film of the abdomen is obtained and shows
free air under the diaphragm. Which of the following is
most likely to be found in the operating room?
A. Necrotic bowel
FIGURE VII-43
B. Necrotic pancreas
CT (not shown). Labs are pending. Which of the following C. Perforated duodenal ulcer
is the most likely cause of his symptoms? D. Perforated gallbladder
E. Perforated gastric ulcer
A. Acute mesenteric ischemia
B. Acute cholecystitis VII-47. Which of the following statements regarding the
C. Acute pancreatitis signs and symptoms of a patient with acute appendicitis
D. Small bowel obstruction is true?
E. Viral gastroenteritis
A. Anorexia is an uncommon symptom.
VII-44. A 32-year-old woman is evaluated in the emergency B. McBurney point describes pain in the mid-
department for abdominal pain. She reports a vague loss epigastrium.
of appetite for the last day and has had progressively severe C. Patients with pelvic appendicitis commonly pre-
abdominal pain, initially at her umbilicus, but now local- sent with dysuria, urinary frequency, diarrhea, or
ized to her right lower quadrant. The pain is crampy. She tenesmus.
has not moved her bowels or vomited. She reports that she D. Right lower quadrant tenderness is present in only
is otherwise healthy and has had no sick contact. Examina- 50% of patients.
tion is notable for a temperature of 38.2°C (100.7°F) and E. Rovsing sign is the most sensitive finding on physical
heart rate of 105 beats/min; otherwise, vital signs are nor- examination.
mal. Her abdomen is tender in the right lower quadrant,
and pelvic examination is normal. Urine pregnancy test VII-48. The greatest source of nutrients and calories in a
is negative. Which of the following imaging modalities is typical individual’s diet come from which source?
most likely to confirm her diagnosis? A. Alcohol
A. CT of the abdomen without contrast B. Carbohydrates
B. Colonoscopy C. Fat
C. Pelvic ultrasound D. Protein
D. Plain film of the abdomen
VII-49. Which of the following factors accounts for the larg-
E. Ultrasound of the abdomen
est amount of water loss per day?
VII-45. The patient in question VII-44 is diagnosed with A. Evaporation and exhalation
acute appendicitis. Which of the following is the most B. Fever
important next step in management? C. Normal stool output (i.e., no diarrhea)
A. Colonoscopy D. Pregnancy
B. Empiric antibiotics and watchful waiting for 48 hours E. Urine output in a person with a very low solute diet
C. Exploratory laparotomy
D. IV corticosteroids
E. Laparoscopic appendectomy

489
 VII-50. Mr. Ryan is a 56-year-old man who was admitted
to the surgical service for care due to exposure injury and
SECTION VII
frostbite in his distal extremities. He has a long-standing
history of alcoholism, drinking about 1 L of vodka on a
daily basis. You are asked to consult due to concerns of
bizarre behaviors exhibited by the patient. He is express-
ing a belief that his wounds were the result of burns that
were inflicted on him by “torturers” in the government
because he “knows too much” about government surveil-
Disorders of the Gastrointestinal System
lance plans. The surgical team reports it is difficult to keep
the patient in his bed, and he seems unsteady on his feet
at times. He has been medicated throughout his stay for
prevention of alcohol withdrawal via a symptom-triggered
approach and last received lorazepam 2 mg orally about
2 hours ago. At that time, the patient was noted to be
tremulous, tachycardic, and hypertensive. The delusional
thoughts are not responsive to treatment of alcohol with-
drawal symptoms. When you see the patient, he is sleeping
quietly. Vital signs are blood pressure 110/82, heart rate
94 beats/min, respiratory rate 16 breaths/min, tempera-
ture 37.1°C (98.7°F), and SaO2 is 97% on room air. He
awakens easily and has a minimal resting tremor. On neu-
rologic examination, he exhibits past-pointing, difficulty
with rapid alternating movements, horizontal nystagmus,
and decreased sensation to light touch and pinprick in
the lower extremities below the mid-tibia. His gait is wide
based and ataxic. He no longer expresses his prior delu-
sional beliefs, but he is disoriented and thinks he is in jail.
He states he was brought to “this gulag” so that the gov-
ernment could experiment on him. He has 5% dextrose in
half-normal saline infusing at 100 mL/h and is also receiv-
ing nafcillin 2 g IV every 4 hours for cellulitis. Which of
the following is the most likely cause of Mr. Ryan’s altered
mental state and neurologic findings?
A. Hypoglycemia
B. Hyponatremia
C. Niacin deficiency
D. Thiamine deficiency
E. Undertreated alcohol withdrawal
VII-51. A 48-year-old man is diagnosed with carcinoid
syndrome after presenting with diarrhea, flushing, and
hypotension. With appropriate treatment, he experiences
an appropriate response biochemically, and his flushing
and blood pressure are markedly improved. However, he
continues to have some mild diarrhea and also has mouth
soreness. He remains fatigued with a loss of appetite and
irritability. On examination, you notice his tongue is
bright red and somewhat enlarged. It is tender to touch.
In addition, he has a pigmented and scaling rash that is
most prominent around his neckline. Which of the follow-
ing is the most likely vitamin or mineral deficiency in this
patient?
A. Copper
B. Niacin
C. Riboflavin
D. Vitamin C
E. Zinc
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VII-52. A 51-year-old alcoholic man presents to the emer-
gency department complaining of vomiting blood. On
further evaluation including gastric lavage, you deter-
mine that he is not experiencing an upper gastrointestinal
bleed, but he is having significant gingival bleeding. He is
intoxicated and complains of fatigue. Reviewing his chart,
you find that he had a hemarthrosis evacuated 6 months
ago and has been lost to follow-up since then. He takes
no medications. Laboratory data show platelets of 250,000
and international normalized ratio of 0.9. He has a diffuse
hemorrhagic eruption on his legs that is centered around
hair follicles. Which of the following is the recommended
treatment for this patient’s underlying disorder?
A. Folate
B. Niacin
C. Thiamine
D. Vitamin C
E. Vitamin K
VII-53. A 46-year-old male from Mexico was found to be
purified protein derivative–positive on routine health
screening prior to beginning a new job in a hospital. He
was started on isoniazid for treatment of latent tubercu-
losis. Three months into his treatment course he develops
numbness and tingling in his bilateral feet. On laboratory
assessment his liver function tests are normal. He reports
taking his isoniazid faithfully but does not remember
being told to take any additional medications along with
the isoniazid. Which of the following is the likely cause of
his symptoms?
A. Niacin deficiency
B. Thiamine deficiency
C. Vitamin A toxicity
D. Vitamin B6 deficiency
E. Vitamin B12 deficiency
VII-54. A 3-year-old who recently arrived from Indonesia
comes in for a routine wellness check with his new adop-
tive parents. On physical examination he is noted to have
white patches of keratinized epithelium appearing on the
sclera. Which of the following would be the most appro-
priate treatment for this condition?
A. Biotin 10 mg/day for 7 days
B. Pyridoxine 50 mg/day for 14 days
C. Vitamin A 200,000 IU orally on day 1, day 2, and
day 15
D. Vitamin B12 1000 mcg per day for 1 month
E. Vitamin C 100 mg/day for 7 days
VII-55. A 21-year-old woman is admitted to the cardiac care
unit after collapsing in her college dormitory. When emer-
gency personnel arrived, she was found to be in a torsades
de pointes arrhythmia and was pulseless. She received
cardiopulmonary resuscitation, defibrillation, and mag-
nesium en route to the hospital. On arrival, her initial
potassium is 1.2 mEq/L. Her physical examination is
remarkable for an excessively thin appearance with lanugo
hair on arms and chest. Her body mass index is 14.6 kg/m2.
 Which of the following statements is true regarding this VII-60. All of the following are CAGE questions, which
patient’s nutritional state? should be a component of the medical history focusing on

SECTION VII
alcohol abuse and dependence, EXCEPT:
A. Mortality in the disease is most commonly due to
complications of malnutrition. A. Do you feel like you have a greater tolerance for alco-
B. Poor wound healing and frequent skin infections are hol than your friends?
common complications. B. Have you ever felt you ought to cut down on your
C. Systemic inflammation is a predominant finding on drinking?
laboratory examination. C. Have people annoyed you by criticizing your
D. The serum albumin is typically less than 2.8 g/dL. drinking?

QUESTIONS
E. Triceps skinfold <3 mm and mid-arm muscle cir- D. Have you ever felt guilty or bad about your drinking?
cumference <15 cm are useful diagnostic criteria. E. Have you ever had a drink first thing in the morning
to steady your nerves or get rid of a hangover?
VII-56. You are caring for a 54-year-old woman in the inten-
sive care unit who was admitted for treatment of severe VII-61. A 43-year-old female presents to her primary care
sepsis and pneumonia. You would like to initiate enteral physician with fatigue and malaise. On routine laboratory
nutrition and plan to calculate basal energy expenditure testing she is found to have an aspartate aminotransferase
for the patient. All of the following factors are used to of 150 IU/L, and alanine aminotransferase of 165 IU/L,
determine the patient’s caloric needs EXCEPT: an alkaline phosphatase of 125 IU/L, a total bilirubin of
1.2 mg/dL, and an international normalized ratio of 0.9.
A. Age
Which of the following best describes the pattern of liver
B. Albumin
tests?
C. Gender
D. Height A. Cholestatic
E. Weight B. Cirrhotic
C. Hepatocellular
VII-57. Which of the following conditions would be best D. Mixed
classified as starvation-associated malnutrition? E. Peritonitic
A. Closed head injury
VII-62. All of the following are potential advantages of mag-
B. Major depression
netic resonance cholangiopancreatography over endo-
C. Motor-vehicle accident
scopic retrograde cholangiopancreatography EXCEPT:
D. Pancreatic cancer
E. Sarcopenic obesity A. Faster image acquisition
B. Higher sensitivity for identifying ampullary lesions
VII-58. Which of the following statements regarding the C. No risk of ionizing radiation
methodologies for determining body composition and D. No risk of pancreatitis
nutritional status is true? E. No need for contrast media
A. Albumin is useful in assessing nutritional status
VII-63. Elevation in all of the following laboratory studies
because of its long half-life.
would be indicative of liver disease EXCEPT:
B. Anthropomorphic analyses such as measur-
ing skinfolds and circumferences are reliable and A. 5′-Nucleotidase
reproducible. B. Aspartate aminotransferase
C. Bioelectrical impedance can be readily applied and C. Conjugated bilirubin
interpreted in individuals of different races and eth- D. Unconjugated bilirubin
nic groups. E. Urine bilirubin
D. C-reactive protein is a specific marker for
malnutrition. VII-64. Which of the following statements regarding liver
E. Dual energy x-ray absorptiometry scanning can be function tests is true?
used to compare truncal and appendicular soft tissue. A. Alanine aminotransferase (ALT) is found in liver,
cardiac muscle, skeletal muscle, and kidney.
VII-59. Which of the following is the most common symp-
B. Elevation of aspartate aminotransferase (AST) and
tom or sign of liver disease?
ALT to >1000 IU/L is typical of ischemic hepatitis.
A. Fatigue C. Elevation of AST is more specific for liver dysfunc-
B. Itching tion than elevation of ALT.
C. Jaundice D. Increased AST and ALT with an AST:ALT ratio of >3
D. Nausea is typical of acute viral hepatitis.
E. Right upper quadrant pain E. The magnitude of elevated AST and ALT has impor-
tant prognostic significance in acute hepatitis.

491
 VII-65. Which of the following is true about aspartate ami- A. Bilirubin values <4 mg/dL imply concomitant gall-
notransferase (AST) and alanine aminotransferase (ALT) bladder or biliary dysfunction.
SECTION VII

in liver injury? B. Bilirubin values >4 mg/dL (68 μmol/L) imply con-
comitant liver dysfunction.
A. A ratio of ALT:AST greater than 1 is suggestive of
C. It is typically composed of 50% conjugated and 50%
cirrhosis.
unconjugated bilirubin.
B. ALT is usually equal to or greater than AST in most
D. Prolonged hemolysis may result in the development
causes of acute liver injury.
of cirrhosis.
C. AST is often normal is cases of alcoholic cirrhosis.
D. AST and ALT usually remain elevated for days after
Disorders of the Gastrointestinal System

VII-69. A 26-year-old female who is 3-months pregnant

the passage of a gallstone. presents for a routine prenatal visit and is found to be
E. If the ALT:AST ratio is greater than 3, then alcoholic jaundiced. This is her first pregnancy and she reports no
hepatitis should be suspected. symptoms other than occasional early morning nausea
that resolves after eating breakfast. She has no pruritus. Her
VII-66. Which of the following is true about biochemical
physical examination is unremarkable with the exception
liver testing?
of obvious jaundice. She has no hepatosplenomegaly and
A. γ-Glutamyl transpeptidase elevation is specific for her fundus is not yet palpable. Labs are notable for a total
cholestatic liver injury. bilirubin of 6 mg/dL, with a direct bilirubin of 5 mg/dL.
B. Increased IgM levels may be a marker of autoim- Her aspartate aminotransferase, alanine aminotransferase,
mune hepatitis. and alkaline phosphatase levels are all within the normal
C. Low factor VIII levels may indicate chronic liver range. Which of the following is the most likely cause of
disease. her hyperbilirubinemia?
D. Patients over the age of 60 can have a mild elevation
A. Benign recurrent intrahepatic cholestasis
in their alkaline phosphatase levels up 1.5 times the
B. Cholestasis of pregnancy
upper limit of normal.
C. Crigler-Najjar syndrome type 2
E. Serum albumin is a good marker of the severity of
D. Dubin-Johnson syndrome
acute liver injury.
E. HELLP (hemolysis, elevated liver enzymes, and low
VII-67. A 26-year-old male resident is noticed by his attend- platelet) syndrome
ing physician to have yellow eyes after his 24-hour call
VII-70. A 34-year-old man presents to the physician com-
period. When asked, the resident states he has no medi-
plaining of yellow eyes. For the past week, he has felt ill,
cal history and is a social drinker, but on occasion, he
with decreased oral intake, low-grade fevers (~100°F),
has thought he might have mild scleral icterus when he
fatigue, nausea, and occasional vomiting. With the onset
is stressed or has more than four to five alcoholic drinks.
of jaundice, he has noticed pain in his right upper quad-
He never sought medical treatment because his eyes would
rant. He currently uses marijuana and ecstasy and has a
return fully to normal within 2 days. He denies nausea,
prior history of injection drug use with cocaine. He has
abdominal pain, dark urine, light-colored stools, pruri-
no other past medical history, but he was unable to donate
tus, or weight loss. On examination, he has a body mass
blood for reasons that he cannot recall 4 years previously.
index of 20.1 kg/m2, and his vital signs are normal. Scleral
His social history is remarkable for working as a veterinary
icterus is present. There are no stigmata of chronic liver
assistant. On sexual history, he reports five male sexual
disease. The patient’s abdomen is soft and nontender. The
partners over the past 6 months. He does not consistently
liver span is 8 cm to percussion. The liver edge is smooth
use condoms. On physical examination, he appears ill and
and palpable only with deep inspiration. The spleen is not
has obvious jaundice with scleral icterus. His liver is 15 cm
palpable. Laboratory examinations are normal except for a
to percussion, palpable 6 cm below the right costal margin.
total bilirubin of 3.0 mg/ dL. Direct bilirubin is 0.2 mg/dL.
The edge is smooth and tender to palpation. The spleen is
Aspartate aminotransferase, alanine aminotransferase,
not enlarged. There are no stigmata of chronic liver dis-
and alkaline phosphatase are normal. Hematocrit, lactate
ease. His aspartate aminotransferase is 1232 IU/L, alanine
dehydrogenase, and haptoglobin are normal. Which of the
aminotransferase is 1560 IU/L, alkaline phosphatase is
following is the most likely diagnosis?
394 IU/L, total bilirubin is 13.4 mg/dL, and direct bilirubin
A. Autoimmune hemolytic anemia is 12.2 mg/dL. His international normalized ratio is 2.3,
B. Crigler-Najjar syndrome type 1 and activated partial thromboplastin time is 52 seconds.
C. Choledocholithiasis Hepatitis serologies are sent and reveal the following:
D. Dubin-Johnson syndrome
Hepatitis A IgM: negative
E. Gilbert syndrome
Hepatitis A IgG: negative
VII-68. Which of the following statements regarding the Hepatitis B core IgM: positive
hyperbilirubinemia seen in patients with significant intra-
Hepatitis B core IgG: negative
vascular hemolysis is true?
Hepatitis B surface antigen: positive

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 Hepatitis B surface antibody: negative tender liver below the right costal margin. In regard to
acute hepatitis, which of the following is true?

SECTION VII
Hepatitis B e antigen: positive
Hepatitis B e antibody: negative A. A distinction between viral etiologies cannot be
Hepatitis C antibody: positive made using clinical criteria alone.
B. Based on age and risk factors, he is likely to have a
What is the cause of the patient’s current clinical hepatitis B infection.
presentation? C. He does not have hepatitis E virus, as this infects only
A. Acute hepatitis A infection pregnant women.
D. This patient cannot have hepatitis C because his pres-

QUESTIONS
B. Acute hepatitis B infection
C. Acute hepatitis C infection entation is too acute.
D. Chronic hepatitis B infection E. This patient does not have hepatitis A because his
E. Drug-induced hepatitis presentation is too fulminant.

VII-71. In the patient described in question VII-70, what VII-74. Which of the following best explains why neonatal
would be the best approach to prevent development of infection with hepatitis B virus (HBV) does not result in
chronic hepatitis? significant hepatocellular inflammation early in life?

A. Administration of anti-hepatitis A virus IgG A. Effective priming of HBV-specific T cells with HBV
B. Administration of lamivudine leads to the lack of an immune response.
C. Administration of pegylated interferon-α plus B. HBV does not easily cross the placenta.
ribavirin C. In utero exposure to HBV induces immune tolerance.
D. Administration of prednisone beginning at a dose of D. Maternal antibodies against hepatitis core antigen
1 mg/kg daily result in immunity against infection.
E. Do nothing and observe as 99% of individuals with E. Natural killer cells are not particularly effective early
this disease recover in life.

VII-72. A 16-year-old girl had visited your clinic 1 month ago
with jaundice, vomiting, malaise, and anorexia. Two other
family members were ill with similar symptoms. Based on
viral serologies, including a positive anti-hepatitis A virus
IgM, a diagnosis of hepatitis A was made. The patient was
treated conservatively, and 1 week after first presenting,
she appeared to have made a full recovery. She returns to
your clinic today complaining of the same symptoms she
had 1 month ago. She is jaundiced, and an initial panel
of laboratory tests returns elevated transaminases. Which
of the following offers the best explanation of what has
occurred in this patient?
VII-75. A 57-year-old female presents to your clinic for a
routine health evaluation. She is complaining of intermit-
tent abdominal pain so you decide to order serum chemis-
tries. Her aspartate aminotransferase is mildly elevated at
75 IU/L, and her alanine aminotransferase is also mildly
elevated at 66 IU/L. Her bilirubin and international nor-
malized ratio are normal. She denies recent alcohol use
and has never used injection drugs. She is sexually active
and has had two recent male partners. She does not use
barrier protection. She was born in China but has lived in
the United States for 40 years. You decide to check hepati-
tis serologies and obtain the following results:

A. Co-infection with hepatitis C Hepatitis B surface antigen: positive

B. Inappropriate treatment of initial infection Hepatitis B surface antibody: negative
C. Incorrect initial diagnosis; this patient likely has hep- Hepatitis B core antibody: positive
atitis B Hepatitis B e-antigen: negative
D. Reinfection with hepatitis A Hepatitis B e-antibody: positive
E. Relapse of hepatitis A
Which of the following best describes her hepatitis B
VII-73. An 18-year-old man presents to a rural clinic with status?
nausea, vomiting, anorexia, abdominal discomfort, myal- A. Acute hepatitis B
gias, and jaundice. He describes occasional alcohol use and B. Chronic Hepatitis B, high infectivity
is sexually active. He describes using heroin and cocaine “a C. Immunization against hepatitis B
few times in the past.” He works as a short-order cook in D. Late acute or chronic hepatitis B, low infectivity
a local restaurant. He has lost 15.5 kg (34 lb) since his last E. Recovery from hepatitis B
visit to the clinic and appears emaciated and ill. On exami-
nation, he is noted to have icteric sclerae and a palpable,

493
 VII-76. Which of the following statements is true about the
prevention of viral hepatitis?
SECTION VII
A. Health care workers in endemic areas should receive
the hepatitis D vaccine every 5 years.
B. Patients with acute hepatitis A should be placed on
contact isolation to prevent transmission to health
care workers and other patients.
C. Serum Ig has been shown to be effective in postexpo-
sure prophylaxis for hepatitis C.
Disorders of the Gastrointestinal System
D. The hepatitis B vaccine is a live attenuated vaccine
that should be avoided in immunocompromised
patients.
E. There is an effective vaccine against hepatitis E
genotype 1 that also has effectiveness against other
genotypes.
VII-77. A 32-year-old woman is admitted to the inten-
sive care unit following an overdose of acetaminophen
with co-ingestion of alcohol. She was known to be alert
and interactive about 4 hours prior to her presentation
when she had a fight with her boyfriend who then left
the home. When he returned 6 hours later, he found an
empty bottle of acetaminophen 500-mg capsules as well
as an empty vodka bottle. The exact number of pills in the
bottle is unknown, but the full bottle held as much as 50
capsules. The patient was unresponsive and had vomited,
so her boyfriend called 911. On arrival to the emergency
department, the patient is stuporous. Her vital signs are
pulse 109 beats/min, respiratory rate 20 breaths/min,
blood pressure 96/52, and oxygen saturation 95% on room
air. Her examination shows mild nonspecific abdominal
pain with palpation. The liver is not enlarged. Her initial
laboratory values show a normal complete blood count,
normal electrolytes, and kidney function. The aspartate
aminotransferase is 68 IU/L, alanine aminotransferase is
46 IU/L, alkaline phosphatase is 110 IU/L, and total bili-
rubin is 1.2 mg/dL. Glucose and coagulation studies are
normal. The serum alcohol level is 210 g/dL. The acetami-
nophen level is 350 μg/mL. What is the most appropriate
next step in the treatment of this patient?
A. Administration of activated charcoal or
cholestyramine
B. Administration of N-acetylcysteine 140 mg/kg fol-
lowed by 70 mg/kg every 4 hours for a total of
15–20 doses
C. Continued monitoring of liver function, glucose, and
coagulation studies every 4 hours with administra-
tion of N-acetylcysteine if these begin to change
D. Do nothing as normal liver function tests and coagu-
lation studies are indicative of only a minor ingestion
E. Initiate hemodialysis for toxin clearance
VII-78. A 31-year-old health care worker is found to have a
newly positive tuberculin skin test 6 weeks after an expo-
sure to a patient with active pulmonary tuberculosis. He is
asymptomatic and has a normal chest radiograph. Which
of the following statements regarding initiation of isonia-
zid (INH) prophylactic therapy is true?
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WWW.BOOKBAZ.IR
A. Acute hepatocellular injury due to INH is an idio-
syncratic reaction that will manifest within the first
2 months of initiation of therapy.
B. Controlled trials have demonstrated that monthly
monitoring of aminotransferase levels reduces mor-
bidity in U.S. health care workers receiving INH
prophylaxis.
C. Elevation of aminotransferase levels in the first
2 months of therapy is an indication to stop INH and
switch to another drug.
D. The patient has a 50–70% chance of transient ele-
vation of his aminotransferase levels in the first
2 months of treatment.
E. The frequency of acute hepatocellular injury due
to INH is age dependent, increasing in patients
>35 years of age.
VII-79. Which of the following statements is true about
drug-induced liver injury (DILI)?
A. Direct toxic hepatitis is usually clinically indistin-
guishable from viral hepatitis.
B. Direct toxic hepatitis occurs with predictable regu-
larity after exposure and is dose dependent.
C. “Idiosyncratic” drug reactions are easily identified by
their histologic pattern on liver biopsy.
D. The incidence of DILI is higher in patients with
chronic liver disease.
E. The occurrence of jaundice in a phase 3 clinical trial
is not predictive of severe hepatotoxicity in post-
marketing surveillance.
VII-80. Which of the following statements regarding drug-
induced liver injury is true?
A. Amiodarone-induced liver injury resolves within
days of stopping the drug.
B. Phenytoin-induced liver injury is only rarely accom-
panied by systemic symptoms and is usually picked
up on screening liver enzyme testing.
C. Sodium valproate liver toxicity is more common in
patients with mitochondrial deficiencies and can be
ameliorated by the administration of IV carnitine.
D. The incidence of amoxicillin-induced liver injury is
decreased when administered in combination with
clavulanate.
E. When it occurs, nitrofurantoin liver toxicity happens
soon after the initiation of the drug.
VII-81. A 38-year-old woman is evaluated for elevated
transaminase levels that were identified during routine
laboratory testing for life insurance. She is originally from
Thailand and immigrated to the United States 10 years
previously. She has been married to an American for the
past 12 years, meeting him while he was living abroad
for business. She previously worked in Thailand as a
deputy tourism minister for the government but is not
currently employed. She has no significant past medical
history. She had one uncomplicated pregnancy at the age
of 22. When queried about risk factors for liver disease,
she denies alcohol intake or drug abuse. She has never
 had a blood transfusion. She recalls an episode of jaun-
dice that she did not seek evaluation for about 15 years
ago as it resolved spontaneously. She currently feels well,
and her husband wished to have her added to his life
insurance policy. On physical examination there are no
stigmata of chronic liver disease. Her laboratory studies
reveal an aspartate aminotransferase of 346 IU/L, alanine
aminotransferase of 412 IU/L, alkaline phosphatase of
98 IU/L, and total bilirubin 1.5 of mg/dL. Further workup
includes the following viral studies: hepatitis A IgG posi-
tive, hepatitis B surface antigen positive, hepatitis B e anti-
gen positive, anti-hepatitis B virus core IgG positive, and
hepatitis C IgG negative. The hepatitis B virus DNA level
is 4.8 × 104 IU/mL. Which of the following medications is
indicated for this patient?
A. Acyclovir
B. Entecavir
C. Ritonavir
D. Simeprevir
E. No treatment is necessary
VII-82. A 46-year-old man is known to have chronic hepati-
tis C virus (HCV) infection. He is a former IV drug user for
more than 20 years who has been abstinent from drug use
for 1 year. He was treated for tricuspid valve endocarditis
3 years previously. He does not know when he acquired
HCV. His laboratory studies show a positive HCV IgG
antibody with a viral load of greater than 1 million copies.
The virus is genotype 2. His aspartate aminotransferase is
82 IU/L, and his alanine aminotransferase is 74 IU/L. He
undergoes liver biopsy, which demonstrates a moderate
degree of bridging fibrosis. Which of the following is the
most predictive of the development of cirrhosis?
A. Abnormal transaminases
B. Bridging fibrosis on liver biopsy
C. Genotype 2
D. History of bacterial endocarditis
E. History of IV drug use
VII-83. For the patient in described in question VII-82,
which of the following statements is true about potential
treatment options for his hepatitis C virus?
A. A liver biopsy should be performed to determine the
appropriate treatment regimen.
B. Combination therapy with sofosbuvir and velpatasvir
would be a reasonable first-line treatment based on
his genotype.
C. He should be treated with ribavirin and pegylated
interferon as first-line agents.
D. Monotherapy with boceprevir would avoid any
potential interactions with the CYP3A4 pathway.
E. Because his alanine aminotransferase and aspartate
aminotransferase are not more than three times the
upper limit of normal he does not currently require
treatment.
SECTION VII
VII-84. A 34-year-old woman is evaluated for fatigue,
malaise, arthralgias, and a 10-lb weight loss over the past
6–8 weeks. She has no past medical history. Since feeling
poorly, she has taken approximately one or two tablets
of acetaminophen 500 mg daily. On physical examina-
tion, her temperature is 37.9°F (100.2°F), respiratory rate
QUESTIONS
is 18 breaths/min, blood pressure is 100/48, heart rate is
92 beats/min, and oxygen saturation is 96% on room air.
She has scleral icterus. Her liver edge is palpable 3 cm
below the right costal margin. It is smooth and tender.
The spleen is not enlarged. She has mild synovitis in the
small joints of her hands. Her aspartate aminotransferase
is 542 IU/L, alanine aminotransferase is 657 IU/L, alkaline
phosphatase is 102 IU/L, total bilirubin is 5.3 mg/dL, and
direct bilirubin is 4.8 mg/dL. Which of the following tests
would be LEAST likely to be positive in this diagnosis?
A. Antinuclear antibodies in a homogeneous pattern
B. Anti-liver/kidney microsomal antibodies
C. Antimitochondrial antibodies
D. Hypergammaglobulinemia
E. Rheumatoid factor
VII-85. Which of the following statements is true about the
mechanism of liver injury in patients with autoimmune
hepatitis?
A. Acute viral hepatitis has not been associated with the
subsequent development of autoimmune hepatitis.
B. Circulating autoantibodies in patients have been
directly linked to hepatocyte injury.
C. Immune complex deposition is an important mecha-
nism of hepatocyte injury.
D. Macrophages are the main effector cell of liver injury.
E. Molecular mimicry by cross-reacting antigens that
contain epitopes similar to liver antigens is postu-
lated to activate cytotoxic T cells.
VII-86. All of the following statements regarding alcoholic
liver disease are true EXCEPT:
A. Fatty liver is present in >90% of daily and binge
drinkers.
B. Hepatitis C infection worsens the prognosis of alco-
holic liver disease.
C. Over 50% of alcoholics will develop alcoholic
hepatitis.
D. Quantity and duration of alcohol consumption are
the most important risk factors for the development
of alcoholic liver disease.
E. The pathologic hallmarks of alcoholic liver disease
are fatty liver, hepatitis, and cirrhosis.
495
 VII-87. A 32-year-old woman is admitted to the hospi-
tal with fever, abdominal pain, and jaundice. She drinks
SECTION VII
approximately 6 beers daily and has recently increased
her alcohol intake to more than 12 beers daily. She has no
other substance abuse history and has no prior history of
alcoholic liver disease or pancreatitis. She is not taking any
medications. On physical examination, she appears ill and
disheveled with a fruity odor to her breath. Her vital signs
are heart rate 122 beats/min, blood pressure 95/56, respir-
Disorders of the Gastrointestinal System
atory rate 22 breaths/min, temperature 38.4°C (101.2°F),
and oxygen saturation 98% on room air. She has scleral
icterus, and spider angiomata are present on the trunk.
The liver edge is palpable 10 cm below the right costal
margin. The liver is smooth and tender to palpation. The
spleen is not palpable. No ascites or lower extremity edema
is present. Laboratory studies demonstrate an aspartate
aminotransferase of 431 IU/L, alanine aminotransferase of
198 IU/L, bilirubin of 8.6 mg/dL, alkaline phosphatase of
201 IU/L, amylase of 88 U/L, and lipase of 50 U/L. Total
protein is 6.2 g/dL, and albumin is 2.8 g/dL. The pro-
thrombin time is 29 seconds (control, 13 seconds) with
international normalized ratio of 2.2. What is the best
approach to treatment of this patient?
A. Administer IV fluids, thiamine, and folate and
observe for improvement in laboratory tests and
clinical condition.
B. Administer IV fluids, thiamine, folate, and imipenem
while awaiting blood culture results.
C. Administer prednisone 40 mg daily for 4 weeks
before beginning a taper.
D. Consult surgery for management of acute
cholecystitis.
E. Perform an abdominal CT with IV contrast to assess
for necrotizing pancreatitis.
VII-88. Which of the following is true about the pathophysi-
ology of alcoholic liver disease?
A. Alcoholic fatty liver disease is a benign condition and
does not lead to lasting liver injury.
B. Alcoholic fatty liver disease is characterized by bal-
looning degeneration, spotty necrosis, polymorpho-
nuclear infiltrate, and fibrosis in the perivenular and
perisinusoidal space of Disse.
C. Fatty accumulation begins in the perivenular hepato-
cytes and can eventually involve the entire hepatic
lobule.
D. It is relatively easy to differentiate alcoholic from
nonalcoholic fatty liver disease on liver biopsy.
E. Once fatty accumulation occurs in the liver, it is not
reversible.
VII-89. A 44-year-old man seeks evaluation for an abnor-
mal finding on abdominal ultrasonography. He has a his-
tory of type 2 diabetes mellitus and is on insulin therapy.
Last week, he was evaluated in the emergency department
for mid-epigastric pain likely due to nonsteroidal anti-
inflammatory drug therapy for muscle aches (he recently
started exercising because his wife told him to lose weight).
During the evaluation, an abdominal ultrasound showed
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marked fatty infiltration of the liver. Laboratory studies
show his transaminases are 2× normal with normal alka-
line phosphatase, bilirubin, and prothrombin time. Other
than insulin, he takes no medications, does not consume
alcohol or illicit drugs, and has no family history of liver
disease. On physical examination, he is obese (body mass
index 32 kg/m2) with normal vital signs and no other
abnormalities. You think he likely has nonalcoholic fatty
liver disease (NAFLD). All of the following statements
regarding his potential therapy are true EXCEPT:
A. Bariatric surgery is safe in patients with NAFLD.
B. Exercise may reduce hepatic steatosis.
C. Statins may worsen inflammation in NAFLD.
D. There are no therapies approved by the Food and
Drug Administration for NAFLD.
E. Vitamin E may reduce aminotransferase levels and
hepatic steatosis.
VII-90. Which of the following statements about non-
alcoholic steatohepatitis (NASH) is true?
A. Insulin resistance is an important driver of lipid
uptake, fat synthesis, and fat storage that leads to tri-
glyceride accumulation in hepatocytes.
B. Greater than 50% of patients with nonalcoholic fatty
liver disease (NAFLD) also have some component of
NASH.
C. Serum biomarkers are useful in distinguishing
NAFLD from NASH.
D. The contribution of NASH to the development of cir-
rhosis is on the decline in the United States.
E. Triglyceride accumulation within hepatocytes is
directly cytotoxic.
VII-91. A 63-year-old man with cirrhosis and portal hyper-
tension due to hemochromatosis presents with altered
mental status. He has chronic ascites controlled with
diet and spironolactone. He has a history of one esopha-
geal bleed but none since starting propranolol. His fam-
ily reports that over the last 2 days, he has become more
confused, but he has had no melena or hematemesis. He is
afebrile with normal vital signs, and physical examination
is notable for ascites, asterixis, and being oriented only to
person. His laboratory examination is notable for a hemo-
globin of 10.1 g/dL (baseline 9.5), creatinine of 1.4 mg/dL
(baseline 1.4), and blood urea nitrogen of 45 mg/dL (base-
line 18). A paracentesis is performed that yields reveals
clear fluid with 800 white blood cells/μL (40% neutrophils).
Which of the following is the most indicated therapy?
A. Ampicillin, ceftriaxone, vancomycin
B. Cefotaxime
C. Esophagogastroduodenoscopy with banding
D. Hemodialysis
E. Lactulose
VII-92. A 48-year-old woman presents complaining of
fatigue and itching. She has been tired for the past
6 months and recently has developed itching diffusely. It
is worse in the evening hours but is intermittent. She does
 not note it to be worse following hot baths or showers. Her A. 24-Hour urine copper
past medical history is significant only for hypothyroid- B. Antimitochondrial antibodies

SECTION VII
ism for which she takes levothyroxine 125 μg daily. On C. Endoscopic retrograde cholangiopancreatography
physical examination, she has mild jaundice and scleral D. Hepatitis B serologies
icterus. The liver is enlarged to 15 cm on palpation and is E. Serum ferritin
palpable 5 cm below the right costal margin. Xanthomas
are seen on both elbows. Hyperpigmentation is notice- VII-95. A 55-year-old man with cirrhosis thought second-
able on the trunk and arms where the patient has exco- ary to nonalcoholic steatohepatitis presents with altered
riations. Laboratory studies demonstrate the following: mental status. All of the following can precipitate hepatic

QUESTIONS
white blood cells 8900/μL, hemoglobin 13.3 g/dL, hema- encephalopathy in this type of patient EXCEPT:
tocrit 41.6%, and platelets 160,000/μL. The creatinine is A. Dehydration
1.2 mg/dL. The aspartate aminotransferase is 52 IU/L, ala- B. Hyperkalemia
nine aminotransferase is 62 IU/L, alkaline phosphatase is C. Hypokalemia
216 IU/L, total bilirubin is 3.2 mg/dL, and direct bilirubin D. Medication nonadherence
is 2.9 mg/dL. The total protein is 8.2 g/dL, and albumin is E. Spontaneous bacterial peritonitis
3.9 U/L. The thyroid-stimulating hormone is 4.5 U/mL.
Antimitochondrial antibodies are positive. Perinuclear VII-96. A 64-year-old man with known cirrhosis is admitted
antineutrophil cytoplasmic antibodies (ANCA) and cyto- to the intensive care unit with a large gastrointestinal bleed
plasmic ANCA are negative. What is the most likely cause and altered mental status. He is confused and unable to
of the patient’s symptoms? provide any history. His initial hemoglobin is 6.9 g/dL, and
his vital signs are notable for a heart rate of 115 beats/min
A. Lymphoma
and a blood pressure of 90/55. In addition to fluid resus-
B. Polycythemia vera
citation including transfusion of packed red blood cells,
C. Primary biliary cirrhosis
all of the following are appropriate therapy at this time
D. Primary sclerosis cholangitis
EXCEPT:
E. Uncontrolled hypothyroidism
A. Endoscopic sclerotherapy
VII-93. A 42-year-old man with cirrhosis related to hepatitis B. Endoscopic variceal ligation
C and alcohol abuse has ascites requiring frequent large- C. Octreotide
volume paracentesis. All of the following therapies would D. Propranolol
be indicated for this patient EXCEPT: E. Transjugular intrahepatic portosystemic shunt
A. Fluid restriction to less than 2 L daily
VII-97. In the patient in question VII-96, all of the following
B. Furosemide 40 mg daily
could be used as prophylaxis for further variceal bleeding
C. Sodium restriction to less than 2 g daily
EXCEPT:
D. Spironolactone 100 mg daily
E. Transjugular intrahepatic portosystemic shunt if A. Initiation of a nonselective beta blocker such as
medical therapy fails propranolol
B. Initiation of daily subcutaneous octreotide injections
VII-94. You are asked to consult on a 62-year-old white C. Liver transplantation
woman with pruritus for 4 months. She has noted progres- D. Repeated variceal ligation if the initial bleed was con-
sive fatigue and a 5-lb weight loss. She has intermittent trolled with endoscopic variceal ligation
nausea but no vomiting and denies changes in her bowel E. Transjugular intrahepatic portosystemic shunt
habits. There is no history of prior alcohol use, blood trans-
fusions, or illicit drug use. The patient is widowed and had VII-98. Which of the following statements is true about
two heterosexual partners in her lifetime. Her past medical alcoholic cirrhosis?
history is significant only for hypothyroidism, for which
A. Alcoholic cirrhosis is characterized by predomi-
she takes levothyroxine. Her family history is unremark-
nantly large (>2 cm) nodules in the liver.
able. On examination, she is mildly icteric. She has spi-
B. If patients with alcoholic cirrhosis are able to stop
der angiomata on her torso. You palpate a nodular liver
drinking alcohol, their 5-year survival improves.
edge 2 cm below the right costal margin. The remainder of
C. It is the most common cause of cirrhosis in the
the examination is unremarkable. A right upper quadrant
United States.
ultrasound confirms your suspicion of cirrhosis. You order
D. Parenterally administered tumor necrosis factor
a complete blood count and a comprehensive metabolic
inhibitors have emerged as an important treatment
panel. What is the most appropriate next test?
option that can reduce mortality in patients with
alcoholic cirrhosis.

497
 VII-99. A 63-year-old female with primary biliary cirrhosis
has refractory ascites that is managed with serial large vol-
SECTION VII
ume paracentesis. She presents to the emergency depart-
ment the night after an outpatient large volume tap with
altered mental status. On arrival her laboratory studies
are notable for a serum creatinine of 2.7 mg/dL (baseline
0.9 2 weeks ago) and a serum sodium of 127 mEq/L. Her
urine output is low. You suspect possible hepatorenal syn-
drome. All of the following would be potential next steps
Disorders of the Gastrointestinal System
in her evaluation and management EXCEPT:
A. Administer IV albumin to restore effective circulat-
ing volume
B. Look for alternative causes of renal failure
C. Referral for liver transplantation if creatinine contin-
ues to worsen
D. Start furosemide and spironolactone to increase her
urine output
E. Start midodrine and octreotide to try to reduce
splanchnic vasodilation and improve renal perfusion
VII-100. Which of the following patients is the highest pri-
ority for liver transplantation?
A. A 24-year-old woman with cirrhosis due to autoim-
mune hepatitis; she has been on the transplant list for
VII-103. A 62-year-old man has been hospitalized in inten-
2 months and now has an elevated bilirubin, interna-
tional normalized ratio (INR), and creatinine.
B. A 38-year-old woman with chronic hepatitis C and
normal bilirubin and INR.
C. A 49-year-old man with alcoholic cirrhosis who has
been on the transplant list for 6 months; he has had
two esophageal variceal bleeds.
D. A 59-year-old man with a history of hyperlipidemia
who was admitted to the intensive care unit 2 days
ago with fulminant hepatic failure due to mistakenly
ingesting Amanita mushrooms from his lawn.
E. A 64-year-old woman with primary hepatocellular
carcinoma admitted to the hospital with acute renal
failure.
VII-101. Which of the following statements regarding liver
transplantation is true?
A. ABO incompatibility is an absolute contraindication
to transplant.
B. Hepatocellular carcinoma is one of several conditions
that receive disease-specific model for end-stage liver
VII-104. A 41-year-old woman presents to your clinic with
disease exceptions.
C. HIV infection is a contraindication to transplant.
D. Living donor transplants pose very little risk to the
donor.
E. Preformed cytotoxic human leukocyte antigen anti-
bodies are a contraindication to transplantation.
VII-102. A 44-year-old woman is evaluated for complaints
of abdominal pain. She describes the pain as a postpran-
dial burning pain. It is worse with spicy or fatty foods and
is relieved with antacids. She is diagnosed with a gastric
ulcer and is treated appropriately for Helicobacter pylori.
During the course of her evaluation for her abdominal
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pain, the patient had a right upper quadrant ultrasound
that demonstrated the presence of gallstones. Following
treatment of H. pylori, her symptoms have resolved. She
is requesting your opinion regarding whether treatment is
required for the finding of gallstone disease. On review of
the ultrasound report, there were numerous stones in the
gallbladder, including in the neck of the gallbladder. The
largest stone measures 2.8 cm. What is your advice to the
patient regarding the risk of complications and the need
for definitive treatment?
A. Given the size and number of stones, prophylactic
cholecystectomy is recommended.
B. No treatment is necessary unless the patient develops
symptoms of biliary colic frequent severe enough to
interfere with the patient’s life.
C. The only reason to proceed with cholecystectomy
is the development of gallstone pancreatitis or
cholangitis.
D. The risk of developing acute cholecystitis is about
5–10% per year.
E. Ursodeoxycholic acid should be given at a dose of
10–15 mg/kg daily for a minimum of 6 months to
dissolve the stones.
sive care for the past 3 weeks following an automobile
accident resulting in multiple long bone fractures and
acute respiratory distress syndrome. He has been slowly
improving but remains on mechanical ventilation. He is
now febrile and hypotensive requiring vasopressors. He is
being treated empirically with cefepime and vancomycin.
Multiple blood cultures are negative. He has no new infil-
trates or increasing secretions on chest radiograph. His
laboratory studies demonstrated a rise in his liver func-
tion tests, bilirubin, and alkaline phosphatase. Amylase
and lipase are normal. A right upper quadrant ultrasound
shows sludge in the gallbladder but no stones. The bile
duct is not dilated. What is the next best step in the evalu-
ation and treatment of this patient?
A. Discontinue cefepime
B. Initiate treatment with clindamycin
C. Initiate treatment with metronidazole
D. Perform hepatobiliary scintigraphy
E. Refer for exploratory laparotomy
a week of jaundice. She notes pruritus, icterus, and dark
urine. She denies fever, abdominal pain, or weight loss.
The examination is unremarkable except for yellow dis-
coloration of the skin. Total bilirubin is 6.0 mg/dL, and
direct bilirubin is 5.1 mg/dL. Aspartate aminotransferase
is 84 IU/L, alanine aminotransferase is 92 IU/L, and alka-
line phosphatase is 662 IU/L. CT scan of the abdomen is
unremarkable. Right upper quadrant ultrasound shows
a normal gallbladder but does not visualize the common
bile duct. What is the most appropriate next management
step?
 A. Antibiotics and observation
B. Endoscopic retrograde cholangiopancreatography
C. Hepatitis serologies
D. Hepatobiliary iminodiacetic acid scan
E. Serologies for antimitochondrial antibodies
VII-105. All of the following are contributing factors to cho-
lesterol stone formation EXCEPT:
A. An excess of biliary cholesterol in relation to bile
acids and phospholipids
B. Increased biliary secretion of cholesterol
C. Gallbladder hypomotility
D. Nucleation of cholesterol monohydrate crystals
E. Rapid weight gain through a high-fat diet
VII-106. A previously healthy 46-year-old female presents
with 12 hours of right upper quadrant pain and nausea.
The pain occasionally radiates to her right scapula. She
has exquisite right upper quadrant tenderness on deep
palpation. Laboratory studies show a mild elevation in her
serum alkaline phosphatase. A right upper quadrant ultra-
sound shows stones in the bladder and a thickened gall-
bladder wall consistent with acute calculous cholecystitis.
All of the following statements about cholecystectomy are
true EXCEPT:
A. Five to ten percent of patients who undergo elective
cholecystectomy develop diarrhea.
B. Atelectasis and subphrenic abscesses may occur after
cholecystectomy.
C. Cholecystectomy provides near total relief of symp-
toms in up to 75–90% of patients.
D. The complication rate is higher in patients who
undergo early cholecystectomy as opposed to delayed
cholecystectomy (>6 weeks).
E. Undetected common bile duct stones are left behind
in 1–5% of patients.
VII-107. A 46-year-old woman presents with a 1-week his-
tory of right upper quadrant pain, intermittent fever,
and nausea. Her initial labs are notable for a markedly
elevated bilirubin, mild elevations in her transaminases,
and a modest elevation in her alkaline phosphatase.
Ultrasound shows no gallstones. Magnetic resonance
cholangiopancreatography reveals a beaded appearance
of her intrahepatic and extrahepatic bile ducts due to
multiple discrete strictures. Which of the following lab
tests would be most helpful in understanding the cause
of her current disease?
A. Hepatitis C antibody
B. Procalcitonin
C. Serum IgG-4 levels
D. Serum triglycerides
E. Urine histoplasma antigen
VII-108. All of the following disorders may be associated
with a rise in serum amylase levels EXCEPT:
A. Esophageal carcinoma
B. Intestinal obstruction
SECTION VII
C. Mumps
D. Pregnancy
E. Renal Failure
VII-109. Which of the following statements about imaging
of the pancreas is true?
A. Abdominal CT has no role in the diagnosis of acute
QUESTIONS
pancreatitis.
B. Endoscopic ultrasound (EUS) and magnetic reso-
nance cholangiopancreatography have largely
replaced endoscopic retrograde cholangiopancrea-
tography in the diagnostic evaluation of pancreatic
disease.
C. EUS is not helpful in the diagnosis of chronic
pancreatitis.
D. Plane radiographs of the abdomen are com-
monly used in the evaluation of acute and chronic
pancreatitis.
E. One advantage of pancreatic ultrasound is that intes-
tinal bowel gas does not interfere with the ability to
obtain images.
VII-110. Which of the following statements regarding pan-
creatic enzyme secretion is true?
A. Acetylcholine is an important neurotransmitter that
stimulates pancreatic enzyme secretion.
B. All pancreatic enzymes have pH optima in the acidic
range.
C. All pancreatic enzymes are secreted in their active
forms.
D. Cholecystokinin receptors on human pancreatic aci-
nar cells are important in pancreatic enzyme secretion.
E. Enterokinase found in the duodenal mucosa acti-
vates vasoactive intestinal peptide which then cleaves
zymogens into active proteases.
VII-111. A 45-year-old woman with a known history of
cholelithiasis is admitted to the hospital with severe mid-
epigastric pain, fever to 38.5°C (101.3°F), tachycardia to
110 beats/min, and a blood pressure of 100/50. Her exami-
nation shows a diffusely tender abdomen with guarding.
Radiographs show an abdominal ileus with no free air.
Labs are notable for a hemoglobin of 15 g/dL and eleva-
tions of amylase and lipase. Which of the following state-
ments regarding this patient’s likely diagnosis is true?
A. Elevated lipase is more specific than elevated amylase
for the diagnosis of acute pancreatitis.
B. Hypercalcemia occurs in >75% of cases of acute
pancreatitis.
C. Magnitude of lipase elevation above normal is cor-
related with the severity of acute pancreatitis.
D. Serum amylase levels will remain elevated for up to
30 days after the resolution of acute pancreatitis.
E. The combination of elevated serum amylase and
metabolic acidosis (pH <7.32) has a >90% positive
predictive value for acute pancreatitis.
499
 VII-112. A 27-year-old woman is admitted to the hospital
with acute-onset severe right upper quadrant pain that
SECTION VII
radiates to the back. The pain is constant and not relieved
with eating or bowel movements. Her labs show marked
elevation in amylase and lipase, and acute pancreatitis is
diagnosed. Which of the following is the best first test to
demonstrate the etiology of her pancreatitis?
A. Right upper quadrant ultrasound
B. Serum alcohol level
Disorders of the Gastrointestinal System
C. Serum triglyceride level
D. Technetium hepatobiliary iminodiacetic acid scan
E. Urine drug screen
VII-113. A 58-year-old female with known alcohol abuse to
the hospital with abdominal pain after a drinking binge.
Her symptoms have been present for 3 days, and she has
persisted to drink heavily. She now has persistent vomit-
ing and feels dizzy on standing. On examination, she has
severe epigastric and right upper quadrant tenderness and
decreased bowel sounds, and she appears uncomfortable.
She has a blue-red discoloration of the flanks bilaterally
but denies any recent trauma. What is the significance of
this finding?
A. Abdominal plain film is likely to show pancreatic
calcification.
B. CT of the abdomen is likely to show severe necrotiz-
ing pancreatitis with hemoperitoneum.
C. Endoscopic ultrasound is likely to reveal a pancreatic
mass.
D. Right upper quadrant ultrasound will likely show
acute cholecystitis.
E. Transvaginal ultrasound will likely show a ruptured
ectopic pregnancy.
VII-114. A 42-year-old male is admitted with severe epigas-
tric pain radiating to the back. You suspect acute pancrea-
titis. All of the following are accepted diagnostic criteria
for acute pancreatitis EXCEPT:
A. Confirmatory findings of acute pancreatitis on cross-
sectional abdominal imaging
B. PaO2 <60
C. Threefold or greater elevation in serum lipase and/or
amylase
D. Typical abdominal pain in the epigastrium that may
radiate to the back
VII-115. A 45-year-old female with known gallstones pre-
sents to the hospital with 2 days of mid-epigastric tender-
ness radiating to her back, as well as nausea and vomiting.
Her serum lipase is elevated to four times the upper limit
of normal and abdominal ultrasound reveals gallstones
and findings consistent with acute pancreatitis. Her initial
hematocrit is 48 and her vital signs are notable for sinus
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tachycardia with a pulse of 110 beats/min and a fever up
to 38.1°C (100.6°F). After receiving 3 L of IV lactated ring-
ers solution over the first 24 hours, her hematocrit drops
to 38. Her heart rate and temperature have also improved.
What is the significance of the drop in hematocrit?
A. Current fluid management should be continued as
her drop in hematocrit is evidence of effective fluid
resuscitation.
B. She has likely developed hemorrhage from severe
necrotizing pancreatitis and should undergo urgent
CT scanning of the abdomen.
C. She should be evaluated for hemolysis as a cause of
the drop in hematocrit.
D. She should receive two units of packed red blood
cells to prevent organ dysfunction from hypoperfu-
sion related to evolving anemia.
E. She should undergo endoscopic ultrasound to look
for an evolving pancreatic pseudocyst.
VII-116. A 56-year-old male presents to the emergency
department with 1–2 days of worsening abdominal pain,
fever, tachycardia and shortness of breath. He denies any
alcohol use and has no known history of gallstones. His
initial labs are notable for a markedly elevated amylase and
lipase. He is given 2 L of IV isotonic fluids and is started
on empiric antibiotics. CT of the chest, abdomen, and pel-
vis reveal severe necrotizing pancreatitis, as well as bilat-
eral alveolar infiltrates with basilar atelectasis. He requires
intubation and mechanical ventilation for evolving respir-
atory failure. All cultures are negative. Which of the fol-
lowing best explains the etiology of his respiratory failure?
A. He has developed acute respiratory distress syn-
drome (ARDS) from severe pancreatitis.
B. He has developed heart failure from overly aggressive
fluid resuscitation.
C. He has developed pulmonary hemorrhage related to
coagulopathy from sepsis.
D. He likely has culture-negative pneumonia and devel-
oped ARDS from direct lung injury.
E. He likely has sepsis from necrotizing pancreatitis and
developed ARDS from the resulting bacteremia.
VII-117. Which of the following statements regarding
enteral feeding in acute pancreatitis is true?
A. A patient with persistent evidence of pancreatic
necrosis on CT 2 weeks after acute presentation
should be maintained on bowel rest.
B. All patients with elevations of amylase and lipase and
CT evidence of pancreatitis should be fasted until
amylase and lipase normalize.
C. Enteral feeding has been demonstrated to have
fewer infectious complications than total parenteral
 nutrition in the management of patients with acute VII-118. A 25-year-old woman with cystic fibrosis is diag-
pancreatitis. nosed with chronic pancreatitis. She is at risk for all of the

SECTION VII
D. Patients requiring surgical removal of infected pan- following complications EXCEPT:
creatic pseudocysts should be treated with total par-
A. Vitamin B12 deficiency
enteral nutrition.
B. Vitamin A deficiency
E. Total parenteral nutrition has been shown to maintain
C. Pancreatic carcinoma
integrity of the intestinal tract in acute pancreatitis.
D. Niacin deficiency
E. Steatorrhea

ANSWERS
ANSWERS

VII-1. The answer is E. (Chap. 314) The colon is primarily responsible for stool dehydration,
decreasing volumes from 1000–1500 mL to 100–200 mL. The stomach triturates and
mixes the food bolus with pepsin and acid. The stomach also secretes intrinsic factor,
which is necessary for vitamin B12 absorption. Gastric acid sterilizes the upper gut. Pan-
creatic juice contains enzymes for carbohydrate, protein, and fat digestion as well as
bicarbonate to optimize the pH for enzyme activation.

VII-2. The answer is C. (Chap. 314) Pernicious anemia is associated with little or no gastric acid
due to a lack of intrinsic factor. This is caused by autoantibodies that damage the gastric
parietal cells. Gastrin G-cell hyperplasia results in increased gastrin levels, which leads
to gastric acid hypersecretion. About 50% of G-cell hyperplasia is related to Helicobacter
pylori infection and can be treated with eradication of the bacterium. Retained antrum
syndrome is a rare postgastrectomy syndrome following a Billroth-II procedure in which
the antrum has not been entirely removed. Some patients with duodenal ulcers have acid
hypersecretion. Zollinger-Ellison syndrome is caused by a tumor (usually in the pancreas
or duodenum) that secretes gastrin and therefore causes gastric acid hypersecretion.

VII-3. The answer is D. (Chap. 314) Mesenteric ischemia, biliary colic, and neoplasms most
commonly cause noninflammatory visceral pain. Peptic ulcer, appendicitis, diverticuli-
tis, inflammatory bowel disease, pancreatitis, cholecystitis, and infectious enterocolitis
are all painful inflammatory diseases.

VII-4. The answer is A. (Chap. 314) Diarrhea from malabsorption usually improves with fast-
ing, whereas secretory diarrhea persists without oral intake. Sudden awakening from
sound sleep by pain suggests organic rather than functional disease. Symptoms from
mechanical obstruction, ischemia, inflammatory bowel disease, and functional bowel
disorders are worsened by meals. Ulcer pain occurs intermittently over weeks to months,
whereas biliary colic has a sudden onset and lasts up to several hours. Ulcer symptoms
may be relieved by eating or antacids.

VII-5. The answer is B. (Chap. 315) Since this patient is over 50 years old, even without a fam-
ily history, screening for colorectal cancer is recommended. Colonoscopy is the gold
standard for imaging the colonic mucosa. The cecum is reached in >95% of cases and
the terminal ileum can often be examined. Colonoscopy has greater sensitivity than
barium enema for colitis, polyps, and cancer. CT colonography rivals the accuracy of
colonoscopy for detection of some polyps and cancer, although it is not as sensitive for
the detection of flat lesions, such as serrated polyps. Flexible sigmoidoscopy is similar
to colonoscopy, but it visualizes only the rectum and a variable portion of the left colon,
typically to 60 cm from the anal verge.

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 SECTION VIII
Rheumatology and Immunology

QUESTIONS

DIRECTIONS: Choose the one best response to each VIII-4. Which of the following diseases has a strong genetic
question. association with a particular class I major histocompatibility
complex alleles?
A. Ankylosing spondylitis
VIII-1. A 55-year-old woman who was previously incar- B. Celiac disease
cerated has an area of induration that measures 15 mm C. Huntington disease
72 hours after a skin test with tuberculin purified protein C. Rheumatoid arthritis
derivative (PPD). A positive PPD skin test for Mycobac- D. Type 1 diabetes
terium tuberculosis represents which type of immune
reaction? VIII-5. Which of the following statements best describes the
function of proteins encoded by the human major histo-
A. Cytotoxic reaction of antibody compatibility complex I and II genes?
B. Delayed-type hypersensitivity reaction
C. Immediate-type hypersensitivity reaction A. Activation of the complement system
D. Immune complex formation B. Binding to cell surface receptors on granulocytes and
macrophages to initiate phagocytosis
VIII-2. All of the following are key features of the innate C. Nonspecific binding of antigen for presentation to
immune system EXCEPT: T cells
D. Specific antigen binding in response to B-cell activa-
A. Exclusively a feature of vertebrate animals
tion to promote neutralization and precipitation
B. Important cells include macrophages and natural
killer lymphocytes VIII-6. All of the following statements regarding primary
C. Nonrecognition of benign foreign molecules or immunodeficiency disorders are true EXCEPT:
microbes
D. Recognition by germline-encoded host molecules A. Infections of the upper or lower respiratory tract sug-
E. Recognition of key microbe virulence factors but no gest a defective antibody response.
recognition of self-molecules B. Most are diagnosed by the presence of recurrent or
unusually severe infections.
VIII-3. A 29-year-old man with episodic abdominal pain C. Recurrent infections due to Candida species suggest
and stress-induced edema of the lips, tongue, and occa- impaired T-cell immunity.
sionally larynx is likely to have low functional or absolute D. They are typically genetic diseases with Mendelian
levels of which of the following proteins? inheritance.
E. While most aspects of the immune system may be
A. C1 esterase inhibitor
involved, innate immunity is not affected by these
B. C5A (complement cascade)
disorders.
C. Cyclooxygenase
D. IgE
E. T-cell receptor, α chain

543
 VIII-7. A 19-year-old college freshman comes to the uni-
SECTION VIII
versity clinic complaining of tender, painful skin lesions
in his axilla (Figure VIII-7). He reports that he has had
similar episodes throughout his life for which he receives
antibiotics. He has a lab printout from his last episode that
reports a positive culture for Serratia marcescens. All of the
following statements regarding this patient and his likely
diagnosis are true EXCEPT:
Rheumatology and Immunology
VIII-9. A 28-year-old woman seeks evaluation from her pri-
VIII-10. A 45-year-old man from Arkansas with a history
FIGURE VIII-7 Reproduced with permission from Wolff K et al:
Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 8th ed.
New York: McGraw Hill, 2017.
A. Human stem cell transplantation is curative.
B. Infections with catalase-negative organisms are
typical.
C. Prophylactic use of trimethoprim/sulfamethoxazole
is effective in reducing risk of bacterial infections.
D. The disease is caused by defective production of reac-
tive oxygen species in phagolysosomes.
E. The disease is most likely transmitted by X-linked
recessive inheritance.
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WWW.BOOKBAZ.IR
VIII-8. A 35-year-old woman from Virginia presents to your
clinic with worsening sneezing, rhinorrhea, and nasal itch-
ing, which has recurred yearly since she was an adolescent
starting in March and increasing during April and May.
Based on this history she has an elevated risk of having all
of the following additional conditions EXCEPT:
A. Asthma
B. Chronic bilateral sinusitis
C. Food allergies
D. Psoriasis
E. Urticaria
mary care doctor for recurrent episodes of hives and states
that she is “allergic to cold weather.” She reports that for
more than 10 years she would develop areas of hives when
exposed to cold temperatures, usually on her arms and
legs. She has never sought evaluation previously and states
that, over the last several years, the occurrence of the hives
has become more frequent. Other than cold exposure, she
can identify no other triggers for development of hives.
She has no history of asthma or atopy. She denies food
intolerance. Her only medication is oral contraceptive
pills, which she has taken for 5 years. She lives in a single-
family home that was built 2 years ago. On examination,
she develops a linear wheal after being stroked along her
forearm with a tongue depressor. On placing her hand in
cold water, her hand becomes red and swollen. In addition,
there are several areas with a wheal and flare reaction on
the arm above the area of cold exposure. What is the next
step in the management of this patient?
A. Assess for the presence of antithyroglobulin and anti-
microsomal antibodies
B. Check C1 inhibitor levels
C. Discontinue the oral contraceptive pills
D. Treat with cetirizine 10 mg daily
E. Treat with cyproheptadine 8 mg daily
of hypertension that is treated with lisinopril and colorec-
tal cancer presents to your clinic for a follow-up appoint-
ment after a recent emergency room visit. He tells you he
was recently diagnosed with an episode of anaphylaxis. He
presented to an emergency room with laryngeal edema
and diffuse urticaria and was treated successfully with
epinephrine. On further history, he tells you more about
his recent diagnosis of colorectal cancer for which he has
received several doses of cetuximab. He was also sick with
shortness of breath and cough 2 weeks prior to the ana-
phylactic episode. He was evaluated with a CT of the chest
with IV contrast, diagnosed with pneumonia, and treated
with ceftriaxone. Immediately before his episode of ana-
phylaxis, he had been enjoying a steak dinner for his wife’s
birthday. What is the antigen for the IgE antibodies that
most likely caused his anaphylactic reaction?
 A. Alpha-1,3-galactose (alpha-gal) VIII-13. A 25-year-old man is admitted to the intensive care

SECTION VIII
B. Ceftriaxone unit with hypoxemia. His partner tells the intensive care
C. Iodinated contrast team that he has been coughing up blood for the last 2 days
D. Lisinopril in increasing amounts. On laboratory studies his creati-
nine is markedly elevated. He is ultimately diagnosed with
VIII-11. You are working in the emergency department Goodpasture syndrome. What is the immune mechanism
when a 3-year-old boy arrives by ambulance. He was eat- leading to organ damage in Goodpasture syndrome?
ing tonight when he suddenly started wheezing, coughing,
and then became progressively less responsive. His parents A. Antibody-dependent cellular cytotoxicity

QUESTIONS
are certain he did not aspirate. On arrival, his blood pres- B. Complement-activating autoantibody
sure is low, and he is working hard to breathe. You auscul- C. Inactivating autoantibody
tate tight wheezes bilaterally. You accurately diagnose him D. Stimulating autoantibody
with anaphylaxis and initiate appropriate therapy. Which E. T-cell–mediated cellular cytotoxicity
of the following statements regarding anaphylaxis is true?
VIII-14. Rheumatic fever develops due to an autoimmune
A. An atopic history is a risk factor for anaphylaxis to process. Which of the following mechanisms of autoim-
penicillin therapy. munity is primarily responsible for the development of
B. Onset of anaphylaxis is most often 1–2 hours after rheumatic fever?
antigen exposure.
A. Endocrine abnormalities
C. IV glucocorticoids are effective for acute anaphylaxis.
B. Increased B-cell function
D. Older age is associated with improved outcomes in
C. Intrinsic cytokine imbalance
anaphylaxis.
D. Increased T-cell help due to cytokine stimulation
E. The failure to use epinephrine within the first
E. Molecular mimicry
20 minutes of symptoms is a risk factor for death due
to anaphylaxis. VIII-15. A 60-year-old Caucasian man with a history of pso-
riasis presents to the clinic for a follow-up appointment.
VIII-12. A 60-year-old man presents to the clinic with inter-
He has been treated with infliximab (a tumor necrosis
mittent flushing, diarrhea, headaches, and a new skin rash
factor inhibitor) for about a year. Since his last infusion of
of several months’ duration. He has noticed that his symp-
infliximab, he has been experiencing aching in his muscles
toms of diarrhea and flushing tend to worsen if he takes
and joints and a new facial rash. On examination you note
ibuprofen to treat his headaches. On examination, he has
a raised erythematous malar rash, but there is no synovitis
a palpable spleen and cervical lymphadenopathy. Serum
in any joints and there is no weakness on neurologic exam-
tryptase is elevated at 35 ng/mL. His skin rash is shown
ination. Laboratory testing shows a positive anti-nuclear
in Figure VIII-12. A diagnostic skin biopsy is performed.
antibody at a titer of 1:320. Which specific autoantibody is
What histological findings are most likely to be noted on
most likely to be present?
the skin biopsy?
A. Anti-β-2-glycoprotein
A. Interface dermatitis
B. Anti-cyclic citrullinated protein antibodies
B. Multifocal dense infiltrates of mast cells
C. Anti-dsDNA antibodies
C. Neutrophilic dermal infiltrate
D. Anti-histone antibodies
D. Noncaseating granulomas
E. Anti-thyroid peroxidase antibodies
E. Spongiotic changes in the epidermis

FIGURE VIII-12 Reproduced with permission from Lichtman MA et al: Lichtman’s Atlas of Hematology 2016. New York: McGraw Hill, 2017.

545
 VIII-16. All of the following are predisposing factors for sys-
SECTION VIII
temic lupus erythematosus EXCEPT:
A. C1 esterase inhibitor deficiency
B. Female sex
C. HLA-DR alleles
D. Smoking
E. Ultraviolet light
VIII-17. A 32-year-old woman with long-standing diagnosis
Rheumatology and Immunology
of systemic lupus erythematosus is evaluated by her rheu-
matologist as routine follow-up. A new cardiac murmur
is heard, and an echocardiogram is ordered. She is feeling
VIII-20. A 27-year-old woman is admitted to the intensive
well and has no fevers, weight loss, or pre-existing cardiac
disease. A vegetation on the mitral valve is demonstrated.
Which of the following statements is true?
A. Blood cultures are unlikely to be positive.
B. Glucocorticoid therapy has been proven to lead to
improvement in this condition.
C. Pericarditis is frequently present concomitantly.
D. The lesion has a low risk of embolization.
E. The patient has been surreptitiously using injection
drugs.
VIII-18. A 45-year-old African American woman with sys-
temic lupus erythematosus (SLE) presents to the emer-
gency department with complaints of headache and
fatigue. Her prior manifestations of SLE have been arthral-
gias, hemolytic anemia, malar rash, and mouth ulcers, and
she is known to have high titers of antibodies to double-
stranded DNA. She currently is taking prednisone, 5 mg
VIII-21. A 28-year-old woman comes to the emergency
daily, and hydroxychloroquine, 200 mg daily. On presen-
tation, she is found to have a blood pressure of 190/110
with a heart rate of 98 beats/min. A urinalysis shows 25 red
blood cells (RBCs) per high-powered field with 2+ protein-
uria. No RBC casts are identified. Her blood urea nitrogen is
88 mg/dL, and creatinine is 2.6 mg/dL (baseline 0.8 mg/dL).
She has not previously had renal disease related to SLE and
is not taking nonsteroidal anti-inflammatory drugs. She
denies any recent illness, decreased oral intake, or diarrhea.
What is the most appropriate next step in the management
of this patient?
A. Initiate cyclophosphamide, 500 mg/m2 body surface
area IV, and plan to repeat monthly for 3–6 months
B. Initiate hemodialysis
C. Initiate high-dose steroid therapy (IV methylpred-
nisolone, 1000 mg daily for three doses, followed by
oral prednisone, 1 mg/kg daily) and mycophenolate
mofetil, 2 g daily
D. Initiate plasmapheresis
E. Withhold all therapy until renal biopsy is performed
VIII-19. All of the following statements regarding antiphos-
pholipid antibodies are true EXCEPT:
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WWW.BOOKBAZ.IR
A. Antiphospholipid antibodies are generally directed
against negatively charged phospholipids including
cardiolipin, phosphocholine, and phosphatidylserine.
B. Patients who are positive for the lupus anticoagulant
will have an elevated activated partial thromboplas-
tin time in vitro.
C. Patients with antiphospholipid antibodies may test
false positive for syphilis.
D. The majority of patients with systemic lupus erythe-
matosus and antiphospholipid antibodies develop
clinical manifestations of antiphospholipid syndrome.
care unit after recent delivery of a full-term infant 3 days
prior. The patient was found to have right hemiparesis and
a blue left hand. Physical examination is also notable for
livedo reticularis. Her laboratories were notable for a white
blood cell count of 10.2/μL, hematocrit of 35%, and platelet
count of 13,000/μL. Her blood urea nitrogen is 36 mg/dL,
and her creatinine is 2.3 mg/dL. Although this pregnancy
was uneventful, the three prior pregnancies resulted in early
losses. A peripheral smear shows no evidence of schisto-
cytes. Which of the following laboratory studies will best
confirm the underlying etiology of her presentation?
A. Anticardiolipin antibody panel
B. Antinuclear antibody
C. Doppler examination of her left arm arterial tree
D. Echocardiography
E. MRI of her brain
department complaining of 1 day of worsening right leg
pain and swelling. She drove in a car 8 hours back from a
hiking trip 2 days ago and then noticed some pain in the
leg. At first she thought it was due to exertion, but it has
worsened over the day. Her only past medical history is
related to difficulty getting pregnant, with two prior spon-
taneous abortions. Her physical examination is notable for
normal vital signs and heart and lung examination. Her
right leg is swollen from the mid-thigh down and is tender.
Doppler studies demonstrate a large deep venous throm-
bosis in the femoral and iliac veins extending into the pel-
vis. Laboratory studies on admission prior to therapy show
normal electrolytes, normal white blood cell and platelet
counts, normal prothrombin time, and an activated par-
tial thromboplastin time three times the normal value. Her
pregnancy test is negative. Low-molecular-weight heparin
therapy is initiated in the emergency department. Subse-
quent therapy should include which of the following?
A. Rituximab 375 mg/m2 per week for 4 weeks
B. Warfarin with international normalized ratio (INR)
goal of 2.0–3.0 for 3 months
C. Warfarin with INR goal of 2.0–3.0 for 12 months
D. Warfarin with INR goal of 2.5–3.5 for life
E. Warfarin with an INR goal of 2.5–3.5 for 12 months
followed by daily aspirin for life
VIII-22. When compared with patients with rheumatoid A. Bilateral interstitial infiltrates

SECTION VIII
arthritis (RA) who do not have anti-cyclic citrullinated B. Bronchiectasis
protein (CCP) antibodies, patients with RA who have anti- C. Lobar infiltrate
CCP antibodies: D. Solitary pulmonary nodule
E. Unilateral pleural effusion
A. Are less likely to develop extra-articular manifesta-
tions of RA (e.g., vasculitis) VIII-27. Which of the following is the earliest plain radio-
B. Are less likely to have a history of smoking graphic finding of rheumatoid arthritis?
C. Develop fewer subchondral bone erosions on imag-
A. Juxta-articular osteopenia

QUESTIONS
ing over their disease course
D. Have a higher prevalence of shared epitope (HLA- B. No abnormality
DRB1) risk alleles C. Soft tissue swelling
E. Have lower scores for physical disability D. Subchondral erosions
E. Symmetric joint space loss
VIII-23. A 65-year-old woman with a 10-year history of
untreated rheumatoid arthritis presents to your clinic with VIII-28. All of the following agents have been shown to have
worsening joint pain and malaise over the last 6 months. On disease-modifying antirheumatic drug efficacy in patients
examination of her joints, she has swan neck deformities with rheumatoid arthritis EXCEPT:
and ulnar deviation. Her skin examination demonstrates A. Infliximab
rheumatoid nodules in the olecranon bursa bilaterally. On B. Leflunomide
abdominal examination, she has splenomegaly. Labora- C. Methotrexate
tory studies show neutropenia, elevated C-reactive pro- D. Naproxen
tein, and anemia. She is diagnosed with Felty syndrome. E. Rituximab
What type of hematologic malignancy or lymphoprolifera-
tive disorder may present similarly to Felty syndrome in VIII-29. Which of the following findings is the most com-
patients with rheumatoid arthritis? mon clinical presentation of acute rheumatic fever?
A. Acute myeloid leukemia A. Carditis
B. Chronic lymphocytic leukemia B. Chorea
C. Essential thrombocytosis C. Erythema marginatum
D. Polycythemia vera D. Polyarthritis
E. T-cell large granular lymphocyte leukemia E. Subcutaneous nodules

VIII-24. Patients with rheumatoid arthritis are at higher risk VIII-30. A 19-year-old recent immigrant from Ethiopia
for all of the following health conditions than the general comes to your clinic to establish primary care. She cur-
population EXCEPT: rently feels well. Her past medical history is notable for a
recent admission to the hospital for new-onset atrial fibril-
A. Colorectal cancer
lation. As a child in Ethiopia, she developed an illness that
B. Coronary artery disease
caused uncontrolled flailing of her limbs and tongue lasting
C. Hypoandrogenism
approximately 1 month. She also has had three episodes of
D. Lymphoma
migratory large-joint arthritis during her adolescence that
E. Osteoporosis
resolved with pills that she received from the pharmacy.
VIII-25. Which of the following is the most frequent site of She is currently taking metoprolol and warfarin and has
joint involvement in established rheumatoid arthritis? no known drug allergies. Physical examination reveals an
irregularly irregular heart beat with normal blood pres-
A. Distal interphalangeal joint sure. Her point of maximal impulse is most prominent
B. Hip at the midclavicular line and is normal in size. An early
C. Knee diastolic rumble and 3/6 holosystolic murmur are heard at
D. Spine the apex. A soft early diastolic murmur is also heard at the
E. Wrist left third intercostal space. You refer her to a cardiologist
for evaluation of valve replacement and echocardiography.
VIII-26. In patients with established rheumatoid arthritis,
What other intervention might you consider at this time?
all of the following pulmonary radiographic findings may
be explained by their rheumatologic condition EXCEPT: A. Daily aspirin
B. Daily doxycycline
C. Low-dose corticosteroids
D. Monthly penicillin G injections
E. Penicillin G injections as needed for all sore throats

547
 VIII-31. Most of the manifestations of acute rheumatic weight loss and night sweats. Physical examination shows
SECTION VIII

fever present approximately 3 weeks after the precipitating parotid gland swelling bilaterally and decreased salivary
group A streptococcal infection. Which manifestation may pooling, but no rashes, joint swelling, or other findings.
present several months after the precipitating infection? Laboratory testing is negative for anti-nuclear antibodies,
Ro/SS-A antibodies, and La/SS-B antibodies. Chest radio-
A. Chorea
graph shows no infiltrates or lymphadenopathy. What is
B. Erythema marginatum
the most likely diagnosis?
C. Fever
D. Polyarthritis A. HIV infection
Rheumatology and Immunology

E. Subcutaneous nodules B. IgG4-related disease

C. Primary Sjögren syndrome
VIII-32. A 60-year-old woman with long-standing sclero- D. Rheumatoid arthritis with secondary Sjögren
derma (Raynaud phenomenon, diffuse skin disease, and syndrome
pulmonary fibrosis) presents to the clinic with new weight E. Sarcoidosis
loss. She has also been noting increased lower abdomi-
nal pain, bloating, and diarrhea recently. She denies any VIII-37. A 57-year-old woman with depression and chronic
heartburn or dysphagia. She has not had melena or hema- migraine headaches reports several years of dry mouth and
tochezia. Which of the following mechanisms related to dry eyes. Her primary complaint is that she can no longer
her scleroderma could be contributing to her symptoms? eat her favorite crackers, although she does report photo-
sensitivity and eye burning on further questioning. She
A. Gastric antral vascular ectasia
has no other associated symptoms. Examination shows
B. Gastroesophageal reflux disease
dry, erythematous, sticky oral mucosa. All of the following
C. Impaired intestinal motility
tests are likely to be positive in this patient EXCEPT:
D. Small bowel bacterial overgrowth
E. C and D A. La/SS-B antibody
B. Ro/SS-A antibody
VIII-33. Patients with scleroderma are at higher risk for all C. Schirmer I test
of the following complications in the cardiovascular sys- D. Scl-70 antibody
tem EXCEPT: E. Sialometry
A. Abdominal aortic aneurysm
VIII-38. A patient with primary Sjögren syndrome that was
B. Heart block due to conduction system fibrosis
diagnosed 6 years ago and treated with tear replacement
C. Left ventricular dysfunction
for symptomatic relief notes continued parotid swelling
D. Pulmonary arterial hypertension
for the last 3 months. She has also noted enlarging pos-
E. Raynaud phenomenon
terior cervical lymph nodes. Evaluation shows leukopenia
VIII-34. A patient with a diagnosis of scleroderma who and low C4 complement levels. What is the most likely
has diffuse cutaneous involvement presents with malig- diagnosis?
nant hypertension, oliguria, edema, hemolytic anemia, A. Amyloidosis
and renal failure. You make a diagnosis of scleroderma B. Chronic pancreatitis
renal crisis. Which of the following is the recommended C. HIV infection
treatment? D. Lymphoma
A. Captopril E. Secondary Sjögren syndrome
B. Carvedilol
VIII-39. Which of the following is the most common extrag-
C. Clonidine
landular manifestation of primary Sjögren syndrome?
D. Diltiazem
E. Nitroprusside A. Arthralgias/arthritis
B. Lymphoma
VIII-35. Which of the following conditions is nearly twice as C. Peripheral neuropathy
common in patients with diffuse cutaneous systemic scle- D. Raynaud phenomenon
rosis than in limited cutaneous systemic sclerosis? E. Vasculitis
A. Esophageal involvement
VIII-40. All of the following medications are effective in
B. Pulmonary arterial hypertension
treating both psoriatic arthritis and the skin disease of
C. Pulmonary fibrosis
psoriasis EXCEPT:
D. Raynaud phenomenon
E. Skin involvement A. Adalimumab
B. Infliximab
VIII-36. A 22-year-old man with a history of injection drug C. Rituximab
use presents to the clinic with a new complaint of dry D. Secukinumab
mouth. He denies any eye dryness, photosensitivity, or E. Ustekinumab
foreign body sensation in the eye. He has also experienced

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VIII-41. A 30-year-old woman presents to an internal medi- urination. Examination shows inflammatory arthritis of

SECTION VIII
cine clinic for evaluation of joint pain and swelling of the right knee, dactylitis, and normal genitourinary exam-
about 2 years duration accompanied by morning stiffness. ination. He is diagnosed with reactive arthritis. Which
She denies any back or neck pain. Symptoms have primar- of the following was the most likely etiologic agent of his
ily affected her lower extremities. She notes intermittent diarrhea?
swelling in her Achilles tendons, ankles, and knees. She
A. Campylobacter jejuni
denies any psoriasis or family history of skin disease. She
B. Clostridium difficile
denies any gastrointestinal symptoms or preceding infec-
C. Escherichia coli
tious episodes. On physical examination she has right-

QUESTIONS
D. Helicobacter pylori
sided Achilles enthesitis, left ankle synovitis, and dactylitis
E. Shigella flexneri
of the third and fourth fingers of her right hand. Imag-
ing of her sacroiliac joints with MRI shows no erosions or VIII-46. Which of the following definitions best fits the term
bone marrow edema. Laboratory testing shows an elevated enthesitis?
C-reactive protein, negative rheumatoid factor, and nega-
tive anti-cyclic citrullinated protein antibodies. Which of A. A palpable vibratory or crackling sensation elicited
the following is the most likely diagnosis? with joint motion
B. Alteration of joint alignment so that articulating sur-
A. Ankylosing spondylitis faces incompletely approximate each other
B. Peripheral spondyloarthritis C. Inflammation at the site of tendinous or ligamentous
C. Psoriatic arthritis insertion into bone
D. Reactive arthritis D. Inflammation of the periarticular membrane lining
E. Rheumatoid arthritis the joint capsule
E. Inflammation of a saclike cavity near a joint that
VIII-42. Which of the following clinical manifestations can
decreases friction
be seen in the syndrome of synovitis, acne, pustulosis,
hyperostosis, and osteitis? VIII-47. All of the following help distinguish psoriatic
A. Acromegaly arthritis from other joint disorders EXCEPT:
B. Hidradenitis suppurativa A. Dactylitis
C. Plaque psoriasis B. Enthesitis
D. Sternoclavicular osteomyelitis C. Nail pitting
E. B and D D. Presence of diarrhea
E. Shortening of digits
VIII-43. Histocompatibility antigen human leukocyte
antigen-B27 is present in what percentage of North Amer- VIII-48. Which cardiac valvular lesion is most common in
ican patients with ankylosing spondylitis? patients with ankylosing spondylitis?
A. 10% A. Aortic regurgitation
B. 30% B. Mitral regurgitation
C. 50% C. Mitral stenosis
D. 80% D. Pulmonic stenosis
E. 100% E. Tricuspid regurgitation
VIII-44. Which of the following is the most common extra- VIII-49. A 55-year-old man presents to the emergency
articular manifestation of ankylosing spondylitis? department with weight loss, fever, testicular pain, and
A. Anterior uveitis a new rash on his legs. On physical examination, he has
B. Aortic insufficiency abdominal tenderness and raised nonblanching erythe-
C. Inflammatory bower disease matous lesions on his legs. Laboratory studies show an
D. Pulmonary fibrosis elevated erythrocyte sedimentation rate and C-reactive
E. Third-degree heart block protein as well as a positive hepatitis B surface antigen. He
undergoes a surgical skin biopsy. The biopsy is most likely
VIII-45. A 27-year-old man is seen at his primary care phy- to show:
sician’s office for evaluation of painful arthritis involving
A. Fibrinoid necrosis of small- and medium-sized
the right knee associated with diffuse bilateral finger swell-
arteries
ing. He is otherwise healthy but does recall a severe bout
B. Interface dermatitis
of diarrheal illness about 3–4 weeks prior that spontane-
C. Leukocytoclastic vasculitis with IgA deposition on
ously resolved. He works as a recreation supervisor at a
immunofluorescence
daycare center and said many of the children had a similar
D. Noncaseating granulomas
diarrheal illness. He takes no medications and reports rare
E. Septal panniculitis
marijuana use. On review of systems, he reports painful

549
 VIII-50. All of the following arteries are commonly affected A. Hepatitis B surface antigen
SECTION VIII

in Takayasu arteritis EXCEPT: B. Antineutrophil cytoplasmic antibody

C. Hepatitis C polymerase chain reaction
A. Abdominal aorta
D. HIV antibody
B. Cerebral arteries
E. Rheumatoid factor
C. Common carotid artery
D. Renal arteries VIII-54. An 18-year-old man is admitted to the hospital
E. Subclavian artery with acute onset of crushing substernal chest pain that
began abruptly 30 minutes ago. He reports the pain radiat-
VIII-51. A 40-year-old male presents to the emergency
Rheumatology and Immunology

ing to his neck and right arm. He has otherwise been in

department with 2 days of low-volume hemoptysis. He
good health. He currently plays trumpet in his high school
reports that he has been coughing up 2–5 tablespoons
marching band but does not participate regularly in aero-
of blood each day. He does report mild chest pain, low-
bic activities. On physical examination, he is diaphoretic
grade fevers, and weight loss. In addition, he has had about
and tachypneic. His blood pressure is 100/48 and heart
1 year of severe upper respiratory symptoms including fre-
rate is 110 beats/min. His cardiovascular examination has
quent epistaxis and purulent discharge treated with several
a regular rhythm but is tachycardic. A 2/6 holosystolic
courses of antibiotics. Aside from mild hyperlipidemia, he
murmur is heard best at the apex and radiates to the axilla.
is otherwise healthy. His only medications are daily aspirin
His lungs have bilateral rales at the bases. The electrocardi-
and lovastatin. On physical examination he has a saddle
ogram demonstrates 4 mm of ST elevation in the anterior
nose deformity. His vital signs are normal and his lungs are
leads. On further questioning regarding his past medical
clear. A CT of the chest shows multiple 1- to 2-cm cavitat-
history, he recalls having been told that he was hospital-
ing nodules, and urinalysis shows red blood cells. Which
ized for some problem with his heart when he was 2 years
of the following tests offers the highest diagnostic yield to
old. His mother, who accompanies him, reports that he
make the appropriate diagnosis?
received aspirin and γ-globulin as treatment. Since that
A. Deep skin biopsy time, he has required intermittent follow-up with echocar-
B. Percutaneous kidney biopsy diography. What is the most likely cause of this patient’s
C. Pulmonary angiogram acute coronary syndrome?
D. Surgical lung biopsy
A. Dissection of the aortic root and left coronary ostia
E. Upper airway biopsy
B. Presence of a myocardial bridge overlying the left
VIII-52. An 84-year-old woman is seen by her primary care anterior descending artery
physician for evaluation of severe headaches. She noted C. Thrombosis of a coronary artery aneurysm
these several weeks ago, and they have been getting worse. D. Vasospasm following cocaine ingestion
Although she has not had any visual aura, she is concerned E. Vasculitis involving the left anterior descending
that she has been intermittently losing vision in her left eye artery
for the last few days. She denies new weakness or numb-
VIII-55. You are seeing in follow-up a 46-year-old man
ness, but she does report jaw pain with eating. Her past
who, 6 months ago, presented to the hospital acutely with
medical history includes coronary artery disease requiring
hemoptysis, diffuse nodular pulmonary infiltrates, and
a bypass grafting 10 years prior, diabetes mellitus, hyper-
glomerulonephritis. Workup revealed a positive serologic
lipidemia, and mild depression. Full review of symptoms
study for antibodies against cytoplasmic antineutrophil
is notable for night sweats and mild low back pain particu-
cytoplasmic antibodies (ANCA), and he was eventually
larly prominent in the morning. Which of the following is
diagnosed with granulomatosis with polyangiitis. Treat-
the next most appropriate step?
ment was initiated with high-dose glucocorticoids and
A. Aspirin 975 mg orally daily daily cyclophosphamide with excellent clinical response.
B. Measurement of erythrocyte sedimentation rate You are ready today to have the patient transition from
C. Immediate initiation of glucocorticoid treatment induction therapy with cyclophosphamide to maintenance
D. Referral for temporal artery biopsy therapy with azathioprine. What blood test should you
E. Referral for ultrasound of temporal artery check before starting azathioprine?

VIII-53. A 54-year-old man is evaluated for cutaneous vascu- A. ANCA titers

litis and peripheral nephropathy. Because of concomitant B. Cryoglobulins
renal dysfunction, he undergoes kidney biopsy that shows C. CYP3A4 genotyping
glomerulonephritis. Cryoglobulins are demonstrated in D. Glucose-6-phosphate dehydrogenase enzyme levels
the peripheral blood. Which of the following laboratory E. Thiopurine methyltransferase enzyme activity
studies should be sent to determine the etiology?

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VIII-56. Lung biopsy has the greatest diagnostic yield in and needing to swallow multiple times for one bite of food.

SECTION VIII
which of the following vasculitic syndromes? On physical examination he has 4/5 strength in his knee
extensors, 3/5 strength in his finger flexors, and atrophy
A. Cryoglobulinemic vasculitis
in the medial thighs and forearms. On laboratory stud-
B. Cutaneous vasculitis
ies, his creatinine kinase is two times the upper limit of
C. Granulomatosis with polyangiitis (Wegener)
normal. You decide to pursue a muscle biopsy. What find-
D. IgA vasculitis (Henoch-Schönlein)
ings are likely to be noted on the muscle biopsy by light
E. Polyarteritis nodosa
microscopy?
VIII-57. All of the following conditions occur in association

QUESTIONS
A. Multifocal necrotic and regenerating muscle fibers
with Behçet syndrome EXCEPT: with a paucity of inflammation
A. Arthritis B. Perifascicular muscle atrophy
B. Deep venous thrombosis C. Perivascular inflammatory cell infiltrate with no
C. Folliculitis endomysial inflammation
D. Genital ulcers D. Rimmed vacuoles and inclusions
E. Scleritis E. Type 2 muscle fiber atrophy

VIII-58. Which of the following is required for the diagnosis VIII-61. All of the following therapeutic agents are used in
of Behçet syndrome? the treatment of polymyositis EXCEPT:

A. Large vessel vasculitis A. Azathioprine

B. Pathergy test B. Mycophenolate Mofetil
C. Recurrent oral ulceration C. Prednisone
D. Recurrent genital ulceration D. Rituximab
E. Uveitis E. Secukinumab

VIII-59. A 25-year-old woman presents with a complaint of
painful mouth ulcerations. She describes these lesions as
shallow ulcers that last for 1 or 2 weeks. The ulcers have
been appearing for the last 6 months. For the last 2 days,
the patient has had a painful red eye. She has had no geni-
tal ulcerations, arthritis, skin rashes, or photosensitivity.
On physical examination, the patient appears well devel-
oped and in no distress. She has a temperature of 37.6°C
(99.7°F), heart rate of 86 beats/min, blood pressure of
126/72, and respiratory rate of 16 breaths/min. Examina-
tion of the oral mucosa reveals two shallow ulcers with a
yellow base on the buccal mucosa. The ophthalmologic
examination is consistent with anterior uveitis. The car-
diopulmonary examination is normal. She has no arthritis,
but medially on the right thigh, there is a palpable cord
in the saphenous vein. Laboratory studies reveal an eryth-
rocyte sedimentation rate of 68 seconds. White blood cell
count is 10,230/μL with a differential of 68% polymorpho-
nuclear cells, 28% lymphocytes, and 4% monocytes. The
anti-nuclear antibody and anti-dsDNA antibody are nega-
tive, and C3 is 89 mg/dL and C4 is 24 mg/dL. What is the
most likely diagnosis?
A. Behçet syndrome
B. Bullous pemphigoid
C. Discoid lupus erythematosus
D. Sjögren syndrome
E. Systemic lupus erythematosus
VIII-60. A 58-year-old man presents to the clinic for a
routine follow-up visit. He notes he has been dropping
things more frequently and is having trouble rising from
a seated position. He also notes some trouble swallowing
VIII-62. A 64-year-old woman is evaluated for weakness.
She has had several weeks of difficulty brushing her teeth
and combing her hair. She has also noted a rash on her face.
Examination is notable for a heliotrope rash and proximal
muscle weakness. Serum creatinine kinase is elevated, and
she is diagnosed with dermatomyositis. After evaluation
by a rheumatologist, she is found to have anti-Jo-1 anti-
bodies. She is also likely to have which of the following
additional findings?
A. Ankylosing spondylitis
B. Inflammatory bowel disease
C. Interstitial lung disease
D. Primary biliary cirrhosis
E. Psoriasis
VIII-63. A 63-year-old woman is evaluated for a rash on her
eyes and fatigue for 1 month. She reports difficulty with
arm and leg strength and constant fatigue, but no fevers or
sweats. She also has noted that she has a red discoloration
around her eyes. She has hypothyroidism but is otherwise
well. On examination, she has a heliotrope rash and proxi-
mal muscle weakness. A diagnosis of dermatomyositis is
made after demonstration of elevated serum creatinine
kinase and confirmatory electromyograms. Which of the
following studies should be performed as well to look for
associated conditions?
A. Mammogram
B. Serum anti-nuclear antibody measurement
C. Stool examination for ova and parasites
D. Thyroid-stimulating immunoglobulins
E. Titers of antibodies to varicella zoster

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 VIII-64. You are seeing your long-term patient in the clinic.
SECTION VIII

He has a history of coronary artery disease, with a lateral

myocardial infarction 1 year ago. At that time, he was
started on simvastatin, aspirin, metoprolol, and lisinopril.
About 2 months ago, he started noting thigh and shoul-
der soreness. One month after onset, his muscle pain had
increased and he was noticing weakness. His creatinine
kinase (CK) was elevated to eight times the upper limit
of normal. His simvastatin was discontinued 3 weeks ago.
Rheumatology and Immunology

Today, he reports that his pain has continued and, if any-

thing, is worse than a month ago. His CK is 12 times the
upper limit of normal. What is the next best test to estab-
lish a diagnosis?
A. Antibody against 3-hydroxy-3-methylglutaryl–coen-
zyme A reductase
B. Anti-nuclear antibody
C. Anti-Jo-1 antibody
D. Antibody against signal recognition particle
E. Aldolase levels
FIGURE VIII-68
VIII-65. Which of the following disorders is associated with
relapsing polychondritis? bilateral hilar lymphadenopathy. What type of skin rash is
present?
A. Giant cell arteritis
B. Granulomatosis with polyangiitis (formerly Wegener A. Acne vulgaris
disease) B. Acute cutaneous lupus
C. Rheumatoid arthritis C. Erythema nodosum
D. Psoriasis D. Heliotrope rash
E. B and C E. Lupus pernio

VIII-66. A 47-year-old man is evaluated for 1 year of recur- VIII-69. All of the following have been implicated in the
rent episodes of bilateral ear swelling. The ear is painful proposed pathogenesis of sarcoidosis EXCEPT:
during these events, and the right ear has become floppy. A. Exposure to mold
He is otherwise healthy and reports no illicit habits. He B. Genetic susceptibility
works in an office, and his only sport is tennis. On exami- C. Immune response to mycobacterial proteins
nation, the left ear has a beefy red color and the pinna is D. Infection with Propionibacterium acnes
tender and swollen; the earlobe appears minimally swollen E. Malignant expansion of helper T cells
but is neither red nor tender. Which of the following is the
most likely explanation for this finding? VIII-70. Which of the following statements regarding pul-
monary sarcoidosis is true?
A. Behçet syndrome
B. Cogan syndrome A. Lung involvement is the second most common
C. Hemoglobinopathy manifestation of sarcoidosis, behind only cutaneous
D. Recurrent trauma involvement.
E. Relapsing polychondritis B. Obstructive disease is a rare manifestation of pulmo-
nary sarcoidosis.
VIII-67. Which of the following cardiovascular conditions C. Pulmonary hypertension never responds to therapy
can occur in sarcoidosis as a result of granulomatous in sarcoidosis patients.
infiltration? D. Pulmonary infiltrates in sarcoidosis tend to be pre-
A. Abdominal aortic aneurysm dominantly an upper lobe process.
B. Coronary artery disease E. The presence of cough should prompt evaluation for
C. Decreased ejection fraction a cause other than pulmonary sarcoidosis.
D. Ventricular arrhythmia VIII-71. You are seeing a 55-year-old white man with a
E. C and D history of sarcoidosis. He ran out of prednisone about
VIII-68. A 40-year-old African American woman presents to 2 months prior to seeing you and, except for some con-
the clinic with a facial rash. The rash has lasted for several stipation, feels well. A metabolic panel reveals a calcium
months and is raised and erythematous (Figure VIII-68). of 12.2 mg/dL (normal up to 10.5 mg/dL). You know that
She also reports a new dry cough. Chest radiograph shows sarcoidosis can be associated with hypercalcemia. Which

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 of the following is the correct mechanism for sarcoidosis- with periodic fever syndrome, and tumor necrosis factor-

SECTION VIII
associated hypercalcemia? receptor-associated periodic syndrome?
A. Direct granulomatous involvement of the axial skel- A. Adalimumab
eton causing calcium release from bones B. Canakinumab
B. Direct stimulation of increased intestinal calcium C. Colchicine
absorption D. Lisinopril
C. Increased parathyroid hormone production E. Rituximab
D. Increased production of 1,25-dihydroxyvitamin D
VIII-75. You are seeing a 19-year-old woman today in con-

E. Increased production of 25-hydroxyvitamin D
VIII-72. All of the following conditions are manifestations
of IgG4-related disease EXCEPT:
A. Autoimmune pancreatitis
B. Crescentic glomerulonephritis
C. Lymphoplasmacytic aortitis
D. Orbital pseudotumor
E. Sialadenitis
VIII-73. Your patient is a 34-year-old man who presented
to you with unexplained pancreatitis 2 weeks ago. Imag-
ing of his pancreas showed diffuse pancreatic enlarge-
ment. He denies any alcohol intake and did not have any
gallstones on imaging. Interestingly, on examination, he
also has marked lacrimal gland and submandibular gland
enlargement. Biopsy of his submandibular gland is pic-
tured in Figure VIII-73. The cells pictured in the figure
stain strongly positive for IgG4, CD19, and CD138. Which
of the following is the appropriate therapy?
QUESTIONS
sultation for recurrent fevers. She reports several years
of fevers, occurring on average every 2–3 months. These
episodes are unpredictable, although she thinks they may
occur in times of psychological stress. Each febrile episode
lasts 2–3 days. She also has recurrent episodes of abdomi-
nal pain. Repeated blood cultures have been negative,
even during acute febrile episodes. Similarly, abdominal
CT scans have shown no obvious etiology for her pain.
During one episode, she underwent an exploratory lapa-
rotomy, which showed peritoneal adhesions and a sterile
neutrophilic peritoneal exudate. She also notes that when
she exercises, she develops intense muscle pains that last
for days. An extensive serologic search for autoantibod-
ies returned negative, including anti-nuclear antibodies.
Which of the following is the most likely diagnosis?
A. Familial Mediterranean fever
B. Lymphoma
C. Relapsing fever
D. Subacute bacterial endocarditis
E. Systemic lupus erythematosus

VIII-76. For the patient described in question VIII-75,

which of the following medications would you prescribe
to reduce attacks and help prevent the development of sys-
temic amyloidosis?
A. Colchicine
B. Cyclosporine
C. Prednisone
D. Rituximab
E. Vancomycin

VIII-77. In the United States, what percentage of patients

over the age of 60 years have symptomatic osteoarthritis
of the knee?
A. 1%
FIGURE VIII-73 B. 5%
C. 12%
D. 30%
A. Thalidomide and dexamethasone E. 43%
B. Cytomegalovirus immunoglobulin and ganciclovir
C. Systemic chemotherapy VIII-78. Which of the following joints is often spared by
D. Prednisone osteoarthritis?
E. Anakinra
A. Cervical spine
VIII-74. Which of the following drugs can be used to B. Distal interphalangeal joint
treat several genetic periodic fever syndromes including C. Hip
Muckle-Wells syndrome, hyperimmunoglobulinemia D D. Proximal interphalangeal joint
E. Wrist

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 VIII-79. Which of the following statements regarding osteo-
SECTION VIII
arthritis is true?
A. During the diagnostic workup of a suspected osteo-
arthritic joint, MRI is warranted to evaluate for any
other causes.
B. Loss of cartilage causes pain due to direct stimulation
of pain receptors in joint cartilage itself.
C. Osteoarthritis is the second most common cause of
Rheumatology and Immunology
arthritis, behind rheumatoid arthritis.
D. Synovial fluid white blood cell count is usually
<1000 cells/μL in osteoarthritis.
E. The severity of radiographic changes in osteoarthritis
correlates well with symptoms.
VIII-80. You are seeing a 60-year-old obese woman with
bilateral knee osteoarthritis. She describes pain most days
and limiting pain at least 2 days per week. She has tried
activity modification (walking less) without success. All
of the following therapies have been shown to be effica-
cious in treating osteoarthritis symptoms in this patient
EXCEPT:
A. Acetaminophen
B. Glucocorticoid intra-articular injections
C. Glucosamine-chondroitin
D. Naproxen
E. Total joint arthroplasty
VIII-81. A 75-year-old woman presents to the clinic with
a newly swollen right knee. She denies any fevers, night
sweats, or other constitutional symptoms. She does not
have any toe, foot, or ankle pain or swelling. She has never
had a similar episode previously. She has a history of
osteoarthritis and underwent a left total hip arthroplasty
5 years ago. On examination, her right knee is warm with
a moderate size effusion and tender to palpation. Labora-
tory studies show a uric acid level of 5.2 mg/dL (normal).
A radiograph of the knee shows a linear radiodensity in
the joint space consistent with chondrocalcinosis. What is
the most likely diagnosis?
A. Calcium pyrophosphate arthritis (pseudogout)
B. Gout
C. Rheumatoid arthritis
D. Septic arthritis
VIII-82. Mr. Hinsley is a 72-year-old man with only a his-
tory of hypertension on hydrochlorothiazide. He presents
today with acute, excruciating knee pain. On examination,
his knee is warm, mildly erythematous, swollen, and ten-
der to the touch or passive movement. Microscopic exami-
nation of joint fluid is shown in Figure VIII-82A. Which
of the following is Mr. Hinsley’s most likely metabolic
derangement?
A. Acute bacterial joint infection
B. Antibodies to anti-nuclear antigens
C. Hyaline cartilage degeneration
D. Increased production of inorganic pyrophosphate
E. Uric acid overproduction
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FIGURE VIII-82A
VIII-83. You are planning on starting allopurinol for a
55-year-old woman for a new diagnosis of gouty arthri-
tis. Which of the following statements best describes an
appropriate dosing strategy for allopurinol?
A. Allopurinol and azathioprine are commonly used
together in the treatment of gout.
B. Allopurinol dosing should be adjusted for liver
function.
C. Allopurinol dosing should be titrated to achieve a
serum uric acid level <6 mg/dL.
D. Allopurinol should be avoided when patients are tak-
ing colchicine.
E. Allopurinol toxicity is more common in patients
expressing human leukocyte antigen-B27.
VIII-84. Which of the following findings is typically seen in
patients with fibromyalgia?
A. Elevated C-reactive protein
B. Elevated thyroid-stimulating hormone
C. Erosions of the metacarpophalangeal joints on
radiographs
D. Positive anti-nuclear antibody
E. Skin roll tenderness on physical examination
VIII-85. A 42-year-old woman is seen in her primary care
doctor’s office complaining of diffuse pains and fatigue.
She has a difficult time localizing the pain to any particu-
lar joint or location, but she reports it affects her upper
and lower extremities, neck, and hips. It is described as
achy and 10 out of 10 in intensity. She feels that her joints
are stiff but does not notice that it is worse in the morn-
ing. The pain has been present for the last 6 months and
is increasing in intensity. She has tried both over-the-
counter ibuprofen and acetaminophen without significant
relief. The patient feels as if the pain is interfering with
her ability to get restful sleep and is making it difficult for
her to concentrate. She has missed multiple days of work
as a waitress and fears that she will lose her job. There is
a medical history of depression and obesity. The patient
is currently taking venlafaxine sustained release 150 mg
daily. She has a family history of rheumatoid arthritis
in her mother. She smokes one pack of cigarettes daily.
 On physical examination, vital signs are normal. Body VIII-88. A 42-year-old man is found to have the finding

SECTION VIII
mass index is 36 kg/m2. Joint examination demonstrates seen in Figure VIII-88 on a physical examination. All of
no erythema, swelling, or effusions. There is diffuse pain the following conditions are associated with this finding
with palpation at the insertion points of the suboccipital EXCEPT:
muscles, at the midpoint of the upper border of the trape-
zius muscle, along the second costochondral junction, at
the lateral epicondyles, and along the medial fat pad of the
knees. All of the following statements regarding the cause
of this patient’s diffuse pain syndrome are true EXCEPT:

QUESTIONS
A. Cognitive dysfunction, sleep disturbance, anxiety,
and depression are common comorbid neuropsycho-
logical conditions.
B. Pain in this syndrome is associated with increased
evoked pain sensitivity.
C. Pain in this syndrome is often localized to specific
joints.
D. This syndrome is present in 2–5% of the general pop-
ulation, but increases in prevalence to 20% or more FIGURE VIII-88 Reproduced with permission from Kang S et al:
of patients with degenerative or inflammatory rheu- Fitzpatrick’s Dermatology, 9th ed. New York: McGraw Hill, 2019.
matic disorders.
E. Women are nine times more likely than men to be
affected by this syndrome. A. Chronic obstructive pulmonary disease
B. Cyanotic congenital heart disease
VIII-86. A 36-year-old woman presents to your office C. Cystic fibrosis
with diffuse pain throughout her body associated with D. Hepatocellular carcinoma
fatigue, insomnia, and difficulty concentrating. She finds E. Hyperthyroidism
the pain difficult to localize but reports that it is 7–8 out
of 10 in intensity and not relieved by nonsteroidal anti- VIII-89. A 52-year-old man presented to his primary care
inflammatory medications. She has a long-standing his- physician complaining of new-onset pain in the knuckles
tory of generalized anxiety disorder and is treated with of his index and middle fingers of both hands. On exami-
sertraline 100 mg daily as well as clonazepam 1 mg twice nation, the second and third metacarpophalangeal (MCP)
daily. On examination, she has pain with palpation at sev- joints of both hands are swollen and tender. The rest of his
eral musculoskeletal sites. Her laboratory examination physical examination is normal. His past medical history
demonstrates a normal complete blood count, basic meta- is only notable for hyperlipidemia controlled with atorv-
bolic panel, erythrocyte sedimentation rate, and rheuma- astatin. His laboratory studies are notable for an elevated
toid factor. You diagnose her with fibromyalgia. All of the ferritin, and after demonstration of a mutation of the HFE
following therapies are recommended as part of the treat- gene, he is diagnosed with hemochromatosis. Which of
ment plan for fibromyalgia EXCEPT: the following statements regarding his joint abnormalities
is true?
A. An exercise program that includes strength training,
aerobic exercise, and yoga A. The second and third finger MCPs are also typically
B. Cognitive-behavioral therapy for insomnia involved in osteoarthritis.
C. Milnacipran B. Arthropathy is unlikely related to hemochromatosis.
D. Oxycodone C. Arthropathy may progress with phlebotomy.
E. Pregabalin D. Arthropathy occurs in less than 20% of patients with
hemochromatosis.
VIII-87. Which of the following conditions is the most fre- E. Radiographs are likely to show erosions in the MCPs.
quent cause of neuropathic joint disease (Charcot joint)?
VIII-90. All of the following can cause bursitis EXCEPT:
A. Amyloidosis
B. Congenital indifference to pain A. Bacterial infection
C. Diabetes mellitus B. Fibromyalgia
D. Syringomyelia C. Gout
E. Tabes dorsalis D. Rheumatoid arthritis
E. Overuse

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 VIII-91. A 57-year-old man comes to the clinic with new
SECTION VIII
pain in his right elbow. He works for an international
corporation and travels frequently for work. This travel
requires him to carry and pull suitcases through the air-
port on his weekly trips out of town. He notes that the pain
is worse when shaking hands at business meetings. On
examination, no swelling is noted in the elbow or other
joints. The pain is reproducible by palpation of the lateral
elbow. Which of the following is an option for treatment of
Rheumatology and Immunology
his musculoskeletal condition?
A. Adalimumab
B. Corticosteroid injection at the lateral epicondyle
C. Methotrexate
D. Nonsteroidal anti-inflammatory drugs and rest
E. B and D
VIII-92. A 32-year-old woman is seen in the clinic with a
complaint of left knee pain. She enjoys running long dis-
tances and is currently training for a marathon. She is
running on average 30–40 miles weekly. She currently is
experiencing an aching pain on the lateral aspect of her
left knee. There is a burning sensation that also continues
up the lateral aspect of her thigh. She denies any injury to
her knee, and she has not felt that it was hot or swollen. She
is otherwise healthy and takes no medications other than
herbal supplements. Physical examination of the knee
reveals point tenderness over the lateral femoral condyle
that is worse with flexing the knee. The patient is asked to
lie on her right side with her right knee and hip flexed at
90 degrees. Her left leg is extended at the hip and slowly
lowered into adduction behind the bottom leg, reproduc-
ing the patient’s left knee pain. All of the following treat-
ments can be recommended for this patient EXCEPT:
A. Assessment of the patient’s running shoes to ensure a
proper fit
B. Glucocorticoid injection so as not to interfere with
the patient’s continued preparation for the upcoming
marathon
C. Ibuprofen 600–800 mg every 6 hours as needed for
pain
D. Referral for physical therapy
E. Referral for surgical release if conservative therapy
fails
VIII-93. A 58-year-old woman presents complaining of
right shoulder pain. She does not recall any prior injury
but notes that she feels that the shoulder has been get-
ting progressively stiffer over the last several months. She
previously had several episodes of bursitis of the right
shoulder that were treated successfully with nonsteroidal
anti-inflammatory drugs and corticosteroid injections.
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The patient’s past medical history is also significant for
diabetes mellitus, for which she takes metformin and gly-
buride. On physical examination, the right shoulder is
not warm or red but is tender to touch. Passive and active
range of motion are limited in flexion, extension, and
abduction. A right shoulder radiogram shows osteopenia
without evidence of joint erosion or osteophytes. What is
the most likely diagnosis?
A. Adhesive capsulitis
B. Avascular necrosis
C. Bicipital tendinitis
D. Osteoarthritis
E. Rotator cuff tear
VIII-94. A 32-year-old woman presents to the clinic with
right thumb and wrist pain that has worsened over several
weeks. She has pain when she pinches her thumb against
her other fingers. Her only other history is that she is a
new mother with an 8-week-old infant at home. On physi-
cal examination, she has mild swelling and tenderness
over the radial styloid process, and pain is elicited when
she places her thumb in her palm and grasps it with her
fingers. A Phalen maneuver is negative. Which condition
is most likely?
A. Carpal tunnel syndrome
B. De Quervain tenosynovitis
C. Gouty arthritis of the first metacarpophalangeal joint
D. Palmar fasciitis
E. Rheumatoid arthritis
VIII-95. You are evaluating a 42-year-old woman who com-
plains of pain on the underside of her right heel that is
excruciating in the morning when she first walks from bed
to the bathroom. The pain improves somewhat during the
morning but again worsens mid-day particularly when
climbing stairs. She has a past medical history of hyper-
tension, smokes one pack per day of cigarettes, and works
as a waitress at a diner. Medications include hydrochlo-
rothiazide and oral contraceptives. Physical examination
is unremarkable except for flat feet and focal tenderness
on the bottom of the right heel. There is no tenderness at
the ankle or calf, and the diameters of the lower legs are
equivalent. A radiograph of the right heel and ankle shows
only heel spurs. All of the following statements regarding
her condition are true EXCEPT:
A. Heel spurs are not diagnostic.
B. Local glucocorticoid injection incurs a risk of plantar
fascia rupture.
C. Oral contraceptives and smoking are risk factors.
D. Orthotic shoe implants may be beneficial.
E. The prognosis for improvement is good.
 SECTION VI
Disorders of the Kidney and Urinary Tract

QUESTIONS

DIRECTIONS: Choose the one best response to each question. VI-4. Which of the following procedures has the highest risk
for postoperative acute kidney injury?
A. Anterior cruciate ligament repair
VI-1. Which segment of the kidney reabsorbs the highest B. Cataract removal
percentage of filtered sodium chloride? C. Coronary artery bypass
D. Thyroidectomy
A. Collecting duct
E. Total hip arthroplasty
B. Distal convoluted tubule
C. Loop of Henle VI-5. Which of the following is a potential etiology for
D. Proximal convoluted tubule ischemic acute renal failure?
VI-2. A 33-year-old woman with recently treated acute A. Apoptosis and necrosis of tubular cells
myelogenous leukemia now in remission is admitted to B. Decreased glomerular vasodilation in response to
the hospital with lethargy, fever, and tachycardia. Blood nitric oxide
cultures grow Pseudomonas that is resistant to cefepime. C. Increased glomerular vasoconstriction in response to
She is started on IV gentamicin. Five days after starting elevated endothelin levels
gentamicin, her serum creatinine rises from her baseline D. Increased leukocyte adhesion within the glomerulus
of 1.0 mg/dL to 2.4 mg/dL. No red or white cell casts are E. All of the above
seen on her urinalysis. Her magnesium level is decreased
at 1.5 mg/dL. Renal ultrasound is unremarkable with no VI-6. A 57-year-old man with a history of diabetes mellitus
hydronephrosis. Which of the following is the most likely and chronic kidney disease with a baseline creatinine of
mechanism of her acute kidney injury? 1.8 mg/dL underwent cardiac catheterization for acute
myocardial infarction. He is subsequently diagnosed with
A. Acute interstitial nephritis acute kidney injury related to iodinated contrast. All of the
B. Acute tubular necrosis following statements are true regarding his acute kidney
C. Glomerulonephritis injury EXCEPT:
D. Ischemic injury
E. Obstruction A. Fractional excretion of sodium will be low.
B. His creatinine is likely to peak within 3–5 days.
VI-3. Which of the following laboratory abnormalities typi- C. His diabetes mellitus predisposed him to develop
cally can be seen accompanying acute kidney injury? contrast nephropathy.
D. Transient tubule obstruction with precipitated iodi-
A. Hypercalcemia
nated contrast contributed to development of his
B. Hypokalemia
acute kidney injury.
C. Hyponatremia
E. White blood cell casts are likely on microscopic
D. Hypophosphatemia
examination of urinary sediment.
E. Metabolic alkalosis

457
 VI-7. Which of the following acute kidney injury patients is
most likely to have evidence of bilateral hydronephrosis on
SECTION VI
ultrasound evaluation of the kidneys?
A. A 19-year-old man with purpura fulminans associ-
ated with gonococcal sepsis
B. A 37-year-old woman undergoing chemotherapy
and radiation for advanced cervical cancer
C. A 48-year-old man with chronic renal insufficiency
Disorders of the Kidney and Urinary Tract
due to hypertension that received iodinated contrast
for an abdominal angiogram
D. A 53-year-old man with Escherichia coli 0157:H7–
associated thrombotic thrombocytopenic purpura
E. An 85-year-old woman who resides in a nursing
home with pyelonephritis and sepsis
VI-8. A 54-year-old man is admitted to the medical inten-
sive care unit with sepsis associated with pneumococcal
pneumonia. He requires mechanical ventilation as well
as norepinephrine to maintain a mean arterial pressure
>60 mmHg. Invasive hemodynamics show adequate left
heart filling pressures, and he is not known to have left
ventricular dysfunction. On the third hospital day, his
urine output drops and creatinine increases to 3.4 mg/dL.
Acute tubular injury is diagnosed. Which of the following
agents has been shown to improve outcomes associated
with his acute tubular injury?
A. Furosemide
B. Bosentan
C. Low-dose dopamine
D. Insulin-like growth factor
E. None of the above
VI-9. It is hospital day 5 for a 65-year-old patient with pre-
renal azotemia secondary to dehydration. His creatinine
was initially 3.6 mg/dL on admission, but it has improved
today to 2.1 mg/dL. He complains of mild lower back pain,
and you prescribe naproxen to be taken intermittently. By
what mechanism might this drug further impair his renal
function?
A. Afferent arteriolar vasoconstriction
B. Afferent arteriolar vasodilatation
C. Efferent arteriolar vasoconstriction
D. Proximal tubular toxicity
E. Ureteral obstruction
VI-10. Which of the following is the leading cause of chronic
kidney disease in North America?
A. Autosomal dominant polycystic kidney disease
B. Contrast nephropathy
C. Diabetic nephropathy
D. Focal segmental glomerulosclerosis
E. Recurrent renal calculi
VI-11. A 65-year-old man with a history of hypertension,
diabetes, and chronic low back pain presents to the clinic
for follow-up. His physical examination is unremarkable
with no edema or jugular venous distension. Recent labo-
ratory testing shows a decreased glomerular filtration rate
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WWW.BOOKBAZ.IR
of 55 mL/min/1.73 m2. His hemoglobin A1c is 5.4%. He
is currently on metformin, naproxen, and hydrochlorothi-
azide. What medication change could help slow his pro-
gression of chronic kidney disease?
A. Add furosemide
B. Discontinue metformin
C. Discontinue naproxen
D. Substitute lisinopril for hydrochlorothiazide
E. C and D
VI-12. Which of the following patients has the greatest risk
of progression to chronic kidney disease?
A. A 30-year-old man with an estimated glomeru-
lar filtration rate (GFR) of 50 mL/min/1.73 m2 and
350 mg/g of persistent albuminuria
B. A 45-year-old man with an estimated GFR of 90 mL/
min/1.73 m2 and <30 mg/g of persistent albuminuria
C. A 55-year-old man with an estimated GFR of 70 mL/
min/1.73 m2 and 100 mg/g of persistent albuminuria
D. A 65-year-old woman with an estimated GFR of
65 mL/ min/1.73 m2 and <30 mg/g of persistent
albuminuria
E. A 75-year-old man with an estimated GFR of 35 mL/
min/1.73 m2 and <30 mg/g of persistent albuminuria
VI-13. In stage V chronic kidney disease, glomerular filtra-
tion rate is below which of the following levels?
A. 90 mL/min/1.73 m2
B. 60 mL/min/1.73 m2
C. 25 mL/min/1.73 m2
D. 15 mL/min/1.73 m2
E. 0 mL/min/1.73 m2 (anuria)
VI-14. All of the following statements regarding the use of
exogenous erythropoietin in patients with chronic kidney
disease are true EXCEPT:
A. Exogenous erythropoietin should be adminis-
tered with a target hemoglobin concentration of
100–115 g/L.
B. Use of exogenous erythropoietin is associated with
improved cardiovascular outcomes.
C. Use of exogenous erythropoietin is associated with
increased risk of stroke in patients with concomitant
type 2 diabetes mellitus.
D. Use of exogenous erythropoietin may be associated
with faster progression to the need for dialysis.
E. Use of exogenous erythropoietin is associated with
increased incidence of thromboembolic events.
VI-15. A 63-year-old woman with chronic kidney disease is
maintained on daily peritoneal dialysis. Her past medical
history is notable for hypertension and atrial fibrillation.
Her medications include losartan and warfarin. Two days
ago, she noticed a small painful nodule on her abdomen
that has progressed to involve skin necrosis and ulceration
of the abdominal wall (Figure VI-15). All of the following
statements regarding her condition are true EXCEPT:
 VI-19. A 35-year-old woman with hypertensive kidney dis-
ease progresses to end-stage renal disease. She was initi-

SECTION VI
ated on peritoneal dialysis 1 year ago and has done well
with relief of her uremic symptoms. She is brought to the
emergency department with fever, altered mental status,
diffuse abdominal pain, and cloudy dialysate. Her peri-
toneal fluid is withdrawn through her catheter and sent
to the laboratory for analysis. The fluid white blood cell
count is 125/μL with 85% polymorphonuclear neutro-

QUESTIONS
phils. Which organism is most likely to be found in the
culture of the peritoneal fluid?
A. Candida albicans
B. Escherichia coli
C. Mycobacterium tuberculosis
D. Pseudomonas aeruginosa
FIGURE VI-15 E. Staphylococcus epidermidis

VI-20. A 45-year-old woman begins hemodialysis for end-

A. Oral calcium supplement may be a risk factor. stage renal disease associated with diabetes mellitus.
B. Pathologically, there is vascular occlusion. Which of the following is her most likely eventual cause
C. Pseudomonas co-infection is typical. of death?
D. Severe hyperparathyroidism may not be present. A. Dementia
E. Warfarin is a risk factor for development of the lesion. B. Major bleeding episode
C. Myocardial infarction
VI-16. Which of the following is the most common acute
D. Progressive uremia
complication of hemodialysis?
E. Sepsis
A. Anaphylactoid reactions to dialyzer
B. Bleeding from access site VI-21. Your patient with end-stage renal disease on hemodi-
C. Hypertension alysis has persistent hyperkalemia. He has a history of total
D. Hypotension bilateral renal artery stenosis, which is why he is on hemo-
E. Muscle cramps dialysis. He only has electrocardiogram changes when his
potassium rises above 6.0 mEq/L, which occurs a few times
VI-17. A 60-year-old woman with hypertension and type 2 per week. You admit him to the hospital for further evalu-
diabetes has recently started peritoneal dialysis due to ation. Your laboratory evaluation, nutrition counseling,
chronic kidney disease from diabetic nephropathy. Which and medication adjustments have not impacted his serum
complications of peritoneal dialysis are of concern for this potassium. What is the next reasonable step to undertake
patient? for this patient?
A. Hyperkalemia A. Adjust the dialysate
B. Hyperglycemia B. Administer a daily dose of furosemide
C. Hyperphosphatemia C. Perform “sodium modeling”
D. Hypertriglyceridemia D. Implant an automatic defibrillator
E. B and D E. Perform bilateral nephrectomy

VI-18. A patient is followed closely by her nephrologist for VI-22. Which of the following medications used for immu-
stage IV chronic kidney disease associated with focal seg- nosuppression after kidney transplant works by inhibiting
mental glomerulosclerosis. Which of the following is an purine synthesis and can cause diarrhea as a common side
indication for initiation of maintenance hemodialysis? effect?
A. Acidosis controlled with daily bicarbonate A. Belatacept
administration B. Cyclosporine
B. Bleeding diathesis C. Mycophenolate mofetil
C. Blood urea nitrogen >110 mg/dL without symptoms D. Sirolimus
D. Creatinine >5 mg/dL without symptoms E. Tacrolimus
E. Hyperkalemia controlled with sodium polystyrene

459
 VI-23. All of the following are considered expanded donor VI-28. A 50-year-old obese female with a 5-year history
criteria for renal transplantation EXCEPT: of mild hypertension controlled by a thiazide diuretic is
SECTION VI

being evaluated because proteinuria was noted on a urine

A. Deceased donor >60 years
dipstick during her routine yearly medical visit. Physical
B. Deceased donor >50 years, hypertension, and creati-
examination discloses a height of 167.6 cm (66 inches),
nine >1.5 mg/dL
weight of 91 kg (202 lb), blood pressure of 130/80, ele-
C. Deceased donor >50 years, hypertension, and death
vated jugular venous pressure, a fourth heart sound,
caused by cerebrovascular accident (CVA)
and trace pedal edema. Laboratory values are as follows:
D. Deceased donor >50 years, death caused by CVA,
serum creatinine 106 μmol/L (1.2 mg/dL), blood urea
Disorders of the Kidney and Urinary Tract

and creatinine >1.5 mg/dL

nitrogen 6.4 mmol/L (18 mg/dL), and creatinine clear-
E. Presence of antibodies against the donor kid-
ance 87 mL/min. Urinalysis shows pH 5.0, specific grav-
ney in the recipient at the time of the anticipated
ity 1.018, protein 3+, no glucose, and occasional coarse
transplantation
granular cast. Urine protein excretion is 5.9 g/dL. A renal
VI-24. Which of the following clinical features is character- biopsy demonstrates that 60% of the glomeruli, mostly in
istic of patients with nephropathy due to type 1 diabetes? the corticomedullary junction, have segmental scarring
by light microscopy, with the remainder of the glomeruli
A. Kidney size is reduced appearing unremarkable (Figure VI-28). Which of the fol-
B. Most patients also have diabetic retinopathy lowing is the most likely diagnosis?
C. Proteinuria is uncommon
D. Renal failure occurs within 1–2 years after the onset
of proteinuria
E. Urinalysis shows red blood cell casts

VI-25. All of the following are typical causes of secondary

membranous glomerulonephritis EXCEPT?
A. Hepatitis C
B. Malignancy
C. Nonsteroidal anti-inflammatory drug use
D. Systemic lupus erythematosus
E. Tuberculosis

VI-26. A 33-year-old previously healthy woman presents to

the emergency department with malaise, confusion, and
fever of 37.8°C (100.1°F). She had no preceding diarrheal
illness. CT of the head is unremarkable. She is found to have
platelets of 13,000/cu, hemoglobin of 9.0 g/dL, and creati- FIGURE VI-28 EGN/UPenn Collection.
nine of 2.3 mg/dL. Urinalysis shows pH 5.0, protein 1+,
and 11 red blood cells/high-powered field. Which of the A. Focal segmental sclerosis
following laboratory findings would be expected with her B. Hypertensive nephrosclerosis
diagnosis? C. Minimal change (nil) disease
D. Membranous glomerulopathy
A. ADAMSTS13 <10% E. Crescentic glomerulonephritis
B. Anti-glomerular basement membrane antibodies
C. Decreased lactate dehydrogenase VI-29. Which of the following is a genetic disease that can
D. Positive direct Coombs test lead to bilateral renal cysts and carries an increased risk of
E. Spherocytes on peripheral blood smear renal cell carcinoma?

VI-27. A 21-year-old man is diagnosed with poststreptococ- A. Medullary sponge kidney

cal glomerulonephritis. Which of the following is likely to B. Neurofibromatosis type 1
be found in his urine? C. Tuberous sclerosis
D. Von Hippel-Lindau disease
A. >3 g per 24-hour proteinuria without hematuria E. C and D
B. Macroscopic hematuria and 24-hour urinary albu-
min of 227 mg VI-30. A 28-year-old woman was recently diagnosed with
C. Microscopic hematuria with leukocytes and 24-hour autosomal dominant polycystic kidney disease after an
urinary albumin of 227 mg episode of hematuria. She is concerned about intracranial
D. Positive urine culture for Streptococcus aneurysm risk. Which of the following statements is true
E. Sterile pyuria without proteinuria regarding this risk?

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WWW.BOOKBAZ.IR
 A. Family history of ruptured intracranial aneurysms of 15 mEq/L, potassium of 10 mEq/L, and chloride of
does not increase risk of rupture. 12 mEq/L. What is the most likely diagnosis?

SECTION VI
B. Prior intracranial hemorrhage does not increase risk
A. Chronic diarrhea
of subsequent hemorrhage.
B. Type I renal tubular acidosis (RTA)
C. The size of the aneurysm does not correlate with its
C. Type II RTA
risk of spontaneous rupture.
D. Type III RTA
D. There is no increased risk of intracranial aneurysm
E. Type IV RTA
in this condition.
E. Uncontrolled hypertension augments the risk of VI-35. In which of the following cases would treatment with

QUESTIONS
spontaneous rupture. corticosteroids for biopsy-proven interstitial nephritis be
most likely to impact long-term renal recovery?
VI-31. A 21-year-old male college student is evaluated for
profound fatigue that has been present for several years but A. A 37-year-old woman with sarcoidosis
has recently become debilitating. He also reports several B. A 48-year-old man with slowly progressing intersti-
foot spasms and cramps and occasionally sustained mus- tial nephritis over 2 months with fibrosis found on
cle contractions that are uncontrollable. He is otherwise biopsy
healthy, takes no medications, and denies tobacco or alco- C. A 54-year-old man with diabetes mellitus and recent
hol use. On examination, he is well developed with nor- Salmonella infection
mal vital signs including blood pressure. The remainder of D. A 63-year-old man with allergic interstitial nephritis
the examination is normal. Laboratory evaluation shows a after cephalosporin antibiotic use
sodium of 138 mEq/L, potassium of 2.8 mEq/L, chloride E. None of the above
of 90 mEq/L, and bicarbonate of 30 mmol/L. Magnesium
level is normal. Urine screen for diuretics is negative, and VI-36. A 58-year-old woman undergoes a hysterectomy
urine chloride is elevated. Which of the following is the and postoperatively develops acute respiratory distress
most likely diagnosis? syndrome. She is treated with mechanical ventilation and
broad-spectrum antibiotics. Aside from hypothyroidism,
A. Bulimia nervosa she has no underlying medical conditions. On day 5 of
B. Diuretic abuse her hospitalization, her urine output is noted to fall, and
C. Gitelman syndrome her serum creatinine rises from 1.2 to 2.5 mg/dL. Allergic
D. Liddle syndrome interstitial nephritis from cephalosporin antibiotics is sus-
E. Type 1 pseudohypoaldosteronism pected. Which of the following findings will confirm this
diagnosis?
VI-32. A 24-year-old Caucasian man presents to the clinic
after being found to have a creatinine of 1.6 mg/dL on A. Hematuria
routine laboratory studies. The rest of his metabolic panel B. Peripheral blood eosinophilia
and blood counts are normal. He has been mostly healthy, C. Urinary eosinophils on urine microscopy
with the exception of several urinary tract infections in his D. White blood cell casts on urine microscopy
childhood. He takes no medications. Urinalysis shows 1+ E. None of the above
proteinuria and no red or white blood cells. Renal ultra-
sound shows decreased size of both kidneys with thinned VI-37. Eculizumab, used in the treatment of atypical hemo-
cortices and regions of compensatory hypertrophy. What lytic uremic syndrome, targets which of the following?
is the likely cause of his renal disease? A. C5
A. Allergic interstitial nephritis B. Factor V
B. IgG4 disease C. Interleukin (IL)-6 receptor
C. Reflux nephropathy D. IL-17
D. Sickle cell nephropathy E. Tumor necrosis factor-α
E. Sjögren syndrome
VI-38. A 66-year-old woman presents to the emergency
VI-33. All of the following medications can cause acute room with malaise, confusion, and headache. Blood
interstitial nephritis EXCEPT: pressure is found to be 220/105. Physical examination is
notable for skin thickening of the arms and legs, facial
A. Celecoxib telangiectasias, and decreased oral aperture. Laboratory
B. Hydromorphone studies show a creatinine of 3.5 mg/dL, hemoglobin of
C. Pantoprazole 7.0 g/dL, platelets of 75,000/dL, lactate dehydrogenase of
D. Penicillin 700. What is the appropriate initial treatment?
E. Valproate
A. Amlodipine
VI-34. A patient with a history of Sjögren syndrome has the B. Captopril
following laboratory findings: plasma sodium 139 mEq/L, C. Eculizumab
chloride 112 mEq/L, bicarbonate 15 mEq/L, and potas- D. Heparin
sium 3.0 mEq/L. Urine studies show a pH of 6.0, sodium E. Plasmapheresis

461
 VI-39. A 35-year-old woman presents with complaints of 37°C (98.6°F), heart rate of 105 beats/min, blood pressure
bilateral lower extremity edema, polyuria, and moderate of 145/95, respiratory rate of 21 breaths/min, and room
SECTION VI

left-sided flank pain that began approximately 2 weeks
ago. There is no past medical history. She is taking no
medications and denies tobacco, alcohol, or illicit drug
use. Examination shows normal vital signs, including nor-
mal blood pressure. There is 2+ edema in bilateral lower
extremities. The 24-hour urine collection is significant
for 3.5 g of protein. Urinalysis is bland except for the pro-
Disorders of the Kidney and Urinary Tract
air oxygen saturation of 98%. His physical examination is
notable for left flank pain but no abdominal organomeg-
aly or focal tenderness. An electrocardiogram shows sinus
tachycardia with nonspecific ST-T wave changes. Interna-
tional normalized ratio is 2.0. His renal function is normal,
and urine analysis shows many red blood cells, few white
blood cells, no bacteria, and no crystals. Which of the fol-

teinuria. Serum creatinine is 0.7 mg/dL, and ultrasound lowing is the preferred diagnostic study?
examination shows the left kidney measuring 13 cm and
A. 24-Hour urine collection
the right kidney measuring 11.5 cm. You are concerned
B. Cystoscopy
about renal vein thrombosis. What test do you choose for
C. MRI
the evaluation?
D. Noncontrast CT scan
A. CT of the renal veins E. Ultrasound
B. Contrast venography
C. Magnetic resonance venography VI-43. In the patient described above, a noncontrast abdom-
D. 99Tc-labeled diethylene-triamine-pentaacetate acid inal CT is performed (Figure VI-43). Which of the follow-
(DTPA) imaging ing is the most likely diagnosis?
E. Ultrasound with Doppler evaluation of the renal
veins

VI-40. A 28-year-old woman who is in the 30th week of her

second pregnancy has been followed closely because of
mild hypertension. Her first pregnancy was complicated
by preeclampsia. She now complains of worsening fatigue
over the last day. Her blood pressure is 140/90, and she has
a heart rate of 84 beats/min and room air oxygen satura-
tion of 95%. Fetal monitoring shows no distress. Labora-
tory studies are notable for a hemoglobin of 6 g/dL (10 g/
dL 1 week ago) and platelet count of 80,000/dL (180,000/
dL 1 week ago). A peripheral blood smear shows schisto-
cytes. All of the following statements are true about her
condition EXCEPT:
A. Glucocorticoids are effective in reducing morbidity
and mortality.
B. Her liver function enzymes are likely elevated.
C. Preeclampsia predisposes to the condition. FIGURE VI-43 Used with permission from Dr. Stuart Silverman,
D. Renal failure is common. Brigham and Women’s Hospital.
E. The condition will likely resolve after delivery of the
fetus. A. Appendicitis
B. Nephrolithiasis
VI-41. Which of the following interventions has been shown C. Renal cell carcinoma
to decrease the recurrence of calcium oxalate renal stones? D. Pyelonephritis
A. A diet with abundant spinach and rhubarb E. Retroperitoneal hematoma
B. Aspirin
VI-44. Which of the following fluid or electrolyte abnormal-
C. Low-calcium diet (400 mg/day)
ities can be seen in some patients after the relief of bilateral
D. Thiazide diuretics
renal obstruction?
E. Vitamin C supplements
A. Hyperkalemia
VI-42. A 48-year-old man with diabetes mellitus, hyperlipi- B. Hypermagnesemia
demia, and atrial fibrillation presents to the emergency C. Hypernatremia
department for evaluation of left flank pain and groin pain D. Hypovolemia
that has been severe and present for approximately 3 hours. E. C and D
His medications include metformin, atorvastatin, and
warfarin. He is uncomfortable and has a temperature of

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VI-45. A 54-year-old woman with a history of colon cancer A. CT of the abdomen/pelvis with oral contrast
treated with resection and chemotherapy 2 years earlier is B. Postvoid residual volume of bladder

SECTION VI
admitted to the hospital after routine lab work at her pri- C. Retrograde urography
mary care physician’s office showed a blood urea nitrogen D. Ultrasound of the abdomen/kidney
of 65 mg/dL and a creatinine of 4.5 mg/dL. She reports E. Urinary fractional excretion of sodium
mild fatigue and recent lower back pain, but otherwise
feels well. She does admit to recent nonsteroidal anti- VI-46. The pain associated with acute urinary tract obstruc-
inflammatory drug (NSAID) use but has not taken more tion is a result of which of the following?
than the recommended quantity. Aside from stopping the A. Compensatory natriuresis

ANSWERS
NSAID and avoidance of nephrotoxins, which of the fol- B. Decreased medullary blood flow
lowing studies should be the next step? C. Increased renal blood flow
D. Vasodilatory prostaglandins

ANSWERS

VI-1. The answer is D. (Chap. 303) The proximal tubule is responsible for reabsorbing ~60%
of filtered sodium chloride (NaCl) and water, as well as ~90% of filtered bicarbonate and
most critical nutrients such as glucose and amino acids. The proximal tubule uses both
cellular and paracellular transport mechanisms. The apical membrane of proximal tubu-
lar cells has an expanded surface area available for reabsorptive work created by a dense
array of microvilli called the brush border, and leaky tight junctions enable high-capacity
fluid reabsorption. Approximately 15–25% of filtered NaCl is reabsorbed in the loop of
Henle, mainly by the thick ascending limb. The distal convoluted tubule reabsorbs ~5%
of the filtered NaCl. This segment is composed of a tight epithelium with little water per-
meability. The collecting duct modulates the final composition of urine. The two major
divisions, the cortical collecting duct and inner medullary collecting duct, contribute to
reabsorbing ~4–5% of filtered Na+ and are important for hormonal regulation of salt and
water balance.

VI-2. The answer is B. (Chap. 304) Several antimicrobial agents are commonly associated with
acute kidney injury (AKI). Aminoglycosides (e.g., gentamicin) and amphotericin B both
cause tubular necrosis. Nonoliguric AKI (i.e., with a urine volume >400 mL/day) accom-
panies 10–30% of courses of aminoglycoside antibiotics, even when plasma levels are in
the therapeutic range. Aminoglycosides are freely filtered across the glomerulus and then
accumulate within the renal cortex, where concentrations can greatly exceed those of the
plasma. AKI typically manifests after 5–7 days of therapy and can present even after the
drug has been discontinued. Hypomagnesemia is a common finding. AKI secondary to
acute interstitial nephritis can occur as a consequence of exposure to many antibiotics,
including penicillins, cephalosporins, quinolones, sulfonamides, and rifampin. There is
no reason for obstructive nephropathy or ischemic injury by history. Renal ultrasound
shows no evidence of obstruction. There are no red or white cell casts or anything in the
history to suggest glomerulonephritis.

VI-3. The answer is C. (Chap. 304) A variety of electrolyte abnormalities can be seen in acute
kidney injury (AKI) including hyponatremia, hyperkalemia, metabolic acidosis, hyper-
phosphatemia, and hypocalcemia. Abnormalities in plasma electrolyte composition can
be mild or life-threatening. The dysfunctional kidney has limited ability to regulate elec-
trolyte balance. Administration of excessive hypotonic crystalloid or isotonic dextrose
solutions can result in hyposmolality and hyponatremia, which, if severe, can cause neu-
rologic abnormalities, including seizures. Marked hyperkalemia is particularly common

463