Medical Case Study Questions

A 54-year-old male presents to the emergency department with a 1-week history of abdominal pain. His other symptoms are nausea, vomiting, low-grade fever, and loss of appetite. He does not use alcohol. He has a seizure disorder, for which he takes a "prescription drug." X-ray films of his chest and abdomen show no abnormalities. His abdominal CT scan is shown below. Which of the following is the most likely explanation for this patient's abdominal symptoms?

• Liver pathology

• Kidney pathology

• Air in the stomach

• Gall bladder pathology

• Pancreas pathology

A 5-day-old African-American girl is taken to the pediatrician because her "eyes look yellow." She is being exclusively formula-fed with an iron-rich formula. She has six wet diapers a day and stools twice a day. The pregnancy was uncomplicated, and she was delivered by spontaneous vaginal delivery. Her Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. Her temperature is 37°C (98.6°F), her head circumference is in the 50th percentile, and her weight is 3420 g (3 g below her birth weight). Her sclerae are icteric. There is no hepatomegaly or splenomegaly. Her total bilirubin is 9 mg/dL, and her conjugated bilirubin is 0.2 mg/dL. Hemoglobin is 15 g/dL. Which of the following is the most likely diagnosis?

• Biliary atresia

• Dubin-Johnson syndrome

• Rotor syndrome

• a1-Antitrypsin deficiency

• Physiologic jaundice

A 55-year-old white man with a 20-year history of gastroesophageal reflux visits the clinic for worsening reflux symptoms over the past 18 months. His last visit was 7 years ago, and he claims to be otherwise in good health. He has been compliant with his antireflux medications, including an H2-blocker and a proton pump inhibitor. Which of the following is the best next step in management?

• Double the dose of his proton pump inhibitor and schedule him for follow-up in 4 weeks

• Schedule him for emergent Nissen fundoplication

• Schedule him for elective esophagectomy

• Double the dose of his H2-blocker and schedule him for follow-up in 4 weeks

• Perform an esophagoscopy

A term boy with Apgar scores of 9 and 9 at 1 and 5 minutes has failed to pass meconium at 72 hours. He has had no episodes of emesis, and his abdomen is only mildly distended to palpation. The patient's mother reports that her older son had the same problem at birth. A plain radiograph of the abdomen shows a small bowel obstruction with numerous air-filled loops of bowel. The patient is treated with a diatrizoate meglumine (Gastrografin) enema, with good results. Which of the following is the most likely mechanism for this infant's acute intestinal problem?

• Deficiency of pancreatic enzymes

• Total absence of the small bowel

• Intussusception of the large bowel

• Volvulus of the transverse colon

• Deficiency of pancreatic enzymes

A 50-year-old white male presents with complaints of a bitter taste and central chest pain. He further describes the pain as moderate-to-severe, occurring during or after meals, non-radiating, and burning. The pain is relieved with antacids and worsened by lying supine. He has lost 10 lbs (4.5 kg) over the past 5 months (unintentional). He has smoked 2 packs of cigarettes daily for 20 years. His vital signs are stable, and he is afebrile. Chest x-ray and EKG show no abnormalities. Which of the following is the most appropriate next step in management?

• Treatment with antacids

• Treatment with famotidine

• Treatment with omeprazole

• Esophageal pH monitoring

• Esophagoscopy

A 65-year-old man comes to the physician's office with a 2-month history of dysphagia. He initially had difficulty swallowing solids, but now this includes liquids. He has occasional heartburn, which usually responds well to antacids. He has lost 20 lbs of weight in the past 2 months. He has a 40 pack-year history of smoking. He has been a chronic alcoholic for 20 years. His temperature is 36.7°C (98°F), blood pressure is 110/80 mmHg, pulse is 66/min, and respirations are 14/min. Physical examination shows no abnormalities. Barium studies show a minimally dilated esophagus with beak-shaped narrowing. Manometry shows increased lower esophageal sphincter tone. Which of the following is the most likely diagnosis?

• Scleroderma

• Diffuse esophageal spasm

• Achalasia

• Peptic stricture

• Esophageal cancer

A 56-year-old male presents with progressively worsening dyspnea and ankle edema. He denies chest pain, syncope, or palpitations. He does not smoke or drink alcohol. He denies diabetes mellitus, hypertension, or hyperlipidemia. His temperature is 37.1°C (98.7°F), pulse is 70/min, blood pressure is 136/70 mmHg, and respirations are 15/min. Examination shows elevated jugular venous pressure, bilateral ankle edema, and tender hepatomegaly. Chest auscultation shows bibasilar rales. His heart sounds are distant, and there is no murmur. Chest x-ray shows mild cardiomegaly and a right-sided pleural effusion. ECG shows low voltage QRS complexes and nonspecific ST-T wave changes. Echocardiography shows normal left ventricular volume with symmetrical thickening of the left ventricular walls and slightly reduced systolic function. Which of the following would represent a potentially reversible cause of this patient's heart disease?

• Scleroderma

• Hemochromatosis

• LED

• Amyloidosis

• Hemochromatosis

A 33-year-old woman develops mild epigastric abdominal pain with nausea and vomiting of 2 days' duration. Her abdomen is tender on palpation in the epigastric region, and the remaining examination is normal. Her white count is 13,000/mL, and amylase is 300 U/L (25-125 U/L). Which of the following is the most common predisposing factor for this disorder?

• Gallstones

• Malignancy

• Drugs

• Alcohol

• Gallstones