Small bowel transplantation US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Small bowel transplantation. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Small bowel transplantation US Medical PG Question 1: Two weeks after undergoing allogeneic stem cell transplant for multiple myeloma, a 55-year-old man develops a severely pruritic rash, abdominal cramps, and profuse diarrhea. He appears lethargic. Physical examination shows yellow sclerae. There is a generalized maculopapular rash on his face, trunk, and lower extremities, and desquamation of both soles. His serum alanine aminotransferase is 115 U/L, serum aspartate aminotransferase is 97 U/L, and serum total bilirubin is 2.7 mg/dL. Which of the following is the most likely underlying cause of this patient's condition?
- A. Preformed cytotoxic anti-HLA antibodies
- B. Proliferating transplanted B cells
- C. Activated recipient T cells
- D. Donor T cells in the graft (Correct Answer)
- E. Newly formed anti-HLA antibodies
Small bowel transplantation Explanation: ***Donor T cells in the graft***
- The symptoms (rash, GI symptoms, liver dysfunction) after an allogeneic stem cell transplant are classic signs of **acute graft-versus-host disease (GVHD)**. This condition occurs when **immunocompetent T cells from the donor graft** recognize the recipient's tissues as foreign and mount an immune attack.
- The rapid onset within two weeks post-transplant, elevated liver enzymes, jaundice (**yellow sclerae**, **elevated bilirubin**), severe pruritic rash, and GI symptoms (**abdominal cramps**, **profuse diarrhea**) are all characteristic manifestations of acute GVHD.
*Preformed cytotoxic anti-HLA antibodies*
- Preformed antibodies would typically cause **hyperacute rejection**, which occurs within minutes to hours of transplantation and involves widespread thrombosis and necrosis of the graft, not the systemic symptoms seen here.
- This reaction is mediated by the recipient's antibodies attacking donor antigens, leading to immediate graft failure.
*Proliferating transplanted B cells*
- Transplanted B cells can contribute to chronic GVHD through antibody production, but they are not the primary mediators of **acute GVHD**; acute GVHD is predominantly a T cell-mediated process.
- Proliferation of donor B cells is more commonly associated with post-transplant lymphoproliferative disorders (PTLD) or chronic GVHD, not the acute presentation described.
*Activated recipient T cells*
- In an allogeneic transplant, the recipient's immune system is usually heavily suppressed beforehand to prevent host-versus-graft rejection.
- If recipient T cells were active, they would primarily cause **rejection of the donor stem cells** (graft rejection), not the systemic symptoms of GVHD, which is a reaction of the donor cells against the host.
*Newly formed anti-HLA antibodies*
- Newly formed antibodies the recipient develops against the donor's HLA antigens would cause graft rejection, a process often delayed but not presenting as the widespread organ damage of acute GVHD.
- These antibodies are part of the host's attempt to reject the foreign graft, not the donor cells attacking the host.
Small bowel transplantation US Medical PG Question 2: A 55-year-old woman recently underwent kidney transplantation for end-stage renal disease. Her early postoperative period was uneventful, and her serum creatinine is lowered from 4.3 mg/dL (preoperative) to 2.5 mg/dL. She is immediately started on immunosuppressive therapy. On postoperative day 7, she presents to the emergency department (ED) because of nausea, fever, abdominal pain at the transplant site, malaise, and pedal edema. The vital signs include: pulse 106/min, blood pressure 167/96 mm Hg, respirations 26/min, and temperature 40.0°C (104.0°F). The surgical site shows no signs of infection. Her urine output is 250 mL over the past 24 hours. Laboratory studies show:
Hematocrit 33%
White blood cell (WBC) count 6700/mm3
Blood urea 44 mg/dL
Serum creatinine 3.3 mg/dL
Serum sodium 136 mEq/L
Serum potassium 5.6 mEq/L
An ultrasound of the abdomen shows collection of fluid around the transplanted kidney with moderate hydronephrosis. Which of the following initial actions is the most appropriate?
- A. Re-operate and remove the failed kidney transplant
- B. Continue with an ultrasound-guided biopsy of the transplanted kidney (Correct Answer)
- C. Start on pulse steroid treatment or OKT3
- D. Supportive treatment with IV fluids, antibiotics, and antipyretics
- E. Consider hemodialysis
Small bowel transplantation Explanation: ***Continue with an ultrasound-guided biopsy of the transplanted kidney***
- The patient's symptoms (fever, malaise, abdominal pain, rising creatinine) and ultrasound findings (fluid collection, hydronephrosis) are highly suggestive of **acute renal allograft rejection** or an **obstructive uropathy**, necessitating a definitive diagnosis through biopsy.
- A biopsy will differentiate between rejection, drug toxicity, or other causes of allograft dysfunction, guiding appropriate and specific treatment.
*Re-operate and remove the failed kidney transplant*
- Removing the transplanted kidney is a drastic measure and premature at this stage, as the cause of dysfunction is not yet confirmed.
- The elevated creatinine and hydronephrosis could be reversible with proper treatment once the underlying cause is identified.
*Start on pulse steroid treatment or OKT3*
- While pulse steroids or OKT3 (muromonab-CD3) are used to treat acute rejection, administering them without a definitive diagnosis from a biopsy could be inappropriate and potentially harmful.
- The symptoms could also be due to infection or obstruction, which would not respond to these immunosuppressive therapies and could worsen with increased immunosuppression.
*Supportive treatment with IV fluids, antibiotics, and antipyretics*
- Supportive care alone is insufficient given the potential for acute allograft rejection or severe obstruction, which requires specific intervention.
- Although the patient has fever, there are no clear signs of infection, and empirical antibiotics may delay necessary diagnostic steps.
*Consider hemodialysis*
- While the patient's creatinine is elevated and potassium is high, these parameters alone do not immediately warrant hemodialysis without exploring the underlying cause of allograft dysfunction.
- Dialysis is typically considered when there are severe indications like refractory hyperkalemia, fluid overload, acidosis, or uremic symptoms that cannot be otherwise managed, and the primary goal should be to treat the cause of decreasing kidney function.
Small bowel transplantation US Medical PG Question 3: A 72-year-old woman presents to the clinic complaining of diarrhea for the past week. She mentions intense fatigue and intermittent, cramping abdominal pain. She has not noticed any blood in her stool. She recalls an episode of pneumonia last month for which she was hospitalized and treated with antibiotics. She has traveled recently to Florida to visit her family and friends. Her past medical history is significant for hypertension, peptic ulcer disease, and hypercholesterolemia for which she takes losartan, esomeprazole, and atorvastatin. She also has osteoporosis, for which she takes calcium and vitamin D and occasional constipation for which she takes an over the counter laxative as needed. Physical examination shows lower abdominal tenderness but is otherwise insignificant. Blood pressure is 110/70 mm Hg, pulse is 80/min, and respiratory rate is 18/min. Stool testing is performed and reveals the presence of anaerobic, gram-positive bacilli. Which of the following increased this patient’s risk of developing this clinical presentation?
- A. Hypercholesterolemia treated with atorvastatin
- B. Constipation treated with laxatives
- C. Osteoporosis treated with calcium and vitamin D
- D. Peptic ulcer disease treated with esomeprazole
- E. Recent antibiotic use for pneumonia treatment (Correct Answer)
Small bowel transplantation Explanation: ***Recent antibiotic use for pneumonia treatment***
- **Antibiotic exposure** is the single most important risk factor for *Clostridioides difficile* infection (CDI), present in approximately 70% of cases.
- Antibiotics disrupt the normal protective gut microbiota, eliminating competitive bacteria and allowing *C. difficile* spores to germinate, colonize, and produce toxins.
- The patient's recent hospitalization and antibiotic treatment for pneumonia directly precipitated this infection by creating an ecological niche for *C. difficile* overgrowth.
- Common culprit antibiotics include fluoroquinolones, clindamycin, cephalosporins, and penicillins.
*Peptic ulcer disease treated with esomeprazole*
- **Proton pump inhibitors (PPIs)** like esomeprazole are an independent risk factor for CDI, increasing risk approximately 2-3 fold.
- PPIs reduce gastric acid production, which normally serves as a defense mechanism against ingested *C. difficile* spores.
- However, PPIs alone do not typically cause CDI without concurrent disruption of gut flora (usually by antibiotics).
- While this is a contributory risk factor in this patient, it is not the primary cause.
*Hypercholesterolemia treated with atorvastatin*
- **Statins** like atorvastatin have no established association with increased risk of *Clostridioides difficile* infection.
- They work by inhibiting HMG-CoA reductase to lower cholesterol and do not affect gastric pH or gut microbiota composition.
*Constipation treated with laxatives*
- Occasional **over-the-counter laxative use** is not a risk factor for *Clostridioides difficile* infection.
- While laxatives affect gut motility, they do not disrupt the protective gut microbiota or increase susceptibility to CDI.
*Osteoporosis treated with calcium and vitamin D*
- **Calcium and vitamin D supplementation** has no association with increased risk of *Clostridioides difficile* infection.
- These supplements support bone health and calcium metabolism without affecting gut flora or gastric acid production.
Small bowel transplantation US Medical PG Question 4: A 40-year-old male with a history of chronic alcoholism recently received a liver transplant. Two weeks following the transplant, the patient presents with a skin rash and frequent episodes of bloody diarrhea. A colonoscopy is performed and biopsy reveals apoptosis of colonic epithelial cells. What is most likely mediating these symptoms?
- A. Donor T-cells (Correct Answer)
- B. Recipient T-cells
- C. Recipient B-cells
- D. Recipient antibodies
- E. Donor B-cells
Small bowel transplantation Explanation: ***Donor T-cells***
- This clinical presentation of **skin rash**, **bloody diarrhea**, and **colonic epithelial apoptosis** following an allogeneic transplant (like a liver transplant) is classic for **Graft-versus-Host Disease (GVHD)**.
- In GVHD, **immunocompetent T-cells from the donor** recognize the recipient's tissues as foreign and mount an immune attack, causing damage to organs like the skin, gastrointestinal tract, and liver.
*Recipient T-cells*
- **Recipient T-cells** are typically immunosuppressed following an organ transplant to prevent organ rejection.
- Furthermore, if activated, recipient T-cells would target the donor organ (the liver in this case), leading to **rejection**, rather than the systemic symptoms observed (skin rash, bloody diarrhea) which suggest an attack by donor cells on recipient tissues.
*Recipient B-cells*
- While recipient B-cells can be involved in **antibody-mediated rejection** of the transplanted organ, they are not the primary mediators of **cellular GVHD**.
- **Antibody-mediated rejection** would typically involve antibodies targeting the donor liver, leading to liver dysfunction, not the widespread GVHD symptoms described.
*Recipient antibodies*
- **Recipient antibodies** are primarily involved in **antibody-mediated rejection** of the transplanted organ, which would manifest as dysfunction of the transplanted liver.
- They do not mediate the symptoms of **Graft-versus-Host Disease (GVHD)**, which is a cell-mediated immune response.
*Donor B-cells*
- **Donor B-cells** are generally not the primary mediators of GVHD.
- While donor immune cells are crucial for GVHD, the major players are **donor T-cells**, which directly recognize and attack host tissues.
Small bowel transplantation US Medical PG Question 5: A 59-year-old woman comes to the physician for a routine health maintenance examination. She feels well. She has systemic lupus erythematosus and hypertension. She does not drink alcohol. Her current medications include lisinopril and hydroxychloroquine. She appears malnourished. Her vital signs are within normal limits. Examination shows a soft, nontender abdomen. There is no ascites or hepatosplenomegaly. Serum studies show:
Total bilirubin 1.2 mg/dL
Alkaline phosphatase 60 U/L
Alanine aminotransferase 456 U/L
Aspartate aminotransferase 145 U/L
Hepatitis A IgM antibody negative
Hepatitis A IgG antibody positive
Hepatitis B surface antigen positive
Hepatitis B surface antibody negative
Hepatitis B envelope antigen positive
Hepatitis B envelope antibody negative
Hepatitis B core antigen IgM antibody negative
Hepatitis B core antigen IgG antibody positive
Hepatitis C antibody negative
Which of the following is the most appropriate treatment for this patient?
- A. Pegylated interferon alpha therapy
- B. Tenofovir therapy (Correct Answer)
- C. Referral to a liver transplantation center
- D. Reassurance and follow-up
- E. Lamivudine therapy
Small bowel transplantation Explanation: ***Tenofovir therapy***
- This patient has **chronic hepatitis B** with evidence of **active viral replication** (positive HBsAg, HBeAg, and elevated liver enzymes), indicating a need for antiviral treatment.
- **Tenofovir** is a highly effective and well-tolerated oral antiviral agent for chronic hepatitis B, suitable for initial therapy.
*Pegylated interferon alpha therapy*
- While an option for chronic hepatitis B, **pegylated interferon alpha** has more significant side effects and is generally avoided in patients with **systemic lupus erythematosus (SLE)** due to the risk of exacerbating the autoimmune condition.
- It also requires subcutaneous injections and has a lower rate of HBeAg seroconversion compared to nucleos(t)ide analogs in many patient populations.
*Referral to a liver transplantation center*
- This patient currently shows **elevated liver enzymes** but no immediate signs of **decompensated liver disease** (e.g., ascites, encephalopathy, variceal bleeding) or severe liver failure that would warrant urgent transplantation.
- Treatment with antiviral medication is the first step to prevent progression to end-stage liver disease.
*Reassurance and follow-up*
- The patient has **elevated transaminases** and markers of **active viral replication** (positive HBeAg), indicating ongoing liver injury and potential progression to cirrhosis.
- Simply observing the patient without treatment would be inappropriate and could lead to irreversible liver damage.
*Lamivudine therapy*
- **Lamivudine** is an older nucleos(t)ide analog for hepatitis B that has a significantly **higher rate of drug resistance** compared to newer agents like tenofovir.
- It is generally not recommended as a first-line treatment due to its resistance profile.
Small bowel transplantation US Medical PG Question 6: A 66-year-old woman is brought to the emergency department because of fever, chills, night sweats, and progressive shortness of breath for 1 week. She also reports generalized fatigue and nausea. She has type 2 diabetes mellitus and hypothyroidism. Current medications include metformin, sitagliptin, and levothyroxine. She appears ill. Her temperature is 38.7°C (101.7°F), pulse is 104/min, and blood pressure is 160/90 mm Hg. Examination shows pale conjunctivae and small nontender hemorrhagic macules over her palms and soles. Crackles are heard at both lung bases. A grade 2/6 mid-diastolic murmur is heard best at the third left intercostal space and is accentuated by leaning forward. The spleen is palpated 1–2 cm below the left costal margin. Laboratory studies show:
Hemoglobin 10.6 g/dL
Leukocyte count 18,300/mm3
Erythrocyte sedimentation rate 48 mm/h
Urine
Protein 1+
Blood 2+
RBCs 20-30/hpf
WBCs 0-2/hpf
An echocardiography shows multiple vegetations on the aortic valve. Blood cultures grow S. gallolyticus. She is treated with ampicillin and gentamicin for 2 weeks and her symptoms resolve. A repeat echocardiography at 3 weeks shows mild aortic regurgitation with no vegetations. Which of the following is the most appropriate next step in management?
- A. Esophagogastroduodenoscopy
- B. CT scan of the abdomen and pelvis
- C. Colonoscopy (Correct Answer)
- D. Warfarin therapy
- E. Implantable defibrillator
Small bowel transplantation Explanation: ***Colonoscopy***
- The isolation of **_S. gallolyticus_** (formerly _S. bovis_ biotype I) in blood cultures, especially in the context of infective endocarditis, is highly associated with **colorectal neoplasms** (adenomas or carcinomas).
- Therefore, a **colonoscopy** is essential to screen for underlying gastrointestinal malignancy, even after the infection has been successfully treated.
*Esophagogastroduodenoscopy*
- While _S. gallolyticus_ can originate from the GI tract, its strong association is specifically with **colorectal pathology**, not primarily upper GI sources.
- An EGD would not be the initial, most appropriate next step given the specific microorganism.
*CT scan of the abdomen and pelvis*
- A CT scan can detect abdominal masses but is **less sensitive** than colonoscopy for detecting adenomatous polyps or early-stage colorectal cancer.
- It would also not provide a tissue diagnosis, which is crucial for characterizing any detected lesions.
*Warfarin therapy*
- Warfarin is an anticoagulant used to prevent thromboembolic events, but there is **no indication for chronic anticoagulation** in this patient at this stage.
- Her endocarditis has resolved, and the mild aortic regurgitation alone does not necessitate warfarin.
*Implantable defibrillator*
- An implantable defibrillator is used to prevent sudden cardiac death in patients at high risk of **ventricular arrhythmias**.
- There is no information in the clinical scenario suggestive of such a risk, and her cardiac issue (mild aortic regurgitation post-endocarditis) does not warrant this intervention.
Small bowel transplantation US Medical PG Question 7: A 4-month-old boy is brought to the physician by his parents for a well-child examination. He has cystic fibrosis diagnosed by newborn screening. His parents report frequent feedings and large-volume and greasy stools. His 4-year-old brother has autism. Current medications include bronchodilators, pancreatic enzyme supplements, and fat-soluble vitamins. He is at the 18th percentile for height and 15th percentile for weight. Scattered wheezes are heard throughout both lung fields. Examination shows a distended and tympanic abdomen with no tenderness or guarding. Which of the following is a contraindication for administering one or more routine vaccinations?
- A. Allergy to egg protein
- B. History of cystic fibrosis
- C. History of febrile seizures
- D. Fever of 38.2°C (100.7°F) following previous vaccinations
- E. History of intussusception (Correct Answer)
Small bowel transplantation Explanation: ***History of intussusception***
- A history of **intussusception** is a **contraindication for rotavirus vaccine** administration, as the vaccine itself has a small risk of intussusception, particularly with the first dose.
- The rotavirus vaccine is part of routine childhood immunizations, so this would be a contraindication for one of the routine vaccines.
*Allergy to egg protein*
- Egg allergy is a contraindication primarily for yellow fever vaccine and some influenza vaccines, which are typically not routine vaccinations for a 4-month-old. Many flu vaccines are egg-free or can be safely administered to those with egg allergy under supervision.
- The MMR vaccine is generally safe for those with egg allergy since the amount of egg protein is negligible.
*History of cystic fibrosis*
- **Cystic fibrosis** itself is **not a contraindication** to routine vaccinations; in fact, patients with chronic conditions like CF are often *more* encouraged to receive vaccinations to prevent severe infections.
- The patient's symptoms (poor growth, greasy stools, wheezing) are manifestations of CF, not reasons to defer vaccination.
*History of febrile seizures*
- A history of **febrile seizures** is generally **not a contraindication** to routine vaccinations.
- Parents should be counseled on fever management after vaccination, but the risk of recurrent febrile seizures is not increased by vaccination to a level that warrants deferral.
*Fever of 38.2°C (100.7°F) following previous vaccinations*
- A **low-grade fever** after vaccination is a common and **expected immune response**, not a contraindication for future doses.
- Only a **severe allergic reaction** (e.g., anaphylaxis) to a previous dose of a vaccine or one of its components is a contraindication to subsequent doses of that specific vaccine.
Small bowel transplantation US Medical PG Question 8: A 43-year-old woman comes to the office with a 5-day history of a rash. She's had a rash across her neck, shoulders, and the palms of her hands for the past five days. She's also had large-volume watery diarrhea for the same period of time. Past medical history is notable for acute myeloid leukemia, for which she received a stem cell transplant from a donor about two months prior. Physical exam reveals a faint red maculopapular rash across her neck, shoulders, and hands, as well as an enlarged liver and spleen. Labs are notable for a total bilirubin of 10. Which of the following is the mechanism of this patient's pathology?
- A. Drug hypersensitivity reaction
- B. Host CD8+ T cells against graft antigens
- C. Graft T cells against host antigens (Correct Answer)
- D. Pre-existing host antibodies against graft antigens
- E. Host antibodies that have developed against graft antigens
Small bowel transplantation Explanation: ***Graft T cells against host antigens***
- This patient's symptoms (rash, diarrhea, hepatosplenomegaly, elevated bilirubin) occurring after a stem cell transplant are classic for **graft-versus-host disease (GVHD)**.
- GVHD occurs when **donor T cells** from the graft recognize the recipient's (host's) tissues as foreign and mount an immune attack against them.
*Drug hypersensitivity reaction*
- While drug rashes can occur, the widespread nature, severe GI involvement (large-volume watery diarrhea), and liver dysfunction, especially in the context of a recent stem cell transplant, point away from a simple **hypersensitivity reaction**.
- A drug reaction would typically not cause such severe systemic effects or splenomegaly.
*Host CD8+ T cells against graft antigens*
- This describes **host-versus-graft rejection**, where the recipient's immune system attacks the transplanted cells.
- In a stem cell transplant setting, the host's immune system is typically severely suppressed to prevent this, and the clinical picture here is characteristic of the donor cells attacking the host.
*Pre-existing host antibodies against graft antigens*
- Pre-existing antibodies would cause a **hyperacute or acute rejection** much earlier after transplantation, often within minutes to days.
- This patient's symptoms developed two months post-transplant, which is more typical for acute GVHD, mediated by T cells.
*Host antibodies that have developed against graft antigens*
- The development of host antibodies against graft antigens would lead to **humoral rejection**, which typically manifests differently and less commonly causes the specific constellation of symptoms seen here (skin rash, severe diarrhea, cholestatic hepatitis in the context of stem cell transplant).
- T-cell-mediated responses are the primary drivers of GVHD in this scenario.
Small bowel transplantation US Medical PG Question 9: A 24-year-old woman with 45,X syndrome comes to the physician because of diarrhea for 4 months. She also reports bloating, nausea, and abdominal discomfort that persists after defecation. For the past 6 months, she has felt tired and has been unable to do her normal chores. She went on a backpacking trip across Southeast Asia around 7 months ago. She is 144 cm (4 ft 9 in) tall and weighs 40 kg (88 lb); BMI is 19 kg/m2. Her blood pressure is 110/60 mm Hg in the upper extremities and 80/40 mm Hg in the lower extremities. Examination shows pale conjunctivae and angular stomatitis. Abdominal examination is normal. Laboratory studies show:
Hemoglobin 9.1 mg/dL
Leukocyte count 5100/mm3
Platelet count 200,000/mm3
Mean corpuscular volume 67 μmm3
Serum
Na+ 136 mEq/L
K+ 3.7 mEq/L
Cl- 105 mEq/L
Glucose 89 mg/dL
Creatinine 1.4 mg/dL
Ferritin 10 ng/mL
IgA tissue transglutaminase antibody positive
Based on the laboratory studies, a biopsy for confirmation of the diagnosis is suggested, but the patient is unwilling to undergo the procedure. Which of the following is the most appropriate next step in management of this patient's gastrointestinal symptoms?
- A. Avoid milk products
- B. Gluten-free diet (Correct Answer)
- C. Metronidazole therapy
- D. Intravenous immunoglobulin therapy
- E. Trimethoprim-sulfamethoxazole therapy
Small bowel transplantation Explanation: ***Gluten-free diet***
- The patient's symptoms (diarrhea, bloating, abdominal discomfort, fatigue) and lab findings (**microcytic anemia** with **low ferritin**, and **positive IgA tissue transglutaminase antibody**) are highly suggestive of **celiac disease**.
- Given the strong serological evidence and patient's unwillingness for biopsy, initiating a **gluten-free diet** is the most appropriate next step, as it is the primary treatment for celiac disease and should alleviate symptoms.
*Avoid milk products*
- While **lactose intolerance** can cause similar GI symptoms like diarrhea and bloating, and is sometimes comorbid with celiac disease due to damage to intestinal villi, the primary driver here appears to be celiac disease based on the specific antibody test.
- Avoiding milk products without addressing the underlying celiac disease would likely not resolve all symptoms, and a gluten-free diet is the more targeted initial therapy for the confirmed serology.
*Metronidazole therapy*
- **Metronidazole** is an antibiotic used to treat bacterial and parasitic infections, such as *Giardia* or *Clostridium difficile*.
- Although the patient traveled to Southeast Asia, suggesting a possible exposure to parasitic infections, the presence of **positive IgA tissue transglutaminase antibody** strongly points towards celiac disease, not solely an infection requiring antibiotics (though infections can sometimes trigger celiac disease onset).
*Intravenous immunoglobulin therapy*
- **Intravenous immunoglobulin (IVIG) therapy** is used for various immune deficiencies or autoimmune conditions, but it is not indicated for the initial management of celiac disease.
- Celiac disease is managed by dietary changes (gluten-free diet) to prevent autoimmune damage to the small intestine.
*Trimethoprim-sulfamethoxazole therapy*
- **Trimethoprim-sulfamethoxazole** is an antibiotic primarily used for bacterial infections, including some diarrheal diseases.
- Similar to metronidazole, while an infection is plausible given the travel history, the strong serological evidence for celiac disease makes antibiotic therapy a less appropriate first step compared to a gluten-free diet.
Small bowel transplantation US Medical PG Question 10: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?
- A. "Does the diarrhea typically precede the constipation, or vice-versa?"
- B. "Is the diarrhea foul-smelling?"
- C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
- D. "Are the symptoms worse in the morning or at night?"
- E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)
Small bowel transplantation Explanation: ***Can you tell me more about the symptoms you have been experiencing?***
- This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis.
- In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions.
*Does the diarrhea typically precede the constipation, or vice-versa?*
- While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience.
- It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture.
*Is the diarrhea foul-smelling?*
- Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions.
- However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed.
*Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life*
- Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time.
- However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially.
*Are the symptoms worse in the morning or at night?*
- Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related.
- This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.
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