GI motility disorders — MCQs

10 questions

A 25-year-old man presents to his gastroenterologist for trouble swallowing. The patient states that whenever he eats solids, he regurgitates them back up. Given this patient's suspected diagnosis, the gastroenterologist performs a diagnostic test. Several hours later, the patient presents to the emergency department with chest pain and shortness of breath. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 60/min, respirations are 12/min, and oxygen saturation is 99% on room air. On physical exam, the patient demonstrates a normal cardiopulmonary exam. His physical exam demonstrates no tenderness of the neck, a normal oropharynx, palpable crepitus above the clavicles, and minor lymphadenopathy. Which of the following is the best next step in management?

A 7-year-old boy is brought to the physician by his mother for the evaluation of abdominal pain and trouble sleeping for the past 6 months. His mother says he complains of crampy abdominal pain every morning on school days. He started attending a new school 7 months ago and she is concerned because he has missed school frequently due to the abdominal pain. He also has trouble falling asleep at night and asks to sleep in the same room with his parents every night. He has not had fever, vomiting, diarrhea, or weight loss. He sits very close to his mother and starts to cry when she steps out of the room to take a phone call. Abdominal examination shows no abnormalities. Which of the following is the most likely diagnosis?

A 55-year-old woman with type 2 diabetes mellitus presents to her physician with intermittent nausea for the past 2 months. Her symptoms are exacerbated within one hour after eating. She has no other history of a serious illness. She takes metformin and injects insulin. Her vitals are normal. Abdominal examination is normal. An ECG shows normal sinus rhythm with no evidence of ischemia. Hemoglobin A1c is 7%. A gastric emptying scan shows 60% of her meal in the stomach 75 minutes after eating. Which of the following is the most appropriate pharmacotherapy at this time?

A 47-year-old man presents with recurrent epigastric pain and diarrhea. He has had these symptoms for the last year or so and has been to the clinic several times with similar complaints. His current dosage of omeprazole has been steadily increasing to combat his symptoms. The pain seems to be related to food intake. He describes his diarrhea as watery and unrelated to his meals. Blood pressure is 115/80 mm Hg, pulse is 76/min, and respiratory rate is 19/min. He denies tobacco or alcohol use. An upper endoscopy is performed due to his unexplained and recurrent dyspepsia and reveals thickened gastric folds with three ulcers in the first part of the duodenum, all of which are negative for H. pylori. Which of the following is the best next step in this patient's management?

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 55-year-old man presents to his primary care physician for trouble swallowing. The patient claims that he used to struggle when eating food if he did not chew it thoroughly, but now he occasionally struggles with liquids as well. He also complains of a retrosternal burning sensation whenever he eats. He also claims that he feels his throat burns when he lays down or goes to bed. Otherwise, the patient has no other complaints. The patient has a past medical history of obesity, diabetes, constipation, and anxiety. His current medications include insulin, metformin, and lisinopril. On review of systems, the patient endorses a 5 pound weight loss recently. The patient has a 22 pack-year smoking history and drinks alcohol with dinner. His temperature is 99.5°F (37.5°C), blood pressure is 177/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note an overweight man in no current distress. Abdominal exam is within normal limits. Which of the following is the best next step in management?

A 37-year-old woman comes to the physician because of difficulty swallowing for the past 1 year. She was diagnosed with gastroesophageal reflux 3 years ago and takes pantoprazole. She has smoked a pack of cigarettes daily for 14 years. Examination shows hardening of the skin of the fingers and several white papules on the fingertips. There are small dilated blood vessels on the face. Which of the following is the most likely cause of this patient's difficulty swallowing?

A 48-year-old man presents to his primary care physician with diarrhea and weight loss. He states he has had diarrhea for the past several months that has been worsening steadily. The patient recently went on a camping trip and drank unfiltered stream water. Otherwise, the patient endorses a warm and flushed feeling in his face that occurs sporadically. His temperature is 97.2°F (36.2°C), blood pressure is 137/68 mmHg, pulse is 110/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a murmur heard best over the left lower sternal border and bilateral wheezing on pulmonary exam. Which of the following is the best initial step in management?

A 66-year-old woman with no significant past medical, past surgical, or family history presents with new symptoms of chest pain, an oral rash, and pain with swallowing. She lost her husband several months earlier and has moved into an elderly assisted living community. She states that her symptoms began several weeks earlier. Physical examination reveals numerous white plaques on her buccal mucosa and tongue, raising suspicion for oral candidiasis. What is the next step in the patient’s management?

Q10

A 55-year-old man presents to urgent care for weakness and weight loss. He states for the past several months he has felt progressively weaker and has lost 25 pounds. The patient also endorses intermittent abdominal pain. The patient has not seen a physician in 30 years and recalls being current on most of his vaccinations. He says that a few years ago, he went to the emergency department due to abdominal pain and was found to have increased liver enzymes due to excessive alcohol use and incidental gallstones. The patient has a 50 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 161/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam reveals an emaciated man. The patient has a negative Murphy's sign and his abdomen is non-tender. Cardiopulmonary exam is within normal limits. Which of the following is the next best step in management?

GI motility disorders US Medical PG Practice Questions and MCQs

Question 1: A 25-year-old man presents to his gastroenterologist for trouble swallowing. The patient states that whenever he eats solids, he regurgitates them back up. Given this patient's suspected diagnosis, the gastroenterologist performs a diagnostic test. Several hours later, the patient presents to the emergency department with chest pain and shortness of breath. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 60/min, respirations are 12/min, and oxygen saturation is 99% on room air. On physical exam, the patient demonstrates a normal cardiopulmonary exam. His physical exam demonstrates no tenderness of the neck, a normal oropharynx, palpable crepitus above the clavicles, and minor lymphadenopathy. Which of the following is the best next step in management?

A. Barium swallow
B. Gastrografin swallow (Correct Answer)
C. Urgent surgery
D. Ultrasound

Explanation: ***Gastrografin swallow*** - This patient likely has an **esophageal perforation** following a diagnostic procedure, possibly **endoscopy or manometry** for suspected achalasia given the dysphagia, regurgitation, and subsequent symptoms. - A **Gastrografin swallow** is the best initial diagnostic step because it is water-soluble, allowing for detection of a leak without causing severe complications if aspirated into the lungs or mediastinum. *Barium swallow* - This is generally not recommended for suspected esophageal perforation as **barium** is a corrosive agent that can cause a severe inflammatory reaction known as **mediastinitis** if it leaks into the mediastinum. - While it offers superior mucosal detail, the risks associated with extravasation outweigh its benefits in this emergent setting. *Urgent surgery* - While **surgical repair** is the definitive treatment for significant esophageal perforations, it should only be performed after definitive diagnosis and localization of the perforation. - Performing surgery without imaging confirmation would be inappropriate and potentially lead to unnecessary intervention or missing the actual site of injury. *Ultrasound* - **Ultrasound** has limited utility in diagnosing esophageal perforation due to the location of the esophagus behind the trachea and sternum, making it largely inaccessible to acoustic waves. - It also cannot effectively detect the leakage of contrast material from the esophageal lumen.

Question 2: A 7-year-old boy is brought to the physician by his mother for the evaluation of abdominal pain and trouble sleeping for the past 6 months. His mother says he complains of crampy abdominal pain every morning on school days. He started attending a new school 7 months ago and she is concerned because he has missed school frequently due to the abdominal pain. He also has trouble falling asleep at night and asks to sleep in the same room with his parents every night. He has not had fever, vomiting, diarrhea, or weight loss. He sits very close to his mother and starts to cry when she steps out of the room to take a phone call. Abdominal examination shows no abnormalities. Which of the following is the most likely diagnosis?

A. Acute stress disorder
B. Separation anxiety disorder (Correct Answer)
C. Normal behavior
D. Irritable bowel syndrome
E. Conduct disorder

Explanation: ***Separation anxiety disorder*** - This child exhibits classic symptoms of **separation anxiety disorder**, including **school refusal** due to physical complaints (abdominal pain), **difficulty sleeping alone**, and **excessive distress** when separated from a primary attachment figure (mother). - The symptoms started shortly after attending a new school, a common trigger for separation anxiety, and have persisted for 6 months, meeting the **diagnostic criteria for duration** in children (≥4 weeks). *Acute stress disorder* - **Acute stress disorder** typically occurs within one month of exposure to a **traumatic event** and involves symptoms like intrusive thoughts, negative mood, dissociation, and hypervigilance. - The boy's symptoms are **chronic (6 months)** and are related to separation, not a specific traumatic event, making this diagnosis less likely. *Normal behavior* - While some mild separation anxiety is normal in young children, the **severity**, **duration (6 months)**, and **functional impairment** (missing school, difficulty sleeping alone) in this 7-year-old go beyond what is considered typical developmental behavior. - Normal separation anxiety usually resolves by preschool age or is short-lived without significant impact on daily life. *Irritable bowel syndrome* - **Irritable bowel syndrome (IBS)** is a common cause of recurrent abdominal pain, but it is typically associated with **changes in bowel habits** (constipation or diarrhea), which are absent in this case. - Furthermore, the child's other symptoms, such as **school refusal**, **sleep disturbances**, and **distress upon separation**, are not characteristic of IBS and point towards a psychological rather than purely gastrointestinal etiology. *Conduct disorder* - **Conduct disorder** involves a persistent pattern of **aggressive behavior**, **destruction of property**, **deceitfulness or theft**, and **serious rule violations**, none of which are described in this case. - The child's symptoms are characterized by anxiety and emotional distress related to separation, not defiant or antisocial behavior.

Question 3: A 55-year-old woman with type 2 diabetes mellitus presents to her physician with intermittent nausea for the past 2 months. Her symptoms are exacerbated within one hour after eating. She has no other history of a serious illness. She takes metformin and injects insulin. Her vitals are normal. Abdominal examination is normal. An ECG shows normal sinus rhythm with no evidence of ischemia. Hemoglobin A1c is 7%. A gastric emptying scan shows 60% of her meal in the stomach 75 minutes after eating. Which of the following is the most appropriate pharmacotherapy at this time?

A. Dimenhydrinate
B. Octreotide
C. Lorazepam
D. Metoclopramide (Correct Answer)
E. Ondansetron

Explanation: ***Metoclopramide*** - This patient presents with symptoms and gastric emptying scan results consistent with **diabetic gastroparesis**. Metoclopramide is a **prokinetic agent** that increases gastrointestinal motility and reduces nausea and vomiting. - As a **dopamine D2 receptor antagonist**, it enhances cholinergic stimulation of the GI tract, promoting gastric emptying. *Dimenhydrinate* - This is an **antihistamine** primarily used for motion sickness. While it can help with nausea, it does not address the underlying **gastroparesis** and would not improve gastric emptying. - It also has **sedative side effects** that often limit its use. *Octreotide* - **Octreotide** is a **somatostatin analog** used to treat conditions like VIPomas, acromegaly, and esophageal varices. It can actually *slow* gastric emptying. - It is not indicated for the treatment of **gastroparesis** and would likely worsen symptoms. *Lorazepam* - **Lorazepam** is a **benzodiazepine** used for anxiety and sometimes as an antiemetic due to its anxiolytic and sedative properties, not due to direct effects on gastrointestinal motility. - It does not address the underlying pathology of **gastroparesis** and its use would be inappropriate as a primary treatment. *Ondansetron* - **Ondansetron** is a **5-HT3 receptor antagonist** that effectively treats chemotherapy-induced nausea and vomiting. - While it helps with nausea, it does not improve **gastric motility** or address the delayed gastric emptying seen in gastroparesis.

Question 4: A 47-year-old man presents with recurrent epigastric pain and diarrhea. He has had these symptoms for the last year or so and has been to the clinic several times with similar complaints. His current dosage of omeprazole has been steadily increasing to combat his symptoms. The pain seems to be related to food intake. He describes his diarrhea as watery and unrelated to his meals. Blood pressure is 115/80 mm Hg, pulse is 76/min, and respiratory rate is 19/min. He denies tobacco or alcohol use. An upper endoscopy is performed due to his unexplained and recurrent dyspepsia and reveals thickened gastric folds with three ulcers in the first part of the duodenum, all of which are negative for H. pylori. Which of the following is the best next step in this patient's management?

A. Fasting serum gastrin levels (Correct Answer)
B. Secretin stimulation test
C. CT scan of the abdomen
D. Somatostatin receptor scintigraphy
E. Serum calcium levels

Explanation: ***Fasting serum gastrin levels*** - The patient's presentation with **recurrent epigastric pain**, **multiple duodenal ulcers**, **thickened gastric folds**, and the need for **increasing dosages of omeprazole** strongly suggests **Zollinger-Ellison syndrome (ZES)**, caused by a gastrinoma. - **Fasting serum gastrin levels** are the initial diagnostic test for ZES; elevated levels confirm excessive gastrin production. *Secretin stimulation test* - This test is typically performed when **fasting serum gastrin levels are equivocal** (e.g., mildly elevated) to confirm the diagnosis of ZES. - It is not the initial best step, as **fasting gastrin levels** are simpler and often sufficient for initial diagnosis. *CT scan of the abdomen* - A CT scan is used for **tumor localization** after a diagnosis of ZES has been established. - It is not the primary diagnostic test for ZES itself, as it won't directly measure gastrin levels. *Somatostatin receptor scintigraphy* - This imaging study is highly sensitive for **localizing gastrinomas**, especially in metastatic disease, and is often used after biochemical confirmation of ZES. - It is not indicated as the initial diagnostic step and is part of the work-up for staging rather than diagnosis. *Serum calcium levels* - While **hypercalcemia** can be associated with **Multiple Endocrine Neoplasia type 1 (MEN1)**, which includes gastrinomas, it is not the best initial diagnostic test for Zollinger-Ellison syndrome itself. - Elevated calcium would be a secondary finding, and direct measurement of gastrin is essential for diagnosing ZES.

Question 5: 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)

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.

Question 6: A 55-year-old man presents to his primary care physician for trouble swallowing. The patient claims that he used to struggle when eating food if he did not chew it thoroughly, but now he occasionally struggles with liquids as well. He also complains of a retrosternal burning sensation whenever he eats. He also claims that he feels his throat burns when he lays down or goes to bed. Otherwise, the patient has no other complaints. The patient has a past medical history of obesity, diabetes, constipation, and anxiety. His current medications include insulin, metformin, and lisinopril. On review of systems, the patient endorses a 5 pound weight loss recently. The patient has a 22 pack-year smoking history and drinks alcohol with dinner. His temperature is 99.5°F (37.5°C), blood pressure is 177/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note an overweight man in no current distress. Abdominal exam is within normal limits. Which of the following is the best next step in management?

A. Endoscopy (Correct Answer)
B. Omeprazole trial
C. Manometry
D. Barium swallow
E. CT scan

Explanation: ***Endoscopy*** - The patient presents with **dysphagia to solids and liquids**, significant for **recent weight loss**, and a **history of smoking**, all of which are **alarm symptoms** necessitating an upper endoscopy to rule out malignancy. - While he has **GERD symptoms** as well (retrosternal burning), the presence of alarm features mandates a direct investigation of the upper GI tract rather than empirical treatment. *Omeprazole trial* - An empirical trial of **PPIs** like omeprazole is appropriate for classic GERD symptoms without alarm features. - However, **dysphagia to solids and liquids with associated weight loss**, especially in a patient with a significant **smoking history**, are alarm symptoms that require direct visualization via endoscopy, not just symptom management. *Manometry* - **Esophageal manometry** is used to evaluate the motility of the esophagus and diagnose conditions like achalasia or esophageal spasm. - While the patient has dysphagia, **alarm symptoms (weight loss, smoking history)** raise concern for mechanical obstruction or malignancy, which should be investigated before motility disorders. *Barium swallow* - A **barium swallow** can identify structural abnormalities like strictures, masses, or webs, and also assess motility. - However, in the context of alarm symptoms, a **barium swallow is less sensitive** for detecting subtle mucosal changes or early malignancy compared to endoscopy, and any positive findings would still prompt an endoscopy. *CT scan* - A **CT scan of the chest and abdomen** is useful for assessing extraluminal pathology, mediastinal involvement, or distant metastases. - While it may eventually be part of staging if a malignancy is found, the **initial investigation for esophageal symptoms and alarm features** focuses on direct luminal visualization with endoscopy to identify the primary pathology.

Question 7: A 37-year-old woman comes to the physician because of difficulty swallowing for the past 1 year. She was diagnosed with gastroesophageal reflux 3 years ago and takes pantoprazole. She has smoked a pack of cigarettes daily for 14 years. Examination shows hardening of the skin of the fingers and several white papules on the fingertips. There are small dilated blood vessels on the face. Which of the following is the most likely cause of this patient's difficulty swallowing?

A. Tissue membrane obstructing esophageal lumen
B. Demyelination of brain and spinal cord axons
C. Degeneration of neurons within esophageal wall
D. Outpouching of the lower pharyngeal mucosa
E. Esophageal smooth muscle fibrosis (Correct Answer)

Explanation: ***Esophageal smooth muscle fibrosis*** - The patient's symptoms are highly suggestive of **systemic sclerosis (scleroderma)**, specifically **CREST syndrome** (limited cutaneous systemic sclerosis), characterized by **Calcinosis**, **Raynaud's phenomenon**, **Esophageal dysmotility**, **Sclerodactyly**, and **Telangiectasias**. - The **white papules on fingertips** represent **calcinosis cutis** (subcutaneous calcium deposits), and **skin hardening** indicates sclerodactyly. - In scleroderma, **fibrosis** and atrophy of the **esophageal smooth muscle** (particularly the distal two-thirds) lead to impaired peristalsis and lower esophageal sphincter dysfunction, causing the described **dysphagia** and reflux. - This is the most common GI manifestation of systemic sclerosis. *Tissue membrane obstructing esophageal lumen* - An **esophageal web** or **Schatzki ring** can cause dysphagia, typically to solids, but it does not explain the systemic findings like sclerodactyly, calcinosis, or telangiectasias. - These conditions are structural obstructions, whereas the patient's presentation suggests a systemic connective tissue disease affecting esophageal motility. *Demyelination of brain and spinal cord axons* - **Demyelination**, as seen in conditions like **multiple sclerosis**, can cause bulbar symptoms and dysphagia, but it would not explain the **cutaneous manifestations** such as sclerodactyly, calcinosis, and telangiectasias. - This etiology would typically present with other neurological deficits, which are not mentioned here. *Degeneration of neurons within esophageal wall* - **Achalasia**, involving the degeneration of inhibitory neurons in the myenteric plexus, causes absent esophageal peristalsis and impaired LES relaxation, leading to dysphagia. - However, achalasia does not typically present with **sclerodactyly**, **calcinosis**, or **telangiectasias**, which point strongly towards systemic sclerosis. *Outpouching of the lower pharyngeal mucosa* - An **esophageal diverticulum**, such as **Zenker's diverticulum**, can cause dysphagia, regurgitation of undigested food, and halitosis. - This condition is a localized structural abnormality and does not account for the **systemic connective tissue** findings observed in the patient.

Question 8: A 48-year-old man presents to his primary care physician with diarrhea and weight loss. He states he has had diarrhea for the past several months that has been worsening steadily. The patient recently went on a camping trip and drank unfiltered stream water. Otherwise, the patient endorses a warm and flushed feeling in his face that occurs sporadically. His temperature is 97.2°F (36.2°C), blood pressure is 137/68 mmHg, pulse is 110/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a murmur heard best over the left lower sternal border and bilateral wheezing on pulmonary exam. Which of the following is the best initial step in management?

A. Pulmonary function tests
B. Plasma free metanephrine levels
C. Urinary 5-hydroxyindoleacetic acid level (Correct Answer)
D. Echocardiography
E. Stool culture and ova and parasite analysis

Explanation: ***Urinary 5-hydroxyindoleacetic acid level*** - The combination of **diarrhea**, **weight loss**, episodic **flushing**, **wheezing**, and a **cardiac murmur** (suggesting right-sided valve involvement) is highly suggestive of **carcinoid syndrome**. The **urinary 5-HIAA** level is the most reliable initial biochemical test to diagnose this condition. - Carcinoid tumors secrete **serotonin**, which is metabolized to 5-HIAA and excreted in the urine. Elevated levels confirm the diagnosis. *Pulmonary function tests* - While the patient has **wheezing**, which could be due to **bronchospasm** as part of carcinoid syndrome, pulmonary function tests are not the best initial diagnostic step. - They would characterize the lung involvement but not identify the underlying cause of the systemic symptoms. *Plasma free metanephrine levels* - This test is used to diagnose **pheochromocytoma**, a condition that can also cause episodic flushing and palpitations. - However, pheochromocytoma does not typically cause chronic diarrhea, weight loss, or the characteristic right-sided cardiac involvement seen in this patient. *Echocardiography* - An **echocardiogram** would be useful to evaluate the cardiac murmur and assess for **right-sided valvular heart disease**, which is a common manifestation of **carcinoid heart disease**. - However, it is a follow-up imaging study to characterize complications, not the initial diagnostic test to confirm the biochemical syndrome. *Stool culture and ova and parasite analysis* - Given the history of drinking unfiltered stream water, **gastrointestinal infections** are a possibility for the diarrhea. - However, the combination of **flushing**, **wheezing**, and a **cardiac murmur** points away from an infectious etiology as the primary cause of all symptoms.

Question 9: A 66-year-old woman with no significant past medical, past surgical, or family history presents with new symptoms of chest pain, an oral rash, and pain with swallowing. She lost her husband several months earlier and has moved into an elderly assisted living community. She states that her symptoms began several weeks earlier. Physical examination reveals numerous white plaques on her buccal mucosa and tongue, raising suspicion for oral candidiasis. What is the next step in the patient’s management?

A. CD4 count (Correct Answer)
B. Single contrast esophagram with barium sulfate contrast
C. Single contrast esophagram with water soluble iodine contrast
D. Denture fitting assessment
E. Modified barium swallow

Explanation: ***CD4 count*** - This patient presents with **oral candidiasis** (thrush) and symptoms suggestive of **esophageal candidiasis** including **odynophagia** (painful swallowing) and chest discomfort. - While oral candidiasis can occur in elderly patients due to dentures, medications, or transient immune changes, the presence of **presumed esophageal involvement** in a previously healthy 66-year-old woman raises concern for **underlying immunosuppression**. - **HIV infection** is an important cause of esophageal candidiasis and should not be missed. The next step is to evaluate for immunodeficiency with **HIV testing and CD4 count**. - Recent psychosocial stress alone does not typically cause severe candidiasis; an underlying immune defect should be investigated. *Single contrast esophagram with water soluble iodine contrast* - Esophagram has **low sensitivity** for diagnosing esophageal candidiasis and is not the standard diagnostic approach. - There is no clinical indication for **perforation** in this case (no instrumentation, severe vomiting, or trauma), so water-soluble contrast is unnecessary. - If imaging were needed, **upper endoscopy (EGD)** would be far superior for visualizing candidal plaques and obtaining tissue diagnosis. *Single contrast esophagram with barium sulfate contrast* - As noted above, esophagram is **not the test of choice** for esophageal candidiasis. - **EGD with biopsy/brushings** provides direct visualization and allows for definitive diagnosis. - Barium studies have been largely replaced by endoscopy for evaluating esophageal infections. *Denture fitting assessment* - While ill-fitting dentures can contribute to **oral candidiasis**, they do not explain the **esophageal symptoms** (chest pain and odynophagia). - The presence of systemic symptoms warrants investigation for immunosuppression rather than focusing solely on local oral factors. - This would not address the patient's most concerning symptoms. *Modified barium swallow* - A **modified barium swallow** assesses **swallowing mechanics** and aspiration risk, typically used for neurological or structural dysphagia. - The patient has **odynophagia** (painful swallowing) rather than **dysphagia** (difficulty swallowing), indicating mucosal pathology rather than a motility or coordination disorder. - This test would not help diagnose or manage candidal esophagitis.

Question 10: A 55-year-old man presents to urgent care for weakness and weight loss. He states for the past several months he has felt progressively weaker and has lost 25 pounds. The patient also endorses intermittent abdominal pain. The patient has not seen a physician in 30 years and recalls being current on most of his vaccinations. He says that a few years ago, he went to the emergency department due to abdominal pain and was found to have increased liver enzymes due to excessive alcohol use and incidental gallstones. The patient has a 50 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 161/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam reveals an emaciated man. The patient has a negative Murphy's sign and his abdomen is non-tender. Cardiopulmonary exam is within normal limits. Which of the following is the next best step in management?

A. CT scan of the abdomen (Correct Answer)
B. CT scan of the liver
C. Right upper quadrant ultrasound
D. HIDA scan
E. Smoking cessation advice and primary care follow up

Explanation: ***CT scan of the abdomen*** - The patient presents with **constitutional symptoms** (weakness, significant weight loss), **intermittent abdominal pain**, and a **50 pack-year smoking history**, which are red flags for potential **malignancy**. - A CT scan of the abdomen is the most appropriate initial imaging study to **evaluate for masses, metastases, or other pathologies** that would explain these symptoms comprehensively. *CT scan of the liver* - While the patient has a history of elevated liver enzymes and gallstones, focusing solely on the liver might **miss other abdominal pathologies** that could explain his symptoms. - A CT of the liver is a more targeted scan, usually performed after a broader abdominal assessment suggests a primary liver issue. *Right upper quadrant ultrasound* - An ultrasound of the right upper quadrant is excellent for evaluating the **gallbladder, bile ducts, and liver parenchyma** for stones, cholecystitis, or focal lesions. - However, it has **limited ability to visualize the retroperitoneum, pancreas, or other bowel structures** which could be the source of the patient's symptoms. *HIDA scan* - A HIDA scan is used to assess **gallbladder function** and is primarily indicated for suspected **acute cholecystitis** when ultrasound findings are equivocal, or for chronic gallbladder dysfunction. - The patient's presentation of generalized weakness, significant weight loss, and non-tender abdomen does not acutely point towards biliary obstruction or acute cholecystitis. *Smoking cessation advice and primary care follow up* - While **smoking cessation** is crucial for long-term health, and **primary care follow-up** is necessary, these steps are not the *next best step in management* for a patient presenting with alarming symptoms of weakness, significant weight loss, and abdominal pain. - These are important secondary measures, but the immediate concern is to **investigate the cause of his current severe symptoms**.

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