A 25-year-old man presents to the office for a 3-day history of fever and fatigue. Upon further questioning, he says that he also had constant muscular pain, headaches, and fever during these days. He adds additional information by giving a history of regular unprotected sexual relationship with multiple partners. He is a non-smoker and drinks alcohol occasionally. The heart rate is 102/min, respiratory rate is 18/min, temperature is 38.0°C (100.4°F), and blood pressure is 120/80 mm Hg. On physical examination, he is icteric and hepatosplenomegaly is evident with diffuse muscular and abdominal tenderness particularly in the right upper quadrant. The serologic markers show the following pattern:
Anti-HAV IgM negative
HBsAg positive
Anti-HBs negative
IgM anti-HBc positive
Anti-HCV negative
Anti-HDV negative
What is the most likely diagnosis?
Q92
A 35-year-old man presents with erectile dysfunction. Past medical history is significant for diabetes mellitus diagnosed 5 years ago, managed with insulin, and for donating blood 6 months ago. The patient denies any history of smoking or alcohol use. He is afebrile, and his vital signs are within normal limits. Physical examination shows a bronze-colored hyperpigmentation on the dorsal side of the arms bilaterally. Nocturnal penile tumescence is negative. Routine basic laboratory tests are significant for a moderate increase in glycosylated hemoglobin and hepatic enzymes. Which of the following is the most likely diagnosis in this patient?
Q93
A 46-year-old man comes to the clinic complaining of abdominal pain for the past month. The pain comes and goes and is the most prominent after meals. He reports 1-2 episodes of black stools in the past month, a 10-lbs weight loss, fevers, and a skin rash on his left arm. A review of systems is negative for any recent travel, abnormal ingestion, palpitations, nausea/vomiting, diarrhea, or constipation. Family history is significant for a cousin who had liver failure in his forties. His past medical history is unremarkable. He is sexually active with multiple partners and uses condoms intermittently. He admits to 1-2 drinks every month and used to smoke socially during his teenage years. His laboratory values are shown below:
Serum:
Na+: 138 mEq/L
Cl-: 98 mEq/L
K+: 3.8 mEq/L
HCO3-: 26 mEq/L
BUN: 10 mg/dL
Glucose: 140 mg/dL
Creatinine: 2.1 mg/dL
Thyroid-stimulating hormone: 3.5 µU/mL
Ca2+: 10 mg/dL
AST: 53 U/L
ALT: 35 U/L
HBsAg: Positive
Anti-HBc: Positive
IgM anti-HBc: Positive
Anti-HBs: Negative
What findings would you expect to find in this patient?
Q94
A 54-year-old man with known end-stage liver disease from alcoholic cirrhosis presents to the emergency department with decreased urinary output and swelling in his lower extremities. His disease has been complicated by ascites and hepatic encephalopathy in the past. Initial laboratory studies show a creatinine of 1.73 mg/dL up from a previous value of 1.12 one month prior. There have been no new medication changes, and no recent procedures performed. A diagnostic paracentesis is performed that is negative for infection, and he is admitted to the hospital for further management and initiated on albumin. Two days later, his creatinine has risen to 2.34 and he is oliguric. Which of the following is the most definitive treatment for this patient's condition?
Q95
A 62-year-old man is brought to the emergency department for the evaluation of intermittent bloody vomiting for the past 2 hours. He has had similar episodes during the last 6 months that usually stop spontaneously within an hour. The patient is not aware of any medical problems. He has smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks half a liter of vodka daily. He appears pale and diaphoretic. His temperature is 37.3°C (99.1°F), pulse is 100/min, respirations are 20/min, and blood pressure is 105/68 mm Hg. Cardiac examination shows no murmurs, rubs, or gallops. There is increased abdominal girth. On percussion of the abdomen, the fluid-air level shifts when the patient moves from the supine to the right lateral decubitus position. The edge of the liver is palpated 2 cm below the costal margin. His hemoglobin concentration is 10.3 g/dL, leukocyte count is 4,200/mm3, and platelet count is 124,000/mm3. Intravenous fluids and octreotide are started. Which of the following is the most appropriate next step in the management of this patient?
Q96
A 47-year-old man is brought to the emergency department by police. He was forcibly removed from a bar for lewd behavior. The patient smells of alcohol, and his speech is slurred and unintelligible. The patient has a past medical history of alcohol abuse, obesity, diabetes, and Wernicke encephalopathy. The patient's currently prescribed medications include insulin, metformin, disulfiram, atorvastatin, a multi-B-vitamin, and lisinopril; however, he is non-compliant with his medications. His temperature is 98.5°F (36.7°C), blood pressure is 150/97 mmHg, pulse is 100/min, respirations are 15/min, and oxygen saturation is 96% on room air. Physical exam is notable for a palpable liver edge 2 cm inferior to the rib cage and increased abdominal girth with a positive fluid wave. Laboratory values are ordered and return as below:
Hemoglobin: 10 g/dL
Hematocrit: 33%
Leukocyte count: 7,500 cells/mm^3 with normal differential
Platelet count: 245,000/mm^3
Serum:
Na+: 136 mEq/L
Cl-: 102 mEq/L
K+: 4.1 mEq/L
HCO3-: 24 mEq/L
BUN: 24 mg/dL
Glucose: 157 mg/dL
Creatinine: 1.5 mg/dL
Ca2+: 9.6 mg/dL
Which of the following are the most likely laboratory values that would be seen in this patient in terms of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT) (in U/L)?
Q97
A 28-year-old patient presents to the hospital complaining of progressively worsening dyspnea and a dry cough. Radiographic imaging is shown below. Pulmonary function testing (PFT's) reveals a decreased FEV1 and FEV1/FVC, but an increased TLC. The patient states that he does not smoke. Which of the following conditions is most consistent with the patient's symptoms?
Q98
A 44-year-old woman presents to the emergency department with jaundice and diffuse abdominal pain. She denies any previous medical problems and says she does not take any medications, drugs, or supplements. Her temperature is 97.6°F (36.4°C), blood pressure is 133/87 mmHg, pulse is 86/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam is notable for sclera which are icteric and there is tenderness to palpation over the right upper quadrant. Laboratory studies are ordered as seen below.
Hepatitis B surface antigen: Positive
Hepatitis B surface antibody: Negative
Hepatitis B core antibody IgM: Negative
Hepatitis B core antibody IgG: Positive
Hepatitis B E antigen: Positive
Hepatitis B E antibody (anti-HBe): Negative
Which of the following is the most likely diagnosis?
Q99
A 22-year-old student presents to the college health clinic with a 1-week history of fever, sore throat, nausea, and fatigue. He could hardly get out of bed this morning. There are no pets at home. He admits to having recent unprotected sex. The vital signs include: temperature 38.3°C (101.0°F), pulse 72/min, blood pressure 118/63 mm Hg, and respiratory rate 15/min. On physical examination, he has bilateral posterior cervical lymphadenopathy, exudates over the palatine tonsil walls with soft palate petechiae, an erythematous macular rash on the trunk and arms, and mild hepatosplenomegaly. What is the most likely diagnosis?
Q100
A 45-year-old man is brought to the physician for a follow-up examination. Three weeks ago, he was hospitalized and treated for spontaneous bacterial peritonitis. He has alcoholic liver cirrhosis and hypothyroidism. His current medications include spironolactone, lactulose, levothyroxine, trimethoprim-sulfamethoxazole, and furosemide. He appears ill. His temperature is 36.8°C (98.2°F), pulse is 77/min, and blood pressure is 106/68 mm Hg. He is oriented to place and person only. Examination shows scleral icterus and jaundice. There is 3+ pedal edema and reddening of the palms bilaterally. Breast tissue appears enlarged, and several telangiectasias are visible over the chest and back. Abdominal examination shows dilated tortuous veins. On percussion of the abdomen, the fluid-air level shifts when the patient moves from lying supine to right lateral decubitus. Breath sounds are decreased over both lung bases. Cardiac examination shows no abnormalities. Bilateral tremor is seen when the wrists are extended. Genital examination shows reduced testicular volume of both testes. Digital rectal examination and proctoscopy show hemorrhoids. Which of the following potential complications of this patient's condition is the best indication for the placement of a transjugular intrahepatic portosystemic shunt (TIPS)?
Liver disease US Medical PG Practice Questions and MCQs
Question 91: A 25-year-old man presents to the office for a 3-day history of fever and fatigue. Upon further questioning, he says that he also had constant muscular pain, headaches, and fever during these days. He adds additional information by giving a history of regular unprotected sexual relationship with multiple partners. He is a non-smoker and drinks alcohol occasionally. The heart rate is 102/min, respiratory rate is 18/min, temperature is 38.0°C (100.4°F), and blood pressure is 120/80 mm Hg. On physical examination, he is icteric and hepatosplenomegaly is evident with diffuse muscular and abdominal tenderness particularly in the right upper quadrant. The serologic markers show the following pattern:
Anti-HAV IgM negative
HBsAg positive
Anti-HBs negative
IgM anti-HBc positive
Anti-HCV negative
Anti-HDV negative
What is the most likely diagnosis?
A. Viral hepatitis D
B. Viral hepatitis C
C. Viral hepatitis A
D. Viral hepatitis E
E. Viral hepatitis B (Correct Answer)
Explanation: ***Viral hepatitis B***
- The combination of **HBsAg positive** and **IgM anti-HBc positive** indicates an **acute hepatitis B infection**.
- Symptoms like **fever**, **fatigue**, **muscular pain**, **icterus**, and **hepatosplenomegaly** are consistent with acute viral hepatitis.
*Viral hepatitis D*
- This is ruled out by the **negative Anti-HDV** marker, as hepatitis D requires co-infection with hepatitis B.
- While patients can be co-infected with HBV and HDV, the serology explicitly excludes HDV in this case.
*Viral hepatitis C*
- This is excluded by the **negative Anti-HCV** marker, which would be positive in hepatitis C infection.
- Though sexually transmitted, the serological markers point away from HCV.
*Viral hepatitis A*
- This is ruled out by the **negative Anti-HAV IgM** marker.
- Hepatitis A is typically transmitted via the **fecal-oral route**, which is less consistent with the patient's sexual history.
*Viral hepatitis E*
- While hepatitis E can cause acute hepatitis, it is typically diagnosed by **IgM anti-HEV** antibodies, which are not provided as positive here.
- Transmission is usually **fecal-oral**, which is not the primary risk factor suggested by the patient's history.
Question 92: A 35-year-old man presents with erectile dysfunction. Past medical history is significant for diabetes mellitus diagnosed 5 years ago, managed with insulin, and for donating blood 6 months ago. The patient denies any history of smoking or alcohol use. He is afebrile, and his vital signs are within normal limits. Physical examination shows a bronze-colored hyperpigmentation on the dorsal side of the arms bilaterally. Nocturnal penile tumescence is negative. Routine basic laboratory tests are significant for a moderate increase in glycosylated hemoglobin and hepatic enzymes. Which of the following is the most likely diagnosis in this patient?
A. Hemochromatosis (Correct Answer)
B. Porphyria cutanea tarda
C. Wilson's disease
D. Chronic hepatitis
E. Psychogenic erectile dysfunction
Explanation: ***Hemochromatosis***
- This patient's symptoms, including **erectile dysfunction**, **bronze-colored hyperpigmentation**, and **elevated hepatic enzymes**, are classic features of hemochromatosis.
- Hemochromatosis causes **secondary diabetes** due to pancreatic iron deposition (often called "bronze diabetes"), which explains the diabetes diagnosed 5 years ago and the current elevated glycosylated hemoglobin.
- **Hypogonadism** from pituitary iron deposition causes the erectile dysfunction, and the **negative nocturnal penile tumescence** confirms an organic (not psychogenic) cause.
- The history of blood donation can temporarily lower iron levels, potentially delaying diagnosis, but symptoms have now manifested.
*Porphyria cutanea tarda*
- This condition presents with **photosensitive skin lesions** (blisters, bullae on sun-exposed areas) and hyperpigmentation, but it does not typically cause erectile dysfunction.
- While it can be associated with liver involvement and is exacerbated by iron overload, the overall clinical picture—particularly the **organic erectile dysfunction**, **secondary diabetes**, and **bronze hyperpigmentation**—points more strongly toward hemochromatosis.
*Wilson's disease*
- Wilson's disease is characterized by **copper accumulation**, leading to hepatic, neurologic, and psychiatric symptoms, and **Kayser-Fleischer rings** in the eyes.
- It typically presents in younger patients (teens to 20s) and does not cause bronze skin hyperpigmentation or the specific constellation of symptoms seen here.
- The clinical presentation with secondary diabetes and erectile dysfunction is not typical for Wilson's disease.
*Chronic hepatitis*
- While chronic hepatitis can cause elevated hepatic enzymes and potentially lead to cirrhosis, it does not typically cause **bronze hyperpigmentation** or directly lead to this constellation of symptoms.
- The combination of bronze skin, secondary diabetes, erectile dysfunction, and elevated liver enzymes strongly suggests systemic iron overload rather than isolated chronic hepatitis.
*Psychogenic erectile dysfunction*
- **Negative nocturnal penile tumescence** indicates an organic cause for the erectile dysfunction, ruling out psychogenic causes.
- The presence of multiple systemic symptoms, such as hyperpigmentation, diabetes, and elevated liver enzymes, strongly indicates a physical etiology (pituitary iron deposition) rather than a psychological one.
Question 93: A 46-year-old man comes to the clinic complaining of abdominal pain for the past month. The pain comes and goes and is the most prominent after meals. He reports 1-2 episodes of black stools in the past month, a 10-lbs weight loss, fevers, and a skin rash on his left arm. A review of systems is negative for any recent travel, abnormal ingestion, palpitations, nausea/vomiting, diarrhea, or constipation. Family history is significant for a cousin who had liver failure in his forties. His past medical history is unremarkable. He is sexually active with multiple partners and uses condoms intermittently. He admits to 1-2 drinks every month and used to smoke socially during his teenage years. His laboratory values are shown below:
Serum:
Na+: 138 mEq/L
Cl-: 98 mEq/L
K+: 3.8 mEq/L
HCO3-: 26 mEq/L
BUN: 10 mg/dL
Glucose: 140 mg/dL
Creatinine: 2.1 mg/dL
Thyroid-stimulating hormone: 3.5 µU/mL
Ca2+: 10 mg/dL
AST: 53 U/L
ALT: 35 U/L
HBsAg: Positive
Anti-HBc: Positive
IgM anti-HBc: Positive
Anti-HBs: Negative
What findings would you expect to find in this patient?
A. Ulcers at the gastric mucosa
B. Presence of anti-proteinase 3
C. Diffuse bridging fibrosis and regenerative nodules at the liver
D. PAS-positive macrophages in the intestinal lamina propria
E. Segmental ischemic necrosis of various ages at the mesenteric arteries (Correct Answer)
Explanation: ***Segmental ischemic necrosis of various ages at the mesenteric arteries***
- The patient's presentation with **abdominal pain after meals**, **black stools (melena)**, **weight loss**, **fever**, **skin rash**, and **elevated AST** with positive **HBsAg, anti-HBc, and IgM anti-HBc** is highly suggestive of **polyarteritis nodosa (PAN)** associated with **active hepatitis B (HBV) infection**.
- **Segmental ischemic necrosis of various ages at the mesenteric arteries** is the **pathognomonic finding** in PAN, a **necrotizing vasculitis** that affects medium-sized arteries. The **"various ages"** descriptor is key—it reflects the **non-uniform, segmental nature** of arterial involvement with lesions at different stages of evolution, distinguishing PAN from other vasculitides.
- This leads to diverse symptoms due to **ischemia and infarction** in multiple organs: **gastrointestinal tract** (mesenteric ischemia causing postprandial pain and melena), **kidneys** (elevated creatinine), and **skin** (rash).
- Approximately **30% of PAN cases are associated with acute HBV infection**, making the serologic profile highly relevant to the diagnosis.
*Ulcers at the gastric mucosa*
- While **gastric ulcers** can cause abdominal pain and melena, they don't explain the **systemic symptoms** like fever, rash, weight loss, **renal involvement** (elevated creatinine), or the specific **serological markers for active HBV**.
- There is no specific evidence presented (e.g., EGD findings) to directly point to gastric ulcers as the primary etiology for all symptoms.
*Presence of anti-proteinase 3*
- The presence of **anti-proteinase 3 (PR3-ANCA)** antibodies is characteristic of **granulomatosis with polyangiitis (GPA, formerly Wegener's)**, a different type of vasculitis.
- GPA typically presents with **upper and lower respiratory tract involvement** and **glomerulonephritis**, which are not the prominent features in this patient with abdominal symptoms, skin rash, and HBV-associated vasculitis.
*Diffuse bridging fibrosis and regenerative nodules at the liver*
- These findings are characteristic of **cirrhosis**, which can result from chronic HBV infection. However, the patient's **acute presentation** with abdominal pain, melena, fever, rash, and **evidence of acute HBV infection** (positive IgM anti-HBc) with systemic vasculitic features points towards an **active vasculitic process** (PAN) rather than established cirrhosis.
- While chronic HBV infection is a risk factor for cirrhosis, the **IgM anti-HBc positivity indicates acute infection**, not chronic disease, making cirrhosis unlikely at this stage.
*PAS-positive macrophages in the intestinal lamina propria*
- **PAS-positive macrophages** in the intestinal lamina propria are the hallmark of **Whipple's disease**, a rare bacterial infection caused by *Tropheryma whipplei*.
- Whipple's disease typically presents with **malabsorption, arthralgias, weight loss, and neurological symptoms**, but it does not account for the skin rash, elevated creatinine, or the serological markers indicative of active HBV infection and associated vasculitis.
Question 94: A 54-year-old man with known end-stage liver disease from alcoholic cirrhosis presents to the emergency department with decreased urinary output and swelling in his lower extremities. His disease has been complicated by ascites and hepatic encephalopathy in the past. Initial laboratory studies show a creatinine of 1.73 mg/dL up from a previous value of 1.12 one month prior. There have been no new medication changes, and no recent procedures performed. A diagnostic paracentesis is performed that is negative for infection, and he is admitted to the hospital for further management and initiated on albumin. Two days later, his creatinine has risen to 2.34 and he is oliguric. Which of the following is the most definitive treatment for this patient's condition?
A. Liver transplantation (Correct Answer)
B. Transjugular intrahepatic portosystemic shunt (TIPS)
C. Peritoneovenous shunt
D. Hemodialysis
E. Cessation of alcohol use
Explanation: ***Liver transplantation***
- This patient is presenting with **hepatorenal syndrome (HRS)** as indicated by the worsening renal function, presence of cirrhosis, ascites, and lack of response to albumin. **Liver transplantation** is the only definitive treatment as it addresses the underlying liver dysfunction causing HRS.
- While other treatments like vasoconstrictors and albumin can temporarily stabilize the patient, they do not cure the underlying pathophysiology.
*Transjugular intrahepatic portosystemic shunt (TIPS)*
- TIPS can be used to reduce **portal hypertension** and treat complications like refractory ascites or variceal bleeding.
- However, TIPS is generally **contraindicated in HRS** with severe renal impairment due to the risk of worsening liver function and encephalopathy.
*Peritoneovenous shunt*
- A peritoneovenous shunt is a rarely used procedure to drain **ascites** from the peritoneal cavity into the venous system.
- It does not address the underlying **renal dysfunction** or liver failure and carries a high risk of complications like infection and coagulation abnormalities.
*Hemodialysis*
- Hemodialysis can be used as a **bridge therapy** to manage acute renal failure in HRS, but it is not a definitive treatment.
- It provides renal support but does not correct the **hemodynamic derangements** or underlying liver disease.
*Cessation of alcohol use*
- While essential for slowing the progression of liver disease, **cessation of alcohol** can improve liver function in some cases.
- In a patient with end-stage cirrhosis and acute-on-chronic renal failure (HRS), it is **not an immediate or definitive treatment** for the acute crisis.
Question 95: A 62-year-old man is brought to the emergency department for the evaluation of intermittent bloody vomiting for the past 2 hours. He has had similar episodes during the last 6 months that usually stop spontaneously within an hour. The patient is not aware of any medical problems. He has smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks half a liter of vodka daily. He appears pale and diaphoretic. His temperature is 37.3°C (99.1°F), pulse is 100/min, respirations are 20/min, and blood pressure is 105/68 mm Hg. Cardiac examination shows no murmurs, rubs, or gallops. There is increased abdominal girth. On percussion of the abdomen, the fluid-air level shifts when the patient moves from the supine to the right lateral decubitus position. The edge of the liver is palpated 2 cm below the costal margin. His hemoglobin concentration is 10.3 g/dL, leukocyte count is 4,200/mm3, and platelet count is 124,000/mm3. Intravenous fluids and octreotide are started. Which of the following is the most appropriate next step in the management of this patient?
A. Transjugular intrahepatic portal shunt
B. Balloon tamponade
C. Endoscopic band ligation (Correct Answer)
D. Transfusion of packed red blood cells
E. Intravenous ceftriaxone
Explanation: ***Endoscopic band ligation***
- This patient presents with signs of **portal hypertension** (ascites, enlarged liver, thrombocytopenia, leukopenia) and **upper gastrointestinal hemorrhage** suggestive of bleeding esophageal varices. **Endoscopic band ligation** is the most effective and definitive treatment for actively bleeding esophageal varices once resuscitation is initiated.
- The patient's history of heavy alcohol use further supports the diagnosis of **cirrhosis** and **portal hypertension**, making variceal bleeding a high probability.
*Transjugular intrahepatic portal shunt*
- **TIPS** is typically reserved for patients with refractory variceal bleeding that cannot be controlled endoscopically or as a bridge to liver transplantation, not as a first-line intervention in an actively bleeding patient.
- While effective in reducing portal pressure, TIPS carries risks of **hepatic encephalopathy** and is generally performed after initial hemostatic attempts have failed.
*Balloon tamponade*
- **Balloon tamponade** is a temporary measure used to control massive, refractory variceal bleeding when endoscopy is immediately unavailable or unsuccessful, providing a bridge to definitive treatment.
- It is associated with a high risk of **complications** such as esophageal rupture and aspiration and is not a long-term solution.
*Transfusion of packed red blood cells*
- Although the patient's **hemoglobin is low** (10.3 g/dL) and he is bleeding, **blood transfusion** is part of the initial resuscitation efforts to stabilize the patient, not a definitive treatment to stop the bleeding itself.
- **Fluid resuscitation** and addressing the source of hemorrhage are primary concerns; transfusion volume depends on the degree of blood loss and hemodynamic instability.
*Intravenous ceftriaxone*
- While **antibiotic prophylaxis** with ceftriaxone should be administered early in patients with **cirrhosis** and acute gastrointestinal bleeding to reduce risk of bacterial infections and mortality, it does not address the active hemorrhage.
- **Endoscopic hemostasis** remains the immediate priority; antibiotics are important adjunctive therapy but do not provide hemostatic control.
Question 96: A 47-year-old man is brought to the emergency department by police. He was forcibly removed from a bar for lewd behavior. The patient smells of alcohol, and his speech is slurred and unintelligible. The patient has a past medical history of alcohol abuse, obesity, diabetes, and Wernicke encephalopathy. The patient's currently prescribed medications include insulin, metformin, disulfiram, atorvastatin, a multi-B-vitamin, and lisinopril; however, he is non-compliant with his medications. His temperature is 98.5°F (36.7°C), blood pressure is 150/97 mmHg, pulse is 100/min, respirations are 15/min, and oxygen saturation is 96% on room air. Physical exam is notable for a palpable liver edge 2 cm inferior to the rib cage and increased abdominal girth with a positive fluid wave. Laboratory values are ordered and return as below:
Hemoglobin: 10 g/dL
Hematocrit: 33%
Leukocyte count: 7,500 cells/mm^3 with normal differential
Platelet count: 245,000/mm^3
Serum:
Na+: 136 mEq/L
Cl-: 102 mEq/L
K+: 4.1 mEq/L
HCO3-: 24 mEq/L
BUN: 24 mg/dL
Glucose: 157 mg/dL
Creatinine: 1.5 mg/dL
Ca2+: 9.6 mg/dL
Which of the following are the most likely laboratory values that would be seen in this patient in terms of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT) (in U/L)?
A. AST: 265, ALT: 205, GGT: 50
B. AST: 255, ALT: 130, GGT: 114 (Correct Answer)
C. AST: 425, ALT: 475, GGT: 95
D. AST: 225, ALT: 245, GGT: 127
E. AST: 455, ALT: 410, GGT: 115
Explanation: ***AST: 255, ALT: 130, GGT: 114***
- Chronic alcohol abuse typically leads to an **AST:ALT ratio of 2:1 or greater**, as alcohol metabolism depletes **pyridoxal phosphate** (a cofactor for ALT), reducing ALT activity. In this option, 255/130 ≈ 1.96:1.
- **Both AST and ALT are < 500 U/L**, which is characteristic of alcoholic liver disease (in contrast to viral hepatitis or ischemic hepatitis where values often exceed 1000 U/L).
- **GGT levels are often significantly elevated in alcoholic liver disease** due to enzyme induction, which is consistent with 114 U/L (normal < 50 U/L).
*AST: 265, ALT: 205, GGT: 50*
- This option presents an AST:ALT ratio of approximately 1.3:1, which is less indicative of **alcoholic liver disease** due to the relatively lower AST rise compared to ALT.
- The **GGT level** of 50 U/L is at the upper limit of normal or mildly elevated, which is generally not seen in active alcoholic liver injury.
*AST: 425, ALT: 475, GGT: 95*
- This option shows a higher ALT than AST, with an AST:ALT ratio less than 1, which is more typical of **non-alcoholic fatty liver disease (NAFLD)** or viral hepatitis, not alcoholic liver disease.
- While GGT is elevated, the AST:ALT ratio is inconsistent with the patient's history of **alcohol abuse**.
*AST: 225, ALT: 245, GGT: 127*
- This option suggests an ALT higher than AST, indicating an AST:ALT ratio less than 1, which typically points away from **alcoholic liver damage**.
- Although the GGT is elevated, the **AST:ALT ratio** does not fit the characteristic pattern of alcoholic liver disease.
*AST: 455, ALT: 410, GGT: 115*
- While this option shows an AST:ALT ratio slightly above 1 (455/410 ≈ 1.1:1), it is not the characteristic 2:1 or greater ratio often seen in **alcoholic liver disease**.
- The elevated AST and ALT values, while suggestive of significant liver injury, do not perfectly align with the typical enzymatic profile of **alcoholic hepatitis** compared to the correct option.
Question 97: A 28-year-old patient presents to the hospital complaining of progressively worsening dyspnea and a dry cough. Radiographic imaging is shown below. Pulmonary function testing (PFT's) reveals a decreased FEV1 and FEV1/FVC, but an increased TLC. The patient states that he does not smoke. Which of the following conditions is most consistent with the patient's symptoms?
A. Hypersensitivity pneumonitis
B. Chronic bronchitis
C. Alpha1-antitrypsin deficiency (Correct Answer)
D. Pneumothorax
E. Asthma
Explanation: ***Alpha1-antitrypsin deficiency***
- The combination of **decreased FEV1**, **decreased FEV1/FVC**, and **increased TLC** without a history of smoking is highly suggestive of **emphysema**, which can be caused by alpha1-antitrypsin deficiency.
- This genetic condition leads to a lack of protection against **elastase**, causing early-onset panacinar emphysema, typically affecting the lung bases even in non-smokers.
*Hypersensitivity pneumonitis*
- This condition typically presents with a **restrictive pattern** on PFTs (decreased TLC, normal or increased FEV1/FVC), not an obstructive pattern with increased TLC.
- It is an immune-mediated interstitial lung disease, often presenting with symptoms like dyspnea and cough, but the PFTs are inconsistent.
*Chronic bronchitis*
- While chronic bronchitis causes an **obstructive pattern** (decreased FEV1, decreased FEV1/FVC), it primarily manifests with a **chronic productive cough** (at least three months per year for two consecutive years) and is usually associated with smoking.
- An **increased TLC** is not typical in isolated chronic bronchitis; TLC is often normal or slightly increased, but not as pronounced as in emphysema.
*Pneumothorax*
- A pneumothorax is an acute condition involving air in the pleural space, leading to sudden onset dyspnea and chest pain, and would show a **collapsed lung** on imaging, not an obstructive pattern with increased TLC.
- It results in a **reduced lung volume** and would not cause an obstructive pattern with increased TLC on PFTs.
*Asthma*
- Asthma presents with **reversible airway obstruction** (decreased FEV1, decreased FEV1/FVC) but usually involves episodic wheezing and dyspnea, often triggered by allergens.
- While TLC can be increased during severe exacerbations due to **air trapping**, patients usually respond to bronchodilators and do not typically present with progressive, non-reversible obstruction and uniformly increased TLC like emphysema.
Question 98: A 44-year-old woman presents to the emergency department with jaundice and diffuse abdominal pain. She denies any previous medical problems and says she does not take any medications, drugs, or supplements. Her temperature is 97.6°F (36.4°C), blood pressure is 133/87 mmHg, pulse is 86/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam is notable for sclera which are icteric and there is tenderness to palpation over the right upper quadrant. Laboratory studies are ordered as seen below.
Hepatitis B surface antigen: Positive
Hepatitis B surface antibody: Negative
Hepatitis B core antibody IgM: Negative
Hepatitis B core antibody IgG: Positive
Hepatitis B E antigen: Positive
Hepatitis B E antibody (anti-HBe): Negative
Which of the following is the most likely diagnosis?
A. Chronic hepatitis B infection (Correct Answer)
B. Hepatitis B vaccination
C. Acute hepatitis B infection
D. Resolved hepatitis B infection
E. No hepatitis B vaccination or infection
Explanation: ### ***Chronic hepatitis B infection***
- The presence of **Hepatitis B surface antigen (HBsAg) positive** combined with **Hepatitis B core antibody IgG (anti-HBc IgG) positive** indicates infection that has persisted beyond 6 months.
- **Hepatitis B core antibody IgM (anti-HBc IgM) negative** rules out acute infection, as IgM antibodies appear early in acute hepatitis B.
- **Hepatitis B e antigen (HBeAg) positive** indicates active viral replication and high infectivity, consistent with HBeAg-positive chronic hepatitis B.
- The clinical presentation with jaundice and RUQ pain suggests an acute flare of chronic hepatitis B infection.
### *Hepatitis B vaccination*
- Successful hepatitis B vaccination produces **anti-HBs positive** with **HBsAg negative** and **anti-HBc negative**.
- This patient has **HBsAg positive** and **anti-HBc IgG positive**, indicating actual infection rather than vaccine-induced immunity.
### *Acute hepatitis B infection*
- Acute hepatitis B is characterized by **HBsAg positive** with **anti-HBc IgM positive** (IgM appears first in acute infection).
- This patient has **anti-HBc IgM negative** and **anti-HBc IgG positive**, indicating the infection occurred more than 6 months ago, consistent with chronic rather than acute infection.
### *Resolved hepatitis B infection*
- Resolved infection shows **HBsAg negative**, **anti-HBs positive**, and **anti-HBc IgG positive**.
- This patient's **HBsAg positive** status directly indicates ongoing infection, not resolution.
### *No hepatitis B vaccination or infection*
- Complete absence of exposure would show **HBsAg negative**, **anti-HBs negative**, and **anti-HBc negative** (all markers negative).
- This patient has multiple positive markers including **HBsAg** and **anti-HBc IgG**, confirming hepatitis B infection.
Question 99: A 22-year-old student presents to the college health clinic with a 1-week history of fever, sore throat, nausea, and fatigue. He could hardly get out of bed this morning. There are no pets at home. He admits to having recent unprotected sex. The vital signs include: temperature 38.3°C (101.0°F), pulse 72/min, blood pressure 118/63 mm Hg, and respiratory rate 15/min. On physical examination, he has bilateral posterior cervical lymphadenopathy, exudates over the palatine tonsil walls with soft palate petechiae, an erythematous macular rash on the trunk and arms, and mild hepatosplenomegaly. What is the most likely diagnosis?
A. Toxoplasma infection
B. Streptococcal pharyngitis
C. Rubella
D. Acute HIV infection
E. Infectious mononucleosis (Correct Answer)
Explanation: ***Infectious mononucleosis***
- The combination of **fever**, **fatigue**, **sore throat**, **posterior cervical lymphadenopathy**, tonsillar exudates, and **hepatosplenomegaly** in a young adult is highly suggestive of infectious mononucleosis, commonly caused by **Epstein-Barr virus (EBV)**.
- The presence of **soft palate petechiae** and a mild, **erythematous rash** (which can occur in EBV mononucleosis, especially if amoxicillin is mistakenly prescribed) further supports this diagnosis.
*Toxoplasma infection*
- While **Toxoplasma gondii** can cause lymphadenopathy and fatigue, it is less commonly associated with significant **pharyngitis** with exudates and hepatosplenomegaly in immunocompetent individuals.
- The recent unprotected sex and specific rash pattern are not typical features for **primary toxoplasmosis** in this context.
*Streptococcal pharyngitis*
- Classic strep throat presents with **sore throat**, fever, and **tonsillar exudates**, but **marked fatigue**, **hepatosplenomegaly**, and **posterior cervical lymphadenopathy** are unusual.
- The widespread erythematous macular rash is not a typical presentation of uncomplicated strep pharyngitis.
*Rubella*
- **Rubella** typically presents with a **maculopapular rash** that starts on the face and spreads downwards, along with low-grade fever and **postauricular** or **occipital lymphadenopathy**.
- **Significant pharyngitis** with exudates and hepatosplenomegaly are not prominent features of rubella.
*Acute HIV infection*
- **Acute HIV infection** can present with a mononucleosis-like syndrome including fever, fatigue, sore throat, and rash, but **marked exudative tonsillitis** and **hepatosplenomegaly** are less common than in EBV mononucleosis.
- While unprotected sex is a risk factor, the specific constellation of findings, particularly the profound fatigue and physical exam findings, point more strongly to infectious mononucleosis.
Question 100: A 45-year-old man is brought to the physician for a follow-up examination. Three weeks ago, he was hospitalized and treated for spontaneous bacterial peritonitis. He has alcoholic liver cirrhosis and hypothyroidism. His current medications include spironolactone, lactulose, levothyroxine, trimethoprim-sulfamethoxazole, and furosemide. He appears ill. His temperature is 36.8°C (98.2°F), pulse is 77/min, and blood pressure is 106/68 mm Hg. He is oriented to place and person only. Examination shows scleral icterus and jaundice. There is 3+ pedal edema and reddening of the palms bilaterally. Breast tissue appears enlarged, and several telangiectasias are visible over the chest and back. Abdominal examination shows dilated tortuous veins. On percussion of the abdomen, the fluid-air level shifts when the patient moves from lying supine to right lateral decubitus. Breath sounds are decreased over both lung bases. Cardiac examination shows no abnormalities. Bilateral tremor is seen when the wrists are extended. Genital examination shows reduced testicular volume of both testes. Digital rectal examination and proctoscopy show hemorrhoids. Which of the following potential complications of this patient's condition is the best indication for the placement of a transjugular intrahepatic portosystemic shunt (TIPS)?
A. Hepatic hydrothorax
B. Hepatic encephalopathy
C. Recurrent variceal hemorrhage (Correct Answer)
D. Portal hypertensive gastropathy
E. Hepatic veno-occlusive disease
Explanation: ***Recurrent variceal hemorrhage***
- **TIPS** is primarily indicated for patients with **recurrent variceal bleeding** despite endoscopic or pharmacological therapy, as it effectively decompresses the portal system and reduces the risk of rebleeding.
- This patient has advanced cirrhosis with **portal hypertension** (evidenced by ascites, dilated abdominal veins/caput medusae, hemorrhoids, and splenomegaly), placing him at high risk for developing esophageal or gastric varices.
- **Recurrent variceal hemorrhage** is the **strongest and best-established indication** for TIPS placement among the complications listed.
*Hepatic hydrothorax*
- While a complication of portal hypertension (patient has decreased breath sounds bilaterally suggesting pleural effusions), **hepatic hydrothorax** is usually managed with diuretics and thoracentesis first.
- **TIPS** is considered only for **refractory hepatic hydrothorax** that fails medical management - it's a secondary/salvage indication, not the primary best indication.
*Hepatic encephalopathy*
- **Hepatic encephalopathy** is a **relative contraindication** to **TIPS** placement, as the portosystemic shunt can worsen encephalopathy by diverting portal blood directly into systemic circulation, bypassing hepatic detoxification.
- This patient already exhibits signs of encephalopathy (disoriented to time, asterixis/flapping tremor on wrist extension), making him a higher-risk candidate for TIPS-related encephalopathy worsening.
*Portal hypertensive gastropathy*
- **Portal hypertensive gastropathy** is typically managed with non-selective beta-blockers (propranolol, nadolol) and iron supplementation for chronic blood loss.
- **TIPS** is generally reserved for severe, refractory bleeding from gastropathy not controlled by medical therapy - this is uncommon and not the primary indication.
*Hepatic veno-occlusive disease*
- **Hepatic veno-occlusive disease** (sinusoidal obstruction syndrome) is a distinct condition involving obstruction of hepatic venules, typically associated with hematopoietic stem cell transplantation or hepatotoxic drugs.
- This is **not a complication of alcoholic cirrhosis** and is not treated with TIPS in the same manner as portal hypertension complications.
