A 14-year-old girl is brought to the physician because she frequently experiences cramping and pain in her legs during school sports. She is at the 10th percentile for height. Her blood pressure is 155/90 mm Hg. Examination shows a high-arched palate with maloccluded teeth and a low posterior hairline. The patient has a broad chest with widely spaced nipples. Pelvic examination shows normal external female genitalia with scant pubic hair. Without appropriate treatment, this patient is at the greatest risk of developing which of the following complications?
Q2
A 56-year-old man is seen in the hospital for a chief complaint of intense thirst and polyuria. His history is significant for recent transsphenoidal resection of a pituitary adenoma. With regard to the man's fluid balance, which of the following would be expected?
Q3
An 82-year-old woman presents with 2 months of foul-smelling, greasy diarrhea. She says that she also has felt very tired recently and has had some associated bloating and flatus. She denies any recent abdominal pain, nausea, melena, hematochezia, or vomiting. She also denies any history of recent travel and states that her home has city water. Which of the following tests would be most appropriate to initially work up the most likely diagnosis in this patient?
Q4
A 36-year-old African American G1P0010 presents to her gynecologist for an annual visit. She has a medical history of hypertension, for which she takes hydrochlorothiazide. The patient’s mother had breast cancer at age 68, and her sister has endometriosis. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 138/74 mmHg, pulse is 80/min, and respirations are 13/min. Her BMI is 32.4 kg/m^2. Pelvic exam reveals a nontender, 16-week sized uterus with an irregular contour. A transvaginal ultrasound is performed and demonstrates a submucosal leiomyoma. This patient is at most increased risk of which of the following complications?
Q5
A 63-year-old woman comes to the physician because of diarrhea and weakness after her meals for 2 weeks. She has the urge to defecate 15–20 minutes after a meal and has 3–6 bowel movements a day. She also has palpitations, sweating, and needs to lie down soon after eating. One month ago, she underwent a distal gastrectomy for gastric cancer. She had post-operative pneumonia, which was treated with cefotaxime. She returned from a vacation to Brazil 6 weeks ago. Her immunizations are up-to-date. She is 165 cm (5 ft 5 in) tall and weighs 51 kg (112 lb); BMI is 18.6 kg/m2. Vital signs are within normal limits. Examination shows a well-healed abdominal midline surgical scar. The abdomen is soft and nontender. Bowel sounds are hyperactive. Rectal examination is unremarkable. Which of the following is the most appropriate next step in management?
Q6
A 54-year-old man comes to the physician because of diarrhea that has become progressively worse over the past 4 months. He currently has 4–6 episodes of foul-smelling stools per day. Over the past 3 months, he has had fatigue and a 5-kg (11-lb) weight loss. He returned from Bangladesh 6 months ago after a year-long business assignment. He has osteoarthritis and hypertension. Current medications include amlodipine and naproxen. He appears pale and malnourished. His temperature is 37.3°C (99.1°F), pulse is 76/min, and blood pressure is 140/86 mm Hg. Examination shows pale conjunctivae and dry mucous membranes. Angular stomatitis and glossitis are present. The abdomen is distended but soft and nontender. Rectal examination shows no abnormalities. Laboratory studies show:
Hemoglobin 8.9 g/dL
Leukocyte count 4100/mm3
Platelet count 160,000/mm3
Mean corpuscular volume 110 μm3
Serum
Na+ 133 mEq/L
Cl- 98 mEq/l
K+ 3.3 mEq/L
Creatinine 1.1 mg/dL
IgA 250 mg/dL
Anti-tissue transglutaminase, IgA negative
Stool culture and studies for ova and parasites are negative. Test of the stool for occult blood is negative. Fecal fat content is 22 g/day (N < 7). Fecal lactoferrin is negative and elastase is within normal limits. Which of the following is the most appropriate next step in diagnosis?
Q7
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?
Q8
A 63-year-old man comes to the emergency department because of pain in his left groin for the past hour. The pain began soon after he returned from a walk. He describes it as 8 out of 10 in intensity and vomited once on the way to the hospital. He has had a swelling of the left groin for the past 2 months. He has chronic obstructive pulmonary disease and hypertension. Current medications include amlodipine, albuterol inhaler, and a salmeterol-fluticasone inhaler. He appears uncomfortable. His temperature is 37.4°C (99.3°F), pulse is 101/min, and blood pressure is 126/84 mm Hg. Examination shows a tender bulge on the left side above the inguinal ligament that extends into the left scrotum; lying down or applying external force does not reduce the swelling. Coughing does not make the swelling bulge further. There is no erythema. The abdomen is distended. Bowel sounds are hyperactive. Scattered rhonchi are heard throughout both lung fields. Which of the following is the most appropriate next step in management?
Ostomy creation and management US Medical PG Practice Questions and MCQs
Question 1: A 14-year-old girl is brought to the physician because she frequently experiences cramping and pain in her legs during school sports. She is at the 10th percentile for height. Her blood pressure is 155/90 mm Hg. Examination shows a high-arched palate with maloccluded teeth and a low posterior hairline. The patient has a broad chest with widely spaced nipples. Pelvic examination shows normal external female genitalia with scant pubic hair. Without appropriate treatment, this patient is at the greatest risk of developing which of the following complications?
A. Alzheimer disease
B. Hyperphagia
C. Pulmonary stenosis
D. Osteoporosis (Correct Answer)
E. Severe acne
Explanation: ***Osteoporosis***
- This patient's presentation with **short stature**, high blood pressure, **webbed neck** (implied by low posterior hairline), and **wide-spaced nipples** is highly suggestive of **Turner syndrome (45,X0)**.
- Turner syndrome is characterized by **gonadal dysgenesis**, leading to **estrogen deficiency**, which is a major risk factor for developing **osteoporosis**.
- Without estrogen replacement therapy, patients with Turner syndrome have significantly increased risk of **low bone mineral density** and **fractures**.
*Pulmonary stenosis*
- While Turner syndrome is associated with **cardiac anomalies** such as **bicuspid aortic valve** and **coarctation of the aorta**, these are typically **congenital defects** present from birth rather than complications that develop over time.
- **Pulmonary stenosis** itself is not a primary cardiac finding in Turner syndrome.
- The question asks about complications that develop without treatment, making **osteoporosis** more appropriate as it progressively worsens due to chronic **estrogen deficiency**.
*Alzheimer disease*
- **Alzheimer disease** is a neurodegenerative disorder primarily associated with aging and genetics, not typically a direct complication of Turner syndrome.
- While cognitive profiles in Turner syndrome can differ (particularly with visuospatial skills), there is no established increased risk of Alzheimer disease.
*Hyperphagia*
- **Hyperphagia** (excessive eating) is characteristically associated with **Prader-Willi syndrome** due to hypothalamic dysfunction.
- It is not a feature or complication of **Turner syndrome**.
*Severe acne*
- **Severe acne** is often related to increased androgen levels or hormonal fluctuations during puberty.
- In Turner syndrome, there is typically **hypogonadism** and **estrogen deficiency**, which would not predispose to severe acne.
Question 2: A 56-year-old man is seen in the hospital for a chief complaint of intense thirst and polyuria. His history is significant for recent transsphenoidal resection of a pituitary adenoma. With regard to the man's fluid balance, which of the following would be expected?
A. Hyponatremia
B. Increased extracellular fluid osmolarity (Correct Answer)
C. Serum osmolarity <290 mOsm/L
D. Elevated serum ADH
E. Elevated blood glucose
Explanation: ***Increased extracellular fluid osmolarity***
- The symptoms of intense thirst and polyuria after pituitary surgery are classic for **diabetes insipidus (DI)**, which results from insufficient **antidiuretic hormone (ADH)**.
- Lack of ADH leads to the kidneys' inability to reabsorb water, causing excessive water loss and a consequent **increase in plasma osmolality** and extracellular fluid osmolarity as water is lost disproportionately to solutes.
*Hyponatremia*
- **Hyponatremia** (low sodium) typically occurs from over-hydration or conditions causing excess ADH, such as **syndrome of inappropriate ADH (SIADH)**.
- In DI, the primary problem is water loss leading to **hypernatremia** (high sodium) and increased osmolarity.
*Serum osmolarity <290 mOsm/L*
- Normal serum osmolarity is approximately **275-295 mOsm/L**. A value less than 290 mOsm/L suggests **hypo-osmolarity**.
- In DI, the significant water loss due to lack of ADH leads to **increased serum osmolarity**, usually above 295 mOsm/L.
*Elevated serum ADH*
- **Elevated serum ADH** would lead to increased water reabsorption in the kidneys, resulting in concentrated urine and potentially hyponatremia.
- In central diabetes insipidus, the problem is a **deficiency of ADH** secretion or action, leading to low or undetectable ADH levels.
*Elevated blood glucose*
- **Elevated blood glucose** is characteristic of **diabetes mellitus**, where polyuria and polydipsia occur due to osmotic diuresis from high glucose levels.
- This patient's history of pituitary surgery and the specific presentation points to DI, which is a disorder of **water balance** not directly related to glucose metabolism.
Question 3: An 82-year-old woman presents with 2 months of foul-smelling, greasy diarrhea. She says that she also has felt very tired recently and has had some associated bloating and flatus. She denies any recent abdominal pain, nausea, melena, hematochezia, or vomiting. She also denies any history of recent travel and states that her home has city water. Which of the following tests would be most appropriate to initially work up the most likely diagnosis in this patient?
A. Fecal fat test (Correct Answer)
B. Tissue transglutaminase antibody test
C. Stool O&P
D. Stool guaiac test
E. CT of the abdomen with oral contrast
Explanation: ***Fecal fat test***
- The patient's symptoms of **foul-smelling, greasy diarrhea**, along with **fatigue, bloating, and flatus**, strongly suggest **malabsorption**, specifically **steatorrhea** (excess fat in stool).
- A **fecal fat test** (e.g., Sudan stain or 72-hour quantitative stool fat collection) directly assesses fat malabsorption and would be the most appropriate initial diagnostic test.
*Tissue transglutaminase antibody test*
- This test is used to screen for **celiac disease**, which can cause malabsorption symptoms.
- While celiac disease is a possibility, a fecal fat test is a more general and appropriate initial step to confirm fat malabsorption before looking for specific causes.
*Stool O&P*
- Stands for **Stool Ova and Parasites**, used to detect parasitic infections like **Giardia** or **Cryptosporidium**, which can cause diarrhea.
- However, the absence of recent travel, city water, and the prominent greasy nature of the stool make this less likely as the primary initial investigation compared to confirming malabsorption.
*Stool guaiac test*
- This test detects **occult blood in stool**.
- The patient denies **melena or hematochezia**, and there are no signs pointing to gastrointestinal bleeding, making this test irrelevant for her presenting symptoms.
*CT of the abdomen with oral contrast*
- A CT scan with contrast might be used to investigate structural abnormalities or inflammation if other tests confirm malabsorption or point to a specific organ pathology (e.g., pancreatitis, Crohn's disease).
- It's an imaging study and generally not the most appropriate *initial* test for evaluating the described symptoms of malabsorption.
Question 4: A 36-year-old African American G1P0010 presents to her gynecologist for an annual visit. She has a medical history of hypertension, for which she takes hydrochlorothiazide. The patient’s mother had breast cancer at age 68, and her sister has endometriosis. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 138/74 mmHg, pulse is 80/min, and respirations are 13/min. Her BMI is 32.4 kg/m^2. Pelvic exam reveals a nontender, 16-week sized uterus with an irregular contour. A transvaginal ultrasound is performed and demonstrates a submucosal leiomyoma. This patient is at most increased risk of which of the following complications?
A. Endometrial cancer
B. Miscarriage
C. Infertility
D. Uterine prolapse
E. Iron deficiency anemia (Correct Answer)
Explanation: ***Iron deficiency anemia***
- Submucosal leiomyomas (fibroids) can cause significantly **heavy and prolonged menstrual bleeding**, known as menometrorrhagia, leading to chronic blood loss.
- This chronic blood loss depletes iron stores in the body, resulting in **iron deficiency anemia**.
*Endometrial cancer*
- While obesity is a risk factor for endometrial cancer, **leiomyomas themselves are not directly premalignant** or associated with an increased risk of endometrial carcinoma.
- The patient's irregular uterus is consistent with fibroids, not necessarily endometrial hyperplasia or cancer.
*Miscarriage*
- **Large or submucosal fibroids** can increase the risk of miscarriage by disrupting endometrial blood supply or distorting the uterine cavity.
- However, the most immediate and common complication of fibroids, particularly submucosal ones, is heavy bleeding leading to anemia.
*Infertility*
- Submucosal leiomyomas can interfere with **implantation** or **sperm transport**, thus contributing to infertility.
- However, for a G1P0010 patient, the most *likely* immediate complication associated with significant bleeding from a submucosal fibroid is anemia, before issues with future conception are explicitly addressed.
*Uterine prolapse*
- Uterine prolapse is typically due to **weakening of pelvic floor support structures**, often associated with parity, age, and conditions increasing intra-abdominal pressure.
- While a large uterus from fibroids could theoretically contribute, it is not the primary or most common complication of fibroids; heavy bleeding is much more direct and frequent.
Question 5: A 63-year-old woman comes to the physician because of diarrhea and weakness after her meals for 2 weeks. She has the urge to defecate 15–20 minutes after a meal and has 3–6 bowel movements a day. She also has palpitations, sweating, and needs to lie down soon after eating. One month ago, she underwent a distal gastrectomy for gastric cancer. She had post-operative pneumonia, which was treated with cefotaxime. She returned from a vacation to Brazil 6 weeks ago. Her immunizations are up-to-date. She is 165 cm (5 ft 5 in) tall and weighs 51 kg (112 lb); BMI is 18.6 kg/m2. Vital signs are within normal limits. Examination shows a well-healed abdominal midline surgical scar. The abdomen is soft and nontender. Bowel sounds are hyperactive. Rectal examination is unremarkable. Which of the following is the most appropriate next step in management?
A. Dietary modifications (Correct Answer)
B. Stool PCR test
C. Octreotide therapy
D. Metronidazole therapy
E. Stool microscopy
Explanation: ***Dietary modifications***
- This patient's symptoms (diarrhea, weakness, palpitations, sweating, and urge to defecate soon after meals) following a **distal gastrectomy** are classic for **dumping syndrome**. **Dietary modification** is the first-line treatment.
- Recommended modifications include **smaller, more frequent meals**, avoiding high-sugar foods, increasing protein and fiber, and separating solids from liquids during meals.
*Stool PCR test*
- While diarrhea is present, the patient's symptoms are strongly linked to her recent gastrectomy and meal ingestion rather than an infectious cause.
- A stool PCR test would be appropriate if there were other signs of infection, such as fever or severe abdominal pain, or if dietary modifications failed to resolve symptoms.
*Octreotide therapy*
- **Octreotide**, a somatostatin analog, is reserved for **severe cases of dumping syndrome** that do not respond to dietary modifications.
- It works by inhibiting the release of gastrointestinal hormones and slowing gastric emptying, but it is not the initial management step.
*Metronidazole therapy*
- **Metronidazole** is an antibiotic used to treat bacterial and parasitic infections. There is no evidence suggesting an infection in this patient.
- The timing of symptoms immediately post-meal points away from an infection and towards post-gastrectomy complications.
*Stool microscopy*
- Similar to a stool PCR, **stool microscopy** is used to identify parasites or other pathogens.
- Given the classic presentation of dumping syndrome following gastrectomy, an infectious cause is less likely, and other diagnostic tests should be pursued if dietary measures fail.
Question 6: A 54-year-old man comes to the physician because of diarrhea that has become progressively worse over the past 4 months. He currently has 4–6 episodes of foul-smelling stools per day. Over the past 3 months, he has had fatigue and a 5-kg (11-lb) weight loss. He returned from Bangladesh 6 months ago after a year-long business assignment. He has osteoarthritis and hypertension. Current medications include amlodipine and naproxen. He appears pale and malnourished. His temperature is 37.3°C (99.1°F), pulse is 76/min, and blood pressure is 140/86 mm Hg. Examination shows pale conjunctivae and dry mucous membranes. Angular stomatitis and glossitis are present. The abdomen is distended but soft and nontender. Rectal examination shows no abnormalities. Laboratory studies show:
Hemoglobin 8.9 g/dL
Leukocyte count 4100/mm3
Platelet count 160,000/mm3
Mean corpuscular volume 110 μm3
Serum
Na+ 133 mEq/L
Cl- 98 mEq/l
K+ 3.3 mEq/L
Creatinine 1.1 mg/dL
IgA 250 mg/dL
Anti-tissue transglutaminase, IgA negative
Stool culture and studies for ova and parasites are negative. Test of the stool for occult blood is negative. Fecal fat content is 22 g/day (N < 7). Fecal lactoferrin is negative and elastase is within normal limits. Which of the following is the most appropriate next step in diagnosis?
A. CT scan of the abdomen
B. IgG against deamidated gliadin peptide
C. Schilling test
D. Enteroscopy
E. PAS-stained biopsy of small bowel (Correct Answer)
Explanation: ***PAS-stained biopsy of small bowel***
- The patient's history of travel to Bangladesh, chronic diarrhea, malabsorption (weight loss, fatigue, elevated fecal fat, macrocytic anemia), and negative celiac serology (anti-tissue transglutaminase IgA) are highly suggestive of **Whipple's disease**.
- **Periodic Acid-Schiff (PAS) staining** of a small bowel biopsy is the gold standard for diagnosing Whipple's disease, revealing **PAS-positive macrophages** containing *Tropheryma whipplei*.
*CT scan of the abdomen*
- While a CT scan can identify structural abnormalities or masses, it is not the most direct diagnostic test for **malabsorptive conditions** like Whipple's disease.
- It would likely show non-specific findings such as **bowel wall thickening** or **lymphadenopathy**, but not the definitive histological changes.
*IgG against deamidated gliadin peptide*
- This test is used to diagnose **celiac disease**, but the patient's IgA anti-tissue transglutaminase was already negative, and this IgG test is typically performed when IgA deficiency is suspected or in young children.
- Given the strong suspicion of an infectious etiology due to travel history and systemic symptoms, focusing solely on celiac serology is less appropriate as the first next step.
*Schilling test*
- The Schilling test is an **obsolete test** that was historically used to assess **vitamin B12 absorption** and differentiate causes of B12 deficiency (pernicious anemia, bacterial overgrowth, or pancreatic insufficiency).
- This test is **no longer performed in clinical practice** due to unavailability of radioactive B12; modern evaluation uses serum B12, methylmalonic acid, and homocysteine levels.
- While the patient has macrocytic anemia, the test would not directly address the underlying cause of fat malabsorption and systemic symptoms present.
*Enteroscopy*
- Enteroscopy allows for visualization and biopsy of the small bowel beyond the reach of a standard upper endoscopy.
- While useful for obtaining biopsies, simply performing an enteroscopy without knowing what to look for or what specific stain to request (referring to PAS) on the biopsy would be less targeted than ordering a **PAS-stained biopsy** specifically.
Question 7: 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 8: A 63-year-old man comes to the emergency department because of pain in his left groin for the past hour. The pain began soon after he returned from a walk. He describes it as 8 out of 10 in intensity and vomited once on the way to the hospital. He has had a swelling of the left groin for the past 2 months. He has chronic obstructive pulmonary disease and hypertension. Current medications include amlodipine, albuterol inhaler, and a salmeterol-fluticasone inhaler. He appears uncomfortable. His temperature is 37.4°C (99.3°F), pulse is 101/min, and blood pressure is 126/84 mm Hg. Examination shows a tender bulge on the left side above the inguinal ligament that extends into the left scrotum; lying down or applying external force does not reduce the swelling. Coughing does not make the swelling bulge further. There is no erythema. The abdomen is distended. Bowel sounds are hyperactive. Scattered rhonchi are heard throughout both lung fields. Which of the following is the most appropriate next step in management?
A. Laparoscopic surgical repair
B. Surgical drainage
C. Antibiotic therapy
D. Open surgical repair (Correct Answer)
E. Surgical exploration of the testicle
Explanation: ***Open surgical repair***
- The patient presents with a **painful, non-reducible inguinal hernia** that has likely **incarcerated** or **strangulated**, given the acute onset of severe pain, vomiting, and abdominal distension with hyperactive bowel sounds.
- In cases of suspected incarceration or strangulation, **urgent open surgical repair** is indicated to prevent **bowel ischemia** and its serious complications (e.g., perforation, sepsis).
*Laparoscopic surgical repair*
- While laparoscopic repair is an option for elective hernia repair, it is generally **contraindicated** in cases of **incarcerated or strangulated hernias** due to the higher risk of bowel injury, inadequate assessment of bowel viability, and longer operative times in an emergency setting.
- Also, the patient's **COPD** might make him a less ideal candidate for laparoscopy due to the risks associated with pneumoperitoneum.
*Surgical drainage*
- Surgical drainage is typically performed for abscesses or fluid collections, which are **not the primary issue** in this presentation.
- A hernia involves displacement of organs, not an accumulation of fluid or pus requiring drainage.
*Antibiotic therapy*
- Although antibiotics might be considered as an adjunctive therapy if infection is suspected or confirmed (e.g., with bowel necrosis), they are **not the definitive primary treatment** for an incarcerated or strangulated hernia.
- The mechanical obstruction and potential ischemia require surgical intervention for resolution.
*Surgical exploration of the testicle*
- While the bulge extends into the scrotum, the primary concern is the **incarcerated hernia** itself.
- Surgical exploration of the testicle would be indicated for conditions like testicular torsion, epididymitis, or testicular masses, which are not suggested by the presented symptoms.
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