59-year-old woman with renal cell carcinoma
presents to the emergency department with severe
right upper quadrant (RUQ) pain. She is
afebrile, acutely tender in the RUQ, and has
shifting dullness and a palpable liver edge.
Murphy’s sign is negative. Laboratory studies
show:
Na+: 138 mEq/L
K+: 3.6 mEq/L
Glucose: 80 mg/dL
Aspartate aminotransferase: 50 U/L
Alanine aminotransferase: 43 U/L
Alkaline phosphatase: 138 U/L
Total protein: 6.4 g/dL
Albumin: 3.8 g/dL
Total bilirubin: 1.1 mg/dL
Imaging demonstrates a spider web of collateral
veins in the liver. Although extensive measures
are taken, the patient dies 6 hours after
arriving. Which of the following was the most
likely initial treatment?
- (A) β-Blocker followed by lactulose
- (B) Cholecystectomy
- © Endoscopic retrograde cholangiopancreatography with dilation of the common bile duct
- (D) Exploratory laparotomy
- (E) Tissue plasminogen activator followed by anticoagulation
0 voters
35-year-old man comes to the office for follow up or ulcerative colitis. He was diagnosed 8 years ago, and had involvement of the
colon from the hepatic flexure to the rectum at that time. The patient is maintained on daily 5 -aminosalicyl ic acid and reels well;
however, he had an exacerbati on of colitis 6 months ago that required a brief course of treatment with antibiotics and oral
glucocorticoids. He has no nausea, vomiting, blood in his stool, or weight loss. Medical history is otherwise unremarkable. The
patient smokes a pack of cigarettes daily and does not use alcohol or illicit drugs. Family history is negative for inflammatory bowel
disease and cancer. Physical examination is normal. Which of the following is the most appropriate management at this time?
- O A. Offer col onoscopy now and every 1 - 2 years thereafter
- O B. Offer col onoscopy now and every 5 years thereafter
- Q C. Recommend prophylactic colectomy with ilea! pouch
- O 0. Recommend surveillance colonoscopy starting at age 45
- O E. Surveillance colonoscopy is not needed as his disease is well controlled
0 voters
83-year-old woman who lives alone is admitted
because of confusion. She is accompanied
to the hospital by her neighbor, who states
that as recently as 3 months ago the patient was
able to perform basic and independent activities
of daily living, and enjoyed gardening in
her yard. However, after her husband’s death 6
weeks ago the patient has not been seen outside
her home. When the neighbor went to
check on the patient today, she found her to be
awake and alert but confused. Her house was
uncharacteristically unkempt, and a few empty
TV dinners were strewn around the living
room. Her blood pressure is 106/66 mm Hg,
heart rate is 68/min, and temperature is 37.3°C
(98.1°F). The remainder of her examination is
unremarkable, except for marked temporal
wasting. Laboratory tests show:
Na+: 137 mEq/L
K+: 3.5 mEq/L
Ca2+: 6.9 mg/dL
Mg2+: 1.5 mEq/L
BUN: 8 mg/dL
Creatinine: 0.5 mg/dL
Inorganic phosphate: 3.1 mg/dL
Albumin: 1.5 g/dL
What is the best next step in managing this patient’s
low calcium levels?
(A) This patient has low BUN levels; therefore,
her hypocalcemia likely does not represent
a decrease in active calcium. She
does not need calcium repletion at this
time
(B) This patient has low creatinine levels;
therefore, her hypocalcemia is likely more
severe than measured. She needs aggressive
calcium repletion
© This patient has low creatinine levels;
therefore, her hypocalcemia likely does not represent a decrease in active calcium. She does not need calcium repletion at this time
(D) This patient is hypoalbuminemic; therefore,her hypocalcemia is likely more severethan measured. She needs aggressive calcium repletion
(E) This patient is hypoalbuminemic; therefore,her hypocalcemia likely does not represent a decrease in active calcium. She does not need calcium repletion at this time.