Download GI 2006 - The Warren Alpert Medical School of Brown University

Name
Brown Medical School
Bio 351/280
Gastro-Pathophysiology
Systemic Pathology
Organ System Pharmacology
Final Exam
February 22, 2006
Course Leaders
Harlan Rich, MD
Elaine Bearer, MD
Robert Patrick PhD
Pathology
Pharmacology
1. A primary mechanism by which magnesium sulfate induces laxation is:
A. It acts selectively on rectal smooth muscle to increase its contractile activity.
B. It acts as an osmotic agent to increase luminal retention of water, as does lactulose.
C. After hydrolysis to ricinoleic acid, it decreases the net absorption of water and electrolytes
by intestinal mucosal cells.
D. It increases the bulk content of the small intestine as do bran or methyl cellulose.
E. It decreases the synthesis of PGE2 in the intestinal mucosa.
2. What single indicator fully assesses nutritional state?
A.
Serum albumin level
B.
Triceps skinfold thickness
C.
Total urinary nitrogen excretion and Nitrogen Balance
D.
There is no single indicator to assess nutritional status
3. The most common malignant liver tumor in adults is:
A.
B.
C.
D.
E.
Hepatocellular carcinoma
Lymphoma
Metastatic tumor
Hepatic adenoma
Angiosarcoma
4. A bone marrow transplant patient complains of pain on swallowing and is noted to have
small punched out esophageal ulcerations on endoscopy. The most likely cause of the ulcerations
is:
A.
B.
C.
D.
Graft versus host disease
Candida esophagitis
Gram negative sepsis
CMV esophagitis
5. Bacterial contamination of the upper small bowel can occur in all of the following EXCEPT?:
A. Pernicious anemia
B. Stricturing Crohn’s disease
C. Clostridium dificile infection
D. Scleroderma
E. Surgically created blind loops to treat obesity
6. Which of the following agents has both antacid and laxative properties:
A.
B.
C.
D.
E.
Bisacodyl
Ranitidine
Magnesium hydroxide
Sucralfate
Metaclopromide
7. All of the following are true about the use of antibiotics EXCEPT?
A.
B.
C.
D.
E.
They are of little value in the treatment of bacterial overgrowth.
They can cause diarrhea.
They are not used to treat antibiotic induced diarrhea.
They can lower blood ammonia levels.
They can prolong the Prothrombin time or INR
8. Which gas is present in the lowest concentration in intestinal flatus?
A.
B.
C.
D.
E.
CO 2
Oxygen
Methane
Nitrogen
Hydrogen
9. Treatment of Inflammatory Bowel Disease includes:
A.
B.
C.
D.
E.
Azathioprine and 6-mercaptopurine for treatment of acute flares of Crohn’s Disease
and Ulcerative colitis.
Methotrexate for Crohn’s patients who are steroid-resistant or steroid–dependent.
Cyclosporin, an immunomodulator, is useful for widespread treatment of mild-to
moderate Crohn’s Disease and Ulcerative Colitis.
Infliximab, a 5-aminosalicylate, that inhibits recruitment of neutrophils into inflamed
tissue.
All of the above.
10. A 40 year-old woman takes Ibuprofen 800 mg t.i.d. and Prednisone 20 mg daily to control her
rheumatoid arthritis. She was recently diagnosed with a gastric ulcer by endoscopy. Biopsies
from the ulcer demonstrated chronic inflammation. H. pylori was not present. A blood test was
also negative for H. pylori. Each of the following is an appropriate treatment for her ulcer
EXCEPT:
A.
B.
C.
D.
E.
Lansoprazole
Misoprostol
PrevPac (Amoxicillin, Clarithromycin, and Lansoprazole) for 2 weeks
Switching from Ibuprofen to Tylenol once the ulcer has healed
Carafate (sucralfate)
11. Helicobacter pylori infection is considered a risk factor for all of the following
EXCEPT:
A.
B.
C.
D.
Duodenal ulcers
Gastric adenocarcinoma
Autoimmune gastritis
Gastric lymphoma
12. Each of the following is a clinically appropriate test for H. pylori, EXCEPT:
A. Histological examination of an antral biopsy in a 45-year old man taking aspirin who
has a bleeding duodenal ulcer
B. Anti-H. pylori IgG several weeks after treating a patient with documented infection,
to assess eradication
C. H. pylori stool antigen test in a woman found to have a duodenal ulcer on upper GI
barium series
D. A non-radioactive C13-urea breath test in a young woman with a strong family history
of gastric cancer
E. Rapid urease test in a patient with a gastric MALT lymphoma
13. The effects of fasting on a patient with common rotavirus diarrhea include:
A. Rapid repair of the intestinal mucosa
B. Decreased turnover of intestinal mucosa leading to a shorter recovery time
C. Possibly decreased symptoms but a prolonged recovery of the intestinal
mucosa.
D. Improved nutritional outcome in developing countries because so much of
their food is contaminated anyway.
14. Which of the following statements describes motor function of the colon?
A. The colon exhibits three contractile patterns: mixing movements, haustral
migration and mass movements
B. Adrenergic inervation to the colon inhibits spike frequency and inhibits
contraction
C. Vagal inervation provides cholinergic and noncholinergic excitiatory stimuli to
the colon.
D. All of the above
15. All of the following statements about the treatment of autoimmune hepatitis are correct
EXCEPT?
A.
B.
C.
D.
If left untreated, 40% of patients die within 6 months
Remission is rarely achieved within 12 months of treatment
Once remission is achieved, relapse is relatively rare
Typical maintenance treatment includes prednisone and azathioprine
Questions 16 - 17 refer to the following scenario:
A patient with dysphagia has the following barium swallow finding:
16. The mechanism of the underlying pathophysiology of this process includes:?
A. Diminished vagal afferent signals
B. Reduction or absence of inhibitory and excitatory intramural neurons of the smooth
muscle of the esophagus
C. Marked increased in collagen deposition in the mucosa
D. Altered pain threshold with noxious stimuli
17. Definitive treatment of this patient could include which of the following:?
A.
B.
C.
D.
Upper Endoscopy and electrocautery
Use of tricyclic antidepressants
Use of calcium channel blockers
Pneumatic balloon dilation
18. Which statement about IgA is true?
A.
B.
C.
D.
IgA utilizes the classic complement pathway to effect bacterial clearance.
The serum IgA is similar to the IgA found in secretions.
Patients with IgA deficiency are usually quite healthy.
Secretory piece is added while the antibody is being manufactured in the
plasma cell and is necessary for dimerization.
E. Does not appear to prevent viral replication in the intestine.
19. All of the following statements are true EXCEPT?
A. Prebiotics can lower serum cholesterol.
B. Psyllium seed (Metamucil®) is a prebiotic.
C. Probiotics are a non-digestible food ingredient used to stimulate the intestinal
flora.
D. Probiotics are often used to treat and prevent “pouchitis”.
E. Bifidobacteria, an anaerobe, is often used as a probiotic.
20. “Councilman body” describes which of the following:?
A.
B.
C.
D.
E.
Ballooning change of hepatocytes
Cholestasis or feathery degeneration of hepatocytes
Iron accumulation in hepatocytes
Apoptotic or dying hepatocyte
Steatosis
21. Which of the following is NOT a cause of fatty change or hepatic steatosis?:
A.
B.
C.
D.
E.
Diabetes Mellitus
Obesity
Alcohol
Hepatitis B
Hepatitis C
22. The genetics of IBD suggest that:
A. The NOD2/CARD 15 Gene is strongly associated with extraintestinal
manifestations of the Ulcerative Colitis.
B. We are close to identifying the specific gene that is responsible for ulcerative
colitis.
C. If two parents are carriers there is a 25% risk of any particular child having
Crohn’s disease.
D. It is reasonable to believe that as we identify more important genetic
determinants we will be able to predict the course and best therapy for patient.
E. All of the above are correct
Questions 23 – 26 relate to the following scenario:
You are following a 34-year old male with a 16 -year history of Crohn’s disease. The patient has
had several small bowel resections and is known to have at least one blind loop. The patient was
doing well on maintenance therapy with mesalamine (Asacol®) until this past week, when he
experienced abdominal cramping and diarrhea. He is known to have ileal Crohn’s disease. He
abdominal exam reveals normal bowel sounds, and no evidence of tenderness or mass. His WBC
is normal, his ESR is normal, stool is guaiac negative and X-rays do not suggest active
inflammation.
23. The appropriate next step in management would be:
A.
B.
C.
D.
Switch to a different mesalamine preparation (e.g. Pentasa®)
Trial of antibiotics
Switch to budesonide at 9 mg/day for chronic/maintenance therapy
Surgical referral for resection of the involved segments
24. The 5-aminosalicylates are useful in treating Inflammatory Bowel Disease because:
A)
B)
C)
D)
E)
They inhibit prostaglandin and leukotriene production.
They decrease antibody secretion and lymphocyte function.
They scavenge reactive oxygen species.
They reduce neutophil and macrophage chemotaxis.
All of the above.
Eight months later he comes to your office for an acute visit. He complains of pain, fevers,
nausea and vomiting. He is found to have significant tenderness and a right lower quadrant mass
on physical exam. CT scanning shows evidence of a right lower quadrant abscess. He is admitted
to the hospital andstarted on IV antibiotics. Percutaneous drainage of the abscess is attempted,
but unsuccessful. He undergoes resection of the distal ileum (~120 cm.), the small bowel
segment containing the blind loop, as well as the ileocecal valve. The surgeon feels that all of the
active disease and strictured bowel has been resected.
Six weeks after discharge from the hospital, he comes to your office complaining of frequent
loose stools. He has no fever or chills, and no abdominal discomfort, and a benign physical
exam. His WBC is normal, his ESR is normal, stool is guaiac negative, stool WBC is negative,
and stool for C. Dificile is negative.
25. The most appropriate treatment for his diarrhea at this time is:
A.
B.
C.
D.
Colesevelam (or a similar drug like Cholestyramine)
Remicade
6-Mercaptopurine
Prednisone
26. Which part of a Schilling test performed on this patient would be normal?
A.
B.
C.
D.
E.
Part I (B12 alone)
Part II (B12 + intrinsic factor)
Part III (B12 + pancreatic enzymes)
Part IV (B12 + antibiotics)
None of the above
27. Ulcerative colitis is characterized by all of the following EXCEPT:
A.
B.
C.
D.
Knifelike fissuring ulcerations in the colonic wall
Primarily superficial involvement of the colonic mucosa
Sparing of the terminal ileum
Increased incidence of dysplasia in longstanding disease
28. Tumor Necrosis Factor-alpha (TNF-) is believed to have an effect on Macrophages,
Endothelium, Fibroblasts and Epithelium. Which of the following statements is correct?
A. The proinflammatory cytokines released by the macrophages have not been
shown to play a role in Crohn’s disease
B. The effect of TNF- on fibroblasts could account for the therapeutic effect of antiTNF- on Crohn’s fistula.
C. The effects of TNF- on endothelium and epithelium, although impressive, have
no implications for the pathophysiology of inflammatory bowel disease.
D. All of the above
29. All of the following are typical extraintestinal manifestations of Crohn’s or Ulcerative Colitis
EXCEPT?
A.
B.
C.
D.
E.
Uveitis
Non-destructive arthritis of a major joint
Destructive arthritis of the small joints
Osteoporosis
Erythema nodosum and pyoderma gangrenosum
30. A 55-year-old white female, a resident of Rhode Island, complains of mild itching
which she has noticed over the past few months. Liver function test results show an elevated
Alkaline phosphatase, normal transaminases and bilirubin. Serology: negative viral serologies,
and positive anti-mitochondrial antibody with a titer of 1:512. What is the most likely diagnosis
and liver biopsy finding you would expect?
A.
B.
C.
D.
E.
Hepatitis C, portal lymphocytic infiltration
Alcoholic hepatitis, Mallory’s hyaline and steatosis
Primary Biliary Cirrhosis, lymphocytic cholangitis
Alpha-1 Antitrypsin deficiency, Eosinophilic globules
Autoimmune hepatitis, interface hepatitis with plasma cells
31. Alcoholic liver disease manifests as:
A.
B.
C.
D.
E.
Alcoholic hepatitis
Cirrhosis
Steatosis or fatty change
All of the above
None of the above
32. Cimetidine and a calcium-containing antacid preparation administered in an appropriate
dosage regimen for treating peptic ulcer differ in that:
A.
B.
C.
D.
E.
Only the calcium-containing antacid may increase gastric acid secretion.
Only cimetidine is likely to cause an increase in urinary pH.
Only cimetidine is likely to produce a laxative effect.
Only the antacid is likely to block vagally-mediated increase in gastric acid secretion
Only cimetidine can prevent the rise in gastric pH after the consumption of a meal.
Questions 33 – 36 refer to the following case scenario:
An 80-year old male developed dysphagia secondary to vocal cord paralysis following triple
vessel coronary artery bypass grafting (CABG). On post-operative day 3 he was successfully
weaned from the ventilator and extubated. Past medical history is significant for coronary artery
disease, hypertension, history of TIA with RLE weakness. Following extubation he developed
hoarseness, poor cough, and choking with oral intake. He was not short of breath. Physical
examination findings: alert and oriented x 3; breathy, raspy voice; neurological/cranial nerves IIXII intact; strength 5/5 bilaterally. A swallowing evaluation demonstrated inability to initiate dry
swallow, coughing, and regurgitation immediately after trials of puree and thin liquids, requiring
suctioning. A modified barium swallow was obtained which demonstrated aspiration, and it was
recommended that the patient remain NPO. Right vocal cord paralysis was confirmed by
fiberoptic laryngoscopy. The condition could take 6 months or longer to resolve.
33. What type of enteral access should be placed for nutritional support?
A.
B.
C.
D.
Nasogastric tube (NG)
Postpyloric nasoenteric tube
Percutaneous endoscopic gastrostomy (PEG)
Surgically placed jejunostomy (JT)
34. What type of tube feeding formula is most appropriate?
A.
B.
C.
D.
Polymeric, low residue diet
Polymeric, fiber-containing diet
Elemental, chemically defined diet
Immuno-modulating diet
35. What type of feeding schedule would be most appropriate for this patient at home?
A.
B.
C.
D.
Bolus, intermittent feedings of 4-5 meals per day
24-hour continuous feeding
Gravity drip during daytime
Cyclic, night-time infusions administered with feeding pump
36. What precautions can be taken to minimize aspiration risk with enteral feeding?
A.
B.
C.
D.
Add blue dye to the enteral formula
Feed patient only in the supine position
Check gastric residuals and hold feedings if residual volume is > 150 ml
Check pH of the fluid aspirated from tube
37. Which is considered the strongest risk factor for colorectal adenocarcinoma?
A.
B.
C.
D.
Germline FAP mutation
Twenty year history of ulcerative colitis
Germline mutation in one of the DNA repair genes
Hirschsprungs disease
Questions 38 - 41:
Match the following clinical situations with their corresponding tests/serologies:
38. Recent immigrant from Mainland China
39. American Medical student
40. IV Drug user
41. Obese Diabetic female
A.
B.
C.
D.
HBsAg(+), HBeAg(+), HBsAb (-), HBcAb(+), AST 124, ALT 134
HBsAg(+), HBeAg(-), HBsAb (-), HBcAb(+), AST 20, ALT 20
HBsAg(-), HBsAb(-), HBcAb(-), AST 60, ALT 73
HBsAg(-), HBsAb(+), HBcAb(-), AST 41, ALT 41
42. Which of the following statements about the treatment of hepatitis B is NOT correct?
A.
B.
C.
D.
E.
Entecavir is the most potent inhibitor of HBV replication currently in use
Lamivudine resistance may reach 70% after 4 years of use
HBeAg seroconversion is a useful therapeutic endpoint in HBeAg positive cases
HBeAg negative cases are easier to treat compared to HBeAg positive cases
Entecavir is less efficient if given after lamivudine resistance developed
43. All of the following statements about pancreatic secretion are true EXCEPT:
A. Stimulation of the vagus nerve increases pancreatic bicarbonate and enzyme secretion.
B. Secretin stimulates secretion of large quantities of pancreatic juice with high bicarbonate
and low enzyme concentration.
C. The primary function of the ductular cell is to secrete bicarbonate and water in the
formation of pancreatic juice.
D. Cholecystokinin potentiates the effect of secretin on pancreatic secretion.
E. Pancreatic secretions activate pepsin in the bowel lumen.
44. Enzyme initially secreted as a proenzyme by the pancreas :
A.
B.
C.
D.
E.
Colipase
Sterol esterase
Amylase
Carboxypeptidase
Lipase
45. Stimulant laxatives such as senna are effective in the treatment of constipation because:
A. They rapidly increase osmotic pressure of the small and large intestinal contents
and thereby inhibit water absorption.
B. They increase the bulk contents of the colon because they are indigestible.
C. They inhibit sodium absorption and promote chloride excretion by the colonic
mucosa, and increase colonic motility.
D. They have an atropine-like effect on the colonic musculature.
E. They antagonize the effect of PGE2 on chloride flux in the colonic mucosa.
46. The effect of excluding a part of the small intestine from the dietary stream includes:
A. Loss of bacterial colonization with resultant increase in the height and
function of the excluded bowel.
B. A decrease in the height and absorptive capacity of the excluded loop.
C. A decrease in the height and absorptive capacity of the excluded loop that is
readily repaired through intravenous feeding
D. Differentiation of part of the colon into small intestine appearing and
functioning mucosa.
Questions 47 - 51 pertain to the following case scenario:
A 45-year old female patient asks for dietary advice to decrease her risk of breast cancer. Her
sister was recently diagnosed with breast cancer. Your patient is concerned because her diet has
been similar to her sister’s over the years and she thought it was healthy. She said that she eats
lean chicken or fish for both lunch and dinner daily; she only eats red meat 1-2x month and
primarily low fat cuts; she avoids as much dietary fat as she can; she eats salads most days and
uses only low-fat or non-fat salad dressing. She does not like vegetables as much as fruit and she
tries to eat about 3 pieces of fruit each day. To make up for the lack of vegetables in her diet, she
takes a beta-carotene pill daily. She is 65 in tall (165.1 cm), weighs 140 lbs (63.6 kg), and has a
BMI = 23.4. She weighed about 120 when she graduated college.
47. What information would you provide for this patient regarding her body weight?
A. Her body weight falls within the healthy BMI range. She should avoid weight gain.
B. Although her body weight falls within a healthy BMI range, she has gained close to 22 lbs
since young adulthood, which would increase risk of breast cancer. Suggest some weight
loss or at least no further weight gain.
C. Continue to eat the lower fat diet and see if she can lose some body weight.
What specific information would you provide regarding:
48. Her fruit and vegetable consumption?
A. Increase her fruit consumption to 5 pieces per day as she is not eating sufficient
vegetables.
B. Explain to her that fruit has not been as consistently related to decreasing cancer risk as
vegetables. She should try to eat more dark vegetables and cook them in extra virgin
olive oil to help absorb the carotenoids.
C. Dark fruits and vegetables are more related to lowering cancer risk. She should
emphasize consumption of the darker produce.
49. The fat content of her diet?
A. Continue to eat a diet as low in fat as possible as low-fat diets are consistently related to
lowering cancer risk.
B. Low fat diets are not consistently related to lowering cancer risk and too low a diet may
increase risk. Extra virgin olive oil is a dietary fat associated with decreasing cancer risk.
Suggest that she include some olive oil daily and use it to prepare her meals.
C. Include some vegetables oils so that she does not experience essential fatty acid
deficiency.
50. Her meat intake?
A. Congratulate her on using primarily lean cuts of meat. Suggest that she continue this.
B. Explain that meat has been shown to increase breast cancer risk. Suggest that she further
decrease her meat consumption, either the quantity or frequency, and eat more meals that
are mainly plant products.
C. Explain that she needs to make sure that she is getting enough dietary protein each day so
her meat servings should be at least 3-4 oz.
51. Her use of a beta-carotene supplement?
A. Suggest that she continue to take the beta-carotene supplement if she will not eat
vegetables.
B. Suggest that she continue to take the beta-carotene supplement and also add a supplement
of vitamin E. Both pills will help to decrease her risk of cancer.
C. Explain that studies have not shown beta-carotene pills to be of benefit and that there is
the potential for harm. Suggest that she stop taking the beta-carotene pill and start to eat
dark vegetables. Explain that cooking the vegetables in olive oil will make them taste
better and is needed to absorb the carotenoids.
Questions 52 – 54 refer to the following case scenario:
A 54-year old man presents for evaluation of ascites. Paracentesis is performed. Chemistry
reveals the following:
Serum Albumin
Ascites Albumin
3.1 mg/dl
1.1 mg/dl
(nl 3.5-5.2 G/dl)
Ascites WBC
Ascites RBC
110 (10% PMN’s)
2
Cytology:
Negative
52. Which of the following statements is true?
A.
B.
C.
D.
The labwork suggests that he has Spontaneous Bacterial Peritonitis
The labwork suggests that he could have alcoholic cirrhosis
The labwork suggests that he could have tuberculous peritonitis
The labwork suggests that nephrotic syndrome may be the cause of his ascites
He is treated with 40 mg furosemide and 100 mg spironolactone daily. He presents several weeks
later with increasing ascites and bilateral lower extremity swelling while on treatment. His
abdomen is softly distended and non-tender. He has 1-2+ pitting edema to the mid-calf. He lives
alone and eats primarily canned/prepared foods.
53. What is the next therapeutic step?
A.
B.
C.
D.
Re-emphasize the importance of sodium restriction
Consider transjugular intrahepatic portosystemic shunt (TIPS)
Increase furosemide to 80 mg and spironolactone to 200 mg daily
Start therapeutic paracentesis for refractory ascites
54. All of the following are associated with the formation of ascites in cirrhosis EXCEPT?
A.
B.
C.
D.
E.
Increased hydrostatic pressure
Decreased colloid osmotic pressure
Increased capillary permeability
Decreased secretion of atrial natriuretic factor (ANF)
Decreased lymphatic drainage
55. A 49-year-old woman has experienced gradually increasing malaise, icterus, and loss of
appetite for the past 6 months. On physical examination, she has generalized jaundice and scleral
icterus. She has mild right upper quadrant tenderness and the liver span is normal. Laboratory
studies show total serum bilirubin of 7.8 mg/dL, AST 190 U/L. ALT 220 U/L, and alkaline
phosphate 26 U/L. A liver biopsy is performed, and microscopic examination of the biopsy
specimen shows piece meal necrosis of hepatocytes at the limiting plate, with portal bridging
fibrosis and a mononuclear infiltrate in the portal tracts. These findings are most typical of
which of the following conditions?
A.
B.
C.
D.
E.
HAV infection
Congestive heart failure
HCV infection
Hemochromatosis
Metastatic breast carcinoma
56. Which of the following statements about chronic pancreatitis is correct?:
A. There is no role for acid suppression in the treatment of pain or malabsorption
B. Coated pancreatic enzyme preparations are more effective for the treatment of
malabsorption than uncoated preparations
C. Degradation of CCK in the lumen by digestive enzymes helps to reduce the pain of
chronic pancreatitis
D. Malabsorption usually occurs after loss of 50% or more of the exocrine secretory
capacity
E. It is unusual for chronic alcoholics to have any evidence of pancreatic injury
57. A 50 year-old man presents with diarrhea and epigastric pain. He denies taking any
medications at all. Multiple ulcers in the duodenal bulb are noted at endoscopy. His brother has
previously been diagnosed with a pheochromocytoma and his mother has a history of medullary
carcinoma of the thyroid. At endoscopy the pH of his gastric juice was 6. Which of the following
statements is true?
A. He should undergo secretin stimulation testing
B. Surreptitious NSAID use should be considered
C. A very high gastrin level would be diagnostic of an underlying gastrin-secreting
tumor
D. Biopsies for H. pylori are unlikely to be helpful in his further management
E. A nuclear medicine scan for somatostatin receptors (Octreotide scan) is likely to
be positive
58. Which of the following gastric cell types is not correctly associated with its secreted product?
A.
B.
C.
D.
E.
ECL cell: gastrin
Parietal cell: hydrochloric acid
D cell: somatostatin
Parietal cell: intrinsic factor
Chief cell: pepsinogen
59. The pathophysiology of inflammatory bowel disease (Crohn’s disease and ulcerative colitis)
includes which of he following
A.
B.
C.
D.
Genetic factors
Environmental triggers
Immune dysregulation
All of the above
60. Motor function of the lower esophageal sphincter (LES) is characterized by:
A.
B.
C.
Tonic contraction mediated by the release of ACh from cholinergic nerves
Contraction in response to a swallow or to gastric distension
Relaxation mediated by release of nitric oxide from nonadrenergic, noncholinergic
neurons.
All of the above
D.
61. Ulcerative colitis is distinguished from Crohn's disease by all of the following
EXCEPT: (1 pt)
A.
B.
C.
D.
E.
Continuous lesions vs. skip lesions
Involvement of the full thickness of the mucosa vs. superficial ulcers
Fissures
Fistula
Rectal involvement
62. Which of the following statements about fat and fat digestion/absorption is true?:
A. Fat soluble vitamins are incorporated into mixed micelles and absorbed directly across
the microvillus cell membrane
B. Triglycerides are resynthesized from fatty acids and monoglyceride in the intestinal
epithelial cell and are exported directly into the portal circulation
C. Pancreatic lipase functions best at a pH of 3
D. Colipase helps to cleave Prolipase to its active form
Questions 63 – 66 refer to the following case scenario:
A 43-year old male alcoholic patient with biopsy-proven hepatitis C and cirrhosis presents to the
hospital with jaundice, massive ascites and significant peripheral edema, and melena. Several
months earlier, he was found to have esophageal varices and was started on beta-blocker therapy.
He is initially hypotensive, but responds to intravenous fluid. He is confused and is found to have
asterixis. Endoscopy reveals bleeding esophageal varices, which are banded. Bleeding ceases. He
is started on IV octreotide, and empirically treated with IV ciprofloxacin. He stabilizes. The
octreotide and cipro are discontinued, and he is started back on his beta-blockers as well as
diuretics and discharged from the hospital.
63. A likely clinical finding in this patient is:
A.
B.
C.
D.
A wedged hepatic venous pressure gradient > 12 mm Hg
Renal sodium wasting
Normal platelet count
Increased systemic vascular resistance
64. Octreotide is useful for treating acute variceal bleeding because:
A.
B.
C.
D.
It causes splanchnic vasodilation
It reduces gastric acid secretion
It inhibits several GI peptides including glucagon and VIP
It is very inexpensive
65. The probable underlying biochemical cause of his confusion is:
A.
B.
C.
D.
Elevated ammonia (NH3) in the bowel lumen and bloodstream
Decreased central gamma-aminobutyric acid levels
Increased levels of excitatory neurotransmitters
Elevated levels of branched chain amino acids
66. Indicate which of the following medications is NOT recommended in the treatment of
hepatic encephalopathy:
A.
B.
Rifaximine
Metronidazole
C.
D.
E.
Lactulose
Sorbitol
Neomycin
Questions 67-69 refer to the following photomicrograph:
67. The liver biopsy shows the following pattern of injury:
A. Periportal fibrosis
B. Steatosis
C. Central lobular necrosis
D. Ascending cholangitis
68. This pattern is most consistent with a diagnosis of:
A. Alcoholic liver disease
B. Chronic viral hepatitis
C. Acute hepatic necrosis
69. The blue stain represents:
A. Inflammatory cells
B. Hepatoma
C. Bile
D. Fibrosis
70. A newborn infant is found to be jaundiced. Total bilirubin is 4.2 mg/dl and the unconjugated
fraction is 3.8 mg/dl. Transaminases are normal. The most likely contributor to his jaundice is:
A.
B.
C.
D.
Absent uridine diphosphateglucuronide glucuronosyltransferase (UGT) activity
Mutation of the BSEP gene
Increased bilirubin load associated with premature red cell breakdown or hemolysis
Decreased enterohepatic circulation secondary to a bile salt transport defect
Question 71 refers to the following photograph:
71. A 50-year-old man has severe abdominal pain over the past 2 days. Physical
examination shows board-like rigidity of the abdominal muscles, preventing further examination.
There is no abdominal distention. A representative gross appearance of the disease process is
shown in the figure above. Which of the following is the mechanism most likely to produce this
appearance?
A.
B.
C.
D.
Cystic fibrosis gene mutation
Dysregulation of trypsinogen inactivation
Coxsackie B virus infection
Blunt force trauma to the abdomen
72. Which of the following is the most predictable side effect of ribavirin?
A.
B.
C.
D.
E.
Mixed cryoglobulinemia
Elastosis perforans serpiginosa
Hemolytic anemia
Thrombocytopenia
Flu-like symptoms
Question 73 refers to the following case scenario:
A 65-year old woman is evaluated for anemia. Her past medical history is notable for a history of
perforated duodenal ulcer with some type of repair. She is found to have a dimorphic population
of cells on her smear, with some microcytes and macrocytes, as well as hypersegmented
polymorphonuclear cells. Review of systems reveals intermittent diarrhea and bloating. Physical
exam was completely benign; stool was guaiac negative. Evaluation of the anemia reveals:
Folate
Vit B12
Iron
TIBC
Ferritin
3.6 ng/ml
(nl 2 – 9 ng/ml)
165 pg/ml
(nl 230 - 900 pg/ml)
25 g/ml
(nl 35-160 g/ml)\
450 g/ml
(nl 245-400 g/ml)
20 ng/ml
(nl 30-284 ng/ml)
She is sent for further evaluation. Additional studies are sent which reveal:
Fecal Fat
5.4 g/24 hr
(nl < 7 g/24 hr)
Schilling Test Part I 2% of Vit B12 excreted in urine/24 hours
(nl 7-28% excreted in urine/24 hours)
Schilling Test Part II 18% of Vit B12 excreted in urine/24 hours
D-Xylose Test
50 mg/ml in blood sample at 2 hours
(nl > 40 mg/ml at 2 hours)
Anti-parietal cell Ab < 2 I.U.
(nl < 20 I.U.)
73. The most likely diagnostic feature of the cause of her illness would be:
A.
B.
C.
D.
Flattening/loss of gastric folds on an upper endoscopy with atrophyof the oxyntic
glands
Pancreatic calcifications on a plain flat plate of the abdomen
Evidence of a Bilroth II anastomosis on an upper GI series with small bowel
follow-through
Blunting of the small intestinal villi, with elongation of the crypts and increased
intra-epithelial lymphocytes
74. Which of the following statements about Barrett’s Esophagus is true:
A.
B.
C.
D.
Barrett’s esophagus is most commonly seen in women
Barrett’s epithelium can be defined by the presence of intestinal metaplasia in the
mucosa of the gastric cardia, adjacent to the distal esophagus
Barrett’s esophagus tends to involve skip areas through the proximal and midesophagus
Barrett’s esophagus with high-grade dysplasia requires aggressive surveillance
and/or possible ablation or resection
75. The incidence of esophageal adenocarcinoma is:
A.
B.
C.
D.
Greater in females than males
Has been increasing in developed countries over the past 20 years
More common than squamous cell carcinoma in developing countries
Is directly associated with dietary salt content
76. Which of the following statements about esomeprazole is true:?
A.
B.
C.
D.
It is metabolized extensively by cytochrome p450.
It induces many drug-drug interactions.
Peak plasma concentrations of esomeprazole are lower than omeprazole.
It provides greater inhibition of stimulated gastric acid secretion than omeprazole.
77. GERD is treated with which of the following agents:
A.
B.
C.
D.
E.
Metoclopromide to inhibit transient lower esophageal sphincter relaxations
Loxiglumide to enhance esophageal peristalsis and LES pressure
Sulcrafate for cytoprotection
Lansoprazole for acid supresssion
All of the above
78. A 64-year old male presents with dysphagia and weakness. He has difficulty in particular
swallowing liquids, and coughs frequently whenever he eats. A modified barium swallow reveals
poor food bolus formation and propagation, weakness of the pharyngeal constrictors, and
occasional aspiration onswallowing . The most likely diagnosis is:
A.
B.
C.
D.
Myasthenia Gravis
Scleroderma
Diffuse esophageal spasm
Gastroesophageal Reflux Disease
79. Which of the following statements describes motor function of the small intestine?
A. Segmentation movements are characterisitic of small intestinal motor function in the
fasting or interdigestive state.
B. The fed pattern of small intestinal motility is not dependent upon extrinsic neural
input.
C. The migrating motor complex is characterized by three phases of activity ranging
from quiescence to forceful propagating contraction.
D. All of the above
80. Which of the following is true regarding gastric secretion?
A.
B.
C.
D.
E.
Somatostatin stimulates the gastric secretory response following a meal
Basal acid output is mainly dependent on gastrin
Amines stimulate gastrin release from gastric antral G cells
Blocking H2 receptors inhibits ECL cell function
Removing vagal drive improves gastric emptying
81. Which of the following agents has both prokinetic and antiemetic properties:
A.
B.
C.
D.
E.
Bisacodyl
Ranitidine
Magnesium hydroxide
Sucralfate
Metoclopromide
82. Phasic contractions of gastrointestinal smooth muscle depend upon all of the following
EXCEPT:
A.
B.
C.
D.
Rhythmic slow wave potentials
Generation of spike potential in association with slow waves
Slow actin-myosin crossbridge cycling
Elevation of cytosolic calcium levels.
83. A significant contributors to the pathogenesis of hepatocellular carcinoma in chronic hepatitis B
infection is:
A.
B.
C.
D.
Production of the HBx protein, a transcriptional transactivator
Concurrent alcohol consumption
Programmed cell death (apoptosis) of hepatocytes
Integration of viral DNA into host mitochrondrial DNA
84. Which of the following is the correct definition of sustained viral response in the
treatment of chronic hepatitis C?
A.
B.
C.
D.
Undetectable viral load 6 months after the completion of therapy
Undetectable viral load at the completion of therapy
At least 2 log decrease in viral load 6 months after the completion of therapy
Normalized transaminase levels and undetectable viral load at the completion
of therapy
Questions 85 – 89 (True/False)
Answer true (A) or false (B) for each of the following:
(5 points each)
85. Low grade dysplasia in the esophagus may progress to high grade dysplasia or
carcinoma for up to 10 years and thus requires intensive follow-up
86. Herpes simplex virus often infects the esophagus as an opportunistic infection in nonimmunosuppressed patients
87. Extension into the lamina propria distinguishes adenocarcinoma of the stomach from
high-grade dysplasia
88. Helicobacter pylori is a non-invasive spiral-shaped gram positive rod that infects the
stomach and is a risk factor for peptic ulcer disease and carcinoma
89. Chronic gastritis is a wastebasket term for multiple etiologies including autoimmune
disease caused by anti-parietal cell antibodies
90. All of the following statements about celiac disease are true EXCEPT?
A.
B.
C.
D.
E.
These patients must avoid grains such as buckwheat, sorghum and maize.
Patients often have antibodies to transglutamate
Many patients have antigliadin antibodies
There is any increased incidence of intestinal lymphoma and esophageal cancer.
Patients can have a higher incidence of insulin dependent diabetes and osteopenia.
91. Treatment of Irritable Bowel Syndrome includes which of the following?:
A.
B.
C.
D.
Loperimide for constipation-predominant patients.
Anticholinergic agents for pain and distension.
Alosetron to enhance colonic transit and sensation.
Tegaserod to inhibit small and large intestinal and colonic motility and slow colonic
transit.
E. All of the above.
92. Which of the following statements about antiemetic agents is correct:?
A. Ondansetron is a D2 antagonist that blocks dopaminergic receptors in the chemoreceptor trigger zone, and solitary tract nucleus.
B. Metoclopromide is useful for patients treated with highly emetogenic anti
neoplastic therapy because it antagonizes both D2 and 5-HT3 receptors.
C. Antihistamines, such as meclizine, are useful for patients treated with mild to
moderate emetogenic chemotherapeutic agents like fluorouracil or methotrexate.
D. Nabilone enhances the antiemetic efficacy of granisetron.
93. Known common risk factor for developing hepatic adenoma includes:
A. Hepatitis A virus
B. Hemochromatosis
C. Aflatoxin
D. Oral contraceptives
E. Methotrexate
94. Drugs which cause isolated indirect (unconjugated ) hyperbilirubinemia ,such as rifampicin
or probenecid, probably cause jaundice by:
A. Taking up binding sites on circulating albumin
B. Down-regulating uridine diphosphate glucuronide glucuronosyltransferase (UGT)
function
C. Causing mutations of the phospholipid export pump (MDR3)
D. Competitively inhibiting binding with ligandin, allowing back diffusion of
unconjugated bilirubin into the sinusoids and bloodstream
95. Which of the following sphincters relaxes in response to gastrointestinal hormones or
neuropeptides?:
A.
B.
C.
D.
Upper esophageal sphincter
Diaphragmatic “external sphincter”
Sphincter of Oddi
External Anal Sphincter
Questions 96 – 100 refer to the following diagram:
Select a letter from the diagram of the liver that is associated with each of the following terms,
conditions or locations. Each letter can be used more than once or not at all.
A
B
C
96. Location of damage with passive congestion (right-sided heart failure).
97. Site of inflammation during chronic viral hepatitis (HBV)
98. Lowest oxygen tension
99. Sinusoids
100. Affected by primary biliary cirrhosis
101. The time course of gene expression suggests that:
A. All adaptation must occur with in minutes of any insult to the intestine
B. Diet can have no real effect on events involved in intestinal repair
C. Different cell populations may respond to different environmental stimuli through
different molecular mechanisms.
D. Most adaptation will occur within about 25 to 50 minutes of any insult.
Questions 102 – 103 refer to the following scenario:
A 60-year-old woman is evaluated by her primary care physician. Her past medical history is
rather benign and limited to mild hypertension, currently on no medications. On review of
systems she notes mild polyuria and achey joints. She does not smoke, drink or use illicit drugs.
She does not know her family history. She is not sexually active.
On physical examination she is 5 feet 7 inches tall and weighs 150 lbs. Her blood pressure is
137/84 mm Hg, pulse rate 82, respiratory rate 14. She appears well tanned.
She does not smoke, drink or use illicit drugs. She does not know her family history. She is not
sexually active. Fasting bloodwork is obtained, which shows the following results:
Chemistry
Glucose
normal except:
154 mg/dl
(nl 70 – 115 ng/dl; < 100 fasting)
Bilirubin
AST
ALT
Alk Phos
1.2 mg/dl
84 U/L
92 U/L
125 U/L
T. Cholesterol:
Triglycerides:
LDL
HDL
207 mg/dL
(Ideal < 200 mg/dL)
152 mg/dL
119 mg/dL
(Ideal < 130 mg/dl, < 100 mg/dl with risk factors)
43 mg/dL
(Ideal > 45 mg/dl)
Additional labs are drawn:
(nl 0.2-1.2 mg/dl)
(nl 7-40 U/L)
(nl 7-40 U/L)
(nl 30-115 U/L)
Iron
TIBC
Ferritin
Alpha-1-antitrypsin
Ceruloplasmin
ANA
285 g/ml
340 g/ml
400 ng/ml
99 mg/dl
34.1 mg/dl
1:20
(nl 35-160 g/ml)\
(nl 245-400 g/ml)
(nl 30-284 ng/ml)
(nl 83-199 mg/dl)
(nl 25-63 mg/dl)
(nl < 1:20)
102. The most likely mechanism for this patient’s LFT abnormalities is:
A. Homozygous mutation of site 282 (C282Y) on chromosome 6
B. Genetic mutation resulting in abnormal function of the WND/ATP7 transport
protein
C. Pathologic polymerization and excretion from hepatocytes of a mutant protein
D. Insulin resistance with increased free fatty acid production
103. Treatment of her disorder will most likelyrequire:
A.
B.
C.
D.
Penicillamine
Weekly phlebotomy
Inhaled recombinant serine protease inhibitor
Systemic corticosteroids
104. Cholesterol solubility in bile is improved by which of the following?:
A.
B.
C.
D.
Secreted Phospholipids
Bile salt wasting processes, such as ileal Crohn’s disease
Increased cholesterol secretion into bile
Gallbladder mucus
105. Net absorption of sodium in the small intestine can be increased via which of the following
mechanisms:
A.
B.
C.
D.
Inhibiting the Na+, K+ ATPase on the basolateral membrane
Increasing cAMP levels in the absorptive cell
Increasing glucose in the lumen
Use of a heat-stable enterotoxin
Questions 106 - 110 pertain to the following case scenario:
A 54-year old woman with a history of intermittent GI distress associated with fatty meals
presents to the hospital complaining of severe abdominal pain. She has no scleral icterus, and has
epigastric tenderness with mild localizing rebound. She is febrile to 101.7 F. Plain films are
negative for free air. Labs return showing:
Bilirubin
AST
ALT
Alk Phos
Amylase
Lipase
1.5 mg/dl
47 U/L
51 U/L
106 U/L
422 U/L
126 U/L
(nl 0.2-1.2 mg/dl)
(nl 7-40 U/L)
(nl 7-40 U/L)
(nl 30-115 U/L)
(nl 25-128 U/L)
(nl 4-24 U/L)
Ultrasound shows small gallstones in the gallbladder. The gallbladder wall is normal in
appearance, and there is no fluid around the gallbladder. The common bile duct is minimally
dilated to 7 mm in diameter (normal < 6 mm). A CT scan without IV contrast shows that the
pancreas is edematous, with surrounding fluid.
106. Studies or care that might be of immediate value to this patient include all of the following
EXCEPT:
A.
B.
C.
D.
IV crystalloid
Pain medication
CT scan of the abdomen with arterial phase IV contrast
Laparoscopic cholecystectomy
107. Clinical features that would portend a poor prognosis would include any or all of the
following EXCEPT:
A.
B.
C.
D.
Fluid requirement > 6 L/day
Hypoxemia
Hypocalcemia
Serum amylase level > 1000
108. The pancreas is protected from the harmful effects of its own enzymes by which of the
following:
A. Enzymes which can attack membranes are synthesized as lysosomal hydrolases.
B. Acinar cells produce an amylase inhibitor which prevents premature amylase
activation within pancreatic tissue.
C. Enterokinase is activated in the duodenal lumen by trypsin
D. Lysosomal hydrolases deactivate proenzymes when local injury occurs.
She continues to have pain and on day five of her hospitalization, TPN is started.
109. Central venous access is required when using parenteral nutrition solutions that have a final
dextrose concentration greater than:
A.
B.
C.
D.
5%
10%
25%
30%
Four days later she spikes a fever to 103F and is found to be hypotensive and tachycardic.
110. The most likely source of sepsis in this patient is:
A.
B.
C.
D.
Central line associated infection
Mouth Flora
Normal enteric flora
Skin contaminants
Question 111 pertains to the following case scenario and photograph:
A 47-year-old Native-American woman presents with colicky right upper quadrant pain for the
past week. She has nausea, but no vomiting or diarrhea. On physical examination, she is
afebrile. There is marked tenderness on the right upper quadrant. The liver span is normal.
Her height is 160 cm (5 ft 3 in), and her weight is 90 kg (BMI 33). An abdominal
ultrasound scan shows calculi within the lumen of the gallbladder, and the gallbladder wall
appears thickened. Intrahepatic and extrahepatic bile ducts appear normal. The patient’s
gallbladder is removed by laparoscopic cholecystectomy and has the appearance shown
below:
111. Which of the following mechanisms is most likely to play the greatest role in
development of this disease?
A.
B.
C.
D.
E.
Antibody-mediated RBC lysis
Ascaris lumbricoides within bile ducts
Hepatocyte infection by HBV
Biliary hypersecretion of cholesterol
Hepatocyte infection by HBV
112. Intraluminal nutrients can alter intestinal function through their effects on:
A.
B.
C.
D.
Stem cell differentiation
Gene expression in the pericryptal fibroblast sheath
Migrating epithelial cells
All of the above
Questions 113 – 114 refer to the following scenario:
A 14-year-old girl is brought to your office by her mother, who notes progressively worsening
diarrhea over the past 1-2 months. All milk products were stopped and have been continuously
held starting 6 weeks ago, with no effect. Stools are watery and non-bloody. Stool osmolality is
285 mOsm/L. Stool Na+ is 28 mEq/L and Stool K+ is 54 mEq/L. Stool fecal leukocytes are
negative. Stool Ova and Parasites and routine cultures are negative.
113. Of the following, the most likely diagnosis is:
A. Drinking too much Starbucks coffee
B. Crohn’s disease of the ileum
C. Eating camp food containing pre-formed toxins
D. Surreptitious use of magnesium containing laxatives
114. Hydrogen breath testing will most likely demonstrate:
A)
B)
C)
D)
An early peak in breath H2 using lactose
An early peak in breath H2 using glucose
A late peak in breath H2 using lactulose
No significant “bump” in breath H2 using lactose
115. Loperamide and diphenoxylate are like morphine in that a single therapeutic dose of
each produces:
A.
B.
C.
D.
E.
Analgesia.
Slowed transit of intestinal contents.
More rapid gastric emptying.
Euphoria.
Increased colonic secretion of chloride ion.
Questions 116 – 118:
Match the patient to the expected type of gallstones:
116. 43-year old woman treated with clofibrate for hypertriglyceridemia
117. 22-year old patient with sickle cell anemia
118. 37-year old Native American female
A. Cholesterol Stones
B. Pigment Stones
119. Which of the following statements describes motor function of the stomach:?
A.
The pacemaker in the antrum of the stomach determines the frequency, velocity and
direction of the phasic contractions of the antral pump.
Contraction of the antrum provides a grinding and retropulsive force that breaks down
food particles.
Delivery of a high calorie meal to the small intestine relaxes the antrum and increases
the tonic contraction of the corpus.
All of the above
B.
C.
D.
120. A 5-year old boy presents to the ER with an episode of rectal bleeding. On endoscopy
a polypoid lesion is seen in the distal colon. Which of the following statements regarding this
polypoid lesion is true?:
A.
B.
C.
D.
Dysplasia is a universal finding in these polyps
Most commonly occur in the rectum
Histology is characterized by an arborizing smooth muscle component
Are never seen after the age of 30yr in females
121. All of the following statements about the epithelial cell are true EXCEPT:
A.
B.
C.
D.
E.
It can present class II major histocompatibility antigen (MHC)
Secretes IgA
Expresses toll-like receptors
Secretes antimicrobial peptides
Secretes lipopolysaccharide
122. The following statements about Peyer’s patches are true EXCEPT:
A.
B.
C.
D.
They sample for luminal antigens via specialized villi
They are heavily infiltrated with lymphocytes
Sensitized lymphocytes travel from the Peyer’s patches to mesenteric lymph
nodes
They may permissive to intestinal infection
123. Gut peptides have all of the following physiologic actions EXCEPT:
A.
B.
C.
D.
Peptides may be present in presynaptic nerve terminals
Gut peptides may be detected circulating in the blood
The actions of neuropeptides can be elicited by intravenous infusion of the peptide
The effects of a hormonal peptide can be antagonized at the receptor level
124. All of the following serve to reduce gastrin production EXCEPT:
A.
B.
C.
D.
Enterogastrones
Intraluminal gastric acid
Local release of somatostatin
Chewing food without swallowing it
125. The component of bile present in the greatest proportion by weight:
A.
B.
C.
D.
Water
Bile Salts
Cholesterol
Conjugated bilirubin
126. Physiologically acts as a neurotransmitter:
A.
B.
C.
D.
Gastrin
Somatostatin
Secretin
Gastrin-releasing peptide
127. Cause of conjugated (direct) hyperbilirubinemia:
A.
B.
C.
D.
Hereditary Spherocytosis
Ribavirin
Crigler-Najjar Syndrome Type II
Dubin-Johnson Syndrome
128. The pathogenesis of Gastroesophageal Reflux Disease is felt to involve all of the following
EXCEPT:
A.
B.
C.
D.
Poor clearance of refluxed material from the esophagus
Inappropriate relaxation of the lower esophageal sphincter
Hypersecretion of gastric acid
Decreased resting lower esophageal sphincter pressure
129. Cholestasis may be caused by all of the following EXCEPT:
A.
B.
C.
D.
Drug-induced inhibition of bile salt transport proteins
Hemolytic anemia
Sepsis
Pregnancy
130. Which of the following are the simplest and easiest anthropometric measures to monitor in
the elderly?
A.
B.
C.
D.
Height and weight
Triceps skinfold and arm muscle circumference
DEXA
Bio electrical impedence
131. Calculations of energy requirements (total energy expenditure) are adjusted upward for all
of the following EXCEPT:
A.
B.
C.
D.
Skeletal trauma
Major Sepsis
Caloric intake prior to injury
Burn
132. A patient’s pre-treatment risk of developing coronary heart disease (i.e., Framingham
Study risk index), is the most important determinant of:
A. Whether a fibric acid derivative (fibrate) or statin type drug should be the empiric
choice for therapy
B. The intensity of LDL-lowering therapy required (i.e., target LDL levels when on
treatment)
C. The patient’s likely response to lipid lowering therapy with appropriate drugs
D. The patient’s family history of dyslipidemia
E. The patient’s pre-treatment HDL level
133. Indicate which of the following statements concerning niacin is correct:
A. It is the most effective drug for raising HDL levels
B. It is contraindicated in patients taking atorvastatin.
C. It is contraindicated in patients taking the combination of fenofibrate and colesevelam.
D. It has no effect on glucose tolerance
E. It is the most effective drug for reducing VLDL levels.
134. Given an obese 65 year old female patient with the following lipid profile, total
cholesterol= 580 mg/dL, HDL= 25 mg/dL, triglycerides= 756 mg/dL, your best clinical course of
action would be:
A. Order a direct LDL level, and while results are pending, start treatment with
gemfibrozil
B. Calculate the LDL level from the data presented and start treatment with atorvastatin
at maximal dose.
C. Order a direct VLDL level, and while results are pending, start treatment with long
acting niacin
D. Order a direct LDL level, and while results are pending, start patient on simvastatin at
maximal dose, plus ezetimibe.
E. Order a direct VLDL level, and while results are pending, start patient on colesevelam
plus pravastatin at maximal dose
135. A centrally obese 49 year old male patient with a history of alcohol abuse and the
following lipid profile- total cholesterol= 450 mg/dL, HDL cholesterol= 27 mg/dL, and
triglycerides= 2006 mg/dL. Indicate which of the following statements offers the best description
of this patient and your recommendation:
A. Likely has a Type III hyperlipoproteinemia, and should be started on atorvastatin (at
maximal dose), and be encouraged to moderate, then stop his drinking
B. Likely has a Type IV hyperlipoproteinemia, and should be started on atorvastatin (at
maximal dose) plus colesevelam, and be encouraged to moderate, then stop his drinking
C. Likely has a Type V hyperlipoproteinemia, and should be started on fenofibrate
and be encouraged to moderate, then stop his drinking.
D. Likely has a Type V hyperlipoproteinemia, and should be started on simvastatin (at
maximal dose), plus ezetimibe, and be encouraged to moderate, then stop his drinking
E. Likely has a Type IV hyperlipoproteinemia, and should be started on atorvastatin (at
maximal dose), and be encouraged to moderate, then stop his drinking.
136. An increase in triglycerides, a (related) decrease in HDL cholesterol levels, and a mild
increase in LDL levels is associated most consistently with:
A. Niacin use in a patient with Type IIB hypercholesterolemia
B. The use of colesevelam in a patient with normal triglycerides, and mildly elevated LDL
cholesterol levels
C. Moderate alcohol consumption (one alcohol equivalent per day)
D. Hyperthyroidism
E. Obesity/excess weight gain
Questions 137-141 pertain to the following case scenario:
A 23-year old man took 200 aspirin tablets (a very dangerous dose – over 60 grams). He is
brought into the emergency room by his girlfriend, who says that he told her he was trying to kill
himself but thought better of it. He therefore called her and told her that he had taken the aspirin
about 12 hours before calling her. When he arrives in the emergency room, he is awake but
disoriented (he doesn’t know where he is), he has a temperature of 102 degrees, and he appears
to be hyperventilating. Based on your understanding of salicylate toxicity, you realize the
following:
137. The most likely reason he is hyperventilating is:
A. He is hypoglycemic
B. He is upset and agitated
C. He has a primary respiratory acidosis
D. He has a primary respiratory alkalosis
E. None of the above
138. The fact that he has a fever indicates that:
A. He probably took another drug that is causing his temperature to rise
B. He has severe aspirin toxicity
C. He probably has a bacterial infection
D. He must have not really taken aspirin because if he did he would not be febrile
E. He has Reye syndrome
139. Given the above history, which of the following is most likely?
A. The patient’s serum salicylate levels will probably rise during the first 6 hours after he
arrives in the emergency room
B. Based on the fact that he is still alive 12 hours after taking the aspirin, he will probably
do fine with only supportive care (IV fluids, careful monitoring)
C. His serum salicylate levels will fall, indicating that he is recovering from the aspirin
poisoning
D. His mental status will continue to deteriorate
E. He will develop liver failure
140. The initial aspirin level that you obtain is very high, consistent with severe salicylate
intoxication. The most effective way to reduce the patient’s total body aspirin burden is
to:
A. Give a high rate of IV fluid to induce a diuresis
B. Start hemodialysis
C. Acidify his urine with a sodium lactate infusion to increase the rate of salicylate
excretion
D. Give steroids to induce the P450-dependent routes of salicylate metabolism
E. Give acetazolamide (Diamox) until his arterial pH rises above 7.5 (normal is
approximately 7.4)
141. The action of salicylate that accounts for its severe toxicity is:
A. Its ability to uncouple oxidative phosphorylation
B. Its action of inhibiting platelet aggregation and hemostasis
C. Its propensity for causing cardiac arrhythmias
D. Its tendency to cause GI bleeding
E. Its ability to profoundly inhibit renal tubular function