Which physical assessment has good specificity for acute appendicitis?
A. Murphy’s sign
B. Halo sign
C. Carnett’s sign
D. Rovsing’s sign
D. Rovsing’s sign
- Psoas, Obturator, and Rovsing’s are the most accurate for acute appendicitis.
- Murphy’s = cholecystitis or gall bladder disease.
-Halo = presence of CSF after a head injury. - Carnett’s = distinguishes abdominal wall pain from visceral pain.
Both Hepatitis A and Hepatitis B can be transmitted by which of the following modes?
A. Sneezing and coughing
B. Maternal-fetal transmission
C. Consumption of contaminated food or water
D. Sexual transmission
D. Sexual transmission
- Hep A is transmitted via fecal-oral route, person-to-person contact ( household, sexual transmission, residential or daycare centers), contact with contaminated food or water (consumption of raw or undercooked or contaminated food), blood transfusion, or illicit drug use.
A pt presents with generalized fatigue and concern for Hepatitis B virus (HBV) infection. Serology testing is significant for positive HBsAg and IgM anti-HBc. this suggests that the pt:
A. Was previously infected
B. Is immune d/t vaccination
C. Is chronically infected
D. Is acutely infected
D. Is acutely infected
- Acute hepatitis B is diagnosed based on the detection of Hepatitis B surface antigen (HBsAG) and IgM Hepatitis B core antibody (IgM anti-HBc).
- Markers of HBV replication, Hepatitis B e antigen (HBeAG and HBV DNA are also present in the initial phase of infection.
- Recovery is indicated by the disappearance of HBV DNA, HBeAG to hepatitis B e antibody (anti-HBe) seroconversion, and HBsAG to Hepatitis B surface antibody (anti-HBS) seroconversion.
- Previous infection is characterized by the presence of anti-HBs and IgG anti-HBc.
- Immunity after vaccination is indicated by the presence of anti-HBs only.
- Chronic HBV infection is diagnosed by the persistence of HBsAg for more than 6 months.
Pts with Hepatitis D are always dually infected with hepatitis:
A. B
B. A
C. C
D. E
A. B
- Hep D is closely associated with hep B virus (HBV) infection. The presence of HBV is required for complete virion assembly and secretion. Therefore, pts with Hep D are always dually infected with HBV.
A pt presents with LUQ pain. This area of abdominal pain suggests which of the following disease processes?
A. Acute pancreatitis
B. Acute cholecystits
C. Hepatitis
D. Splenomegaly
D. Splenomegaly
- LUQ pain is often related to disorders of the spleen (splenomegaly, splenic infarct, abscess, or rupture.
- RUQ pains = d/t biliary disorders (gallstones, acute cholecystitis, acute cholangitis) and hepatic disorders (hepatitis, liver abscess).
- Epigastric pain = pancreatic and gastric etiologies (peptic ulcer disease, gastritis).
A pt presents with RLQ pain, anorexia, nausea, and vomiting. During the physical assessment, the psoas sign is positive. This suggests which of the following acute processes?
A. Cholecystits
B. Pancreatitis
C. Appendicitis
D. Diverticulitis
C. Appendicitis
- Classic symptoms = RLQ abdominal pain, anorexia, nausea, vomiting.
- Psoas sign = associated with a retrocecal appendix.
- =RLQ pain with passive right hip extension. The pt draws up the right knee to shorten the muscle because the inflamed appendix may lie against the right psoas muscle.
- Cholecystitis = + Murphy’s sign.
- Diverticulitis = pain in LLQ.
- Pancreatitis = severe epigastric and LUQ pain.
An older adult pt was recently hospitalized and prescribed ABX for CAP. The pt presents with c/o severe watery diarrhea, lower abdominal pain, and cramping. The pt denies both a hx of previous episodes of diarrhea and recent travel. Which of the following regimens is indicated for initial treatment?
A. Metronidazole
B. Fecal transplant
C. Probiotics
D. Fidaxomicin
D. Fidaxomicin
- This pt is presenting with risk factors and clinical manifestations of possible C. Diff infection.
- Suspect in pts with acute diarrhea (more than 3 loose stools in 24hrs) with associated risk factors (recent ABX use, hospitalization, older age).
- The initial episode of non-severe C. Diff infection should be treated with either oral Fidaxomicin or oral Vancomycin for 10 days.
- Alternative agents = Metronidazole, but is less effective.
A pt undergoes an upper endoscopy for PUD, the gastric mucosal biopsy is positive for H. pylori. The pt has recently been treated with Azithromycin for a sinus infection. Which of the following ABX regimens is appropriate for this pt?
A. Bismuth, Metronidazole, Tetracycline, and a PPI
B. Clarithromycin, Amoxicillin, and a PPI
C. Clarithromycin, Metronidazole, and a PPI
D. Clarithromycin, Metronidazole, Amoxicillin, and a PPI
A. Bismuth, Metronidazole, Tetracycline, and a PPI
- Tx regimens are based on the presence of risk factors for macrolide resistance and presence of a PCN allergy.
- Bismuth quadruple therapy is recommended for pts with any prior exposure to macrolides for any reason and in areas of local Clarithromycin resistance rates 1>5% or eradication rates with Clarithromycin triple therapy <85%.
- Clarithromycin-based triple therapy is used in pts without risk factors.
- Metronidazole can be used instead of Amoxicillin in pts with a PCN allergy.
A pt presents with dyspepsia and upper abdominal discomfort that radiates to the epigastric area. The pt reports that the pain improves after meals but worsens 2-5 hrs after a meal. The pt also reports bloating and weight gain. This presentation suggests the presence of which of the following?
A. Gastric ulcer
B. Gastroesophageal reflux disease
C. Duodenal ulcer
D. Pancreatitis
C. Duodenal ulcer
- This pt is presenting with s/s of a duodenal ulcer.
- Upper abdominal pain or discomfort is the most common symptom seen in peptic ulcers, 80% report epigastric pain.
- Duodenal ulcers often improve with eating, but worsen 2-5hrs after a meal, when acid is secreted in the absence of a food buffer, and at night 11-2a, when the circadian rhythm of acid secretion is highest.
- Pain associated with gastric ulcers generally worsens while eating.
Which of the following is the serologic hallmark of a Hepatitis B virus infection?
A. Anti-HBs
B. HBcAg
C. Anti-HBc
D. HBsAg
D. HBsAg
- This marker can be detected in high levels during acute or chronic infection.
- Hepatitis B core antibody (anti-HBc) appears at onset and can be detected through the course of Hepatitis B infection.
-Hepatitis B core antigen (HBcAg) = is an intracellular antigen expressed in infected hepatocytes and is usually not detectable. - Hepatitis B surface antibody (Anti-HBs) = persists for life in most pts, conferring lifelong immunity from reinfection.
- Immunity after vaccination is indicated by the presence of anti-HBs.
A pt presents with upper abdominal pain and discomfort. The pt also reports bloating, abdominal fullness, nausea, and pain that worsens immediately after eating. The pt reports a hx of daily use of NSAIDs for chronic back pain. Based on the pt’s presentation, which of the following is the MOST accurate diagnostic test?
A. Abdominal CT scan
B. Upper endoscopy
C. Abdominal ultrasound
D. Urea breath test
B. Upper endoscopy
- This pt is presenting with s/s of peptic ulcer disease (abd pain, dyspepsia).
- Pain that worsens with eating is suggestive of a gastric ulcer.
- The most accurate diagnostic test is an endoscopy (sensitivity is about 90%).
Which of the following is considered a marker of Hepatitis B replication and infectivity?
A. HBeAg
B. IgM anti-HBc
C. HBsAg
D. Anti-HBs
A. HBeAg
- Hepatitis B e antigen (HBeAg) represents Hepatitis B virus replication and infectivity; it’s presence denotes high levels of Hepatitis B virus DNA in serum and high rates of transmission.
- IgM antibody to hepatitis B core antigen (IgM anti-HBc) indicates acute infection with HBV.
- Hepatitis B surface antigen (HBsAg) is the serologic hallmark of hepatitis B virus infection; it can be detected in high levels during acute or chronic infection.
- Anti-HBs persists for life in most pts, conferring lifelong immunity from reinfection. Immunity after vaccination is indicated by the presence of anti-HBs.
A pt presents for routine lab work. An elevated alkaline phosphatase level is noted. In order to confirm that this elevation is due to a liver source, which of the following lab tests should be checked next?
A. Lactate dehydrogenase
B. Alanine aminotransferase (ALT)
C. Gamma-glutamyl transpeptidase (GGT)
D. Aspartate aminotransferase (AST
C. Gamma-glutamyl transpeptidase (GGT)
-Isolated elevation of alkaline phosphatase requires the confirmation that is of hepatic origin since it can also come from other sources, such as bone and placenta.
- A GGT or serum 5’-nucleotidase level should be obtained to confirm that the elevation of alkaline phosphatase is secondary to the liver.
- These tests, along with liver enzymes, AST, ALT, and lactate dehydrogenase, are elevated in liver disorders, but are not increased in bone disorders.
A healthcare worker is concerned that they may have been infected with Hepatitis B d/t an accidental needlestick from an infected pt. Serology testing is significant for negative HBsAg and anti-HBc and positive for anti-HBs. This suggests that the pt is:
A. Immune due to natural infection
B. Immune due to Hepatitis B vaccine
C. Chronically infected
D. Acutely infected
B. Immune due to Hepatitis B vaccine
- Hepatitis B surface antigen is the hallmark of HBV infection; It can be detected in high levels during acute or chronic infection.
- Hepatitis B core antibody (Anti-HBc) appears at onset of symptoms and persists for life, suggesting previous or ongoing infection with HBV.
-Since the pt is negative for both HBsAg and anti-HBc, acute or chronic infection is unlikely. - The presence of anti-HBs suggests recovery and immunity from HBV infection. Immunity after successful vaccination is indicated by the presence of anti-HBs.
A 30-year-old pt presents with mild-to-moderate LLQ pain, constipation, and mild abdominal tenderness. Routine lab work is significant for elevated C-reactive protein and leukocytosis. Abdominal CT scan is pending to confirm diagnosis. The pt’s VS are stable and they are able to tolerate oral intake. Based on this presentation, first-line treatment for most pts includes:
A. IV ABX
B. Nothing by mouth for complete bowel rest
C. Oral ABX
D. Pain control with oral analgesics and a liquid diet
D. Pain control with oral analgesics and a liquid diet
- This pt is presenting with acute diverticulitis (LLQ, abdominal tenderness, and leukocytosis).
- Diagnosis is made based on a CT scan with contrast.
- Most cases can be treated as outpt supportive cares (pain control with oral analgesics and a liquid diet). Pts should be reassessed until resolution of symptoms.
A pt presents with a long hx of crampy abdominal pain, diarrhea, fatigue, and weight loss. Endoscopic findings are significant for transmural inflammation, esophageal ulceration, cobblestone mucosal appearance, and skip lesions with areas of normal-appearing bowel interrupted by large areas of disease along the length of the intestine. These findings are suggestive of what disease?
A. Ulcerative colitis
B. Crohn’s disease
C. Irritable bowel syndrome
D. Gastritis
B. Crohn’s disease
- The hallmark s/s of Crohn’s = campy abdominal pain, chronic intermittent diarrhea, fatigue, and weight loss.
- Crohn’s and UC are subtypes of inflammatory bowel disease.
- Findings specific to Crohn’s = transmural inflammation and involvement of any portion of the gastrointestinal tract whereas UC only affects the colon.
- Endoscopic findings of Crohn’s = cobblestone mucosal appearance, skip areas, pseudopolyps, granulomas, esophageal/duodenal ulceration, and gastric inflammation.
- Pts with irritable bowel syndrome do not have mucosal inflammation on ileocolonoscopy.
- Gastritis = inflammation of the lining of the stomach.
A pt with IBS presents with intermittent abdominal bloating and mild discomfort despite exclusion of gas-producing foods. Which of the following initial therapies can be recommended next?
A. Polyethylene glycol
B. Bile acid sequestrant
C. Probiotics
D. Low FODMAP diet
D. Low FODMAP diet
- Lifestyle and dietary modifications, such as exclusion of gas-producing food and a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAP).
- Pts may also benefit from lactose and/or gluten-free diets with increased consumption of soluble fiber (psyllium-Metamucil) and increased physical activity.
- For pts with moderate to severe symptoms, or those with constipation who have failed with soluble fiber intake, may be started on polyethylene glycol.
- Bile acid sequestrants can be started for pts with IBS-related diarrhea (Loperamide- Imodium)
- Probiotics are not recommended for pts with IBS.
A pt with IBS reports increased flatulence and discomfort despite dietary modifications. When asked about their 34-hr diet recall, the pt reports eating eggs and sausage with herbal tea for breakfast, a turkey sandwich with coleslaw for lunch, and baked chicken with carrots and rice for dinner, with ice cream for dessert. The pt needs further education about the exclusion of which foods?
A. Coleslaw, ice cream
B. Eggs, turkey
C. Turkey, rice
D. Carrots, herbal tea
A. Coleslaw, ice cream
- Foods to avoid for flatulence = wheat germ, pretzels, bagels, certain dairy products (milk, ice cream, cheese), some vegetables (cabbage, brussel sprouts, cauliflower, broccoli, onions), certain fruits (prunes, apples, pears, raisins, cherries), legumes (beans, peas, baked beans, soybeans), fatty and fried foods, high fructose corn syrup, carbonated beverages, alcohol, caffeine, and artificial sweeteners.
UC differs from Crohn’s disease in that it:
A. Can involve any portion of the GI tract
B. Is characterized by transmural inflammation
C. Affects only the colon and rectum
D. Presents with diarrhea and abdominal pain
C. Affects only the colon and rectum
- Both UC and Crohn’s cause crampy abdominal pain and diarrhea.
- Crohn’s = characterized by transmural inflammation and can involve any portion of the GI tract.
Which of the following BEST describes Cullen’s sign?
A. Cessation of inspiration upon deep palpation of the RUQ of the abdomen.
B. Bruising around the periumbilical area of the abdomen.
C. Deep palpation of the LLQ of the abdomen that causes pain to radiate to the RLQ.
D. Blue-black discoloration that is located on the right flank of the trunk.
B. Bruising around the periumbilical area of the abdomen.
- This is associated with pancreatitis. The color can range from blue-black to purple, then changes as the bruise resolves.
- Caused by retroperitoneal bleeding, when the blood migrates to the subcutaneous tissue in the periumbilical area (Cullen’s sign) or flank (Grey-Turner sign).
- It may also appear with other conditions such as splenic rupture, ruptured aortic aneurysm, rectus sheath hematoma, perforated duodenal ulcer, ruptured ectopic pregnancy, and hepatocellular cancer.
Which of the following is the screening test for hepatitis C virus (HCV)?
A. Anti-HCV
B. HBsAg
C. Anti-HAV
D. HCV RNA polymerase chain reaction (PCR)
A. Anti-HCV
- This is the initial screening for Hep C.
- The next step is to order the HCV RNA.
Which of the following suggest gallbladder inflammation?
A. Rovsing’s maneuver
B. Rebound tenderness
C. Murphy’s maneuver
D. McMurray’s maneuver
C. Murphy’s maneuver
- Performed with pt supine, the palpating hand is placed just below the right costal margin midclavicular area. The pt is instructed to exhale. Then the pt is instructed to inhale and the NP presses down, palpating the hand over the liver.
- The result is + if the pt stops mid-inhalation d/t the pain.
A 45-year-old female pt c/o intermittent, burning epigastric pain over the past few months. It is worse at night, especially after a heavy or spicy meal. She goes to sleep about 2 hours after eating. The pis not, or is only partially, relieved by antacids. The pt is not a smoker and denies radiation of pain to the neck, arms, or jaw; diaphoresis; or dyspnea. What is the BEST next step?
A. Order a 12-lead EKG
B. Prescribe a PPI
C. Instruct the pt to stop eating at least 4 hours before bedtime and avoid spicy or heavy meals at night
D. Schedule a fasting lipid profile, including cholesterol, low-density lipoprotein, high-density lipoprotein, and triglycerides.
C. Instruct the pt to stop eating at least 4 hours before bedtime and avoid spicy or heavy meals at night
- Also avoid caffeine and mint.
- PPI prescription may be indicated if symptoms continue after lifestyle changes were made.
A 60-year-old male pt reports a poor appetite and abdominal pain. He states that the middle of his stomach around the umbilicus hurts and that the pain then moved to the right lower side of his abdomen. His temperature is 100.8F, HR of 90, RR of 20, and BP of 110/64. During the abdominal exam, the pt has RLQ abdominal tenderness without rebound. Which of the following is the MOST helpful clue when considering differential diagnoses?
A. The location of the pain
B. The pt’s vitals
C. The pt’s poor appetite
D. The age of the pt
A. the location of the pain
- Appendicitis presents with classic symptoms of RLQ pain, which is initially periumbilical, then migrates to the RLQ as the inflammation progresses.
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