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1. A 30 year male intravenous drug abuser presents to your clinic with malaise, mild right sided abdominal pain, low grade fever, and rash on his lower extremities. He has been injecting heroin and cocaine for over ten years. An HIV test done 2 months ago was negative but he was noted to have elevated transaminase levels. Since that time, he has noted increased fatigue, mental clouding, mild nausea and anorexia, and weight loss of about ten pounds. He has had intermittant night sweats. Exam is notable for anicteric sclera, poor dentition, mild axillary lymphadenopathy and needle (injection) track marks bilaterally, clear chest, normal cardiac exam, mild epigastric and right upper quadrant abomdinal tenderness on moderate palpation (negative Murphey Sign), enlarged liver 4cm below the right costal margin (total span 16cm), no spleen tip, no spider angiomata, mild asterixis, normal distal pulses, and 8mm red to purple, mildly tender, nodular lesions bilaterally below the knees. The following laboratory values are obtained: Sodium 134mM Potassium 3.5mM Chloride 104mM Bicarbonate 17mM BUN 48mg/dl Creatinine 4.3mg/dl Glucose 88mg/dl Calcium 7.3 Phosphate 5.6 Total Protein 7.6gm/dl Albumin 2.6gm/dl AST (SGOT) 135 ALT (SGPT) 170 Alkaline Phosphatase 120 (normal <110) Total Bilirubin 1.8 WBC 5.6K/µl HCT 29% Platelets 120K/µl PT 14.2 seconds (control 11.5) PTT 29.7 seconds (control 28). Urinalysis: pH 7.5, 3+ protein, 1+ blood, 5-10 rbc/field.
2. The most likely cause of the elevated hepatic transminase (AST and ALT) levels is [1]:

   A. HIV Associated Hepatitis
   B. Hepatitis B Virus Infection
   C. Hepatitis B Virus with Delta Virus Infections
   D. Hepatitis C Virus Infection
   E. Hemochromatosis

3. The most improtant predictor of liver synthetic dysfunction is [2]:

   A. Elevated Transaminases
   B. Reduced Albumin level
   C. Elevated Total Bilirubin
   D. Low Hematocrit
   E. Prolonged Prothrombin Time

4. The rash on the legs is most consistent with [3]:

   A. Erythema nodosum
   B. Pyoderma gangranosum
   C. Palpable Purpura
   D. Nodular Leprosy
   E. Rickettsial Infection

5. The most likely cause of the renal dysfunction is [4]:

   A. Chronic emboli from bacterial endocarditis
   B. Cryoglobulinemia
   C. Post-infectious glomerulonephritis
   D. Hepatorenal Syndrome
   E. Idiopathic Membranous Nephropathy

6. Because of the enlarged liver, an ultrasound is scheduled. An alpha-Fetoprotein level is also ordered, and returns highly elevated at 1480 Units. The most likely diagnosis is:

   A. Budd-Chiari Syndrome
   B. Hepatic Cirrhosis
   C. Hepatocellular Carcinoma
   D. Hepatic Vein and/or Inferior Vena Cava Thrombosis
   E. Congestive Heart Failure

7. Which of the following agents has been shown to be effective in reducing liver damage due to chronic hepatitis virus (B or C) infection [6] ?

   A. Interferon alpha
   B. Interferon Gamma
   C. Interleukin 2 (IL-2)
   D. Glucocorticoids
   E. Olsalazine

8. A 45 year old Asian woman presents to your clinic with six months of abdominal bloating, increased gas, and diarrhea. She has lost four pounds despite a good apatite. She thinks there may have been one episode of bloody stool. She recalls eating nothing out of the ordinary, and none of her family or friends are sick. She takes not medicines and has no allergies. There is no family history of diarrheal illness. Serum electrolytes show a normal sodium, potassium of 3.2mM (normal 3.6-5.2mM), chloride of 110mM, bicarbonate of 16mM (normal 20-28mM), blood urea nitrogen of 30mg/dL, creatinine 1.0mg/dL, glucose normal. Complete blood count is notable for a hematocrit of 32% with a mean corpuscular volume (MCV) of 74fl and a platelet count of 425K/µl (normal 150-350K/µl). A full colonscopy with biopsy reveals skip ulcerated lesions throughout the colon with ileo-cecal involvement, and full thickness inflammation and granulomas on the biopsy. The most likely diagnosis is [7]:

   A. Lymphocytic Colitis
   B. Crohn's Disease
   C. Ulcerative Colitis
   D. Subacute Colitis
   E. Colonic (with Ileal) Ischemia

9. The treatment of choice for this patient at this time is [8]:

   A. Sulfasalazine
   B. Prednisone orally
   C. Mesalamine Enemas
   D. Prednisolone Enemas
   E. Methotrexate

10. The patient does well for 6 months but comes to the emergency room two days after the onset of severe bloody diarrhea with 12-14 bloody stools per day, malaise, fever, and anorexia. She is quite orthostatic by vital signs. Exam reveals an ill-appearing woman with a pulse of 115bpm, blood pressure 105/60mm, temperature 101°F orally. There is mild to moderate direct abdominal tenderss, particularly in the right lower quadrant. There is no rebound tenderness. The remainder of the exam is unremarkable. Routine laboratory tests reveal a hematocrit of 28%, a sedimentation rate of 90mm/hr, white blood count 14.5K/µl with a left shift (10% immature neutrophils) on the differential, platelet count is 550K/µl. An abdominal radiograph shows a few air-fluid levels in the small bowel. The most appropriate course of action is [9]:

    A. Obtain blood cultures, give intravenous fluids with glucocorticoids, nothing by mouth
    B. Obtain blood cultures, give broad spectrum antibiotics, nothing by mouth
    C. Obtain an immediate surgical consultation, intravenous fluids, nothing by mouth
    D. Obtain stool cultures, begin ciprofloxacin orally, liquids only
    E. Intravenous fluids, glucocorticoids intravenously, broad spectrum antibiotics

11. The most appropriate therapy for prevention of FIRST EPISODE of variceal bleeding in patients with cirrhosis is [10]:

    A. Octreotide (Somatostatin®)
    B. Prophylactic endoscopic sclerotherapy
    C. ß-Adrenergic Blocking Agents or Isosorbide mononitrate
    D. Combination of sclerotherapy and ß-adrenergic blocking agent
    E. Vasopressin

Answers

1. D
2. E
3. C
4. B
5. C
6. A
7. B
8. A
9. A
10. C
11. TOPIC CARD REFERENCES
12. See Card "Viral Hepatitis"
13. See Card "Cirrhosis" ; See Card "Fulminant Hepatitis"
14. See Card "Vasculitis" ; See Card "Skin Lesions Differential"
15. See Card "Cryoglobulinemia"
16. See Card "Chronic Hepatitis"
17. See Card "Viral Hepatitis"
18. See Card "Inflammatory Bowel Disease Overview" ; See Card "Crohn's Disease"
19. See Card "Cirrhosis"