Gastrointestinal Bleeding case 5

A 47-year-old, darkly pigmented man with a known history of alcohol abuse begins vomiting large quantities of blood and is brought by ambulance to the emergency department.

Q 1

In the emergency department, the man is found to have a temperature of 36.7 C (98.1 F), blood pressure of 65/40 mm Hg and dropping rapidly, a weak pulse of 130/min, and respirations of 29/min. These vital signs suggest that which of the following is developing?

/ A. Congestive heart failure

/ B. Meningitis

/ C. Pneumonia

/ D. Septicemia

/ E. Shock

Q 2

A blood sample is drawn and an IV Iine is started. While the patient is being cross-matched, the physical examination is continued. The patient's sclerae are noted to be icteric and his nail beds and palms have a yellowish hue. A caput medusa

is noted. Which of the following is the most accurate description of a caput medusa?

/ A. Ecchymoses over the mastoid process

/ B. Paradoxical increase in venous distension and pressure during inspiration

/ C. Reflex movement of the eyes in the opposite direction to that in which the head is moved

/ D. Small bony masses found on the terminal phalanges

/ E. Varicose veins radiating from the area of the umbilicus

Q 3

Caput medusa specifically suggests which of the following diagnoses?

/ A. BIadder infection

/ B. Duodenal ulcer

/ C. Gastric ulcer

/ D. Pancreatitis

/ E. Portal hypertension

Q 4

Which of the following is the most common cause of this patient's disorder in the United States?

/ A. Hepatic cirrhosis

/ B. Hepatic vein thrombosis

/ C. Hepatocellular carcinoma

/ D. Metastatic disease to the liver

/ E. Portal vein thrombosis

Q 5

Endoscopic studies demonstrate that this patient has bleeding esophageal varices, and the bleeding is successfully stopped with

sclerotherapy. What percentage of patients with bleeding esophageal varices have another episode of variceal bleeding at a subsequent

time?

/ A. 5%

/ B. 25%

/ C. 40%

/ D. 70%

/ E. 95%

Q 6

Following blood transfusions and sclerotherapy, the patient initially feels reasonably well and is able to converse with medical personneI. Over

the next 12 hours, while he does not begin to rebleed, his mental status deteriorates. Arterial blood levels of which of the following would be

most helpful in confirming the likely diagnosis?

/ A. Ammonia

/ B. Angiotensin l

/ C. Calcitonin

/ D. Carbon monoxide

/ E. Ceruloplasmin

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Gastrointestinal Bleeding case 5 answers

A1

The correct answer is E. The patient's low and dropping blood pressure, tachycardia, high respiratory rate, and slightly below normal body temperature are all consistent with impending shock. At this point, the other conditions listed in the choices have not yet been ruled out, but clinically, the patient should begin to be immediately treated for the shock, even if the therapeutic workup for underlying conditions must be temporarily deferred

A2

The correct answer is E. Medusa was a goddess with snakes instead of hair on her head. The caput medusa (Medusa's head) is an old term still in fairly common use for numerous varicose veins radiating over the abdomen from the area of the umbilicus.

Choice A describes Battle's sign, which is suggestive of basal skull fracture.

Choice B describes Kussmaul's sign, which is seen in constrictive pericarditis.

Choice C describes the doll's eye sign, which is looked for in the evaluation of comatose patients and suggests functional integrity of the brainstem tegmental pathways and cranial nerves involved in eye movement.

Choice D describes Heberden's nodules, which are seen in osteoarthritis.

A3

The correct answer is E. The caput medusa develops when severe portal hypertension induces dilation of the anastomotic channels between the portal venous system and the systemic venous system, some of which involve the superficial veins near the umbilicus. The other answers are distracters.

A4

The correct answer is A. The overwhelmingly most common cause of portal hypertension in the United States is hepatic cirrhosis, which is usually due to either alcoholism or hepatitis viral infection. In this patient's case, the diagnosis of cirrhosis is further clinically substantiated by his jaundice, as evidenced by his sclera, nail beds, and palms. (Look in these areas on individuals in whom dark skin pigmentation may mask the jaundice generally.) The other entities listed are occasional causes of portal hypertension.

A5

The correct answer is D. Patients who have had one episode of bleeding from esophageal varices have an approximately 70% chance of developing a second incident of bleeding, and one third of these episodes of rebleeding is fatal.

A6

The correct answer is A. Hepatic encephalopathy is seen in end-stage cirrhosis patients, and can either present or worsen in the presence of gastrointestinal bleeding. The blood in the upper gastrointestinal tract behaves essentially as a high protein load, and increases the absorption of ammonia and nitrogen, which cannot be appropriately metabolized by the liver. GI bleeding may also predispose for inadequate renal function secondary to hypotension.

Angiotensin I (choice B) is part of the renin-angiotensin-aldosterone system for blood pressure and sodium ion control.

Calcitonin (choice C) is a hormone secreted by the thyroid, which may be increased in medullary carcinoma of the thyroid.

Carbon monoxide (choice D) increases in the blood in smokers.

Ceruloplasmin (choice E) is a copper-carrying protein monitored in patients with Wilson disease.

Cough Case 1

A 50-year-old man consults a physician because he has developed a chronic, non-productive cough and is experiencing a reduced ability to do strenuous work. His symptoms have developed insidiously. On questioning, he states that he is a smoker and has also worked as a
contractor for all of his adult life. Physical examination is notable for the presence of repetitive end-inspiratory basal crackles and finger clubbing. A chest x-ray film shows diffusely distributed, small irregular opacities that are most prominent in the lower lung zones. Localized
areas of pleural thickening are also noted. No large masses are seen.

Q 1

The chest x-ray film is most consistent with which of the following?
/ A. Emphysema
/ B. Interstitial disease
/ C. Lobar pneumonia
/ D. Lung cancer
/ E. Pleural effusion

Q 2

The patient is sent for spirometry for further evaluation. FEV1 and FVC are both shown to be about 60% of the expected values, and the ratio of FEV1/FVC is 90%. These findings are most consistent with which of the following?
/ A. Asthma
/ B. Bronchiectasis
/ C. Chronic bronchitis
/ D. Emphysema
/ E. Restrictive lung disease


Q 3
The patient's work history is most suggestive of exposure to which of the following?
/ A. Asbestos
/ B. Beryllium
/ C. Coal
/ D. Kaolin
/ E. Silica

Q 4

In addition to predisposing for pulmonary fibrosis and bronchogenic carcinoma, this patient's disease is associated which of the following?
/ A. Basal cell carcinoma
/ B. Germ cell tumor
/ C. Hemangioma
/ D. Mesothelioma
/ E. Pleomorphic adenoma

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Cough Case 1 Answers

A1
The correct answer is B. Diffusely distributed small irregular opacities suggest the presence of interstitial lung disease.
Emphysema (choice A) would produce unusually dark lung fields.
Lobar pneumonia (choice C) would produce a "white out" of one or more lung lobes.
Lung cancer (choice D), if large, would produce a mass lesion (often involving a bronchus), or, if very small, might not be recognized on chest x-ray.
Pleural effusion (choice E) would cause a whitened area due to fluid below the lung

A2
The correct answer is E. Spirometry is commonly used to subdivide non-tumorous lung diseases into diseases that are predominately obstructive in nature and those that are predominately restrictive. The process of spirometry involves controlled breathing in and out while airflow is plotted against volume to obtain a continuous loop. FVC (forced vital capacity) is the maximum volume of air that can be forcibly and rapidly exhaled following a maximum inspiration. FEV1 (forced expiratory volume in the first second) is the volume of air expelled in the first second of a forced expiration starting from full inspiration. Restrictive lung disease usually shows a reduction in both FVC and FEV1, and the ratio of FEV1/FVC is greater than 80%. If these readings are obtained in a patient, further studies to measure lung volumes are usually performed to confirm the finding.
Asthma (choice A), bronchiectasis (choice B), chronic bronchitis (choice C), and emphysema (choice D) all tend to produce obstructive patterns, with FEV1 disproportionately decreased when compared to FVC.


A3

The correct answer is A. Working history often offers helpful clues about possible toxic exposures that may have contributed to lung disease. Asbestos was formerly a common constituent of insulating material in buildings because of both its insulating properties and its fire-resistant properties. People working on old buildings, particularly when removing the old insulation, are consequently vulnerable to high exposures unless they take care to minimize exposure with respirators. The risk to individuals living and working in old buildings is usually markedly less, since the asbestos is typically found behind walls. Individuals who work in asbestos mines (principally in Canada, South Africa, and the former USSR) may also have high exposures.
Beryllium (choice B) is used in the nuclear industry and in x-ray tubes, and was formerly used in ceramics, metallic alloys, and fluorescent lights.
Most significant coal (choice C) exposures occur in coal miners.
Kaolin (choice D) is a component of clay dust.
Silica (choice E) is found in sand and glass, and significant exposures can be seen in individuals working in environments where small particles of these materials may become aerosolized.

A4

The correct answer is D. Asbestos exposure is also linked to late (often after 20 years) development of the rare tumor, malignant mesothelioma. The amphibole forms of asbestos appear to be much more likely to induce mesothelioma than does chrysotile, and some authors have even speculated that the rare cases of mesothelioma in persons with predominant exposure to the serpentine form of asbestos may have been actually related to trace exposures to the amphibole forms. In contrast, all types of asbestos can cause pleural plaques, pulmonary fibrosis, and lung cancer. None of the other lesions listed in the choices have ties to asbestos.
Basal cell carcinoma (choice A) is a form of skin cancer.
Germ cell tumors (choice B) usually occur in testes and ovary.
Hemangioma (choice C) is a benign tumor of blood vessels.
Pleomorphic adenoma (choice E) is a salivary gland tumor.