Cram The Pance - S1E25 50 High Yield GI Questions

Episode Date: June 4, 2021

50 high yield Gastrointestinal questions to help you prepare for your Pance, Panre and Eor’s. ►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

Okay, so I had some requests to do another series of these 50 questions that I did for cardiology. A lot of people said it was really helpful. So I'm going to do another one for GI before I move into the pulmonology section. And then I'm going to try to do them kind of every few weeks. I'll release another one because a lot of people have been asking me to make more. So we'll do GI this week and then I'll start to focus on pulmonology and then I'll release some more in the near future. So 50 high yield GI questions. Again, the way I'm doing this is I'm going through the blueprint topic.

I'm picking a few questions from each topic within the GI series, which I feel is important, and that I feel you'll likely be asked on the boards. So really quickly again, thank you so much for all the comments, the new subscriptions, and if you haven't checked out my YouTube page, please check it out. It's under cram the pants on YouTube. So let's get started. 50 GI questions. So question number one, describe Boa's sign and acute colisestitis.

Boa's sign, B-O-A-S sign in acute colisestitis. So this is going to be referred pain. generally just inferior to the right scapula, seen in acute colitis. And what's happening is you have this irritation of the phrenic nerve, which is in front near the gallbladder, and then it's going all the way to the right upper back. So that's why sometimes people will come in with acute colitis, and they have back pain. It's referred pain because of the irritation of the frenic nerve. I always visualized like a boa constrictor around somebody's neck with the head of the boa constrictor

kind of around the front right upper quadrant, and then the tail back. like near the right scapula. So it just was like a visual that always helped me in school. In case that helps you. Okay. Question number two. Describe Charcos triads seen an acute colangitis. Describe Charcos triads seen an acute colangitis. So this is three things. It's going to be a fever, right upper quadrant pain and jaundice. Fever, right upper quadrant pain and jaundice will be the triad and acute colangitis. And remember, you're not going to see this in every patient. Probably about half the patient population will actually have all three. And also remember, in addition to these three, they also have hypotension and altered mental status.

This is going to be known as Reynolds Pentad. So you may be asked either one, but remember, Shalkhose Triadis, Feverida, right up, quadrant pain, and jaundice. Question three. What type of gallstone is seen more commonly in bacterial and parasitic infections, as well as more prevalent in the Asian population? So what type of gallstone is more common in bacterial and parasitic infections as well as more prevalent in the Asian population? This is going to be brown stones. So brown stones are common in rice growing regions of East Asia.

And there's a higher incidence because there's this type of parasite known as a biliary fluke that can grow in this type of crop. And it predisposes these patients in these regions to these brown pigment stones. So remember if you see brown pigment stone, you should be thinking of. a bacterial parasitic infection and then the population that it's more prevalent in is the Asian population, especially East Asia. And then of course remember your most common type of stone is a cholesterol stone. That's going to be about 90% of the patients. All right. So question four. A 16 year old male presents to the office accompanied by his mother. He's complaining of transient episodes of yellowing of his skin. He's noticed it often occurs when he's taking a test

at school or recently when he had an upper respiratory infection. He has no other symptoms. His labs do show an increase in indirect Billy Rubin, but otherwise, no abnormality seen in his lab, all of his other liver function enzymes, all the other liver enzymes are completely normal. So what is the most likely diagnosis in this patient? So that's a classic presentation of Gilbert's syndrome. So Gilbert's syndrome, it's a benign condition, normally doesn't require any treatment, where the liver isn't properly processing bilirubin. Most patients are going to be asymptomatic, but they may describe these transient episodes of jaundice,

and typically the jaundice will occur during periods of stress, illness. Labs are often going to be normal, except for that isolated elevation in indirect billy-rubin. So remember if you see transient jaundice with just elevation in indirect billy-rubin, should be thinking Gilbert's syndrome. Five, what is the most common cause of acute lower GI bleeds? Most common cause of acute lower GI bleeds? It's going to be diverticulosis. Diverticulosis is the most common cause of acute lower GIBleads.

of acute lower GI bleeds. Question six. What is the most common area of the colon to be affected by diverticulitis? Most common area of the colon to be affected by diverticulitis. It's going to be the sigmoid colon, and that's due to the increased intraluminal pressure in that area. So sigmoid colon, most common area affected by diverticulitis. Question seven, what should be suspected in a patient with systemic toxicity, fever, tachycardic, hypotensive, combined with colonic dilation visualized on abdominal radiograph over six centimeters. So patient with systemic toxicity, colonic dilation on abdominal radiograph over six centimeters, you should be thinking toxic megacolon. Remember when you have the combination of those two, toxic megacolon should be high on your

differential. Question eight for a patient presenting with bloody diarrhea, left lower quadrant abdominal pain, and a uniform loss of hostral markings in the bowel visualized on barium minima, what would be the first line treatment for the likely diagnosis in this patient? So left lower quadrant, abdominal pain, bloody diarrhea, and they have a loss of hostral markings in the bowel visualized on bariumenema. First line treatment for this likely diagnosis is going to be a topical 5 amino salicylic acid. So a 5 ASA like mesalamine. And the patient described in this vignette with the left lower quadrant,

abdominal pain, bloody diarrhea, loss of hostral markings, which is known as a stove pipe or lead pipe sign, Sinambarium, Mena, they have ulcerative colitis. That's a very classic vignette description of ulcerative colitis, and the first line treatment for ulcerative colitis is going to be your topical five ASAs, and salamine is going to be the most commonly used of that class. So question nine, describe the findings on colonoscopy and a patient with Crohn's disease. Findings on colonoscopy and a patient with Crohn's disease, that's going to be skip lesions and a cobblestone appearance. So in Crohn's disease, you have this discontinuous transmural lesion. So you have these intermittent areas of normal appearing bowel, which is known as skip lesions,

combined with these deep longitudinal ulcerations. So normal bowel separated by these ulcerations, which has this appearance, which supposedly looks like a cobblestone appearance. So they're known as skip lesions, but actually visualizing in a colonoscopy, it has a cobblestone appearance. So remember either one of those descriptions, he'll be thinking of Crohn's disease. So question 10, Crohn's disease is most commonly found in what segment of the GI tract. Crohn's disease most commonly found in what segment of the GI tract. It's going to be your terminal ilium. The way I used to remember that was Ti, like TI the rapper makes CDs. So TI makes CDs,

TI terminal ilium, CD, Crohn's disease. That was a way that I used to remember in school. Question 11, patient with history of hyperlipidemia. hypertension and a myocardial infarction in the past presents to the office today complaining of dull abdominal pain that increases in intensity after meals. He's lost 15 pounds in the last three months. What diagnostic tests should be ordered to make a definitive diagnosis in this patient? So what diagnostic tests would you want to do in this patient for his likely diagnosis? It's going to be an angiography, a CT angiography.

So the patient in this vignette, history of ethelosclerotic disease, intestinal angina, they're saying worse after meals, weight loss, which we have to assume is from his fear of eating since not otherwise specified. All of these are classic findings and chronic mesenteric ischemia. And to definitively diagnose chronic mesenteric aschemia, you'll do some form of angiography. Normally a CTA, like CT angiography. It can reliably identify the presence of any arthroaclytic vascular disease. So remember, any time you see that intestinal angina description, patient that eats and all of a sudden has this dull abdominal pain or they're losing weight because of this fear of eating, right away you should be thinking of chronic mesenteric ischemia.

That's like a classic vignette finding. 12. What type of adenomatose colonic polyp has the highest risk of becoming cancerous? So what type of adenomatose colonic polyp has the highest risk of becoming cancerous? So that's going to be your vilis adenoma, Vylus adenoma, I-I-L-O-U-S adenoma, villis adenoma. There's a 35 to 40% chance of malignancy in this type of polyp. And that's compared to the other two types.

There's a tubulo-villow villis adenoma, which only carries about a 20% chance risk of malignancy. And then finally, the one that has the least amount of chance of actually becoming malignant, which is going to be your tubular adenoma, is only about a 5% chance of harboring a malignancy. So the way I used to remember that. So villis adenoma is going to be the worst, the highest chance of malignancy. I just used to remember villas like villainous because it's a villainous type of polyp because it's bad villainous like a villain.

That was the way that I remember that one is the highest risk of becoming malignant. So villis adenoma. Question 13. What tumor marker can be used in the diagnosis of colon cancer? What tumor marker can be used in the diagnosis of colon cancer? It's going to be your C.E.A. which is short for carcinone embryonic antigen. It's the most commonly use of the tumor markers for colon cancer,

but it's not really sensitive or specific. It can actually be elevated in gastritis, diverticulitis, really any chronic or acute inflammatory state. So it's more effective really at evaluating prognosis after you have a surgical resection for colon cancer than making the initial diagnosis. It's one of those things that you don't really use, but I definitely was asked that and you should,

you should absolutely know it because you may be asked. So remember, colon cancer, think of CEA. That's going to be the most commonly used marker, the tumor marker. Question 14. What diagnostic test should be used in a patient that has GERD that has developed both adenophage so pain with swallowing and weight loss. So a patient with GERD has developed adenophagea and weight loss. What diagnostic test should you be moving on to in this patient?

So it's going to be an endoscopy. So this patient is presenting with what's known as alarm symptoms. So alarm symptoms are going to be adenophasia, weight loss, any bleeding coming from the esophagus, dysphasia. They can all be suggestive of malignancy. So normally in a patient with GERD, you're going to clinically diagnose. You know, there's not a lot of testing, maybe a 24-hour pH probe to diagnose. But normally you're not going to do an endoscopy unless you have these alarm systems or its refractory to treatment. So again, remember any of those alarm symptoms you're going to do an endoscopy in those types of patients.

Question 15, what diagnosis should be suspected in a patient presenting with dysphasia to both solids and liquids, as well as a lower esophageal sphincter narrowing and the absence of perstallis distally to this area, visualized on barium esophagram? So this patient, what you should be thinking of is acylasia. So it's a classic presentation, dysphasia to both solids and liquids, which we see in this patient. And then the key is the finding on barium oesophagram. We see that narrowed lower esophageal sphincter. That's known as a bird beak appearance. So just prior to that narrowing, you'll have this dilation of the esophagus,

and then it tapers down to this very narrow area because you have all of this pressure in the lower esophageal sphincter. It's not releasing. So you have this narrowed area, and it's known as a bird beak appearance. And then also the loss of peristalysis distally. It's all key findings in Achalegos. Remember acalasia and this patient. Question 16.

10-year-old boy with a history of asthma presents to the office today, accompanied by his father. He's complaining of pain and difficulty with swallowing. He's been experiencing this for several months, and his father finds that there's been a few occasions where he actually vomited during meals. Nandoscopy is performed, which reveals stacked or corrugated rings in the esophagus accompanied by white papules. That's really the key right there. I don't even need to tell you anything else. what diagnosis should be suspected. So there's a few keys to that vignette.

The first is the history of asthma. So the diagnosis here is going to be eocinophilic esophagitis. So that first key is the history of atopic disease. So whether it's asthma or some other type of allergies, that's one of the keys to this patient, as well as the dysphasia that he's experiencing. And then finally, on endoscopy, you see those corrugated rings. which is very pathognomic for eocinophilic asophagitis. So again, remember, see a patient with a history of atopic disease like asthma.

You see corrugated rings on endoscopy, as well as those white papules, which are actually representing a collection of eocinophils forming micro-abscesses. So that's actually what you're seeing on in the endoscopy. So remember those key things. So that's eocinophilic esophagitis. Question 17, a patient with history of excessive. alcohol use is discovered to have a mass in his proximal esophagus. He denies a history of GERD. What type of esophageal neoplasm does this patient likely have? So basically what you're deciding here is do they have

squamous cell carcinoma or is it adenocarsinoma? And then how do you make that decision? So it's squamous cell carcinoma, but why? Well, first squamous cell carcinoma is most commonly found in the upper or the mid-asophagus. As we saw in the vignette, they said it was. They said it was found in his proximal esophagus, the mass. So that right there tells us this could likely be squamous rather than adenocarsinoma. So that checks the first box because adenocarsinoma is generally found in the distal or lower esophagus. And then this patient admits to excessive alcohol use, which is one of the major risk factors for squamous cell carcinoma versus adenocarcinoma, which is generally related to Barrett's esophagus. And this patient denies a history of GERD, which we know Barrett's is caused from longstanding GERD.

So that's the final checkmark. You have a few different things that's pointing us to a squamous cell diagnosis rather than adenocarcinoma. So remember, again, excessive alcohol use is related to squamous cell. Then the area, the mass is located, the proximal esophagus, as well as the patient denying a history of GERD, which, remember, adenocarcinoma is generally caused from Barrett's esophagus. Question 18. A patient presents with halitosis, dysphasia, an occasional regurgitation of undigested food.

What diagnostic tests should be done to reveal the likely diagnosis? So it would be a barium oesophagram. This patient has a pretty classic presentation for zinc or diverticulum. And the key really is halitosis, which is actually caused from food getting caught in this out-pouching of the mucosa and just essentially fermenting, which causes the halitosis. In addition, the dysphasia, the regurgitation of undigested food, they all describe the patient with zincers diverticulum. And in zincers diverticulum, the initial test would be a bigotosis. barium esophogram, aka a barium swallow, where the barium's pretty much just going to collect in the owl pouching on imaging. So any vignette you see with halotosis, anytime I've ever seen it, it was

always zincers diverticulum. That's like a very key finding for this. The other things are, they can actually be a number of different diagnoses, but as soon as you see halotosis, you should be thinking zinc or diverticulum and a barium esophagram will be the way to diagnose that. So question 19, what is the first line treatment for a patient with distal or diffuse esophageal spasm. So first line treatment of the patient with distal or diffuse esophageal spasmasm is going to be calcium channel blockers. They're going to be the meds most commonly used. You can use other antispasmodics like nitrates, low dose TCA's like tricyclic antidepressants if they're refractory to treatment with calcium channel blockers. But generally,

distal or diffuse esophageal spasm, calcium channel blockers are going to be your first line treatment. Question 20, describe Plummer Vincent's syndrome. Describe Plummer Vincent syndrome. So this can be seen in patients with esophageal webs, and it's a triad of dysphagia, esophageal webs, generally in the cervical region, and iron deficiency anemia. So Plummer Vincent syndrome, dysphasia, esophageal webs, and iron deficiency anemia, that triad. Question 21, what is the first-line medical management and a patient with esophagealvarices? So first-line medical management and a patient with esophagealveris is going to be okreous. It's a somatostatin analog that causes vasoconstriction of vessels and the GI tract, and therefore

it decreases the vascular inflow to the portal vein, reduces bleeding. Vasopressin can also be used, but really it's a second line. Not due to the efficacy, it actually works pretty well. It just has a lot more adverse drug reactions, a lot more systemic adverse effects. So remember, this is your first line medical management, but first line management. but first line management overall is going to be an endoscopic intervention like varicil ligation. So as far as medication, it's going to be okreotide, but as far as the overall treatment, you're going to try to do an endoscopic intervention like a versiol ligation.

But if they ask you medical management, like we did in this question, then it's going to be okriotide for esophageal varices. Question 22. What medications are used as primary prophylaxis against a re-bleed and a patient with esophagealvaris? So what meds are used as primary prophylaxis against a re-bleed in a patient with esophageal uverices, it's going to be non-selective beta blockers, natalol, propranolol. These are the only drugs that are recommended for prophylaxis against the first vericil hemorrhage scene in a patient.

So the first time they have it, you're going to use these non-selective beta blockers, natalolol, and a patient with celiac disease presents to the office with pruritic papules and vesicles on their forearms and knees. So they have celiac disease. They have this pruritic papuils and vesicles on their forearms and knees. What is the name of the most likely diagnosis in this patient? So celiac disease, papylus vesicles, dermatotitis, herpetiformis. Know that one very well.

You'll be asked that. So celiac disease, any dermatologic findings you should right away be thinking of dermatotitis, her pediformis. Question 24. What type of peptic ulcer generally improve? with meals. So what type of peptic ulcer generally improves with meals? That's going to be duodenal

ulcers. So since the ulcer is in the now some people say duodenum, I say duodenum, some people say duodenum. So it's, since the ulcers in the duodenum past the stomach, when a patient eats, the stomach stops emptying its contents. It's kind of churning in the stomach,

you know, slowly getting the food broken down with the stomach acid. So for a number of hours, no gas, gastric acid is being released from the stomach into the duodenum. So during this time, they have this temporary relief during meals for about two to five hours. So as soon as they start eating, for a few hours, they'll start feeling better. So duodenal ulcers improve while peptic ulcers actually get worse with, or like gastro, I'm sorry, gastric ulcers generally get worse when they start eating.

So duodenal ulcers remember improve with meals. And the way I remember this, this isn't my demonic, somebody else came up with it, or saying it's dude give me food so like do do doodinal dude give me food because it makes it better duodinal so uh question 25 described triple and quadruple therapy for h pylori positive patients so what is the triple and quadruple medication combination you're going to use for hpilory positive patients so triple is going to be chlorithromycin amoxicillin and a ppi like a meprazol So chlorithromycin amoxicillin PPI, that's going to be your triple. I always remember that by clap.

So C.L. Clarithromycin, A, amoxicillin, P. P.P.I. Clap. And then remember you can use metronidazol if they have a penicillinology. And then quadruple therapy is going to be tetracycline, metronidazole, and a PPI. So tetracycline, metronidazole, bismith, and PPI. I remember that by the mnemonic. Treat my belly pain. Treat my belly pain, tetracycline, metronidazole, bismith, and PPI. So that's triple and quadruple therapy for H. Pylori positive patients. 26, what is the most common cause of gastritis? Most common cause of gastritis is going to be H. pylori. Helicobacter pylori.

Second most common, of course, is going to be n-seds. 27, what diagnosis should be considered in a patient with multiple severe refractory gastric ulcers that are non-responsive to PPI therapy? So what diagnosis should be considered in a patient with multiple severe refractory gastric ulcers? They're not responding to PPI's. It should be thinking of Zollinger-Ellison syndrome. It's a gastron secreting neuroendocrine tumor. It can be seen in the pancreas, lymph nodes, doodinal wall, and doesn't respond to PPI's obviously.

So Zollinger-Ellison, if you have a refractory gastric ulcers, not responding to PPI's. What is the most common type of gastric carcinoma? The most common type of gastric carcinoma? It's going to be a denocarsinoma in about 90% of patients. Question 29. A six-week-old newborn presents with forceful vomiting after breastfeeding. He displays mild signs of dehydration, and on exam, there's a non-tender mass just right of the epigastrium. That's your key right there.

What diagnostic test should be used initially to make the diagnosis? So you're going to do an abdominal ultrasound. This patient has classic signs of pyloroxin,osis. projectile vomiting, the olive-shaped mass, just lateral to the epiastrium, which I didn't say olive-shaped, because they're normally not going to give you those key words. They're dehydrated. The initial diagnostic test in pylorsinosis is going to be an ultrasound in these patients. So remember that olive-shaped mass, or they may just say mass or right of the epigastrium, they'll normally say a forceful vomiting or projectile vomiting, and they may be dehydrated as well. Question 30. What patient

population has the highest mortality rate with hepatitis E infection due to increased risk of fulminate hepatitis. So what is what patient population has the highest mortality risk in hepatitis E? It's going to be pregnant patients. So most patients with hepatitis E are going to recover. No problem. But the overall, so the overall mortality rate in the general population is about 1%. But acute hepatitis E in pregnancy actually has mortality rate anywhere from 15 to 25%. Most susceptible period being during the third trimester. And really the only thing you ever need to remember about hepatitis E for the boards is just this. It's just that it has a very high mortality rate in pregnancy.

The way I remember that was hepatitis E. I just remember the E stands for embryo. So I think of like a baby pregnancy. So hepatitis embryo, hepatitis E. Just remember that it has a very high mortality rate in pregnancy. Question 31. What type of hepatitis virus requires a co-infection with hepatitis B to be able to replicate? and survive. So what type of hepatitis virus requires a co-infection with hepatitis B to be able to

replicate? That's going to be hepatitis D. Hepatitis D virus. The way that I remember that was I remember hepatitis D virus. The D stands for dependent because it's dependent on hepatitis B. D can't survive without B. So remember the hepatitis D stands for dependent. Depends on hepatitis B to survive. Question 32, patient with a history of cirrhosis presents with altered mental status. lured speech and asterixis, which I'll tell you what that is. It's a flapping tremor of the wrists in case you can't, in case you don't remember that one. So what is the first line medication for the likely diagnosis in this patient? So what is the likely, what is the first line medication for the likely diagnosis in this patient?

You have all the key findings there, altered mental status, slurred speech, Asterixis, which is a really important one. And they have a history of cirrhosis. You should be thinking right away, hepatic encephalopathy. And the treatment, first line medication of this patient is going to be lactoics. So they have hepatitis, hepatic encephalopathy, going to give them lactulose. So in patients with cirrhosis that have a triggering event like dehydration, excessive alcohol use, infection, it can lead to further decline of the function of the liver.

And the liver has an even harder time filtering toxins like ammonia. And then there's a buildup of these toxins in the body. And then you start to see the symptoms in this patient like altered mental status as well, some of the tremors. and the first-line medication, like lactulose, neutralizes the ammonia in these patients. There's other options, refaxamine and neomycin, but generally lactulose is going to be first-line. That's the one you'll probably be asked, but be aware, there are other options, generally like a second-line option for neomycin and refaxamine. Question 33, what type of hernia is more commonly seen in female patients versus male patients? So what type of hernia is more commonly seen in female patients versus male patients?

It's going to be femoral hernias. And it's due to the femoral ring being smaller in women, making these hernias more susceptible to strangulation in the narrowed femoral ring. And remember, the way I asked this question was, I didn't ask you what is the most common type of hernia and female patients? Because that would be an indirect inguinal hernia. And that's the most common type overall for males and females. The question I asked was what type of hernia is more common in female patients? And femoral hernias are most common in female patients. Again, the way that I used to remember that is femoral FEM, female FEM, so femoral, female, more common in female patients.

Remember, they will, or they, I don't know if they will, but I remember being tricked in school. And one of my exams in school, and they asked, what is the most common type of hernia overall in female patients? and that's actually inguinal hernia, not formal. But if they ask what's more commonly seen in female versus males, then it's going to be formal hernia is most commonly seen in female patients. Question 34, what is the most common cause of viral gastroenteritis worldwide? Most common cause of viral gastroenteritis worldwide, that's going to be your norovirus. Outbreaks you'll typically see in cruise ships, hospitals,

and just an interesting, completely useless side note. The virus got its name after the same. city, Norwalk, Ohio, where there was an outbreak in 1968. Sorry, that's useless knowledge. I apologize for even sharing that. You have too much in your brain to remember stupid things like that. But question 35. In a patient with Padgett's disease of the bone, remember, you can have Padgett's disease of the breast, or specifically talking about Padgett's disease of the bone. What is the first line medication class you would use for treatment? So Padgette's disease of the bone, what is the first line medication class you would use for treatment? That's going to be your bisphosphonate's

100%, a londronate, soledronic acid, which is generally the first medication used in this class. And this class normalizes that increased osteoclastic activity in these patients. So remember, bisphosphonates as far as the first line medication in patients with Padgius disease of the bone. 36. What is the most common cause of acute pancreatitis? Most common cause of acute pancreatitis is going to be gallstones.

Remember, alcohol is a close second. Acute pancreatitis gallstones is going to be your number one cause. 37 describe the triad of clinical manifestations that can be seen in a patient with chronic pancreatitis. Clinical triad of clinical manifestations that can be seen in a patient with chronic pancreatitis. It's going to be one diabetes mellitis. Remember, this is an exocrine and endocrine dysfunction. So you're going to have problems with both the digestive and the hormones in the pancreas. So one diabetes mellitis, two steatorrhea.

So that's going to be your oily or floating stool due to fat maledis. digestion because the pancreas isn't producing the enzymes to break it down. Remember, endocrine and exocrine function here. That's your exocrine side. And then three calcifications. You'll have these diffuse pancreatic calcifications. So again, the triad chronic pancreatitis, diabetes, steatorrhea, and calcifications. And also be aware, this is not really a common presentation. It's really only seen an advanced disease when about more than 90% of the pancreas has been destroyed. So be aware, they could very well ask you that, but it's not actually really common. in real, you know, clinical settings.

38, a patient with painless jaundice, accompanied by a palpable, non-tender, enlarged gallbladder is most likely to have what diagnosis until proven otherwise. So you have a patient with painless jaundice, they have a palpable non-tender and large gallbladder. What diagnosis should you be suspecting in this patient? So that's going to be a pancreatic carcinoma.

So what they actually have, the name for that palpable, non-tender, and large gallbladder is actually known as Corvassie A sign. And it's often seen in pancreatic cancer because the evolving mass in the pancreas leads to an obstruction in the common bile duct. And it can cause jaundice and gallbladder distension from all the bile backing up. Another possibility, a less likely possibility would be a biliary tract neoplasm, which is actually pretty rare. But generally in a vignette, if you see Corvassier sign, you see this painless jaundice. You see this enlarged gallbladder right away you should be thinking pancreatic cancer.

So that's the most important thing to think with that. 39, what finding on abdominal radiograph would be suggestive of duodenal atresia? So what abdominal radiograph finding are you going to be looking for in a patient who has duodenal atresia? It's going to be your double bubble sign. So double bubble sign, what's going on here? You have air trapped. You have gas trapped in both the stomach and the proximal duodenum. And it's separated by the pyloric valve, which creates this double bubble.

So again, large amount of air in the stomach, small amount of air. air in the proximal duodenum double bubble that's what you're seeing on x-ray and it's highly suggested of duodenal atresia when seen on an abdominal x-ray and then gas distal to these structures are actually going to be absent so you see the double bubble of air but then nothing further down if you do see gas past this point it's more suggestive of a malrotation rather than duodenal atresia question 40 what is the most common cause of small bowel obstruction Should definitely know this one. Most common cause of small bowel obstruction is going to be post-surgical adhesions.

Anywhere from around 55 to 80% of small bowel obstructions can be attributed to adhesions within the abdomen or pelvis. So definitely small bowel obstruction you should be thinking post-surgical adhesions right away. Question 41. 10-month-old child presents to the ER with 15 to 20-minute bouts of inconsolable crying, followed by periods where the child seems to be calm and no longer in distress. So these bouts of screaming, crying, and then they feel fine for a little bit. The mother notes seeing mucus in the child's stool when changing the diaper. And on physical exam, you have a palpable mass felt in the right upper quadrant.

What is the initial test of choice to make the likely diagnosis in this patient? So the diagnostic test of choice, or the initial test, is going to be an ultrasound. The patient has another classic presentation of interception. So they have colicky abdominal. pain sometimes they'll describe the child bringing the knees up to the chest I felt like I already made the question pretty easy to begin with so I didn't want to give you another thing to make it so obvious and then also in the the right upper quadrant area they may have a mass which is described as a sausage-shaped mass sometimes and that's the area of

the interception and the intestine and then the finally the the mucus that I noted in the vignette that's known as crant jelly stools and It can be a stool that are mixed with either blood or mucus. So you have those key findings in there. Remember, the colicky abdominal pain, the right upper quadrant mass, the sausage-shaped mass, and then the current jelly stools are all classic findings in interception, and then ultrasound is going to be your best initial test for that. Question 42.

What test is used to make a definitive diagnosis in a patient with Hirschsprung disease? What tests is used to make a definitive diagnosis in a patient with Hirschsprung disease? So that's going to be a rectal biopsy, and then the rectal biopsy will show an absence of enteric ganglion cells. Question 43, almost there. Right lower quadrant pain with the left lower quadrant palpation. So you're palpating the left lower quadrant, and they're having pain in the right lower quadrant. What is that described as on physical exam and a patient with appendicitis? So if you have right lower quadrant pain with left lower quadrant palpation, that's quite,

going to be Rov Singh sign. So Rov Singh sign is going to be right lower quadrant pain when palpating the left lower quadrant. Question 44. A persistent portion of the embryonic vitalin duct leading the formation of a true diverticulum of the small intestine is known as. So a persistent portion of the embryonic vitiline duct, which leads the formation of a diverticulum in the small intestine, is known as Mechle's diverticulum. And just remember it's the most common congenital malformation of the GI tract, mechols that reticulum. 45. What is the most commonly used tumor marker in pancreatic cancer?

Most commonly used tumor marker and pancreatic cancer is going to be CA 19-9. That's carbohydrate antigen 199. It's the most commonly used tumor marker for pancreatic cancer. Doesn't mean it's a great test, though, just like of the CEA and colon cancer. And it has a pretty low specificity. It's more commonly used to follow patients after, um, potentially curative surgery to track for an increase indicating a potential recurrence. So again, remember that's your most commonly used CA-199 for pancreatic cancer, but it is not a great

test at all, and it's certainly not used for diagnosis, more recurrence. 46, what type of vitamin deficiency should be suspected in a patient with impaired wound healing, paticule and peri-follicular hemorrhages of the legs and feet, and frequent bleeding of the gums or oral mucosa. I say that slowly because that's the most important part of the vignette. So they have bleeding of the gums or mucosa, poor wound healing. It's going to be classic description of vitamin C deficiency. So this is scurvy, vitamin C deficiency. And anytime you see bleeding of the gums combined with poor wound healing in a vignette, right away you should be thinking vitamin C deficiency. That's a classic way to describe that and those are the classic symptoms. 47, the denatured hemoglobin seen within red blood cells in a patient with g-sense,

P.D. deficiency are known as, so denatured hemoglobin seen within red blood cells in a patient with G6PD deficiency are known as Heinz bodies. So Heinz bodies are indicative of oxidative injury to the erythrocyte, which you will see in G6 PD deficiency. So remember Heinz bodies, 48, and a patient with campelobacter and turetis, what is the first line antibiotic class used when treatment is necessary in a severe or high risk patient? So a patient with Campelobacter enteritis. What is the first line antibiotic class used in treatment when necessary in a patient with severe or high risk patients? It's going to be macrolides. In particular, Zithromycin is most commonly used. Fluroquinolones are a second line option. And just remember,

most patients you're generally just going to replace their fluids and their electrolytes. And normally that's enough for treatment. But if you have a high risk patient with really severe symptoms, You want to use antibiotics and macrolides are going to be your go-to, azithromycin in particular. 49. What are the first-line medications used for a patient with C-difacil infection? So first-line meds for a patient with C-dif infection, there's really going to be two. It's going to be oral vancomycin and oral phytomoxysin.

So oral vancomycin, oral phidomoxysin. Those are your first-line agents. You may hear about metronidazol. It's another option. Really, it's a second-line option. Vanco and phidomoxycin work much better. And phidomoxysin is actually the best option, but it's expensive. It actually works really well.

There's a lower rate of recurrence when used compared to oral vanco. But again, it's expensive. So it's not always used Vanco a lot of times is used in place of it. And then also, remember, vancomycin is almost never given PO. It's almost never given orally because it has such poor absorption through the GI tract. But in this case, you don't want it to absorb through the GI tract. You actually, that's exactly where you want it to stay, as within the GI track. So this works perfectly for C-DIF, but otherwise you really don't use oral Vanco for anything

else because it doesn't get systematically absorbed through the GI-Track. So remember, first-line meds, C-Diff, oral vanco, and oral phidomoxicin. Question 50, the last one, patient with Wilson's disease has an abnormal accumulation of what type of trace mineral in the body. Patient with Wilson's disease has an abnormal accumulation of what type of trace mineral in the body. It's going to be copper. So in patients with Wilson's disease, they have a deficiency in what's known as seruloplasmin, and that's what helps transport and excrete copper. And, you know, because they have a deficiency in this, it leads to accumulation in the body, which leads to a number of clinical manifestations in the liver, the eyes.

There's something known as chiroflechirr rings. I'm probably saying that wrong. It's kind of tough for me to say. But there are these brown or green pigmented rings in the cornea, and it's actually due to copper depositing in the eyes. So remember, if you see that, you should be thinking. of Wilson's disease. All right, so that was the last question. I hope that was helpful.

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cram the pants on YouTube. Thank you so much as always. And good luck in, on your pants, your panery, your EORs, and good luck in PA school.