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A 35-year-old man presents with difficulty swallowing, weight loss, and regurgitation of undigested food. A barium swallow shows a 'bird beak' appearance of the lower esophagus. What is the most likely diagnosis?
- A. Esophageal cancer
- B. Achalasia
- C. Peptic stricture
- D. Gastroesophageal reflux disease
Correct Answer: B
Rationale: The correct answer is B: Achalasia. The presentation of difficulty swallowing, weight loss, regurgitation of undigested food, and 'bird beak' appearance on barium swallow are classic for achalasia. In achalasia, there is impaired relaxation of the lower esophageal sphincter and absent peristalsis in the esophagus. This leads to functional obstruction and dilation of the esophagus, causing the characteristic 'bird beak' appearance.
Incorrect Choices:
A: Esophageal cancer typically presents with progressive dysphagia, weight loss, and may show a mass or stricture on imaging.
C: Peptic stricture is usually seen in patients with long-standing gastroesophageal reflux disease or esophagitis. Symptoms are often related to acid reflux.
D: Gastroesophageal reflux disease commonly presents with heartburn, regurgitation, and chest pain. It does not typically cause weight loss or the 'bird
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A 60-year-old woman presents with fatigue, pruritus, and jaundice. Laboratory tests reveal elevated bilirubin and alkaline phosphatase levels. What is the most likely diagnosis?
- A. Hepatitis C
- B. Primary biliary cirrhosis
- C. Hemochromatosis
- D. Wilson's disease
Correct Answer: B
Rationale: The most likely diagnosis is B: Primary biliary cirrhosis. This condition commonly presents with fatigue, pruritus, jaundice, elevated bilirubin, and alkaline phosphatase levels in older women. Primary biliary cirrhosis is an autoimmune liver disease that leads to destruction of bile ducts. The other choices are less likely because Hepatitis C typically presents with acute symptoms, Hemochromatosis presents with iron overload symptoms, and Wilson's disease presents with copper accumulation symptoms, which do not match the patient's clinical presentation.
A 45-year-old woman with occasional indigestion has had episodes of chest pain and dysphagia to both solids and liquids. An upper GI series and EGD fail to disclose any structural abnormalities. What is the most appropriate initial therapy?
- A. Sucralfate
- B. Proton pump inhibitor
- C. Prokinetic agent
- D. Benzodiazepine
Correct Answer: B
Rationale: The correct answer is B: Proton pump inhibitor. In this case, the patient's symptoms of chest pain, dysphagia to solids and liquids, and indigestion suggest possible gastroesophageal reflux disease (GERD). A proton pump inhibitor helps reduce gastric acid production, alleviating symptoms and potentially healing any esophageal damage caused by reflux. This is the most appropriate initial therapy as it targets the underlying cause.
A: Sucralfate is a cytoprotective agent that may help with mucosal protection but does not address acid suppression, which is crucial in GERD.
C: Prokinetic agents enhance gastrointestinal motility and are not the first-line treatment for GERD.
D: Benzodiazepines are not indicated for the treatment of GERD and do not address the underlying acid reflux issue.
In a patient with a history of chronic iron deficiency anemia requiring a recent blood transfusion and an extensive GI work-up, which statement is true based on their medications?
- A. A dedicated small bowel series has a high likelihood of being positive
- B. 81 mg of aspirin per day decreases the benefit of using a COX II inhibitor
- C. The patient should have a provocative arteriogram with heparin infusion to identify the source of blood loss
- D. Hormonal therapy has been shown to be effective in decreasing blood loss due to arteriovenous malformations
Correct Answer: B
Rationale: The correct answer is B: 81 mg of aspirin per day decreases the benefit of using a COX II inhibitor. Aspirin, a non-selective COX inhibitor, can interfere with the action of selective COX II inhibitors by competing for the same binding site on the COX enzyme. This competition can limit the effectiveness of the COX II inhibitor in reducing inflammation and pain. This is particularly important in patients with a history of chronic iron deficiency anemia who may require NSAIDs for pain management.
Option A is incorrect because a dedicated small bowel series may not necessarily be positive for identifying the source of blood loss in this patient. Option C is incorrect as a provocative arteriogram with heparin infusion is an invasive procedure and not typically indicated as a first-line investigation for blood loss in patients with iron deficiency anemia. Option D is incorrect as hormonal therapy is not typically used to decrease blood loss from arteriovenous malformations.
A 35-year-old male patient presents with right upper quadrant pain, fever for the past 48 hours, preceded by new onset jaundice over the past few weeks. He states that he has had diarrhea on and off for several years but never had this investigated. A liver ultrasound is negative for gallstones or evidence of cholecystitis. His lab tests reveal total bilirubin 6.2, alkaline phosphatase 450, AST 150, ALT 120, albumin 2.6. The next diagnostic test of choice would be
- A. Liver biopsy
- B. Magnetic resonance cholangiopancreatography
- C. Hepatitis B surface antigen and hepatitis C RNA assay
- D. Colonoscopy with biopsies
Correct Answer: B
Rationale: The correct answer is B: Magnetic resonance cholangiopancreatography (MRCP). Given the patient's clinical presentation of right upper quadrant pain, fever, jaundice, and abnormal liver function tests, MRCP is the next diagnostic test of choice to evaluate the biliary tree and pancreatic ducts for possible obstruction or structural abnormalities. This would help identify the cause of the patient's symptoms, such as biliary obstruction or choledocholithiasis.
Choice A: Liver biopsy is not the next step in this scenario as the patient's symptoms are suggestive of a biliary or pancreatic etiology rather than a primary liver pathology.
Choice C: Hepatitis B surface antigen and hepatitis C RNA assay may be relevant for evaluating viral hepatitis, but in this case, the patient's symptoms and lab results are more indicative of a biliary or pancreatic issue.
Choice D: Colonoscopy with biopsies is not the next appropriate step as the patient's symptoms and lab results are not
When teaching a client postoperative breathing techniques with an incentive spirometer (IS), what should the nurse encourage the client to do to maintain sustained maximal inspiration?
- A. Exhale forcefully into the tubing for 3 to 5 seconds.
- B. Inspire deeply and slowly over 3 to 5 seconds.
- C. Breathe into the spirometer using normal breath volumes.
- D. Perform IS breathing exercises every 6 hours.
Correct Answer: B
Rationale: The correct answer is B: Inspire deeply and slowly over 3 to 5 seconds. This technique is recommended for using an incentive spirometer (IS) to maintain sustained maximal inspiration. Slow, deep inhalation helps fully expand the lungs and improve lung function postoperatively.
A: Exhaling forcefully into the tubing is incorrect because the purpose of using an IS is to promote deep inhalation, not forceful exhalation.
C: Breathing into the spirometer using normal breath volumes is incorrect as it does not promote maximal inspiration and may not fully expand the lungs.
D: Performing IS breathing exercises every 6 hours is incorrect as regular, consistent practice throughout the day is recommended for optimal lung recovery.