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A 65-year-old woman presents with difficulty swallowing, weight loss, and a history of long-standing heartburn. She has been on proton-pump inhibitors for years, but her symptoms have worsened. What is the most likely diagnosis?
- A. Peptic stricture
- B. Esophageal cancer
- C. Achalasia
- D. Esophageal spasm
Correct Answer: B
Rationale: The correct answer is B: Esophageal cancer. Given the patient's age, symptoms of difficulty swallowing and weight loss, along with a history of chronic heartburn not responding to proton-pump inhibitors, esophageal cancer is the most likely diagnosis. Esophageal cancer commonly presents with dysphagia, weight loss, and a history of chronic reflux. Peptic stricture (A) typically presents with dysphagia but is less likely given the worsening symptoms despite treatment. Achalasia (C) presents with dysphagia and regurgitation, but not typically with weight loss. Esophageal spasm (D) presents with chest pain and dysphagia, but not typically with weight loss or chronic heartburn.
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A 45-year-old man with a history of chronic heartburn presents with progressive difficulty swallowing solids and liquids. He has lost 10 pounds in the past two months. What is the most likely diagnosis?
- A. Esophageal stricture
- B. Esophageal cancer
- C. Achalasia
- D. Peptic ulcer disease
Correct Answer: B
Rationale: The correct answer is B: Esophageal cancer. This patient's symptoms of difficulty swallowing solids and liquids, along with unintentional weight loss, are concerning for a malignancy like esophageal cancer. The progressive nature of dysphagia and significant weight loss are red flags for cancer. Esophageal stricture (A) can cause dysphagia but typically presents with a history of chronic inflammation or injury. Achalasia (C) is characterized by dysfunction of the lower esophageal sphincter, leading to dysphagia, but it is less likely in this case due to the weight loss. Peptic ulcer disease (D) usually presents with epigastric pain and can cause weight loss, but it is less likely to cause progressive dysphagia.
In a 45-year-old woman with a history of arthritis experiencing severe heartburn and indigestion refractory to antacids, which findings on an esophageal manometry study are consistent with her diagnosis?
- A. Vigorous peristalsis and elevated lower esophageal sphincter (LES) pressure
- B. Absent peristalsis and elevated LES pressure
- C. Absent peristalsis and decreased LES pressure
- D. Vigorous peristalsis and decreased LES pressure
Correct Answer: C
Rationale: The correct answer is C: Absent peristalsis and decreased LES pressure. In a patient with severe heartburn and indigestion refractory to antacids, these findings are consistent with achalasia, a motility disorder characterized by impaired esophageal peristalsis and decreased LES pressure. Absent peristalsis leads to poor esophageal clearance and retention of food, causing symptoms like heartburn. Decreased LES pressure results in inadequate closure of the LES, leading to reflux of gastric contents into the esophagus. Choices A, B, and D are incorrect because they do not match the typical findings seen in achalasia. Vigorous peristalsis and elevated LES pressure are not consistent with achalasia, while absent peristalsis with increased LES pressure is not a common presentation.
A 65-year-old white female with a history of arthritis, congestive heart failure, and osteoporosis complains of odynophagia for two weeks. A barium swallow shows a moderate-sized crater just above the gastroesophageal junction. What is the least likely contributor to this condition?
- A. NSAIDs
- B. Alendronate
- C. Iron sulfate
- D. Calcium channel blocker
Correct Answer: D
Rationale: The correct answer is D: Calcium channel blocker. Odynophagia is often associated with esophageal ulcers, which can be exacerbated by NSAIDs (A) due to their effect on the gastric mucosa. Alendronate (B) is a bisphosphonate used to treat osteoporosis and can cause esophagitis. Iron sulfate (C) can also irritate the esophagus. However, calcium channel blockers (D) are least likely to contribute to esophageal ulcers or odynophagia as they do not directly affect the esophagus or increase the risk of ulcers.
A 28-year-old woman at 34 weeks of gestation presents with elevated liver enzymes and pruritus. Labs reveal total bilirubin to be 4.2 mg/dL, AST 480 U/L, ALT 640 U/L, and alkaline phosphatase 232 U/L. Viral hepatitis serologies and ANA are negative. On physical examination, she is jaundiced, but has a normal blood pressure, no edema, and a soft abdomen. The fetus is in no distress. Which of the following is true?
- A. The baby should be delivered immediately
- B. Symptoms will resolve promptly after delivery
- C. There is little risk of recurrence with subsequent pregnancies
- D. The mother should be screened for long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency
Correct Answer: B
Rationale: The correct answer is B: Symptoms will resolve promptly after delivery. The presentation of elevated liver enzymes, pruritus, and jaundice in a pregnant woman at 34 weeks with no signs of severe preeclampsia suggests cholestasis of pregnancy. This condition typically resolves after delivery. The absence of fetal distress and normal maternal blood pressure indicate that immediate delivery is not necessary. There is a risk of recurrence in subsequent pregnancies, so choice C is incorrect. Screening for LCHAD deficiency is not indicated in this scenario, as the presentation is more consistent with cholestasis of pregnancy.
An 82-year-old woman with no past medical history presents to your clinic complaining of arthritic symptoms. She is not taking any medications but needs something for her arthritis. You want to start her on a nonsteroidal anti-inflammatory drug (NSAID) but are concerned about her age and the risk of peptic ulcers. As she has to pay for her medications out-of-pocket and requests the most cost-effective option, what is the most appropriate treatment plan?
- A. Prescribe an inexpensive NSAID alone
- B. Prescribe an inexpensive NSAID and misoprostol
- C. Prescribe celecoxib
- D. Prescribe an inexpensive NSAID and sucralfate
Correct Answer: A
Rationale: The correct answer is A: Prescribe an inexpensive NSAID alone. This option is the most appropriate because it balances the need for cost-effectiveness with the concern for peptic ulcers in an elderly patient. Starting with a simple NSAID reduces the risk of adverse effects and minimizes the financial burden on the patient. Option B adds misoprostol, which may help protect the stomach but increases the cost. Option C, prescribing celecoxib, is more expensive and carries a higher cardiovascular risk. Option D, adding sucralfate, does not have strong evidence for preventing NSAID-induced ulcers and adds unnecessary cost. Therefore, option A is the most suitable choice for this scenario.