Internal Medicine_Evals 4 Rationalization

INTERNAL MEDICINE EVALS No. 4 Number of Topics Involved: 3

Dissector: The Sixth Fiddler Editor: ??? Number of Pages: 7

1. Hepatic uptake of unconjugated bilirubin involves: a. Passive transport b. Coupling of Glutathione S transferase c. Binding with albumin d. Oxidative cleavage of porphyrin ring

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Oxidative cleavage of porphyrin ring is the initial step in bilirubin formation and is carried out in reticuloendothelial (RE) cells. Before bilirubin is released from RE cells in the liver and spleen, it has to be bound to albumin for transport in blood. Conjugated bilirubin in the blood stream is not excreted in the urine due to the presence of albumin. Unconjugated bilirubin is taken up in the liver by coupling to Glutathione S transferase and transported across the hepatocyte cell membrane via a CARRIERMEDIATED MEMBRANE TRANSPORT

2. Conjugation of glucuronic acid to bilirubin is catalyzed by: a. Glucuronosyl transferase b. Multidrug resistance associated protein (MRAP) c. Glutathione S transferase d. Bilirubin reductase Rationalization: 

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Glucuronosyl transferase is responsible for the conjugation of glucuronic acid to bilirubin in hepatocytes. MRAP2 is involved in the ATP dependent transport process of excreting bilirubin glucuronides into bile canaliculi. Glutathione S transferase is responsible for HEPATIC UPTAKE of unconjugated bilirubin. Bilirubin reductase is responsible for REDUCTION of bilirubin in RE cells before being transported by blood to the liver.

3. Bilirubin glucuronides are excreted across the canalicular membrane into the bile canaliculi by a transport process involving: a. Diphosphate glucuronosyl transferase b. Glutathione S transferase c. Multidrug resistance associated protein d. Heme oxygenase Rationalization:  

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MRAP2 is responsible for BILIRUBIN GLUCURONIDE EXCRETION into bile canaliculi. Diphosphate glucuronosyl transferase is involved in INTRACELLULAR BINDING of bilirubin to glucuronic acid. Glutathione S transferase is involved in HEPATIC UPTAKE of unconjugated bilirubin. Heme oxygenase is responsible for oxidative cleavage to open heme ring.

80 to 90% of bilirubin is excreted as urobilinogen in the FECES/STOOL. Urobilinogen is oxidized to urobilin which is responsible for the brown, green or yellow color of stool. 10-20% is passively absorbed and enters the venous circulation.

5. A patient with conjugated hyperbilirubinemia may not exhibit bilirubinuria during the recovery phase of his disease because bilirubin is: a. Excreted in feces b. Reabsorbed in proximal tubules c. Filtered by the renal glomeruli d. Bound to albumin Rationalization: Binding of bilirubin to albumin prevents its excretion through the renal glomeruli. 6. Bilirubinuria is suggestive of: a. Overproduction of bilirubin b. Impaired hepatic uptake c. Impaired conjugation d. Decreased bile excretion Rationalization: Bilirubinuria is an indicator of increased serum bilirubin due to DECREASED BILE EXCRETION. One of its manifestations is darkening of urine due to renal excretion of conjugated bilirubin that should have been excreted in bile canaliculi. 7. A phenotypically related disease syndrome that presents early in infancy as initially episodic cholestasis is: a. Benign recurrent intrahepatic cholestasis b. Dublin Johnson Syndrome c. Criggler Najjar Type I d. Progressive Familial Intrahepatic Cholestasis (PFIC) PFIC is a group of phenotypically related disease syndromes and has three types: 

PFIC Type 1 or Byler Disease presents in early infants with initially episodic cholestasis and is a result of a FIC1 gene mutation.

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PFIC Type 2 is caused by a mutation in pglycoprotein, a bile salt excretory protein

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PFIC Type 3 is caused by a mutation in MDR3protein and associated with high serum levels of gamma glutamyl transferase.

4. Urobilinogens are excreted mainly (80-90%) in the: a. Urine b. Feces c. Bile d. Blood

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INTERNAL MEDICINE EVALS No. 4 Number of Topics Involved: 3

Dissector: The Sixth Fiddler Editor: ??? Number of Pages: 7

8. A disorder characterized by mild fluctuating hyperbilirubinemia, often identified only during periods of fasting is: a. Criggler-Najar Type II b. Rotor’s syndrome c. Gilbert’s syndrome d. Dubin-Johnson Syndrome

12. Which of the following most likely indicates a severe hepatocellular injury?

Gilbert’s Syndrome is marked by impaired conjugation of bilirubin due to REDUCED (not absent like in Criggler Najar II) bilirubin UDP glucuronosyl transferase activity. It is only identified during periods of fasting.

Prolonged Prothrombin time (PT) measures the quality of the extrinsic pathway particularly that of Factor VII. Factor VII production will be greatly decreased due to hepatocellular injury leading to prolonged PT despite addition of Vitamin K.

9. Which of the following disorders of bilirubin metabolism will lead to predominantly unconjugated hyperbilirubinemia?

13. The liver may be palpable without hepatomegally in: a. Riedel’s lobe b. Lymphoma c. Early cirrhosis d. Diabetes mellitus

a. b. c. d.

Hemolysis Rotor Syndrome Benign Recurrent Intrahepatic Cholestasis (BRIC) Pancreatic Carcinoma

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UNCONJUGATED HYPERBILIRUBINEMIA results from: o Overproduction (can be due to hemolysis where there is an abundance of heme to be metabolized) o Impaired Uptake o Impaired Conjugation Rotor Syndrome, Dubin-Johnson Syndrome, BRIC, Progressive Familial Intrahepatic Cholestasis (FIC) are examples of CONJUGATED HYPERBILIRUBEMIA.

10. Which of the following disorders of bilirubin metabolism will lead to predominantly conjugated hyperbilirubinemia? a. b. c. d.

Criggler Najjar Type I Gilbert’s Syndrome Dubin Johnson Syndrome Ineffective erythropoiesis

A, B, hemolysis and Criggler Najjar Type II lead to UNCONJUGATED HYPERBILIRUBINEMIA. 11. In jaundiced patients presenting with pruritus, tea colored urine and alcoholic stools, which will most likely be significantly elevated. a. b. c. d.

ALT AST Alkaline Phosphatase GGT

Pruritus, tea colored urine and alcoholic stools are manifestations of increased serum bilirubin due to cholestasis and impaired bile excretion in bile canaliculi. Increase in alkaline phosphatase is indicative of cholestasis. Increase in ALT, AST and GGT are increased in pathologic liver conditions.

a. b. c. d.

Markedly elevated aminotransferases Prolonged protime unresponsive to Vitamin K Alkaline phosphatase > 4X normal Markedly increased direct and indirect bilirubin

Riedel’s lobe is a normal anatomic variant that may or may not extend to the pelvis and is not pathologic. 14. Falsely increased liver span can be due to: a. Fatty Liver b. Pneumothorax c. Atelectasis d. Subdiaphragmatic abscess Atelectatic lungs are consolidated and give a dull sound upon percussion. The percussion finding of an atelectatic lung and the liver is the same, thus may mislead an examiner into believing that the patient has an increased liver span. 15. Falsely decreased liver span can be due to: a. Emaciation b. Pneumonia c. Emphysema d. Pleural effusion Emphysema is characterized by a hyperinflated lung. The increased size of the lung can obscure a portion of the liver and give a falsely decreased liver span value. 16. A 73 year old asymptomatic patient with family background for colonic malignancy should undergo: a. b. c. d. e.

Colonoscopy Fecal occult blood testing Colonic transit studies Barium enema CT/PET scan of the while abdomen

Colonoscopy is done to look for polyps in the colon which have a high risk of becoming malignant in individuals with a family history of colonic malignancy.

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INTERNAL MEDICINE EVALS No. 4 Number of Topics Involved: 3 17. Of foremost importance in the history of a patient presenting with constipation EXCEPT: a. b. c. d. e.

Dietary preferences Sexual preferences Blood in stools Weight loss Family history for colonic malignancy

Sexual preferences are asked in history of patients with diarrhea usually caused by herpes simplex proctitis 18. In the PE of patients with constipation, least pertinent will be: a. Presence of ascites b. Palpable mass c. Presence of tender areas d. Peri-orbital/bi-pedal edema e. Character of bowel sounds 19. Constipation may mean: a. Small stools b. Dyschezia c. Rectal fullness d. All of the above e. None of the above Dyschezia is another term for constipation. One has a feeling of rectal fullness due to the inability to pass out stool. Small stools are a result of excessive mucosal absorption by the colon, which one of the mechanism of constipation. 20. Constipation may result from: a. Excessive mucosal absorption of water b. Motor dysfunction due to electrolyte imbalance c. Luminal obstruction d. All of the above e. None of the above 21. Constipation maybe attributable to the intake of: a. Calcium containing antacids b. Anticholinergic agents c. Iron containing vitamins d. All of the above e. None of the above Etiology of constipation can be divided into:  Systemic o Drugs  Antacids  Anticholinergics  hematics o Metabolic  Diabetes  Uremia  Hypothyroidism  Hypokalemia o Neurogenic o  GI Origin o Colonic, rectal or anal OBSTRUCTION

Dissector: The Sixth Fiddler Editor: ??? Number of Pages: 7 22. A patient is complaining of passage of fresh blood admixed with stools. The diagnostic/laboratory least indicated in this situation is: a. Proctosigmoidoscopy b. Barium enema c. Colonoscopy d. CBC, blood typing, bleeding time e. Fecal occult blood test 23. Features of large stool diarrhea EXCEPT: a. Tenesmus usually absent b. Visceral pain is usually hypogastric in location c. Greasy oily stools d. Foul smelling stools e. Stools rarely with blood Visceral pain in the hypogastric area is a feature of SMALL STOOL DIARRHEA. Other features of large stool diarrhea are: less frequent bowel movements, watery stools and periumbilical pain.

24. Encopresia is best managed with: a. Anticholinergics b. Fluid, electrolyte replacement c. Intestinal antiseptics d. All of the above e. None of the above Encopresia is the repeated passage of feces into inappropriate places whether voluntary or unintentional (“paradoxical diarrhea in constipation”). Encopresia is managed by disimpaction, enema, lubricants and emollients (retards colonic absorption of fecal water and thus soften stool), and laxatives. These aim to eliminate stool that had been stored in the colon through impaction. (Basta yung stool naipit sa isang portion ng colon at di makalabas – thus the constipation part-. Yung portion na yun continuously na nagso-store ng stool hanggang sa mag-overflow sya causing the “diarrhea”. Gets? :D )

25. In dysentery, stools are usually a. Mucoid b. Scanty in amount c. Bloody d. All of the above e. None of the above Features of dysentery are scanty, small, bloody and mucoid stools, prominent tenesmus, and are of large intestinal origin.

26. Bloody, mucoid diarrhea with tenesmus are the hallmark symptoms of: a. Giardasis b. Amoebiasis c. Cholera d. Shigellosis e. Viral enteritis    

Giardiasis - Watery, foul-smelling, explosive diarrhea Cholera - Rice water stool Shigellosis - Bloody, mucoid stools with or w/o pus with tenesmus (actually possible answer din ito) Viral enteritis – diarrhea and tenesmus

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INTERNAL MEDICINE EVALS No. 4 Number of Topics Involved: 3 (FYI: bloody and mucoid stools are almost always associated with bacterial infection. Absence of bloody and mucoid stools rules out a bacterial infection.)

27. High risk groups for diarrhea include: a. Prison inmates b. Travelers c. Gay people d. All of the above e. None of the above High risk groups for diarrhea are:  antibiotic users (susceptibility to pseudomembranous colitis, carbohydrate fermentation and fungi overgrowth)  Travelers  Homosexuals (herpes simplex proctitis)  Day care facilities and institutions such as prisons

28. Secretory diarrhea may be associated with intake of, EXCEPT: a. Metformin b. Biscodyl c. Sennia d. Antacids Antacid intake is associated with OSMOTIC diarrhea. Substances associated with SECRETORY diarrhea are:  Laxatives (castor oil, bisacodyl, senna)  Metformin  Prostaglandins  Toxins (seafood/shellfish, bacteria)

29. Palpation of the abdomen in a patient presenting with abdominal pain entails doing, EXCEPT a. Light palpation b. Deep palpation c. Eliciting rebound tenderness d. All of the above e. None of the above Light palpation is done to assess muscle spasm and rigidity. Deep palpation, on the other hand, is used to estimate organ sizes (liver, kidney, etc) and to look for abdominal masses. Eliciting rebound tenderness is to see if there is aggravation of the parietal layer of peritoneum such as in appendicitis and ulcerative colitis.

30. Landmarks in doing a digital rectal exam a. Genital structures b. Ano-rectal ring c. Sacro spinous ligament d. All of the above e. None of the above Other landmarks in doing a digital rectal exam are:  Intersphincteric groove  Lower valve of Houston  Ischial spines  Prostate and cervix

Dissector: The Sixth Fiddler Editor: ??? Number of Pages: 7 31. When the severity of the pain is out of proportion to the findings in the PE, makes one suspect for the possibility of a. Acute cholecystitis b. Acute pancreatitis c. Biliary ascariasis d. Perforated peptic ulcer e. Acute pyelonephritis Pain in biliary ascariasis is severe when worms are migrating into or moving in the area of the bile ducts. 32. Pain relief on bending forward is usually a characteristic feature of: a. Acute pyelonephritis b. Perforated peptic ulcer c. Acute pancreatitis d. Hemo/pneumoperitoneum e. Acute cholecystitis Pain relief on bending forward is a characteristic of a retroperitoneal source of pain such as the pancreas. (Actually pwede ring sagot ang A kasi retroperitoneal organ naman ang kidney pero mas common sa mga may acute pancreatitis ang pagbend forward to relive pain. :p ) 33. A common manifestation of abnormal GI motility mostly revealed by way of inspection: a. Pain b. Vomiting c. Diarrhea d. Constipation e. Distention A, B , C, and D are elicited during history taking and NOT during inspection. 34. The visceral pain in early stages of acute appendicitis is usually felt by the patient over the a. Epigastric b. Umbilical c. Hypogastric d. Right lower quadrant Visceral pain projection pattern from jejunum up to mid-transverse colon is in the periumbilical area. GIT portion affected Esophagus

Stomach to duodenum Pancreas and hepato-biliary Jejunum up to mid-transverse colon Mid-transverse colon to anal canal

Visceral pain projection pattern PROXIMAL Base of neck or suprasternal notch MIDDLE Sub/midsterna DISTAL Xiphoid or base of neck Mid-epigastric (radiating to the back) Epigastric

Periumbilical

Hypogastric

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INTERNAL MEDICINE EVALS No. 4 Number of Topics Involved: 3 35. The visceral pain in early stages of acute cholecystitis is usually felt by the patient over the a. Epigastric b. Umbilical c. Hypogastric d. Right lower quadrant

Dissector: The Sixth Fiddler Editor: ??? Number of Pages: 7 41. It must be considered when pain and fever is heralded by dysuria a. Biliart ascariasis b. Perforated peptic ulcer c. Acute pyelonephritis d. Acute cholecystitis e. Acute pancreatitis

See table above :p 36. In classic cases of acute diverticulitis involving the sigmoid colon, the early visceral pain is usually felt by the patient over the: a. Epigastric b. Umbilical c. Hypogastric d. Right Lower Quadrant See table above :p 37. Cause/s of abdominal distention wherein abnormal intestinal motility is least expected to play a role: a. Feces b. Flatus c. Fluid d. Tumor

Bacterial infection is the usual suspect of acute pyelonephritis with E coli being the most common culprit. Symptoms of pain and fever heralded by dysuria indicate an infection in the urinary tract.

42. The slowly progressive evolving pattern of pain over a long period of time in an elderly is a hallmark manifestation of: a. Acute pancreatitis b. Mesenteric ischemia c. Acute pyelonephritis d. Perforated peptic ulcer e. Acute cholecystitis Among the 5 diseases above, only mesenteric ischemia presents with chronic and progressive pain. All the rest are acute in pain onset. Also, mesenteric ischemia commonly occurs in the aging population.

38. Disproportion in the severity of pain and the paucity of PE findings is a characteristic of: a. Cholecystitis b. Intestinal Obstruction c. Appendicitis d. Pancreatitis e. Biliary ascariasis

43. A bruit in the setting of severe abdominal pain and shock is suggestive of a. Intestinal angina b. Aortic aneurysm c. Mesenteric ischemia d. Ruptured ectopic pregnancy e. Acute myocardial infarction

Pain experienced in biliary ascariasis is caused by worms moving in the biliary area. Their movements are not detected or observed during PE.

Aortic aneurysms tend to cause no symptoms, although occasionally they cause pain in the abdomen and back (due to pressure on surrounding tissues) or in the legs (due to disturbed blood flow). Shock is due to excessive amounts of blood spilling in the abdominal cavity.

39. Marked pallor in the setting of abdominal pain is suggestive of: a. Severe anxiety b. Anemia with bleeding c. Vasoconstriction in shock d. A+B e. B+C Change in pallor in the setting of abdominal pain is due to blood loss. 40. Sudden changes in the pattern of long standing visceral epigastric pain to a parietal type in an elderly strongly points to the possibility of a. Acute pancreatitis b. Biliary ascariasis c. Acute pyelonephritis d. Perforated peptic ulcer e. Acute cholecystitis Sudden change of pain characterization from chronic and dull (visceral pain) to intense (parietal pain) is plausible for a perforated peptic ulcer condition.

44. Fecaloid vomitus is suggestive of a. Gastric outlet obstruction b. Colonic obstruction c. Biliary obstruction d. A + B e. B + C Fecaloid vomitus is suggestive of intestinal, ileal and gastric obstruction with bacterial overgrowth. Biliary obstruction is suggested by bilious vomitus.

45. Bilous vomitus is least suggestive of a. Biliary tract disease b. Acute pancreatitis c. Peptic Ulcer d. All of the above e. None of the above Bilous vomitus is brought about by loss of patency in the pyloro – antral area and the bile ducts.

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INTERNAL MEDICINE EVALS No. 4 Number of Topics Involved: 3

Dissector: The Sixth Fiddler Editor: ??? Number of Pages: 7

46. A 21 year old male medical student came in due to hematochezia and diarrhea of less than 1 week duration associated with fever. The most likely diagnosis is: a. Irritable bowel syndrome b. Colonic malignancy c. Inflammatory bowel disease d. Amebic colitis

50. A 45 year old female with history of melena. EGD and colonoscopy revealed unremarkable findings. Where is the most likely source of GI bleeding? a. Large intestine b. Small intestine c. Stomach d. Esophagus e. All of the above

A, B and C all present with chronic duration of symptoms. Presence of fever and acute onset of symptoms in the patient makes bacterial infection a probable cause of disease.

Melena is the passage of black, tarry stools usually caused

47. A 61 year old male alcoholic with history of vomiting of previously ingested food preceding hematemesis. What is the most likely cause of hematemesis? a. Gastric malignancy b. Mallory – Weiss Tear c. GERD d. PUD Mallory – Weiss Tears are tears on mucosal layer of the gastric side of the gastro-esophageal junction and is common among alcoholics. Initial vomitus is non-bloody but because of the forceful coughing, vomiting, or retching, tears may present and causes hematemesis.

48. Melena in 21 year old male, smoker, with gnawing epigastric pain is most likely due to: a. Esophageal varices b. GERD c. PUD d. Gastric Malignancy Peptic Ulcer Disease manifests as pain in the epigastric region and may present with either hematemesis or melena. Risk factors for the development of PUD are H. pylori infection, NSAIDS use, intake of acids and smoking. Esophageal varices, gastric malignancy and long standing GERD also present with hematemesis but has a different visceral pain projection pattern from PUD.

49. A 56 year old male with intake of aspirin. On EGD revealed visualized gastric subepithelial hemorrhage and erosions. What is the most likely cause of melena? a. PUD b. Esophagitis c. Hemorrhagic Duodenitis d. Erosive Gastropathy e. All of the above Erosive gastropathy is characterized by erosions limited to the gastric mucosa. PUD on the other hand has characteristic lesions that extend beyond the gastric mucosa.

by bleeding from the upper and/or lower GIT. Blood passes as black stools because it had stayed for more than 14 hours. Since esophagogadtroduodenoscopy (EGD) and colonoscopy revealed unremarkable findings, it is safe to assume that bleeding is in the area of the small intestine particularly in the ileum or jejunum, the areas not reached by EGD and colonoscopy.

51. Hematemesis in a 61 year old alcoholic male associated with jaundice and ascites is most likely due to: a. PUD b. Esophageal varices c. GERD d. Gastric Malignancy e. All of the above Esophageal varices are associated with signs and symptoms of liver disease such as jaundice and ascites. The varices form due to portal hypertension. 52. Hematemesis in a 72 year old male associated with early satiety, epigastric pain and weight loss is most likely due to a. PUD b. Gastric Malignancy c. Esophageal varices d. All of the above e. None of the above A malignancy should be considered when a patient presents with change in bowel habits, pain, and weight loss. 53. A 20 year old male consulted because of hematochezia. What is the most common cause of lower GI bleeding in general population? a. Colonic malignancy b. Anal fissures, Hemorrhoid c. Colonic Diverticuloses d. Angiodysplasia 54. A 71 year old male with history of hematochezia associated with change in bowel habit and weight is usually due to a. Colonic malignancy b. Hemorrhoid c. Diverticular disease d. All of the above A malignancy should be considered when a patient presents with change in bowel habits, pain, and weight loss.

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INTERNAL MEDICINE EVALS No. 4 Number of Topics Involved: 3

Dissector: The Sixth Fiddler Editor: ??? Number of Pages: 7

55. The best way to assess a patient with GI bleeding internally is to a. Request for CBC b. To check HR and BP c. To do CT-Scan d. All of the above e. None of the above

60. Small amount of GI bleeding which can only be detected by stool chemical testing. a. Hemetemesis b. Melena c. Hematochezia d. All of the above e. None of the above

Vital signs SHOULD always be checked first and is the best way to assess a patient with GIT bleeding. Postural changes in HR or BP are manifestations of tachycardia and recumbent hypotension.

Hematemesis, melena and hematochezia do not need stool chemical testing since presence of blood is already visually obvious.

56. Vomiting of fresh blood from esophageal varices is a. Hematemesis b. Melena c. Hematochezia d. All of the above e. None of the above Hematemesis is the vomiting of blood and is always a manifestation of upper GI bleeding. 57. Blood has been present in the GI tract for atleast 14 hours a. Hemetemesis b. Melena c. Hematochezia d. All of the above e. None of the above Melena is the passage of dark, tarry stools. The color is due to blood that had been in the GIT for more than 14 hours. It is a manifestation of upper or lower GI bleeding. 58. Bleeding from internal hemorrhoids a. Hemetemesis b. Melena c. Hematochezia d. All of the above e. None of the above Hematochezia is the passage of bright red blood in the stool. It can be a manifestation of upper or lower GI (actually more of the lower) bleeding. If it is an upper GI bleeding, then it must be a massive one. 59. Usual presentation of GI bleeding a. Hemetemesis b. Melena c. Hematochezia d. All of the above e. None of the above

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