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I don't know what you wanted to show Prove that you could remove the hands, give a way to do. But again, do not interfere in the history, in your case, yes, the reflection and hands would be a huge interference, here.. Paul Getty Museum. Voting period ends on 6 Apr at UTC Visit the nomination page to add or modify image notes. Peter and St. Paul's Church 3, Vilnius, Lithuania - Diliff.

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On Megapixels Dllu : The stitched image has a field of view equivalent to a 3mm lens. Obviously, such a lens doesn't exist so it simply wouldn't be possible at all to take such a photo as a single frame. It would look rather ugly, too. You can have a look at the PTGui preview for a rectilinear version of the same view and I don't believe you'd find it better than this "Vedutismo"-version. I usually don't use stitching to increase the megapixel count but for other reasons: First I'm using the panorama head to simulate a tilt-shift-lens. When taking a multirow panorama and stitching it with PTGui I can easily get the verticals rectilinear without any loss of quality.

Then I'm using the panorama head to get a field of view that I wouldn't get using a single picture. You can see here an example of more or less the same view taken with a 24mm lens. Everything is sharp then and you don't get any complaints about noise and so on. All in all I prefer image quality over image size. I could of course upload a version with some more megapixels but I honestly don't see the use of it.

You can print this version in any size you want and even on the screen you won't see anything in the 50MPix version that you can't see in the 20MPix version. By the way the buliding on the left isn't a church. I see the motivation for the Vedutismo projection now. Regarding downsampling, Commons:Image guidelines explicitly states "do not downsample", with the reason being that future devices may support more pixels. Indeed, there is already a 33 megapixel monitor. Regardless of whether the human eye can see so much detail, I still think that for a project like Wikimedia Commons, which seeks to document human knowledge, one should store as much information as possible.

As stated above I don't use stitching to increase the megapixel count but to get a wider field of view and straight verticals without losing quality or image size compared to a single exposure out of the camera. And as I already said I don't care much about Megapixels but I do care about visual quality. And we all know very well that many of our fellow Commoners would complain about noise and sharpness regardless of whether they look at a 50 or MPix picture.

With a rectilinear projection especially, the stretching that occurs is effectively upsampling, and so that's why I think some downsampling can be justified to get back to reasonable pixel sizes in the corners. All of Diliff's stitched photos are downsized significantly, though not nearly as much as this one here. I think, Code, you could have uploaded a significantly larger version than 20MP without any issues. Some of my stitched images are not downsized at all, and I was happy with the sharpness. My guess here is that you generated an image well over MP and downsized to only 20MP.

Your sharp lens, HDR technique and tripod will reduce noise and ensure a sharp image. So if we consider stretching A cylindrical projection does not stretch the horizontal, only the vertical. So how do the pixels at the top of this image compare with the source pixels in each of your photos? IMO you should aim to be about the same, then you can claim the downsizing is appropriate, and the centre will be extra sharp. Rapid onset of dysphagia D. Anemia E. A year-old man with 1 year history of gastroesophageal relux disease GERD returns for follow-up. He has a history with you as follows: You irst saw him a little over 9 months ago and recommended that he sleep with the head of his bed elevated by 6 to 9 inches, lose 10—15 pounds of weight, eat small meals, and eat dinner 3 hours before bedtime.

You additionally strongly recommended that he stop smoking. At that time, you started him on ranitidine mg twice daily. He returned 1 month later saying that he had done everything that you recommended, but his GERD was still quite severe. You started him on omeprazole 20 mg daily and discontinued the ranitidine. He returned a month after that and said his symptoms were markedly improved and that he could sleep lat without discomfort. He continued to lose weight and also quit smoking. You recommended he complete a 3-month course of therapy with omeprazole.

He returned 4 months later now, off of omeprazole and told you that his symptoms had all returned and actually seemed worse. You restarted his omeprazole for another 3-month course. His symptoms resolved and he was doing well. He now returns again today, 2 weeks off therapy, reporting that his symptoms have returned again. He asks you what would be his best option for treatment of his GERD, based on his age and current health status. Because he is young, it may be best to begin metoclopramide for long-term therapy.

He has severe disease that will likely require long-term medical therapy, so the best option is chronic proton pump inhibitor therapy. Because he is young, the best therapy is over-the-counter medications such as calcium-containing antacids, because they are much safer than the proton pump inhibitors.

Omeprazole cannot be used for long-term maintenance therapy. Even though he has frequent recurrences, it is likely that as he gets older these episodes will become less frequent; therefore, medical management with omeprazole is the most prudent choice to see if his GERD will resolve over time.

A year-old Caucasian male with a history of Barrett esophagus presents for follow-up. He has been doing fairly well on omeprazole 20 mg daily, which seems to reduce his GERD symptoms to a minimum. Additionally, he stopped smoking several years ago and has lost about 20 pounds in the last 4 years. Today, he is returning for the pathology report from his last endoscopy, performed last week. Clinically, he has been doing well.

Now that he has conirmed high-grade dysplasia, which of the following is one of the currently recommended treatment options? Increase dose of omeprazole to 40 mg and repeat EGD in 1 month; if no change, recommend surgery or ablation. Increase endoscopy frequency to every 6 months and intervene in 1 year if changes still exist. Perform EGD monthly and watch for changes. Refer for surgery. Apply low-grade beam radiation to the affected area.

A year-old personal trainer with a negative past medical history presents for a routine checkup.

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She denies any symptoms of heartburn or excessive belching. She came in only out of concern from this testing. Since she has known Helicobacter pylori, it is prudent to treat her with appropriate antimicrobial therapy. Because she is asymptomatic, further investigation is not indicated or necessary; treatment is also not required. Because the test she received in the supermarket is likely a false positive, it is best to repeat the test in the ofice with a more speciic test for Helicobacter pylori to determine if therapy is indicated.

She should undergo endoscopy. She should undergo barium swallow. A year-old male presents with a history of deep burning epigastric pain for the past week. The pain is worse 1 to 3 hours after eating and is relieved by ingestion of antacids or food. The pain has also awakened him from sleep at night on occasion. He has no anorexia, dysphagia, vomiting, or weight loss. He smokes a pack of cigarettes daily.

Non-invasive testing for Helicobacter pylori. Barium swallow. Esophagogastroduodenoscopy EGD. Treat empirically with H2 blockers; if no improvement in 2 weeks then test for Helicobacter pylori. Esophagogastroduodenoscopy EGD with biopsy, because this is the only deinitive method to determine if Helicobacter pylori is the etiology of his symptoms. A year-old man presents for follow-up of a gastric ulcer diagnosed 8 weeks ago.

It was a relatively large, non-bleeding ulcer located in the duodenum. Helicobacter pylori was found in the biopsy specimen, as well as with a rapid urease test on the clinical specimen taken at biopsy. He was adherent with his medication regimen and reports no problem taking the medication correctly. He returns for follow-up 6 weeks after the completion of therapy. None; patients who are treated with triple therapy for H. Repeat endoscopy is indicated because the other non-invasive tests are likely to still be false-positive this early after therapy is completed.

Convalescent serology for H. A urea breath test is indicated at this point to determine cure. It is too early to test for cure; you must wait until 3 months after therapy is complete. A year-old man presents with recently diagnosed peptic ulcer disease. His ulcer was found on EGD and was in the 2nd portion of the duodenum. Also on EGD, he was noted to have fairly signiicant esophagitis.

He had presented with an upper gastrointestinal bleed yesterday. Based on his history and indings at EGD, which of the following tests or diagnostic studies should you order now? Computed tomography of the abdomen to rule out malignancy. Repeat EGD in 5 days. Fasting serum gastrin level. Follow-up H. A year-old Asian male who immigrated to the United States in was recently diagnosed with gastric carcinoma that is distal in character. He has started adjuvant combination chemotherapy.

Pernicious anemia B. Blood type A D. Alcohol consumption E. Diet low in fruits and vegetables A year-old woman presents with a history of recurrent diarrhea. Recently, she has become concerned because the diarrhea has occurred while she is sleeping. Additionally, she notes that she has had abdominal pain on occasion.

The pain is relieved by defecation. Usually the pain is located in the right lower quadrant. On further questioning, she relates a lb weight loss over the past 5 months. Their last camping trip was 3 months ago. They boiled water for drinking while camping and did not go swimming. Her husband has not been ill.

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MRI of the abdomen and pelvis. Endoscopic laparotomy. Repeat ova and parasite studies x 3. Rectal biopsy. Colonoscopy with upper endoscopy. A year-old Hispanic male with history of Crohn disease presents for usual routine checkup. He has been doing very well on his current regimen, which includes sulfasalazine and metronidazole.

Initially during the ofice visit he has no complaints. However, during the end of your examination, he jokes that he and his wife have been trying to get pregnant during the last year without any luck. He says that they have been reading suggestions in books and on the Internet without any luck. His wife is healthy—they have had 2 children, now ages 8 and 7. Formal urological evaluation. Fertility testing of his wife. Stop sulfasalazine and use another agent for control of his disease. Check serum testosterone. Have him wear boxers instead of briefs. A year-old man with ulcerative colitis UC presents for follow-up.

He has been doing well, except recently he had an exacerbation with severe bleeding and anemia. He has a history of pancolitis, and on his recent colonoscopy, the biopsy showed high-grade dysplasias in lat mucosa. He did not have a mass lesion to biopsy. Previous colonoscopies have shown mild dysplasia with inlammation. Since his recent exacerbation, he has been doing well without any further episodes of bleeding. Of signiicance is that his last exacerbation prior to this was over 10 years ago. Reinstitute maintenance therapy, assuming that he will continue to do well long-term based on his relapse rate of every 10 years.

Continue routine colonoscopy on a yearly basis unless another exacerbation occurs; then repeat colonoscopy at that time. Recommend referral to surgery. Repeat colonoscopy in 2 weeks. An year-old hip-hop artist presents with diarrhea for the past 2 weeks. She says that she noted the diarrhea began while she was performing in Mexico. You are the physician for the cruise line on which she is performing now. She tells you that she has had a low-grade temperature since returning from Mexico.

She did not eat any fresh vegetables. She drank only bottled water and a soft drink for which she is a national spokesperson. She has lost about 2 pounds in the last week. Ciproloxacin mg bid for 10 days B. Erythromycin mg bid for 5 days C. Tetracycline mg qid for 10 days D. Amoxicillin mg tid for 10 days E. No antibiotic therapy A year-old lifeguard at the local water park in your area presents for his inal routine hepatitis B vaccine before going to college. Recently, there has been an outbreak of diarrhea at the water park conirmed as E.

He is concerned about the diarrhea at the park and asks what he can do to limit his exposure. You explain that the outbreak has been linked to hamburgers at the park that were undercooked. He is concerned because he eats hamburgers twice daily. You explain that it is unlikely that he will become ill but to call you at the irst sign of diarrhea. The next morning, you receive a call from him saying that he has diarrhea. It is bloody in character. You tell him to come in right away. He arrives and is ill appearing.

He says the diarrhea started early this morning, and he has gone about 5 times since. He noted large amounts of blood in the initial stool, but it has since tapered off to a few streaks. He says he is lightheaded and dizzy. Penicillin 3 million units IV q 4 hours. Ceftriaxone 1 gm IV q day. Await sensitivities before starting therapy. Ciproloxacin mg IV bid. Give supportive care only. A year-old man presents with new onset of a debilitating neurological syndrome. He has been healthy until about a month ago when he had gastroenteritis.

He says the gastroenteritis lasted about a week and then resolved without any speciic therapy. Most of the disease was a diarrheal illness. He has a puppy that also had diarrhea just before he became ill. His diarrhea was bloody in character, and he had crampy abdominal pain. The diarrhea lasted about 5 days. He noted painless onset of mild weakness in the lower extremities, often accompanied by tingling paresthesias in his toes and ingers.

He became aware of this irst with dificulty walking up stairs. Over a period of days, the weakness progressed rapidly and ascended from the lower extremities to the upper extremities and inally to the face. Campylobacter jejuni B. Shigella dysenteriae C. Salmonella enteritidis D. Rotavirus infection A year-old woman presents with a history of chronic diarrhea for over a year.

She has complained of diarrhea on many visits to your ofice.

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Listed below is the laboratory work that has been done to date, including a few tests done today. The diarrhea is intermittent in character, lasts 3—5 days, and then her stools gradually return to normal. She has not noticed any blood in the stool. She has no nausea or vomiting.

She has no other health problems. No one that she lives with her boyfriend and 1-year-old have problems with diarrhea. She has not had signiicant weight loss. The stools are not foul smelling and are usually fairly watery in character. Bisacodyl abuse B. Irritable bowel syndrome C. Phenolphthalein abuse D. Carcinoid E. A year-old Irish-American man with a history of celiac disease presents with complaint of increasing fatigue for the past 3 months.

He reports he has been compliant with his diet. He was not diagnosed until several years ago. His celiac disease resulted in growth retardation as a child. He occasionally suffers from dermatitis herpetiformis. B12 deiciency anemia B. Toxicity from wearing green leprechaun paint C. Celiac sprue exacerbation D. Iron deiciency anemia E. A year-old man presents with a wasting type illness for the past 6 months. He describes arthralgias and frank arthritis of the larger joints that seem to come and go.

He has had marked episodes of diarrhea over the past 6 months and has lost 20 pounds. Based on these indings, which of the following is your diagnosis? Celiac sprue B. AIDS-related complex C. Infection with Tropheryma whippeli D. Mycobacterium avium intracellulare infection E. A year-old African-American woman presents for her routine job screening physical examination. She is applying to be a security guard at her local airport. She is very healthy and works out at her local gym on a regular basis. Begin annual fecal occult blood testing and lexible sigmoidoscopy every 5 years starting at age Colonoscopy every 5 years beginning now.

Colonoscopy every 5 years beginning at age Colonoscopy every 10 years beginning now. A year-old man presents after undergoing a screening colonoscopy last week. It was normal except for the inding of a 0. He is healthy otherwise and has no risk factors for colorectal carcinoma except for his age. He reports that he exercises regularly and eats plenty of fruits and vegetables. Repeat colonoscopy in 3—6 months to be sure the polyp was completely resected.

Repeat colonoscopy in 1 year. Order CEA level. Repeat colonoscopy in 3 years. Repeat colonoscopy in 10 years. You are seeing a year-old Puerto Rican man with a history of colonoscopic excision of a 3 cm sessile polyp earlier today. He is otherwise healthy and has not had any health issues come up in the past 3 years that you have been following him.

He has a history of mild hypertension controlled with diet but otherwise has not been into the ofice except for an occasional upper respiratory infection. The pathologist reports that she is reasonably sure the polyp was completely removed—the edges are distinct; no malignancy was found in the biopsy taken.

Based on these indings, which of the following should be your recommendation? Schedule for routine colonoscopy in 5 years. Schedule for routine colonoscopy in 10 years. Repeat colonoscopy in 3—6 months to be sure that resection was complete. Refer to surgeon for surgical resection of affected area. A year-old man presents for routine colonoscopy. He returns in 1 week for his pathology report.

These indings show: The polyp was completely excised and submitted in toto for pathological examination. The polyp was ixed and sectioned so that it was possible to accurately determine the depth of invasion, grade of differentiation, and completeness of the excision of the polyp. Unfortunately, carcinoma is found in the tissue. The cancer is well differentiated. There is no vascular or lymphatic involvement. The margin of the excision is not involved. Repeat colonoscopy in 3 months shows no residual abnormal tissue at the polypectomy site. Based on your indings, which of the following should be your recommendation?

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Repeat colonoscopy in 3 months. Repeat colonoscopy in 6 months. Determine CEA levels. Refer for surgical intervention and chemotherapy. Because the incidence of recurrent cancer is small, no other laboratory or imaging studies are indicated for this patient; follow-up should proceed as with benign adenomas. A year-old woman has been diagnosed with colon cancer. She was diagnosed by colonoscopy and had a left hemicolectomy performed 3 days ago.

You are seeing her in the hospital to discuss the results of her pathology specimens from surgery. Other than this new diagnosis, she has been very healthy. The cancer was found on a routine screen, and she had not been having any symptoms. Pathology report: Cancer was present in the left portion of the colon just proximal to the sigmoid colon and has spread to the regional lymph nodes.

Only 2 nodes are positive. CT Scan: No evidence of distant metastases; liver is normal in appearance. No lung, bone, or rectal mets. Her left hemicolectomy alone is adequate therapy. Besides the hemicolectomy, institute local radiation therapy. Start adjuvant chemotherapy and initiate local radiation therapy. Start adjuvant chemotherapy without radiation therapy. She will need to return to surgery for a complete colectomy with local radiation therapy. An year-old African-American woman presents to your ofice with complaints of lower abdominal pain. Her pain is crampy and bilateral but worse on the right side.

The pain started approximately 24 hours ago. The location has not changed, but the intensity of the pain increased overnight. The pain is accompanied by nausea. She vomited 2 or 3 times the preceding day. She also reports diarrhea and chills during the past 24 hours. Diverticulitis B.

Appendicitis C. Crohn disease D. Colon carcinoma E. Viral gastroenteritis She has had some associated diarrhea with the pain. See image from endoscopy in See Appendix B color image Figure 2. Emergent colonoscopy. Emergent barium enema. Bowel rest only is adequate at this point.

Bleeding scan. Abdominal CT scan. All of the following are indications for colonoscopy except: A. Bright red blood on toilet paper in a year-old man B. Gross lower gastrointestinal bleeding in a year-old man C. Streptococcus bovis bacteremia D. Hemoccult-positive screen in a year-old woman E. Iron deiciency anemia in a year-old man A year-old man complains of abdominal pain after eating meals and has noted a lb weight loss.

The weight loss, he says, is because he cannot eat very much without having the pain. Otherwise negative. Colonoscopy B. Barium swallow with enteroclysis C. Ultrasound of abdomen D. Arteriogram E. Trial of omeprazole A year-old man with history of chronic alcohol abuse presents with complaint of severe abdominal pain for the past 8 hours. He tried to relieve the pain by drinking beer.

He eventually drank 12 beers without relief of the pain. He then started to vomit and noted that his abdominal pain was even worse. He has vomited about 5 times in the past 3 hours. In a few hours after initiating therapy, you note on physical examination that he now has a faint blue discoloration around the umbilicus. This inding indicates that he may have developed which of the following? Tissue catabolism of hemoglobin B. A milder form of pancreatitis C. Fluid overload and you need to back down on luid resuscitation D.

Hemoperitoneum E. A pseudocyst Today, he said he noted that his skin was also yellow. He has no nausea, vomiting, or other complaints. He has acute hepatitis A and past infection with hepatitis B. He has chronic hepatitis A and acute hepatitis B. He has chronic hepatitis A and chronic hepatitis B. He has acute hepatitis B and past infection with A. He has neither hepatitis A or hepatitis B; he is just antibody positive. A year-old Caucasian male comes in as a referral from his pediatrician. Mark has been having dificulty in the last few months.

His pediatrician has also been following him for chronic active hepatitis, with all serologies for hepatitis A, B, and C being negative. His physical exam is remarkable for this inding when you look in his eyes see Appendix B color image Figure 3. Additionally, on physical exam, he has hepatomegaly with a span of about 13 cm.

Besides his psychosis which appears now to be under control , he has a slight tremor to his left upper extremity. He has no sign of biliary obstruction. Additionally, he has a Coombs-negative hemolytic anemia. Alcohol-induced cirrhosis B. Unexplained hepatitis C. Drug abuse D. Wilson disease E. Smith-Jones syndrome A year-old patient presents to the hospital with his second cerebrovascular accident.

Although he was functional after his irst episode, after 3 days in the hospital he is still unable to speak, and attempts at swallowing liquids have led to coughing. Which of the following is true? Percutaneous endoscopic gastrostomy PEG is appropriate intervention to allow hydration and nutrition. Antibiotics are not required before a PEG since this is a sterile procedure. Most patients with a PEG placement have severe relux afterwards; therefore, one should consider a surgical jejunostomy instead. Upper endoscopy should be done to evaluate the cause of dysphagia prior to any decision on long-term management.

A year-old male presents to the ofice with 10 years of typical heartburn symptoms. The symptoms typically occur after large meals or when he lies down at night. He has treated these with OTC dosing of famotidine, as well as frequent use of antacids. The symptoms are non-progressive but present 4 days out of each week. He is overweight by about 20 pounds.

ROS: He denies any dysphagia, hoarseness, or sore throat; he has never had any asthma or wheezing. No Barrett esophagus changes are identiied. The rest of the exam is normal. Your recommendation to the patient for the most complete relief of his symptoms would be which of the following? Omeprazole 20 mg PO, before breakfast B. Omeprazole 20 mg PO q hs C.

Ranitidine mg bid, before breakfast and hs D. A year-old male with a long history of asthma is admitted to the Intensive Care Unit with severe respiratory failure. He requires intubation, ventilatory support, bronchodilators, and IV corticosteroids. He has no other medical problems. After 3 days of therapy, the critical care physicians are able to extubate the patient. However, once there is initiation of oral feedings, the patient complains of severe pain while swallowing.

Upper endoscopy is performed and reveals multiple small, shallow ulcers in the distal esophagus. Biopsies are pending at this time. Which of the following is the least likely diagnosis? Herpes esophagitis B. Candida esophagitis C. Pill-induced esophagitis D. Relux esophagitis E. Mechanical injury related to nasogastric tube A year-old male presents to the ofice complaining of intermittent chest pain for the past year. This is a brief pain that lasts only 1—2 minutes in duration. It is unpredictable and not related to meals. It never wakes him.

He says that it can radiate into the left chest, and he describes it as a sharp stabbing pain. There are no other factors in his past medical history. He does have a family history of premature coronary artery disease. In his social history, he admits to signiicant stress in his job as an IRS auditor. In review of systems, he denies any dysphagia or any typical relux symptoms. Physical examination is normal. Stress echo: Normal EGD: Normal Esophageal motility: This demonstrated mostly normal peristalsis, but there were intermittent simultaneous contractions seen.

Lower esophageal sphincter pressure was 40, but with complete relaxation. The amplitude in the esophageal body was normal 40— Nitrates are effective therapy and well tolerated for this condition. Empiric dilatation may help this pain. Additional cardiac tests are needed e. You should get a CT of the chest. Which of the following is the least common GI location for carcinoid tumor? Rectum B. Ileum C. Stomach D. Appendix E.

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Colon A year-old patient with ulcerative colitis, who has been in clinical remission for the past year on mesalamine, develops diarrhea and abdominal pain. She denies rectal bleeding. This is similar to past lares of the colitis except for the lack of bleeding. Check the stool for Clostridium dificile toxin before initiating therapy. Admit to the hospital for IV corticosteroids and careful monitoring for possible toxic megacolon. Check for fecal leukocytes and if positive, treat with metronidazole. Perform an unprepped lexible sigmoidoscopy to assess for pseudomembranes.

Send a stool culture for Clostridium dificile. A year-old woman presents with abdominal discomfort, distention, and diarrhea. These symptoms have been present about 6 months. She describes 5—6 bowel movements a day that are loose and foul smelling. Her past medical history is signiicant in that she has been told by one of her physicians in the past that she may have scleroderma.

Review of systems is signiicant for a 5-lb. There is slight distention of the abdomen with tympany. There is no focal tenderness or any palpable masses. Metoclopramide 10 mg PO qid B.

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Amoxicillin-clavulanate mg PO bid C. Erythromycin mg PO tid D. Octreotide mcg SubQ bid E. Azithromycin mg PO q day x 5 days Which of the following is true regarding the treatment of chronic hepatitis C? By attaching a polyethylene glycol moiety to interferon alpha, there is an increased response rate.

Interferon alpha given alone 6 million units 3 times a week is more eficacious than when used with ribavirin. Infectious complications related to neutropenia frequently require cessation of antiviral therapy. Patients rarely respond to therapy. HCV genotype 1 is more responsive to therapy. A year-old patient with known cirrhosis secondary to alcoholic liver disease presents with hematemesis and melena.

He has no prior history of gastrointestinal bleeding. He was stabilized in the emergency department and transferred to the Intensive Care Unit. Upper endoscopy reveals bleeding esophageal varices that are successfully treated with band ligation. Over the next several days, he shows no signs of further bleeding. He is improving overall and tolerating oral feedings. Physical exam reveals a jaundiced male. He has prominent ascites in the abdomen. The abdomen does not have any focal tenderness. There is enlargement of the spleen and the liver edge is 3 cm below the right costal margin.

This is unlikely to be spontaneous bacterial peritonitis, since he has no abdominal pain or tenderness. Paracentesis is the appropriate diagnostic test at this time. Antibiotics have not been shown to be beneicial when given prophylactically to cirrhotics with upper GI hemorrhage. If the paracentesis yields acidic luid with a PMN count greater than , this conirms SBP and treatment should be initiated with gentamicin.

A year-old man presents to the ofice with a chief complaint of fatigue. He has been very distressed and upset since his older brother recently required a liver transplantation for hemochromatosis. He has 1 drink of alcohol per night. He takes no other medications. On review of systems, he complains of occasional knee pain after tennis. The sclera is anicteric, and there is no sign of jaundice.

There is no hepatomegaly or enlargement of the spleen. No ascites felt on exam. You consider further testing. A serum ferritin of greater than is diagnostic for hereditary hemochromatosis. Laboratory tests for iron are notoriously unreliable and therefore not needed. This patient should have a liver biopsy looking for hepatic iron concentration.

No further testing is necessary with normal laboratories and no hepatomegaly or abnormal skin color. Which of the following is the most common cause of acute fulminant liver failure in the United States? Wilson disease B. Hepatitis B virus C. Ingestion of amanita species mushrooms D. Drug hepatotoxicity E. Hepatitis C virus A year-old male is referred for evaluation of microcytic anemia.

He was recently in the hospital after presenting to the emergency department with a Hgb of 7 and an MCV of He had noticed gradual weakness for 3 months prior to this but thought it was due to a viral syndrome. He denied any speciic complaints and, in fact, denied any overt rectal bleeding or change in bowel movements. While he was in the hospital, he had an upper endoscopy, which was normal.

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  5. Colonoscopy was also performed with good visualization of the colon to the cecum, again without any abnormalities. He received 2 units of packed RBCs and was discharged on oral iron. Upper GI small bowel series B. Trial of estrogen empirically for presumed AV malformation bleeding C. CT scan of the abdomen and pelvis D. Tagged RBC bleeding scan E. Ultrasound of the liver A year-old male patient has absolutely no complaints. He is in for his routine checkup. At this time, he is found to have a Hgb of He denies any weakness or fatigue. There is a single 5-mm AVM found in the cecum. There is also a 5-mm sessile rectal polyp, which was removed.

    At this point, which of the following would you recommend? Endoscopic ablation of the AV malformation, because this was the likely cause of anemia. Elective sigmoid resection, because diverticulosis was the most likely cause of bleeding. Place patient on estrogen therapy to stop the bleeding from the AV malformation.

    Start patient on iron and monitor the Hgb every 2 months. Administer an H2 blocker initially. A year-old male presents to the emergency department with hematemesis that occurred 8 hours before presentation. Just prior to presentation, he noted a black tarry stool. He does not remember vomiting prior to the episode, but admits to heavy drinking and poor recollection of some events. The rest of the stomach is normal. There is no blood present in the stomach, and the duodenum is clear as well.

    Endoscopic treatment should be performed using a heater probe applied to the length of the tear. Mallory-Weiss tears rarely bleed suficiently to require blood transfusions. This patient will likely not have recurrent bleeding after admission, though his Hct will likely fall with hydration. The linear erosion is probably due to relux rather than Mallory-Weiss tear, since there is no report of prior retching. A year-old female comes in the ofice with the complaint that 7 days ago she had a dark, tarry stool. Yesterday, she had her normal brown stool. She initially thought the dark stool was due to something that she might have eaten, but her daughter convinced her to come and get checked out.

    She denies any weakness or lightheadedness. At no time has she had any abdominal pain recently. CLO test is done from an antral biopsy, and the preliminary result is negative. Which of the following should you recommend? Discharge home on lansoprazole 30 mg qd with caution to return to the emergency department in case of another black stool. Endoscopic treatment with a heater probe to the entire base of the ulcer, and then admit to the ICU for careful observation overnight. Admit to General Medicine ward, and obtain a surgery consult in case of rebleeding.

    Admission to an observation unit with Hct every 4 hours and discharge the next day if stable. A year-old woman of Irish descent is referred to your ofice after another internist noted microcytic anemia on a routine test. She has no speciic complaints. She describes 2 soft and slightly loose bowel movements every day, but this has been her normal pattern for many years. It has not progressed in any way. She denies any abdominal pain, although admits to some nonspeciic bloating, again present for many years.

    Flat plate x-ray of the abdomen and a trial of pancreatic enzymes if calciications are found. IgG antigliadin and antiendomysial antibodies; if positive, treat with steroids and gluten-free diet. Colonoscopy and endoscopy. If the latter is grossly normal, obtain oriented biopsies of the duodenum.

    Order upper GI small bowel series. A year-old patient has had ulcerative colitis since age In the past 5 years, he has been completely asymptomatic and in remission since the initiation of therapy with azathioprine. His bowel movements are normal, and he never notices rectal bleeding.

    He further denies any abdominal pain. Which of the following studies should you recommend as the next best step? Liver biopsy B. ERCP C. Laparoscopic cholecystectomy D. Abdominal CT scan A year-old female originally presented to the emergency department with severe acute abdominal pain. This pain was unlike any pain she had ever experienced in the past. It radiated to the back and was associated with nausea and vomiting. The pain started 8 hours earlier and had been constant since that time. The pancreas is edematous. The common bile duct was identiied and was of normal diameter.

    Stolen Child

    On the 2nd day of admission, the amylase increased to , and the bilirubin climbed to 3. However, at the time, the patient felt much better. It is now the 5th day and her amylase has been rechecked and found to be completely normal. Her abdomen is soft and nontender. She is not jaundiced and is now tolerating a liquid diet. Which of the following studies would you recommend? Discharge from the hospital now and then elective cholecystectomy in 2 weeks. Open cholecystectomy with common bile duct exploration now before discharge from the hospital. Percutaneous transhepatic cholangiogram.

    A year-old female complains of vague abdominal discomfort. She has never had any severe pain.

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