Liver disease Practice Questions

Q: A 54-year-old woman with a 30-pack-year smoking history presents with progressive dyspnea on exertion over 8 months and a chronic productive cough. She reports that her breathlessness limits her to walking on level ground at her own pace and she must stop after about 100 yards due to dyspnea (mMRC grade 2). She has had one exacerbation requiring a course of oral antibiotics in the past year. She denies fever, hemoptysis, or weight loss. Vital signs are normal. Spirometry is performed. Her post-bronchodilator FEV₁/FVC ratio is 0.58 and FEV₁ is 52% of predicted. She is currently using only a short-acting beta-agonist as needed. Which of the following is the most appropriate addition to her maintenance therapy?

Long-acting muscarinic antagonist monotherapy once daily. ***Long-acting muscarinic antagonist monotherapy once daily*** - This patient falls into **GOLD Group B** (mMRC ≥2 and 0-1 moderate exacerbations not requiring hospitalization), for which initial maintenance therapy with a **LAMA** or **LABA** is recommended. - A **LAMA** is often preferred as it is highly effective at improving symptoms, increasing exercise tolerance, and reducing the risk of future **exacerbations**. *Inhaled fluticasone-salmeterol combination twice daily* - **Inhaled corticosteroids (ICS)** are generally reserved for **Group E** patients with a high exacerbation risk or those with blood **eosinophil counts** ≥300 cells/ʹL. - Use of ICS in patients with low exacerbation risk is avoided to minimize the side effect of an increased risk of **pneumonia**. *Oral theophylline with serum level monitoring* - **Theophylline** is considered a second-line or third-line adjunctive therapy due to its narrow **therapeutic index** and significant side effect profile. - Modern **long-acting bronchodilators** are superior in efficacy and safety, making them the preferred first-line choice for symptomatic **COPD**. *Inhaled short-acting muscarinic antagonist four times daily* - Short-acting agents (**SAMA**) like ipratropium are used for acute relief but are less effective than long-acting agents for **maintenance therapy**. - The goal for a **Group B** patient is to provide sustained bronchodilation with a **long-acting** agent to improve daily quality of life. *Initiation of long-term low-dose oral prednisone* - **Systemic corticosteroids** are not recommended for the long-term maintenance of stable COPD due to a high risk of **systemic toxicity** and osteoporosis. - Their use is strictly limited to the management of **acute exacerbations** over a short duration (typically 5 days).

Q: A person with a history of chronic alcohol consumption who indulged in binge drinking 10 days ago is brought to the emergency department in an unconscious state. A non-contrast CT scan was normal, and his blood glucose level is 45 mg/dL. What is the most appropriate treatment?

IM thiamine followed by dextrose. **IM thiamine followed by dextrose** - Administering **thiamine** prior to **dextrose** is crucial in patients with chronic alcohol use to prevent **Wernicke-Korsakoff syndrome**, as glucose administration can precipitate or worsen Wernicke encephalopathy in thiamine-deficient individuals. - The patient's **hypoglycemia** (45 mg/dL) requires immediate correction with **dextrose**, but **thiamine** must be given first due to the patient's history of chronic alcohol consumption. *Normal saline* - While **normal saline** is used for rehydration and volume expansion, it does not address the patient's immediate and life-threatening **hypoglycemia** or **thiamine deficiency**. - Without addressing **hypoglycemia**, the patient's unconscious state will persist and lead to further neurological damage. *5% dextrose/vitamin K* - **5% dextrose** alone might correct **hypoglycemia**, but administering it without prior **thiamine** in a chronic alcoholic can precipitate **Wernicke encephalopathy**. - **Vitamin K** is typically given for coagulopathies or bleeding disorders, not as a primary treatment for **hypoglycemia** or **alcohol-related neurological emergencies** unless specific indications are present. *25% dextrose* - **25% dextrose** would rapidly correct **hypoglycemia**, but as with 5% dextrose, administering it without prior **thiamine** in a chronic alcoholic can precipitate or worsen **Wernicke encephalopathy**. - The primary concern in this context for an alcoholic patient with hypoglycemia is the potential for **thiamine deficiency**. *IV dextrose followed by thiamine* - While this option includes both necessary treatments, the **incorrect sequence** is critical—administering **dextrose before thiamine** in a chronic alcoholic can precipitate **Wernicke encephalopathy**. - The correct protocol requires **thiamine first** to replenish stores before glucose metabolism is accelerated by dextrose administration.

Q: A 40-year-old farmer presents with fever, calf tenderness, conjunctival suffusion, retro-orbital pain, and hypokalemia. What is the diagnosis?

Leptospira. ***Leptospira*** - The combination of **fever**, **calf tenderness**, **conjunctival suffusion** (red eyes without purulent discharge), **retro-orbital pain**, and **hypokalemia** is highly suggestive of **leptospirosis**. - A farmer's occupation increases the risk of exposure to contaminated water or soil, which is a common transmission route for Leptospira. - **Calf tenderness** and **conjunctival suffusion** are particularly characteristic features. *Malaria* - Characterized by **cyclic fevers**, **chills**, and **sweats**, often with **splenomegaly** and **anemia**. - **Calf tenderness**, **conjunctival suffusion**, and **retro-orbital pain** are not typical primary symptoms of malaria. *Dengue* - Often presents with **high fever**, **severe headache** (especially retro-orbital), **muscle and joint pain** ("breakbone fever"), and **rash**. - **Conjunctival suffusion** and significant **calf tenderness** are not classic features, and hypokalemia is less common than with leptospirosis. *Influenza* - Acute respiratory illness with **fever**, **cough**, **sore throat**, **muscle aches**, and **fatigue**. - While muscle aches can occur, **calf tenderness**, **conjunctival suffusion**, and **hypokalemia** are not characteristic of influenza. *Typhoid fever* - Presents with **sustained fever**, **relative bradycardia**, **rose spots**, and **hepatosplenomegaly**. - **Conjunctival suffusion**, **calf tenderness**, and **retro-orbital pain** are not typical features of typhoid fever.

Question 1

A 68-year-old woman with a history of hypertension and type 2 diabetes presents to the emergency department with 3 hours of epigastric discomfort, nausea, and diaphoresis. She denies chest pain or dyspnea. Her blood pressure is 148/92 mmHg, heart rate is 94 bpm, respiratory rate is 18/min, and oxygen saturation is 97% on room air. The ECG demonstrates 2 mm ST-segment elevations in leads II, III, and aVF with reciprocal ST depressions in leads I and aVL. Troponin I is pending. Which of the following is the most appropriate immediate next step in management?

Accepted Answer

Administer aspirin 325 mg and activate the cardiac catheterization laboratory for emergent percutaneous coronary intervention

Answer

Obtain an echocardiogram to assess wall motion abnormalities before initiating reperfusion therapy

Answer

Administer IV metoprolol to achieve rate control and reduce myocardial oxygen demand

Answer

Start IV heparin infusion and admit to the coronary care unit for observation pending troponin result

Answer

Perform CT angiography of the chest to exclude aortic dissection before antiplatelet therapy

Question 2

A 67-year-old woman with a history of type 2 diabetes mellitus and hypertension presents to the emergency department with 3 hours of epigastric discomfort, nausea, and diaphoresis. She denies chest pain or shortness of breath. Her blood pressure is 148/92 mmHg, heart rate is 96 bpm, and oxygen saturation is 97% on room air. An ECG is performed showing ST elevations in leads II, III, and aVF. Which of the following is the most appropriate next step in management?

Accepted Answer

Activate the cardiac catheterization laboratory for emergent coronary angiography

Answer

Administer sublingual nitroglycerin and obtain serial troponins over 6 hours

Answer

Perform urgent upper endoscopy to evaluate for peptic ulcer disease

Answer

Administer IV proton pump inhibitor and observe for symptom resolution

Answer

Obtain a CT angiogram of the chest to rule out aortic dissection

Question 3

A 54-year-old woman with a 30-pack-year smoking history presents with progressive dyspnea on exertion over 8 months and a chronic productive cough. She reports that her breathlessness limits her to walking on level ground at her own pace and she must stop after about 100 yards due to dyspnea (mMRC grade 2). She has had one exacerbation requiring a course of oral antibiotics in the past year. She denies fever, hemoptysis, or weight loss. Vital signs are normal. Spirometry is performed. Her post-bronchodilator FEV₁/FVC ratio is 0.58 and FEV₁ is 52% of predicted. She is currently using only a short-acting beta-agonist as needed. Which of the following is the most appropriate addition to her maintenance therapy?

Accepted Answer

Long-acting muscarinic antagonist monotherapy once daily

Answer

Inhaled fluticasone-salmeterol combination twice daily

Answer

Oral theophylline with serum level monitoring

Answer

Inhaled short-acting muscarinic antagonist four times daily

Answer

Initiation of long-term low-dose oral prednisone

Question 4

A person with a history of chronic alcohol consumption who indulged in binge drinking 10 days ago is brought to the emergency department in an unconscious state. A non-contrast CT scan was normal, and his blood glucose level is 45 mg/dL. What is the most appropriate treatment?

Accepted Answer

IM thiamine followed by dextrose

Answer

Normal saline

Answer

5% dextrose/vitamin K

Answer

25% dextrose

Answer

IV dextrose followed by thiamine

Question 5

A 40-year-old farmer presents with fever, calf tenderness, conjunctival suffusion, retro-orbital pain, and hypokalemia. What is the diagnosis?

Accepted Answer

Leptospira

Answer

Malaria

Answer

Dengue

Answer

Influenza

Answer

Typhoid fever

Liver disease — MCQs

Liver disease — MCQs

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