Your patient is a 33-year-old female gave birth last week. She complains of constipation, rectal ...

The answer to question 1  ANS: A
The most common cause of lower GI bleeding is hemorrhoids. The bleeding associated with hemorrhoids is usually evident as red blood on the formed stool, in the toilet bowl, or on the toilet tissue following a bowel movement. Patients with hemorrhoids often complain of rectal discomfort as well as the contributing factors for hemorrhoid development, including constipation. Inspect the perianal rectal tissue. Anoscopy may be indicated. Perform a digital rectal examination to assess internal haemorrhoids.

The answer to question 2  ANS: D
Primary or metastatic cancers of the liver and/or pancreas can cause obstructive hyperbilirubinemia and jaundice. Jaundice may be the initial sign of a malignancy or may follow the development of other symptoms. Ask about associated symptoms, such as RUQ discomfort, nausea, fever, back pain, weight loss, fatigue/weakness, and pruritus. None of these symptoms are specific to malignancy; however, other causes of jaundice are less likely to be associated with weight loss. During the abdominal examination, carefully palpate the area of the liver and the remainder of the abdomen, checking for masses or unexpected findings. In addition to a CBC, liver functions, amylase, lipase, and bilirubin levels, abdominal CT and/or ultrasound should be ordered promptly.

The answer to question 3  ANS: C
Bleeding occurs after an area of gastric mucosal injury has ulcerated. Explore symptoms of epigastric and/or periumbilical discomfort. Identify potential causes of gastric mucosal injurythe most common being NSAID use and stress. Many elderly individuals self-medicate with over-the-counter aspirin preparations and various NSAIDs. Commonly, they use too many medications that have side effects of gastric irritation.

The answer to question 4  ANS: B
AFP can help diagnose and guide the treatment of liver cancer (hepatocellular carcinoma). CA-125 is the standard tumor marker used to follow women during or after treatment for epithelial ovarian cancer (the most common type of ovarian cancer) as well as fallopian tube cancer and primary peritoneal cancer. Serum beta HCG is a pregnancy marker. CEA is not used to diagnose or screen for colorectal cancer, but it's the preferred tumor marker to help predict outlook in patients with colorectal cancer. The higher the CEA level at the time colorectal cancer is detected, the more likely it is that the cancer is advanced.

The answer to question 5  ANS: A
Upper GI hemorrhage may result from a tear at the gastroesophageal junction, known as a Mallory-Weiss tear. A patient may develop more than one tear. These tears are most common in alcoholic or bulimic patients following repeated episodes of vomiting or severe retching. If a laceration/tear of the mucosa causes GI bleeding, the patient may demonstrate alterations in hemodynamic status.

The answer to question 6  ANS: C
Occlusion of the common bile duct may occur with disorders of the gallbladder and/or bile duct, such as cholecystitis, cholelithiasis, and cholangitis. All three conditions are generally accompanied by RUQ discomfort, anorexia, and nausea. Charcot's triad, which includes jaundice, RUQ pain, and fever/chills, is common to problems resulting in obstructions of the bile duct.

The answer to question 7  ANS: D
Patients with portal hypertension may develop GI bleeding from varices of the esophagus, stomach, intestines, or other sites. Portal hypertension is most commonly associated with cirrhosis, usually caused by alcohol abuse or hepatitis. Check for signs of liver disease, including jaundice, cirrhosis, telangiectasia, hepatomegaly, and RUQ tenderness. Ascites occurs due to venous congestion. Caput medusa is the distension of paraumbilical veins due to portal hypertension.

The answer to question 8  ANS: A
Cirrhosis develops with the replacement of normal liver tissue by regenerative, fibrotic nodules and may occur in the late phase of a variety of disorders that damage the liver, such as alcohol toxicity. A patient may present with jaundice and describe an associated, progressive pattern of pruritus, weakness, anorexia, nausea, and weight loss. Determine the size and consistency of the liver as well as any tenderness. The scratch test is a method used to ascertain the location and size of a patient's liver during a physical assessment. The scratch test uses auscultation to detect the differences in sound transmission through the abdominal cavity over solid and hollow organs and spaces. After placing a stethoscope over the approximate location of a patient's liver, the examiner will then scratch the skin of the patient's abdomen lightly, moving laterally along the liver border. When the liver is encountered, the scratching sound heard in the stethoscope will increase significantly. In this manner, the size and shape of a patient's liver can be ascertained.

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