An 82-year-old female nursing home resident was admitted with left-sided aspiration pneumonia. She improved quickly on intravenous antibiotics. During her admission, a chest x-ray incidentally revealed a large calcification in the right upper quadrant of the abdomen. Subsequent abdominal ultrasound confirmed the presence of a single large stone in the gallbladder (3 cm in diameter). She denies any abdominal discomfort or pain. What would be the best course of treatment for her gallstone disease?

Correct Answer: C

Rationale: Step-by-step rationale for choosing answer C: 1. The patient is asymptomatic with no abdominal pain or discomfort. 2. Asymptomatic gallstones do not require immediate treatment. 3. The incidental finding of a gallstone in an asymptomatic patient does not warrant surgical intervention. 4. Watchful waiting is recommended for asymptomatic gallstones to avoid unnecessary procedures. 5. Reassurance is essential to prevent unnecessary anxiety or interventions. Summary: Choice C, reassuring the patient that she does not need any additional therapy for the gallstone at this time, is the best course of action because the patient is asymptomatic, and asymptomatic gallstones do not require immediate treatment. Choices A, B, and D involve unnecessary interventions for an asymptomatic gallstone.

Correct Answer: D

Rationale: The correct answer is D: Check antimitochondrial antibodies. Rationale: 1. The patient's presentation of elevated alkaline phosphatase without bilirubin or aminotransferase elevation suggests a cholestatic pattern of liver injury. 2. Cholestatic pattern with elevated alkaline phosphatase in the setting of a normal physical exam and ultrasound with no ductal abnormalities points towards primary biliary cholangitis (PBC). 3. Antimitochondrial antibodies are highly specific for PBC and should be checked to confirm the diagnosis. 4. Requesting an ERCP is invasive and not indicated at this point. CT scan may not provide relevant information for this specific presentation. Checking viral serologies is not indicated based on the clinical presentation. Summary: A: Requesting an ERCP is not the next step. B: Obtaining a CT scan may not provide relevant information. C: Checking viral serologies is not indicated at this point.

Correct Answer: C

Rationale: The correct answer is C because the patient should be transferred to a transplant center immediately due to the severity of her condition, not only if she does not awaken with lactulose therapy. The patient's rapidly progressing encephalopathy, significant liver enzyme elevations, high INR, and metabolic acidosis indicate severe hepatotoxicity from acetaminophen overdose. Prompt evaluation by a transplant center is essential for potential liver transplant candidacy. Choices A, B, and D are incorrect because: A - She may indeed need a liver transplant due to the severity of her liver injury. B - Intubation and hyperventilation may be necessary for respiratory support in severe cases of acetaminophen overdose. D - N-acetylcysteine is the standard treatment for acetaminophen overdose to prevent liver damage.

Correct Answer: C

Rationale: The primary symptom of a peptic ulcer is abdominal pain. Peptic ulcers are sores that develop on the lining of the stomach, small intestine, or esophagus, causing a dull or burning pain in the stomach area. This pain typically occurs when the stomach is empty and can be relieved by eating or taking antacids. Nausea (choice A) and vomiting (choice D) can occur but are not typically the primary symptoms of a peptic ulcer. Heartburn (choice B) is more commonly associated with gastroesophageal reflux disease (GERD) rather than peptic ulcers.

Correct Answer: A

Rationale: The correct answer is A: Avoid spicy foods. Spicy foods can irritate the stomach lining and exacerbate symptoms of peptic ulcer disease (PUD). By avoiding spicy foods, the patient can reduce the risk of worsening their condition. B: Increasing caffeine intake can stimulate acid production in the stomach, which can aggravate PUD symptoms. C: Limiting fluid intake is not recommended as staying hydrated is important for overall health and can help with digestion. D: Eating three large meals per day can put a strain on the stomach and increase acid production, potentially worsening PUD symptoms. It is better to eat smaller, more frequent meals to help manage PUD.