USMLE STEP 3 MCQ 40: a 58-year-old man who presented to the outpatient clinic with diarrhea

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Question:
a 58-year-old man who presented to the outpatient clinic with diarrhea and complaints of a twelve pound weight loss over six months. He also had experienced anorexia for one month. He did not complain of fever, chills, lymphadenopathy, nausea, vomiting, abdominal pain, melena, hematochezia, palpitations or flushing. The patient's physical exam was notable only for heme-occult positive brown stool. His laboratory studies revealed a mild normocytic anemia (PCV 39.9%, MCV 91.3 ml) and a chronically elevated alkaline phosphatase of 138 IU/liter. The electrolyte panel, thyroid function tests, erythrocyte sedimentation rate, and prostate specific antigen were all within normal limits. what diagnostic test would you order?

 

a) Ultrasound abdomen
b) Chest Xray
c) CT scan of the abdomen
d) full colonoscopy
e) Prostatic biopsy

 
Correct Answer: D

Explanation:


The history of weight loss and heme-occult positive stools in an elderly patient indicates a gastrointestinal malignancy. The likelihood of colon cancer is greatest, followed by gastric and small bowel malignancies. Diarrhea was not a prominent component of this patient's symptoms. If it were, and if he had symptoms of peptic ulcer disease, Zollinger-Ellison Syndrome should be considered. The most appropriate initial diagnostic test would be a flexible sigmoidoscopy plus barium enema or full colonoscopy


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