Welcome to your 2. 🫀 Hepatocellular Disease, Cirrhosis, Liver Failure & Hepatic Encephalopathy with Chronic Liver Disease Clinical Long Case Arena — 40 MCQs
1.
A 64-year-old man with cirrhosis develops severe drowsiness after taking a prescribed sedative for insomnia. He has no fever, bleeding or constipation. His family reports that he was previously alert and independent. Which principle should guide medication review?
2.
A 34-year-old woman presents with jaundice, vomiting and worsening lethargy following an acute viral illness. Her INR is 2.4, and examination reveals disorientation and fluctuating consciousness. There is no previous liver disease. Which management approach is most appropriate?
3.
A 59-year-old man with cirrhosis is admitted with confusion and asterixis. He is constipated and has no evidence of gastrointestinal bleeding or infection. After initial assessment and supportive care, which treatment is most appropriate for his hepatic encephalopathy?
4.
A 53-year-old man with cirrhosis presents with increasing abdominal distension and bilateral pedal edema. His serum sodium is 128 mmol/L, and renal function is preserved. Examination confirms moderate ascites. Which pathophysiological process most directly promotes persistent fluid accumulation?
5.
A 59-year-old man with cirrhosis presents with progressive abdominal distension. His serum creatinine has increased from 0.9 to 1.7 mg/dL after a recent increase in diuretic dosage. He has reduced oral intake and no evidence of gastrointestinal bleeding. Which initial step is most appropriate?
6.
A 61-year-old man with hepatitis C-related cirrhosis presents with fever, diffuse abdominal discomfort and increasing confusion. Diagnostic paracentesis reveals an ascitic neutrophil count of 380 cells/mm³. Blood pressure is 102/64 mmHg. Which is the most appropriate immediate management?
7.
A 51-year-old man with compensated hepatitis B-related cirrhosis attends follow-up. He has no ascites or encephalopathy and feels clinically well. His family asks whether regular surveillance is still required. Which long-term plan is most appropriate?
8.
A 57-year-old man with decompensated cirrhosis presents with marked abdominal distension and discomfort. He is alert, afebrile and hemodynamically stable. Investigations confirm portal hypertensive ascites without infection or significant renal impairment. Which initial long-term management approach is most appropriate?
9.
A 54-year-old man with cirrhosis and ascites is receiving spironolactone and furosemide. During follow-up, he develops postural dizziness and reduced urine output. Laboratory testing reveals increasing serum creatinine and hyponatremia. Which management decision is most appropriate?
10.
A 58-year-old man with decompensated cirrhosis becomes progressively drowsy after developing hematemesis. He is now difficult to arouse, responds only to painful stimulation and cannot cooperate with examination. Which is the most appropriate immediate priority?
11.
A 56-year-old man with cirrhosis undergoes diagnostic paracentesis for newly detected ascites. Ascitic fluid analysis reveals a serum-ascites albumin gradient of 1.6 g/dL with a neutrophil count of 90 cells/mm³. Which conclusion is most appropriate?
12.
A 52-year-old woman with cirrhosis has recurrent episodes of confusion despite taking lactulose. Her family reports that she has two to three soft stools daily, and no new precipitating factor is identified. Which additional intervention is most appropriate to reduce further episodes?
13.
A 55-year-old man with chronic hepatitis C presents with new-onset ascites. Diagnostic paracentesis reveals a serum albumin concentration of 2.8 g/dL and ascitic fluid albumin of 1.0 g/dL. The ascitic neutrophil count is 80 cells/mm³. What is the most appropriate interpretation?
14.
A 49-year-old man with chronic liver disease undergoes diagnostic paracentesis. Serum albumin is 2.9 g/dL, ascitic albumin is 1.4 g/dL and ascitic total protein is 0.9 g/dL. Ultrasonography shows a nodular liver and splenomegaly. Which interpretation best integrates these findings?
15.
A 55-year-old man with chronic liver disease is examined for progressive abdominal distension. He has bilateral pitting edema, flank fullness and shifting dullness. Which interpretation best explains these findings?
16.
A 57-year-old man with chronic hepatitis C presents with fatigue and abdominal distension. Examination reveals spider angiomas, palmar erythema, splenomegaly and dilated abdominal wall veins. Which underlying process best explains the combination of splenomegaly and abdominal wall collateral veins?
17.
A 60-year-old man with decompensated cirrhosis has serum bilirubin of 4.2 mg/dL, albumin 2.3 g/dL and INR 2.0. He also has clinically evident ascites. Which interpretation best explains the albumin and INR abnormalities?
18.
A 40-year-old man develops severe acute hepatitis following ingestion of an unknown herbal preparation. He is initially alert but becomes increasingly confused over the next 12 hours. His INR rises from 1.8 to 3.1, and blood glucose is 54 mg/dL. Which combination of actions is most appropriate?
19.
A 59-year-old man with established cirrhosis develops abdominal pain, fever and increasing confusion. Examination reveals tense ascites and diffuse abdominal tenderness. Which complication should be strongly suspected?
20.
A 46-year-old man with chronic hepatitis B presents with progressive jaundice and fatigue. Laboratory results show ALT 920 U/L, AST 780 U/L, ALP 165 U/L and total bilirubin 5.8 mg/dL. Ultrasonography shows no biliary dilatation. Which interpretation best explains the biochemical abnormalities?
21.
A 45-year-old woman presents with jaundice, dark urine and right upper abdominal discomfort. Laboratory testing shows markedly elevated ALP and GGT with only modest ALT elevation. Ultrasonography demonstrates dilated intrahepatic bile ducts. Which next step best addresses the likely cause?
22.
A 54-year-old man with cirrhosis presents with massive hematemesis, tachycardia and hypotension. He has known esophageal varices. After initial airway and circulatory assessment, which treatment combination is most appropriate?
23.
A 58-year-old woman with established cirrhosis is reviewed for progressive jaundice and easy bruising. Her bilirubin is 4.2 mg/dL, albumin 2.5 g/dL and INR 2.0. She has no history of anticoagulant use. Which combination most strongly indicates impaired hepatic synthetic capacity?
24.
A 62-year-old man with advanced cirrhosis and ascites develops worsening renal function. His creatinine continues to rise despite correction of hypovolemia and withdrawal of diuretics. There is no evidence of shock or intrinsic renal disease. Which complication should be considered?
25.
A 53-year-old man with cirrhosis is brought to hospital because of confusion. He is lethargic but responds to verbal commands, is disoriented to time and has asterixis. Which grade of hepatic encephalopathy is most consistent with these findings?
26.
A 56-year-old man with chronic hepatitis C has progressive abdominal distension, bilateral pedal edema and easy bruising. Examination reveals ascites, splenomegaly and spider angiomas. Laboratory investigations show serum albumin 2.4 g/dL and INR 1.8. Which diagnosis best integrates these findings?
27.
A 55-year-old man with cirrhosis is reviewed after two hospital admissions for ascites and hepatic encephalopathy. His albumin remains low, INR is prolonged and daily activities are increasingly limited. Which management decision best reflects the overall clinical course?
28.
A 60-year-old man with decompensated cirrhosis presents with confusion after several episodes of vomiting. His potassium is 2.8 mmol/L, and he has recently received increased doses of furosemide. Which abnormality is an important contributor to his neurological deterioration?
29.
A 60-year-old man with known cirrhosis presents with increasing confusion. He is disoriented to time and has a flapping movement of the hands when his wrists are extended. Which interpretation of this examination finding is most appropriate?
30.
A 54-year-old man presents with progressive abdominal distension, bilateral leg swelling and fatigue over three months. He has chronic hepatitis C infection and reports increasing abdominal girth despite reduced food intake. Which additional history is most important for identifying a potentially serious complication of his chronic liver disease?
31.
A 52-year-old man with hepatitis C-related cirrhosis presents with increasing abdominal distension and reduced appetite. He reports that he stopped taking his prescribed diuretic medication two weeks ago because of frequent urination. Which is the most likely consequence of this medication interruption?
32.
A 63-year-old patient with decompensated cirrhosis is admitted with reduced consciousness. His serum ammonia is elevated, but he also has fever, hypotension and leukocytosis. Which clinical approach is most appropriate?
33.
A 56-year-old man with known cirrhosis is found to have thrombocytopenia, splenomegaly and dilated collateral veins on abdominal imaging. His hemoglobin and leukocyte counts are mildly reduced. Which mechanism best explains the hematological abnormality?
34.
A 58-year-old man with known cirrhosis is brought by his family because of increasing confusion and daytime sleepiness. His wife reports that he has passed black stools twice during the preceding day. Which interpretation of this history is most appropriate?
35.
A 57-year-old man with cirrhosis develops confusion after several days of constipation. He is awake, disoriented and unable to perform simple calculations. Examination shows intermittent lapses of sustained wrist extension. Which management strategy best addresses the reversible cause and neurological disturbance?
36.
A 47-year-old patient with cirrhosis undergoes a large-volume therapeutic paracentesis for tense ascites. Approximately 7 liters of fluid are removed. Which intervention helps prevent circulatory dysfunction after the procedure?
37.
A 58-year-old man with cirrhosis is admitted with fever and worsening ascites. Diagnostic paracentesis reveals an ascitic fluid polymorphonuclear leukocyte count of 420 cells/mm³. The bacterial culture result is pending. Which interpretation is most appropriate?
38.
A 55-year-old man with hepatitis C-related cirrhosis has recovered from an episode of ascites and hepatic encephalopathy. He asks about long-term care and prevention of further deterioration. Which follow-up plan is most appropriate?
39.
A 58-year-old woman with hepatitis C-related cirrhosis completes antiviral treatment and achieves a sustained virological response. She has previously documented advanced fibrosis and portal hypertension. Which counselling statement is most appropriate?
40.
A 61-year-old man with cirrhosis and tense ascites undergoes large-volume therapeutic paracentesis. Approximately 7 liters of ascitic fluid are removed. Which additional intervention is most appropriate to reduce the risk of post-paracentesis circulatory dysfunction?
