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E M Q s F O R M E D I C A L S T U D E N T S – V O L U M E 2 5. THEME: DIARRHOEA A B C D E F G H I J Amoebic dysentery Autonomic neuropathy Bacterial enterocolitis Caecal carcinoma Crohn’s disease Irritable bowel syndrome Overflow (faecal impaction) Pseudomembranous colitis Thyrotoxicosis Ulcerative colitis The patients below have all presented with diarrhoea as a predominant symptom. Please select the most appropriate diagnosis from the above list. Each diagnosis may be used once, more than once or not at all. 1. A 25-year-old man has returned recently from a holiday in Mexico. He gives a 24-hour history of severe, cramp-like, lower abdominal pain with passage of watery, brown, offensive diarrhoea. He had felt generally unwell, with flu-like symptoms <strong>for</strong> the preceding 2–3 days. On examination, he is clinically dehydrated and febrile (38.2 °C) with a pulse of 100 bpm. His haemoglobin is 15.4 g/dl and his WCC is 14.8 × 10 9 /1. 2. A 70-year-old man presents with a history of several months of diarrhoea. He previously opened his bowels once daily with <strong>for</strong>med stool. He has lost approximately 1 stone in weight. Investigations show: haemoglobin 8.1 g/dl, MCV 72.2 fl, WCC 7.6 × 10 9 /l; erythrocyte sedimentation rate (ESR) 40 mm/h; C-reactive protein (CRP) 55 mg/l. 3. A 32-year-old woman presents with a 2-week history of passing bloody diarrhoea with mucus up to 12 times per day. This is associated with lower abdominal, cramp-like pain and general malaise. On examination, she looks pale and generally unwell and there is some tenderness in the left-iliac fossa. Investigations show: haemoglobin 9.8 g/dl; MCV 76.2 fl; WCC 12.2 × 10 9 /1; ESR 100 mm/h; CRP 123 mg/l. 4. A 24-year-old woman gives a long history (several years) of intermittent diarrhoea and constipation. She also complains of abdominal bloating and left iliac fossa pain. The pain and bloating are made worse by eating and are relieved to some extent by defecation. Abdominal examination is unremarkable, and investigations show: haemoglobin 12.6 g/dl, WCC 6.5 × 10 9 /l; ESR 10 mm/h; CRP 5 mg/l. Flexible sigmoidoscopy is normal. 5. An 80-year-old woman is admitted to hospital with a left lower lobe pneumonia. She receives intravenous amoxicillin and cefuroxime. You are asked to review her because the nurses are having difficulty coping with her frequent episodes of diarrhoea and incontinence. Rectal examination reveals an empty rectum. 10
G A S T R O E N T E R O L O G Y 6. THEME: WEIGHT LOSS A B C D E F G H I J Alcohol dependency Anorexia nervosa Carcinomatosis Cardiac failure Coeliac disease Crohn’s disease Giardiasis Thyrotoxicosis Tuberculosis Type 1 diabetes mellitus The following patients have all presented with weight loss. Please choose the most appropriate diagnosis from the above list. Each diagnosis may be used once, more than once or not at all. 1. A 22-year-old woman with hypopigmented patches over the dorsum of her hands presents to her GP with weight loss, loose stools and oligomenorrhoea. On examination, she has onycholysis, fine tremor, resting tachycardia and warm peripheries. 2. A 16-year-old schoolboy presents to his GP with a 6-week history of malaise, weight loss and polydipsia. Examination is unremarkable other than his obvious weight loss. Initial investigations reveal: haemoglobin 14.4 g/dl, MCV 82 fl, WCC 7.2 × 10 9 /l, platelets 229 × 10 9 /l; Na + 135 mmol/l, K + 4.1 mmol/l, urea 4.1 mmol/l, creatinine 76 mmol/l; random blood glucose 18.9 mmol/l; thyroid-stimulating hormone (TSH) 1.43 mU/l, free thyroxine (fT 4 ) 22.6 pmol/l. 3. A 41-year-old woman presents to her GP with weight loss and ‘anxiety’. She confesses to feeling low since her divorce some 18 months ago. On examination she is thin and mildly icteric. Cardiovascular and respiratory examinations are unremarkable but abdominal examination reveals 3-cm hepatomegaly below the right costal margin. Investigations reveal: haemoglobin 9.4 g/dl, MCV 101 fl, WCC 4.2 × 10 9 /l, platelets 107 × 10 9 /l; Na + 131 mmol/l, K + 4.1 mmol/l, urea 2.1 mmol/l, creatinine 76 mmol/l; random blood glucose 3.9 mmol/l; total bilirubin 27 mmol/l, aspartate aminotransferase (AST) 76 IU/l, alanine aminotransferase (ALT) 59 IU/l, alkaline phosphatase 133 IU/l, albumin 31 g/l; INR 1.3. 4. A 51-year-old woman presents to her GP with weight loss, anorexia and swelling of the abdomen. On examination she is unwell, thin and pale, and has signs of a left pleural effusion, hepatomegaly and shifting dullness in the abdomen. Her chest radiograph confirms the effusion and shows multiple opacities in both lung fields. 11
Page 1 and 2: EMQs for Medical Students Volume 2
Page 3: CHAPTER 1 Gastroenterology 1. Anato
Page 6 and 7: E M Q s F O R M E D I C A L S T U D
Page 20 and 21: ANSWERS TO CHAPTER - GASTROENTEROLO
Page 22 and 23: A N S W E R S - G A S T R O E N T E
Page 30: A N S W E R S - G A S T R O E N T E

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