EMQs for Medical Students - PasTest

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
secretions – hence the dry mouth), the bladder (inability to pass urine), eyes (blurring
of vision) and many others. While some psychiatric disorders are clearly associated
with constipation (eg depression) a causal relationship is less clear.
3. J – Simple constipation
Constipation is the second most common gastrointestinal symptom in the developed
world after dyspepsia. In the majority, the symptom is mild and self-limiting. Low fluid
intake, a low-fibre diet, and lack of exercise and mobility are all factors that contribute
to simple constipation. In addition, it is a common accompaniment of ageing. Elderly
inpatients such as the woman described here are very commonly affected by constipation
for these reasons. Treatment should aim at reversing the above causative factors
where possible but laxatives are usually required, at least in the short term.
4. B – Chronic idiopathic constipation
The long history from an early age and the female sex make an organic diagnosis very
unlikely. When no organic cause can be found, the problem is described as ‘idiopathic’.
The majority of such patients have intractable symptoms which do not
respond to simple laxative therapy. The group can be further divided by physiological
studies into those with a delay in transit in all or part of the colon (slow-transit constipation),
those with abnormalities of rectal evacuation and those with no abnormality
(‘constipation-predominant irritable bowel syndrome’). The cause or causes of such
disorders are unclear.
5. F – Hypercalcaemia
The diagnosis can be deduced indirectly. This man is likely, on the basis of the history,
to have a carcinoma of the bronchus (cough and haemoptysis). Hypercalcaemia can
occur quite commonly with lung cancer due to malignant infiltration of bone (osteolysis
and calcium release) or due to ectopic secretion by the tumour of parathyroid
hormone- (PTH-) like hormone. The bowel can also rarely be affected by autoantibodies
to myenteric neurones in association with small-cell carcinoma of the lung. In
this situation, intestinal pseudo-obstruction develops. While severe constipation does
occur with pseudo-obstruction, the main presentation is with small-bowel obstruction
(leading to distension and vomiting).
5. DIARRHOEA
1. C – Bacterial enterocolitis
This patient has bacterial enterocolitis, as evidenced by the history of foreign travel and
the symptoms and signs. A preceding flu-like ‘prodrome’ is also common before diarrhoea
ensues. Common causative infective agents include Escherichia coli and species
of Salmonella, Shigella and Campylobacter. Amoebic dysentery is by definition associated
with bloody diarrhoea.
2. D – Caecal carcinoma
This gentleman has the classic clinical presentation of a caecal carcinoma, with a
change in bowel habit (usually to diarrhoea), weight loss and microcytic anaemia.
164