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
4. C – Carcinomatosis
This woman has signs of disseminated malignancy, with ascites, hepatomegaly and
multiple pulmonary metastases. The most likely cause is an ovarian cancer, which often
presents late with evidence of intra-abdominal metastases. The diagnosis can be
confirmed by ultrasound of the pelvis and/or an ascitic tap, which might show
evidence of malignant cells.
5. F – Crohn’s disease
This young man has returned from Nepal with a history suggestive of an acute infective
diarrhoeal illness. The negative stool cultures and microscopy do not rule out an
infective cause but make it less likely. The endoscopic findings and biopsy results,
however, suggest that this is in fact his first presentation of Crohn’s disease. The patient
requires steroids, nutritional supplementation and education regarding his diagnosis.
7. ABDOMINAL PAIN I
1. C – Ascending cholangitis
This man has ascending cholangitis with the classic Charcot’s triad of fever, rigors
and jaundice. The low blood pressure is common in this disorder because of the
effect of endotoxaemic shock caused by the Gram-negative organisms (mainly
Escherichia coli) that cause this condition. This shock should be corrected and the
sepsis treated aggressively because this condition carries a 30% mortality. A plain
abdominal film might confirm the diagnosis (showing gas in the biliary tree). The
commonest cause is gallstones.
2. B – Appendicitis
This patient has appendicitis, as evidenced by the short history of right iliac fossa
pain and associated gastrointestinal upset with a leucocytosis. The diagnosis is a
clinical one and one would also expect to find evidence of peritonism (guarding,
rebound tenderness) in the right iliac fossa. Other causes of an identical picture
could include Crohn’s ileitis, but this is uncommon if there is no preceding history of
abdominal symptoms.
3. A – Acute pancreatitis
This patient has acute pancreatitis, as evidenced by the history of alcohol abuse and the
clinical presentation. The results confirm the dehydration and hypokalaemia associated
with the prolonged vomiting, which is a marked feature of this abdominal condition.
The raised WCC occurs secondary to pancreatic inflammation but might also indicate
impending septic complications.
4. E – Diverticulitis
This patient has diverticulitis. This is very common for a woman of her age. The long
previous history of pain and change in bowel habit is indicative of diverticulosis, and
this has become complicated by inflammation in a diverticulum, leading to the
increase in symptoms and peritonism in the left iliac fossa.
5. J – Ureteric colic
This patient has ureteric colic, which is caused by a calculus obstructing the right
ureter. The appearance of a patient unable to get comfortable in any position is classic
166