classic presentations

Question 1

a patient with a past medical history of COPD comes in as his wife has noticed his skin + eyes have more of yellowish tinge than usual

• diagnosis?
• management?

Answer 1

alpha-1 antitrypsin deficiency

Quit smoking, vaccinations ( no specific treatment)

key words- COPD, jaundice

Question 2

Tom Fergusson comes in complaining that he is struggling to swallow his breakfast sandwiches every morning :( A Ba swallow is conducted which shows a dilated oesophagus with a ‘bird beak’ appearance

• diagnosis?
• management?

Answer 2

• achalasia
• dilate LOS endoscopically or surgically

key words- struggling to swallow food, bird beak, dilated oesophagus

Question 3

Leah sunshine comes in after the Sarah Evarard vigil experiencing pain in the central abdomen which later migrated to the RIF. On further investigation it is found he is also experiencing anorexia, nausea & vomiting, tenderness in RIF, rebound pain, fever, leucocytosys and a left shift of the white cells.

• diagnosis?
• management?

Answer 3

-acute appendicitis

4As

• analgesia
• anti pyretic
• antibiotics (pipercillin/tazobactm)
• appendectomy

Question 4

Jane, a pregnant woman in her third trimester comes in complaining of an itch. Her bloods are done and show she has raised bilirubin and LFTs

• diagnosis?
• management?

Answer 4

• acute cholestasis of pregnancy
• Ursodeoxycholic acid and aquesous cream with menthol for itch

key words- pregnant, third trimester, itch, raised LFTs and bilirubin

Question 5

Maggie, an 80 year old, elderly woman, who frequently experiences arterial thromboembolisms comes in complaining of a sudden onset cramping in the left lower abdomen and rectal bleeding.

• diagnosis?
• management?

Answer 5

• acute colonic ischaemia
• symptoms usually resolve spontaneously over 24 to 48 hours and healing occurs in 2 weeks. If complications arise then surgical resection of the affected bowel may be required.

key words- woman, elderly, thromboembolisms, sudden onset cramping in left lower abdomen and rectal bleedinh

Question 6

Colm, a crazy frat boy who loves to party and drink, comes in as his stools have been rather pale recently and he has noticed his urine is darker than usual. On further investigation you find out he’s lost a bit of weight recently, tired and has sore joints. You also notice he keeps itching himself. You do his bloods and discover he has abnormal LFTs

• diagnosis?
• management?

Answer 6

-acute liver disease

• alcohol abstinence, increase calories, fluids and rest (up to 3-6 months)
• sodium bicarbonate bath/ cholestyramine/ursodeoxycholic acid for itch

key words- drink, pale stool, dark urine, weight loss, fatigue, sore joints, itch, abnormal LFTs

Question 7

A kid comes in after getting into his mums paracetamol stash. He is vomiting, confused and jaundiced. On further investigation he has raised ALTs, bilirubin, albumin and prothrombin time.

• diagnosis?
• treatment?

Answer 7

• acute liver failure
• inotropes, fluids, renal replecement, management of raised ICP, N- acetylcysteine therapy, liver transplant

key words -paracetamol, vomiting, jaundice, confusion, raised ALTs, bilirubin, albumin and especially prothrombin time

Question 8

Zoe Coyne tanned a few too many coronas at kilted after the first year exam and found herself whitying in the toilets at the early hours of 6pm. Her friends get a little worried because she starts vomiting blood and take her to ninewells

• diagnosis?
• treatment?

Answer 8

• Mallory Weiss Tear
• Observe poor zozo overnight + discharge

key words -drinking, vomiting blood

Question 9

Eve Hollis comes in complaining of a very severe epigastric pain that radiates through to her back, she says over the past couple hours it has been getting worse and she is now feeling very whitey. She has recently had gallstones and is worried they’ve come back. You get talking to her and find out she enjoys a drink and a round of ring of fire in her garden shed

• diagnosis?
• treatment?

Answer 9

• acute pancreatitis
• nil by mouth, IV saline/crystalloids, analgesia (morphine/pethidine), O2 if hypoxic, insulin if hypercalcaemic, IV calcium if hypocalcaemia, LMWH and monitor via repeat CT scan

treat any complications

key words- severe epigastric pain that radiates through to her back, got worse over hours, nausea/vomiting, gallstones, drink

Question 10

a patient comes in experiencing severe abdominal pain in the RIF/central of abdomen. He has a silent and distended abdomen. On further investigastion you discover his WCC and lactate is raised. He had recently been diagnosed with thromboembolism.

• diagnosis?
• management?

Answer 10

• acute small bowel ischaemia
• resus with fluids, antibiotics, LMWH/heparin, urgent surgery with resection of non viable intestines/ revascularisation on potentially viable bowel

key words- severe avdominal pain in RIF/central of abdomen, silent + distended abdomen, raised WCC + lactate, past history of thromboembolism

Question 11

Shannon Park has had a rough time at work the past couple years dealing with pedo Tim and to cope has been drinking her dad’s moonshine on the reg. She has noticed that even when she has scrubbed off her tan there is a yellowish tinge to her skin. On further investigation you find she has features of portal hypertension, hepatomegaly and malnutrition.

• diagnosis?
• management?

Answer 11

• alcoholic hepatitis
• alcohol abstinence, good nutrition, liver transplant if it goes on to cirrhosis

key words- female, alcohol consumption, jaundice, hepatomegaly, portal hypertension, malnutrition

Question 12

Ian has been experiencing pain on defecation recently and blood and mucus in his stool. He compares the pain to shitting shards of glass. Prior to this pain he had noticed his faeces had been very firm/hard.

• diagnosis?
• treatment?

Answer 12

-anal fissure

1st line -bulk forming laxatives, increase fluid intake, increase fibre in diet, lidocaine ointment + GTN ointment or topical diltiazem

2nd line- Botox injections & topical diltiazem

3rd line- surgical sphincterotomy

key words- pain on defecation, often compared to shards of glass, blood/ muscus in stool, hard faeces

Question 13

Ellie has Crohn’s disease and begins to experience extreme perianal pain, fever and discharge of pus.

• diagnosis?
• treatment?

Answer 13

• ano rectal abscess
• surgical drainage

key words- chron’s disease, perianal pain, fever, discharge of pus

Question 14

Ania Bed always leaves her essays to last minute and gets hella stressed doing them. She has noticed each time she is writing her essays she develops recurrent superficial and painful oral ulcers. By coincidence every essay she’s done is due a week before she gets her period.

• diagnosis?
• treatment?

Answer 14

• apthous ulceration
• normally fixes itself but may need glucorticoids and symptomatic relief with loax anasthetics mouthwashes. If very severe may need oral glucocorticoids

key words- stress, pre menstrual, recurrent, superficial and painful oral ulcers

Question 15

Poor eve is back again after being diagnosed with acute pancreatitis after too many late nights at the garden shed. This time she is experiencing abdominal distention, fullness in the flanks and shifting dullness on percussion.

• diagnosis?
• treatment?

Answer 15

-ascites

1. Diuretics- spironolactone, + furesomide if not enough
2. Paracentesis
3. TIPSS
4. Transplantation

key words- past acute pancreatitis, abdominal distention, fullness in flanks and shifting dullness on percussion

Question 16

Ellie Stirling being the shagger she is, is back on the contraceptive pill. However this time she’s experiencing some side effects. She has noticed once she scrubs off the St Moritz that her skin looks more yellow than usual and she is complaining of a fever, hives, malaise and sore joints. On further investigation you discover she has raised AST & ALT and is IgG, ANA and ASMA +ve

• diagnosis?
• management?

Answer 16

-autoimmune hepatitis

immunosuppressant therapy:
-prednisolone to induce remission and azathioprine to maintain remission

-if failure to respond to meds/cirrhosis occurs do liver transplant

key words- contraceptive pill, female, yellow skin, autoimmune signs (hives/malaise/sore joints/fever), raised AST & ALT, IgG, ANA and ASMA +ve

Question 17

Sofia Rodriguez Gomez keeps having acid reflux after having a couple too many birthday shooters at the union.

-what condition may she develop if this continues to experience acid reflux and what is the management?

Answer 17

• she may develop Barretts oesophagus (stratified squamous epithelium -> columnar epithelium with goblet cells)
• give antacids and PPIs

Question 18

poor susannah (a young girl) has been experiencing lower abdo discomfort and bloating which is only improved upon defecation :( She has also noticed that she has been pooing a lot less than usual!! She has been spending a lot of time in the lib so hadn’t really realised until recently. Looking back she thinks this has been going on for about 3 months

• diagnosis?
• management?

Answer 18

IBS- C

1. Change diet- high fibre and lots of water
2. Bulk forming laxatives ( e.g. Ipsalga husk) or Osmotic laxatives (e.g. lactulose)
3. 5-HT4 receptor agonist (prucalopride)/SSRI (fluoextine)
4. Guanylate cyclase agonist (linaclotide)/ chloride channel activator (lubiprostone)

For pain/bloating:

• diet low in FODMAP
• oral antispasmodics (mebeverine)
• probiotics

key words- young girl, abdo discomfort, bloating, improves on defecation, change in frequency of stool, 3 months