Medicine solved scenario based questions (GASTROENTEROLOGY SYSTEM)

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Medicine solved scenerio based questions (GASTROENTEROLOGY SYSTEM)


Hematemesis

A 38-year-old barber presents to the emergency with hematemesis. On examination,
he is pale with pulse rate 110/min and a BP of 90/60.
a) What are the four most likely causes of his condition?
b) Enumerate the four most important procedures in the management of this
patient.
c) Write down most important investigations in this case.


Abdominal Pain

A 35-year-old person presents with history of persistent pain in upper abdomen for
the past two months. There is no history of previous illness and he denies taking any
medicines. His father died of a tumor in the abdomen in his mid-40. On examination,
he is pale and has tenderness in the epigastrium.
a) What are the differential diagnoses? Name atleast four conditions.
b) Name atleast three specific investigations to confirm the diagnosis.

Gastro-esophageal Reflux Disease (GERD)

A 55-year-old male presents with two months history of retrosternal pain and reflux
of food contents sometimes reaching to the pharynx whenever he bends forward
during prayers. He also has night time attacks of cough and wheeze. The physical
examination is unremarkable.
a) What is the most likely diagnosis? What are three treatment options available
which should be used initially?
b) What lifestyle advice you will give?

A 44-year-old male, who is morbidly obese, presents with complaints of heart burn
and indigestion. He also experiences water brash. An endoscopy is performed and a
Hiatus Hernia is found.
a) What are the two types of Hiatus Hernia?
b) Write any four complications associated with Gastro-esophageal Reflux Disease?
c) Enlist the treatment options.

A middle-aged lady has presented with severe burning sensation behind the sternum
along with regurgitation and feeling of stickiness of food at the level of xiphisternum.
On examination, she is an obese lady with normal physical examination.
a) What is the likely diagnosis?
b) Name atleast three specific tests to confirm the diagnosis.
c) How will you manage the patient?


Achalasia

A 45-year-old female presents in an OPD with complaints of difficulty in swallowing
for solids and liquids for the last 1 year. This is accompanied by nocturnal coughing
and vomiting undigested food taken 2 to 3 days ago.
a) What is the likely diagnosis?
b) Name the investigations you may like to carry out in tis patient.

A 26-year-old female presents with a complaint of difficulty swallowing which has
worsened gradually over time for last one year. She gives history of feeling as if food
gets stuck in her mid-chest. She notices that swallowing difficulty is worse for liquids
and by standing and moving around after eating. She has had a 15-pound weight loss
and reports occasional regurgitation of undigested food after eating.
a) What is your diagnosis?
b) How will you confirm it?
c) Give brief treatment options.


Esophageal Carcinoma

A 55-year-old heavy smoker presents with progressive dysphagia to solids and a
significant weight loss over the last three months. On examination, he is pale and
emaciated with no other detectable clinical abnormalities.
a) Give two most likely possibilities of this clinical condition.
b) Write down three most useful investigations for this case.
c) Enumerate two most important steps in the management of this case.

A 75-year-old man is brought to you with progressive difficulty in swallowing
especially solids. He gives history of chronic retrosternal pain, preceding dysphagia.
On examination, the man looks emaciated and pale.
a) Name three possible diagnoses.
b) Name three investigations.
c) What will be the long-term management? [Supple 2008 held in 2009]


Peptic Ulcer Disease

A 55-year-old male presents with two days history of burning in epigastrium with
nausea and vomiting. He had passed a black tarry foul smelling stool this morning
and is worried. He gives history of intake of some medication for his joint pain. The
physical examination is unremarkable.
a) What is the most likely diagnosis and what is the cause? Enumerate four other
probable causative factors for such presentation.
b) What can be the two differentials?
c) What investigations are available for diagnosis of a bacterial infection causing
these symptoms and what four drugs you will use for the treatment?

A 35-year-old male seen in emergency department with 2 days history of coffee
colored vomiting & epigastric pain. There is history of NSAIDs for his chronic lower
back pain. Patient is non-alcoholic. On examination, he is pale, epigastric tenderness,
no hepatosplenomegaly. Upper GI endoscopy shows small duodenal ulcer on the
posterior wall. Serology for H. pylori is positive.
a) What other invasive/non-invasive tests to confirm that he is suffering from H.
pylori infection?
b) Write down a standard non-bismuth H. pylori eradication triple therapy
prescription for this patient.

A 45-year-old obese male gave history of periodic epigastric pain radiating to the
back particularly 2-4 hours after meals and occasionally at bed time. There was no
history of smoking or use of NSAIDs. However, he is fond of eating junk food. On
examination, there is no history of Diabetes Mellitus, Hypertension and Ischemic
Heart Disease. His BP is 120/80 mm Hg, pulse is 80/min which is regular and there is
no hepatomegaly. Lab investigations showed CBC 10×10^9/L, Hb 13.5 g/dL and
platelets are 234×10^9/L. His liver function tests (LFTs) are: ALT 85 IU, AST 75 IU, ALP
140 IU. BUN and Serum Creatinine levels are normal.
a) What is the most likely diagnosis? List two other possibilities.
b) What further investigations are required to confirm the diagnosis and its
etiology?
c) Outline the management of your most likely diagnosis.

A 50-year-old obese woman is taking drug for painful osteoarthritis for last two
years. For last one week, she was complaining of upper abdominal pain and vomited
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blackish material on the day of admission. On examination, she was not looking pale,
her pulse and blood pressure were normal. Her liver was normal and spleen was not
enlarged.
a) What is the most likely cause of hematemesis in this patient?
b) Enumerate three investigations required in this patient.
c) What is the drug treatment for duodenal ulcer?

A 40-year-old male with history of recurrent epigastric pain that occurs after meal
presents in medical emergency with massive hematemesis. His blood pressure is
90/60 mm Hg. He has tachycardia and sweating. There is no history of chronic liver
disease.
a) What is the diagnosis?
b) Give important steps of management.

A 50-year-old executive presented with history of episodic epigastric pain for the last
many years with remission. His upper GI endoscopy shows an ulcerated lesion on the
lesser curvature of the stomach.
a) List three investigations to detect possible etiologic factor.
b) How would you treat him?
c) How would you like to follow up the patient?

A 70-year-old lady helping her grandson in green grocery shop attended medical
outpatient department with complaints of nausea, abdominal distension and
vomiting in which she had noticed food eaten 24 hours previously. On examination,
she was dehydrated and succussion splash was elicited 4 hours after food intake. On
investigations Hb 10 gm/dl, ESR 10 mm 1st hour, serum sodium 145 mEq/L, serum
potassium 2.5 mEq/L, serum bicarbonate 32 mEq/L, serum chloride 90 mEq/L.
a) What is the clinical diagnosis and associated biochemical abnormality?
b) Give two investigations to confirm the diagnosis and help in management.
c) Give an outline of management.

A 60-year-old woman presents in the emergency with massive hematemesis. She has
history of pain in her knee joints for which she is seeing her orthopedic surgeon who
has prescribed her some painkillers. She is pale and tender in her epigastrium.
a) What is the likely diagnosis?
b) What immediate treatment should be started?

A 28-year-old woman has chronic dyspepsia. There is no history of NASIDs intake.
She has been treated with omeprazole which gave her temporary relief. On
examination, there is mild pallor and epigastric tenderness. Blood culture
examination revealed mild hypochromic microcytic anemia. Stool was positive for
occult blood. Upper GI endoscopy showed an ulcer in the first part of duodenum.
a) What do you think may be the cause of her ulcer?
b) How will you confirm the diagnosis?
c) How will you manage her?


Celiac Disease

A fourteen-year-old boy presented with iron deficiency anemia. During examination,
you notice finger clubbing and a rash on the dorsum of elbows about which he
reported to be intensely pruritic. He also looked slightly smaller as compared to his
older siblings.
a) Which tests will help you make a diagnosis?
b) What is the treatment?
c) What is the associated skin condition called?

A 19-year-old boy has a long history of weight loss, abdominal distension, bloating,
recurrent anemia and diarrhea, calcium is low. A small bowel biopsy reveals blunting
and flattening of villi.
a) What is your diagnosis?
b) What laboratory investigations you order?
c) What are the long-term complications of the disease?
d) What is the treatment plan?

A 1-year-old pale looking boy of small height presented with frequent bulky diarrhea
for the last 10 years. There was no history of abdominal pain or fever. His
hemoglobin was 8 g/dL with microcytic and macrocytic picture of RBCs. His serum
vitamin D level was low.
a) What is the most likely diagnosis?
b) What is the cause of small height, anemia in this patient?
c) Enumerate two blood tests for the diagnosis of this patient.

A 45-year-old male presents with complaints of chronic diarrhea for last 3 months.
Stools are bulky, difficult to flush and don’t contain any bleed. There is history of
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generalized bodyaches and difficulty to climb stairs and stand from sitting position.
On examination, he is markedly pale with koilonychia present.
a) What are the differential diagnoses?
b) There is an itchy vesicular rash over extensor surface of elbows and legs. What is
the reason for this rash in this patient?

A 45-year-old male presents with complaints of chronic diarrhea for last 3 months.
Stools are bulky and difficult to flush but do not contain any blood. There is history of
generalized bodyaches and difficulty to go upstairs and standing from sitting
position. On examination, he is markedly pale and has koilonychia. What are your
differential diagnoses? Give any four
What is the cause of proximal muscle weakness in this case and how would you treat
it?

A young person has presented with chronic diarrhea for the past three months. He
passes three to six bulky motions without mucus or blood. He passes motions usually
every time he eats or drinks. The food contents can be recognized in the stool
sample. On examination, he is pale and has evidence of loss of muscle mass. There is
itchy erythematous papulovesicular rash on the lower limb extremities. Abdomen
distended with loud bowel sounds.
Laboratory evaluation show Hb 10 gm/ dL, MCV 66 fL, MCH 55 pg/L, ferritin 5 ng/ml
& albumin 3 gm/dl, stool examination is normal except for undigested food particles
and start molecules.
a) What is the most likely diagnosis & differential diagnoses?
b) Outlie the steps to reach the diagnosis.

A 15-year-old unmarried female is on maintenance L-thyroxine 50 ugm 3 tablets
daily. On follow-up, she complains of tiredness, easy fatigue, abdominal distension,
loose stool 2-3 times/day since previous 5 months and normal menstrual periods. On
examination, conjunctivae are little pale. Physical examination shows no other
abnormality. Her Hb is 9 gm/dL. Blood film shows microcytic hypochromic RBCs, T4
and TSH normal, serum iron is low and total iron binding capacity is high.
a) What two investigations are required to reach the diagnosis?
b) What is the likely diagnosis?
c) How will you treat this patient?


Inflammatory Bowel Disease

A 28-year-old female 6 months history of chronic diarrhea associated with lower
abdominal crampy pain & fever. The stool contains mucus and blood. On
examination, she is pale, mild tenderness all over the abdomen, no
hepatosplenomegaly.
Investigations: Hb 9.5 mg/dL, TLC 15000, Platelets 550, ESR 75, Serum Albumin 2.5
g/dL, LFTs: Total Bilirubin 1 mg/dL, AST 70 IU/L, ALT 65 IU/L, ALP 240 IU/L.
Ultrasound Abdomen was normal.
a) What is the most likely diagnosis?
b) List the features of severe disease.
c) Name various groups of pharmacological drugs used and outline the
management of this illness.

A 35-year-old female presented with 3 months history of bloody diarrhea with lower
abdominal crampy pain. She also gives history of fever, weight loss and occasional
large joint pains.
a) What is the most likely diagnosis?
b) Enlist four other diseases causing chronic diarrhea.
c) Outline the management of such patient.

A 30-year-old man presents with diarrhea for 5 days. Stools are mixed with fresh
blood and mucus. Frequency of stools I 9-11/day with fever and abdominal
distension. He says that he has similar episodes of diarrhea, although of less intensity
in the last six months. On examination, he is pale, dehydrated and has toxic look. His
BP is 110/70 mm Hg, pulse is 110/min and temperature is 102 F. His lab reports show
Hb 7 g/dl, ESR 80 mm in 1st hour. WBC 14 x 10^9/L
a) What is your diagnosis?
b) How will you manage him?

A 24-year-old policeman presents with bloody diarrhea accompanied by colic for the
last two months along with low grade fever and some weight loss. His clinical
examination reveals clubbing, pallor and deep tenderness over the left lower
abdomen.
a) Give four most likely possibilities of this clinical condition.
b) Enumerate four most important investigations for this gentleman.
c) Write down the three most appropriate therapeutic options.

A 55-year-old man presented with history of diarrhea containing blood and
abdominal pain for three months. He also reports low grade fever and weight loss.
Examination revealed a temperature of 99 F and some abdominal tenderness.
a) Enumerate four differential diagnoses.
b) How will you investigate the case?

A 43-year-old woman presents to you with 27 days history of watery, bloody
diarrhea mixed with mucus. Her diarrhea has not responded to previous medication
of ciprofloxacin & metronidazole by her primary physician. She is weak and
exhausted and is passing 10-12 stools during the day and night. She has severe
tenesmus and has lost her appetite. Physical examination is unremarkable except
left hypochondriac tenderness. Fever is 100 F. Her investigations show ESR: 62 mm,
Hb 10.2 gm%, SGPT 58, Albumin 2.9 gm & sigmoidoscopic examination revealed
inflamed friable mucosa. Biopsy examination showed crypt abscess formation. How
would you manage this patient?


Irritable Bowel Syndrome

A 47-year-old female presents with recurrent abdominal pain and fullness associated
with increased number of stools. Her pain improves after defecation and the
symptoms worsen whenever she has some issues with her husband.
a) What is the most likely diagnosis?
b) What alarm features (any six) you must ask her before starting her treatment?
c) Name any two medicines used to decrease her stool frequency.

A 23-year-old male of normal built presents with complaints of crampy abdominal
pain relieved by defecation which is associated with loose stools along with mucus
but not blood, 3 to 4 episodes per day. There is no history of fever, travelling or any
restaurant food intake. He reported that similar episodes have occurred over past 6
months which last for 7 to 10 days and resolved spontaneously. There is no
abdominal tenderness, mass or visceromegaly. Rest of systemic examination is
normal.
a) What is your diagnosis?
b) What relevant investigations you can advise?
c) Give four treatment options.

A 35-year-old woman comes with history of chronic diarrhea and lower abdominal
discomfort which is relieved by defecation. Occasionally she had noticed some
mucus but never blood in the stool.
a) What is the most likely diagnosis?
b) Name three most relevant investigations.
c) How will you treat this case?


Pseudomembranous Colitis

A 45-year-old male presents in medical OPD with high grade fever, abdominal
cramps and loose stools containing blood for 2 days. He gave history of dysuria for
which he has been on tablet Ciprofloxacin 500 mg twice a day for 12 weeks. On
examination, he is markedly dehydrated, pale, toxic and febrile and has diffuse
abdominal tenderness but no visceromegaly.
a) What is your provisional diagnosis?
b) How will you confirm diagnosis?
c) Write down two treatment options.


Carcinoid Tumor

A 52-year-old man is admitted for the workup of chronic recurrent diarrhea of about
six months duration in addition to the watery diarrhea. He also has recurrent
wheezing of the chest for which inhalers have been prescribed. He is noted to have a
bluish red rash over the face and necklace area. He also complains of pain right
hypochondrium on ultrasound examination. His liver is found to have multiple
rounded space occupying lesions.
a) What is the likely cause of his clinical features?
b) What one investigation will help confirm?
c) Give treatment.


Miscellaneous

A 32-year-old housewife complains of excessive dysphagia, pain epigastrium and
intermittent vomiting for the past three years. She has been treated with antacids,
H2 receptor blockers and various PPIs on many occasions with temporary relief. Her
clinical examination is unrevealing except for deep tenderness in the epigastrium.
a) Give three possible causes of her clinical condition.
b) Enumerate three most important investigations to reach the diagnosis.
c) Write down three most important steps in the management of this case.

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