Year 3 Met3A Questions
50 year old female presents with purulent discharge from anal region and recurrent episodes of pain, intense and throbbing. O/E anal pruritis.
Abscess
20 year old man has a 24 hour history of abdominal pain which started in the para-umbilical region but seems to have moved to right iliac fossa. Tender here with guarding and rebound tenderness.
Acute appendicitis
35 year old woman has a 2 day history of severe abdominal pain and profuse vomiting. Previous episodes of RUQ pain particularly after fatty meals. Jaundiced and mildly tender in epigastrium. Pulse 120, BP 90/50
Acute cholecystitis
26 year old male with stab wound, operated on for ruptured spleen and dissected kidney due to knife wounds. Post op has severe epigastric pain, radiating to back between scapulae. Associated with nausea and vomiting
Acute pancreatitis
42 year old homeless man presents in A&E with left sided abdominal pain which radiated to the back. Jaundiced and smells of alcohol.
Acute pancreatitis
50 year old man fell from ladder and injured his back. Needs regular pain-killers for back pain. Since accident he has had issues opening bowels and noticed reduced bowel frequency.
Adverse drug effect of opiates.
52 year old male with abdominal distention and ankle swelling. He has been drinking 6 pints of beer and half a bottle of whisky a day for some years. On examination he has palmar erythema and spider naevi on his chest. Cause of ascites?
Alcoholic liver disease
18 year old man, severe right iliac fossa pain which has been present for 24 hours. Pain started more centrally and moved to the right. Nauseous and vomited several times. Fever and HR 110bpm
Appendicitis
18 year old student goes to A&E with acute onset vomiting at 2am followed by abdominal cramps and profuse diarrhea. He has eaten a take away that evening. There is some blood in the stool and he has high fever. No recent foreign travel and FBC shows normal hemoglobin and raised neutrophils.
Bacterial gastroenteritis
24 year old woman has 24 hours of vomiting and diarrhea maybe due to eating reheated takeaway food. Fresh blood in last 3 vomits. Stable vital signs
Bleeding diathesis
34 year old male with Crohn's disease has had no bowel movements for 4 days and has been vomiting for 24 hours. Examination reveals a distended abdomen and tinkling bowel sounds.
Bowel obstruction
4 year old male, profuse vomiting, no motions for 2 days, severe abdominal pain which is intermittent. Distended abdomen and increased bowel sounds. High pitched.
Bowel obstruction
60 year old man with previous laparotomy for perforated duodenal ulcer has 24 hour history of colicky abdominal pain, absolute constipation and vomiting. Distended resonant abdomen and high pitched bowel sounds.
Bowel obstruction
78 year old woman attends complaining of recent onset of tiredness. She is pale and has hepatosplenomegaly and generalized lymphadenopathy in neck, axillae and groin.
CLL
50 year old male with 1 month history of progressive abdominal distention preceded by increased tiredness, SOB on exertion and weight loss of 10kg. Non-tender irregular mass in the right iliac fossa. Cause of ascites?
Carcinoma of the cecum and peritoneal secondaries
70 year old male presents with significant weight loss, progressive painless jaundice. USS shows dilated biliary system down to the head of the pancreas.
Carcinoma of the head of the pancreas
25 year old female with history of weight loss, fatigue, abdominal discomfort and foul smelling diarrhea. Maybe due to certain foods.
Celiac disease
An obese 40 year old woman with history of right upper quadrant pain presents with rapid onset jaundice with severe abdominal pain, fever and rigors.
Cholecystitis
45 year old man has a long history of drinking excess alcohol. 3 month history of intermittent severe abdominal pain and diarrhea with pale, bulky, foul-smelling stool which are hard to flush away.
Chronic pancreatitis
46 year old sales rep recently lost his job and presents with jaundice and ascites. USS biliary tract is normal.
Cirrhosis
50 year old male with hemophilia and hepatitis C presents with weight loss and abdominal discomfort. Mildly icteric with features of chronic liver disease and large left lobe of the liver.
Cirrhosis and hepatoma
76 year old woman admitted with chest infection which was treated with cefuroxime and erythromycin. On day prior to discharge, she develops diarrhea not associated with blood. She appears unwell with temp 38 and CRP 150.
Clostridium difficile
62 year old male with knee replacement gives history of allergy to dihydrocodeine. Which post op analgesia?
Co-dydramol
75 year old man with 6 month history of straining at stool. He thinks he is not emptying his rectum properly. He is passing blood and mucus per rectum. He has some weight loss and anorexia.
Colorectal cancer
80 year old male with PMH severe osteoarthritis, taking co-codramol. Recently bowel habit has changed to watery diarrhea and complains of abdominal pain. Increasing confusion.
Colorectal cancer
52 year old woman recently developed constipation and not incomplete evacuation of rectum. Passed blood per rectum on 2 occasions.
Colorectal carcinoma
60 year old woman found to have hepatomegaly. History of moderate alcohol use. Anterior MI two years previously. Significant ankle edema, elevated JVP and 1-2 spider naevi on her chest.
Congestive cardiac failure
30 year old man admitted via A&E complaining of right iliac fossa pain, diarrhea and weight loss over several weeks. Laparotomy revealed oedmatous, reddened terminal ileum.
Crohn's disease
30 year old male IVDU with history of TB develops profuse watery diarrhea with no abdominal pain.
Cryptosporidum
65 year old man undergoes elective excision of rectal carcinoma and primary anastomosis, and is left with a stoma. What is it?
Defunctioning loop ileostomy
65 year old man with history of peptic ulceration requires aortic aneurysm repair electively. Which post op analgesia?
Diclofenac
85 year old known to be hypertensive and have mild impaired renal function presents with signs of dehydration and undergoes a laparotomy for small bowel obstruction. Which post op analgesia?
Diclofenac
40 year old multiparous woman presents with a midline abdominal mass, which is non tender and appears when straining. On examination the mass is visible when she raises her head off the examining bed.
Divarication of the recti
70 year old male with 2 day history of constipation, anorexia and pain in the left iliac fossa. On examination he is pyrexial and there is localized tenderness and rebound on the left iliac fossa. White blood cell count 14x10^9/l
Diverticulitis
Epigastric pain associated with dyspepsia, worse at night and when patient is hungry
Duodenal ulcer
40 year old man has just returned from holiday in Kenya, since return he has watery diarrhea with crampy abdominal pain
E coli infection
40 year old man presents with painless swelling in scrotum which is fluctuant and transilluminable. Both testes easily palpable.
Epididimyal cyst
60 year old male with diarrhea is transferred from another hospital for urgent femoral-distal bypass surgery and arrives with a heparin infusion in situ. APTT is 2.4. Which post op analgesia?
Epidural bupivacane fentanyl
20 year old male presents with painful defecation which persists for 30 minutes afterwards. The still is smeared with blood and he has noticed recent constipation.
Fissure
25 year old male student presents with 12 hours of abdominal pain, vomiting and watery diarrhea. Once before.
Food poisoning
70 year old smoker with a 6 week history of epigastric discomfort which is worse on eating. Lost appetite, sense of fullness all the time, 3kg weight loss. Unremarkable abdominal examination. Investigation?
Gastroscopy
40 year old male presents with PR bleed and palpable lump from anus with associated mucus discharge. Blood splashed around lavatory pan.
Haemorrhoids
85 year old man presented with perforated diverticular disease in sigmoid colon. After resus he had an emergency procedure - what was made?
Hartmann's procedure + end colostomy
24 year old unemployed rough sleeping male presents unwell with jaundice, anorexia and lassitude (fatigue). Number of venipuncture marks in antecubital fossa.
Hepatitis B
20 year old male has been constipated since childhood, opens his bowels once or twice a week and has noticed fecal soiling
Hirschsprung's disease
20 year old secretary complains of abdominal discomfort and bloating over the last 3 months. Intermittent diarrhea but when she opens her bowels her symptoms are relieved. No blood or mucus in stool. Abdominal and rectal exam normal. Investigation?
History only - IBS?
45 year old man presents with painless swelling in the scrotum. Left testis cannot be felt. Swelling transillumiates
Hydrocele
70 year old woman seen her GP for depression. Now complains of abdominal pain, constipation and thirst.
Hypercalcemia
40 year old woman has constipation, weight gain and menorrhagia. Opens bowels twice a week. Pulse 50/min and dry skin.
Hypothyroidism
52 year old patient is 24h post laparotomy for perforated duodenal ulcer has a pulse rate of 120/min and a BP of 95/40mmHg. Pyrexial with a WCC of 1.5
Hypovolemia
60 year old female had a fractured femur fixed 12 hours earlier. Post operative blood loss was measured at 4 liters. and was replaced with three units of packed red cells and 1l gelofusine. She has been written up for 1l dextrose saline 8 hourly. HR 110 and BP 100/70mmHg
Hypovolemia
32 year old female presents with 4 week history of bloody liquid stool with mucus 9x daily. She has anorexia, weight loss and anaemia.
IBD
25 year old female trainee solicitor presents complaining of bloating and excessive flatus. She is passing pellet like stools associated with abdominal pains. Symptoms have been intermittent for several years.
IBS
30 year old city banker comes to the GP with symptoms of abdominal bloating, intermittent constipation and diarrhea and occasional nausea. Ongoing for last 6 months with no weight loss or malaise. No blood in stools.
IBS
35 year old woman with mild longstanding constipation without weight loss. passes hard pellet like stools, often with straining and incomplete evacuation. Normal examination
IBS
69 year old patient with midline scar and stoma in right iliac fossa where there is urine in the bag. Which procedure/stoma?
Ileal conduit
19 year old male returns from recent backpacking holiday in India. He is passing bloody liquid stool about 15x daily. He has lassitude (fatigue) anorexia and temp 37.5C
Infectious diarrhea
65 year old male had an elective AAA repair 5 days ago. Now has abdominal distention and left sided abdominal pain. Passing small amount of blood and mucus per rectum.
Ischaemic colitis
72 year old woman has a disseminated malignancy of the colon. Suffering from abdominal distention and increasing constipation. She has a procedure before going onto palliative care. What is it?
Loop colostomy.
62 year old man in recovery following abdominal surgery complains of chest pain, pale, clamminess, HR 100 and BP 90/65 mmHg.
MI
68 year old obese Asian man presents with severe upper abdominal pain and nausea. Sweaty, cannot get his breath. Abdomen looks normal, no palpable masses. FBC ordered but not available.
MI
30 year old woman recently returned from Gambia, in the third trimester of pregnancy and complains of headache and fever. On examination BP is 110/70 there is soft ESM, shotty lymphadenopathy, and hepatosplenomegaly. Examination of the skin is unremarkable. Hb 10.5g/dl, WBC 5X10^9/l, platelet count of 80x10^9/l.
Malaria
21 year old student been on a drinking binge to celebrate end of final exams. 6 hour history of profuse vomiting with small amount of fresh blood mixed in the vomit. Vital signs are stable.
Mallory Weiss tear
25 year old presents with pyrexia, headache and painful swelling of face and testes.
Mumps orchitis
20 year old man presents with generalised swelling of the limbs, face and abdomen. Tests show normal blood counts and liver function tests, except albumin of 18g/l and cholesterol 9.5mmol/L. Cause of ascites?
Nephrotic syndrome
35 year old male with long history of EtoH excess presents with massive hematemesis. He is also jaundiced, hypotensive and tachycardic.
Oesophageal varices
55 year old male alcoholic patient presents with vomiting 800ml of blood. His blood pressure is 80/50, pulse 120, ascites.
Oesophageal varices
7 year old girl presents with spontaneous massive haematemesis.
Oesophageal varices
40 year old woman describes intermittent haemoptysis as well as small amounts of hematemesis. She has telangiectasia on her face.
Oster- Weber-Rendu syndrome
50 year old alcoholic man presents with nausea, vomiting and epigastric pain. On examination he has a palpable epigastric mass, and a raised amylase. CT scan of the abdomen shows a round well circumscribed mass in epigastrium
Pancreatic pseudocyst
54 year old publican has 48 hour history of severe epigastric pain and vomiting. On examination he is unwell. Pulse 110, BP 130/90, temp 38C, Upper abdomen very tender. Amylase 1000U/l
Pancreatitis
55 year old male has chronic back pain for which he takes diclofenac. He has epigastric pain after meals and has recently developed black tarry stools and an episode of coffee-ground vomiting
Peptic ulcer
50 year old man presents with 24 hour history of sudden onset of severe epigastric pain, which is now generalized. Pyrexia 37.8C, rigid abdomen, absent bowel sounds. WBC 18x10^9/l. Serum amylase raised at 450IU/l. X ray of abdomen shows opacities in right hypochondrium and gas under diaphragm.
Perforated peptic ulcer
78 year old woman attends complaining of widespread itching. Examination reveals hepatosplenomegaly. Patient appears plethoric with no lymphadenopathy.
Polycythemia rubra vera
82 year old female presents with a large lump which appears at the anus after defecation and spontaneously on coughing. Uncomfortable lump and patient has tenesmus. Incontinence and noticed mucus PR.
Prolapse
70 year old man with gastrectomy for GI bleed complains of shortness of breath. Heart rate 120/min and hypotension. Already had 10 units of packed red cells, 3l gelofusine and 1l crystalloid. Post operative hemoglobin is 15.2g/dl
Pulmonary oedema
28 year old woman has a 24 hour history of severe constant right loin pain and vomiting, rigors and sweats. Urinalysis reveals blood and protein.
Pyelonephritis
71 year old man had an MI 6 months ago, now presents with SOB and fatigue. On examination, raised JVP and pitting edema to the knees. Tenderness in the RUQ with smooth liver edge at 5cm. Cause of ascites?
Right heart failure
70 year old man with long history of hypertension and recent history of intermittent back pain collapsed with severe central abdominal pain which radiates to the back. Abdomen is tender and pulsatile mass in midline.
Ruptured AAA
33 year old woman collapsed with generalized abdominal pain. Apyrexial, with pulse 140/min and BP 90/40. Abdomen rigid and tender with guarding. She cannot be pregnant as IUD coil inserted.
Ruptured ectopic pregnancy
34 year old manhas been vomiting 2-3 times a day for 3 days. Complains of severe crampy abdominal pain and blood stained watery diarrhea. On examination temperature is 37.7C and abdomen soft. Complains of generalised tenderness. No masses, rebound tenderness or guarding
Salmonella
33 year old male presents with swelling of left testis which is gradually increased in size. On examination, swelling is hard, non-tender and non-transilluminating
Seminoma
45 year old unmarried laborer who had increasingly severe central abdominal pain over last 3 hours. The pain radiates through to back and makes him vomit. No PMH. On examination cold and sweaty, pulse 120, BP 90/70, guarding over whole abdomen. Investigation?
Serum amylase
65 year old heavy smoker. Progressive SOB over few years. Smooth liver edge 2cm below costal margin.
Severe emphysema
70 year old woman presents with a 2 day history of colicky abdominal pain and 24 hour history of vomiting. On examination there is abdominal distension, visible peristalsis and mid line laparotomy scar. Tinkling bowel sounds.
Small bowel obstruction
19 year old man presents with sudden severe right upper abdominal pain after being tackled during rugby practice. Recently diagnosed with glandular fever
Splenic rupture
25 year old previously well man with three day history of abdominal cramps, diarrhea, bloody stool 5/6 times a day. Examination shows soft tender abdomen. Investigation?
Stool examination for pathogens
25 year old man with a history of UC, deteriorates and requires an emergency operation to treat the disease. Left with a stoma. What is it?
Subtotal colectomy and end ileostomy
20 year old mane presents with acute onset of vomiting and pain in lower abdomen after playing football. Abdomen soft but has tender, soft right testis which lies high within the scrotum.
Testicular torsion
65 year old woman admitted with diarrhea and weight loss. On examination she has a fine tremor, is in rapid AF. FBC, ESR and CRP are normal.
Thyrotoxicosis
19 year old student with abdominal pain, just returned from gap year where she went backpacking across india. Constipation and dry cough. Enlarged spleen.
Typhoid
50 year old housewife and mother of 5 has sudden epigastric pain radiates to the back and right and has vomited. Recent meal of fish and chips, never has fatty food normally. Examination difficult due to obesity. May have guarding at epigastrium and right hypochondrium. Investigation?
USS abdomen
27 year old woman presents with 2 week history of bloody diarrhea and abdominal pain. Passed mucus per rectum at times.
Ulcerative colitis
30 year old female with history of bloody diarrhea for 2 months. Diarrhea has been present for 3 years but he has never noticed blood and it has become worse since giving up smoking a few months ago.
Ulcerative colitis
30 year old man with swelling within the left scrotum which aches when he stands. On examination it is not tender and feels like a bag of worms
Variocele
55 year old man who takes bendrofluazide for hypertension, presents with 2 month history of watery diarrhea with occasional blood and mucus mixed in stool. Potassium of 2.3mmol/l
Villous adenoma of rectum
25 year old travelling salesman is awoken with crampy abdominal pain. Feeling ill and vomits three times over next half an hour. Asks receptionist to call a doctor
Viral gastroenteritis
80 year old lady with severe left/right pain radiating through to loin and back. Found collapsed at home due to pain. Smoker.
leaking AAA
83 year old man with longstanding heart failure for which he takes digoxin and diuretics.. For last 24 hours he has been vomiting and has passed very little urine. On examination he is pale and mildly dehydrated. Normal abdo exam
uraemia
49 year old man presents with severe right sided abdominal pain which radiates to the groin. Poor english. Anxious, lots of pain, unable to get comfortable. Abdominal X ray normal.
ureteric colic
