A 63-year-old patient presents to the acute medical service with sudden onset jaundice. The patient reports occasional wine consumption and a history of recurrent urinary tract infections managed with prophylactic antibiotics. Liver function tests show elevated levels of total bilirubin, unconjugated bilirubin, conjugated bilirubin, ALP, and AST. What is the probable cause of these findings?
A 35-year-old man comes to the clinic with complaints of persistent heartburn and indigestion for the past year. He is worried as his father was diagnosed with oesophageal cancer at a young age. You schedule him for an upper GI endoscopy.
Investigations:
Haemoglobin 140 g/l 130–170 g/l
White cell count (WCC) 6.2 × 109/l 4–11 × 109/l
Platelets 200 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine 80 µmol/l 60–110 µmol/l
Endoscopy Helicobacter gastritis
He undergoes successful eradication therapy. What advice would you give him regarding his future risk of cancer and the possibility of needing retreatment for Helicobacter?
A 25-year-old woman presents to gastroenterology clinic with a 6 months history of abdominal bloating and diarrhoea. She is a graduate student and finds that her symptoms are exacerbated by periods of stress. She does not take any regular medications and has no drug allergies. Her aunt was diagnosed with ulcerative colitis at the age of 30 and is currently on biologic therapy for it.
On examination, her temperature is 36.7ºC, blood pressure is 100/50 mmHg and heart rate is 90 beats per minute. Her body mass index is 20.5 kg/m². There were no abnormalities to find on an examination of her cardiovascular, respiratory or abdominal systems.
Her GP had organised some blood tests prior to referring her to clinic:
Hb 130 g/l Na+ 135 mmol/l Bilirubin 12 µmol/l
Platelets 280 * 109/l K+ 4.6 mmol/l ALP 85 u/l
WBC 6.5 * 109/l Urea 3.5 mmol/l ALT 40 u/l
Neuts 4.0 * 109/l Creatinine 50 µmol/l γGT 35 u/l
CRP <1 mg/l Albumin 40 g/l
What is the most appropriate next investigation for this patient?
A 60-year-old man visits his GP to inquire about bowel cancer screening after receiving an invitation by mail. What is the most accurate statement about the screening process according to the National Health Service guidelines?
A 24-year-old individual with no prior medical issues presented to the clinic complaining of experiencing diarrhea for the past three weeks, occurring up to ten times per day, including at night. The stools are semi-formed with blood mixed within them. The individual reported experiencing gripping abdominal pain and feeling unwell, but continued to attend classes. Their father had a history of ankylosing spondylitis and uveitis.
During the examination, the individual’s abdomen was soft and non-tender. Rectal examination confirmed bloodstained stool. Although there was no evidence of arthritis, red regions on the shin suggested erythema nodosum. The chest and cardiovascular systems were unremarkable.
What investigation should be conducted first?
A 55-year-old man with known alcoholic hepatitis is admitted to the Emergency Department feeling generally unwell. He has been experiencing vague abdominal pain and general malaise for the past 4 days. His wife reports that he has been eating and drinking much less during this time and confirms that he has been abstinent from alcohol for over a year.
Upon examination, he appears clinically dehydrated and is drowsy. His heart rate is 121 beats per minute and his blood pressure is 102/55 mmHg. His temperature is 37.4 ºC. His chest is clear. His abdomen is soft with suprapubic tenderness but no organomegaly. There is some dullness in the flanks.
His urine dip is positive for nitrites and 1+ leucocytes.
The following are his blood test results:
Hb 115 g/l Na+ 125 mmol/l Bilirubin 24 µmol/l
Platelets 189 * 109/l K+ 4.9 mmol/l ALP 250 u/l
WBC 14 * 109/l Urea 11 mmol/l ALT 124 u/l
Neuts 10 * 109/l Creatinine 230 µmol/l γGT 255 u/l
Lymphs 2.5 * 109/l CRP 75 mg/dl Albumin 30 g/l
He is given antibiotics and normal saline, but after 24 hours, his sodium is 124 mmol/l and creatinine is 229 µmol/l.
His urine sodium is 12 mmol/l, and an ultrasound of the abdomen shows mild ascites, a cirrhotic liver, and a normal renal tract.
What is the most appropriate next step?
A 26-year-old female undergraduate student presented to the gastroenterology clinic with a three-year history of irritable bowel syndrome (IBS) and complaints of constipation. Despite trying dietary advice and various laxatives, including senna and sodium docusate in full doses and a trial of macrogol, there has been no improvement. The patient reports that the issue mainly occurs during exam periods. She had an appendectomy five years ago with no complications. Blood tests revealed:
– Hb: 120 g/L
– Platelets: 310* 10^9/L
– WBC: 8* 10^9/L
– Na+: 140 mmol/L
– K+: 4.4 mmol/L
– Urea: 6.5 mmol/L
– Creatinine: 100 µmol/L
What is the next step in managing this patient’s condition?
A 38-year-old man presents to the emergency department with bleeding from hair follicles on his head. He has also been experiencing a loss of appetite and weight loss. The patient is currently homeless after being laid off from his job a year ago. He consumes 30-units of hard liquor per week and is alcohol dependent. However, he is not confused.
The patient has a medical history of tuberculosis, which he completed treatment for six months ago. The treatment ended two months ago. Upon examination, the patient appears disheveled with poor oral hygiene and gingivitis. He has global muscle weakness rated at 4+/5 on the MRC scale, but there is no sensory impairment. What is the most probable diagnosis?
A 43-year-old woman has been referred for investigation of persistent iron deficiency anaemia despite taking oral iron supplements. She has a medical history of menorrhagia, depression, and gastro-oesophageal reflux disease.
Her current medications include ferrous fumarate, tranexamic acid, sertraline, and amitriptyline. Additionally, she occasionally takes over-the-counter paracetamol, ibuprofen, and an antacid solution.
Despite normal endoscopy and imaging results, recent blood tests confirm ongoing iron deficiency anaemia. What could be the possible cause for her persistent iron deficiency?
A 38-year-old woman presents to the emergency department feeling generally unwell. She has been experiencing a productive cough, worsening abdominal swelling, and severe constipation for the past five days. Her friend who is with her has noticed that she has been increasingly confused and mentions that she has a history of extensive alcohol use. The patient has a medical history of cirrhosis and COPD, but cannot recall the names of her medications, except for a red inhaler that she uses regularly.
Upon examination, the patient appears jaundiced, feels hot and clammy, and has crepitations in the left lower lobe. Her abdomen is distended with evidence of ascites, and she has distended veins on her chest.
Observations:
– Saturations: 93%
– Respiratory rate: 18/min
– Blood pressure: 121/58 mmHg
– Heart rate: 109/min
– Temperature: 38.2°C
Blood tests reveal:
– Hb: 121 g/l
– Platelets: 52 * 109/l
– WBC: 16 * 109/l
– Na+: 147 mmol/l
– K+: 4.8 mmol/l
– Urea: 11.1 mmol/l
– Creatinine: 153 µmol/l
– Bilirubin: 57 µmol/l
– ALP: 173 u/l
– ALT: 121 u/l
– Albumin: 26 g/l
– INR: 2.3
– PT: 25s
Further tests are ordered, including a CXR that shows left lower lobe consolidation, blood cultures, and an ultrasound scan of her abdomen. Additionally, calcium, phosphate, magnesium, and glucose levels are checked. In the acute setting, what other investigation would be most appropriate?