Archives: Medical Student Finals

MSFinals-1367

A 50-year-old man presents to his general practitioner (GP) with several months of difficulty swallowing both liquids and solid foods. He states he also often regurgitates undigested food. He no longer looks forward to his meals and is beginning to lose weight. He denies chest pain.
Physical examination is normal. An electrocardiogram (ECG) and chest X-ray are also normal. Blood tests reveal normal inflammatory markers and normal renal function. He has had a trial of proton pump inhibitor (PPI) therapy, without relief of his symptoms. An upper gastrointestinal endoscopy is performed by the Gastroenterology team, which is also normal.
Which of the following is the most appropriate investigation for this patient?

MSFinals-1368

An 80-year-old woman presents with a history of melaena on three separate occasions in the past three years. She reports having had many tests, including barium enemas, flexible sigmoidoscopies, and oesophagogastroduodenoscopies, which were all normal.

One year ago she required two units of blood to raise her haematocrit from 24% to 30%. She has been taking iron, 300 mg orally BD, since then.

The patient has hypertension, coronary artery disease, and heart failure treated with digoxin, enalapril, furosemide, and metoprolol. She does not have chest pain or dyspnoea.

Her body mass index is 32, her pulse is 88 per minute, and blood pressure is 120/80 mm Hg supine and 118/82 mm Hg standing. The conjunctivae are pale. A ventricular gallop is heard. There are bruits over both femoral arteries.

Rectal examination reveals dark brown stool that is positive for occult blood. Other findings of the physical examination are normal.

Barium enema shows a few diverticula scattered throughout the descending and transverse colon.

Colonoscopy shows angiodysplasia of the caecum but no bleeding is seen.

Technetium (99mTc) red cell scan of the colon is negative.

Haemoglobin is 105 g/L (115-165) and her haematocrit is 30% (36-47).

What would be the most appropriate course of action at this time?

MSFinals-1369

A 40-year-old man comes to the Emergency Department complaining of epigastric pain and vomiting. He has a history of heavy alcohol consumption. His serum amylase level is 1020 u/l, and acute pancreatitis is diagnosed. Which of the following factors is NOT included in the modified Glasgow severity scoring?

MSFinals-1370

A 47-year-old man is admitted with acute epigastric pain and a serum amylase of 1500 u/l. His IMRIE score confirms acute pancreatitis. On examination, a large ecchymosis is observed around the umbilicus.
What clinical sign does this examination finding demonstrate?

MSFinals-1329

A 28-year-old man presents with generalised pruritus, right upper quadrant pain and jaundice for the past month. He has a history of recurrent bloody bowel movements and painful defecation and is now being treated with sulfasalazine. His previous colonoscopy has shown superficial mucosal ulceration and inflammation, with many pseudopolyps involving the distal rectum up to the middle third of the transverse colon. On abdominal examination, the liver is slightly enlarged and tender. Total bilirubin level is 102.6 μmol/l and indirect bilirubin level 47.9 μmol/l. Alkaline phosphatase and γ-glutamyltransferase concentrations are moderately increased. Alanine aminotransferase and aspartate aminotransferase levels are mildly elevated.
Which of the following autoantibodies is most likely to be positive in this patient?

MSFinals-1330

A 40-year-old woman presents with chronic diarrhoea. She reports that her stools float and are difficult to flush away. Blood tests reveal low potassium levels, low corrected calcium levels, low albumin levels, low haemoglobin levels, and a low mean corpuscular volume (MCV). The doctor suspects coeliac disease. What is the recommended first test to confirm the diagnosis?

MSFinals-1331

A 30-year-old woman presents with sudden onset of abdominal pain and swelling. She works as a teacher and is in a committed relationship. Upon examination, her abdomen is tender, particularly in the right upper quadrant, and there is mild jaundice. She is currently taking the combined oral contraceptive pill (COCP) and has no significant medical history or regular medication use. After three days of hospitalization, her abdomen became distended and fluid thrill was detected. Laboratory tests show:
Parameter Result
Investigation Result Normal value
Haemoglobin 150 g/l 115–155 g/l
Bilirubin 51 μmol/ 2–17 μmol/
Aspartate aminotransferase (AST) 1050 IU/l 10–40 IU/l
Alanine aminotransferase (ALT) 998 IU/l 5−30 IU/l
Alkaline phosphatase (ALP) 210 IU/l 36–76 IU/l
Gamma-Glutamyl transferase (γGT) 108 IU/l 8–35 IU/l
Albumin 30 g/l 35–55 g/l
An ultrasound revealed a slightly enlarged liver with a prominent caudate lobe.
What is the most appropriate definitive treatment for this patient?

MSFinals-1332

A 22-year-old woman presents with unintentional weight loss and blood stained diarrhoea. The blood is fresh, and mucous is often present in the stool. On examination, she has oral ulcers, erythema nodosum and conjunctivitis. The mucosa looks abnormal and multiple biopsies are taken. Ulcerative colitis is suspected.
Which of the following findings would support a diagnosis of ulcerative colitis over Crohn’s disease?

MSFinals-1333

A 35-year-old woman presents to the Emergency Department complaining of RUQ pain, nausea, and vomiting. She has a past medical history of gallstones. The patient reports experiencing severe stabbing pain that began earlier today. Upon examination, her heart rate is 110 beats/min (normal 60-100 beats/min), her temperature is 38.5°C (normal 36.1-37.2°C), and she is positive for Murphy’s sign. There is no evidence of jaundice, and she had a bowel movement this morning. What is the most likely diagnosis based on this clinical presentation?

MSFinals-1334

A 55-year-old man with a long history of ulcerative colitis (UC) presents to the clinic for evaluation. Although his inflammatory bowel disease is currently under control, he reports experiencing increased lethargy and itching. During the physical examination, his blood pressure is 118/72 mmHg, and his pulse is 68 bpm. The patient displays mildly jaundiced sclerae and evidence of scratch marks on his skin.
Lab Results:
Test Result Normal Range
Hemoglobin 112g/L 135–175 g/L
White blood cell count (WBC) 8.9 × 109/L 4–11 × 109/L
Platelets 189 × 109/L 150–400 × 109/L
Sodium (Na+) 140 mmol/L 135–145 mmol/L
Potassium (K+) 4.2 mmol/L 3.5–5.0 mmol/L
Creatinine 115 μmol/L 50–120 µmol/L
Alkaline phosphatase 380 U/L 30–130 IU/L
Alanine aminotransferase (ALT) 205 U/L 5–30 IU/L
Bilirubin 80 μmol/L 2–17 µmol/L
Ultrasound Evidence of bile duct dilation
What is the most probable diagnosis?