Gastroenterology 🍽️

A 24 year old female presents with a 4 month history of bloody diarrhoea, lethargy and weight loss. She complains of abdominal discomfort and passing stools more than 8 times a day. An endoscopy was performed which shows deep ulcers, and skip lesions. What is the SINGLE most likely diagnosis?

A 33 year old lady who has been traveling around Europe for a few months now returns to the United Kingdom with lethargy, abdominal pain, loose watery diarrhoea and bloating. She has lost a few kilograms since coming back from the trip. Her physical examination remains unremarkable with abdominal examination having mild generalised tenderness. What is the SINGLE most likely organism causing her symptoms?

A 21 year old woman complains of diarrhoea, and abdominal cramps for the past 5 months. She says that her diarrhoea has recently become bloody. A rectal biopsy was performed and histology was reported as “decreased amounts of goblet cells”. What is the SINGLE most likely diagnosis?

A 67 year old woman complains of intermittent difficulty in swallowing. She had a stroke 6 months ago and shortly after she started losing weight. She has had three chest infections in the span for 6 months. The medical team has decided that she would require a procedure to address her feeding issue. What is the most appropriate procedure to perform for long term feeding?

A 44 year old woman has been experiencing chest pain, nausea and vomiting over the past few days. She has a burning sensation in her chest. A chest X-ray shows the presence of an air-fluid level in a mass behind a normal-size heart. What is the SINGLE most likely diagnosis?

A 56 year old woman has had severe abdominal pain for 24 hours radiating to her back and is accompanied by nausea and vomiting. She denies any diarrhoea or fever. She appears to be tachycardic and in shock. She has a history of gallstones. What is the SINGLE most likely investigation to confirm the diagnosis?

A 44 year old male was admitted to the medical ward with complaints of diarrhoea, abdominal pain and weight loss for the last few months. The examination notes finger clubbing, perianal skin tags and abdominal tenderness. A colonoscopy reveals transmural granulomatous inflammation involving the ileocaecal junction. What is the SINGLE most likely diagnosis?

A 55 year old man presents with persistent dysphagia to both solids and liquids for a few weeks. He finds that hot liquids result in worsening pain. There is no associated weight loss. He does not have regurgitation after meals. He suffers from gastro-oesophageal reflux disease and takes regular antacids. What is the SINGLE most likely diagnosis?

A 42 year old female presents to her GP following a staging CT for her recently diagnosed renal cell carcinoma. On the CT scan, gallstones were noticed in the gallbladder. She has no history of abdominal pain or jaundice and is otherwise well. A left sided nephrectomy for her renal cell carcinoma has been scheduled. What is the SINGLE most appropriate course of action?

A 41 year old man has had a liver biopsy as part of investigations for abnormal liver function test. The pathology report states: special stains demonstrate the presence of a very large amount of iron pigment within hepatocytes. What SINGLE condition is identified by the pathology report?

A 35 year old male presents to his GP with the complaint of diarrhoea. He complains that he has been having recurrent, chronic diarrhoea for the past 5 months now. He claims to not have noticed any discernible pattern. He does not smoke and is a teetotaler. Upon examination, the patient’s clothing appears to be ill-fitting. A blood test was subsequently done and revealed the following:

Haemoglobin 118 g/L (130-180 g/L)

Mean cell volume (MCV) 106 fL (76-96 FL)

A peripheral blood film is significant for a dimorphic picture of red cells.

Following the results of the blood tests, the patient was booked for an endoscopy. A few tissue samples were taken during the endoscopy and sent to for histology evaluation. What is the SINGLE most likely pathology to be seen on histology?

A 65 year old female was admitted to the hospital with a severe community acquired right lower labe pneumonia as seen on a chest X-Ray. Treatment was commenced with 1.2 g of co-amoxiclav intravenously. On the fourth day, her skin, sclerae and mucosae were noted to be yellow in colour and it was also observed that she was passing dark urine. The patient’s vitals were noted as follows:

Blood pressure 120/80 mmHg

Heart rate 80 beats per minute

Respiratory rate 30 breaths per min

A liver function test and coagulation screen was subsequently done and the results are shown as follows:

Bilirubin 65 μmol/L (3-17 μmol/L)

Aspartate transaminase (AST) 250 IU/L (S-35 IU/L)

Alanine transferase (ALT) 190 (5-35 IU/L)

Alkaline phosphatase (ALP) 610 IU/L (30-130 IU/L)

Prothrombin time (PT) 15 seconds (10-14)

The patient’s past medical history is significant for her drinking around 20 units of alcohol per week for the last ten years. What is the SINGLE most likely cause of this patient’s deranged liver function tests?

A 56 year old man comes for a routine check up. He is noted to have increased skin pigmentation, spider angioma and a heart murmur. He has mild joint pain particularly in those of the hands. He rarely drinks alcohol. On examination, his liver is firm and has a span of 10 cm. On further investigations of the heart murmur, he was given the diagnosis of restrictive cardiomyopathy. What is the SINGLE condition that he is most likely at risk of?

A 38 year old man has just returned from Kenya a few days ago. Since his return, he has developed watery diarrhoea with crampy abdominal pain. What is the SINGLE most likely causative organism?

A 40 year old woman complains of dysphagia when eating solids and drinking liquids which has been worsening over the past year. She sometimes suffers from severe retrosternal chest pain. Barium swallow reveals a dilated oesophagus which tapers to a fine distal end. What is the SINGLE most appropriate management?

A 23 year old woman has abdominal bloating, weight loss and intermittent diarrhoea. She describes her stools as “frothy” and difficult to flush down the toilet. Her blood test show:

Haemoglobin 105 g/L (115-160 g/L)

White cell count 7.1 x 10^9/L (4-11 x 10^9/L)

Platelets 350 x 10^9/L (150-400 x 10^9/L)

Ferritin 11 ng/ml (20-300 ng/ml)

Vitamin B12 225 ng/L (150-700ng/L)

Folate 1.9 mcg/L (2.0-11.0 mcg/L)

What is the SINGLE most appropriate test to next perform?

A 25 year old man presents to his GP with the complaint of diarrhoea for the last seven days. Upon further questioning, he reveals that he opens his bowels in excess of two to six times per day. He describes his stool as being watery in consistency. He has also noticed blood in his stool. When asked about the character of the blood, the patient claims that the blood appeared to be fresh and was bright red in colour. He also complains about abdominal pain and describes his pain as being cramping in nature. He complains about an urgency to visit the toilet all the time. The patient is a bank manager by profession and for the last seven days, has been unable to cope with his situation. He says that it is affecting his work and overall general health as he is feeling very tired and lethargic all the time. He also complains about a lack of appetite. He has not traveled outside of the United Kingdom for the last eight months. The patient has no significant past medical history and does not have any allergies. On examination, he has a blood pressure of 120/80 mmHg and a heart rate of 70 beats/minute. His abdomen is tender with no guarding or rigidity. What SINGLE most appropriate investigation will you perform to aid in the management of this patient?

A 42 year old obese woman has severe upper abdominal pain. She vomited several times today. She has a temperature of 37.8°C. She is married and has 5 living children. She has no previous surgeries. Her blood count shows:

Haemoglobin 123 g/L (130-180)

White cell count 17.3 x 109/L (4-11)

Platelets 150 x 109/L (150-400)

CRP 180 mg/L (<10)

What is the SINGLE most likely diagnosis?

A 36 year old lady has diarrhoea for the last 2 months. She has lost 8 kg in that time period. A colonoscopy was performed which showed fistulas. Perianal fistulas are also noticed. What is the SINGLE most likely diagnosis?

A 60 year old man presents with difficulty swallowing solids. He denies pain and weight loss. He boasts to you that he is in top physical shape and is still able to run half- marathons faster than the “kids” that are less than half his age. He attributes this success to being a life-long teetotaller, maintaining a healthy diet and never having smoked a cigarette in his life. The patient cannot recall the last time he has needed to visit a doctor. Upon history taking he admits that his clothes have been becoming looser over the past several months. He also admits to having heart burn and an acidic taste in his mouth whilst eating for as long as he can remember but he thinks this is due to the speed at which he consumes his meals. What is the most appropriate investigation that will lead to a diagnosis?

A 55 year old male presents with longstanding gastric reflux, dysphagia and chest pain. He says it came on gradually and initially only noticed it with solid food but more recently has been having symptoms with soft foods also. Barium swallow shows irregular narrowing of the mid-thoracic oesophagus with proximal shouldering. What is the SINGLE most appropriate diagnosis?

A 58 year old man has been having frequent episodes of secretory diarrhea for the past 2 weeks. His diarrhoea is extremely watery with large amounts of mucus. A diagnosis of villous adenoma was made after performing an endoscopy. What is the SINGLE most likely electrolyte abnormality?

A 55 year old man has had new-onset jaundice and epigastric pain which started a week ago. He has started feeling nauseous with vomiting 2 days ago. He has no history of weight loss. He drinks an average of 35 units of alcohol a week and has done so for several years. There is epigastric tenderness with no abnormal masses on palpation of his abdomen. His blood results show the following:

Bilirubin 89 μmol/L (3-17)

Serum alanine transferase (ALT) 238 U/L (5-35)

Serum alkaline phosphatase (ALP) 899 U/L (30-150)

Aspartate transaminase (AST) 55 U/L (5-35)

Gamma glutamyl transferase (GT) 490 U/L (8-60)

Albumin 36 g/L (35-50)

Amylase 399 U/L (0-140)

More than 50% of his bilirubin is conjugated. His observations are within the normal limits aside from a temperature of 38.3°C.

What is the SINGLE most likely diagnosis?

A 51 year old man presents to the GP surgery with new-onset jaundice which started three days ago. He has no abdominal pain. He lost 5 kg over the past month. He drinks an average of 30 units of alcohol a week and has done so since his late twenties. There are no abnormal masses on palpation of his abdomen. His blood results show the following:

Haemoglobin 141 g/L (130-180)

White cell count 4.1 x 10^9L (4-11)

Platelets 250 x 10^9/L (150-400)

Bilirubin 99 μmol/L (3-17)

Serum alanine transferase (ALT) 202 U/L (5-35)

Serum alkaline phosphatase (ALP) 539 U/L (30-150)

Gamma glutamyl transferase (GT) 290 U/L (8-60)

Albumin 36 g/L (35-50)

More than 50% of his bilirubin is conjugated. His observations are within the normal limits. What is the SINGLE most appropriate action?

A 60 year old man presents with weight loss and complains of mild abdominal pain, bloating and diarrhoea for the past 6 months. A recent blood test shows a haemoglobin of 7 g/dl. What is the SINGLE most appropriate investigation?

A 49 year old woman is brought to the Emergency Department with severe lethargy and a history of black tarry stools for the past 2 days. She has a medical history of rheumatoid arthritis and suffers from chronic anaemia. She takes regular naproxen for pain relief. Her blood pressure is 80/40 mmHg and her heart rate is 119 beats/minute. Her blood test shows the following results:

Haemoglobin 52 g/L (115-160)

White cell count 8 x 10^9/L (4-11)

Platelets 390 x 10^9/L (150-400)

She was given intravenous fluids and 4 units of packed red blood cells. Her heart rate is 107 beats/minute, her temperature is 37.1°C and her blood pressure is 90/60 mmHg after the transfusion. Which of the following is the most appropriate next step in managing this patient?

A 39 year old patient was recently diagnosed with coeliac disease and has been treated with a gluten free diet for 2 years. He now has an exacerbation of the classic symptoms of coeliac disease such as abdominal pain, diarrhoea, and has loss significant weight. The biopsy of the small intestine shows lymphomatous infiltrates. What is the SINGLE most likely diagnosis?

A 30 year old lady complains of intermittent diarrhoea, chronic abdominal pain and tenesmus. Sometimes she notices blood in her stool. What is the SINGLE most likely cause of her symptoms?

A 44 year old man is seen in his GP with a history of fatigue, pruritus and abdominal pain over the past 3 months. His medical history includes ulcerative colitis. He does not drink alcohol or smokes. He has no history of weight loss. His blood test shows the following:

Bilirubin 52 μmol/L (3-17)

Serum alanine transferase (ALT) 123 U/L (5-35)

Serum alkaline phosphatase (ALP) 480 U/L (30-150)

Aspartate transaminase (AST) 159 U/L (5-35)

Gamma glutamyl transferase (GT) 290 U/L (8-60)

Albumin 38 g/L (35-50)

More than 50% of his bilirubin is conjugated. What is the SINGLE most likely diagnosis?

A 60 year old man presents with a lump in the left supraclavicular region. He complains that he does not eat as much anymore because he does not have the appetite. He has also lost 10kg in the last 3 months. What is the SINGLE most probable diagnosis?

A 35 year old man presents with burning retrosternal pain for the past few days. He has recently completed a course of treatment for H.pylori. Endoscopy shows multiple ulcers along the lower esophagus, stomach and duodenum. What is the SINGLE next most appropriate investigation?

A 33 year old woman has severe upper abdominal pain with radiation to the back within 24 hours of removing gallstones by endoscopic retrograde cholangiopancreatography (ERCP). The pain is eased when she leans forward. She reports some nausea and vomiting but denies any diarrhoea. Jaundice is noted and the epigastric region is tender on palpation. Her blood pressure is 120/80 mmHg, and temperature is 37.3°C. What is the SINGLE most likely reason for his signs and symptoms?

A 25 year old man has been having persistent diarrhoea over the past 8 weeks. He has cramping abdominal pain especially after meals. He started passing blood and mucous in his stools over the past few days. On examination, his abdomen is tender at the right lower quadrant. His blood results show the following:

Haemoglobin 109 g/L (130-180)

White cell count 15 x 10^9/L (4-11)

Platelets 521 x 10^9/L (150-400)

CRP 42 mg/L (<10)

What is the SINGLE most appropriate investigation that would lead to a diagnosis?

A 49 year old female presents with right hypochondrial pain. An ultrasound shows a large gallstone. Her BP is 120/85 mmHg: respiratory rate 18/min; Heart rate 90 bpm; Temperature 37.6°C; WBC 15 x 109/L. What is the SINGLE most appropriate management?

A 75 year old man presents with difficulty swallowing both solids and liquids. While he admits to having a mild and more bearable difficulty in swallowing for the past three years, his symptom has worsened over the past two weeks, and he has been unable to eat or drink since yesterday despite maintaining a good appetite. He was diagnosed with cesophageal cancer a year ago, which had metastasized to the liver and lungs at the time. Additionally, he reports that he lost 2 kg of body weight since the time of diagnosis. Provided the stage of cancer and the age of the patient, surgery was not a feasible option. He understands the implications of his diagnosis and wishes to live in comfort for the remainder of his time. Which of the following is the most appropriate management of this patient?

A 57 year old man has had dyspepsia for the past 6 months. He has been prescribed H2 blockers and proton pump inhibitors which he takes regularly over the past few months but it provides minimal relief. Over the past 2 weeks, he has started to have difficulty swallowing. What is the SINGLE most appropriate investigation?

A 36 year old bodybuilder presents with sudden onset of severe abdominal pain. He was previously fit and well and only suffers from indigestion occasionally. He has been taking ibuprofen for a long term knee injury. On examination, he has a rigid abdomen, lies motionless on the bed and has no bowel sounds. His pulse rate is 115 bpm and blood pressure is 100/60 mmHg. What is the SINGLE most likely diagnosis?

While performing an appendectomy, a surgeon found a mass in the caecum of a patient. The mass was removed and sent for analysis. Analysis revealed a transmural infiltration with lymphocytes and granulomas without necrosis. What is the SINGLE most probable diagnosis?

A 70 year old man presents with persistent dysphagia to both solids and liquids for a few months now. There is no associated weight loss. He does not have regurgitation after meals. He suffers from dyspepsia and occasionally has a burning sensation of his chest which lasts for a few hours before it fades away. His medical history includes osteoporosis which he takes alendronate once a week for the past 2 years. What is the SINGLE most likely diagnosis?

A 28 year old man has been having diarrhoea and recurrent abdominal pain several days a month for the last 12 months. The pain improves on defecation. He has mucous in his stools. He describes the pain in the centre of his abdomen and the right lower quadrant. He denies any weight loss. His full blood count and coeliac autoantibodies have been found to be normal. On examination, his abdomen is soft but with general tenderness. There is no abnormal mass palpable. What is the SINGLE most appropriate investigation?

A 35 year old woman has sudden onset epigastric pain, chills and nausea. She gave birth to a healthy baby 2 days ago. Her blood pressure was normal throughout pregnancy. Her temperature is 37.8°C, blood pressure is 139/90 mmHg and heart rate is 115 beats/minute. Urinalysis reveals no proteins. On examination, there is tenderness in the right upper quadrant. Her blood test show.

Alkaline phosphatase (ALP) 222 U/L (30-150 U/L)

Alanine transferase (ALT) 55 U/L (5-35 U/L)

Bilirubin 25 μmol/L (3-17 μmol/L)

International normalized ratio (INR) 1.0

Haemoglobin 101 g/L

Platelets 350 x 10°/L (150-400 x 10^9/L)

White cell count (WCC) 15.5 x 10^9/L (4-11 x 10^9/L)

What is the SINGLE most likely diagnosis?

A 44 year old man complains of intermittent dysphagia for the past 5 weeks. He also has a nocturnal cough. He has dropped from a weight of 80 kg to 70 kg during this period. Occasionally, he suffers from heartburn when lying flat. He does not smoke. He has no significant medical history. What is the SINGLE most appropriate initial investigation?

A 25 year old woman complains of diarrhoea, and abdominal cramps for the past 8 months. She says that her diarrhoea has recently become bloody. A biopsy was performed and the colonic mucosa shows crypt abscesses. What is the SINGLE most likely diagnosis?

A 54 year old woman, known case of pernicious anaemia refuses to take hydroxocobalamin intramuscularly as she is needle shy. She is asking for oral medication. What is the SINGLE best reason that describes why oral medications will not be effective?

A 52 year old man who underwent a partial gastrectomy 10 years ago presents with increasing fatigue. He also shows signs of cognitive deterioration, peripheral paresthesia and disturbances of position and vibration sense. A yellow tinge is noted on his skin and he has a red sore tongue. A recent full blood count shows macrocytic anaemia. What is the SINGLE most likely diagnosis?

A 72 year old smoker has been having progressive symptoms of difficulty swallowing solid foods over the past 3 months. He has the sensation that “food is sticking” in his throat. He denies any chest pain. He has lost 8 kg over the past 3 months. He smokes 12 cigarettes a day. What is the first condition to suspect?

A 27 year old woman comes to the hospital with pain and distension of her abdomen. The pain started a few days ago and it has been worsening over the past 24 hours. She gives a history of recent bloody diarrhea. She has been suffering with chronic diarrhoea and abdominal cramping for a few months associated with fever and malaise. Her diarrhoea is often episodic with periods where she has normal stool consistency for a few days however she feels greatly inconvenient during episodes where she has increase frequency of defecation. An erect abdominal X-ray was requested and performed which shows mucosal oedema and a dilated transverse colon. Her temperature is 38.5°C. She has a pulse rate of 105 beats/minute and a blood pressure of 100/60 mmHg. Her blood results show:

White cell count (WCC) 16.3 (4-11 x 10^9/L)

CRP 125 mg/L (< 10 mg/L)

Haemoglobin 100 g/L (115-160 g/L)

What is the SINGLE most likely diagnosis?

A 55 year old woman complains of retrosternal chest pain and difficulty swallowing which is intermittent and unpredictable. She says that food gets stuck in the middle of the chest and she has to clear it with a drink of water. She is then able to finish the meal without any further problem. A barium meal shows a ‘corkscrew patterned oesophagus. What is the SINGLE most likely cause of the dysphagia?

A 40 year old woman is admitted to the hospital for management of a pulmonary embolism which was diagnosed 3 days ago. She starts having epigastric pain over the past few hours and has bouts of diarrhoea. There is no blood in her stools. She feels nauseous but has not vomited. What is the SINGLE most likely reason for her symptoms?

A 31 year old man has a history of passing loose stools for the past 6 months. He says his stools contain a small amount of blood and mucous and are associated with abdominal pain. He has around 3 bowel movements a day. There is no evidence of weight loss. His last blood results show the following:

Haemoglobin 92 g/L (130-180)

A colonoscopy was organised which features are suggestive of ulcerative colitis. What is the SINGLE most appropriate treatment for his condition?

A 25 year old woman is brought into the Emergency Department after ingestion of 42 paracetamol tablets after receiving news that she failed her medical exams. She is confused and disoriented. She is regretful of her actions. She was admitted in the medical ward and N-Acetylcysteine was given. 24 hours later, her laboratory results show the following:

Serum alanine transferase (ALT) 159 U/L (5-35)

Serum alkaline phosphatase (ALP) 180 U/L (30-150) Arterial pH of 7.2

Serum creatinine 263 μmol/L (70-150)

What is the SINGLE most appropriate management?

A 26 year old man has a history of passing loose stools for the past 2 months. He says his stools contain a small amount of blood and mucous and are associated with abdominal pain. He has around 4 to 5 bowel movements a day. His blood results show ANCA positive and ASCA negative. A colonoscopy was organised and performed after which he was started on treatment. What is the SINGLE most appropriate treatment for his condition?

A 41 year old lady attends the clinic complaining of a long history of mild pruritus and fatigue. She looks jaundiced. Alkaline phosphatase was raised on routine liver function test. She was diagnosed with Sjögren syndrome a few years back. What is the SINGLE most appropriate test to perform to help make a diagnosis?

A 59 year old man has multiple liver metastases with the primary tumour originating from the large bowel. He has abdominal pain and jaundice. On general inspection, he looks cachexic and drowsy. He has significant ascites and oedema seen on both ankles. His family have concerns that he is not having sufficient fluids orally. His urine output is low. He currently takes regular haloperidol 1.5 mg three times a day for nausea and lactulose 10ml twice a day to manage his constipation. His blood test show:

Serum urea 6.2 mmol/L (20-7)

Serum creatinine 85 μmol/L (70-150)

Sodium 129 mmol/L (135-145)

Calcium 2.42 mmol/l (2.1-2.6)

Potassium 3.6 mmol/l (3.5-5)

Albumin 18 g/L (35-50)

Bilirubin 105 μmol/L (3-17)

Alkaline phosphatase (ALP) 411 U/L (30-150)

What is the SINGLE most appropriate management?

An 83 year old woman who is a resident in a nursing home is admitted to a hospital with a 4 day history of diarrhoea. She has had no weight loss or change in appetite. She has been on analgesics for 3 weeks to manage her back pain. She is in obvious discomfort. Rectal examination reveals faecal impaction with hard stools. What is the SINGLE most appropriate immediate management?

A 61 year old woman complains of intermittent chest pain and dysphagia. His symptoms have been gradually worsening over the past 12 months. He also suffers with heartburn and takes regular omeprazole. He had an oesophagogastroduodenoscopy (OGD) 6 months ago which showed evidence of a tortuous oesophagus. A recent barium swallow shows the following 2 images:

What is the SINGLE most likely diagnosis?

A 45 year old man had an endoscopy earlier in the day for investigations for chronic abdominal pain. The next evening, he returns to the hospital with complaints of chest pain and shortness of breath. The pain is worse at the epigastric area and radiates to the interscapular region of the back. His abdomen is soft and non tender. His respiratory rate is 29 breaths/minute, pulse rate is 110 beats/minute, a temperature of 37.8 C and blood pressure is 120/70 mmHg. A chest X-ray reveals mediastinal widening. What is the SINGLE most likely diagnosis?

A 43 year old male alcoholic presents after a large haematemesis. He has some spider naevi on his chest. His blood pressure is 100/76 mmHg and pulse rate is 110 beats/minute. On examination, a swollen abdomen with shifting dullness is seen. What is the SINGLE most likely diagnosis?

A 51 year old man has become increasingly fatigued over the past 10 months. His medical history includes having a gastrectomy a year ago. His physical examination is unremarkable. His blood tests show.

Haemoglobin 85 g/L

White cell count 7 x 10^9/L

Platelets 240 x 10^9/L

Mean cell volume 129 fL

What is the SINGLE most likely finding on a blood smear?

A 46 year old woman presents with a sudden episode of abdominal pain which started about 5 hours ago. The pain is located in the epigastrium and radiates to her back. She has vomited twice since the onset of the attack. The pain is made worse by lying flat on her back and she is more comfortable sitting up and bending forwards. She was informed of the presence of gallstones in her gallbladder four weeks earlier when she reported pain in the right hypochondrium. Her temperature is 38.4°C, blood pressure is 120/85 mmHg, and pulse rate is 115 beats/minute. There is no presence of jaundice but there is marked tenderness in the epigastrium. What is the SINGLE most appropriate investigation?

A 57 year old hospitalized cirrhotic man has abdominal swelling which has slowly worsened over the past three weeks. He has a generalised abdominal pain which has been worsening and developed a fever overnight. An abdominal examination demonstrates rebound tenderness and shifting dullness. His bowel sounds are absent. He has a temperature of 39.5°C and a heart rate of 105 beats/minute. What is the most appropriate investigation?

A 44 year old man started having severe retching and vomiting followed by interscapular and chest pain a few hours following an upper gastrointestinal endoscopy. The following day, he develops a fever. He has a temperature of 38.9°C, respiratory rate of 25 breaths/minute and a heart rate of 110 beats/minute. On examination, he has subcutaneous emphysema on his chest. What is the SINGLE most likely cause of his presentation?

A 47 year old women diagnosed with coeliac at the age of three has recently developed diarrhea and weight loss for the past three months. What is the SINGLE most likely reason for this?

A 34 year old man with long-standing symptoms of gastro-oesophageal reflux disease has an endoscopy which confirms Barret’s oesophagus. What kind of histological change is seen in the mucosal cells lining the lower portion of the oesophagus?

A 38 year old man has worsening abdominal distension over the past year. He has a history of alcohol abuse. His recent blood test show the following:

Bilirubin 80 μmol/L (3-17)

Serum alanine transferase (ALT) 295 U/L (5-35)

Serum alkaline phosphatase (ALP) 305 U/L (30-150)

Gamma glutamyl transferase (GT) 210 U/L (8-60)

Albumin 21 g/L (35-50)

Amylase 110 U/L (0-140)

Spider naevi are noted on his trunk. Paracentesis shows clear fluid with 60 U/L of amylase. He has a temperature of 37.1°C, a pulse of 85 beats/minute, a blood pressure of 130/85 mmHg and a respiratory rate of 21 breaths/minute. What is the SINGLE most appropriate medication to start?

A 28 year old woman has a recent liver screen for hepatitis as her liver function was seen to be elevated. The last liver function test show.

Bilirubin 29 μmol/L (3-17)

Alanine transferase 1020 U/L (5-35)

Aspartate transaminase 250 U/L (5-35)

Alkaline phosphatase 194 U/L (30-150)

Amongst her liver screen results show.

Hepatitis A virus IgG positive

Hepatitis B and C antibody negative

On further questioning, she has had a recent episode of fatigue and tiredness several weeks ago followed by muscle aches. She also feels a dull ache on the right upper quadrant of her abdomen. On examination, her skin appears yellow. Her observations are within normal limits. Which of the following is the most appropriate antibody level to view based on her liver screen results and symptoms?

A 21 year old man has been having abdominal pain over the past 8 months. He complains of mucus in his stools on occasion. He has abdominal bloating on most days. The bloating and abdominal pain is worsened after a meal and relieved by defecation. He has no weight loss. His abdomen is soft and non-tender. What is the SINGLE most likely diagnosis?

A 52 year old smoker complains of trouble swallowing and a burning pain under the sternum which is worse after a large meal. He has a history of a hiatus hernia seen 12 years ago. He takes regular lansoprazole and when the pain is worse, he has to take antacids. He was sent for an endoscopy which reveals inflammatory changes in the lower cesophagus. What is the SINGLE most likely diagnosis?

A 25 year old woman has diarrhoea and abdominal bloating over the last 4 months. On examination, she has blistering rash over her elbows. Her blood test show.

Haemoglobin 105 g/L

Mean cell volume (MCV) 79 fL

On duodenal biopsy, there is shortening of the villi and lymphocytosis. What is the SINGLE most likely diagnosis?

A 58 year old man attends a follow-up visit to discuss his liver function test. He initially presented a week ago, complaining of passing bulky, foul-smelling stool which was difficult to flush for the past four months. He also reports having an intermittent, dull epigastric pain which radiates to his back and has lost 3 kg of weight unintentionally. On further discussion, he mentioned that he was admitted to the hospital four times over the past five years for acute pancreatitis and consumes a battle of vodka every other day with no intention of cutting down. On examination, he appeared mildly icteric and did not have a palpable abdominal mass.

Alkaline phosphatase 100 U/L (30-150)

Alanine transferase 30 U/L (5-35)

Gamma-glutamyl transferase 80 U/L (8-60)

Tissue transglutaminase IgA negative

Which of the following is the most appropriate investigation to perform?

42 year old obese woman presents to the emergency department with a 12 hour history of severe epigastric pain. The pain started suddenly and is seen to radiate to her back. It is relieved when sitting forward. She is nauseous and has vomited twice since the pain started. She drinks ane and a half glasses of wine per day. She has no significant past medical history. She has a pulse rate of 110 beats/minute and is tender in the epigastric region. What is the SINGLE most appropriate investigation?

A 70 year old woman is reviewed following a course of oral clindamycin for a right lower limb cellulitis. She was initially admitted in the hospital for 3 days for the management of her cellulitis as she was unable to weight bear. She was discharged 2 days ago and quickly developed bloody diarrhoea and abdominal pain. She has a temperature of 38.8°C. Her blood tests show:

Haemoglobin 125 g/L (115-160)

White cell count 18 x 10^9/L (4-11)

CRP 160 mg/L (<10)

What is the SINGLE most likely management?

A 32 year old woman complains of brief episodes of severe shooting pain in the rectum that usually occur at night. When the pain occurs, it last for around 5 minutes. She denies any constipation. Rectal examination and flexible sigmoidoscopy detect no abnormalities. What is the SINGLE most probable diagnosis?

A 43 year old lady presents with jaundice. Skin excoriations were seen on physical examination. Blood tests reveal a raised alkaline phosphatase with mildly raised alanine transaminase. Antimitochondrial antibodies are found to be positive. What is the SINGLE most likely diagnosis

A 72 year old man has been having loose stools over the past 5 weeks. He has noticed blood in his stool on several occasions. He has mild generalised abdominal pain most times of the day. On examination, his blood pressure is 130/80 mmHg, heart rate is 80 beats/minute and his temperature is 38.1°C. Abdominal examination reveals generalised tenderness without any palpable masses. A digital rectal examination is unremarkable. What is the SINGLE most appropriate initial investigation?

A 28 year old female presents with a 4 month history of diarrhoea, lethargy and weight loss. She complains of abdominal discomfort and passing stools more than 6 times a day. An endoscopy was performed which shows cobblestone mucosa. What is the SINGLE most likely diagnosis?

A 35 year old female presents with secondary amenorrhoea. Her blood test show the following:

Serum bilirubin 42 μmol/L

Alanine transferase (ALT) 115 iu/L

Aspartate transaminase (AST) 89 iu/L

Alkaline phosphatase (ALP) 189 iu/L

What is the SINGLE most likely diagnosis?

A 21 year old man has been brought to A&E by his friends as he is having a yellow sclera and yellowing of the skin. He has recently been having flu-like symptoms and a non-productive cough. A urine dipstick was performed and was normal. His blood results show:

Haemoglobin 129 g/L Reticulocytes 1.2%

Bilirubin 44 μmol/L

Alkaline phosphatase (ALP) 88

Alanine transferase (ALT) 24

Albumin 42

What is the SINGLE most likely diagnosis?

A 55 year old man with no past medical history comes to your office for the evaluation of “difficulty swallowing” foods. He has had this problem for almost a year and finds it difficult for him to swallow both solids and liquids. A barium meal shows gross dilatation of the oesophagus with a smooth narrowing at the lower end of the oesophagus. What is the SINGLE most likely diagnosis?

A 35 year old man presented to his GP with the complaint of heartburn. This first occurred four weeks ago when he noticed epigastric pain with acid-reflux causing a sour taste in his mouth following a meal. At the time of presentation, he claimed that the only discomfort that he experienced was tenderness and pain in his epigastric region. He complained of no altered bowel habits, sweating, dysphagia or generalised weakness. There was no history of weight loss. He was otherwise fit and well before this episode with no previous history of non-steroidal anti-inflammatory drug (NSAID) use or recent infections. A neighbour advised him to try a popular heartburn remedy so he went to his local pharmacy and tried an over-the-counter heartburn medication (Gaviscon®). This only improved his symptoms minimally. The patient’s past medical history is significant for hypertension, diagnosed two years ago which is now well controlled with medication. He used to drink around two to four cups of coffee per day which he claims he has now reduced to one cup per day. He has no history of smoking and only drinks socially. Following his consultation, the patient was subsequently further investigated for a Helicobacter pylori infection, and the test returned with a positive result. He was started on triple therapy to eradicate his Helicobacter pylori infection and his treatment regimen was successfully completed. He has now returned for a review and states that he is still suffering from heartburn and indigestion. What is the SINGLE most appropriate test to ensure successful eradication of Helicobacter pylori?

A 33 year old pregnant woman develops severe epigastric pain, nausea and vomiting at 35 weeks gestation. She was diagnosed with pre-eclampsia 2 weeks ago. On examination, she has yellow sclerae. Laboratory investigations show a deranged liver function, low platelets, low serum glucose, and raised serum ammonia. What is the SINGLE most likely diagnosis?

A 50 year old man comes to A&E with abdominal pain that began suddenly about 1 hour aga. The pain is now generalized, constant, and extremely severe. He lies motionless on the stretcher, is diaphoretic, and has shallow, rapid breathing. His abdomen is rigid, very tender to deep palpation, and has guarding. X-ray shows free air under the diaphragm. What is the SINGLE most likely diagnosis?

A 52 year old man presents to the Emergency Department with complaints of worsening epigastric and back pain. The pain is episodic and there are times that he is pain-free. He has presented three times to his GP in the past 6 months with generalised abdominal pain. He also complains of having has loose pale, offensive stools. He has lost weight over the past few months which he attributes due to the fear of eating as the pains often worsen after eating. He drinks 25 units of alcohol a week. On examination, he has epigastric tenderness. An X-ray of the abdomen was performed which showed diffuse calcifications in the abdomen. What is the SINGLE most likely diagnosis?

A 33 year old woman has intermittent diarrhoea and abdominal bloating which is usually exacerbated by the consumption of wheat and eggs. She has been feeling more tired in the past few months. She has no significant weight loss. Which condition should be firstly investigated?

A 23 year old female presents with an 8 week history of bloody diarrhoea. She says her bowels have not been right for the past few months and she frequently has to run to the toilet. A diagnosis of ulcerative colitis is made. What is the SINGLE most likely sign to be seen on a barium enema?

A 45 year old woman is brought to the Emergency Department having vomited large amounts of blood over the past hour. She had 3 episodes of vomiting at home and one more episode in the ambulance. Her husband reports that the blood was bright red in colour. She had been diagnosed with rheumatoid arthritis 6 years ago and is being managed an celecoxib. She was otherwise fit and well and tries to maintain a healthy lifestyle. In addition to regular exercise, she neither consumes alcohol nar smokes. On assessment, she has a heart rate of 130 beats per minute and blood pressure of 70/50 mmHg. Which of the following is the most appropriate next step in managing this patient?

A 21 year old female presents to the Emergency Department with the complaint of severe diarrhoea. She says that she opens her bowels in excess of eight times a day for the past week and that she has noticed that her stool is covered in blood yesterday. She is extremely anxious and scared about the fact that she has bloody stools as she is afraid that she could have colon cancer. On further questioning, she reveals that her grandfather passed away five years ago from colorectal carcinoma. She also complains of colicky abdominal pain and an urgency to visit the toilet. Her medical history is significant for ulcerative colitis which she takes sulfasalazine for. On physical examination, the patient appears pale. Examination of her abdomen reveals a tender abdomen with no palpable masses or distention. Her heart rate is 100 beats/minute and temperature is 38°C. What is the SINGLE next best step in this patient’s management?

A 22 year old man presents with a 2-month history of diarrhoea. He has experienced discomfort for the past few months and he frequently runs to the toilet. These symptoms were improving up until two weeks ago when he noticed blood in his stools. On examination, he also had aphthous oral ulcers. He has not lost any weight and has a good appetite. Examination of his abdomen demonstrates mild tenderness in the left lower quadrant but no guarding. What is the SINGLE most likely diagnosis?

A 58 year old man has a history of moderate to severe recurrent epigastric pain at night for the past three months. He has no history of peptic ulcers diagnosed previously and has no previous investigations for dyspepsia. He takes regular ibuprofen over the counter for his knee pain. On examination, he has a tender upper abdomen. His heart rate is 85 beats/minute and blood pressure is 95/65 mmHg. What is the SINGLE most appropriate investigation that would lead to a diagnosis?

A 21 year old woman has been having episodes of diarrhoea for the past 6 months. She complains of abdominal pain and bloating. On occasion, she can have up to 10 episodes of loose stool in a day. She also has a history of recurrent anal fissures. On examination, she has mild generalised abdominal tenderness. There is pain and swelling around the anus. What is the SINGLE most appropriate investigation?

A 15 year old boy has a 5 month history of watery stools and vague intermittent abdominal pain. He has no blood in his stools. On most days, he would defecate 4 times. His weight has dropped from 47 Kg 5 months ago to 43.5 kg currently. On palpation, there is mild tenderness at the right iliac fossa. What is the SINGLE most likely diagnosis?

A 22 year old man is seen in the Emergency Department with shortness of breath and abdominal pain. He has been experiencing bloody diarrhoea over the past week. He has a background of ulcerative colitis. An ECG is performed which shows normal sinus rhythm. His temperature is 39.1°C and his heart rate is 100 beats/minute. An X-ray of his chest and abdomen is seen below:

What is the SINGLE most likely diagnosis?

A 34 year old man presents with slow progressive dysphagia. He has been using H2 blockers for the last year because of retrosternal discomfort. He has not notice any weight loss. A haemoglobin level was done a month ago which reads 13.3g/dL. What is the SINGLE most likely diagnosis?

A 42 year old man with type 2 diabetes presents with fatigue and shortness of breath. He is noted to have a bronze tinge to his skin. Abdominal examination reveals hepatomegaly. His blood test show a high ferritin level. A diagnosis has been made but he is refusing all treatment. Which organ is the most likely to be at risk of developing cancer?

A 15 year old child complains of right iliac fossa pain worsening over the past few weeks. He also has bouts of diarrhoea coming in episodes for more than a year. He has lost 7 kg in the last 5 months. On examination, perianal skin tags were seen. He was subsequently referred to the gastroenterology team. A colonoscopy was performed which showed deep ulcers and skip lesions on the colonic mucosa. What is the SINGLE most appropriate management?

A 22 year old female comes to the GP surgery with complaints of diarrhoea for several months which have been worsening over the past week. She says that she opens her bowels in excess of five times in a day for the past week. She also has recurrent bloating that makes her very uncomfortable, with right sided abdominal pain. The pain is mild and does not interfere with her daily activities, but she is quite concerned about the blood in stools which she noticed this morning. She leads a busy lifestyle, holding down two jobs and has had some recent weight loss which she attributes to stress and poor nutrition. She smokes a pack of cigarettes a day to deal with her stress. There is no significant past medical history. On physical examination, the patient appears pale. Her body mass index is 17 kg/m. On further oral examination, she is noted to have multiple ulcers in her mouth. Abdominal examination reveals distended abdomen, tenderness on right lower quadrant with no palpable masses. What is the SINGLE most likely cause of her condition?

A 43 year lady had endoscopic retrograde cholangiopancreatography for gallstone disease. Twenty-four hours after the procedure she returns to the emergency department with severe right upper quadrant pain. On examination, she appears generally unwell with a pyrexia of 38.9°C. She looks yellow and she is extremely tender in the right upper side of her abdomen. What is the SINGLE most likely diagnosis?

An 8 year old child presents with recurrent abdominal pain. He has had three episodes of abdominal pain within the last 3 months and it is severe enough to affect his activity in school. The abdominal pain is intense and located periumbilically lasting for a few hours and is associated with nausea and episodic headaches. He maintains a good appetite and is an appropriate weight for his age. On examination, there were no significant findings. Full blood count, urea and electrolytes are found to be normal. What is the SINGLE most appropriate next step in management?

A 28 year type 1 diabetic has intermittent diarrhoea and abdominal bloating over the last 6 months. He also complains of feeling tired all the time. His blood results show the following:

Haemoglobin 135 g.L ((130-180 g/L)

Ferritin 30 ng/ml (20-300 ng/ml)

Thyroid stimulating hormone (TSH) 2.5 mU/L (0.5-5.7 mU/L)

Immunoglobulin A (IgA) tissue transglutaminase positive

What is the SINGLE most appropriate next step in action?

A 75 year old man living in a nursing home is taken to the hospital by his nurse. He has been suffering from long standing constipation and has been having difficulty in passing stools for the past 7 days. He appears mildly confused and agitated. He has a heart rate of 110 beats/minute and a respiratory rate of 30 breaths/minute. On rectal examination, faecal impaction is noted. What is the SINGLE most appropriate management?

A 48 year old woman is admitted to A&E with a productive cough and a moderate fever. She complains of central chest pain and regurgitation of undigested food. She finds it difficult to swallow both food and liquids. These symptoms of swallowing have been present for the last 4 months. A chest X-rays shows megaesophagus. What is the most likely diagnosis?

A 50 year old man has severe pain on defecation. On examination, a tender, reddish blue swelling is seen near the anal verge. What is the SINGLE most likely diagnosis?

A 33 year old man attends the GP surgery with a history of 7 days of epigastric pain. He describes it as a burning sensation. He was treated with a Helicobacter pylori eradication regimen 6 weeks ago following an endoscopy which shows a duodenal ulcer with a positive test for helicobacter pylori. He is a non-smoker. What is the SINGLE most appropriate test to ensure successful eradication of Helicobacter pylori?

You are a junior doctor in a busy A&E, a 65 year old male presents with significant hematemesis. Following his resuscitation, you thoroughly examine him. You find he has a distended abdomen, hepatomegaly and ascites. He is also remarkably jaundiced with spider naevi on his chest. He also has evidence of gynaecomastia. He has a significant medical history of chronic heavy alcohol consumption – having drunk on average two 1 litre bottles of whiskey weekly for the past 25 years. His blood results show.

Haemoglobin 120 g/L (130-180 g/L)

Mean cell volume (MCV) 110 FL (76-96 FL)

Gamma-glutamyl transferase 202 U/L (8-60 U/L)

Alanine transferase (ALT) 70 (5-35 U/L)

Aspartate transaminase (AST) 150 (5-35 U/L)

Alkaline phosphatase (ALP) 160 (30-150 U/L)

What is the SINGLE most cause diagnosis?

A 45 year old man complained of epigastric pain and the passage of loose stools for the past 3 months. A full blood count indicated iron deficiency anaemia, prompting the gastroenterologist to perform an endoscopy. The endoscopy revealed multiple ulcers involving the lower oesophagus, stomach, duodenum and proximal jejunum. Which of the following is the SINGLE best initial investigation to determine the cause of the ulcers?

A 33 year old woman presents to the emergency department with right upper quadrant pain for the past 7 days. The pain is constant and gradually worsening over the past few days. The pain radiates to the back and is usually seen to be worse after eating meals. She feels nauseous and has vomited twice today. She has no history of any liver or gallbladder disease. On examination, there are no signs of jaundice. On palpation of the right costal margin at the midclavicular line, her breathing is interrupted due to tenderness. She has a temperature of 37.6°C and a heart rate of 90 beats/minute. Her blood results show:

Haemoglobin 120 g/L

White cell count 13 x 10^9/L

Platelets 350 x 10^9/L

CRP 30 mg/L

Amylase 30 U/L

Bilirubin 59 μmol/L

Alanine transferase (ALT) 189 U/L

Alkaline phosphatase (ALP) 409 U/L

Albumin 39 g/L

What is the SINGLE most likely diagnosis?

A 20 year old man has had on and off bloody diarrhoea for the past 8 weeks. He has abdominal pain and weight loss aver the same period. On examination, there is generalised abdominal tenderness. A biopsy of the rectum was taken during a colonoscopy which reveals granulomatous inflammation. What is the SINGLE most likely diagnosis?

An 65 year old lady had a urinary tract infection which was treated with a 7 day course of broad spectrum antibiotics. A few days later she developed bloody diarrhoea and severe abdominal pain. She has a temperature of 38.6°C and a pulse rate of 90 beats/minute. Her blood tests show:

Haemoglobin 119 g/L (115-160)

White cell count 18 x 10^9/L (4-11)

CRP 180 mg/L (<10)

What is the SINGLE most likely management?

A 31 year old female presented with complaints of chest pain and difficulty in swallowing liquids and solids. Her symptoms have been progressively worsening over the past year. She has also been suffering from recurrent chest infection for the past few months. What is the SINGLE most likely diagnosis?

A 78 year old nursing home resident with a history of dementia has become agitated over the past few days. She has poor oral intake and the nursing staff report that she has not opened her bowels for the past week. She would usually open her bowels once every 2 days. Rectal exam reveals impacted faeces. What is the most appropriate treatment?

A 54 year old man presents with a worsening history of intermittent dysphagia over a period of 6 months. He has not experienced any weight loss and complains of sometimes regurgitating food, after which he says he experiences a feeling of great relief. He has a history of recurrent respiratory tract infections over the past few years. He is a non smoker. What is the SINGLE most likely diagnosis?

A 41 year old man with type 2 diabetes mellitus presents to the clinic with complains of pain in his joints and an unusual increase in breast size. He feels increasingly fatigue aver the past few months. On examination, there is a deep tan colour of his skin and his liver is enlarged on palpation. What is the SINGLE most likely diagnosis?

A 56 year old man has had a history of intermittent epigastric pain at night for the past three month. He has lost 5 kg in weight over the past 3 months unintentionally. He does not take regular medications. He drinks around 20 units of alcohol a week for the past 5 years. He has no palpable abdominal mass on examination and his abdomen is soft and non-tender. What is the SINGLE most appropriate action?

A 32 year old man has had recurrent abdominal bloating and periodic passage of loose stool over the past 6 months. He describes vague abdominal pain which occurs a few times a week. He denies any mucous and blood in the stool. He has no history of any weight loss. His father has gastric cancer. On examination, he has generalized abdominal tenderness with no abnormal palpable masses. What is the SINGLE most likely diagnosis?

A 61 year old man presents with fatigue and palpitations. His past surgical history includes an ileal resection which was performed one year ago. An FBC was requested and the results are as follows:

Haemoglobin 93 g/L

Mean cell volume (MCV) 111 fL

What is the SINGLE most likely diagnosis?

A 64 year old man presents to the clinic with lethargy and a dull pain in the right hypochondrium that has been worsening over the past for a few months. He has significant weight loss over the last several weeks. On examination, he is noted to be have a slight yellow tinge of his skin and whites of his eyes. Abdominal palpation reveals a tender right upper quadrant with a firm, enlarged liver. Further investigations were perform over the next few weeks. The histology of his liver biopsy returns with the report showing evidence of adenocarcinoma and immunostaining of Thyroid transcription factor 1 (TTF-1) which indicates a primary pulmonary tumour. What is the SINGLE most likely route of metastasis in this patient?

A 58 year old man presents with a lump in the left supraclavicular fossa. It has been present for the last 6 months. The lump is firm. He also complains of dyspepsia and loss of weight which he accounts for due to his reduced appetite. What is the SINGLE most likely diagnosis?

What is the pathological change in Barrett’s esophagus?

A 45 year old man had his head of pancreas removed due to malignancy. 10 days later, he complains of worsening abdominal pain. On examination, he has a rigid abdomen which is tender. He has a temperature of 37.5°C, a blood pressure of 95/55 mmHg and pulse rate of 125 bpm. His past medical history includes peptic ulcer disease. What is the SINGLE most appropriate next action?

A 12 year old child complains of right iliac fossa pain and diarrhoea that has worsened over a period of weeks. He was referred to the gastroenterology team for further management. On colonoscopy, a transmural, cobblestone appearance mucosa is seen near the ileo-caecal junction. He does not wish for corticosteroids due to the side effects. Which of the following can be used as monotherapy to induce remission?

A 61 year old man is brought to the Emergency Department with a 2 day history of epigastric pain and constant vomiting. He has been vomiting bright red blood. He has a medical history of rheumatoid arthritis and has been taking naproxen and prednisolone. On examination, he has a very tender epigastrium. His blood pressure is 100/60 mmHg and his heart rate is 101 beats/minute. He was given intravenous fluids. What is the primary diagnostic investigation for this patient?

A 19 year old boy attends the hospital at 7.30 am for his elective oesophago- gastroduodenoscopy. He is scheduled to be first on the theatre list, however, he admits to having eaten a few mint sweets 4 hours ago. He has also taken sips of water an hour ago. What is the SINGLE most appropriate action?

A 44 year old man who has attended the Emergency Department multiple times in the past several months with complaints of upper abdominal pain. He develops episodes of pain lasting for weeks. There has been a gradual rise in his amylase on every visit. He has had a variety of investigations to explore the cause during his previous visits to the department. These included gastroscopy and an ultrasound which was found to be normal. On examination his abdomen is soft and mildly tender at the epigastrium. What is the SINGLE most likely cause of his abdominal pain?

A 28 year old female presents with 1 week history of jaundice, fever and malaise. She was diagnosed with hypothyroidism for which she is receiving levothyroxine. Her blood tests show:

Serum bilirubin 40 μmol/L

Alanine transferase (ALT) 120 iu/L

Aspartate transaminase (AST) 90 iu/L

Alkaline phosphatase (ALP) 200 iu/L

Prothrombin time (PT) 25 sec

What is the SINGLE most likely diagnosis?

A 28 year old man has intermittent diarrhoea, fatigue and weight loss over the last 6 months. He has excluded gluten from his diet in the last 2 months and his symptoms have resolved. He wants to be tested to confirm the diagnosis of coeliac disease. What is the SINGLE most appropriate next step in action?

A 33 year old man is recovering from a major burn injury. He sustained a 40% partial thickness burn during a house fire. He has started vomiting blood and experiencing epigastric pain over the past 24 hours. He has a total estimate of 350 ml of bright red blood seen when vomiting. Intravenous fluids have been started. An endoscopy reveals several gastric ulcers of which endoscopic treatment followed. What is the SINGLE most appropriate management?

A 72 year old woman has severe pain on the lower left abdomen. It started as a gradual ache a week ago but worsened acutely over the past 2 days. Her temperature is 38.6°C, heart rate is 90 beats/minute, and respiratory rate is 19 breaths/minute. On examination, a tender mass is palpable at the left iliac fossa with the presence of guarding. What is the SINGLE most likely diagnosis?

A 23 year old man complains of difficulty swallowing solid food over the past 2 years. It is intermittent and he has an episode once every few days. There is chest pain associated with dysphagia. Occasionally, he would regurgitate food. He has recurrent chest infections. He has no history of weight loss. What is the SINGLE most appropriate initial investigation?

A 20 year old woman with a history of type 1 diabetes presents to her GP complaining of a six week history of intermittent abdominal pain with mild diarrhoea. She also reports fatigue and 8 kg of weight loss over 6 months. She denies any blood in her stool. Examination reveals conjunctival pallor and aphthous ulcers. Which investigation should be considered first?

A 35 year old man presents to his GP surgery with a history of dyspepsia intermittently for the past 3 months. Serum antibodies for Helicobacter Pylori were seen to be negative a month ago. There has been no improvement with his symptoms despite taking a proton pump inhibitor for the past 1 month. He reports no weight loss or blood in his stools. There is no previous history of non-steroidal anti-inflammatory drug (NSAID) use. He does not smoke. He drinks a cup of coffee a day. An abdominal examination reveals slight tenderness at the epigastric region without a mass felt. What is the SINGLE most appropriate next step?

A 38 year old man complains of “crushing” chest discomfort for 1 hour that started when he drank a cold drink. He has no significant medical history. ECG shows sinus rhythm. He is given sublingual nitroglycerin in the emergency room that improves his chest pain almost immediately. He has a pulse of 70 beats/minute, a blood pressure of 130/80 mmHg and a respiratory rate of 18 breaths/minute. Cardiac enzymes came back negative. What is the SINGLE most likely diagnosis?

A 39 year old woman is admitted with central abdominal pain radiating through to the back. She has vomited several times in the last 24 hours. She denies any diarrhoea.. Bending forward helps alleviate the pain. On examination, there is epigastric tenderness associated with guarding. She has a blood pressure of 100/70 mmHg, a respiratory rate of 20 breaths/minute, a pulse rate of 106 beats/minute and a temperature of 37.9°C. Her blood test show.

Amylase 1335 U/mL

CRP 214 mg/L

White cell count (WCC) 19.6 x 10^9/L

What is the SINGLE best step in management?

A 69 year old smoker has had increasing dysphagia when eating solid food which has been on going for the past 3 months. He has noticed a drop of 8 kg in weight in the past few months. He now finds drinking fluids difficult. What SINGLE investigation is most likely to lead to a diagnosis?

A 45 year old smoker has suspected oesophageal carcinoma with a mass seen within the middle third of the oesophagus with metastasis to the liver. He has severe dysphagia which has worsened over the past few months since his diagnosis. What is the SINGLE most appropriate management to treat his symptoms?

A 55 year old man develops fatigue and palpitations. He had a gastrectomy a years ago. Recent blood test were ordered which shows:

Haemoglobin 98 g/L

Mean cell volume (MCV) 110 L

On neurological examination, loss of proprioception and vibration sense were noted. What is the SINGLE most likely diagnosis?

A 48 year old female presents with tiredness and painless dysphagia. She complains of a feeling of something stuck in her throat. A full blood count shows microcytic hypochromic anaemia. On examination, glossitis is noted. An oesophageal web is found at the post cricoid region. What is the SINGLE most likely diagnosis?

A 36 year old woman presents with the complaint of a right-sided abdominal pain which began two days ago. She also complains that she has been feeling drained, with a generalised body ache, joint pains and feeling nauseated for the past ten days. She vomited twice this morning and at least thrice over the past few days. She noticed that her urine is darker than usual, and her stool appears somewhat pale, which was never the case in the past. She does not have a past medical history of note, and apart from social drinking, she neither smokes nor uses recreational drugs. Furthermore, she did not travel overseas in the recent past, and her only outing was a date to a seafood restaurant about a month ago. Her partner also developed similar symptoms two days ago. On examination, she is icteric with a temperature of 38°C, blood pressure of 110/80 mmHg and a heart rate of 110 beats/minute. On examination of the abdomen, a few scratch marks are noted, and she admits to having itchiness. Additionally, an enlarged and tender liver is palpable. A liver function test is requested, and the results are as follows.

Bilirubin 30 μmol/L (3-17)

Alanine transferase 1100 U/L (5-35)

Aspartate transaminase 350 U/L (5-35)

Alkaline phosphatase 180 U/L (30-150)

Which of the following is the most appropriate investigation to request?

A 31 year old man complains of intermittent episodes of sudden chest pain associated with dysphagia lasting for a few hours that started 3 weeks ago. The pain is described as crushing and occurs in the lower substernal area, especially when swallowing a large amount of water. There is occasional regurgitation of undigested food. His ECG done on 2 occasions has been shown to be normal. Which is the best investigation to diagnose the condition?

A 66 year old has been having progressive symptoms of difficulty swallowing solid foods over the past 3 months. Over the past few weeks, he also has difficulty swallowing liquids. He starts to cough and choke when he drinks fluids. He has lost 9 kg over the past 2 months. Which is the most likely diagnosis?