Abdominal

Question 1

A 52-year-old man presents with a 6-month history of heartburn and atypical chest pain, both unrelated to food. He also described ‘gurgling’ sounds in his chest. A month before presentation he developed intermittent dysphagia to both solids and liquids, regurgitation, and weight loss of 3 kg.

Answer 1

Achalasia

Question 2

A 65-year-old woman presents to the emergency department with a 2-day history of progressive RUQ pain that she rates as 9/10. She reports experiencing fever, and being unable to eat or drink due to nausea and abdominal pain at baseline, exacerbated by food ingestion. Her bowel movements are less frequent and have started to become loose but with no diarrhoea, bright red blood, or black tarry stools. Her pain is not relieved by bowel movement and is not related to food. She has not recently taken antibiotics, nor does she use non-steroidal anti-inflammatory drugs (NSAIDs) or drink alcohol. On examination, she is febrile at 39.4°C (102.9°F); supine BP is 97/58 mmHg; standing BP is 76/41 mmHg; HR is 127 bpm; and respiratory rate is 24 breaths per minute with normal oxygen saturation. Her examination is remarkable for scleral and sublingual icterus, tachycardia, RUQ pain with no rebound, and involuntary guarding on the right side. Faecal occult blood test is negative.

Laboratory results show a WBC of 18.0 x 10^9/L (reference range 4.8-10.8 x 10^9/L)

AST is 207 units/L (reference range 8-34 units/L),

ALT is 196 units/L (reference range 7-35 units/L),

alkaline phosphatase is 478 units/L (reference range 25-100 units/L),

total bilirubin is 107.7 micromol/L (6.3 mg/dL) (reference range 3.4-22.2 micromol/L or 0.2-1.3 mg/dL),

and amylase is 82 units/L (53-123 units/L).

Answer 2

Ascending cholangitis

Question 3

A 50-year-old man presents to his general practitioner with complaints of fatigue for 2 months. The patient also notes distension of his abdomen and shortness of breath beginning 2 weeks ago. His wife reports that the patient has been having episodes of confusion lately. The patient has a significant medical history of chronic heavy alcohol consumption of about half a pint of vodka daily for around 20 years. On physical exam the patient is noted to have scleral icterus, tremors of both hands, and spider angiomata on the chest. There is abdominal distension with presence of shifting dullness, fluid waves, and splenomegaly. Laboratory examination shows low haemoglobin, low platelets, low sodium, AST elevation > ALT elevation, and high PT and INR. Ultrasound of the abdomen shows liver hyperechogenicity, portal hypertension, splenomegaly, and ascites.

Answer 3

Alcoholic liver disease

Question 4

A 28-year-old woman presents with a history of severe pain on defecation for the last 3 months. She has noticed a small amount of blood on the stool. The pain is severe and she is worried about the pain she will experience with the next bowel action.

Answer 4

Anal fissure

Question 5

A 22-year-old male presents to the emergency department with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing. Physical examination reveals a low-grade fever (38°C; 100.5°F), pain on palpation at right lower quadrant (McBurney’s sign), and leukocytosis (12 x 10^9/L or 12,000/microlitre) with 85% neutrophils

Answer 5

Appendicitis

Question 6

A 45-year-old woman presents with insidious onset of fatigue, malaise, lethargy, anorexia, nausea, abdominal discomfort, mild pruritus, and arthralgia involving the small joints. Her past medical history includes coeliac disease. Physical examination reveals hepatomegaly and spider angiomata.

Answer 6

Autoimmune hepatitis

Question 7

A 55-year-old obese man presents with frequent heartburn. He describes retrosternal burning, associated with fatty, spicy meals. This heartburn frequently wakes him from sleep, with occasional coughing. He has tried many OTC antacids, which relieve symptoms in the short term. He has suffered from this symptom for many years; in fact, he cannot recall when he did not have heartburn. He denies dysphagia or weight loss. He reports that his voice becomes hoarse the morning after a night of heartburn with coughing, but he denies other respiratory symptoms. His past medical history is significant only for HTN. His family history is unremarkable. He did smoke, but stopped 5 years ago.

Answer 7

Barrett’s

Question 8

A 20-year-old obese woman with a 2-year history of gallstones presents to the emergency department with severe, constant RUQ pain, nausea, and vomiting after eating fried chicken for dinner. She denies any chest pain or diarrhoea. Three months ago she developed intermittent, sharp RUQ pains. On physical examination she has a temperature of 38°C (100.4°F), moderate RUQ tenderness on palpation, but no evidence of jaundice.

Answer 8

Cholecystitis

Question 9

A 56-year-old man with a remote history of intravenous drug use presents to an initial visit complaining of increased abdominal girth but denies jaundice. He drinks about 2 to 4 glasses of wine with dinner and recalls having had abnormal liver enzymes in the past. Physical examination reveals telangiectasias, a palpable firm liver, mild splenomegaly, and shifting dullness consistent with the presence of ascites. Liver function is found to be deranged with elevated aminotransferases (AST: 90 U/L, ALT: 87 U/L).

Answer 9

Cirrhosis

Question 10

A 46-year-old woman presents with fatigue and is found to have iron deficiency with anaemia. She has experienced intermittent episodes of mild diarrhoea for many years, previously diagnosed as irritable bowel syndrome and lactose intolerance. She has no current significant gastrointestinal symptoms. Examination reveals 2 oral aphthous ulcers and pallor. Abdominal examination is normal and results of faecal testing for occult blood are negative.

Answer 10

Coeliac disease

Question 11

A 25-year-old white man presents to his general practitioner with cramping abdominal pain for 2 days. He reports having loose stools and losing 6.8 kg over a 3-month duration. He also reports increased fatigue. On physical examination, his temperature is 37.6°C (99.6°F). Other vital signs are within normal limits. Abdomen is soft with normal bowel sounds and moderate tenderness in the left lower quadrant, without guarding or rigidity. Rectal examination is normal and the stool is guaiac positive. The rest of the examination is unremarkable.

Answer 11

Crohn’s

Question 12

A 57-year-old female with history of hypertension and hypercholesterolaemia presents to the emergency department with a 24-hour history of gradually worsening left-lower quadrant abdominal pain associated with nausea and vomiting. Prior to this episode, the patient did not have any significant GI problems, except slight constipation and occasional dyspepsia after heavy meals. She felt feverish but did not take her temperature. Her family history is negative for GI disorders.

Answer 12

Diverticular disease

Question 13

A 42-year-old woman has heartburn after meals and a sour taste in her mouth. For the past 4 to 6 months she has had symptoms several times per week. Symptoms are worse when she lies down or bends over. Antacids help somewhat. The patient has no dysphagia, vomiting, abdominal pain, exertional symptoms, melaena, or weight loss. Past medical history and family history are non-contributory. The patient drinks alcohol occasionally and does not smoke. On physical examination, height is 1.63 m (5 feet 4 inches), weight 77.1 kg, and BP 140/88 mmHg. The remainder of the examination is unremarkable.

Answer 13

GORD

Question 14

A 42-year-old man presents with a 48-hour history of bloody diarrhoea. He has been opening his bowels 6 to 8 times per day, and has associated nausea, lethargy, and generalised abdominal discomfort. There is no recent travel history. He lives with his wife and 2 children, who are all well. They had a meal in a restaurant 5 days ago, when he ate a beef burger and French fries. A friend who was with them ate the same meal and has developed similar symptoms. Exam shows a low-grade pyrexia (37.5°C [99.5°F]) but is otherwise unremarkable. FBC reveals a raised white cell count (15,000/mm^3). Stool culture results are available 3 days later and are positive for Escherichia coli, and serotyping confirms the presence of E coli O157:H7.

Answer 14

Gastroenteritis

Question 15

A 42-year-old man presents to his primary care physician complaining of a 3-month history of lower intestinal bleeding. He describes the bleeding as painless, bright blood appearing on the tissue following a bowel movement. He has had 2 episodes recently where blood was visible in the toilet bowl following defecation. He denies any abdominal pain and any family history of GI malignancy. Physical examination reveals a healthy man with the only finding being bright blood on the examining finger following a digital rectal examination.

Answer 15

Haemorrhoids

Question 16

A 51-year-old man with moderate obesity (BMI of 34 kg/m^2) is seen in consultation for heartburn and regurgitation. He ha a diagnosis of GORD and has been treated with proton-pump inhibitors. His heartburn is less severe with the medication, but he is still bothered by regurgitation. His physical examination is unremarkable. A barium oesophagram and upper endoscopy demonstrate a type I (sliding) hiatal hernia, with about one third of the upper stomach in the chest. The patient has free reflux to the level of the cervical oesophagus.

Answer 16

Hiatus hernia

Question 17

A 6-month-old healthy girl presents with a bulge at her umbilicus that her parents have noticed since birth. She has no accompanying symptoms and has been growing and developing normally. Physical examination of the abdomen reveals a soft, non-tender bulge at the umbilicus that is easily reduced into the peritoneal cavity with gentle pressure. Reduction allows palpation of the abdominal fascia, revealing an 8 mm fascial defect.

Answer 17

Umbilical hernia

Question 18

A 68-year-old retired labourer presents to his primary medical doctor with a 3-week history of a dull dragging discomfort in his right groin toward the end of the day. The discomfort is associated with a lump while standing but disappears when lying supine. He denies any other significant past medical or surgical history. On physical examination, a bulge is present when standing that disappears when supine.

Answer 18

Inguinal hernia

Question 19

A 72-year-old white man presents with a 5-day history of abdominal pain, nausea, severe diarrhoea, fever, and malaise. He was started on levofloxacin for community-acquired pneumonia 2 weeks prior with resolution of his pulmonary symptoms. Examination reveals a fever of 38.3°C (101°F) and mild abdominal distension with minimal tenderness. Laboratory tests reveal a peripheral WBC of 12,000/mm^3 and stool guaiac mildly positive for occult blood.

Answer 19

Infective/pseudomembranous colitis

Question 20

A 72-year-old male presents to the emergency department with sudden-onset, diffuse abdominal pain that began 18 hours ago. He has not been vomiting, but he has had several episodes of diarrhoea, the last of which was bloody. He was hospitalised 1 week ago for an acute MI.

Answer 20

Ischaemic colitis

Question 21

A 34-year-old mother of 3 presents to her family physician with a 3-week history of abdominal cramping pain in both lower quadrants. She has been having frequent small, soft stools accompanied by some mucus but no blood. Her symptoms are improved with bowel movement or passage of flatus. She has had these symptoms almost monthly since she was in college, but they have been worse recently. Past history is negative except for 3 normal pregnancies. Family history is negative for colon cancer. A sister has similar symptoms but has not seen a physician. Personal/social history reveals that she is an accountant working long hours. Her firm is about to merge with another, and she fears her job situation is tenuous. Review of systems is otherwise negative. She has not lost any weight or had any other constitutional symptoms. On physical examination, the only finding is some mild tenderness in the RLQ. No mass is felt.

Answer 21

Irritable bowel syndrome

Question 22

A healthy 55-year-old man presents with a 1-week history of fevers, chills, fatigue, and anorexia, followed by right shoulder pain, paroxysmal cough, and generalised abdominal pain. He is ill-appearing, and his physical examination is notable for a temperature of 38.3°C (101°F) and a tender liver edge that is palpated approximately 2 cm below the right costal margin. Percussion or movement worsens the pain.

Answer 22

Liver abscess

Question 23

A 48-year-old woman with a history of migraine headaches presents to the emergency department with altered mental status over the last several hours. She was found by her husband, earlier in the day, to be acutely disorientated and increasingly somnolent. On physical examination, she has scleral icterus, mild right upper quadrant tenderness, and asterixis. Preliminary laboratory studies are notable for a serum ALT of 6498 units/L, total bilirubin of 95.8 micromol/L (5.6 mg/dL), and INR of 6.8. Her husband reports that she has consistently been taking pain medications and started taking additional 500-mg paracetamol (acetaminophen) pills several days ago for lower back pain. Further history reveals a medication list with multiple paracetamol-containing preparations.

Answer 23

Acute liver failure

Question 24

A 53-year-old man presents to the emergency department complaining of severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forwards or assumes the fetal position and worsens with deep inspiration and movement. He also complains of nausea, vomiting, and anorexia, and gives a history of heavy alcoholic intake this past week. He is tachycardic, tachypnoeic, and febrile with hypotension. He is slightly agitated and confused. He is diaphoretic with decreased breath sounds over the base of the left lung.

Answer 24

Acute pancreatitis

Question 25

A 41-year-old alcoholic man has a 6-year history of recurrent attacks of pancreatitis characterised by epigastric pain radiating to the back. The initial attack required hospitalisation for severe pain, and clinical chemistry showed a >15-fold elevation in serum amylase and lipase. Subsequent attacks were less severe, managed primarily as an outpatient, and lasted less than 10 days, with long symptom-free intervals. After detoxification 6 months ago he had no further attacks, but has recently developed evidence of diabetes and steatorrhoea. CT imaging shows pancreatic calcifications but no cystic or mass lesions.

Answer 25

Chronic pancreatitis

Question 26

A 42-year-old man presents with a recent history of abdominal pain, distension, and nausea. Urea breath testing for Helicobacter pylori is positive.

Answer 26

Gastritis

Question 27

A 40-year-old man presents to his primary care physician with a 2-month history of intermittent upper abdominal pain. He describes the pain as a dull, gnawing ache. The pain sometimes wakes him at night, is relieved by food and drinking milk, and is helped partially by ranitidine. He had a similar but milder episode about 5 years ago, which was treated with omeprazole. Physical examination reveals a fit, apparently healthy man in no distress. The only abnormal finding is mild epigastric tenderness on palpation of the abdomen.

Answer 27

Peptic ulcer

Question 28

A 50-year-old woman undergoing health screening is found to have a cholestatic pattern on her LFT results. Her alkaline phosphatase and gamma-GT concentrations are elevated, although transaminases, bilirubin, and albumin concentrations are normal. On questioning she mentions that she had been getting increasingly tired over the past few years but felt that this was simply a result of her age and work pattern. She also describes occasional itch that feels as if it is deep underneath the skin and that is not associated with a rash. She had no other past medical history but had a family member who had autoimmune thyroid disease. Clinical examination reveals no abnormal findings other than excoriations related to itch and xanthelasmata around the eyes.

Answer 28

PBC

Question 29

A 43-year-old man with a history of mild ulcerative colitis is noted to have an elevated serum alkaline phosphatase, slightly elevated aminotransferases, and normal bilirubin on routine laboratory testing. He complains of fatigue and upper abdominal pain. He denies pruritus or fevers. Physical examination is unremarkable.

Answer 29

PSC

Question 30

A 34-year-old man presents 2 weeks after returning from a month-long trip to India. He denies attending pre-travel vaccination clinic and did not take prophylaxis of any sort while in India. He reports a 6-day history of malaise, anorexia, abdominal pain, nausea with emesis, and dark urine. He admits to dietary indiscretion and consumed salad at a road-side vendor 3 weeks before onset of symptoms. On examination there is icterus. His ALT is 5660 units/L, and total bilirubin 153.9 micromols/L (9 mg/dL). Serum IgM anti-hepatitis A virus (HAV) antibodies are detected.

Answer 30

Hep A

Question 31

A 50-year-old man presents with 5 to 6 months of gradually worsening abdominal swelling, intermittent haematemesis, and dark stool. He denies chest pain or difficulty breathing. Past medical and family history are not contributory. Past surgical history is significant for back surgery requiring blood transfusion in 1980. Social history is significant for occasional alcohol use. BP is 110/80 mmHg. Physical examination is significant for spider angiomata on the upper chest, gynaecomastia, caput medusae, and a fluid wave of the abdomen. The rest of the examination is normal.

Answer 31

Hep. C

Question 32

A 40-year-old asymptomatic man presents for a routine visit with elevated ALT level (55 international units [IU]/mL). His mother died of hepatocellular carcinoma and he has a middle-aged sister with “hepatitis B infection”. He has a normal physical examination and has no chronic stigmata of liver disease.

Answer 32

Hep. B