KFP – Gastrointestinal health

Brenton Wallace, aged 47, presents to your clinic with a 4-week history of worsening upper abdominal discomfort described as a burning pain in the epigastric area, especially after meals. He reports occasional nausea but no vomiting or weight loss. He has been using over-the-counter antacids with some relief. He drinks two coffees per day, does not smoke, and drinks 4–6 standard drinks on weekends. He denies NSAID use. There is no history of gastrointestinal malignancy in the family. He works as a sales manager and reports significant stress lately due to a company restructure.

Medications: Nil regular

Allergies: Nil known

Past history: Unremarkable

Social history: Lives with partner, two teenage children. Moderate alcohol consumption. Sedentary lifestyle.

Examination findings: Mild epigastric tenderness on palpation. No guarding or rebound. Bowel sounds present and normal. No hepatosplenomegaly. Vitals stable.

Investigations: FBC, LFTs, lipase and coeliac serology all within normal range. H. pylori stool antigen test pending.

What are the most appropriate next steps in Brenton’s management? Select three (3) from the following list:

Sarah Langford, aged 31, presents with a 24-hour history of increasing right lower quadrant abdominal pain. She describes the pain as dull initially but now sharp and constant. She reports associated nausea and anorexia but no vomiting or diarrhoea. She is not sexually active and has had no recent travel. Her last menstrual period was two weeks ago. She denies any urinary symptoms or vaginal discharge.

Medications: Nil regular

Allergies: Nil known

Past history: Appendectomy at age 12

Family history: Father with colorectal cancer at age 60

Social history: Office worker, lives alone, non-smoker

Examination findings: Temperature 37.8°C, HR 92, BP 118/74, RR 16, SpO2 99% RA. Localised right iliac fossa tenderness with mild guarding, no rebound tenderness. No palpable masses. Bowel sounds normal.

Investigations: Urine dipstick: normal. FBC: WCC 11.5 (4.0–11.0 x10⁹/L), neutrophils 8.2 (2.0–7.5 x10⁹/L), CRP 22 mg/L (<5). Serum beta-HCG: negative.

What are the most appropriate next steps in her management? Select three (3) from the following list:

Naomi Fraser, a 62-year-old woman, presents with a 3-month history of intermittent diarrhoea and unintentional weight loss of 6 kg. She reports bloating, crampy abdominal discomfort, and fatigue. The diarrhoea is non-bloody, occurring 3–4 times per day, and not related to specific meals. She denies fever, nausea, or vomiting. There is no recent travel, no known sick contacts, and she has not taken antibiotics recently.

Medications: Perindopril 5 mg daily, atorvastatin 20 mg daily

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia

Family history: Mother had rheumatoid arthritis; no family history of bowel cancer or IBD

Social history: Retired schoolteacher, lives with husband, non-smoker, drinks one glass of wine most evenings

Examination findings: BMI 20.8 kg/m². Abdomen soft, mild diffuse tenderness, no masses, no hepatosplenomegaly. No signs of anaemia or thyroid disease. PR exam: normal stool, no blood or masses.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Andrew Hollis, a 54-year-old man, presents with a 2-month history of increasing fatigue and intermittent right upper quadrant discomfort. He denies nausea, vomiting, or weight loss. He has noted dark urine and pale stools for the last week. There is no fever. He drinks approximately 6–8 standard drinks of alcohol daily and has done so for over 15 years. He smokes 10 cigarettes per day. He has not travelled recently and is not on any regular medications. He is unaware of any family history of liver disease.

Medications: Nil

Allergies: Nil known

Past history: Nil of note

Social history: Lives alone, works part-time as a taxi driver

Examination findings: Appears mildly jaundiced. No flapping tremor. Abdomen soft with mild hepatomegaly, non-tender. No ascites. Spider naevi present on chest.

Investigations:

What are the most appropriate next steps in management? Select four (4) from the following list:

Rania El-Sayed, a 28-year-old woman, presents with a 6-week history of loose, bulky stools and abdominal bloating. She reports increased flatulence and an unintentional weight loss of 4 kg. She describes her stools as pale and foul-smelling. She is otherwise well and has no nausea or vomiting. She has recently returned from a backpacking trip through Southeast Asia and reports drinking untreated water on occasion.

Medications: Nil

Allergies: Nil known

Past history: Nil of note

Social history: Vegetarian, non-smoker, occasional alcohol

Examination findings: BMI 19 kg/m². Mild abdominal distension. No tenderness or organomegaly. No peripheral signs of chronic disease.

Investigations: FBC: Hb 128 g/L, MCV 86 fL; CRP <5 mg/L; Coeliac serology: negative; Stool microscopy: pending

What are the most appropriate next steps in her investigation and management? Select three (3) from the following list:

Tommy Duong, aged 72, presents with a 3-month history of increasing early satiety, anorexia, and a 5 kg weight loss. He reports occasional nausea but no vomiting. His bowel habits have changed from daily formed stools to looser stools every second day. He has also noticed a vague epigastric discomfort, worse after meals. He denies any overt gastrointestinal bleeding or melaena. There is no family history of gastrointestinal malignancy. He is an ex-smoker with a 30-pack-year history, quitting 10 years ago.

Medications: Aspirin 100 mg daily, atorvastatin 40 mg daily, amlodipine 5 mg daily

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia, mild osteoarthritis

Social history: Lives with wife, independent with ADLs

Examination findings: Thin, BMI 20.1 kg/m². Mild epigastric tenderness on deep palpation. No palpable masses or hepatosplenomegaly. No lymphadenopathy or jaundice.

Investigations:

What are the most appropriate next steps in management? Select four (4) from the following list:

Emily Tran, aged 22, presents with a 2-month history of intermittent lower abdominal pain and bloating associated with altered bowel habits. She describes periods of diarrhoea alternating with constipation. The pain is relieved by defecation. She denies any weight loss, rectal bleeding, or nocturnal symptoms. She feels increasingly anxious about the unpredictability of her bowel habits, which are impacting her studies.

Medications: Combined oral contraceptive pill

Allergies: Nil known

Past history: Nil significant

Family history: Mother has coeliac disease. No family history of colorectal cancer.

Social history: University student, non-smoker, occasional alcohol. Balanced diet. No recent travel.

Examination findings: BMI 22. Abdominal examination: mild lower abdominal tenderness without guarding or masses. Normal bowel sounds.

Investigations: FBC, CRP, coeliac serology, and TSH all normal. Faecal calprotectin <50 µg/g.

What are the most appropriate next steps in management? Select three (3) from the following list:

George Sotiropoulos, aged 66, presents for evaluation of persistent reflux symptoms despite regular over-the-counter antacids. He describes burning retrosternal discomfort after meals and frequent regurgitation, particularly when lying down. He has also experienced nocturnal coughing and a hoarse voice in the mornings. He denies dysphagia, weight loss, vomiting, or bleeding. He has had these symptoms for several years, but they have worsened over the past six months.

Medications: None

Allergies: Nil known

Past history: Hypertension (controlled with lifestyle)

Family history: Father had peptic ulcer disease; no known cancer

Social history: Retired, BMI 29, non-smoker, drinks wine with dinner most nights

Examination findings: Normal

What are the most appropriate next steps in management? Select three (3) from the following list:

Layla Karim, a 35-year-old woman, presents with a 6-week history of rectal bleeding, mucus in stools, and lower abdominal cramping. She reports loose bowel motions up to five times per day, often associated with urgency and tenesmus. She denies recent travel or antibiotic use. There has been no weight loss or fever. She is otherwise well and has no significant past history.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Sister has Crohn’s disease

Social history: Works in childcare, non-smoker, does not drink alcohol

Examination findings: Mild lower abdominal tenderness, no mass or rebound. No perianal disease. PR exam: small amount of fresh blood and mucus, no mass.

Investigations: FBC: Hb 118 g/L, MCV 88 fL; CRP: 15 mg/L; Stool culture: negative; Faecal calprotectin: 486 µg/g

What are the most appropriate next steps in her investigation and management? Select three (3) from the following list:

Daniel Kowalski, a 49-year-old man, presents with a 6-month history of episodic upper abdominal pain and nausea, often occurring at night or when meals are delayed. He describes the pain as a burning sensation relieved by eating or taking antacids. He reports occasional bloating but no vomiting or weight loss. There is no dysphagia or gastrointestinal bleeding. He has a stressful job in finance and smokes 10 cigarettes per day.

Medications: Occasional ibuprofen for back pain

Allergies: Nil known

Past history: Nil significant

Family history: Father had peptic ulcer disease

Social history: Works full time, drinks 2–3 standard drinks on weekends, poor diet, smoker

Examination findings: Unremarkable; abdomen soft and non-tender

Investigations:

What are the most appropriate next steps in his management? Select three (3) from the following list:

Margaret Devlin, a 77-year-old woman, is brought in by her daughter due to progressive confusion and drowsiness over the past 3 days. Her daughter reports that Margaret has a known history of liver cirrhosis related to non-alcoholic fatty liver disease and had been increasingly lethargic over the past week. She also noted a recent episode of constipation. Margaret has not had any melena or vomiting. There is no history of recent infections.

Medications: Spironolactone 25 mg daily, frusemide 20 mg daily

Allergies: Nil known

Past history: Type 2 diabetes, cirrhosis (Child-Pugh B)

Family history: Non-contributory

Social history: Retired teacher, lives with daughter

Examination findings: Drowsy but rousable, oriented to person only. Flapping tremor (asterixis) present. Abdomen distended with shifting dullness. No focal neurological signs. Vitals: HR 92, BP 108/65, T 36.9°C, SpO₂ 97% RA.

Investigations: BSL 6.4 mmol/L, UEC: Na 132, K 4.1, Urea 9.2, Creatinine 100. LFTs stable from baseline. INR 1.6. Serum ammonia: elevated.

What are the most appropriate next steps in management? Select three (3) from the following list:

Sophia Marinos, a 41-year-old woman, presents with persistent upper abdominal pain for the past 3 months. She describes the pain as dull and constant, localised to the epigastric area and radiating to the back. The pain is worse after meals and partially relieved by leaning forward. She has also experienced intermittent nausea and has unintentionally lost 4 kg. She has no vomiting or changes in bowel habits. She reports a history of recurrent episodes of ‘indigestion’ over the past few years.

Medications: None

Allergies: Nil known

Past history: Gallstones diagnosed 5 years ago; not treated surgically

Social history: Smokes 10 cigarettes per day, drinks 3–4 standard drinks on weekends, works as a chef

Examination findings: Epigastric tenderness on deep palpation, no guarding or masses. No jaundice or hepatomegaly.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Michael Hadid, a 68-year-old man, presents with a 3-month history of increasing difficulty swallowing solid foods, which has now progressed to include some difficulty with liquids. He also reports unintentional weight loss of 6 kg and intermittent chest discomfort not related to exertion. He denies vomiting, odynophagia, or gastrointestinal bleeding. He has a 40-pack-year smoking history and drinks 2–3 standard drinks per night.

Medications: Atorvastatin 20 mg daily

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Family history: Non-contributory

Social history: Retired truck driver, lives with partner

Examination findings: Thin, BMI 21 kg/m². No lymphadenopathy. Cardiorespiratory and abdominal exams unremarkable.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Alice Bennett, a 30-year-old woman, presents with a 4-week history of perianal discomfort, anal pruritus, and occasional bright red blood on toilet paper. She describes the bleeding as small amounts with defecation and denies any mucus, weight loss, or change in bowel habits. She has a history of constipation, often straining to pass hard stools. No family history of bowel cancer or inflammatory bowel disease.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works as a lawyer, mostly sedentary, non-smoker, drinks socially

Examination findings: Perianal inspection reveals a skin tag and a small posterior anal fissure. Digital rectal exam is mildly tender with no mass or blood. No external haemorrhoids or fistulae noted.

What are the most appropriate next steps in management? Select three (3) from the following list:

David McKenna, a 60-year-old man, presents with a 3-month history of persistent bloating, early satiety, and mild nausea. He also reports a sensation of abdominal fullness after small meals and has noticed a 3 kg weight loss. He denies vomiting, reflux, or changes in bowel habits. He has type 2 diabetes mellitus, diagnosed 15 years ago, with suboptimal glycaemic control (recent HbA1c 8.5%).

Medications: Metformin 1000 mg BD, gliclazide MR 60 mg daily

Allergies: Nil known

Past history: Diabetic retinopathy, peripheral neuropathy

Family history: Father had type 2 diabetes

Social history: Retired electrician, lives with wife, moderate alcohol use, non-smoker

Examination findings: BMI 28. Abdomen soft with epigastric fullness but no tenderness or mass. No signs of organomegaly. Bowel sounds present.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Elena Rossi, a 45-year-old woman, presents with a 2-month history of intermittent abdominal pain, bloating, and loose stools occurring several times a week. She describes the pain as crampy and generalised, often triggered by meals, and relieved by defecation. She denies weight loss, rectal bleeding, or nocturnal symptoms. She became vegan 6 months ago. She reports fatigue and occasional mouth ulcers. She has not travelled recently and is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Nil of note

Family history: Mother with rheumatoid arthritis

Social history: Office worker, non-smoker, no alcohol, strict vegan

Examination findings: Pale conjunctivae, no lymphadenopathy. Abdominal exam: mild diffuse tenderness without peritonism or masses.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Ruben Singh, a 52-year-old man, presents with a 6-month history of episodic upper abdominal pain and nausea. The pain is described as a deep, gnawing ache that occurs about an hour after meals and occasionally wakes him at night. He has also noticed black, tarry stools on two occasions over the past fortnight. He takes ibuprofen regularly for chronic lower back pain. He has not sought medical attention until now.

Medications: Ibuprofen 400 mg TDS (self-prescribed)

Allergies: Nil known

Past history: Nil significant

Family history: Father died of myocardial infarction, no GI malignancy

Social history: Works as a mechanic, non-smoker, drinks 1–2 beers most nights

Examination findings: Pale, BP 108/72 mmHg, HR 94 bpm, conjunctival pallor. Abdomen soft with mild epigastric tenderness. PR exam reveals melaena.

Investigations:

What are the most appropriate next steps in management? Select four (4) from the following list:

Fatima Hussein, a 58-year-old woman, presents with increasing abdominal distension and early satiety over the past two months. She also reports vague lower abdominal discomfort and a 4 kg weight loss. Her bowel habits are normal and she denies nausea, vomiting, or rectal bleeding. She has a history of endometriosis in her 30s and underwent a hysterectomy at age 45.

Medications: Ezetimibe 10 mg daily

Allergies: Nil known

Past history: Endometriosis, hypercholesterolaemia

Family history: Mother had ovarian cancer at age 62

Social history: Lives with husband, retired nurse, non-smoker, drinks 1–2 glasses of wine per week

Examination findings: Abdomen distended with shifting dullness. No tenderness or palpable mass. No peripheral oedema. No hepatosplenomegaly or lymphadenopathy.

Investigations: FBC: Hb 117 g/L; WCC and platelets normal. LFTs: mildly elevated ALP and GGT. Serum CA-125: elevated.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

James Callahan, a 38-year-old man, presents with a 5-week history of intermittent lower abdominal cramps, flatulence, and loose stools. He describes 3–4 bowel motions per day, occasionally greasy and difficult to flush. He reports fatigue and has lost 3 kg unintentionally. He returned from a hiking trip in northern Queensland 2 months ago where he drank untreated creek water. He has no vomiting, bleeding, or fever.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Non-contributory

Social history: Works as an engineer, lives with partner, non-smoker

Examination findings: Thin but not cachectic, mild right lower quadrant tenderness, no peritonism or organomegaly. Vitals normal.

Investigations: FBC normal; coeliac serology negative; faecal elastase normal; stool microscopy: Giardia lamblia cysts identified

What are the most appropriate next steps in management? Select three (3) from the following list:

Linda Zhang, a 64-year-old woman, presents with progressive jaundice, dark urine, pale stools, and pruritus over the past 2 weeks. She also reports mild right upper quadrant discomfort and a 3 kg unintentional weight loss over the past month. She denies fever, vomiting, or abdominal trauma. She has a remote history of cholelithiasis but has never undergone surgery.

Medications: Rosuvastatin 10 mg daily

Allergies: Nil known

Past history: Hyperlipidaemia, gallstones

Family history: Non-contributory

Social history: Lives with husband, retired librarian, no alcohol or smoking history

Examination findings: Jaundiced. No fever. Abdominal exam: non-tender but mild fullness in the right upper quadrant. No palpable masses or organomegaly. No ascites.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Adam Foster, a 25-year-old man, presents with a 6-week history of intermittent perianal pain, particularly when sitting or during defecation. He has also noticed occasional blood on the toilet paper and a persistent foul-smelling discharge from the perianal area. He denies weight loss, change in bowel habits, or abdominal pain. He has no history of gastrointestinal illness.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Uncle has Crohn’s disease

Social history: Works in construction, smokes 5 cigarettes/day, drinks socially

Examination findings: Inspection reveals an external opening lateral to the anus with surrounding induration and purulent discharge. Digital rectal exam is limited due to pain. No palpable masses. No systemic signs of infection.

What are the most appropriate next steps in management? Select three (3) from the following list:

Chloe McGrath, a 19-year-old university student, presents with a 4-week history of intermittent right lower quadrant abdominal pain and diarrhoea. She reports having up to 5 loose bowel movements per day, with occasional blood and mucus. She also describes fatigue, reduced appetite, and a 2 kg weight loss. There is no history of recent travel, antibiotic use, or sick contacts. She denies any vomiting or fever.

Medications: Combined oral contraceptive pill

Allergies: Nil known

Past history: Nil significant

Family history: Brother diagnosed with Crohn’s disease at age 23

Social history: Lives in student accommodation, non-smoker, minimal alcohol use

Examination findings: Afebrile, mild tenderness in the right lower quadrant. No mass or peritonism. No perianal disease noted.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Bridget O’Donnell, a 50-year-old woman, presents with recurrent episodes of upper abdominal pain and nausea over the past 3 months. The pain is postprandial, colicky, and located in the right upper quadrant, often radiating to the right shoulder. Episodes last about an hour and resolve spontaneously. She has had three similar episodes in the past month, particularly after eating fatty meals. There is no jaundice, fever, vomiting, or weight loss.

Medications: Nil

Allergies: Nil known

Past history: Hypertension (well controlled), BMI 31

Family history: Mother had cholecystectomy at age 52

Social history: Schoolteacher, non-smoker, drinks 1–2 standard drinks on weekends

Examination findings: Abdomen soft, non-distended. Mild tenderness in right upper quadrant. No Murphy’s sign. No palpable mass. Vitals normal.

Investigations: FBC, LFTs, lipase all within normal limits. Abdominal ultrasound: gallbladder with multiple small stones, no wall thickening or pericholecystic fluid. CBD not dilated.

What are the most appropriate next steps in management? Select three (3) from the following list:

Henry Lee, a 71-year-old man, presents with a 3-month history of generalised abdominal discomfort, bloating, and altered bowel habits. He reports alternating diarrhoea and constipation, with occasional narrow-calibre stools. He also notes an unintentional weight loss of 5 kg and increasing fatigue. He denies rectal bleeding or significant pain. He had a negative FOBT 4 years ago and has never had a colonoscopy.

Medications: Perindopril 5 mg daily, aspirin 100 mg daily

Allergies: Nil known

Past history: Hypertension, ischaemic heart disease

Family history: Father died of bowel cancer at age 75

Social history: Lives with wife, retired teacher, ex-smoker, moderate alcohol use

Examination findings: Pale conjunctivae, abdomen soft, non-tender with no palpable masses. Digital rectal exam: normal stool, no blood or masses.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Meera Patel, a 48-year-old woman, presents with a 6-month history of chronic bloating, excessive flatulence, and intermittent watery diarrhoea. The symptoms are worse after eating, particularly high-carbohydrate meals. She reports no weight loss, blood in stools, or recent infections. She has tried avoiding dairy without improvement. She is otherwise well and denies fatigue or systemic symptoms.

Medications: Nil

Allergies: Nil known

Past history: Nil of note

Family history: Mother has type 2 diabetes

Social history: Works in IT, vegetarian diet, non-smoker, occasional wine

Examination findings: Abdomen soft, mild bloating, non-tender, no organomegaly or masses

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Isla McKenzie, a 67-year-old woman, presents with early satiety, anorexia, and a 4 kg weight loss over the past 2 months. She also reports vague epigastric discomfort, occasional nausea, and has noted a progressive decline in energy levels. She denies vomiting, melena, or overt bleeding. Her appetite has significantly decreased. She takes aspirin for primary prevention.

Medications: Aspirin 100 mg daily

Allergies: Nil known

Past history: Hypertension, osteoarthritis

Family history: Brother diagnosed with stomach cancer at age 70

Social history: Lives alone, non-smoker, moderate alcohol use

Examination findings: Pale. Mild epigastric tenderness, no masses or organomegaly. No lymphadenopathy or jaundice.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Thomas Rowe, a 56-year-old man, presents with a 2-month history of increasing rectal discomfort, tenesmus, and small amounts of bright red blood per rectum. He reports mucus in the stool and a feeling of incomplete evacuation. He has not had any weight loss or change in appetite. His bowel motions remain regular but are looser than usual. He denies abdominal pain, fever, or vomiting.

Medications: Nil

Allergies: Nil known

Past history: Haemorrhoids diagnosed 10 years ago

Family history: Father had colon cancer diagnosed at age 72

Social history: Works as an accountant, non-smoker, drinks 2–3 glasses of wine on weekends

Examination findings: Digital rectal examination reveals a palpable irregular firm mass in the rectal vault. No external haemorrhoids noted. No inguinal lymphadenopathy. No abdominal masses or hepatomegaly.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Leanne Wallace, a 36-year-old woman, presents with persistent nausea, early satiety, and epigastric discomfort over the past 3 months. She also reports occasional upper abdominal bloating but denies vomiting, weight loss, or gastrointestinal bleeding. Her symptoms are unrelated to food timing. She has tried over-the-counter antacids with little benefit. There is no history of NSAID use, alcohol excess, or recent infection.

Medications: Nil

Allergies: Nil known

Past history: Migraine (stable)

Family history: No GI cancers or relevant history

Social history: Office worker, non-smoker, drinks socially

Examination findings: Unremarkable. BMI 24. Abdomen soft, non-tender, no masses, normal bowel sounds.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Samuel Ibrahim, a 44-year-old man, presents with ongoing upper abdominal discomfort, nausea, and mild weight loss over the past 2 months. He reports that symptoms are worse with stress and after large meals. He has also experienced intermittent loose stools. He is otherwise well and has no vomiting, jaundice, or gastrointestinal bleeding. He has a history of type 2 diabetes and hypothyroidism.

Medications: Metformin 1000 mg BD, thyroxine 100 mcg daily

Allergies: Nil known

Past history: Diabetes mellitus, hypothyroidism

Family history: Non-contributory

Social history: Works as an IT consultant, non-smoker, occasional alcohol

Examination findings: BMI 29. Abdomen soft, mild epigastric tenderness, no masses or organomegaly

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Angela Tomlinson, a 62-year-old woman, presents with increasing fatigue and shortness of breath on exertion over the past three months. She also reports occasional upper abdominal discomfort and reduced appetite. There is no vomiting, weight loss, or visible gastrointestinal bleeding. Her diet is unremarkable, and she denies NSAID use. She completed bowel cancer screening (FOBT) two years ago with a negative result.

Medications: Atorvastatin 20 mg daily

Allergies: Nil known

Past history: Hypercholesterolaemia, osteoarthritis

Family history: Mother had bowel cancer at age 70

Social history: Retired teacher, non-smoker, minimal alcohol intake

Examination findings: Pale conjunctivae, no jaundice or lymphadenopathy. Abdomen soft, mild epigastric tenderness, no masses.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Joshua Nguyen, a 42-year-old man, presents with a 3-month history of intermittent central abdominal pain, bloating, and non-bloody diarrhoea occurring several times a day. He reports that his symptoms started after returning from a business trip to Southeast Asia, where he experienced a short bout of gastroenteritis. His current stools are loose and watery, and he occasionally sees undigested food. He has tried a lactose-free diet and probiotics without improvement. He denies fever, vomiting, or weight loss.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Non-contributory

Social history: Works in finance, non-smoker, drinks socially, no regular medications

Examination findings: Abdomen soft, mildly distended with active bowel sounds. No tenderness or masses.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Kylie Simmons, a 28-year-old woman, presents with a 3-week history of frequent watery diarrhoea (6–8 times per day), urgency, and mild lower abdominal cramping. She also reports fatigue and one episode of waking at night to open her bowels. She returned from a yoga retreat in Bali five weeks ago, where she experienced an episode of gastroenteritis that resolved spontaneously. She has not noticed any blood in her stool and has no significant medical history.

Medications: Oral contraceptive pill

Allergies: Nil known

Past history: Nil

Family history: Non-contributory

Social history: Works as a travel consultant, non-smoker, vegetarian

Examination findings: Afebrile, mildly tender in the left lower quadrant, no guarding or rebound. Vitals normal. No lymphadenopathy. No perianal disease.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Geoffrey Martin, a 75-year-old man, presents with progressive difficulty swallowing solid foods over the past 3 months, now extending to liquids. He has lost 6 kg unintentionally and describes episodes of regurgitation and a sensation of food getting stuck in the lower chest. He denies nausea, vomiting, or heartburn. There is no history of gastroesophageal reflux or previous GI surgery.

Medications: Amlodipine 5 mg daily

Allergies: Nil known

Past history: Hypertension, benign prostatic hyperplasia

Family history: Non-contributory

Social history: Retired pharmacist, lives with wife, non-smoker

Examination findings: Mildly cachectic, BMI 20. Abdominal and cardiorespiratory exams unremarkable. No lymphadenopathy.

Investigations: FBC: Hb 108 g/L, MCV 84 fL; CRP normal. CXR: Normal. UEC/LFTs: Normal.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Sarah Delaney, a 34-year-old woman, presents with a 4-month history of intermittent bloating, flatulence, and loose stools. Symptoms are worse after eating bread, pasta, and other wheat-containing foods. She describes episodes of crampy abdominal pain and frequent tiredness. There is no rectal bleeding, fever, or recent travel. She has unintentionally lost 3 kg over the past two months and reports iron deficiency in the past.

Medications: Nil

Allergies: Nil known

Past history: Iron deficiency anaemia, no previous gastrointestinal investigations

Family history: Mother has hypothyroidism and osteoporosis

Social history: Works as a graphic designer, vegetarian diet, non-smoker

Examination findings: Mild pallor, BMI 21. Abdominal exam: soft with mild bloating, no tenderness or masses.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Brandon Ellis, a 50-year-old man, presents with fatigue, pruritus, and darkening of the skin over the past six months. He also reports intermittent right upper quadrant discomfort and recent onset of dry eyes and mouth. He denies alcohol use, medication changes, or recent infections. There is no history of jaundice or gastrointestinal bleeding.

Medications: None

Allergies: Nil known

Past history: Nil significant

Family history: Sister with rheumatoid arthritis

Social history: Accountant, non-smoker, no alcohol use

Examination findings: BMI 26. Generalised skin hyperpigmentation and mild hepatomegaly. No jaundice, spider naevi, or ascites. No lymphadenopathy.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Emily Rosen, a 29-year-old woman, presents with a 2-month history of recurrent nausea, early satiety, and postprandial fullness. She reports occasional vomiting of undigested food several hours after eating. She has had type 1 diabetes since age 12, with erratic glycaemic control. She denies weight loss, fever, abdominal pain, or changes in bowel habits. She recently started a new job and reports high levels of stress.

Medications: Insulin glargine and insulin aspart

Allergies: Nil known

Past history: Type 1 diabetes mellitus with known peripheral neuropathy

Family history: Father has type 2 diabetes

Social history: Non-smoker, occasional alcohol, lives alone

Examination findings: Normal BMI, mild epigastric tenderness, no abdominal distension, bowel sounds present

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Martin Doyle, a 64-year-old man, presents with a 6-month history of vague upper abdominal discomfort, bloating, and early satiety. He reports occasional nausea and fatigue but no vomiting or significant pain. He has a history of chronic alcohol use and has lost 5 kg unintentionally. He denies any overt bleeding. His appetite is reduced, and he describes steatorrhoea (pale, greasy stools that float and are difficult to flush).

Medications: Thiamine 100 mg daily (self-initiated)

Allergies: Nil known

Past history: Long-standing alcohol use (40+ years), hypertension

Family history: Nil of note

Social history: Lives alone, drinks 6–8 standard drinks daily, smokes 10 cigarettes/day

Examination findings: Thin appearance, BMI 19. Mild epigastric tenderness, no hepatosplenomegaly, no jaundice, no ascites.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Clare Whitton, a 46-year-old woman, presents with a 5-month history of recurrent central abdominal pain, bloating, and loose stools. The pain is crampy, often relieved by defecation, and worsens during periods of stress. She reports alternating bowel habits with some constipation. There is no weight loss, blood in stool, nocturnal symptoms, or recent infections.

Medications: Sertraline 50 mg daily

Allergies: Nil known

Past history: Generalised anxiety disorder, iron deficiency during pregnancy

Family history: Mother with hypothyroidism

Social history: Works in retail, lives with husband and two children, non-smoker

Examination findings: Abdomen soft and mildly tender in the lower quadrants, no masses or organomegaly. Normal bowel sounds.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Peter Wallace, a 60-year-old man, presents with worsening fatigue and upper abdominal discomfort. He describes a dull ache in the right upper quadrant and mild nausea, particularly after meals. He denies vomiting or significant weight loss. His GP recently noted mildly elevated liver enzymes during a health check. He has a history of type 2 diabetes, obesity (BMI 32), and hypertension. He drinks 2–3 standard drinks most days.

Medications: Metformin 1000 mg BD, ramipril 10 mg daily

Allergies: Nil known

Past history: Type 2 diabetes, hypertension, hyperlipidaemia

Family history: Father had coronary artery disease

Social history: Works part-time, non-smoker, drinks daily

Examination findings: Overweight, BP 138/82 mmHg, mild right upper quadrant tenderness, no hepatomegaly, no signs of chronic liver disease

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Jane Holloway, a 70-year-old woman, presents with progressive dysphagia to solids and unintentional weight loss of 7 kg over 4 months. She also reports intermittent regurgitation of undigested food and retrosternal discomfort. She denies vomiting, haematemesis, or odynophagia. Her appetite has declined, and she eats slowly due to discomfort. She has a 40-pack-year smoking history and drinks two glasses of wine nightly.

Medications: Amlodipine 5 mg daily

Allergies: Nil known

Past history: Hypertension, osteoarthritis

Family history: Mother had oesophageal cancer

Social history: Retired librarian, lives alone, independent with ADLs

Examination findings: Thin, BMI 19. Mild pallor. Abdominal exam unremarkable. No palpable lymphadenopathy or hepatomegaly.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Melissa Tran, a 22-year-old university student, presents with persistent nausea, occasional vomiting, and upper abdominal pain that has worsened over the past 6 weeks. The pain is described as burning in nature, located in the epigastrium, and is often worse on an empty stomach and at night. She occasionally vomits small amounts of blood-streaked material. She denies weight loss, jaundice, or change in bowel habits.

Medications: Ibuprofen 400 mg PRN for menstrual cramps

Allergies: Nil known

Past history: Nil significant

Family history: Mother has gastro-oesophageal reflux disease

Social history: Full-time student, occasional alcohol, non-smoker

Examination findings: Vitals normal. Mild epigastric tenderness on palpation. No guarding or peritonism. No signs of anaemia.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Anthony Russo, a 62-year-old man, presents with worsening anorexia, abdominal distension, and confusion over the past 2 weeks. He has a history of alcoholic cirrhosis diagnosed 3 years ago. His partner reports increasing drowsiness and that he has been forgetful and irritable. He also has had two episodes of passing dark stools. He drinks approximately 4–6 standard drinks daily despite advice to cease. He was hospitalised for ascites 6 months ago.

Medications: Spironolactone 100 mg daily, furosemide 40 mg daily, thiamine

Allergies: Nil known

Past history: Alcoholic liver disease, hypertension

Family history: Non-contributory

Social history: Lives with partner, former builder, ongoing alcohol use

Examination findings: Confused, GCS 14. Flapping tremor present. Distended abdomen with shifting dullness. No fever. Mild peripheral oedema. Jaundice and spider naevi noted.

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Susan Barker, a 39-year-old woman, presents with a 4-month history of intermittent upper abdominal discomfort, bloating, and mild nausea. She also reports a 6 kg unintentional weight loss despite a normal appetite. She denies vomiting, altered bowel habits, or gastrointestinal bleeding. Her symptoms are non-specific but occur more frequently in the mornings and are not related to meals. She does not consume alcohol and is a non-smoker.

Medications: Oral contraceptive pill

Allergies: Nil known

Past history: Nil significant

Family history: Mother had type 1 diabetes and autoimmune thyroiditis

Social history: Works as a primary school teacher, lives with her partner, balanced diet

Examination findings: BMI 20. Mild epigastric tenderness, no masses, hepatosplenomegaly, or lymphadenopathy

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Benjamin Foster, a 58-year-old man, presents with ongoing fatigue, mild jaundice, and intermittent right upper quadrant discomfort. He has a history of haemochromatosis diagnosed via genetic testing (C282Y homozygous) 6 years ago, but has not engaged with follow-up for the past 3 years. He reports increased skin pigmentation and has recently noticed reduced libido. He drinks 1–2 glasses of wine most nights and does not smoke.

Medications: Nil

Allergies: Nil known

Past history: Genetic haemochromatosis, hypertension

Family history: Brother with diabetes, father died of liver cancer

Social history: Accountant, married, no recent travel

Examination findings: Mild jaundice, hepatomegaly, bronze discolouration of the skin, no ascites or peripheral oedema

Investigations:

What are the most appropriate next steps in management? Select three (3) from the following list:

Louise Carter, a 33-year-old woman, presents with frequent episodes of regurgitation, chronic heartburn, and retrosternal burning pain that worsens after meals and when lying down. Symptoms have been present for over 6 months and have not responded to over-the-counter antacids. She denies weight loss, dysphagia, vomiting, or GI bleeding. She works as a schoolteacher and recently gained 5 kg during a period of stress and reduced physical activity.

Medications: Nil regular

Allergies: Nil known

Past history: Nil significant

Family history: Mother with gastro-oesophageal reflux disease (GORD)

Social history: Lives with partner, drinks alcohol occasionally, non-smoker

Examination findings: BMI 29. Abdominal exam unremarkable. No tenderness or organomegaly.

Investigations: Not yet performed

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Ravi Shah, a 45-year-old man, presents with a 2-week history of right lower quadrant abdominal pain and low-grade fever. The pain is dull and intermittent but has become more constant over the last few days. He reports loose stools and tenesmus. He denies rectal bleeding, vomiting, or weight loss. He has not travelled recently. There is no family history of colorectal cancer or inflammatory bowel disease (IBD).

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Nil of note

Social history: IT consultant, non-smoker, drinks occasionally

Examination findings: Temperature 37.8°C, mild tenderness in the right iliac fossa with no rebound or guarding. No palpable mass or hepatosplenomegaly. Bowel sounds present and normal.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Deborah Langley, a 68-year-old woman, presents with progressive abdominal distension, early satiety, and ankle swelling over the past two months. She also reports fatigue and mild right upper quadrant discomfort. She has a history of chronic hepatitis C infection, which was treated successfully 5 years ago. She denies alcohol use and has not had any recent infections. Her weight is stable, but she notes that her clothes feel tighter around the waist.

Medications: Ramipril 5 mg daily

Allergies: Nil known

Past history: Treated hepatitis C, hypertension

Family history: Non-contributory

Social history: Retired nurse, non-smoker, no alcohol

Examination findings: BP 110/70 mmHg, pulse 76 bpm. Distended abdomen with shifting dullness. Mild bilateral ankle oedema. No jaundice, spider naevi, or asterixis. No palpable masses or lymphadenopathy.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Daniel Moore, a 52-year-old man, presents with recurrent episodes of upper abdominal pain, bloating, and early satiety. The pain is non-radiating, worse after eating, and occasionally wakes him at night. He has been self-medicating with antacids for several months with partial relief. He denies vomiting, weight loss, or gastrointestinal bleeding. He smokes 10 cigarettes a day and drinks 3–4 standard drinks most evenings. He recently lost his job and reports increased stress levels.

Medications: None regularly

Allergies: Nil known

Past history: Nil significant

Family history: Father had peptic ulcer disease

Social history: Lives alone, high caffeine intake, limited physical activity

Examination findings: Vital signs normal. Mild epigastric tenderness, no rebound or guarding. No organomegaly or palpable mass.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Helen Marks, a 72-year-old woman, presents with recent onset of jaundice, pruritus, dark urine, and pale stools over the past week. She also reports anorexia and a 4 kg unintentional weight loss over 2 months. She denies alcohol use, recent travel, or known liver disease. Her past health has been generally good. There is no family history of gastrointestinal or liver disease.

Medications: Calcium carbonate for osteoporosis

Allergies: Nil known

Past history: Osteoporosis, hypertension

Family history: Non-contributory

Social history: Retired librarian, lives alone, non-smoker, no alcohol use

Examination findings: Jaundiced. No hepatomegaly or ascites. Palpable non-tender gallbladder in the right upper quadrant (Courvoisier’s sign). No fever or abdominal tenderness.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Mark Jennings, a 40-year-old man, presents with sudden onset severe epigastric pain radiating to the back, associated with nausea and vomiting. The pain started 6 hours ago after a large meal. He describes the pain as constant and worsening. He drinks alcohol daily and had a similar, milder episode one year ago. There is no history of trauma, gallstones, or recent infections.

Medications: Nil

Allergies: Nil known

Past history: Hypertriglyceridaemia, previous mild pancreatitis

Family history: Father with type 2 diabetes

Social history: Works in construction, drinks 4–5 standard drinks daily, smokes 15 cigarettes per day

Examination findings: Temp 37.9°C, HR 108 bpm, BP 102/66 mmHg. Abdomen distended with marked epigastric tenderness and guarding. Bowel sounds reduced.

Investigations:

What are the most appropriate next steps in investigation and management? Select three (3) from the following list: