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PLAB Part 1; Free Online Mock Test 24.1 with explanatory answers

Author: RxPG, Posted on Tuesday, July 08 @ 00:00:00 IST by RxPG  

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PLAB Part 1

Multiple Choice Test



1) A businessperson has just returned from a business trip to Asia. He now develops copious watery and bloody diarrhea.

One answer only.
a. Amebic dysentery
b. Pseudomembranous colitis
c. Crohn`s involvement of the colon
d. Ulcerative Proctitis
e. Ulcerative pancolitis
f. Diverticular disease
g. Cecal carcinoma
h. Sigmoid carcinoma
i. Condyloma accuminatum
j. Anal fissure
k. Sigmoid volvulus
Clinchers

Ø Business person: Risk of amoebiasis in developed countries is more in travellers, recent immigrants and homosexual men.

Ø Just returned from a business trip to Asia: Highest incidence of amoebiasis is seen in developing countries in the topics, particularly Mexico, India, tropical Asia, central and south America and Africa.

Ø Copious watery and bloody diarrhea: In amoebiasis diarrhoea develops slowly, but becomes profuse and bloody.

CONFUSA

Bacillary dysentery often has sudden onset and may cause dehydration. Stools are more watery. Acute ulcerative colitis has more gradual onset and stools are very bloody.

Investigation of choice

Stool microscopy showing trophozoites, blood and pus cells.

Immediate management

Correct dehydration: Oral rehydration is more beneficial than IV rehydration. In severe dehydration give 0.9% saline + 20 mmol K+/L IVI.

Treatment of choice

Metronidazole 800 mg/8h PO for 5 days then diloxanide furoate 500 mg/8h for 10 days to destroy gut cysts.

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2) A middle-aged man develops constipation with overflow diarrhea and bright red bleeding per rectum. A barium enema reveals an ulcerated stricture in the sigmoid colon.

One answer only.
a. Amebic dysentery
b. Pseudomembranous colitis
c. Crohn`s involvement of the colon
d. Ulcerative Proctitis
e. Ulcerative pancolitis
f. Diverticular disease
g. Cecal carcinoma
h. Sigmoid carcinoma
i. Condyloma accuminatum
j. Anal fissure
k. Sigmoid volvulus
Clinchers

Ø Middle-aged man: Carcinoma of colon usually occurs in patients over 50 years of age but it is not rare earlier in adult life.

Ø Constipation with overflow diarrhea: In the carcinoma of left side of colon (sigmoid), alteration of basal habit is seen. The episodes of constipation are followed by attacks of diarrhoea.

Ø Bright red bleeding per rectum: Low tumors may result in tenesmus accompanied by the passage of mucus and blood, especially in the early morning.

Ø An ulcerated stricture in the sigmoid colon: Ulcerated stricture is a sign of malignancy, but it may well be Crohn's involvement of the colon. Sigmoidoscopic examination becomes important here. Biopsy should be taken to ascertain the diagnosis.

CONFUSA

This question may be confused with Crohn's involvement of the colon. Sigmoidoscopy and biopsy should be performed.

Investigation of choice

Sigmoidoscopy

Barium enema: It shows 'apple core' appearance, i.e. a short, irregular stenosis with sharp shoulders at each end (look at Figure 57.43, page 1051, Bailey and Love, 23rd edn).

Treatment of choice

Preoperative treatment: Bowel is cleared by enemas and oral stimulant laxatives (e.g. picolax). Principle of operative treatment is wild resection of the growth together with a regional lymphatics.

In obstructed cases, where bowel preparation is con­traindicated the primary goal is to relieve obstruction.

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3) A young man develops bloody diarrhea. A rigid sigmoidoscopy examination revealed granular ulceration in the sigmoid colon with proximal sparing.

One answer only.
a. Amebic dysentery
b. Pseudomembranous colitis
c. Crohn`s involvement of the colon
d. Ulcerative Proctitis
e. Ulcerative pancolitis
f. Diverticular disease
g. Cecal carcinoma
h. Sigmoid carcinoma
i. Condyloma accuminatum
j. Anal fissure
k. Sigmoid volvulus
Clinchers

Ø Young man: Peak occurrance between 15 and 30 years of age and between 60 and 80 years of age, but onset may occur of any age.

Ø Bloody diarrhea: Though bloody diarrhoea is more commonly seen in ulcerative colitis, sometimes Crohn's disease may present with bloody diarrhoea. Moreover the options include ulcerative pancolitis and not ulcerative colitis, therefore since rectal involvement is not there we can safely exclude UC.

Ø Granular ulceration in the sigmoid colon with proximal sparing: Inflammation seen in UC is continuous (no skip areas), where as in Crohn's disease any part of GI involved, usually terminal ilium and/or colon, with linear ulcerations and submucosal thickening leading to cobblestone pattern, disconti­nuous skip areas are characteristic of Crohn's disease.

CONFUSA

There may be confusion with ulcerative collitis (UC) but in that case rectum involvement should be there. In UC rectal involvement is almost always seen.

Investigation of choice

Sigmoidoscopy.

Immediate management

Antidiarrhoeal agents, IV hydration and blood trans­fusion in severe cases.

Treatment of choice

5 ASA oral or enema, metronidazole and/or ciproflo­xacin.

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4) A middle-aged woman has been on several anti­biotic treatments recently because of a persistent pneumonia. She now develops a severe watery diarrhea. Colonoscopy reveals whitish plaques scattered throughout the colon.

One answer only.
a. Amebic dysentery
b. Pseudomembranous colitis
c. Crohn`s involvement of the colon
d. Ulcerative Proctitis
e. Ulcerative pancolitis
f. Diverticular disease
g. Cecal carcinoma
h. Sigmoid carcinoma
i. Condyloma accuminatum
j. Anal fissure
k. Sigmoid volvulus
Clinchers

Ø On several antibiotic treatments recently: Pseudomem­branes colitis is caused by overgrowth of clostridium difficile, following any antibiotic therapy.

Ø Severe watery diarrhoea: Most often diarrhoea is pro­fuse and watery, although bloody diarrhoea occurs in 5% cases.

Ø Whitish plaques scattered thoughout the colon: Charac­teristic multiple, discrete, yellowish plaques are seen on sigmoidoscopy which on biopsy shows features of acute inflammation and ulceration with a pseudo­membrane of fibrin and necrotic material.

CONFUSA

Currently, strains of C. difficile that produce toxins detectable in the stool the only identified cause of colitis idncued by antibiotics, therefore there should be no confusion in this question.

Investigation of choice

Sigmoidoscopy occasionally colonoscopy may be required.

Immediate management

Should be initially directed in eradicating C. difficile from the stool.

Treatment of choice

Vancomycin 125 mg/6h PO or metronidazole 400 mg/8h PO.

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5) An elderly woman is found anemic. As part of her examination, she has a barium enema, which reveals a mass lesion in the ascending colon.

One answer only.
a. Amebic dysentery
b. Pseudomembranous colitis
c. Crohn`s involvement of the colon
d. Ulcerative Proctitis
e. Ulcerative pancolitis
f. Diverticular disease
g. Cecal carcinoma
h. Sigmoid carcinoma
i. Condyloma accuminatum
j. Anal fissure
k. Sigmoid volvulus
Clinchers

Ø Elderly woman: Caecal carcinoma presents in older age group with a long history.

Ø Anaemia: Carcinoma of caecum presents with anaemia diarrhoea weight loss, and sometimes as right iliac fossa mass. Anaemia occurs due to occult blood loss.

Ø Mass in the ascending colon: Barium enema showing mass in ascending colon confirms our diagnosis of caecal carcinoma.

Ø Ascending colon: Right sided colonic carcinoma typically presents with constipation with or without diarrhoea, whereas left sided colonic carcinoma presents with anorexia, weight loss and constipation.

CONFUSA

Young parents with diarrhoea and right iliac fossa a mass focus on Crohn's disease and there should be no confusion with an appendicular mass.

Investigation of choice

Barium enema and occult blood test.

Immediate management

Estimate hemoglobin.

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This question comes from “RxPG First Aid for PLAB” – Jaypee Publishers, India & Blackwell Science Publishers, Europe and USA

The preface of the book can be read at rxpg.com


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