11/09/2023…Monday

1…..Theme: Gastrointestinal disease

A Anal fissure
B Carcinoma of the colon
C Carcinoma of the oesophagus
D Carcinoma of the stomach
E Clostridium difficile colitis
F Crohn's disease
G Epistaxis
H Mallory-Weiss tear
I Oesophageal varices
J Peptic ulcer disease
K Ulcerative colitis

From the given list please choose the most appropriate cause of the clinical scenarios described
below.

A 64-year-old obese male presents with a two month history of weight loss. He has lost
10 kg. He has also been suffering from retrosternal chest pain and dysphagia. He drinks
Please select an option
approximately 60 units of alcohol weekly.

A 22-year-old female presents with a three month history of intermittent abdominal pain.
She has unintentionally lost 4 kg in weight over this period and she has also been
suffering from diarrhoea. On examination, it is noted that she has several aphthous
Please select an option
ulcers in her mouth.

A 23-year-old female presents with a seven day history of rectal bleeding. The bright
red blood was noticed as it had stained the toilet paper. She has had some slight
discomfort when passing stools. On examination there is a posterior longitudinal tear in
Please select an option
the midline.

Explanation

An anal fissure is a tear in the wall of the anal mucosa. The common age for its
incidence is in people aged between 20-30 years. Constipation tends to precipitate the
symptoms of an anal fissure that include bright red rectal bleeding after defecation, pain
or discomfort and on examination a small tear may be observed.
Key learning points
Gastroenterology

 The most typical presenting feature in oesophageal cancer is

dysphagia, with risk factors including obesity, excess alcohol
consumption, smoking, coeliac disease and Barrett's oesophagus

2….A 74-year-old woman makes an appointment to see you due to constipation. She
has an four week history of reduced stool frequency with firmer stool consistency. She
reports that at present she is opening her bowels every other day; prior to the last four
weeks she opened her bowels typically once a day.

She denies any rectal bleeding or diarrhoea. She has no anal symptoms and has had
no incontinence. Further discussion reveals that she does still sometimes open her
bowels on consecutive days.

Examination is unremarkable with a soft, non-tender abdomen with no masses. Rectal

examination is also normal. Her weight is stable.

She saw a colleague about her arthritic knee one month ago and was prescribed
codeine phosphate 30mg qds. She has had recent blood tests which show normal full
blood count, ESR, thyroid function and calcium.

What is the most appropriate management of this patient at this point?

Arrange faecal occult blood testing

Provide advice regarding the constipation and reassure
Refer directly for flexible sigmoidoscopy
Refer routinely to a lower gastrointestinal specialist
Refer urgently to a lower gastrointestinal specialist
Key learning points
Gastroenterology

 Constipation with an identifiable cause in the absence of any other

alarm symptoms does not require urgent referral for suspected
colorectal cancer.

Explanation
The key point here is that this lady's constipation is not unexplained. It coincides with
the prescribing of moderate analgesia (codeine phosphate, which reduces bowel transit)
and there are no other red flags. This lady has no features in the history or examination
that require urgent referral to a lower gastrointestinal specialist for suspected cancer.

This patient should be given advice on diet and lifestyle, her medication should be
reviewed to see if she is taking anything that is contributing to her constipation and she
can be counselled with regard to 'red flags'. She has had bloods to look into secondary
causes of constipation (for example, hypothyroidism, hypercalcaemia). Laxative use can
be discussed.

Further Reading:
NICE Clinical Knowledge Summaries. Constipation.

3….A 56-year-old male presents to the clinic regarding red discolouration of the urine.

Two months ago he was diagnosed with a deep vein thrombosis and has been
commenced on warfarin. His most recent INR performed two days ago is 2.7.

On examination, there are no abnormalities to find yet his dipstick urine result reveals +
++ of blood and + protein. A MSU reveals no growth.

Which of the following is the most appropriate action for this man?

Reassure and monitor INR and warfarin dose closely

Monitor INR closely and refer to urology
Request repeat INR
 Suggest discontinuing warfarin
Treat with trimethoprim

Key learning points

Kidney & Urology

 Warfarin treatment within therapeutic range can unmask underlying

malignancy and haematuria should not be disregarded or simply
attributed to warfarin therapy

Explanation
This patient has unexplained haematuria and in the context of a previous DVT,
underlying occult neoplasia of the renal tract must be considered.

Therefore, an urgent referral to the urologists is the most appropriate course of action in
this patient.

In such cases, with a therapeutic INR, warfarin may unmask a potential neoplasm and
one must not attribute the haematuria to the warfarin.

4…..A 48-year-old lady has obesity with a BMI of 37 kg/m 2 and her waist measurement
is 115 cm (which is very high). She gained most of the weight about 10 years ago and
since that time she has tried many different forms of diets and weight-loss clubs.
Although she enjoys swimming she is finding it harder to keep up her exercise and
walking is restricted to a few hundred metres because of foot pain.

On further questioning, it is evident that her diet is quite reasonable consisting of about
1800 KCal per day. She eats breakfast, bases her meals on starchy foods, eats plenty
of fibre and at eats at least five portions of vegetables or fruit per day.

According to NICE guidance on Obesity (CG43), which of the following management

strategies would be advisable for this lady?

Diet and physical activity, consider drugs

Extended period, very low calorie diet
General advice on healthy weight and lifestyle
 Referral for bariatric surgery
Referral to specialist obesity service

Key learning points

Metabolic Problems and Endocrinology

 With a very high waist circumference (>88 cm) and, in the absence of
co-morbidities, the initial management of obesity should be diet and
exercise with consideration of drug treatment which should be
discussed

Explanation
NICE recommendations are first to classify the level of this lady's obesity. This can
easily be achieved by looking at the tables in the Obesity (CG189) guidelines:
Classification BMI kg/m2
Healthy weight 18.5-24.9
Overweight 25-29.9
Obesity I 30-34.9
Obesity II 35-39.9
Obesity III 40 or more

Her waist circumference is very high (>88 cm) and, in the absence of co-morbidities, we
can see that the initial management should be diet and exercise with consideration of
drug treatment which should be discussed.
For an extended period (longer than 12 weeks) low-calorie diet and bariatric surgery
may be considered, but would warrant specialist referral.

5…..A 34-year-old woman comes to see you with a prolonged cough.

Which symptoms would be suggestive of pertussis in an adult?

Haemoptysis
Nocturnal coughing
Productive coughing
Vomiting after coughing
Weight loss

Key learning points

Infectious Disease and Travel Health , Population Health, Respiratory Health

 Prolonged paroxysms of coughing associated with vomiting raise the

possibility of pertussis infection in adults

Explanation
Adults with pertussis tend to display mild symptoms; a paroxysmal cough and vomiting
after coughing should raise the suspicion of pertussis.

Unlike infants, adults with pertussis tend to display mild symptoms. The clinical
presentation is an initial catarrhal stage with a cough that comes in paroxysms, often
resulting in vomiting. Symptoms slowly improve, and the patient may have a prolonged
cough for weeks or months.

The cough is not usually productive, and nor is there haemoptysis.

Weight loss is not a typical feature.

A prolonged duration of cough may occur in pertussis, but may also occur with other
diseases including asthma, post-nasal drip, and bronchitis. Nocturnal coughing is
usually associated with asthma rather than pertussis

Vomiting after coughing is the symptom most suggestive of pertussis.

Pertussis tends to be under-diagnosed in adults. Health professionals are familiar with

the typical clinical picture of an infant with whooping cough, but are less aware that
when older teenagers and adults get the disease, the symptoms are milder and less
typical than in an infant.

Reference:
Public Health England: Pertussis brief for healthcare professionals (PDF)

BMJ Best Practice: Pertussis

BMJ Clinical Updates: Pertussis (whooping cough)

6…..You have been taking care of a 55-year-old gentleman with chronic lower back
pain for years. During a medication review, you note he has been on regular
paracetamol, PRN NSAIDs and oral morphine. In regards to his oral morphine, he is
taking 120mg in total during a 24 hour period. He is not sure if the morphine has ever
had much effect and asks if you can increase the dose.

What would be the next most appropriate step in his management?

 Increase his oral morphine to 140mg/24 hours
Make no changes to his regime; he is already on the maximum dose of oral
morphine
Switch to a different opioid
Switch to a transdermal patch
Taper his morphine down

Key learning points

Musculoskeletal Health

 The Faculty of Pain Management set a clear threshold for maximum

dose for oral morphine use: "A maximum dose of drug should be
defined at initiation, and this should not exceed oral morphine
equivalent 120mg/day."

Explanation
The Faculty of Pain Management set a clear threshold for maximum oral morphine use:
"A maximum dose of drug should be defined at initiation, and this should not exceed
oral morphine equivalent 120mg/day." This is because the risk of harm increases
substantially above this dose with no additional benefit.

In this case, as the patient is not sure the morphine had an effect, it would be sensible
to try and taper him off completely. If opioids are ineffective, the dose taper is unlikely to
lead to increased pain and the patient will be free of opioid-related side effects.

Switching to a different opioid or different route of administration is unlikely to be

beneficial if he has reported no benefit from the dose of oral formulation that he is on.
Immediate-release preparations allow patients to be flexible with dosing where patients
can be encouraged to look for opportunities to avoid taking opioids.

Further reading:

Drugs and Therapeutics Bulletin: Where now for opioids in chronic pain?

Royal College of Anaesthetists, Faculty of Pain Medicine: Long-Term Prescribing

7….A 40-year-old lady returns to clinic four weeks after starting treatment with
fluoxetine for moderate depressive symptoms.

She has not previously taken any antidepressant medication and does not have any
coexisting medical problems. During your assessment she does not express any
suicidal ideation and is well supported at home by her partner.

Despite not missing any doses of fluoxetine she does not feel any benefit from the
medication so far and wonders if she should change to another tablet. She has not
experienced any side effects with fluoxetine, however she has heard great things about
St John's Wort from a friend.

What is the best course of action for this patient?

Change to a tricyclic antidepressant
Continue the current dose of fluoxetine
Increase the dose of Fluoxetine and arrange weekly telephone contact to
increase support
Stop the fluoxetine and refer for CBT
Stop the fluoxetine and start St John's Wort

Key learning points

Mental Health

 If after three to four weeks there is only minimal (or absent) response to
SSRI, you should consider increasing the dose or changing to an
alternative agent

Explanation
This patient has been taking a Selective serotonin reuptake inhibitor (SSRI) for four
weeks without benefit, and has expressed concern about this. Continuing at the current
dose is not a satisfactory plan.

If after three to four weeks there is only minimal (or absent) response and the patient is
compliant with therapy there are essentially two options in addition to increasing the
level of support:
 1. Increase the dose of the current antidepressant, or
2. Change to an alternative agent if there are side effects or the patient
prefers.

Although there is some evidence of the benefit of St John's Wort it is not recommended
that doctors prescribe or advocate its use due to the lack of clarity regarding doses,
duration of effect and variation in the nature of preparations. There are also serious
drug interactions, particularly with oral contraceptives and antiepileptics.

CBT is recommended in addition to medication for moderate depression.

Great caution is needed when switching from fluoxetine to tricyclics because it inhibits
the metabolism, therefore a lower than usual starting dose of tricyclic would be required.

8….A 60-year-old immigrant asylum seeker has severe pain in his great toe. The MTP
joint is hot, warm and exquisitely tender. He is under the care of the local chest clinic,
where he is being treated for TB.

Which one of the following is the most likely cause of his symptoms?

Doxycycline
Ethambutol
Isoniazid
Pyrazinamide
Rifampicin

Key learning points

Improving Quality, Safety and Prescribing, Musculoskeletal Health

 Gout can arise from treatment with pyrazinamide

Explanation
Immigrant workers and asylum seekers in both inner city and practices in agricultural
regions can present new challenges to GPs with the presentation of conditions seen
less often in the UK. Whilst the description given could apply to a joint infection, it would
be difficult to correlate that with the options presented. The description here is one of
classical gout.

Pyrazinamide can cause hyperuricaemia and attacks of gout and is the most likely
treatment to have resulted in these symptoms.

Previous candidates have queried the role of ethambutol in gout. The BNF does not
list gout as a side effect of ethambutol. In the main, when our editorial team looked at
this, references conclude that ethambutol can cause joint pains but none included overt
gout.

The British National Formulary also urges caution in using pyrazinamide during an
acute attack of gout, whereas no such caution exists for ethambutol.

9….A 69-year-old woman with osteoarthritis is reviewed.

She was using regular paracetamol and a topical NSAID for symptom control but due to
insufficient pain relief an oral NSAID was recently started. She has been taking
ibuprofen 400 mg as required up to three times a day. On further discussion she is
using the ibuprofen at least once a day. She has no significant gastrointestinal past
medical history, particularly no previous problems with gastro-oesophageal reflux or
peptic ulceration.

In terms of gastro-protection which is the most appropriate management strategy?

Co-prescribe a prokinetic (e.g. domperidone)

Co-prescribe a proton pump inhibitor (e.g. omeprazole)
Co-prescribe an alginate preparation to use on a PRN basis (e.g.
Gaviscon)
Co-prescribe an H2-receptor antagonist (e.g. ranitidine)
No gastro-protection is needed

Key learning points

Musculoskeletal Health

 When treatment with an oral 'traditional' NSAID such as ibuprofen (or a

COX-2 inhibitor) is prescribed a proton pump inhibitor with the lowest
acquisition cost should be co-prescribed
Explanation
When treatment with an oral 'traditional' NSAID such as ibuprofen (or a COX-2 inhibitor)
is prescribed a proton pump inhibitor should be co-prescribed (NICE guidance advises
one with the lowest acquisition cost).

Anti-inflammatories should be used at the lowest effective dose for the shortest possible
time period in order to minimise any gastrointestinal, liver or cardio-renal side effects.

Regardless of whether a patient has a past history of gastrointestinal problems a proton

pump inhibitor is indicated and should be co-prescribed to prevent against any
gastrointestinal problems.

Other medications such as steroids, aspirin, anti-depressants (SSRIs, NRIs -

venlafaxine) are considered additive GI-risk factors when used in combination with
NSAIDs.

NICE - Pharmacological treatments for osteoarthritis

10….A 30-year-old woman comes to see you because she is worried about her family history of
breast cancer. She has no symptoms herself.

Which of the following family histories should be referred for further genetic assessment of their
risk of breast cancer?

A maternal aunt who had bowel cancer at 50 and another maternal aunt who had breast
cancer at 55
A maternal grandmother and her sister who both developed breast cancer when they were 55
A mother who has developed breast cancer at 55
A paternal grandmother who had breast cancer at 55 and a paternal aunt who had breast
cancer at 55
A sister who has been diagnosed with breast cancer at 39

Key learning points

Genomic Medicine , Gynaecology and Breast, Population Health

 Criteria exist to aid referral for those at risk of breast cancer based on
their family history.
Explanation
It can be very difficult to decide who needs referral for genetic assessment for breast
cancer. In order to help you in your decision, you need to consider the age, sex,
relationship to the patient and, if you have the information to hand, whether the relative's
breast cancer was bilateral. It is also important to note any additional history of ovarian
cancer in first degree relatives.

Sex:
Any patient with a first degree male relative with breast cancer at any age should be
referred.

Age:
The two important age thresholds are 40 and 50. If a first degree female relative has
been diagnosed with breast cancer under 40, then they should be referred. If their
breast cancer was bilateral then you may refer if the first primary relative was diagnosed
under the age of 50.

Numbers of cases in relatives:

In terms of numbers of relatives diagnosed with breast cancer you should concentrate
on first degree and second degree relatives. If two first degrees or a first and second
degree relatives are diagnosed at any age, they should be referred.

Family history of ovarian cancer:

There are genetic links with ovarian cancer, so if a first or second degree relative has
been diagnosed with breast cancer and another first degree relative has been
diagnosed with ovarian cancer at any age then this also warrants referral for further
genetic counselling.

Further Reading:

1. BMJ Learning. Suspected breast cancer: when you should refer - in

association with NICE.
2. NICE Clinical Knowledge Summaries. Breast cancer - managing family
history.
Key things for you to remember
 The most typical presenting feature in oesophageal cancer is dysphagia, with risk
factors including obesity, excess alcohol consumption, smoking, coeliac disease
and Barrett's oesophagus
 Constipation with an identifiable cause in the absence of any other alarm
symptoms does not require urgent referral for suspected colorectal cancer.
 Criteria exist to aid referral for those at risk of breast cancer based on their family
history.
 Gout can arise from treatment with pyrazinamide
 Prolonged paroxysms of coughing associated with vomiting raise the possibility
of pertussis infection in adults
 Warfarin treatment within therapeutic range can unmask underlying malignancy
and haematuria should not be disregarded or simply attributed to warfarin
therapy
 If after three to four weeks there is only minimal (or absent) response to SSRI,
you should consider increasing the dose or changing to an alternative agent
 With a very high waist circumference (>88 cm) and, in the absence of co-
morbidities, the initial management of obesity should be diet and exercise with
consideration of drug treatment which should be discussed
 When treatment with an oral 'traditional' NSAID such as ibuprofen (or a COX-2
inhibitor) is prescribed a proton pump inhibitor with the lowest acquisition cost
should be co-prescribed
 The Faculty of Pain Management set a clear threshold for maximum dose for oral
morphine use: "A maximum dose of drug should be defined at initiation, and this
should not exceed oral morphine equivalent 120mg/day."