Focused history. Ascites and chronic diarrhoea.

A 60 (ish) year old woman was introduced to the candidates for a tutorial for a prep class for the FCPS 2 exam.

Observation: she was in distress and had trouble getting up from her chair, walking up to the examination couch and climbing up onto it and asked to remain sitting up, as lying down made her uncomfortable. She appeared emaciated, tired and appeared to have muscle weakness in all her movement. She was not obviously breathless but looked as if she had been ill for months. Her legs were swollen. All this was visible to a casual observer. Remember when you were taught to start your examination of the patient from when they entered the room?

The candidate asked her name, her age, whether she was married, how many children she had, what was her occupation, what her husband did and whether her mother and father had diabetes or hypertension or if any other member of her family suffered from these diseases. Is this a job interview or a sociology survey? You can understand that as an examiner my level of frustration is sky-high as none of us is any nearer to making a diagnosis or finding out what is wrong with her. All this information can be obtained later for filling in the slots on the admissions form. You are preparing to present her case or the information about her illness before 2 examiners in order to demonstrate that you know how to make an intelligent and quick diagnosis. Remember you have 1/2 an hour to take a history and examine her. Start by asking her how she feels and which symptom brought her to the hospital.

She said that it was her swollen stomach which brought her to the hospital. Remember the patients use the word stomach or tummy synonymously with abdomen.  The next question was “Did the swelling start around the eyes?” Is this 60-year-old likely to be suffering from post streptococcal glomerulonephritis in which the fluid retention is initially mild and the patient or the patient’s mother (usually the disease is seen in children and teenagers) notices it in the periorbital region before the feet? You are thinking of the wrong disease. On the tutor’s prompting the candidate asked “How long have you been ill and what else is wrong with you?”

The answer was “I have been ill for over 6 months, have had loose motions with abdominal pain, then my feet became swollen and so did my stomach. I have very little appetite and have stopped eating rice and chappatis and vegetables as I feel worse when I eat solid food”. The candidate jumped to the natural conclusion that the poor lady had coeliac disease!!! The commoner diseases vying for a differential diagnosis are intestinal tuberculosis, inflammatory bowel disease, (not IBS as that does not cause malnourishment to an extensive degree), chronic pancreatitis, protein losing enteropathy either primary or secondary to chronic liver disease specially cirrhosis, small intestine bacterial overgrowth (SIBO), small gut lymphoma etc. If you do eventually prove that she has adult coeliac disease you will not pass the exam but you can write it up for a medical journal!!! At least you will have been wrong for making an intelligent D/D. The chances are you might even pass.

Questions you are likely to be asked.

  • Why does she need to go to the toilet whenever she eats? The answer is not that she has gluten enteropathy or a food allergy but whenever the intestines are inflamed there is intestinal hurry i.e. the intestines have a wave of peristalsis so that the intestine empties rapidly. It is part of the disease.
  • How can you distinguish between food allergy and gluten enteropathy?
  • What tests will you do to make a diagnosis of intestinal tuberculosis?
  • Explain what is a PCR or polymerase chain reaction?
  • How will you diagnose SIBO? Explain a carbon breath test.
  • How will you confirm that she has CIBD?
  • Why does chronic pancreatitis cause diarrhoea? How will you confirm the diagnosis?
  • Does this lady have the Zollinger Ellison syndrome? If yes why? If no why not?
  • She has been given a PPI for the past six months. How does this effect her disease?
  • How will you manage her loose motions? What dietary advice will you give her?
  • If your diagnosis of intestinal TB prove to be right how soon will you expect a response to antiTB drugs?
  • If she is anemic how will you manage her anemia?
  • If she has excessive fat in her stools which minerals is she likely to be losing?

These are some of the questions the examiners are mulling over in their heads. Have fun finding the answers. I will post some more when I think of more.



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I am a Professor of Medicine and a Nephrologist. Having served in the Army Medical College, Pakistan Army for 27 years I eventually became the Dean and Principal of the Bahria University Medical and Dental College Karachi from where I retired in 2016. My passion is teaching and mentoring young doctors. I am associated with the College of Physicians and Surgeons Pakistan as a Fellow and an examiner. I find that many young doctors make mistakes because they do not understand how they should answer questions; basically they do not understand why a question is being asked. My aim is to help them process the information they acquire as part of their education to answer questions, pass examinations and to best take care of patients without supervision of a consultant. Read my blog, interact and ask questions so that I can help you more.

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