ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA

KEY FEATURES PROBLEM

KFP CASE 1 (3 QUESTIONS)

KFP CASE 2 (3 QUESTIONS)
KFP CASE 3 (4 QUESTIONS)

QUESTIONS AND ANSWERS

PROGRAMME : ADVANCED TRAINING IN FAMILY MEDICINE

MODULE : 05 GIT – GASTROINTESTINAL AND HEPATOBILIARY
DISEASES (GIT 145)
KFP QUESTIONS

CASE 1 (3 QUESTIONS)

Arul Mohan, aged 45 years, presents to you for medical advice. His older brother passed away a month ago due to liver
cancer. The doctor who was treating his brother had advised family members to undergo blood test to check for their
‘liver status’. His family members are surprised because they have never had any liver problem before.

Arul has no significant past medical history. He is married with one son and working as an accountant.

On examination, Arul is obese with BMI of 30 kg/m2 and waist circumference of 110 cm. His blood pressure is 134/86
mmHg and pulse rate 76 beats per minute. Other system examinations are normal.

Arul is worried if he will get the same liver disease as his brother.

Case 1, Question 1, (30%)

What specific relevant history would you like to take from him? Write in note form six (6) relevant histories. (3 marks)

Code Answer/Description of key words or phrases Score

1 Family history of hepatitis infection 0.5
2 Family history of liver disease 0.5
3 History of prolonged exposure to chemicals / liver carcinogens 0.5
4 History of traditional / complimentary medicine 0.5
5 History of taking anabolic steroid consumption 0.5
6 History of hepatitis B immunization 0.5
7 History of promiscuity/ multiple partners/ unprotected sex/ MSM 0.5
8 Excessive alcohol intake 0.5
9 History of intravenous drug use / needle sharing 0.5
10 History of tattoo 0.5
11 Alcohol intake 0
12 Drug abuse 0
13 Sexual history alone 0
History of blood transfusion – Case stated that he has no past medical
14 0
history
Fatty liver or symptoms of liver cirrhosis - Case stated that he has no past
15 0
medical history

Number of responses requested = 6

Number of responses accepted = 10
Total score for this question = 3
Percent value of question = 30%

Comments
This question is for asking specific histories regarding risk for liver disease including congenital/hereditary and acquired
causes.
Case 1, Question 2, Select (40%)
What investigations are you going to do for him now? Select five (5) investigations. (4 marks)

Code Answer Score

1 Liver function test 1
2 Fasting serum lipid 1
3 Anti Hep C 1
4 Hep Bs Ag 0.5
5 Hep Bs Ab 0.5
6 FBS 0.5
7 Hba1c (link to 6) 0.5
8 Abdominal ultrasound 0
9 Urine bilinogen 0
10 Serum alpha fetoprotein 0
11 FibroScan 0
12 Renal profile 0
13 Thyroid function test 0
14 ESR 0
15 HIV I & II 0
16 Liver biopsy 0
17 HBe Ag 0
18 Anti HBe 0

Number of responses requested = 5

Number of responses accepted = 6 (number 7 is link to no 6)
Total score for this question = 4
Percent value of question = 40%

Comments:
Investigations done should be the baseline to screen for current hepatitis status, other liver disease and chronic disease
to avoid liver damage in future.
Hep Bs Ag & Ab are given 0.5 mark because next question is a clue for this answer.
FBS – he has obesity, glucose screening is acceptable as part of screening of fatty liver
Further Hepatitis B profile and liver ultrasound should be done as second line investigations.

Case 1 (continue)
A week later, he comes to see you for his blood results and he turns out to be a hepatitis B carrier. Arul would like to
know more on what he should do now.

Case 1, Question 3, Write in (30%)

What would be your non-pharmacological advice? Write in note form six (6) management strategies. (3 marks)

Code Answer/Description of key words or phrases Score

1 His wife and son should get tested 0.5
His family should be vaccinated if they are
2 0.5
negative of hepatitis infection
3 Advise him to lose weight 0.5
4 He should avoid excessive alcohol intake 0.5
5 He should avoid hepatotoxic drugs 0.5
He will need to undergo further quantitative
6 0.5
tests for hepatitis B
 He needs proper follow up with liver
7 0.5
ultrasound 6 months to 12 monthly
8 He will need to do 6 monthly LFT and AFP 0.5
He might need to be referred to physician for
9 initiation of treatment if his liver enzymes 0.5
worsen.
‘Family alone’ should get tested – not specific
10 0
which family member

Number of responses requested = 6

Number of responses accepted = 9
Total score for this question = 3
Percent value of question = 30%

Comments
Answers are on how to manage a Hepatitis B carrier and also strategies to avoid further damage to his liver eg: excessive
alcohol intake or taking hepatotoxic drugs.

CASE 2 (3 QUESTIONS)

Agnes Lee aged 65 years, presents with a three-month history of intermittent passing of fresh blood in the stools. This is
associated with feeling of incomplete bowel emptying. She also feels more tired than usual. There is no significant loss of
weight. Agnes was previously well and has been taking a balanced diet. She does not smoke, consume alcohol or take
any traditional medication.

On examination, she has mild pallor, her blood pressure is 110/70 mmHg, pulse 90 beats per minute and temperature is
37℃. Abdominal and other systemic examinations are normal. Proctoscopy and digital rectal examination did not reveal
any abnormality.

Case 2, Question 1
What are the most likely diagnoses? Write in note form FOUR (4) most likely diagnoses. (5 marks)

Code Answer/Description of key words or phrases Score

1 Carcinoma of colon 2
2 Arterio-venous malformation 1
3 Gastrointestinal lymphoma 1
4 Diverticulosis 1
5 Inflammatory bowel disease (uncommon to present at later age) 0.5
6 Hemorrhoids (less likely as proctoscopy examination is normal) 0.5
7 Mesenteric ischemia (presents with abdominal pain and weight loss in chronic cases) 0

Number of responses requested = 4

Number of responses accepted = 6
Total score for this question = 5

Comments
The answers given are the most common causes of per rectal bleeding in an elderly person. The symptoms of incomplete
bowel emptying and tiredness favors carcinoma of colon. Inflammatory bowel disease rarely starts in the elderly age group
hence it is further down the list. Hemorrhoids is less likely in this case. Mesenteric ischemia does not present with per
rectal bleeding. (occult blood may be present)
Case 2, Question 2
What are the more important investigations would you arrange for this patient to aid in your diagnosis?
Select TWO (2) investigations. (2 marks)

Code Answer/Description of key words or phrases Score

1 Colonoscopy 1
2 Full blood count 1
3 iFOBT (immunochemical fecal occult blood test) 0
4 Liver function test 0.5
5 Renal function test 0.5
6 Serum carcinoembryonic antigen 0.5
7 Serum ferritin 0.5
8 Serum iron 0.5
9 Sigmoidoscopy 0.5
10 Ultrasound abdomen 0.5

Number of responses requested = 2

Number of responses accepted = 9
Total score for this question = 2

Comments
Colonoscopy and full blood count are the two more important investigations to aid in the diagnosis. The rest are supportive
investigations. Sigmoidoscopy is not very useful. iFOBT is not a correct choice as patient is having fresh bleeding.

Case 2 (continue)
You referred her to hospital and Agnes came back to you after two months.
She informed you that she had an operation done that involved part of her bowel and she now has a stoma.

Case 2, Question 3
What should Agnes look out for to ensure that her stoma is healthy? Write in note form THREE (3) signs and symptoms.
(3 marks)

Code Answer/Description of key words or phrases Score

1 Presence any bleeding 1
2 Any change of color of surrounding skin indicating necrosis 1
3 Presence of vomiting indicating bowel obstruction 1
4 Abnormal output amount from the stoma 1
5 Peristomal skin excoriation 1

Number of responses requested = 3

Number of responses accepted = 5
Total score for this question = 3

Comments
Stomas may be temporary or permanent, depending on their indication and patient comorbidities. Indications for
ileostomy and colostomy include bowel resection for benign, malignant or inflammatory bowel disease, congenital
anomalies or continence problems. It is important that clinicians have a basic understanding of stomas, are aware of the
significance of certain examination findings and know when to refer to a surgeon or stomal therapy nurse (STN).
Complications of stomas are relatively common, with the literature citing rates as high as 37–56%. Many complications
are dependent on surgical factors, including site selection and stoma construction. However, diabetes, obesity and
smoking may also predispose complications. Early complications include stomal necrosis, dehiscence and retraction.
Later complications include stomal stenosis, parastomal hernia and prolapse. Other complications that may occur at any
time are bleeding, peristomal skin excoriation, bowel obstruction and high stromal output.

Reference:
1. Rectal bleeding in general practice: new guidance on commissioning Ciaran J Walsh, Simon Delaney and Andrew
Rowlands British Journal of General Practice 2018; 68 (676): 514-
515. DOI: https://doi.org/10.3399/bjgp18X699485 https://bjgp.org/content/68/676/514
2. Approach to lower gastrointestinal bleeding in adults: Uptodate
https://www.uptodate.com/contents/approach-to-acute-lower-gastrointestinal-bleeding-in-adults
3. Care of patients with stomas in general practice https://www1.racgp.org.au/getattachment/ed23b9f5-4c7c-4514-
8979-b42eaef9234b/stomas-in-GP.aspx
4.

CASE 3 (4 QUESTIONS)

Sam Liew, aged 46 years, presents to your practice with a two- year history of increasing heartburn and soreness in his
throat. The discomfort sometimes spreads throughout his chest and occasionally can be felt in his back.

Initially his symptoms occurred monthly but now over the last six months, he notices daily symptoms after meals and
soon after going to bed. His symptoms worsen with spicy and large meals. He takes a glass of wine daily with his dinner.

He always thought his condition to be ‘wind related’ and has been self-medicating with over-the-counter antacids with
good relief but seems to be needing frequent doses lately.
Despite this, his weight has been steady with BMI of 35kg/m2.

Case 3, Question 1,
What are your differential diagnoses? Write in note form TWO (2) differential diagnoses [3 marks]

Code Answer/Description of key words or phrases Score

1 Gastro-esophageal reflux disease 2
2 Eosinophilic esophagitis 1
3 Angina 1
4 Peptic ulcer disease 1
5 Chronic pancreatitis 0.5
6 Hiatus hernia 0.5
7 Biliary colic 0.5

Number of responses requested = insert number here, 2

Number of responses accepted = insert number here, 6
Total score for this question = 3

Explanation:
The most common presenting symptoms of GERD are heartburn (a burning sensation); retrosternal, rising discomfort;
and regurgitation (the occurrence of sour-tasting, acidic gastric contents in the back of the throat or mouth without a
vomiting action.

The intermittent, non-progressive nature of his dysphagia without anorexia and weight loss makes a malignancy unlikely,
and it is not a sufficient trigger for endoscopy. However, this presentation requires careful prospective observation.
Other alarm symptoms include recurrent vomiting, anaemia, haematemesis or melaena.
A differential diagnosis to GERD is eosinophilic oesophagitis, an allergic condition with wide-ranging symptoms, although
dysphagia is the most predominant symptom. There is often a history of atopy (e.g. eczema, allergic rhinitis, asthma)
and a history of intermittent food bolus obstruction. Although more frequent in males, it remains much less common
than GERD.

A careful assessment for exertional exacerbation of chest pain is important to exclude angina, and appropriate
assessment is recommended if there is any concern.
Biliary colic can present in bouts and can have spontaneous relieve

Case 3, Question 2,
What would be the most appropriate pharmacological treatment? Write in full ONE medication with generic name,
route, dose, and duration. (1 mark)

Code Answer/Description of key words or phrases Score

1 H2 receptor antagonist blocker
T. cimetidine 800mg twice daily orally for 12 weeks
or
1
T. famotidine 20mg twice daily orally for six weeks
or
T. nizatidine 150mg twice daily orally for four weeks
2 Proton pump inhibitors
T. omeprazole 20mg once a day orally for four weeks
or
T. lansoprazole 15mg once a day orally for eight weeks
or
1
T. rabeprazole 20mg once a day orally for four to eight weeks
or
T. esomeprazole 20-40 mg once a day orally for four to eight weeks
or
C. dexlansoprazole 30 mg once a day orally for four weeks
3 Antacids 0
4 Prokinetics 0
Number of responses requested = 1
Number of responses accepted = 2
Total score for this question = 1

Case 3, Question 3,
What are the non-pharmacological advice you would give Sam? Write in note form SIX (6) advice. (3 marks)

Code Answer/Description of key words or phrases Score

1 Elevate head end of bed 0.5
2 Avoid alcohol 0.5
3 Avoid caffeine 0.5
4 Stop smoking 0.5
5 Lose weight to achieve healthy BMI 0.5
6 Eat at least two hours before bedtime 0.5
7 Limit provoking foods/drinks 0.5
8 Take smaller meals particularly at night 0.5

Number of responses requested = 6

Number of responses accepted = 8
Total score for this question = 3

Case 3, Question 4
When will you send Sam for endoscopy? Write in note form SIX (6) indications. (3 marks)

Code Answer/Description of key words or phrases Score

1 Significant dysphagia or odynophagia 0.5
2 Hematemesis, melena 0.5
3 Anemia 0.5
4 Weight loss 0.5
5 Persistent vomiting 0.5
6 Inadequate response to standard medication after four to eight weeks 0.5
7 First degree relative with gastric cancer 0.5
Endoscopy is indicated if diagnostic clarification is required – for
8 example, when reflux is thought to be responsible for dental erosions, 0.5
globus sensation, vocal hoarseness, laryngitis, cough and wheeze

Number of responses requested = 6

Number of responses accepted = 8
Total score for this question = 3

Reference:
1. Check, unit 556, December 2018: Digestive https://gplearning.racgp.org.au/Content/2022/check/2018/Dec.pdf
2. Gastroesophageal reflux disease treatment and management https://emedicine.medscape.com/article/176595-
treatment