Nutrition

1.An 89-year old was admitted with a severe community-acquired pneumonia. Their family reported that the patient was struggling to manage at home and they were concerned about ongoing weight loss. The family did not think the patient had eaten properly for the past seven days. The patient used to weigh 75 kg but on this admission weighed 63 kg. Their body mass index (BMI) was 24.6 kg/m².

What is their Malnutrition Universal Screening Tool (MUST) score?

A. 0

2.A 67-year-old woman presented to the outpatient clinic with a 14-month history of diarrhoea, nausea, fatigue, and 12 kg weight loss. She had a past medical history of hypertension, chronic kidney disease, type 2 diabetes, osteoarthritis, and hypothyroidism.

Investigations:

Haemoglobin	116 g/L
Mean corpuscular volume (MCV)	87 fL
Serum ferritin	21 µg/L
Serum C-reactive protein (CRP)	<0.2 mg/L
Vitamin B12	421 ng/L
Serum folate	4.1 µg/L
Thyroid-stimulating hormone (TSH)	2.3 mU/L
IgA tissue transglutaminase antibody	<0.2 U/mL
Total IgA	1.26 g/L
Human leucocyte antigen (HLA) status	DQ2.5 homozygote
Gastroscopy	Scalloped duodenal mucosa
Duodenal histology	Marsh 3B villous atrophy and crypt hyperplasia with intra-epithelial lymphocytosis

Which of her medications is most likely to be the cause of her symptoms?

3.A 46-year-old woman presented with a long history of fullness after eating, nausea, and weight loss with a current BMI of 17.3 kg/m². There was no history of diabetes, previous abdominal surgery, or psychiatric illness. Despite dietary manipulation and a trial of nasogastric feeding, she continued to lose weight.

Investigations:

Gastroscopy	Normal
Computed tomography (CT) chest and abdomen	No evidence of bowel obstruction or malignancy
Gastric scintigraphy	85% retention at two hours
	40% retention at four hours

What is the best next step in management?

A. Amitriptyline 10 mg once a day and refer for urgent psychiatric assessment

B. Commence parenteral nutrition

C. Long-term metoclopramide 10 mg three times a day

D. Refer for surgical jejunostomy

E. Trial of nasojejunal feeding

4.A 55-year-old woman with secondary progressive multiple sclerosis developed recurrent lower respiratory tract infections. A percutaneous endoscopic gastrostomy was placed two years ago for long-term enteral tube feeding and to reduce aspiration risk. The patient presented with difficulty flushing the tube and leakage around the gastrostomy site.

Which of the following statements is most accurate?

A. Balloon gastrostomies are more likely to become buried than ones with a silicon disc

B. Buried bumper syndrome is difficult to prevent even with good nursing aftercare

C. Buried bumper syndrome should be suspected if the enteral feed pump alarms regularly

D. Buried bumpers are mostly managed with surgical removal of the gastrostomy

E. Gastrostomy tubes can be safely advanced into the stomach within three days of initial insertion

5.A 45-year-old man with Crohn’s disease presented to the emergency department with unsteady gait, impaired concentration, dysarthria, loose stools, and blurred vision. Following previous operations, he had been left with 80 cm small bowel in continuity with a full colon. His only medications were omeprazole and loperamide. He denied any recreational drug use but admitted to consuming a large amount of beer over the past three days. His diet was poor, largely comprising carbohydrate-based meals. Examination revealed nystagmus and dysmetria on finger–nose testing. Abdomen was soft and non-tender.

Investigations:

Serum sodium	138 mmol/L
Serum potassium	3.2 mmol/L
Serum urea	2.1 mmol/L
Serum creatinine	66 mmol/L
Serum chloride	106 mmol/L
Serum glucose	6.7 mmol/L
Arterial pH	7.21
Arterial lactate	1.9 mmol/L
Arterial HCO₃	8 mmol/L

What is the most likely diagnosis?

A. Acute alcohol intoxication

B. Beer potomania

C. Diabetic ketoacidosis

D. D-lactic acidosis

E. Wernicke’s encephalopathy

6.A 45-year-old man with a history of small bowel Crohn’s disease had undergone multiple ileal resections for stricturing disease. His current anatomy was 80 cm jejunum anastomosed to full colon with no evidence of active inflammation. He presented with a one-day history of severe left loin pain radiating into his groin with macroscopic haematuria.

Investigations:

CT kidney, ureter, bladder

Large non-obstructing calculus at the left vesico-ureteric junction

Which of the following dietary measures would you recommend?

A. Increasing dietary beetroot

B. Increasing dietary chocolate

C. Increasing dietary fat

D. Reducing dietary calcium

E. Reducing dietary spinach

7.A 19-year-old being managed for dysmotility and gastroparesis presented with ongoing weight loss and diarrhoea. Feeding via a surgical jejunostomy had not been tolerated due to pain at the insertion site and bloating on increasing rate of feed administration. The patient demanded this be removed. She was commenced on parenteral nutrition but would not allow the rate of feeding to be increased in line with recommendations from the nutrition team. The nursing staff commented that she could be manipulative, and the portering staff frequently saw her running up and down the stairs.

Investigations:

Urinary laxative screen

Positive

What would be the next best step in management?

A. Nasogastric feeding

B. Refer to psychological medicine

C. Remove jejunostomy and continue current rate of parenteral feeding

D. Restart jejunal feeding against patient’s wishes

E. Sedate patient and increase rate of parenteral feeding

8.A 57-year-old was established on parenteral nutrition due to short bowel syndrome. They received 2 500 ml over 12 hours, 7 nights per week (1 400 kcal glucose, 14 g nitrogen, sodium 120 mmol, potassium 60 mmol, magnesium 14 mmol). They were admitted with a suspected central line infection but were haemodynamically stable. Their vascular access was difficult but you were able to insert a 22G cannula.

What is the best option for management over the subsequent 24 hours?

A. Encourage the patient to drink water; no intravenous support required

B. Prescribe 1 litre 0.9% sodium chloride with 40 mmol potassium chloride, 1 litre 0.9% sodium chloride with 14 mmol magnesium sulphate, and 500 ml 5% dextrose to be administered through the 22G cannula

C. Prescribe 1 litre 0.9% sodium chloride with 40 mmol potassium chloride, 1 litre 5% dextrose with 14 mmol magnesium sulphate, and 500 ml 5% dextrose with 20 mmol potassium chloride to be administered through the 22G cannula

D. Prescribe usual parenteral nutrition to be administered through the 22G cannula

E. Prescribe usual parenteral nutrition to be administered through the central venous catheter

9.A 56-year-old man had undergone small bowel resection with primary anastomosis in the context of small bowel volvulus. Following an anastomotic leak, he developed an enterocutaneous fistula and is now six weeks following his last surgery. He had lost 12 kg in weight and was losing 1200 ml of effluent through the fistula per day. He was haemodynamically stable and CRP had been reducing.

Investigations:

CT abdomen

Multiple small intra-abdominal abscesses, too small to drain radiologically

What of the following is most appropriate at present?

A. Commence octreotide

B. Laparoscopic formation of stoma proximal to fistula

C. Prolonged course of antibiotics

D. Unrestricted oral intake

E. Urgent repeat laparotomy and washout

10.A 35-year-old woman was reviewed in clinic. She had been on home parenteral nutrition for eight years for short bowel syndrome and had had three central line infections. She had a thrombosed right internal jugular and left subclavian vein.

Investigations:

Parameter (units)	6 months ago	Currently
Serum bilirubin (μmol/l)	24	94
Serum alanine transferase (ALT) (U/L)	37	153
Serum alkaline phosphatase (ALP) (U/L)	117	326