MLA Domain 5 · Presentation
Constipation
21 conditions in Finalist present this way. Work down the list and ask what would separate each one from the next — that discriminator is the exam question.
classic presentation · 6
NEW change in bowel habit, rectal bleeding, weight loss, anaemia, abdominal/rectal mass, age ≥50 → investigate for color
Intestinal perforation/GI bleeding (third week) → surgical emergency
Myxoedema coma (hypothermia, bradycardia, reduced consciousness, hyponatraemia) → emergency
Hypercalcaemia, acute kidney injury, or metastatic spinal cord compression → emergencies
Incarcerated/irreducible prolapse with ischaemia → urgent reduction/surgery
Ischaemia/perforation (peritonism, raised lactate, free gas) → emergency surgery
recognised feature · 12
LATERAL or multiple fissures → consider Crohn, infection (HIV/syphilis/TB) or anal cancer — investigate
Symptomatic postural hypotension with falls; severe gastroparesis; coexisting cardiac autonomic involvement
Severe hypercalcaemia (≥3.5 / symptomatic) → IV fluids + treat the cause; hypercalcaemia of malignancy → IV fluids then
Hypoactive delirium is easily missed; a new acute confusion is delirium until proven otherwise — find the cause
Severe (>3.5 mmol/L) or symptomatic (confusion, dehydration, arrhythmia) → emergency IV fluids + bisphosphonate
Severe (>3.5) / symptomatic hypercalcaemia → emergency IV fluids + bisphosphonate
Strangulation/ischaemia (constant pain, peritonism, fever, raised lactate) → emergency surgery
Red flags → investigate, NOT IBS: rectal bleeding, weight loss, anaemia, nocturnal symptoms, family history of bowel/ova
Underlying small-cell lung cancer — investigate (CT chest, and re-screen if initially negative); respiratory/bulbar invo
Early falls/postural instability, vertical gaze palsy, early autonomic failure, or symmetry/poor levodopa response → a P
Hyperkalaemia with ECG changes (or K ≥6.5) → EMERGENCY: IV calcium gluconate first (cardioprotection) then insulin-dextr
Severe hypercalcaemia (>3.5) or hypercalcaemic crisis (confusion, dehydration, arrhythmia) → emergency (IV fluids ± bisp
differential of the above · 3
2-week-wait referral: age ≥40 with weight loss + abdominal pain; ≥50 with rectal bleeding; ≥60 with iron-deficiency anae
Severe/complicated falciparum malaria (cerebral, hypoglycaemia, acidosis, AKI, high parasitaemia) → medical EMERGENCY →
Perforation (sudden deterioration, free air, peritonitis) → emergency colectomy