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Homework answers / question archive / The CEO was keen to see more product development and saw a strengthening of the research and development functions in both product divisions
The CEO was keen to see more product development and saw a strengthening of the research and development functions in both product divisions. Whilst it was recognised that the recent issue with the product recall was a concern, it should not deter the company from launching new products, particularly in the area of precision farming. The CEO felt that they were now placing too much emphasis on the financial performance and although the share price had dropped in response to the product recall he suggested that the EMT should be looking at a much wider review of performance measures. He suggested that they adopt the Balanced Scorecard as the basis of a performance management system and asked each member of the EMT to think about the performance measures that would be important for their area.
1 In pseudomembranous colitis, what is the first treatment of choice, metronidazole or vancomycin?
2 Is Crohn's disease considered as an autoimmune disease. If it is, are there other predisposing factors to it other than genetics? If it is not, what is its nature?
3 Why does carcinoma of the ascending colon cause more anaemia than obstruction, and carcinoma of the descending colon more obstruction features and less anaemia?
4 Can you explain why a patient with colorectal carcinoma might present with diarrhoea and abdominal pain?
5 What causes the blood to be altered in the presentation of melaena: is it intestinal juice?
6 What is the differential diagnosis of multiple rectal ulcers in an 18-yearold female?
7 What is the best surgical technique in a chronic (2-3 years) painful anal fissure that is located sagittally posteriorly?
8 Can I make a diagnosis of irritable bowel syndrome (IBS) in a 40-year-old female patient without doing gastrointestinal investigations?
9 What is the cause of abdominal bloating, which is often a symptom in patients with irritable bowel syndrome (IBS)?
10 1. Where is the Traub's area situated anatomically? 2. What does it mean if it is dull on percussion? 3. What is the proper way to percuss this area?
Answer:
1 Metronidazole is the first choice, largely due to the cost of oral vancomycin.
2 Crohn's disease is not usually considered to be an autoimmune disease, although the immune system is very involved in the pathological process. We do not know the exact cause of Crohn's disease but it is felt by most that some aetiological agent (perhaps a bacterium?) stimulates the immune system to over-respond in a genetically susceptible person. CARD 15 gene mutations contribute to disease susceptibility. Further reading Podolsky D (2002) Inflammatory bowel disease. New England Journal of Medicine 347: 417-429.
3 Carcinoma of the caecum and ascending colon tend to bleed and cause anaemia but not obstruction because of the large size and 'give' in the right side of the colon. The reverse is true of the descending colon; a carcinoma is more likely to obstruct the smaller, more rigid left colon.
4 Very often, the symptoms are not related and the colorectal cancer is found incidentally when a patient is investigated for pain or diarrhoea. Right-sided colonic lesions do not usually produce gut symptoms. Lesions in the sigmoid do, probably by partial obstruction.
5 No; it is bacteria.
6 Multiple rectal ulcers are common in inflammatory bowel disease. They also occur in infective proctitis (e.g. due to amoebae) or in sexually transmitted infections (e.g. herpes viral infections). Rectal spread occurs in gonococcal infection and can produce ulcers. The answer is to take samples for cultures and biopsies for histological diagnosis.
7 A lateral internal sphincterotomy is the best surgical procedure. This is the advice of the American Gastroenterological Association (AGA) in its Medical Position Statement 2002.
8 You must first make sure that there are no 'alarm' symptoms (Box 6.1). Take a very careful history because most patients of this age with IBS will have a preceding history of IBS. Simple blood tests and a follow-up of the patient are also very helpful in the diagnosis.
9 This is difficult to answer! We agree this is a very common symptom. It is not due to air/wind, which most patients think.
10 Traub's space is an area of resonance overlying the gas bubble in the left lateral hemithorax. Its size and localization depend on the contents and position of the stomach. Percuss with the patient on his or her right side.
