MODULE 16 EMQs
Match each clinical vignette to the correct diagnosis.
Addisonian Crisis
Congenital adrenal hypoplasia
Panhypopituitarism
Cushing’s disease (pituitary adenoma)
Waterhouse Freidrichsen syndrome
Adrenal adenoma
Renal tubular acidosis
Diabetes Mellitus
Neurogenic diabetes insipidus
Acetazolamide toxicity
Nephrogenic diabetes insipidus
Milk-alkali syndrome
Frusemide toxicity
Primary hyperparathyroidism
Secondary hyperparathyroidism
Addisonian Crisis
Congenital adrenal hypoplasia
Panhypopituitarism
Cushing’s disease (pituitary adenoma)
Waterhouse Freidrichsen syndrome
Adrenal adenoma
Renal tubular acidosis
Diabetes Mellitus
Neurogenic diabetes insipidus
Acetazolamide toxicity
Nephrogenic diabetes insipidus
Milk-alkali syndrome
Frusemide toxicity
Primary hyperparathyroidism
Secondary hyperparathyroidism
EMQ 1.
A 67 year old man is brought into the emergency department with a decreased level of consciousness. He was seen 6 weeks previously and diagnosed with polymyalgia rheumatica.
His vital signs are:
HR 110 /min
BP 72/41 mmhg
RR 26 /min
Sats 99% RA
GCS 6
A blood gas shows:
pH 7.15
CO2 32 mmHg
HCO3 17 mmol/L
Na 121 mmol/L
K 7.2 mmol/L
Cl- 101 mmol/L
Answer: addisonian crisis
Comment: this patient has a disease almost uniformly treated with corticosteroids. The combination of a non-anion gap acidosis, hyponatraemia and hyperkalaemia is highly suggestive of an addisonian crisis.
EMQ 2.
A 57 year old woman presents with weight gain, fatigue and difficulty with her vision. On clinical examination she has a bitemporal hemianopia.
Her vital signs are:
HR 68 /min
BP 156/99 mmhg
RR 21 /min
Sats 99% RA
GCS 15
A blood gas shows:
pH 7.55
CO2 44 mmHg
HCO3 30 mmol/L
Na 151 mmol/L
K 3.2 mmol/L
Cl- 101 mmol/L
Glucose 10.2 mmol/L
Answer: Cushing’s disease (pituitary adenoma)
Comment: the clinical history is consistent with glucocorticoid excess, and the visual changes make it likely that there is a primary pituitary adenoma
EMQ 3.
A 37 year old woman presents increasing urinary frequency. She has a history of lithium use for bipolar disorder.
Her vital signs are:
HR 68 /min
BP 156/99 mmhg
RR 21 /min
Sats 99% RA
GCS 15
Pathology shows:
Na 149 mmol/L
K 5.2 mmol/L
Cl- 101 mmol/L
Osmm 301 mosm/Kg
Her urinary osmolality is measured at 100mosm/Kg
Answer: Nephrogenic diabetes insipidus
Comment: the presence of hyperosmolar serum and dilute urine with a history of polyuria suggests diabetes insipidus. Lithium is associated with nephrogenic diabetes insipidus.
EMQ 4.
An 82 year old man presents with a left hip fracture. He has taken calcium supplements and vitamin D for a long period of time for osteoporosis.
Pathology shows:
pH 7.50
CO2 46 mmHg
HCO3 32 mmol/L
Na 139 mmol/L
K 5.1 mmol/L
Cl- 101 mmol/L
PO4 0.5 mmol/L
Ca 3.1 mmol/L
Answer: Milk-alkali syndrome
Comment: The ingestion of large amounts of calcium and an alkali (usually as calcium carbonate) can be associated with metabolic alkalosis, hypercalcaemia and renal failure. Classically the milk-alkali syndrome occurred with peptic ulcer treatment, but can occur in older people on calcium supplements.
EMQ 5.
A 26 year old man presents with dyspnoea and weakness. He mentions a history of “kidney problems” and says he is non compliant with his medication.
Pathology shows:
pH 7.20
CO2 21 mmHg
HCO3 9 mmol/L
Na 138 mmol/L
K 2.1 mmol/L
Cl- 123 mmol/L
Urea 4.5 mmol/L
Cr 55 umol/L
Answer: Renal tubular acidosis
Comment: This patient has normal renal indices and a non-anion gap metabolic acidosis complicated by life threatening hypokalaemia. This suggests either a proximal or distal RTA.
A 67 year old man is brought into the emergency department with a decreased level of consciousness. He was seen 6 weeks previously and diagnosed with polymyalgia rheumatica.
His vital signs are:
HR 110 /min
BP 72/41 mmhg
RR 26 /min
Sats 99% RA
GCS 6
A blood gas shows:
pH 7.15
CO2 32 mmHg
HCO3 17 mmol/L
Na 121 mmol/L
K 7.2 mmol/L
Cl- 101 mmol/L
Answer: addisonian crisis
Comment: this patient has a disease almost uniformly treated with corticosteroids. The combination of a non-anion gap acidosis, hyponatraemia and hyperkalaemia is highly suggestive of an addisonian crisis.
EMQ 2.
A 57 year old woman presents with weight gain, fatigue and difficulty with her vision. On clinical examination she has a bitemporal hemianopia.
Her vital signs are:
HR 68 /min
BP 156/99 mmhg
RR 21 /min
Sats 99% RA
GCS 15
A blood gas shows:
pH 7.55
CO2 44 mmHg
HCO3 30 mmol/L
Na 151 mmol/L
K 3.2 mmol/L
Cl- 101 mmol/L
Glucose 10.2 mmol/L
Answer: Cushing’s disease (pituitary adenoma)
Comment: the clinical history is consistent with glucocorticoid excess, and the visual changes make it likely that there is a primary pituitary adenoma
EMQ 3.
A 37 year old woman presents increasing urinary frequency. She has a history of lithium use for bipolar disorder.
Her vital signs are:
HR 68 /min
BP 156/99 mmhg
RR 21 /min
Sats 99% RA
GCS 15
Pathology shows:
Na 149 mmol/L
K 5.2 mmol/L
Cl- 101 mmol/L
Osmm 301 mosm/Kg
Her urinary osmolality is measured at 100mosm/Kg
Answer: Nephrogenic diabetes insipidus
Comment: the presence of hyperosmolar serum and dilute urine with a history of polyuria suggests diabetes insipidus. Lithium is associated with nephrogenic diabetes insipidus.
EMQ 4.
An 82 year old man presents with a left hip fracture. He has taken calcium supplements and vitamin D for a long period of time for osteoporosis.
Pathology shows:
pH 7.50
CO2 46 mmHg
HCO3 32 mmol/L
Na 139 mmol/L
K 5.1 mmol/L
Cl- 101 mmol/L
PO4 0.5 mmol/L
Ca 3.1 mmol/L
Answer: Milk-alkali syndrome
Comment: The ingestion of large amounts of calcium and an alkali (usually as calcium carbonate) can be associated with metabolic alkalosis, hypercalcaemia and renal failure. Classically the milk-alkali syndrome occurred with peptic ulcer treatment, but can occur in older people on calcium supplements.
EMQ 5.
A 26 year old man presents with dyspnoea and weakness. He mentions a history of “kidney problems” and says he is non compliant with his medication.
Pathology shows:
pH 7.20
CO2 21 mmHg
HCO3 9 mmol/L
Na 138 mmol/L
K 2.1 mmol/L
Cl- 123 mmol/L
Urea 4.5 mmol/L
Cr 55 umol/L
Answer: Renal tubular acidosis
Comment: This patient has normal renal indices and a non-anion gap metabolic acidosis complicated by life threatening hypokalaemia. This suggests either a proximal or distal RTA.