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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
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. 

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