Thursday, August 14, 2008

Some practice questions for QE1

Please answer questions 1-3 based on information from the following vignette.

Mr. John Wong, a 34-year-old restaurant owner, visits his family physician’s office for a routine check-up. On repeated testing his blood pressure is elevated at 180/105 mmHg. He admits to stress at work and states that his father was diagnosed as hypertensive at the age of 60 but, thus far, has not required treatment. He has no symptoms with the exception of mild constipation for which he takes bran supplements. He is on no prescribed medication although he does admit to occasionally taking Chinese herbal remedies. He denies taking any other medications. He smokes 25 cigarettes per day but takes no alcohol. On physical examination he is not obese, has no signs of cardiovascular disease, and no hypertensive retinopathy. The results of investigations are given below: Urine analysis negative Na 146 mmol/L K 2.8 mmol/L Cl 102 mmol/L HCO3 33 mmol/L Urea 4.2 mmol/L Creatinine 92 mmol/L Glucose 6.2 mmol/L 1. What is the most likely explanation for hypokalemia

A. increased urinary losses of potassium
B. reduced dietary intake
C. surreptitious laxative abuse
D. metabolic alkalosis
E. chinese herb nephropathy

2.Which of the following investigations is/are indicated?

a. dietary intake assessment
b. captopril renal isotope scan
c. urine metanephrines
d. plasma Renin Activity
e. 24 hour urine collection for aldosterone estimation

3. Which of the following is/are appropriate step(s) in management?

a) Arrange for the patient to go to the nearest ER
b) 5 mmol of Potassium Chloride intravenously
c) Refer the patient for further investigation
d) Oral Potassium supplements
e) Thiazide diuretic for treatment of hypertension

*****

Please answer questions 4 – 6 based on information from the following vignette.

Primary hypertension is almost always the most likely diagnosis for patients with hypertension. For each patient in questions 1-3 select the SECONDARY CAUSE of hypertension worthy of investigation from choices A-N. If No secondary cause is worthy of investigation, SELECT CHOICE “O”. Choices A-O may be used once, more than once or not at all.
A. Acute renal failure
B. Birth control pills
C. Chronic renal failure
D. Coarctation of the aorta
E. Licorice ingestion
F. Pheochromocytoma
G. Polycythemia
H. Primary hyperaldosterone (mineralocorticoid excess)
I. Renal artery stenosis, bilateral
J. Renal artery stenosis, unilateral
K. Renal parenchymal disease
L. Sympathomimetics (e.g. ephedrine for nasal congestion)
M. Transplant donor
N. White coat hypertension
O. None of the above

4. Mr. Harry Conroy, a 52-year-old newspaper assistant editor, is seen in the office of his family physician complaining of blood in the urine over the past four days. He states that he has had this on two previous occasions, both in relation to an upper respiratory tract infection. On both previous occasions the urine cleared spontaneously over a period of five to seven days. At the time of the present visit he states that he has been feeling lethargic with a sore throat for the past five days. He is a vegetarian and smokes a pack of cigarettes each day. Blood pressure is 170/95 mmHg in both arms, sitting and supine, on repeat testing. Urine analysis shows specific gravity 1020, nitrites negative, +++ blood and +++ protein. Urine microscopy reveals oxalate crystals, dysmorphic red blood cells and red cell casts.

5. Mr. James McKeen, a 49-year-old tax assesor, visits his family physician’s office for his monthly blood pressure check. He has been hypertensive for the past four years and his blood pressure control has been erratic during this time. His only other medical problem is gout, which he experiences on average once every eighteen months. He continues to smoke two packages of cigarettes per day. He has a maternal family history of hypertension and cerebrovascular disease and a paternal family history of lung carcinoma. His present antihypertensive medications are hydrochlorothiazide and adalat XL. On physical examination he is obese with blood pressure is 174/96 mmHg. Urine analysis at his last three visits has shown a trace of protein. Urine microscopy is unremarkable. A 24 hour urine collection shows a normal creatinine clearance with excretion of 340mg of albumin during this time period. Serum liver enzymes are normal.

6. Ms. Jane Wallace, a 29-year-old interior decorator, visits his family physician’s office for a routine check-up. On repeated testing her blood pressure is elevated at 180/105 mmHg. She admits to stress at work and states that her father was diagnosed as hypertensive at the age of 60 but, thus far, has not required treatment. She has no symptoms with the exception of mild constipation for which she takes bran supplements. She is on no prescribed medication although she does admit to occasionally taking Vitamins C and E. She denies taking any other medications. She does not smoke but takes alcohol socially. On physical examination she is not obese, has no signs of cardiovascular disease, and no hypertensive retinopathy. The results of investigations are given below: Urine analysis negative Na 146 mmol/L K 2.8 mmol/L Cl 102 mmol/L HCO3 33 mmol/L Urea 4.2 mmol/L Creatinine 92 mmol/L Glucose 6.2 mmol/L

*****

Please answer questions 7 – 9 using information from the following vignette.

Mrs. Hogan brings her daughter Natascha to the emergency room. Natascha is a previously well, one-year-old girl who developed a fever two days ago. Her temperature, measured orally by her mother, was 39.8o C. For the past two days Natascha has been listless and has eaten very little other than juice and milk. She has had neither diarrhea nor vomiting. Her mother thinks she may have had a bit of a runny nose earlier in the week. Her mother has been treating her with Tylenol, and although Natascha appears flushed and ill when the fever is high, she is her usual self when the fever is down. Her mother is concerned because Natascha has had a fever once before and it was an ear infection that required antibiotics. Her mother is wondering if she needs some today. Natascha has otherwise been a healthy child and has received all her immunizations including MMR vaccine one week ago. On examination, she is sleeping in her mother’s arms during the interview. She cries during the entire exam, but is comforted after by her mother and stops crying. Her temperature is 40 degrees Celsius rectally. Her tympanic membranes are normal. Her throat is mildly erythematous, with no exudate. Her lungs are clear, respiratory rate is 30/min, and there are no extra heart sounds. Abdomen is soft. She has a diaper rash.

7. What causes of fever must you consider in this case?
a. viral infection
b. vaccine reaction
c. meningitis
d. occult bacteremia
e. urinary tract infection

8. What investigations would you undertake in this case?
a. lumbar puncture
b. urinalysis & urine culture
c. CBC and differential
d. chest X ray
e. blood cultures

9. A CBC is drawn and her WBC is 20 x 109/L, with a high neutrophil count. All other investigations are normal. How would you manage this case?

a. administer aspirin q4h
b. administer ibuprofen q6h
c. administer acetaminophen q4h
d. admit to hospital, refer to a pediatrician
e. administer Ceftriaxone im

*****

Please answer questions 10 - 13 using information from the following vignette.
Ms Angela Keating, a 38-year-old woman originally from Australia , presents with a 3-month history of fatigue and diarrhea. Over the last 4 months she has been having between 3 to 5 soft bowel movements per day. She denies constipation, blood in her stool or liquid stool. Her normal bowel routine that dates back to childhood is 1 to 3 bowel movements per day and she remembers the occasional episode of liquid stool and rarely hard, painful to pass bowel movements. She is normally very active, but recently she has had to take leave of absence from her job as a waitress at a hotel in the mountains. She states she has lost about 5 kg in the last 6 months. Her past medical history is negative except for two therapeutic abortions. About two weeks ago she finished a course of antibiotics prescribed for a Chlamydia infection. Her medications include acetaminophen 500 mg po tid prn for joint pains, the birth control pill, a multivitamin, and a topical hydrocortisone cream she uses for a an itchy skin rash that she has had for several years on her back and buttocks. Her family history is negative except that her mother has osteoporosis (age 63) and her father has panic attacks. Her physical examination revealed a thin, pale, tired looking female appearing younger than her stated age. Vital signs revealed a BP of 110/70 mmHg, HR 90/min, temperature 36.5 C. Pale conjunctiva, no oral lesions or lymphadenopathy. Her chest and cardiovascular exam was normal except for a 2/6 systolic ejection murmur at the LSB. MSK and CNS exam were normal except for leukonychia, a vesicular rash and excoriations on her buttocks. Mild hepatomegally was noted by percussion and palpation but no masses, tenderness or splenomegally were noted. Rectal exam was normal. CBC: Hgb 82 g/l, microcytic red cells and Howell Jolly bodies were noted on the peripheral smear. Her electrolytes and glucose were normal.

10. In assessing the cause of her diarrhea which of the following is/are correct;
a. If diarrhea continues with fasting it is more likely to be an osmotic diarrhea.
b. Smaller volumes of diarrhea and tenesmus are more commonly associated with small bowel diarrhea.
c. Chronic diarrhea is defined as any diarrheal episode lasting longer than 10 days.
d. Irritable bowel syndrome can be associated with the passage mucus per rectum.
e. Antibiotic associated colitis can cause chronic diarrhea.

11. Which of the following is/are consistent with the diagnosis of irritable bowel syndrome;
a. chronic alternating constipation and diarrhea
b. pain relieved by having a bowel movement
c. pain or diarrhea waking the patient from sleep
d. onset before the age of 45 years
e. a feeling of incomplete evacuation following a bowel movement.

12. Which of the following is/are a likely causes of Ms AK’s problems;

A. Ulcerative colitis
B. Antibiotic associated colitis
C. Celiac disease
D. Cystic fibrosis
E. Hemochromatosis

13. In regards to investigating the cause of Ms A.K.’s problems which of the following are true.

a. There is a reproducible and accurate blood test for the diagnosis of Crohn’s disease.
b. There is a reproducible and accurate blood test for the diagnosis of Celiac disease.
c. An upper endoscopy may aid in the diagnosis of both Celiac disease and Giardia.(0.5)
d. HIV serology should be ordered
e. A macrocytic anemia favors the diagnosis of ulcerative colitis over Crohn’s disease.

*****

Please answer questions 14 – 15 based on information from the following vignette.

Cody, a six-year-old boy presently undergoing treatment for Wilm's tumor, visits the oncology clinic regarding a sudden loss of vision in his right eye of one day's duration. He has completed his treatment protocol six months ago and has been stable until this new symptom developed. His general physical examination shows no obvious problems. His vision in the right eye is restricted to light perception only. His vision in the left eye is 20/20. Pupils are 4 mm in size each eye, pupillary reactions are sluggish right eye, but brisk with a normal consensual reaction when the light is shown to the left eye. Swinging the flashlight from left to right eye, the right pupil dilates. Swinging the flashlight from right to left eye, the left pupil constricts. Fundal examination shows a normal optic nerve, peripheral retina, within normal vessel pattern.

14. The pupillary reactions demonstrated represent:

A Horner’s Syndrome (impaired pupil dilatation)
B. Adie’s pupil (pathological pupil reaction)
C. afferent pupillary defect (Marcus-Gunn pupil)
D. normal pupillary reactions
E. anisocoria (inequality of pupils in diameter)

15. The most likely diagnosis is:
A metastasis to the right optic nerve
B. Orbital tumor
C. hemorrhage within the right optic nerve sheath
D. retinal detachment
E. Increased Intracranial Pressure

*****

16. A 64-year-old man is brought to see you by his wife because of increasing memory problems and confusion over three months. He has become gradually more listless and apathetic, with a significant change in personality. She has noted that he has had increasing difficulty with recalling recent events. One week ago, while he was driving home with her from visiting a friend, he became lost and was unable to find his way home. The patient does not complain of memory problems, but has complained of bilateral headache over the past two months, for which he has been taking acetaminophen, 1mg daily. Review of systems shows that he smokes one pack per day, and has drunk four bottles of beer every day for twenty years, although his drinking has decreased over the last two months. On examination, the patient is disoriented for time, does not recall the name of the current Prime Minister, and has difficulty subtracting 7 from 100. He shows hyperactive reflexes in his legs, and plantar responses are upgoing bilaterally. His gait is slightly unsteady and wide-based.

What is the most likely diagnosis?

A. Chronic bilateral subdural hematoma.
B. Glioma involvingboth frontal lobes.
C. Azheimer’s disease.
D. Hypothyroidism.
E. Lewey-body dementia.

********

Please answer questions 17 – 18 based on information from the following vignette.

A fourteen-year-old boy attends his family physician’s office for examination of his eyes. His mother believes something is wrong with them because he is constantly blinking. The boy is otherwise well. He was suspected to have Attention Deficit / Hyperactivity Disorder (AD/HD) in elementary school, but was never placed on stimulant medication. He currently takes no medications. He was adopted at birth, thus his family history is not known. During conversation with the boy, you note that he frequently clears his throat, yet he denies sore throat or other upper respiratory tract symptoms. He blinks frequently, yet is able to hold his eyes open during examination with an ophthalmoscope. His fundi, visual acuity, extraocular movements, visual fields, eyelids and eyelashes are normal. He also exhibits intermittent facial grimacing without apparent pain. The remainder of his examination is normal.

17. This boy’s eye movements are most consistent with which of the following?

A. Fidgeting
B. Motor tics
C. Simple partial seizures
D. Blepharospasm
E. Blepharitis

18. Which of the following conditions are frequently associated with this boy’s diagnosis?

a. Oppositional Defiant Disorder (ODD)
b. Attention Deficit / Hyperactivity Disorder (AD/HD)
c. Conduct Disorder (CD)
d. Obsessive Compulsive Disorder (OCD)
E. Developmental Coordination Disorder (DCD)

*****

Please answer questions 19 – 20 based on information from the following vignette.

A 14-year-old male presents to your office complaining of recent growth of his breasts. He has a history of cardiac disease and is currently taking digoxin and hydrochlorothiazide. On examination your patient is slim, his blood pressure is 160/96 mmHg, and he has bilateral non-tender gynecomastia. The remainder of his physical examination is within age normal limits.

19. The patient asks you why his breasts are growing and you site which of the following reasons as a possible cause?

A. His slender body habitus
B. Digitalis
C. His elevated blood pressure
D. Hydrochlorothiazide
E. His underlying cardiac disease

20. Your patient desires more information about breast enlargement in males. Which of the following information should be given?
a. Gynecomastia is very uncommon and he needs to have his breast tissue biopsied as soon as possible to exclude breast carcinoma.
b. Asymptomatic palpable breast tissue can be seen in normal males, particularly in neonates, at puberty and with increasing age above 45 years.
c. Avoid heavy alcohol abuse since it may be lead to gynecomastia
d. Gynecomastia will almost never spontaneously regress leading to the single therapeutic option of surgical removal of the breast tissue.
e. Gynecomastia results from an increased estrogen to testosterone ratio.

*****

Please answer questions 21 – 23 based on information from the following vignette.

Mr. William Connell, a 41-year-old freelance photographer, is seen in the office of his family physician complaining of red discolouration of his urine over the past four days. He states that he has had this on two previous occasions, both in relation to an upper respiratory tract infection. On both previous occasions the urine cleared spontaneously over a period of five to seven days. At the time of the present visit he states that he has been feeling lethargic with a sore throat for the past five days. He is a vegetarian and smokes a pack of cigarettes each day. Blood pressure is 170/95 mmHg in both arms, sitting and supine, on repeat testing. Urine analysis shows specific gravity 1020, nitrites negative, +++ blood and +++ protein. Urine microscopy reveals oxalate crystals, dysmorphic red blood cells and red cell casts.

21.Which ONE of the following is the most likely diagnosis?

A. IgA nephropathy
B. Ingestion of beets
C. Renal calculi
D. Bladder carcinoma
E. Post-streptococcal glomerulonephritis

22. Which of the following investigations does this patient require?
a. Cystoscopy
b. Urine culture
c. Serum creatinine
d. Plain X-ray of the kidney, ureter and bladder
e. 24 hour urine collection for creatinine clearance and protein excretion

23. The presence of dysmorphic red blood cells is indicative of:
A. Urine infection
B. Delay in analysis of the urine sample
C. Glomerular bleeding
D. Urothelial malignancy
E. Urinary tract calculus

*****

Please answer questions 24 – 25 based on the following vignette.

Miss Tracy Patterson, a 17-year-old university student, visits her family physician’s office complaining of fatigue and “strong smelling” urine. Her only past medical problem is infectious mononucleosis two years previously form which she made a complete but protracted recovery. Her only medication is the birth control pill. She is a member of the university basketball team and has noted a dip in her performance since the onset of these symptoms. She denies any other symptoms. There are no abnormal findings on examination. Blood pressure is 110/68 mmHg. Urine analysis shows specific gravity 1030, nitrites negative, + protein. Urine microscopy reveals a few vaginal epithelial cells/hpf, 0-1 wbc’s/hpf, and 0-1 hyaline casts/hpf. A 24 hour urine collection shows a normal creatinine clearance with 0.41g of protein for this time period.

24. Which ONE of the following is the most likely diagnosis?

A. IgA nephropathy
B. Membranous glomerulonephritis
C. Exercise-induced proteinuria
D. Urinary tract infection
E. Reflux nephropathy

25. Which of the following investigation(s) does this patient require?
a. Cystoscopy
b. Split urine collections (0800 – 2000, and 2000 – 0800)
c. Repeat 24 hour collection after avoiding exercise
d. Renal biopsy
e. Serum and urine electrophoresis

*****

Please answer questions 26 – 27 based on information from the following vignette.

Theresa Gallagher, arrives at her family physician’s office complaining of easy bruising over the past month. She is not as concerned about her “rash-like” skin bruising as she is about her gums bleeding with brushing her teeth over the past three days. Theresa is 25 years old and otherwise healthy. She is not taking any medications, and drinks only socially. She has never been hospitalized except for the birth of her daughter three years ago after an uneventful pregnancy. Family history is completely negative. She denies any large bruises, denies deep muscle or joint pain, and has not noticed any blood in her urine.

26. What investigations would you order?

a. CBC and differential
b. Serum electrolytes & creatinine
c. fibrin split products
d. PT & PTT (includes INR)
e. AST, ALT, alkaline phosphatase

27. The only abnormality detected is a platelet count of 70,000/mm3. What is/are the possible cause(s)?
a. Renal failure
b. Folate/B12 deficiency
c. Lymphoma/leukemia
d. Factor VIII deficiency
e. SLE

*****

28. A concerned father calls your office because his three-week-old son Damien has a fever of 39.5 degrees Celsius measured axially. He was born at term and had no complications after a spontaneous vaginal delivery. He was breast-feeding well until yesterday. Since then he has been sleeping more. He has a two-year-old brother who has a cold.

What is the best advice to give the parents?

A. Treat the fever with Tylenol, bring the baby to the office if fever lasts over 48 hours
B. Bring baby to the office for further evaluation sometime later today.
C. Take baby to the emergency room for hospital admission
D. Make a house call
E. Make appointment for the baby with a pediatrician

*******


Please answer questions 29 – 31 based on information from the following vignette.

Mr. David Wallace is a 57 year old male that presents with a longstanding history of heartburn and reflux of acid-like material in to his mouth. He usually treats himself with oral antacids but lately they have not been as effective. Yesterday he had some pain and a sticking sensation after swallowing a piece of bread. He has noticed this on at least on 3 separate occasions before, these episodes having occurred over the last 2 months or so. When asked to point to where he feels the food is sticking he points to he points to an area just below his thyroid gland. Each time he could not swallow, he was able to down the food with water and did not need to seek medical attention. He has not had trouble swallowing hot or cold liquids. His past medical history is significant for polio as a child and feels he has some arm and leg weakness due to that. He has a 50-pack year smoking history. His family history is negative except he has one sister that died of breast cancer. His physical exam is completely normal.

29. In assessing Mr. Wallace which of the following is/are correct;

a. Since he points to an area near his thyroid he probably has oropharyngeal dysphagia secondary to post polio syndrome.
b. Assess for signs of stroke or post-polio syndrome since his dysphagia is likely due to a neuromuscular disease.
c. He likely has uncomplicated reflux esophagitis and should be managed with a proton pump inhibitor and requires no further investigation.
d. Esophageal carcinoma usually presents with both liquid and solid dysphagia
e. Since coughing, choking, and aspiration are absent, difficulty in initiating swallowing (in contrast to difficulty swallowing) may be safely excluded

30. Which of the following management/investigation strategies is/are most appropriate for Mr. Wallace?

a. Start him on H2 antagonist (ranitidine) and arrange for him to have an upper endoscopy.
b. If a barium swallow is normal and his symptoms progress start him on a proton pump inhibitor and advice him that since the barium swallow is normal no further investigation are required.
c. Since an upper endoscopy is not available in your community you order a chest xray and a barium swallow.
d. His barium swallow is normal but the dysphagia persists, order a CT scan of his head to rule out a neurological cause of his dysphagia.
e. Since dysphagia can occur in uncomplicated reflux esophagitis you reassure the patient that he has uncomplicated gastroesophageal reflux and counsel him on conservative management of reflux disease suggest he eat small meals, quits smoking and limits his caffeine consumption.

31. The most likely diagnosis for Mr. D. W. is:

A. Lower esophageal ring
B. Peptic stricture
C. Esophageal carcinoma
D. Esophageal spasm
E. Achalasia

*****

32. The emergency room nurse pages you to come examine a two-year old girl who is the daughter of one of your patients. Upon arriving in the emergency room, you see an obtunded girl with no known prior medical problems. Her father states that his daughter fell down the stairs earlier in the evening, but he does not think that she hit her head during the fall. Physical examination shows no visible signs of external injury. After a brief but complete physical examination, the only abnormality detected was on examination of her eyes. Although examination of her anterior chambers is normal, posteriorly in each eye there are large, dome-shaped hemorrhages in the macula. In addition, there are multiple scattered retinal hemorrhages visible in the retinal periphery of each eye.

The most likely diagnosis in this case is:

A. acute myelogenous leukemia
B. diabetic retinopathy
C. childhood hypertensive retinopathy
D. child abuse (shaken baby s yndrome)
E. retinal edema

*******

33. A 63-year-old man experienced a ten-minute attack of right-sided weakness with associated difficulty speaking one week ago. Carotid ultrasound testing showed bilateral carotid atheroma, with a 20% carotid stenosis on the left, and an 80% carotid stenosis on the right. Past illnesses include mild hypertension under treatment. Review of systems reveals no symptoms suggestive of coronary artery disease. His neurological examination is normal.

Appropriate management of this patient would be:

A. Left carotid endarterectomy.
B. Right carotid endarterectomy.
C. Coumadin anti-coagulation.
D. Enteric coated aspirin.
E. Hydergine (ergoloid mesylates).

*****

34. Sara has terminal bone cancer unresponsive to chemotherapy. She is 7 years old and has been in hospital for palliative care for just over 3 weeks. Today she is feeling tired, she is repeatedly complaining of pain in her leg, and wants to be held in her mother’s arms. She refuses to eat because according to her there is no point in eating if she will die anyway.

Which of the following procedures is/are appropriate for Sara (choose all correct ones):

a. force feed
b. provide adequate analgesia
c. initiate parental nutrition
d. prescribe antidepressants
e. provide emotional support

**********

Please answer questions 35 – 36 based on information from the following vignette.

A full term infant with a birth weight of 3.5 kg, length of 50 cm and head circumference of 35 cm (all at 50th percentile) comes for an office appointment at 2 weeks of age. The mothers states that the infant was discharged home at 24 hours of age and has done well since. The infant is being fed Carnation milk diluted to 25%. The child’s sleep pattern is characterised by 1.5 hours of sleep after each feed. His weight today is identical to birth. On exam the infant appears to be well hydrated, the mucosa colour is normal and in no distress. The exam is unremarkable except for irritability.

35. Why has the infant failed to gain weight?

A. This infant was small for gestational age at birth
B. This infant is microcephalic
C. The nutritional support provided to this child is adequate for a newborn
D. Encourage breast feeding or change milk to an appropriate infant formula
E. Recommend that the dilution of the milk be changed to 50% 36.

Considering the appropriate nutritional management of infants, select the appropriate advice to be given to new mothers:
A. Avoid feeding newborn infants in the first 12 hours of life in order to prevent aspiration
B. Breast milk is deficient in iron and iron supplementation is recommended for breast fed infants
C. Breast milk does not contain enough vitamin D and vitamin D supplementation is recommended for exclusively breast fed infants
D. Institute solid food at three months of age
E. Breast milk may causes diarrhea if used exclusively, so formula should be added

*****

Please answer questions 37 – 39 based on information from the following vignette.

Mr. Lyle Murrin, a 75-year-old retired train engineer, saw his family physician on March 18, 2000 complaining of breathlessness. He had signs of cardiac failure with atrial fibrillation. Serum creatinine at that time was 145 mmol/L, similar to the value from eight months ago. Because he was in moderate distress, he was admitted to hospital. No invasive procedures were considered necessary. His diagnosis of congestive heart failure led to treatment with enalapril, furosemide, and digoxin. He was discharged from hospital on March 28, 2000. Today, April 3rd, 2000 he returns to the office of his family physician complaining of increasing nausea, vomiting, decreasing amounts of urine, pain in his right great toe and difficulty sleeping. He has a history of hypertension and ischemic heart disease. On physical examination he appears unwell with a heart rate of 46 bpm (irregularly irregular). Sitting BP is 190/88 mmHg. JVP is 5cm above the sternal angle. He has an apical pan-systolic murmur, a right carotid and bilateral femoral artery bruits, bilateral basal inspiratory crackles and a red tender swollen right first metatarsal phalangeal joint. The results of his initial investigations are given below: Na 139 mmol/L Hb 114g/L K 5.8 mmol/L WBC 14.3 x109/L HCO3 22 mmol/L Plat 274 x109/L Cl 101 Urea 13.5mmol/L Creatinine 325mmol/L 37.

What is the most likely explanation for the rise in serum creatinine?

A. Hypertensive nephrosclerosis
B. Bilateral renal artery stenosis
C. Dehydration secondary to diuretics
D. Urate-containing renal calculi
E. Chronic glomerulonephritis

******************************************************
*********************************
****************
*********
***
*

No comments: