A 42-year-old man presents with severe, left, renal, angle pain.
On examination he has severe, left, renal, angle tenderness, his BP is elevated at 155/90 mmHg, and his pulse is 95. He is apyrexial.
Investigations show:
Haemoglobin 121 g/L (135-180)
White cell count 6.1 ×109/L (4-10)
Platelets 201 ×109/L (150-400)
Sodium 140 mmol/L (134-143)
Potassium 4.9 mmol/L (3.5-5)
Creatinine 110 µmol/L (60-120)
Urine blood +++
Which one of the following would be your best next step?
A 50-year-old man presents to the emergency department with a 48 hour history of dysuria and visible blood in his urine. He also reports some frequency of urination. However, he denies fever, abdominal pain or loin pain and feels generally well. He mentions that his urine has gradually cleared and looks normal again since he first noticed the frank blood. On examination, he appears systemically well with a regular pulse rate of 76 and blood pressure of 138/76 mmHg. His abdomen and loins are unremarkable on palpation. A urine sample is obtained and dipstick testing reveals leucocytes ++ and blood+++. You prescribe antibiotics to cover a urinary tract infection. What is the most appropriate next step in managing this patient?
A 28-year-old patient visits your clinic seeking travel and immunisation advice for an upcoming trip overseas. The patient has Addison’s disease and takes hydrocortisone and fludrocortisone on a daily basis. She plans to bring extra medication with her and has been advised by her travel agent to obtain a letter from you confirming the need to carry injections. During the consultation, she asks what she should do if she experiences vomiting.
What guidance would you provide?
What is a symptom that is unique to a severe asthma attack in an adult that could be life-threatening?
A 60-year-old man presents to the clinic for follow-up. He has been experiencing increasing difficulty with swallowing and feels like food is getting stuck shortly after he swallows. He has resorted to blending most of his meals and has lost 4 kg in weight over the past two months. He has also developed a hoarse voice recently.
The patient has a history of knee osteoarthritis and regularly takes ibuprofen. He has a BMI of 21 kg/m2 and no cervical lymphadenopathy is noted.
Laboratory results show:
– Hb 98 g/L (135-180)
– WCC 7.4 ×109/L (4.5-10)
– PLT 182 ×109/L (150-450)
– Na 137 mmol/L (135-145)
– K 4.7 mmol/L (3.5-5.5)
– Cr 115 µmol/L (70-110)
Based on these findings, you suspect an upper esophageal cancer.
What is the most important next step?
A 63-year-old woman presents with a painful swollen left calf. She recently returned from a walking holiday in Austria where she walked up to 10 miles a day. There is no history of venous thromboembolism. On examination, the left calf is 4 cm larger than the right with tenderness and mild pitting oedema. Non-varicose superficial collateral veins are present. The right calf is normal. What is the correct diagnostic reasoning and management plan for this patient?
A 78-year-old man presents with a suspected right sided deep vein thrombosis (DVT). He has a history of cardiac failure and is currently taking ramipril 5 mg BD, bisoprolol 7.5 mg OD, atorvastatin 20 mg OD and furosemide 40 mg OD.
Upon examination, his right calf measures 2 cm larger than the left (when measured 10cm below the tibial tuberosity) and there is mild erythema of the skin on the right lower leg. Palpation of the back of the right calf elicits some tenderness. He also has mild bilateral pitting oedema of the feet that is symmetrical when comparing both feet.
Which of the following would earn one point when calculating his two-level DVT Wells score?
A 32-year-old woman with a history of Crohn’s disease presents to the clinic with abdominal discomfort and bloody stools. She has been managing her condition with daily mesalamine 1 g. She has not undergone any previous surgeries.
Upon further questioning, she reports experiencing colicky abdominal pain and passing bloody stools 8-10 times a day for the past three days.
During the physical examination, her temperature is 37.8°C, pulse rate is 96 bpm, and blood pressure is 104/68 mmHg. The abdomen is tender to palpation but no masses or signs of peritonitis are present.
What is the most appropriate course of action for management?
A 61-year-old gentleman presents to the emergency department with a persistent cough that has been troubling him for the last six months. His wife has brought him in as he has coughed up small amounts of blood on several occasions and has lost about a stone in weight over the last few months. He is a heavy smoker of 40 cigarettes a day for the last 40 years and has developed noisy breathing over the last few days. He also complains of a persistent headache and feeling a little dizzy. On examination, he has a soft stridor at rest and dilated veins on his chest wall. His oxygen saturations are 98% in room air, blood pressure is 128/88 mmHg, and pulse rate is 90 regular. He is alert, oriented, and afebrile with clear chest sounds on auscultation.
What is the most appropriate management plan?
A 36-year-old woman presents with complaints of generalised lethargy and weakness. She has a significant medical history of childhood asthma and vitiligo, and currently only uses a salbutamol inhaler as needed. She reports feeling constantly worn out, weak, and experiencing body aches. She also feels dizzy when standing up quickly. On examination, she appears well and has no fever, shortness of breath, or pain. Her blood pressure is 106/60, but drops to 94/56 when standing, causing brief lightheadedness. Cardiovascular, respiratory, and abdominal examinations are normal. There is no joint swelling and she walks with a normal gait. Blood tests reveal a slightly low sodium of 130 mmol/L and a slightly raised potassium of 5.5 mmol/L. Which investigation is most likely to aid in establishing a diagnosis?