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  • Question 1 - A 47-year-old woman is brought into the Emergency Department after collapsing in a...

    Correct

    • A 47-year-old woman is brought into the Emergency Department after collapsing in a shopping mall. Her identity is unknown and she is unable to provide any medical history. The patient undergoes assessment and blood tests are taken, including an arterial blood gas (ABG). The ABG results reveal a metabolic acidosis with a normal anion gap.
      What condition could potentially present with this ABG result in a 47-year-old woman?

      Your Answer: Proximal renal tubular acidosis

      Explanation:

      Causes of Metabolic Acidosis and their Anion Gap

      Metabolic acidosis is classified based on the anion gap, which determines the presence of an unmeasured acid in the circulation. Proximal renal tubular acidosis is caused by the loss of bicarbonate in the kidneys, which is replaced by chloride, maintaining the anion gap but causing acidosis. High anion gap acidosis can be caused by lactic acidosis, ketoacidosis, rhabdomyolysis, and ingestion of certain compounds. Normal anion gap acidosis can be caused by gastrointestinal loss of bicarbonate, hyperventilation, and hypoaldosteronism. Lactic acidosis occurs due to excess production of lactic acid in anaerobic metabolism, while rhabdomyolysis releases intracellular anions causing acidosis. Diabetic ketoacidosis is caused by ketones, and salicylate overdose causes a mixed picture of metabolic acidosis and respiratory alkalosis.

    • This question is part of the following fields:

      • Clinical Biochemistry
      17.6
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  • Question 2 - A 28-year-old woman is diagnosed with nephrotic syndrome secondary to focal segmental glomerulosclerosis...

    Correct

    • A 28-year-old woman is diagnosed with nephrotic syndrome secondary to focal segmental glomerulosclerosis after presenting with pedal oedema. She is being treated with furosemide 40 mg and prednisolone 60 mg. Her potassium level is 3.0 mEq/l (3.5–5.1).
      Which of the following medications will not increase potassium levels?

      Your Answer: Corticosteroids

      Explanation:

      Medications that can cause hyperkalaemia

      Hyperkalaemia, or high levels of potassium in the blood, can be caused by certain medications. Here are some medications that can lead to hyperkalaemia:

      1. Corticosteroids: Oral or IV steroids with glucocorticoid properties, such as prednisone and hydrocortisone, can be used to treat chronic obstructive pulmonary disease (COPD) and increase renal potassium excretion.

      2. Angiotensin receptor blockers (ARBs): Use of ARBs can be associated with hyperkalaemia, particularly in patients with chronic renal insufficiency. It is important to monitor serum potassium levels shortly after initiating therapy.

      3. Angiotensin-converting enzyme (ACE) inhibitors: Use of ACE inhibitors can also be associated with hyperkalaemia, particularly in patients with chronic renal insufficiency. ACE inhibitors can cause potassium retention by suppressing angiotensin II, which leads to a decrease in aldosterone levels.

      4. Spironolactone: Hyperkalaemia is an established adverse effect of both spironolactone and eplerenone. Potassium levels should be monitored regularly in patients taking spironolactone.

      5. Digoxin: Hyperkalaemia is the most common electrolyte abnormality in acute digoxin toxicity. Chronic toxicity does not cause hyperkalaemia. Digoxin blocks the sodium-potassium ATPase pump.

      It is important to be aware of these medications and their potential to cause hyperkalaemia, and to monitor serum potassium levels in patients taking them.

    • This question is part of the following fields:

      • Clinical Biochemistry
      45.4
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  • Question 3 - An 85-year-old woman presents in the Emergency Department with a 3-week history of...

    Correct

    • An 85-year-old woman presents in the Emergency Department with a 3-week history of increasing confusion and falls. Routine investigations reveal:
      FBC: Hb 123 g/l, MCV 86 fl, WCC 7.9 × 109/l, platelets 478 × 109/l
      U&Es: Na+ 109 mmol/l, K+ 4.9 mmol/l, urea 5.2 mmol/l, creatinine 76 μmol/l
      Which of the following would clinically exclude a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH)?

      Your Answer: Gross peripheral oedema and ascites

      Explanation:

      Understanding the Exclusion Criteria for SIADH: Causes of Hyponatremia in the Elderly

      Hyponatremia is a common incidental finding in the unwell elderly, and its causes can be understood by knowing the exclusion criteria for SIADH. SIADH secretion should not be diagnosed in the presence of hypovolemia, hypotension, Addison’s disease, signs of fluid overload (such as effusions, ascites, and peripheral edema), hypothyroidism, or drugs that cause hyponatremia. Once these are excluded or corrected, the diagnosis is confirmed by sending paired serum and urinary specimens for sodium and osmolality measurements. SIADH is confirmed when one has hyponatremia and a low measured serum osmolality, with measurable urinary sodium and a relatively concentrated urinary osmolality. Causes are found in the chest and in the head, so all patients with unexplained hyponatremia should have a chest X-ray and, if this is normal, a computed tomography brain scan.

      Understanding the Exclusion Criteria for SIADH: Causes of Hyponatremia in the Elderly

    • This question is part of the following fields:

      • Clinical Biochemistry
      43.8
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  • Question 4 - A 70-year-old man with metastatic prostate cancer presents with bony leg pain, constipation...

    Correct

    • A 70-year-old man with metastatic prostate cancer presents with bony leg pain, constipation for 4 days, abdominal pain, thirst and disorientation. On examination, he is cachectic and dehydrated. He is apyrexial and haemodynamically stable. He has a past medical history of hypertension and is an ex-smoker. He has no known drug allergies. His calcium is 3.1 mmol/l and he has normal renal function.
      What is the most suitable initial management for this patient?

      Your Answer: Intravenous (iv) 0.9% normal saline

      Explanation:

      Management of Hypercalcaemia in Cancer Patients

      Hypercalcaemia is a medical emergency commonly seen in cancer patients. It presents with symptoms such as lethargy, anorexia, nausea, constipation, dehydration, polyuria, polydipsia, renal stones, confusion, and generalised aches. Other causes of hypercalcaemia include primary and tertiary hyperparathyroidism, sarcoidosis, myeloma, and vitamin D excess. The management of hypercalcaemia involves intravenous (iv) normal saline and bisphosphonates. Local protocols should be referenced for specific guidelines.

      Steroids such as dexamethasone are not recommended for patients who do not have cord compression. Furosemide may be used alongside iv fluids if the patient is at risk of fluid overload, such as in heart failure. Bisphosphonates, such as iv pamidronate, act over 48 hours by preventing bone resorption and inhibiting osteoclasts. Urgent chemotherapy is not recommended for hypercalcaemia as it does not address the underlying cause of the symptoms.

      In conclusion, hypercalcaemia in cancer patients requires prompt management with iv normal saline and bisphosphonates. Other treatment options should be considered based on the patient’s individual needs and local protocols.

    • This question is part of the following fields:

      • Clinical Biochemistry
      100.3
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  • Question 5 - A 78-year-old man is referred to rheumatology outpatients with increasing pain in the...

    Incorrect

    • A 78-year-old man is referred to rheumatology outpatients with increasing pain in the left leg. On examination, the left leg is slightly larger than the right and appears slightly deformed. An X-ray demonstrates cortical expansion and coarsening of trabeculae in keeping with Paget’s disease of bone.
      What is likely to be found on serum biochemistry?

      Your Answer: Raised ALP, raised calcium, normal phosphate

      Correct Answer: Raised ALP, normal calcium, normal phosphate

      Explanation:

      Interpreting Blood Test Results for Paget’s Disease and Other Conditions

      Paget’s disease of bone is a chronic disorder that affects bone turnover and can lead to bone pain and deformity. When interpreting blood test results, a raised alkaline phosphatase (ALP) level is a key indicator of Paget’s disease, while normal levels of calcium and phosphate are typical. However, if calcium is raised along with ALP, other conditions such as parathyroid disease or cancer may be the cause. If ALP and calcium are both raised, osteitis fibrosa cystica may be the culprit, while raised levels of all three (ALP, calcium, and phosphate) may indicate vitamin D intoxication or Milk alkali syndrome. Treatment for Paget’s disease typically involves analgesia, with bisphosphonates as a secondary option if needed. It’s important to seek specialist input for proper diagnosis and management.

    • This question is part of the following fields:

      • Clinical Biochemistry
      35.1
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  • Question 6 - An 82-year-old woman visits her GP complaining of increasing weakness all over her...

    Correct

    • An 82-year-old woman visits her GP complaining of increasing weakness all over her body. She had recently been hospitalized for a severe chest infection and heart failure. The GP notes that she is taking bendroflumethiazide, furosemide, aspirin, and atorvastatin. The GP conducts a physical examination, which reveals nothing significant, but orders some routine blood tests. The results show a hemoglobin level of 93 g/l, MCV of 84 fl, WCC of 5.9 × 109/l, and platelets of 108 × 109/l. Her U&Es show a sodium level of 129 mmol/l, potassium level of 2.1 mmol/l, urea level of 12.2 mmol/l, and creatinine level of 146 μmol/l. Her blood glucose level is 9.6 mmol/l, and her CK level is 112 iu/l. Which of these blood results is likely causing her weakness?

      Your Answer: K+ 2.1 mmol/l

      Explanation:

      Hypokalaemia and Non-Specific Symptoms in Elderly Patients

      Elderly patients who have suffered from a serious illness may take several months to recover and may experience multiple symptoms during this period. However, non-specific symptoms should not be dismissed as part of their overall condition. Hypokalaemia, especially in the presence of heart failure, may present insidiously and non-specifically as muscle weakness.

      To treat hypokalaemia, supplemental potassium should be given initially, followed by potassium-retaining medications such as angiotensin-converting enzyme inhibitors (ACEIs) or spironolactone if necessary. Other factors that may contribute to muscle weakness, such as depression, should also be addressed.

      A normocytic anaemia may cause fatigue but is less likely to cause global muscle weakness. Thrombocytopenia and hyponatraemia may also cause fatigue but are less likely to cause global muscle weakness. Mild renal impairment may cause fatigue but is also less likely to cause global muscle weakness.

    • This question is part of the following fields:

      • Clinical Biochemistry
      36.8
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  • Question 7 - A 67-year-old woman comes to the General Practice complaining of lethargy and fatigue....

    Correct

    • A 67-year-old woman comes to the General Practice complaining of lethargy and fatigue. She had undergone abdominal surgery for ulcerative colitis and was discharged from the hospital recently. She is waiting for the reversal of a stoma and has been experiencing profuse diarrhoea and high output from the stoma. Her routine blood tests are normal, except for a significantly low magnesium level. What is the best course of action to correct her magnesium levels?

      Your Answer: Intravenous (IV) magnesium sulfate

      Explanation:

      Management of Magnesium Deficiency in a Patient with High Stoma Output and Diarrhoea

      Magnesium deficiency is a common problem in patients with high stoma output and diarrhoea. The most appropriate management for correcting magnesium levels in such patients is intravenous (IV) magnesium sulfate. While an intramuscular injection is also an option, it can be painful. Once magnesium levels are corrected, it is important to involve the Colorectal Team to discuss management of the stoma and prevent further recurrence.

      While loperamide can improve diarrhoea and stoma output, it is not the best answer for correcting magnesium levels. Oral magnesium aspartate and oral magnesium sulfate are not well absorbed and can worsen diarrhoea. Oral magnesium glycerophosphate can prevent recurrence of magnesium deficiency after correction via IV or intramuscular routes, but IV correction is preferred in symptomatic patients with significantly low magnesium levels and increased losses.

    • This question is part of the following fields:

      • Clinical Biochemistry
      36.8
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  • Question 8 - A 35-year-old man is brought to your Emergency Department after falling off a...

    Correct

    • A 35-year-old man is brought to your Emergency Department after falling off a ladder while working on his roof. He has been evaluated at the scene and transported for further evaluation and treatment of a severe head injury.
      Upon arrival, an arterial blood gas is obtained: pH 7.2, PaCO2 8.0 kPa, PaO2 8.0 kPa, HCO3− 24 mmol/l, base excess −0.5 mmol/l.
      What is the abnormality indicated by this blood gas?

      Your Answer: Respiratory acidosis

      Explanation:

      Understanding Arterial Blood Gases: Interpreting Respiratory Acidosis

      Arterial blood gases can be complex to interpret, but a stepwise approach can simplify the process. The first step is to determine whether the pH is low (acidaemia) or high (alkalaemia). Next, identify whether the acid-base derangement is due to the metabolic component (HCO3-, base excess) or the respiratory component (CO2).

      In the case of respiratory acidosis, the pH is low and the carbon dioxide is higher than the normal range. The bicarbonate and base excess are within normal limits, indicating a respiratory rather than metabolic cause. Normal ranges for arterial blood gases include pH (7.35-7.45), PaCO2 (4.6-6.0 kPa), PaO2 (10.5-13.5 kPa), HCO3- (24-30 mmol/l), and base excess (-2 to +2 mmol/l).

      Other acid-base derangements include metabolic acidosis, metabolic alkalosis, and respiratory alkalosis. A normal blood gas falls within the normal range for all components. Understanding arterial blood gases is crucial for diagnosing and managing respiratory and metabolic disorders.

    • This question is part of the following fields:

      • Clinical Biochemistry
      20
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  • Question 9 - A 72-year-old man visits the Emergency Department with severe sharp pain in the...

    Correct

    • A 72-year-old man visits the Emergency Department with severe sharp pain in the left groin and chronic lower back pain after falling in his garden. He is unable to walk. He has a body mass index (BMI) of 28 kg/m2. His pulse is 80 bpm and regular, blood pressure (BP) 140/80 mm Hg. Fracture of the left neck of the femur is identified on X-ray and treated.
      Routine laboratory results are below:
      Investigation Result Normal value
      Serum calcium concentration 2.1 mmol/l 2.15 – 2.6 mmol/l
      Serum phosphate concentration 0.8 mmol/l 0.8 – 1.4 mmol/l
      Parathyroid hormone level 60 pg/ml 11 – 54 pg/ml
      Urea 5 mmol/l 2.5 – 7.1 mmol/l
      Creatinine 80 μmol/l 60 – 110 μmol/l
      What is the next most appropriate investigation?

      Your Answer: Serum 25-hydroxy vitamin D (25(OH)D) levels

      Explanation:

      Diagnostic Tests for Vitamin D Deficiency, Hyperparathyroidism, and Multiple Myeloma

      Vitamin D deficiency, hyperparathyroidism, and multiple myeloma are conditions that can affect calcium and phosphate levels in the body. To diagnose these conditions, various tests are used.

      Serum 25-hydroxy vitamin D (25(OH)D) levels are the best test to determine vitamin D status. Levels lower than 25 nmol/l indicate positive vitamin D deficiency. Treatment should commence if serum 25(OH)D levels are in the range of 25–50 nmol/l.

      Serum protein electrophoresis is used in the diagnosis of multiple myeloma. In multiple myeloma, there are osteolytic bone lesions leading to hypercalcemia.

      Ultrasonogram (USG) neck is used to assess parathyroid adenoma, which is associated with hyperparathyroidism. In hyperparathyroidism, serum PTH levels are very high with increased calcium and decreased phosphate levels.

      Urine Bence Jones Protein is positive in multiple myeloma. In multiple myeloma, there are osteolytic bone lesions leading to hypercalcemia, with impaired renal function.

      24-hour urinary calcium is elevated in hyperparathyroidism, type I renal tubular acidosis, vitamin D intoxication, and Bartter syndrome. However, it has no role in the diagnosis of vitamin D deficiency.

      Overall, these diagnostic tests can help healthcare professionals identify and treat these conditions, leading to improved patient outcomes.

    • This question is part of the following fields:

      • Clinical Biochemistry
      63.1
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  • Question 10 - A 68-year-old man with extensive peripheral vascular disease has sudden-onset severe abdominal pain...

    Correct

    • A 68-year-old man with extensive peripheral vascular disease has sudden-onset severe abdominal pain with cramping and bloody stools. An arterial blood gas shows a pH of 6.9.
      Which one of the following would you most likely find in this patient?

      Your Answer: pCO2: decreased; HCO3−: decreased; urine pH: decreased

      Explanation:

      Interpreting Acid-Base Disorders: Understanding the Relationship between pCO2, HCO3−, and Urine pH

      When analyzing acid-base disorders, it is important to understand the relationship between pCO2, HCO3−, and urine pH. Here are some examples:

      1. Metabolic acidosis: pCO2 decreased, HCO3− decreased, urine pH decreased. This is due to excess H+ ions, which causes HCO3− to decrease and respiratory compensation to increase. The kidneys also work to excrete excess acid, lowering the pH of the urine.

      2. Respiratory acidosis: pCO2 increased, HCO3− increased, urine pH decreased. A pH of 6.9 suggests acidosis, so CO2 would be reduced and HCO3− would be increased to try and normalize the pH. The urinary pH would be decreased.

      3. Metabolic alkalosis: pCO2 increased, HCO3− increased, urine pH increased. HCO3− is increased as they are metabolically alkalotic, CO2 increased to try and offset the alkalosis, and the urinary pH increased as the kidneys try to excrete the excess HCO3−.

      4. Renal metabolic acidosis: pCO2 decreased, HCO3− decreased, urine pH increased. In this case, the urine pH will be increased as the metabolic acidosis is due to renal dysfunction, and the kidneys are excreting the excess acid.

      5. Mixed acidosis/alkalosis: pCO2 decreased, HCO3− increased, urine pH decreased. This is not seen in any straightforward acid-base disorder but could be seen in states of mixed acidosis/alkalosis.

      Understanding these relationships can help healthcare professionals diagnose and treat acid-base disorders effectively.

    • This question is part of the following fields:

      • Clinical Biochemistry
      18.9
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SESSION STATS - PERFORMANCE PER SPECIALTY

Clinical Biochemistry (9/10) 90%
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