LFTs
Blood gas
U&Es
Bone profile
Wild card
100
A 45 year old female presents with severe right upper quadrant abdominal pain, fever and nausea. She reports that the pain is worse after eating fatty foods.
Investigations:
- WBC: 14 x 10^9/L (3.6 – 11.0 x 10^9/L)
- Neutrophils: 10 x 10^9/L (1.8 – 7.5 x 10^9/L)
- Bilirubin: 18 μmol/L (3-17 μmol/L)
- ALP: 150 IU/L (30-130 IU/L)
- ALT: 45 IU/L (3-40 IU/L)
- GGT: 80 IU/L (8-60 IU/L)
- Amylase: 40 IU/L (30-110 IU/L)
What is the most likely diagnosis? (and why?)
Cholecystitis
Clinical features: RUQ pain, fever (not biliary colic), nausea (no jaundice so not cholangitis).
Ix: Raised WCC and ALP, mildly raised ALT and bilirubin (below 30 unlikely to be clinically jaundiced), normal amylase (rules out pancreatitis)
100
A 70 year old male with a long history of smoking presents with worsening shortness of breath and confusion. He has a chronic productive cough and has been using his inhalers more frequently.
- pH: 7.32 (7.35-7.45)
- PaCO2: 8.0 kPa (4.7-6.0 kPa
- HCO3–: 32 mEq/L (22-26 mEq/L)
- PaO2: 9 kPa (11-13 kPa)
- BE: +6 (-2 to +2)
Please interpret the results and give the most likely diagnosis.
Respiratory acidosis secondary to CO2 retention from COPD.
100
A 70 year old man takes furosemide for heart failure and has been treated for an acute asthma attack with 5 back to back salbutamol nebulisers. He is found to have a potassium of 2.4 and has associated ECG changes.
How should this case be managed?
Pause furosemide, check Magnesium (and replace if low), cardiac monitoring and commence potassium IV replacement at a maximum rate of 10 mmol/hr.
100
How does vitamin D act on calcium levels?
Increases intestinal absorption of Ca, increases renal Ca reabsorption and mobilises bone Ca and PO4.
100
34 year old male requires the following blood tests done as part of the pre-op assessment:
FBC
U&Es
LFTs
Clotting
Which colour bottles are needed and in which order should they be drawn in?
Light blue (clotting), Yellow (U&Es and LFTs), Purple (FBC)
200
A 25 year old male presents with intermittent jaundice, which he notices more during periods of stress or after a "heavy" night out in the pub. He denies any other symptoms.
- Bilirubin: 25 μmol/L (3-17 μmol/L)
- ALT: 30 IU/L (3-40 IU/L)
- AST: 25 IU/L (3-30 IU/L)
- ALP: 70 IU/L (30-130 IU/L)
- GGT: 25 IU/L (8-60 IU/L)
What is the most likely cause of the jaundice (and what is the mechanism).
Gilbert's which leads to defect in bilirubin uridine diphosphate glucuronosyltransferase (bilirubin-UGT) leading to reduced activity, only noticeable when the body / liver is under stress.
200
28 year old female presents with sudden onset shortness of breath and palpitations. She has hypothyroidism and takes thyroxine and the combined oral contraceptive pill. She has just come back from a holiday in Thailand.
She is breathing room air.
Please interpret the following arterial blood gas results:
pH: 7.47 (7.35-7.45)
PaO2: 9.0 kPa (11-13 kPa)
PaCO2: 3.5 kPa (4.7-6.0 kPa)
HCO3-: 22mEq/L (22-26 mEq/L)
Respiratory alkalosis (raised pH, low CO2 and low HCO3 - also has low PaO2). Most likely differential diagnosis PE (risk factors of recent flights and COCP, SOB is sudden onset).
200
A 55 year old man has an ECG done at his GP practice. The GP tells him that he needs to go into hospital for some more investigations including a blood test to check his electrolytes.
What is the key finding on this ECG and what electrolyte abnormality is most likely?
Tented T waves
Caused by hyperkalaemia
200
A 55 year old woman has fatigue, constipation, lethargy and feels achy which she thinks is pain in her bones. She has a past medical history of hypertension and coronary artery disease.
Investigations:
- Calcium: 2.8 mmol/L (2.2 – 2.6 mmol/L)
- Phosphate: 0.7 mmol/L (0.8 – 1.5 mmol/L)
- PTH: Elevated (Above normal range)
- ALP: 100 IU/L (30-130 IU/L)
What is the most likely cause of her hypercalcaemia? (and why?)
Primary hyperparathyroidism
High PTH despite a high calcium (not secondary hyperparathyroidism), with low phosphate (not tertiary hyperparathyroidism).
200
What errors during phlebotomy may lead to inaccurate results?
- Taking bloods in close proximity to IV fluids
- Prolonged tournique
- Tubes not filled adequately
- Incorrect labelling
- Vigorous shaking of tube
- Extremes of temperature
300
28 year old woman presents to A&E after an episode of syncope. She is experiencing palpitations, dizziness and fatigue. She has said that her urine looks dark.
On examination she looks pale and jaundiced and is tachycardic.
Investigations:
- Hemoglobin (Hb): 85 g/L (115-165 g/L)
- White Cell Count (WCC): 8.0 x 10^9/L (3.6 – 11.0 x 10^9/L)
- Platelet Count: 250 x 10^9/L (140 – 400 x 10^9/L)
- Red Cell Count (RCC): 3.0 x 10^12/L (3.8 – 5.8 x 10^12/L)
- Mean Cell Volume (MCV): 83 fL (80 – 100 fL)
- Reticulocyte Count: 5% (0.2 – 2%)
Liver Function Tests (LFTs)
- ALT: 35 IU/L (3-40 IU/L)
- AST: 40 IU/L (3-30 IU/L)
- ALP: 120 IU/L (30-130 IU/L)
- GGT: 45 IU/L (8-60 IU/L)
- Bilirubin: 50 μmol/L (3-17 μmol/L
- Albumin: 40 g/L (35-50 g/L)
a) Is this pre-hepatic, hepatic or a post hepatic jaundice?
b) Which would be the most predominant form of bilirubin?
a) Pre-hepatic
b) Unconjugated bilirubin (as liver is unable to keep up with the amount of bilirubin being produced during haemolysis)
300
A 19 year old male is brought in by ambulance with pinpoint pupils and a respiratory rate of 6 breaths per minute. His GCS is 13/15 and appears drowsy.
Investigations:
pH 7.25 (7.35-7.45)
PaO2 8.1 kPa (10.6-13.4 kPa) on room air
PaCO2 8.3 kPa (4.0-6.0 kPa)
HCO3 22mmol/L (22-26 mmol/L)
Is this an acute or chronic presentation?
What is the most likely cause of his presentation?
Most likely acute due to no evidence of chronic compensation as normal HCO3.
Most likely cause is respiratory depression secondary to opiates overdose.
300
A 50 year old female presents with fatigue, weight loss, abdominal pain, nausea and dizziness. She has had recent episodes of syncope in the last 24 hours, and also has type 1 diabetes mellitus. A recent thyroid function test was normal.
Investigations:
- Na: 130 mmol/L (135-146 mmol/L)
- K: 5.8 mmol/L (3.5-5.3 mmol/L)
- Urea: 7.3 mmol/L (2.5-7.8 mmol/L)
- Creatinine 83 umol (45-84 umol/L)
- Glucose: 3.7 mmol/L (3.6-5.3 mmol/L)
What is the most likely diagnosis?
Addison's disease
90% of Addison's patients are female.
Clinical features of abdo pain, nausea, fatigue, weight loss, syncope.
U&E's show hyponatraemia and hyperkalaemia. Normal TFTs.
300
Shortening of the QT interval, Osborn waves (J waves) and ventricular irritability are all potential ECG features of which electrolyte abnormality?
Hypercalcaemia
300
Which tests tell us about the liver's function?
Albumin, clotting (e.g. INR)
400
A 39 year old woman has deranged LFTs and the gastroenterology team orders a "liver screen". What blood tests make up the "liver screen"?
Viral:
- Hep B and C (A and E if clinically relevant)
- CMV
- EBV
Immunological:
- Anti-smooth muscle (autoimmune hepatitis type 1)
- Anti-mitochondrial (PBC)
- Anti-nuclear antibodies (autoimmune hepatitis type 1, SLE)
- ANCA
- C3
- A1- antitrypsin
- Immunoglobulins and protein electrophoresis (PBC, alcoholic liver disease, autoimmune hepatits)
- Tissue transglutaminase antibody (coeliac)
Tumour markers
- AFP
- CEA
Others:
- Copper
- Caeruloplasmin
- Ferritin and iron studies
- Paracetamol
400
25 year old male presents with rapid breathing, abdominal pain and confusion. He is unable to tell you his past medical history.
Arterial blood gas:
- pH: 7.20 (7.35-7.45)
- PaO2: 12.1 kPa (11-13 kPa)
- PaCO2: 4.6 kPa (4.7-6.0 kPa)
- HCO3–: 10 mEq/L (22-26 mEq/L)
- Glucose: 25 mmol/L (3.6-5.3 mmol/L)
Please interpret these ABG results and give your most likely diagnosis.
Metabolic acidosis (As CO2 does not explain low pH - metabolic acidosis. HCO3- low. Patient breathing fast and has a slightly low CO2 as attempting to compensate.)
Most likely diagnosis is DKA (metabolic acidosis, BMs >11, abdo pain, confusion and fast breathing).
400
A 67 year old female with a background of heart failure and osteoarthritis takes furosemide, spironolactone, ramipril and ibuprofen.
Investigations:
- Sodium: 140 mmol/L (135-146 mmol/L)
- Potassium: 7.1 mmol/L (3.5-5.3 mmol/L)
- Urea: 6.5 mmol/L (2.5-7.8 mmol/L)
- Creatinine: 82 μmol/L (45-84 μmol/L)
- eGFR: 75 ml/min/1.73m² (>90 ml/min/1.73m²
Which of these medications can cause hyperkalaemia?
NSAIDs (Ibuprofen), ACE inhibitors (Ramipril) and Potassium sparing diuretics (Spironolactone).
400
A 65 year old female being treated in hospital with multiple myeloma is found to be severely hypercalcaemic.
What is the management of hypercalcaemia?
Rehydration (at least 3L of fluids in 24hrs).
Bisphosphonates (in severe cases - for e.g. IV zoledronic acid).
Stop drugs which can worsen hypercalcaemia
Drugs to alleviate symptoms (laxatives for constipation)
ECG monitoring
Recheck Calcium levels
500
A 30 year old female attends a GP appointment for follow up investigations after having abnormal LFTs.
Investigations:
Hepatitis B surface antigen (HBsAg): +ve
Antibody to Hepatitis B surface antigen: -ve
Antibody to Hepatitis B core antigen (anti-HBc) IgM: +ve
Antibody to Hepatitis B core antigen (anti-HBc) IgG: -ve
Hepatitis B envelope antigen (HBeAg): +ve
Hepatitis B envelope antibody (anti-HBe): -ve
Acute infection with Hepatitis B
-------------------------------------
HBsAg is the first serum marker to be detected after initial infection. Its presence always implies active infection.
A +ve anti-HBs without its antigen implies immunity to Hep B (either cleared infection or vaccination).
Anti-HBc IgM shows recent infection within last 6 months, IgG gradually replaces IgM after class switching indicating chronic infection.
HBeAg - present in acute and chronic infection and indicates active viral replication. The antibody against this marks a transition from active disease to an inactive carrier state.
500
A 35 year old female has weight gain, particularly around her abdomen and face.
On examination she has multiple bruises around her arms and legs and proximal muscle wasting.
Her U&Es show:
- Sodium: 147 mmol/L (135-146 mmol/L)
- Potassium: 3.2 mmol/L (3.5-5.3 mmol/L
- Urea: 5.0 (2.5-7.8 mmol/L)
- Creatinine: 90 umol/L (59-104umol/L)
- eGFR: >90 (>90)
What other investigations would you like to do?
Bedside - Capillary blood glucose
Bloods - FBC (check Hb as bruises), Mg (as hypokalaemic), Clotting (as bruises)
Orifices - Late night salivary cortisol (for diagnosis), 24h Urinary Free Cortisol (for diagnosis). May check urinary sodium as hypernatreamic.
X-rays - None
ECG - YES (look for hypokalaemic ECG changes)
Special tests - Overnight low dose dexamethasone suppression test (for diagnosis)
Further investigations such as a High-dose dexamethasone suppression tests and plasma ACTH can help identify underlying cause of Cushing's
500
What is the (most common) cause of secondary hyperparathyroidism?
A condition such as CKD (most common cause) can result in hypocalcaemia as failing kidneys cannot convert enough vitamin D to its active form, and they do not adequately excrete phosphate. When this happens, insoluble calcium phosphate forms in the body and removes calcium from circulation. This leads to hyperplasia of the parathyroid glands and high secretion of PTH (and despite this there is low calcium).