1. A 87 year old man has been in hospital for 3 days following an episode of confusion. He has developed hypokalaemia. Apart from diuretics, which 5 medicines could explain this?
Amphotericin, salbutamol, dobutamine, vit B12, folate - also consider chemotherapy for causing tubulopathy.
2. Which ECG changes aer associated with hypokalaemia?
Flattened T wave, U waves in all leads
3. How does aldosterone affect the ECF?
It causes sodium and water retention, expanding the ECF volume.
4. An 83 year old woman who has been in hospital for 5 days following UTI is noted to have hyponatraemia. She DOES NOT HAVE dry mucous membranes, decreased urine output or confusion. How might you manage this?
Fluid restriction, diuretic.
5. An 83 year old woman who has been in hospital for 5 days following UTI is noted to have hyponatraemia. She also has dry mucous membranes, decreased urine output and confusion. How should you manage?
Treat clinically as sodium depletion, replace sodium SLOWLY
6. An 83 year old woman who has been in hospital for 5 days following UTI is noted to have hyponatraemia. You note oedema. Serum osmolality is low. What 2 causes should you consider?
Increased water intake (e.g. IV saline), decreased excretion (e.g. CCF, nephrotic syndrome)
7. An 83 year old woman who has been in hospital for 5 days following UTI is noted to have hyponatraemia. You note lack of oedema. Serum osmolality is low. What 2 causes should you consider?
Increased water intake (e.g. Water drinking), decreased water excretion (eg. SIAD, renal failure)
8. A 29 year old woman is being investigated for infertility. You note high prolactin. What 2 drugs might you consider to manage this?
Bromocriptine, cabergoline (dopamine agonists)
9. A 15 year old boy is being investigated for shortness. What 2 natural and 1 other stimulus may test GH sufficiency?
Excersize, sleep and clonidine.
10. A 87 year old man has been in hospital for 3 days following an episode of confusion. He has developed hypokalaemia. He does not have vomiting, diarrhoea and he is not on diuretics. What 3 investigations would you perform now and what might you expect them to show?
pH (high), phosphate (low), glucose (low)
11. A 76 year old woman is noted to have high serum osmolality, without hypernatraemia. What 3 major causes exist for this?
increased urea in renal disease, increased glucose in diabetes mellitus, increased ethanol.
12. A 59 year old man is very unwell with pneumococcal septicaemia. What 4 coagulation proteins may be increased in the acute phase response?
Fibrinogen, prothrombin, factor VIII, plasminogen
13. A 81 year old woman presents with breathlessness. ABG shows type I respiratory failure. What are the 2 main causes of this?
15. A 69 year old woman recovering from her hysterectomy is noted to have magnesium deficiency. What are the 2 most likely causes?
dietary insufficiency (vomiting and diarrhoea included), osmotic diuresis (diabetes mellitus)
16. A 87 year old man has been in hospital for 3 days following a GI illness. He is now noted to have hypokalaemia. What are the 3 commonest causes of hypokalaemia?
Diarrhoea, vomiting, diuretics (loop and thiazide).
17. A 32 year old woman presents with hirsutism. you note she is not obese. what are the 3 differential diagnoses (aside from obesity and idiopathic)?
adrenal/ovarian tumour, late onset CAH, insulin resistance syndrome
18. A 51 year old man presents with confusion and a fever. Urine dipstick notes that protein is raised. What are the 3 main causes of proteinuria?
Glomerular, tubular, overflow
19. A 71 year old woman is being managed for her postural hypotension. You note hyperphosphataemia. Rena function is normal. What are the 3 most likely causes for this?
20. A 49 year old man presents with muscle weakness. You note hypophosphataemia. What are the 3 most likely causes of this?
Hyperparathyroidism, DKA treatment, alkalosis - note that phosphate follows H+
21. A 79 year old woman presents with lethargy and depression. You note hypercalcaemia. What are the commonest 2 causes of this?
malignancy, primary hyperparathyroidism
22. A 79 year old woman presents with tingling and tetany. You note hypocalcaemia. What are the main 4 causes of this?
Vit D deficiency, hypoparathyroidism, magnesium deficiency, renal disease
23. An 83 year old woman who has been in hospital for 5 days following UTI is noted to have hyponatraemia. Serum osmolality is normal. What are the two commonest causes of this?
GI losses (e.g. Vomiting and diarrhoea), urinary loss (Addison's, spironolactone)
24. A 58 year old man presents with a tremor. You note hypermagnesaemia. What are you concerned about?
This is rare, but sometimes seen in renal failure.
25. An 83 year old woman who has been in hospital for 5 days following UTI is noted to have hyponatraemia. She also has dry mucous membranes, decreased urine output and confusion. What are you concerned about?
Sodium depletion
26. An 83 year old woman who has been in hospital for 5 days following UTI is noted to have hyponatraemia. You note raised protein and normal serum osmolality. What are you suspicious of and how might you check?
Pseudohyponatraemia - measure the osmolal gap
27. A 58 year old woman presents with jaundice. Haptoglobin is decreased. What causes are there of this, broadly speaking?
Haemolytic jaundice
28. A 58 year old woman presents with jaundice. LDH is slightly raised. What causes are there of this, broadly speaking?
Haemolytic, cholestatic.
29. A 58 year old woman presents with jaundice. There is bilirubin in her urine. What causes are there of this, broadly speaking?
cholestatic and hepatocellular
30. Your registrar leaves you on Friday afternoon to find the results of a GnRH test. What do they suspect and what is a normal result?
Hypogonadism - A marked rise in LH and a smaller rise in FSH is normal.
31. Your registrar leaves you on Friday afternoon to find the results of an insulin stress test. What do they suspect and what is an abnormal result?
Hypopituitarism - ACTH (proxy is cortisol) and GH are not raised in response to hypoglycaemic stress
32. Your registrar leaves you on Friday afternoon to find the results of an TRH test. What do they suspect and what is an abnormal result?
Inadequate anterior pituiary reserve. - Both TSh and prolactin rise normally
33. A 29 year old woman is investigated for subfertility. She has oligomenorrhoea and is not pregnant. What do you measure now?
FSH, LH, prolactin
34. What does AVP rise in response to?
Raised serum osmolality
35. A 81 year old woman presents with fatigue and paraesthesia. You note hyperkalaemia. GFR is normal, CK, urate, glucose and pH are normal. What drugs are most likely to cause hyperkalaemia?
potassium salts, ACEI, ARB, spironolactone
36. A 85 year old man has been in the hospital for 7 days following a LRTI. He is now noted to have hypernatraemia. Urine is not concentrated and normal volume. What four causes might you suspect?
diabetes insipidus, osmotic diuresis (diabetes mellitus), Conn's syndrome, Cushing's syndrome (the latter two only if water intake restricted)
37. A 59 year old man on your ward 'for investigation' has hyperglycaemia. You are the on call FY1. Flicking through the notes, you see 'OGTT with GH measurement abnormal' written in poor handwriting, which appears to have been unnoticed by other teams. What is the cause of his hyperglycaemia?
Acromegaly
38. A 32 year old woman presents with hirsutism. What is the commonest cause?
Idiopathic, particularly in obesity with insulin resistance. - it is associated with polycystic ovarian disease
39. A 32 year old woman presents with hirsutism. you note she is not obese. What is the first test you perform?
Testosterone levels
40. A 81 year old woman presents with fatigue and paraesthesia. You note hyperkalaemia. What is the first thing you should look for?
reduced GFR as this is the most common cause.
41. A 49 year old man presents with muscle weakness. You note hypophosphataemia. What is the largest risk factor for this?
Alchoholism
42. A 59 year old man on your ward 'for investigation' has fallen unconscious. You are the on call FY1. You have sent off bloods urgently. Flicking through the notes, you see 'high dose dexamethasone suppression test abnormal' scrawled untidily and retrospectively. What is the likely cause of his unconsciousness?
ectopic ACTH overproduction - consider hyperglycaemia and do BMs.
43. A 59 year old man on your ward 'for investigation' has fallen unconscious. You are the on call FY1. You have sent off bloods urgently. Flicking through the notes, you see 'low dose dexamethasone suppression test abnormal' scrawled untidily and retrospectively. What is the likely cause of his unconsciousness?
Cortisol overproduction - consider hyperglycaemia and do BMs.
44. A 59 year old man on your ward 'for investigation' has fallen unconscious. You are the on call FY1. You have sent off bloods urgently. Flicking through the notes, you see 'short synacthen test abnormal' scrawled untidily and retrospectively. What is the likely cause of his unconsciousness?
Primary adrenal insufficiency - consider hypoglycaemia and do BMs
45. An 83 year old woman who has been in hospital for 5 days following UTI is noted to have hyponatraemia. What is the most frequent cause for this and how might it be indicated?
Water retention - increased ECF space
46. A 71 year old woman is being managed for her dehydration. You note hyperphosphataemia. What is the most likely cause for this?
Renal failure, hypoaldosteronism (often due to ACE inhibitors and ARBs).
47. A 79 year old woman presents with lethargy and depression. You note hypercalcaemia. What is the next thing you should check?
PTH
48. An 83 year old woman who has been in hospital for 5 days following UTI is noted to have hyponatraemia. What is the rare but serious cause for this and how might this be indicated?
Sodium depletion - Dehydration or ECF depletion
49. A 57 year old man has had a fever ofr 2 days. He presents with nausea, adominal pain. He is severely dehydrated, with high blood glucose and an osmotic diuresis. Ketosis is absent. What is this and what is management?
HONK - Rehydration, insulin, prophylactic heparin
50. A 79 year old woman presents with lethargy and depression. You note hypercalcaemia. PTH is low. What is this most likely to be and how would you manage calcium levels?
Malignancy - alendronic acid
51. A 79 year old woman presents with lethargy and depression. You note hypercalcaemia. PTH is high. What is this most likely to be?
Primary hyperparathyroidism (usualyl adenoma)
52. A 29 year old woman is investigated for subfertility. She has oligomenorrhoea and is not pregnant. Her LH is high, her FSH is also high. What is this?
ovarian failure
53. A 29 year old woman is investigated for subfertility. She has oligomenorrhoea and is not pregnant. Her LH is high, her FSH is low. What is this?
polycystic ovarian syndrome
54. A 71 year old woman is recovering from a parathyroidectomy due to longstanding primary hyperparathyroidism. You note hypocalcaemia. What is this?
Hungry bone syndrome - this is due to rapid remineralisation of bone and can be life-threatening
55. A 85 year old man has been in the hospital for 2 days following severe diabetic acidosis. He is now noted to have hypernatraemia. Clinically he doesn't appear dehydrated. Urine is maximally concentrated and low volume. What should you consider?
56. An 83 year old woman who has been in hospital for 5 days following UTI is noted to have hyponatraemia. What should you examine and investigate next?
oedema, serum osmolality
57. A 85 year old man has been in the hospital for 7 days following a LRTI. He is now noted to have hypernatraemia. What should you examine and investigate next?
Examine for dehydration, investigated serum and urine osmolality
58. A 32 year old woman presents with hirsutism. Her testosterone is raised. What two androgens would you now measure and what do they tell you?
Androstenedione (if only this is raised then ovarian source), DHA sulphate (adrenal source)
59. A 85 year old man has been in the hospital for 7 days following a LRTI. He is now noted to have hypernatraemia. Urine is maximally concentrated and low volume. What two causes are there?
Dehydration or sodium administration - Sweating, diarrhoea, reduced water intake, sodium administration
60. A 81 year old woman presents with fatigue and paraesthesia. You note hyperkalaemia and reduced GFR. What two causes should you consider?
Renal failure, hypoaldosteronism (often due to ACE inhibitors and ARBs).
61. A 87 year old man has been in hospital for 3 days following an episode of confusion. He is now noted to have hypokalaemia. What two types of diuretics may cause this?
Loop and thiazide
62. A 87 year old man has been in hospital for 3 days following an episode of confusion. He has developed hypokalaemia. He does not have vomiting, diarrhoea and he is not on diuretics. His pH, phosphate and glucose are normal. What would you check now and what 3 conditions would this inform you about?
63. A 81 year old woman presents with fatigue and paraesthesia. You note hyperkalaemia. GFR is normal, CK, urate, glucose and pH are normal. What would you consider next?
drug review (particularly potassium salts, ACEI, ARB, spironolactone), adrenal insufficiency
64. A 81 year old woman presents with fatigue and paraesthesia. You note hyperkalaemia. GFR is normal. What would you investigate next and what 4 conditions are you looking for?
65. A 69 year old woman is admitted to your ward. You are told she has chronic renal failure. Which 4 electrolytes and 1 hormone should you be particularly careful of?
