1. ED setting. Middle-aged man with chronic renal failure of unknown cause. Furosemide recently doubled ( 40 mg to 80 mg) by GP. Recent attack of gout with self-medication of indomethacin. Now weak, confused, vomiting and hypotensive. Take history, PE, investigations, explain further treatment to patient. On Hx, pt wth CRF, reduced urine output 24 hours, feeling very tired, dizzy. Nil hx of heart failure. Examiner provided two sheets containing physical examination and investigation findings: BP 90/60, hyperkalemia (k+6.3),hyponatraemia, acidosis, creatinine 400 µmol/L.ECG provided- explained ECG ( sinus rhythm,prolonged PR interval wide QRS and tall t wave), as soon as I explained the ECG examiner hastened to go through diagnosis mx plan, started my explanation by saying pt is having acute renal failure on top of chronic renal failure exactly this sentence, also drew picture of loop of henle to explain the electrolyte absorbtion and effect of frusemide, ACEI, and CRF on electrolyte imbalance,also impaction on Na+/K+ pump of cardiac cells for high concentration of potassium as pt is having ecg changes, pt for IV fluid to keep blood pressure up,reduce creatinine, try fluid challenge to increase urine out put, withhold BP medication (frusemide and lisinopril) now,treatment for hyperkalamia, as pt has ECG changes and symptomatic needs to be reviewed by medical team for admission and then r/v by renal team for suitability of dialysis. Questions from examiner: Will you continue to prescribe frisemide and lisinopril? Role player: Is dialysis going to take place to improve kidney function ? Feedback: Acute renal failure on top of chronic renal failure (passed)
Posted on: Tue, 11 Mar 2014 03:55:02 +0000
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