BMJ Cases

Question 1

A 54-year-old man with a 10-year history of diabetes and hypertension, with complications of diabetic retinopathy and peripheral neuropathy, presents to his primary care physician with complaints of fatigue and weight gain of 4.5 kg over the past 3 months. He denies any changes in his diet or glycaemic control, but does state that he has some intermittent nausea and anorexia. He states that he has noticed that his legs are more swollen at the end of the day but improve with elevation and rest. Physical examination reveals an obese man with a sitting blood pressure of 158/92 mmHg. The only pertinent physical examination findings are cotton wool patches and micro-aneurysms bilaterally on fundoscopic examination and pitting, bilateral lower-extremity oedema.

What is the diagnosis?

Answer 1

Answer; Chronic Kidney Disease

Reason; Note risk factors - diabetes etc
Other presentations
The disease presents insidiously over months with vague complaints of fatigue, mild reduction in appetite, and, at more advanced stages, nausea and anorexia. Oedema is a common presentation - as the glomerular filtration rate declines, there is an inability to effectively excrete salt and water to remain in metabolic balance with dietary intake. Additionally, proteinuria with a decrease in serum albumin may contribute to the development of peripheral oedema.

Question 2

A 35-year-old man with a history of congenital valvular heart disease undergoes a dental procedure without appropriate antibiotic prophylaxis. Several weeks later, he presents with fever and respiratory distress. He is intubated, and Streptococcus viridans is isolated in all blood cultures drawn at the time of admission. Echo demonstrates a mitral valve vegetation. Laboratory tests reveal a rising serum creatinine and urine output decline. Urine analysis reveals more than 20 WBCs, more than 20 RBCs, and red cell casts. Urine culture is negative. Renal ultrasound is unremarkable. Serum ESR is elevated.

Answer 2

Acute kidney injury
sounding pre-renal to me

AKI may develop in the setting of normal urine output and an otherwise asymptomatic patient. Associated laboratory abnormalities including elevated serum creatinine and urea, hyperkalaemia, and anion gap or non-gap metabolic acidosis may be all that are seen. Symptoms such as arthralgias, myalgias, or rash may be seen in cases of vasculitis or glomerulonephritis.

Question 3

A 65-year-old male smoker with hypertension, dyslipidaemia, and diabetes mellitus presents with chest pain. ECG changes suggest an acute MI. He is taken for an urgent coronary angiogram. Three days later, he is noticed to have developed an elevated serum creatinine, oliguria, and hyperkalaemia.

Answer 3

This is AKI because;

• creatinine, oliguria, k+
• cvs risk factors

AKI following vascular catheterisation or systemic anticoagulation may result from atheroembolic injury. Abdominal masses, found on examination or by imaging, may be found in otherwise asymptomatic individuals with obstructive nephropathy and renal failure. AKI with allergy symptoms (fever, rash, arthralgia), haematuria, and sterile pyuria suggests interstitial nephritis.

Question 4

A 45-year-old man presents to the emergency department with a 1-hour history of sudden onset of left-sided flank pain radiating down towards his groin. The patient is writhing in pain, which is unrelieved by position. He also complains of nausea and vomiting.

Answer 4

renal calculi

Question 5

Mets of Renal cell carcinoma causes which xray appearance?

Answer 5

Cannon ball mets

can also be caused by choriocarcinoma