05/04/2016
A 60-year-old lady from Syria presented with rigors and presyncope. No further
history was available. On examination she was febrile at 38.5 °C and flushed.
Her pulse was 120/min. Blood pressure was 120/80 mmHg when lying down and
100/60 mmHg when sitting. Her JVP was not visible and heart sounds were normal.
Her chest was clear. A left paramedian abdominal scar was evident, together with a
tender right flank. There was no neurological abnormality as far as it was possible
to assess.
Hb 13.4 g/dl, white cell count 18.9 109/l, platelets 447 109/l, PT 13 s (normal:
10–12 s), Na 144 mmol/l, K 2.9 mm/l, urea 10.4 mmol/l, creatinine 140mol/l,
chloride 118 mmol/l, bicarbonate 13 mmol/l. No urine was available for analysis.
1. Select the two most likely diagnoses from the following:
a) Diabetic ketoacidosis (DKA)
b) Acute renal failure
c) Right-sided pyelonephritis
d) Malignant bowel perforation with tracking of bowel contents down right
paracolic gutter
e) Ureterosigmoidostomy
f) Type 2 renal tubular acidosis
g) Pancreatitis
h) Haemorrhage into metastatic neuroendocrine tumour