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BOF: 127

A 50-year-old male presents with malaise. He finds it difficult to cope with his work, sleeps poorly and has an itch especially at night.  He has difficulty climbing stairs and also finds it difficult to stand up from a seated position.  He had no significant past illnesses but had been told that he had high blood pressure years earlier but had taken no action regarding this.

On examination he underweight and pale. His skin was dry and covered in scratch marks. Blood pressure 190/110. No oedema. Heart sounds were normal, lungs were clear. Fundus showed arteriovenous nipping and thickened arteries.  On neurological examination it was noticed that he had difficulty standing from the seated position.


Hb 8.0

MCV 90 fl

WBC 4.8 x 10 9 /l

Na 138 mmol/l

K 6.1 mmol/l

Chloride 90 mmol/l

Urea 53 mmol/l

Creatinine 1850 micromoles/l

Calcium 1.40 mmol/l

Phosphate 2.31 mmol/l

Albumin 30 g/l

Fasting Blood Glucose 5.2 mmol/l

In this patient:

a)      Excellent control of blood pressure is not a priority as he is not diabetic

b)      Control of blood pressure is essential but care should be taken not to lower the blood pressure to less than 130/80 as this will compromise renal function

c)      ACE inhibitors should be avoided as they will cause further deterioration of renal function

d)      Treatment of hypertension with ACE inhibitors would be of particular value

e)      Low dose diuretics should be used so as to avoid dehydration which will further compromise renal function 

In this patient:

a)      Treatment of hypercalcaemia should aim to keep the PTH level below three times the upper limit of normal

b)      Calcitriol should be given immediately

c)      Dietary restriction of phosphate will control the high phosphate levels

d)      Calcium carbonate will reduce bioavailibilty of dietary phosphate

e)      H2 antagonists should be used to increase the effectiveness of phosphate binders



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