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YOUR LATEST ISSUE ABOUT MRCP PACES IS HERE! Examine this gentleman's abdomen.
Discussion: I have discussed about this case in my previous issue. This case is always a popular case MRCP PACES station 1. You notice that there are two vertical surgical scars over this gentleman's flanks. If you have a general inspection before you touching this gentleman's abdomen, you would have an idea what you are dealing with. Yes, you are seeing a patient with kidney transplantation. You are expecting to find the following physical signs during your physical examination, two vague masses in the flanks( he underwent two kidney transplantations before)
the masses are not tender on palpation and there is no bruits heard ( always check for possibilities of renal artery stenosis in a post transplanted kidney). However, you should try to find the following after you find that he has previous kidney transplantation, the possible cause of his end stage renal disease, therefore you must look hard for polycystic kidney and suggest to examiners that you would like to look at his fundus for diabetic retinopathy as well as hypertensive changes ( remember that cyclosporin also causes hypertension) whether the transplanted kidney is functioning well ( therefore suggest to examiners that you would like to look at this patient's urine output and check for any haematuria) look beyond for other possible complications of medications ( immunosuppressants patient is currently on) such as cataract, osteoporosis ( spine tenderness), proximal myopathy ( secondary to long term steroid) etc
Common questions examiners would ask you, 1)
What are common problems patients face after kidney transplantation? ( Remember to divide that into acute and chronic complications.) Conclusion: This gentleman has two previous kidney transplantations and currently not dialysis dependent . Extra points: 1) Common side effects of Calcineurin Inhibitor ( such as cyclosporin and tacrolimus) are Nephrotoxicity
Station 4: You are the SHO in charge of Nephrology Ward. Subject: Mr Lee, 52-year old Kindly see Mr Lee who has recently been diagnosed to have end stage renal disease with a creatinine level of 1000. He has background history of diabetes mellitus for the past 15 years which is poorly controlled. He was admitted to your ward 4 days due to ureamic symptoms and urgent haemodialysis was done for him. Currently he is well and waiting to see you to discuss about further plan.You are asked by your consultant to discuss about long term renal replacement therapy with him. His latest FBS in the ward was 12 mmol and HbA1C=10%. His Blood Pressure was 150/90 during the morning round. You have 14 min until the patient leaves the room followed by 1 min for reflection before the discussion with the examiners. Discussion: A popular question in MRCP PACES station 4. You are expected to discuss long term renal replacement therapy with Mr Lee. Before you proceed, you must remember that there are three possible ways available namely Haemodialysis, CAPD ( Continuous Ambulatory Peritoneal Dialysis) and Kidney Transplantation. However, before you start your formal discussion with Mr Lee, remember to do the following, During you MRCP PACES examination, you must know the basic knowledge a patient know about his condition before you try to explain his illness. In this scenario, briefly talk about how haemodialysis and CAPD is being done. Try to explain to Mr Lee as well about the pros and cons about each technique available and their limitations ( such as in CAPD, patients may need to have adequate visual acuity to handle himself the CAPD). You must explore the option of kidney transplantation as well to Mr Lee and warn him about the problems he might face in future with all the immunosuppressants.However, remember to talk about a few other related issues with Mr Lee as well such as, his diabetic control and tell him about importance of sugar control towards progression of kidney disease. Remember that counseling is always not an easy station in MRCP PACES, look beyond your problems and discuss according to your scenario. Such as in this case, you certainly would be very interested to know about Mr Lee's social history, financial support ( such as insurance coverage) and impact of the disease towards Mr Lee's daily life ( discuss about depression as well if possible). Summarize your discussion with Mr Lee and present to the examiners, your examiners will like to know what problems you encounter during your counseling with Mr Lee ( such as poor social or financial support, etc....) Source: 1) Handbook of Kidney Transplantation, Gabrieal M. Danovitch To see previous issues, click here! To send a quick comment, click here! |
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