Station - Instructions for candidate
You are an intern in the general medicine outpatient clinic of a Perth teaching hospital.
Li Liu, a 38-year-old high-school teacher, has been referred by her GP about her blood pressure. The referral letter and her recent results are printed on your sheet. The clinic nurse has checked her observations and can answer brief questions about her.
| GP referral letter (extract) | Raised blood pressure since age 34, never at target; amlodipine 10 mg and hydrochlorothiazide 25 mg for three years, ramipril 5 mg added two weeks ago. Adherence confirmed with the practice nurse. Non-smoker, BMI 22, no diabetes, no family history of high blood pressure. Urine dipstick negative for protein and blood. I noted a soft bruit in the right upper abdomen. |
|---|---|
| Clinic observations today | BP 168/102 mmHg right arm, 166/100 mmHg left arm; HR 74 regular; weight 58 kg; afebrile |
Results provided:
Home blood pressure diary (7 days, twice daily)
| Item | Value | Reference range |
|---|---|---|
| Morning average | 166/101 mmHg | <135/85 mmHg |
| Evening average | 162/99 mmHg | <135/85 mmHg |
| Lowest single reading | 152/94 mmHg | <135/85 mmHg |
Readings taken with a validated upper-arm monitor while on all three medicines.
Urea, electrolytes and creatinine - before and two weeks after ramipril
| Item | Value | Reference range |
|---|---|---|
| Creatinine (before) | 78 umol/L | 45-90 umol/L |
| Creatinine (two weeks after) | 128 umol/L | 45-90 umol/L |
| eGFR (before / after) | >90 / 48 mL/min/1.73 m2 | >90 mL/min/1.73 m2 |
| Potassium (before / after) | 4.1 / 4.9 mmol/L | 3.5-5.2 mmol/L |
| Sodium (after) | 139 mmol/L | 135-145 mmol/L |
| Urea (after) | 8.9 mmol/L | 2.5-8.0 mmol/L |
Both samples taken at the same laboratory; no intercurrent illness, no NSAIDs, no change in fluid intake reported.
Your tasks are to:
- Interpret the results provided.
- State your most likely diagnosis and differential diagnoses to the examiner.
- Outline your initial management plan to the examiner.
- The examiner will ask you two questions at the end.
- You do NOT need to take a history or examine the patient; the clinic nurse can answer brief questions about her.
- Further results are available from the examiner on request.
This is a 10-minute station, with 2 minutes of reading time.