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Flashcards in Chem Path Qs Deck (206):
1

Combined Pituitary Function Tests involves what:

Insulin tolerance test - this should increase cortisol (>170nmol/l) and GH (>6mcg/l)
TRH test - Stimulates TSH and prolactin, the 30m sample should be greater than the 60m sample, otherwise primary hypothalamic disease is indicated.
GnRH test - LH > 10U/l and FHS > 2U/l (early hypopirtuitarism).

2

Non functioning pituitary adenoma casuses:

Panhypopituitarism and raised prolacting. Adenoma presses on stalk and causes pituitary failure. Dopamine can reach pituitary and suppress prolactin.

3

Acromegaly - Cause and Treatment

Excess GH from the pituitary. Treat with ocreotide or ianreotide (somatostatin analogues).

4

Osteoporosis
Low/High Turnover?
Main Causes?
Risks (nutrition/social, endocrine, immobile and iatrogenic)

High turnover from increase resorption
Low turnover from decrease resorption.
90% due to insufficient Ca intake or menopause.
Nutritional/Social - age, female, smoking, xs alcohol, vit d/ca deficiency, immobility, malabsorption.
Endocrine - thyroid, PTH, menopause, cushings, DM
Inatrogenic - steroids, heparin (long-term).

5

Osteomalacia
Definition
Two causes
Symptoms

Defective bone mineralisation
Cause by deficiency in Vit D or phosphate.
Bone pain/tenderness, fracture, proximal weakness, bone deformity.
FRACTURES IN LOOSER'S ZONE

6

Hyperparathyroidism
Urine and Serum changes?

Excess PTH leads to increase Ca and PO excretion in unripe. Hypercalcaemia, hypophosphataemia.
INAPPROPRIATELY NORMAL PTH level relative to Ca

7

Hyperparathyroidism
Skeletal Changes?

Osteitis fibrosa cystica (replacement of bone with fibrous tissue)

8

Hyperparathyroidism
Skeletal Changes?

Osteitis fibrosa cystica

9

Primary Hyperparathyroidism
Causes?

Parathyriod adenoma (85-90%) - chief cell hyperplasia

10

Secondary Hyperparathyroidism
Cause?

Chronic renal deficiency, vit D deficiency, malabsorption.

11

Renal Ostendystrophy
Bone Changes?

Comprises all skeletal changes of chronic renal disease.
Osteitis fibrosa cystica
Osteomalacia
Osteosclerosis
Growth retardation
Osteoporosis

12

Renal Osteodystrophy
Serum Changes?

hyperphospataemia
hypo calcaemia as a results of decrease vit d
Secondary hyperparathyroidism
Metabolic acidosis
Al deposit.

13

Paget's - Definition and Sx

Disorder of bone turnover.
Pain, microfracturers, nerve compression, skull changes.
Onset > 40y
M=F
Rare in asian and africans

14

Commonest electrolyte abnormality in hospitalised patients?

Hyponatraemia

15

ADH/Vasopressin
Target?
Effect?
Controls?

Acts on V2 receptors
Results in aquaporin insertion in DCT
At high concentration bind V1 receptors on smooth muscle causing contraction.
Results in water retention.

16

ADH/Vasopressin
Target?
Effect?
Controls?

Acts on V2 receptors
Results in aquaporin insertion in DCT
At high concentration bind V1 receptors on smooth muscle causing contraction.
Results in water retention and DECREASE Na

17

What are the two main stimuli for ADH?

Serum osmolality (via hypothalmic osmoreceptors, also stimulates thirst)
Blood volume (barroreceptors in carotids, atria, aorta).

18

What is the first step in the assessment of a patient with hyponatraemia?

Check volume status

19

What are the clinical signs of hypovolaemia? (6)

Tachycardia, postural hypotension, dry mucous membranes, reduced skin turgor, confusion, reduce urine output.

20

What are the clinical signs or hypervolaemia? (3)

Raised JVP, bibasal crackles, peripheral oedema.

21

What are the causes of hypovolaemic hyponatraemia? (3)

Renal causes of volume depletion (diuretics)
Extra-renal causes of volume depletion (diarrhoea, vomiting).
Salt loosing nephropathy.

22

What are the causes of hypervolaemic hyponatraemia? (3)

Cirrhosis
Cardiac Failure
Nephrotic Syndrome

23

What are the causes of euvolaemic hyponatramia? (3)

Hypothyroidism
Adrenal insufficiency
SIADH

24

SIADH Causes? (4)

Malignancy - small cell lung, prostate, pancreas, lymphoma
CNS disorder - meningoencephalitis, haemorrhage, abscess
Chest disease - TB, pneumonia, abscess
Drugs - opitates, SSRIs, TCA, carbemazepine

25

SIADH Lab Criteria?
Urine Osmolality?

Reduced plasma osmolaity
Inappropriately high urine osmolality (>100) and increase renal sodium excretion. Normal renal, adrenal, thyroid and cardiac function.

26

What Ix in a patient in euvolaemic hyponatraemia? (3)

TFTs, Short Synacthen Test, Plasma and urine osmolality

27

How would you manage a hypovolaemic patient with low Na?

Volume replacement with 0.9% saline

28

How would you manage a hypervolaemic patient with low Na?

Fluid restriction and treat cause.

29

How would you manage a euvolaemic patient with low Na?

Fluid restriction and treat cause.

30

Symptoms of Severe hyponatraemia?

Reduced GCS, seizures

31

At what rate can you correct hyponatraemia?

Less that 12mmol/l in the first 24h

32

What is the risk of correcting Na too quickly>

Osmotic demyelination (central pontine myelionlysis) leading to?
quadriplegia, pseudobulbar palsy, seizures, coma, death.

33

What is the risk of correcting Na too quickly>

Osmotic demyelination (central pontine myelionlysis) leading to?
quadriplegia, pseudobulbar palsy, seizures, coma, death.

34

What drugs can be used to treat SIADH? (2)

Demeclocycline - reduces responsiveness of collecting tube cells to ADH (SE nephrotoxic)
Tolvaptal (V2 receptor antagonist)

35

Hyponatraemia is mostly due to?

Increase extra cellular water

36

What are the main causes of hypernatraemia?

Unreplaced water loss - GI losses, sweat losses, renal losses (osmotic diuresis, reduced ADH release aka DI)
Patient cannot control water intake (elderly/children)

37

What Ix for at patient in suspected DI?

Serum glucose (exclude DM)
Serum K (exclude hypokalaemia)
Serum Ca (exclude hypercalcaemia)
Plasma and urine osmolality
Water deprivation test

38

How do you treat raised Na?

Fluid replacement, treat cause.

39

What are the effects of DM on serum Na?

Variable. Hyperglycaemia draws water out of cells leading to hyponatraemia.
Osmotic diuresis in diabeteres leads to loss of water and hypernatraemia.

40

What are the effects of DM on serum Na?

Variable. Hyperglycaemia draws water out of cells leading to hyponatraemia.
Osmotic diuresis in diabeteres leads to loss of water and hypernatraemia.

41

Causes of Nephrogeic DI (3)

Inherited
Lithium
Chronic renal failure

42

Causes of Cranial DI (3)

Head trauma
Tumour
Surgery

43

Which hormones regulate K (renal)

Angiotensin 2 and Aldosterone. Angiotensin 2 causes aldosterone release from adrenal. which leads to Na reabsorption and K loss.
K can directly stimulate the adrenal leading to aldosterone secretion.

44

What are the main causes of hyperkalaemia due to decrease excretion?

CRF (leading to decreased GFR)
Renal tubular acidosis (diabetic nephropathy)
NSAIDS
ACE/ARB
Addisons
Aldosterone antagonists (Spiro)

45

What causes hyperkalaemia due to transcellular movement?

Rhabdo
Acidosis
Insulin shortage

46

What is the main ECG change assoc with raised K?

Peaked T waves

47

How would you manage raised K?

10ml 10% Ca gluconate
50ml 50% dextrose + 10 units of insulin
Neb salbutamol
Treat cause

48

How would you manage raised K?

R10ml 10% Ca gluconate
50ml 50% dextrose + 10 units of insulin
Neb salbutamol
Treat cause

49

Causes of hypokalaemia?

Renal loss (hyperaldoseronism, excess cortisol, osmotic diuresis)
GI loss
Redistribution into cells (insulin, beta agonists, alkalosis)

50

What are the clinical features of hypokalaemia?

Muscle weakness
arrhythmia
polyuria and polydipsia (neprogenic DI)

51

Which diuretics causes K loss?

Loop (equivalent to Bartters synd)
Thiazide (equivalent to Gitelman syndrome)

52

What Ix would you do in a patient with hypokalaemia and hypertension?

Aldosterone:Renin ratio to assess primary hyperaldoseronism.

53

How do you manage a serum potassium between 3 and 5?

Oral potassium chloride (two SandoK tablets tds for 48h) and recheck

54

How do you manage a serum potassium less that 3?

IV KCl max rate 10mmol/h (higher rates irritate peripheral veins).

55

How do you manage a serum potassium less that 3?

IV KCl max rate 10mmol/h (higher rates irritate peripheral veins).

56

Drugs that cause hypoglycaemia?

Sulphonylureas
Insulin
Beta blocker, salicylate, alcohol.

57

Causes of hypoglycaemia which suppressed insulin and C-peptide?

Normal response to hypoglycaemia
Exercise, fasting, critical illness, endrocrine deficiency, liver failure, Anorexia

58

Neonate hypoglycaemia with decrease insulin, c-peptide and ketons and FFAs present?

Premature, IUGR, Co-morbidity
If no ketones suggest a metabolic disorder.

59

Insulinoma - symptoms and lab results

Fitting, weight gain, increased appetite, personality change.
Raised insulin, raised c-peptide, negative sulphonylurea screen (required for dx of insulinoma).
Assoc with MEN1

60

Non-islet cell tumour hypoglycaemia

Decrease insulin, c-peptide, FFAs and Ketones. Tumours that secrete big-IGF2 which binds insulin receptors (paraneoplastic syndrome)

61

Non-islet cell tumour hypoglycaemia

Decrease insulin, c-peptide, FFAs and Ketones. Tumours that secrete big-IGF2 which binds insulin receptors (paraneoplastic syndrome)

62

Metabolic Acidosis Causes (4)

DKA (increase H ion production)
Renal Tubular Acidosis (Decreased H ion excretion)
Intenstinal fistula (bicarb loss)
Lactate build up

63

Resp Acidosis Causes (3)

Decreased ventilation
Poor lung perfusion (PE)
Impaired gas exchange (pneumonia, COPD)

64

Metabolic Alkalosis Causes (3)

Pyloric stenosis (H ion loss)
Hypokalaemia
Ingestion of bicarobonate

65

Res Alkalosis Causes (2)

Panic/hyperventilation
Artificial ventilation

66

Useful in staging extracaspular spread of prostate CA

Acid phosphatase

67

Hashimotos Thyroditis is associated with

autoimmune hepatitis

68

SCID is often caused by a deficiency in?

Adenosine deaminase

69

Which cardiac marker is a good indication of reinfarction?

CKMB

70

A 44-year-old woman known to have multi-focal ER and PR negative breast cancer that is inoperable is admitted with sudden onset of nausea, vomiting, polyuria and delirium. She also has reduced muscle strength and her husband describes her marked personality change and increased thirst over the previous few days as well as increasing back and hip pain not well relieved with her oral morphine preparation. Pelvic radiology reveals Osteolytic lesions. Which of the above do you think would be raised given her presenting symptoms?

Calcium

71

McArdle's Glycogen Storage Disease (type V) Stiffness after exercise. Is a deficiency in which enzyme?

Mycophosphorylase

72

Farby's Disease. X-linked disorder of glycolipid metabolism due to deficiency in?
Symptoms?

Galactosidase A.
Recurrent febrile illness, painful parasthesiae in hands and feet. Red papules in pelvic region. Protinuria.

73

Thiamine Deficiency Sx?

Nystagmus and board based gate. Associated with Alcoholics.

74

Vitamine D Def Sx?

Bone pain, knock-kneed (gunu varus), bow legged, waddling gate.

75

Wilsons Disease is a deficiency in?

Caeruloplasmin

76

Riboflavin (vit B2) deficiency Sx?

Cheilosis (chapping and fissure of lips), a sore red tongue, scaly skin rashes on scrotum, vulva and philtrum.
Riboflavin is absorbed in the terminal ileum.

77

Folic Acide Def Sx?

Anaemia, weightloss

78

Thiamine (B1) Deficiency Sx?

Nystagmus and board based gate. Associated with Alcoholics.

79

Folic Acide Def Sx?

Anaemia, weightloss

80

Atrophic gastritis can lead to deficiency in?

Lack of intrinsic factor produced by the parietal cells leads to b12 deficiency and a megaloblastic anaemia.

81

Vitamin C (ascorbic acid) def?

Required for the synthesis of collagen.
Early -Malaise, lethargy
Middle (1-3m) -SOB, bone pain
Other - Bruising, gum bleeding, poor wound healing and emotional changes.

82

Vitamin A deficiency?

Difficulty seeing in dim light.

83

A 35 yr old woman presents with pain in her neck which radiates to her upper neck, jaw and throat. The pain is worse on swallowing. She has a Hx of an upper respiratory tract infection two weeks ago. On Ix she has a free T4 of 30pmol/l, free T3 of 11pmol/l and a TSH level of 0.1mU/l. On technetium scanning of the thyroid there is low iodine uptake.

Subacute granulomatous thyroditis

84

Thyroid Canacer associated with calcitonin and MEN1?

Medullary

85

32 year old female presented with weight loss and anxiety. The thyroid gland was enlarged, firm, fleshy and pale, infiltrated by lymphocytes. Askanazy cells were noted

Hashimoto's thyroditis

86

Metformin effect of TSH?

suppression

87

Askanazy cells (aka Hurthle cells) are found in? (3)

Benign adenoma, hashimoto's thyroditis, toxic multinodular goitre. Are of follicular cell origin.

88

Drugs contraindicated in porphyria?

Alcohol, NSAID (diclofenac), Co-trimoxazole.

89

Treatment for acute intermittent porphyria?

Haem arginate

90

Autosomal dominantly inherited porphyria with neurovisceral manifestations only, resulting from porphobilinogen deaminase deficiency.

Acute intermittent porphyria

91

Neurotoxic product(s) of heme breakdown producing neurovisceral damage in certain porphyrias

5-aminolevulinic acid

92

Autosomal dominantly inherited (or spontaneous mutation) porphyria with cutaneous manifestations only, resulting from uroporphyrinogen decarboxylase deficiency

Porphyria cutanea tarda

93

Enzyme that catalyses the rate-limiting step of heme breakdown

ALA synthase

94

Product(s) of heme breakdown resulting in photosensitivity (i.e. cutaneous) damage in certain porphyrias

Activated porphyrinsand oxygen free radicals.

95

Porphyria definition?

Deficiency in enzymes of haem biosynthesis pathway

96

Enzyme affected in acute intermittent porphyria?

HMB synthase

97

Enzyme affected in Porphyria cutanea tarda

Uroporphyrinogen decarboxylase

98

Enzyme affected in Congenital erythopoietic porphyria

Uroporphyrinogen III synthase

99

ALA synthase deficiency gives?

X-linked sideroblastic anaemia

100

Acute Intermitted Porphyria
Inheritance?
Symptoms?

Autosomal dominanat.
Neurovisceral attached. Abdo pain, vomiting. Tachycardia, hypertension, constipation, urinary incontinence, seizures, psychological symptoms. NO SKIN SYMPTOMS

101

Acute Intermittent Porphyria
Enzyme activity level?
Precipitating Factors?

Usually 50% of normal 90% of people have no symptoms.
ALA synthase inducers - barbituates, steroids, ethanol, anticonvulsants
Stress - infection surgery

102

Acute Intermittent Porphyria diagnosis? Treatment?

Raised urinary PBG and ALA
Avoid precipitators, IV carbohydrate, IV haem arginate

103

Hereditary Coprophorphyria (HCP)

Autosomal dominant
Acute neurovisceral attacks
Skin lesions - blistering, skin fragility
Coprophorphyrinogen oxidase deficiency

104

Variegate Porphyria (VP)

Autosomal dominant
Acute attacks
Skin lesions
Protoporphyrinogen oxidase deficiency

105

Phorphyria cutanea Tarda

Inherited or acquired.
Uroporphyrinogen decarboxylase deficiency
Vesicle in sun-exposed skin, crusting, scarring, pigmentation.
Urinary and plasma uroporphyrin increased

106

Erythropoietic protoporphyria

Photosensitivity, burning, itching, oedema following sun exposure. NOT Acute.
Only RBCs affected. May need phlebotomy for haemochromotosis.

107

A 67-year-old man was started on bendroflumethiazide for hypertension 2 weeks ago. On examination he has dry mucous membranes and decreased skin turgor. His past medical history is otherwise unremarkable.
Na 129, K 3.5, Ur 8, Cr 100

Thiazide induced hypovlaemic hyponatraemia, Treat with 0.9% saline

108

A 57-year-old woman is admitted with increasing breathlessness worse on lying flat. Her past medical history includes a Non-STEMI and hyperlipidaemia. She is on ramipril, bisoprolol, aspirin and simvastatin. On examination she has elevated JVP, bibasal crackles and bilateral leg oedema.
Na 128, K 4.5, Ur 8, Cr 100

Cardiac failure leading to hypervolaemic hyponatraemia. Treat underlying cause and fluid restriction.

109

A 55-year-old man presents with jaundice. He has a past history of excessive alcohol intake. On examination he has multiple spider naevi, shifting dullness and splenomegaly.
Na 122, K 3.5, Ur 2, Cr 80

Hyervolemic hyponatramia secondary to alcoholic liver disease. Fluid restriction and treat underlying cause.

110

A 40-year-old woman presents with fatigue, weight gain, dry skin and cold intolerance. On examination she looks pale.
Na 130, K 4.2, Ur 5, Cr 65

Euvolaemic hyponatraemia secondary to hypothyrodism. Treat cause. Thyroxine replacement.

111

A 45-yeard-old woman presents with dizziness and nausea. On examination she looks tanned and has postural hypotension.
Na 128, K 5.5, Ur 9, Cr 110

Addisions disease. Euvolemic hyponatraemia. Treat with hydrocortisone and fludrocortisone. Dx with short synacthen test.

112

A 62-year-old man presents with chest pain, cough and weight loss. On examination he looks cachectic. He has a 30 pack year smoking history.
Na 125, K 3.5, Ur 7, Cr 85

SIADH 2nd to malignanacy. Dx plasma and urine osmolality. Treat underlying cause.

113

Causes of SIADH

CNS or Lung Pathology.
Drugs - SSRIs, TCA, opiates, PPIs, Carbemazepine
Malignancy

114

Causes of SIADH

CNS or Lung Pathology.
Drugs - SSRIs, TCA, opiates, PPIs, Carbemazepine
Malignancy

115

A 20-year-old man presents with polyuria and polydipsia. On examination he has bitemporal hemianopia.
Na 150, K 4, Ur 5, Cr 70

Cranial DI. ADH insufficiency leading to water loss in collecting duct.

116

DI investigations?

Serum glucose, K, Ca, plasma and urine osmolality, Water deprivation test.

117

When is a death reported to a coroner? (3)

Violent
Unnatural/sudden
Cause unknown

118

Schmidt Syndrom

Addisions (autoimmune adrenal isufficiency) with AI hypothyroidism and/or DM. Is part of polyendocrine syndrome.
In exam hypothyroidism with disturbed electrolytes.

119

Test for Addisions?

Short Synacthen Test.
Measure ACTH and cortisol at the start of the test.
Administer 250mcg of ACTH
Check cortisol at 30 and 60. Cortisol doesn't rise.

120

32, with hypertension and an adrenal mass. Three possible Ddx?

Cons (Aldosterone secreting tumour)
Phaeochromocytoma (adrenaline secreting tumour in medulla)
Cushing's Syndrome (crotisol secreting tumour)

121

Phaeochromocytoma
Investigation?
Treatment?

Hypertension, high urinary catecholamines.
Alpha block with phenoxybenzamine
Add beta block
Surgery

122

Hypertensive 33 year old
Na 147, K 2.8, U 4, Glucose 4
Raised aldosterone, suppressed renin

Cons syndrome (primary hyperaldosteronism)
Causes HTN which in turn suppresses renin at the JGA

123

Hypertensive 33 year old
Na 147, K 2.8, U 4, Glucose 4
Raised aldosterone, suppressed renin

Cons syndrome (primary hyperaldosteronism)
Causes HTN which in turn suppresses renin at the JGA

124

32 year old obsess woman with DM, HTN and bruising. Na 146, K 2.9, U 4, Glucose 14. Aldosterone low, Renin Low

Cushing's Syndrome. Investigation 9am cortisol and midnight cortisol.
Low Dose Dexamethasone suppression test. Dex wont suppress cortisol in Cushing's SYNDROME!

125

Causes of Cushing's

Iatrogenic
Pituitary dependent 85%
Adrenal Adenoma 10%
Ectopic ACTH 5%

126

Pituitary Dependent Cushing's Disease Investigation?

Low dose Dex suppression test won't suppress cortisol
How dose Dex suppression test WILL suppress cortisol if pituitary dependent.

127

Serum Calcium is in 3 forms?

Free 50%
Protein bound 40% (albumin)
Complexed 10% (citrate/phosphate)

128

Three effects of PTH

Increased Vit D which causes increase Ca absorption in intestine
Increase renal Ca resorption
Increase bone resorption

129

Four effects of PTH

Increased Vit D which causes increase Ca absorption in intestine
Increase renal Ca resorption
Increase bone resorption
Stimulate renal phosphate wasting

130

Vitamine D (1,25 (OH)2 cholecalciferol) functions?

Intestinal Ca absorption
Intestinal PO4 absorption
Deficiency associated with ai disease, cancer and metabolic syndrome

131

Hypercalcaemia symptoms

Polyuria, polydipsia
Constipation
Neuro - confusion, seizures, coma

132

Primary Hyperparathyroid
Serum Ca, PO and PTH?
Cause?

Raised Ca with inappropriately normal or raised PTH (i.e. not suppressed), decreased phospate
Parathyroid adenoma/hyperplasia/carcinoma
Hyperplasia associated with MEN1
F>M

133

Familial Hypocalciuric hypercalcaemia

Calcuium sensing receptor mutation increased the set point for PHT release causing a mild hypercalcaemia. Benign

134

Hypercalcaemia in malignancy (3)

Humoral hypercalcaemia of malignancy (small cell lung Ca and PTHrP)
Bone mets (local bone osteolysis)
Haem malignancy (myeloma)

135

Non-PTH drive hypercalcaemia

Sarcoidosis
Thyrotoxicosis
Hypoadrenalism
Thiaide diruetic
Excess vit D (sunbeds)

136

Non-PTH drive hypercalcaemia

Sarcoidosis
Thyrotoxicosis
Hypoadrenalism
Thiazide diuretic
Excess vit D (sunbeds)

137

Hypercalcaemia acute treatment

Fluids, bisphosphonates, treat underlying cause

138

Symptoms of hypocalcaemia

Neuro-muscular excitability (Trousseau's and Chvosteks signs), hyperreflexia, laryngeal spasm, convulsions, choked disc (retina)

139

Non-PTH causes of hypocalcaemia (3)

Vit D deficiency
Chronic kidney disease
PTH resistance (pseudohypoparathyroidism)

140

PTH related causes of hypocalcaemia (4)

Surgical (post thyroidectomy)
Autoimmune hypoparathyroidism
Congenital absence of parathyroid (DiGeorge)
Mg deficiency (required for PTH regulation)

141

Dexa Scan Results
Osteoporosis?
Osteopenia?

Osteoporosis T-score

142

Risks for osteoporosis?

Sedentary, EtOH, Smoking, low BMI, malnutrition
Endocrine - hyperprolatin, thyrtoxicosis, cushings
steroids
prolonged illness

143

Treatment for osteoporosis

Lifestyle modification (exercise, stop drink/smoke)
Vitamin D/Ca
Bisphosphonates (decrease bone respiration)
Strontium
Oestrogen (HRT)

144

Treatment for osteoporosis

Lifestyle modification (exercise, stop drink/smoke)
Vitamin D/Ca
Bisphosphonates (decrease bone respiration)
Strontium
Oestrogen (HRT)

145

Risk Factors for Renal Stones?

Dehydration
Abnormal urine pH -high meat intake, renal tubular acidosis.
UTI
Anatomical abnormalities

146

Renal stone compositions?

Calcium 80%
Struvite (stage head) 10%
Uric acid 5%

147

Struvite stones pathogenesis?

Mg and Ca phosphate stones. Form during UTI from urea splitting organisms like Klebsiella or proteus
Give stag horn calculi

148

Lesch Nyham Syndrome

HGPRT deficiency which is required for purine metabolism. Leads to increase urate.
Normal at birth, developmental delay by 6/12
Choreiform movements (1y)
Spasticity and mental retardation. Self-mutilation.
Hyperuricaemia

149

Clinical features of gout?

Exquisit pain, hot, red, swollen joint.
1st MTP 50%

150

Mx Acute Gout?

NSAIDs
Colchicine
Glucocorticoids
Do NOT modify plasma urate conc.

151

Mx hyperuricaemia

Not in an acute attack
Drink water
Reverse lifestyle factors
Reduce synthesis with allopurinol
Increase renal excretion with probenecid

152

Mx hyperuricaemia

Not in an acute attack
Drink water
Reverse lifestyle factors
Reduce synthesis with allopurinol
Increase renal excretion with probenecid

153

SEs of Allopurinol?

Makes Azathioprine more toxic to bone marrow
Allopurinol makes the azathioprine intermediary mercaptopurine last longer which interferes with purine metabolism.

154

Dx of Gout?

Negatively birefringent crystals, needle shaped.

155

Pseudogout?

Occurs in OA patients, last 1-3 weeks, PYROPHOSPHATE crystals. Positively birefringent.

156

Immune Cells of the Liver?

Kupffer Cells. Clear infection and LPS.
Antigen presenting and immune modulating.
Break down RBCs?

157

Serum markers of Liver Damage?

ALT, AST, ALP, GGT

158

Serum markers of Liver Function

Albumin, Pro-thrombin Time, Bilirubin

159

Liver Enzyme that rises more in alcohol and cirrhosis

AST - in cytoplasm of hepatocyte, elevate when hepatocyte dies. Also present in other organs (muscle, kidney, brain, pancreas)

160

GGT
Locations?
Raises in?

Found in hepatocytes and epithelium of small bile ducts. Also found in liver, kidney, pancreas, spleen, heart, brain and seminal vesicles.
Elevated in chronic alchohol abuse, bile duct disease and hepatic metastasis.

161

ALP
Sources?
Raised in?

Liver and also bone, small intestine, kidney, WBCs and placenta.
Markedly elevated in obstructive jaundice or bile duct damage.

162

Reasons for low albumin? (3)

Low production - liver disease, malnutrition
Loss - kidney or gut pathology
Sepsis - 3rd spacing

163

Albumin function and half life

Half life 20d
contributes to oncotic pressure, binds steroids, drugs, bilirubin, Ca

164

Measure of extrinsic pathway function

PT - 2, 5, 7, 10. Affected by Warfarin?

165

Alpha Feto Protein

Fetal transport/immune regulation protein. No know function in adults.
Used to diagnose hepatocellular carcinoma
Also raised in hepatic damage, regeneration, pregnancy and testicular cancer.

166

Gilberts Ix?

Fasting and non-fasting bilirubin. Raised fasting unconjugated bilirubin.

167

38 y/0 female presents with itch, jaundice, dark urine. Treated for UTI 5/7 ago.
Bil +, ALT & AST +, ALP +++, GGT +
No bile duct obstruction on USS

Dx - drug induced cholestasis 2nd to augmentin.

168

Physiological causes of raised ALP?

Pregnancy and childhood (growth spurt)

169

Pathological causes of raised ALP?

>5x normal - bone disease (pagers), cholestasis, cirrhosis

170

Pathological causes of raised ALP?

>5x normal - bone disease (pagers), cholestasis, cirrhosis

171

Three forms of CK

CK-MM muscle
CK-MB cardiac muscle
CK-BB brain

172

Statin Related Myopathy
What is it?
Risks?

Spectrum of myalgia to rhabdo
Risks
Polypharmacy - fibrates, cyclosporin
High dose
Genetic
Previous Hx of statin myopathy

173

Causes of Raised CK?

Muscle damage
Myopathy (Duchennes >10x)
MI (>10x)
Severe exercise (5x)
Physiological - afro-caribbean (

174

Troponin time course post MI

Rises 4-6h post
Peaks at 12-24h (100% sensitive, 98% specific at 12-24h)
Remains elevated for 3-10d
Measure at 6 and 12h post onset of chest pain

175

Diagnostic criteria for acute MI

One of the following
(1) Typical rise and fall of troponin or rapid rise and fall of CK-MB with at least one of:
ischemic symptoms, pathological Q waves, ECG changes of schema, coronary artery intervention.
(2) Pathological findings of an acute MI

176

One inter nation unite of enzyme activity is?

Quantity of enzyme that catalyses the reaction of one micro mol of substrate per minute. Temperature and pH dependent.

177

Fat soluble vitamins?

A (Retinol): Def - colour blindness, Exc - exfoliant hepatitis
D (Cholecalciferol) Def - osteomalacia, Exc - hypercalcaemia
E (Tocopherol) - anaemia/neuopathy
K (Phytomenadion) - defective clotting

178

Fat soluble vitamins? def/excess

A (Retinol): Def - colour blindness, Exc - exfoliant hepatitis
D (Cholecalciferol) Def - osteomalacia, Exc - hypercalcaemia
E (Tocopherol) - anaemia/neuropathy
K (Phytomenadion) - defective clotting

179

Thiamin (B1) def/excess

Deficiency - beri beri, neuropathy, wernicke syndrome

180

Pyridoxine (B6) def/excess

Def - dermatitis/anaemia
Excess - neuropathy

181

Ascorbate © def/excess?

Deficiency - scurvy
Excess - renal stones

182

Pellagra

Niacin (B3) deficiency.
Symptoms - photosensitivity, aggression, red tongue, red skin lesions.

183

Marasmus

Severe deficiency of protein, carbs and fat
Shrivelled, growth retarded, muscle wasting, no s/c fat.

184

Kwashiorkor

Protein deficient
Odematous, scaling/ulcerataed
lethargic
large liver, s/c fat

185

Normal GFR?

120ml/min

186

Gold standard measurement of GFR?

Inulin clearance. GFR = (urin conc of inulin x volume cleared)/plasma conc of inulin

187

Gold standard measurement of GFR?

Inulin clearance. GFR = (urin conc of inulin x volume cleared)/plasma conc of inulin
To difficult to be clinically useful

188

Disadvantages of Cratinine as a marker of GFR?

Variable resorption by tubular cells.
Influenced by intake of fat
Related to muscle mass
Lower in black population

189

Cockcroft Gault

Estimates creatinine clearance (not GFR directly) can overestimate GFR when

190

MDRD

Estimates GFR based on age, sex, serum creat and ethnicity. May underestimate GFR if above average weight and young.

191

CKD-EPI

Similar to MDRD to calculate eGFR, current recommended equation.

192

Causes of pre-renal AKI

Volume depletion
Hypotension
Odematous states
Selective renal ischemia
Drugs affecting GFR (NSAID, calcineurin inhibitors, ACEi/ARB)

193

Causes of pre-renal AKI

Volume depletion
Hypotension
Odematous states
Selective renal ischemia
Drugs affecting GFR (NSAID, calcineurin inhibitors, ACEi/ARB)

194

AKI/RTA

AKI is dependent on circulating volume, RTA is structural damage to kidney.

195

Obstructive uropathy causes?

Ureteric obstruction
Intra-renal obstruction
Prostatic
Blocked urinary catheter
Immediate relief restores GFR with no structural damage. Prolonged obstruction can cause structural damage (glomerular schema, scarring).

196

Stages of CKD?

1 - kidney damage normal GFR > 90
2 -Mild GFR 60-89
3 - Moderate GFR 30-59
4 - Severe 15-29
5 - End-stage

197

Common causes of CKD (6)

Diabetes
Astherosclerotic renal disease
HTN
Chronic glomerulonephritis
Infective/Obstructive uropathy
PCKD

198

Renal Acidosis

Failure of renal excretion of protons in CKD
Results in: muscle and portein degradation, osteopenia, cardiac dysfunction
Treat with oral sodium bicarb

199

Consequences of CKD

Acidosis and Hyperkalaemia
Anaemia - decline in EPO cells
Renal bone disease
Cardiovascular disease due to vascular calcification/uraemic cardiomyopathy.
Uraemia and death

200

Stages of uraemia cardiomyopathy?

LV hypertrophy
LV dilation
LV dysfunction

201

Antibodies raised in Coeliac Disease?

AntiTTG and Anti emdomysial

202

Antibodies raised in Coeliac Disease?

AntiTTG and Anti emdomysial

203

Ix for herediatary shereocytosis?

Osmotic fragility

204

Antibody in primary billary cirrhosis

Anti mitochodrial

205

Ix for Paroxysmal nocturnal haemoglobinuria?

Ham's test

206

Anti GAD is raised in

T1DM