Metabolic Medicine

Question 1

What are causes of raised ALP?

Answer 1

Cholestasis

Paget’s disease - isolated ALP

Osteomalacia - raised ALP, low calcium+phosphate

Bone mets - raised ALP + calcium

Hyperparathyroidism - raised ALP + calcium

Renal failure - raised ALP + low calcium

Pregnancy

Question 2

What are the 2 main cause of hypercalcaemia?

Answer 2

Primary hyperparathyroidism + Malignancy (bone mets, myeloma, squamous cell lung cancer)

Question 3

What are other causes of hypercalcaemia other than the 2 main causes?

Answer 3

Sarcoidosis
Vitamin D intoxication
Acromegaly
Thiazide-like diuretics
Addison's disease

Question 4

What ECG finding is seen in hypercalcaemia?

Answer 4

Short QT

Question 5

How does hypercalcaemia present?

Answer 5

Stones, groans, bones, moans

Bone pain
Renal stones
Depression

Question 6

How is hypercalcaemia treated?

Answer 6

IV Sodium Chloride 0.9%

Question 7

What are causes of hypocalcaemia?

Answer 7

Vitamin D deficiency (osteomalacia)
CKD
Hypoparathyroidism
Pseudohypoparathyroidism
Magnesium deficiency
Acute pancreatitis

Question 8

What are signs of hypocalcaemia?

Answer 8

Tetany - muscle twitching/cramping/spasm
Perioral parasthaesia

Trousseau’s sign
Chvostek’s sign

Question 9

What is Trousseau’s sign?

Answer 9

Carpal spasm if brachial artery is occluded with blood pressure cuff

Question 10

What is Chvostek’s sign?

Answer 10

Tapping the parotid causes the facial muscles to twitch

Question 11

How is hypocalcaemia managed?

Answer 11

10ml calcium glutinate 10% over 10 mins

Question 12

What ECG changes are seen in hyperkalaemia?

Answer 12

Tall tented T waves
Widened QRS
Small P waves
Prolonged PR interval

Question 13

What are causes of hyperkalaemia?

Answer 13

AKI
Addison’s disease
Rhabdomyolysis

Drugs: ACEi, ARB, Spironolactone

Question 14

How is the cardiac membrane stabilised in hyperkalaemia?

Answer 14

IV calcium gluconate

Question 15

How is hyperkalaemia treated?

Answer 15

IV insulin - shifts potassium back into cells

oral calcium resonium - removes potassium

Question 16

What are causes of hypokalaemia with ACIDOSIS?

Answer 16

Diarrhoea
Renal tubular acidosis
Acetazolamide
Partially treated DKA

Question 17

What are causes of hypokalaemia with ALKALOSIS?

Answer 17

Vomiting
Thiazide diuretics
Loop diuretics
Salbutamol
Cushing's syndrome
Hyperaldosteronism

Question 18

What is seen on ECG in hypokalaemia?

Answer 18

Small/absent T waves
Prolonged PR interval
Prolonged QT interval
ST depression
U waves

Question 19

How is hypokalaemia managed?

Answer 19

Potassium infusion - maximum of 10mmol an hour

Question 20

What are causes of hypernatraemia?

Answer 20

Dehydration
Osmotic diuresis e.g. HHS
Diabetes insipidus
Excess IV saline
Cushing's
Hyperaldosteronism

Question 21

How is hypernatraemia managed?

Answer 21

Mild hypernatraemic dehydration: (146-149)
• Manage underlying cause

Moderate hypernatraemic dehydration (150-169)
• Slow fluid resus – avoid rapid infusion due to risk of cerebral oedema

Question 22

What is the most important investigation for determining the cause of hyponatraemia?

Answer 22

Serum and urine osmolality

Question 23

What are causes of hyponatraemia with a HIGH urine osmolality?

Answer 23

If patient is hypovolaemic.. think sodium depletion (renal)
Diuretics (thiazide, loop)
Addison’s

If patient is euvolaemic.. think…
SIADH
Hypothyroidism

Question 24

What are causes of hyponatraemia with a LOW urine osmolality?

Answer 24

If patient is hypovolaemic.. think sodium depletion (non-renal)
Diarrhoea, vomiting, sweating, burns

If patient is euvolaemic/oedematous.. think water excess...
Heart failure
Liver cirrhosis
Nephrotic syndrome
Psychogenic polydipsia

Question 25

How is hypovolaemic hyponatraemia managed?

Answer 25

IV saline -- 0.9% Sodium Chloride If serum sodium rises - supports diagnosis of hypovolaemic hyponatraemia

Question 26

How is euvolaemic hyponatraemia managed?

Answer 26

SIADH --> Tolvaptan, Sodium, furosemide Hypothyroidism --> levothyroxine Fluid restrict

Question 27

How is hyponatraemia treated if the patient is acutely unwell with seizures?

Answer 27

Hypertonic saline e.g. 3% sodium chloride | Be careful of risk of central pontine myelinosis

Question 28

How is hypervolaemic hyponatraemia managed?

Answer 28

Fluid restriction | Treat underlying cause

Question 29

How does central pontine myelinosis present?

Answer 29

Dysarthria, dysphagia, paraparesis or quadriparesis, seizures, confusion, and coma Locked in syndrome

Question 30

What is renal tubular acidosis?

Answer 30

A cause of metabolic acidosis due to a pathology in the tubules of the kidney

Question 31

What is type 1 renal tubular acidosis? What electrolyte abnormality is seen? How is it treated?

Answer 31

Metabolic acidosis due to the distal tubule being unable to excrete hydrogen ions Associated with renal stones Causes a hypokalaemia and metabolic acidosis Treatment = oral bicarbonate

Question 32

What is type 2 renal tubular acidosis? What is the main associated condition? how is it treated?

Answer 32

Metabolic acidosis due to the proximal tubule being unable to reabsorb bicarbonate Associated with Fanconi syndrome and OSTEOMALACIA Hypokalaemia Treatment = oral bicarb

Question 33

What is type 4 renal tubular acidosis? What electrolyte abnormalities are seen? What is the treatment?

Answer 33

Metabolic acidosis due to reduced aldosterone (usually due to adrenal insufficiency) Leads to hyperkalaemia Treated with fludrocortisone and sodium bicarbonate Treat the hyperkalaemia

Question 34

What is the most common type of renal tubular acidosis?

Answer 34

Type 4

Question 35

What is familial hypercholesterolaemia?

Answer 35

Autosomal dominant condition High levels of LDL Can lead to early cardiovascular disease

Question 36

When should you suspect familial hypercholesterolaemia?

Answer 36

Total cholesterol level >7.5 Personal/family history of CVD event before 60 years Tendon xanthomata