Module 10 Exam Flashcards by Christine Le

10.1 1. 20 year old woman on athletic scholarship

10.1 1 Urinary Tract Infection because of protein, blood, leukocyte esterase, microscopy results. Granular casts may mean spread to kidney. Urobilinogen result may mean stress not liver disease. Hyaline casts mean dehydration. Kidney failure not likely but tell patient of risk and possibly monitor urine protein, creatinine etc.

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10.1 2. 25-year-old woman has a history of depression and suicide attempts. She is breathing rapidly. She was taken to the Emergency Department of the local
Hospital.

Laboratory results:
Blood pH 7.58 (7.35-7.45), pCO 2 26 mm Hg (35-45), bicarbonate 18
mmol/L (22-30), pO 2 115 mm Hg (80-100).
Serum sodium 150 mmol/L (135-147)
Serum chloride 120 mmol/L (96-108)
Serum bicarbonate 16 mmol/L (22-30)

What is the most likely reason for the serum sodium and chloride result?
What is the acid base status of the patient?
What does the kidney do to normalize the acid base status? Why is this not yet evident?
Source: Sunnybrook Emergency Case.

10.1 2. Na Cl increased result due to dehydration. There is respiratory alkalosis. Kidney excretes bicarbonate. Overload of kidney capacity but not fast enough to keep pH normal

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1 3. A 16 year-old schoolboy recently returned from a trip to Jamaica. He is competing at a track meet at 100 metres and in relay races when he has explosive
diarrhoea. His mother brought him to the Clinic.

Laboratory results:
Plasma sodium 145 mmol/L (135-147)
Plasma chloride 100 mmol/L (96-108)
Plasma bicarbonate 40 mmol/L (22-30)

What is the most likely reason for his increased serum bicarbonate?
What will the pH of his urine be?

10.1 3. Doping to combat lactic acidosis of anaerobic effort by ingesting bicarbonate. Urine pH will be alkaline (high, basic)

Trying to hide anabolic steroid use (by retaining them in the body so it is not excreted in urine)

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10.1 4. 70-year-old woman has been taking aspirin regularly since a teenager. Her family brings her to the Emergency Department because she seems “dopey”.

Laboratory results on plasma:
Sodium 133 mmol/L (135 - 147); urine sodium 29 mmol/L (50 - 150)
Potassium 5.1 mmol/L (3.5 - 5.0)
Chloride 101 mmol/L (96 - 108)
Bicarbonate 16 mmol/L (22 – 30)
Urea 34 mmol/L (3 – 7)
Creatinine 1, 130 umol/L (50 - 120); urine creatinine 7 mmol/L (7 - 16)
Osmolality 315 mmol/kg (290 - 300); urine osmolality 330 mmol/kg (50 - 1,250)
Calcium 1.69 mmol/L (2.20 - 2.60)
Phosphate 2.8 mmol/L (0.8 - 1.5)

What is the laboratory evidence for kidney damage?
What disease does she have?

10.1 4. Chronic Kidney Failure. Urea, creatinine, osmolality, calcium, phosphate indicate kidney failure. She has kidney necrosis caused by long term ingestion of salicylate.

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10.1 5. A 20-year-old man had his legs crushed by falling into an industrial meat grinder. He is now making little or no urine an hour or so after admission to the Emergency Department at Sunnybrook.

Laboratory results on plasma:
Sodium 135 mmol/L (137 - 145); urine sodium 55 mmol/d (50 -150)
Potassium 6.3 mmol/L (3.5 - 5.0)
Chloride 96 mmol/L (96 - 108)
Bicarbonate 15 mmol/L (22 - 30)
Urea 55 mmol/L (3 - 7)
Creatinine 790 umol/L (50 - 120); urine creatinine 4 mmol/d (7 - 16)
Osmolality 335 mmol/kg (290-300), urine osmolality 360 mmol/kg (50 - 1,250)

Why is his plasma potassium increased?
Which of the tests from the list above indicate developing kidney failure?
Source: Sunnybrook Emergency Department.

10.1 5. Acute Kidney Failure. K is increased because of cell death and lysis. Kidney failure indicated by urea, creatinine and osmolality results.

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10.1 6. See PowerPoint for a possible acute kidney failure. Key tests are the
electrolytes and creatinine.

10.1 6 Acute kidney failure on PowerPoint.

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10.1 7. 78-year-old woman complains that for the last 6 months she has become increasingly tired. She has no appetite, feels constantly nauseated. She has lost 8 kg
during the 6 months. She complains of generalized itching and cramps. She has had high blood pressure for the last 20 years. Her conjunctivae are pale. She has swollen ankles with pitting oedema.

Laboratory results on plasma: 
Sodium 136 mmol/L (135 - 147) 
Potassium 4.8 mmol/L (3.5 - 5.0) 
Urea 46 mmol/L (3 – 7) 
Creatinine 770 umol/L (50 - 120) 
Calcium 1.94 mmol/L (2.20 - 2.60) 
Phosphate 3.4 mmol/L (0.8 - 1.5) 
Albumin 37 g/L (35-50) 
Glucose 4.1 mmol/L (4-6) 
Alanine amino transferase 23 U/L (5-35) 
Alkaline phosphatase 423 U/I (30-300) 
Urinalysis: protein +, blood + (negative) 
Blood haemoglobin 72 g/L (117-157)

What is the diagnosis of the most likely disease?

10.1 7. Chronic Kidney failure from history, symptoms and blood and urine abnormal results..

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10.1 8. A 7-year-old girl has a sore throat and fever, which was untreated. A week or so later her urination was more frequent and it was noted to be frothy - a sign of proteinuria.

Laboratory results on plasma: 
Sodium 130 mmol/L (137 - 145) 
Potassium 4.0 mmol/L (3.5 - 5.0) 
Chloride 95 mmol/L (96 - 108) 
Bicarbonate 20 mmol/L (22 - 30) 
Urea 3 mmol/L (3 - 7) 
Creatinine 50 umol/L (50 - 120) 
Calcium 1.5 mmol/L (2.20 - 2.60) 
Albumin 15 g/L (35 - 50) 
Protein 35 g/L (60 - 80) 
Cholesterol 11 mmol/L (< 5.2) 
24-hour urine protein 12 g/d (< 0.15)

What disease does she most likely have?
Why is her serum cholesterol elevated? Source: old textbook. Such cases are now rare
because of lavish use of antibiotics.

10.1 8. Nephrotic syndrome caused by autoimmune response to an infection of the throat. Lipoproteins are made to replace the albumin which is lost at the kidney so total cholesterol is increased in amount.

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10.1 9. 60-year-old man complains of prostate hypertrophy and chronic urinary retention. He is increasingly lethargic and short of breath. He has low back pain.

Laboratory results on plasma:
Sodium 140 mmol/L (135 - 147); urine sodium 74 mmol/L (50 -150 mmol/d)
Potassium 5.0 mmol/L (3.5 - 5.0)
Chloride 107 mmol/L (96 - 108)
Bicarbonate 21 mmol/L (22 - 30)
Urea 57 mmol/L (3 - 7)
Creatinine 900 umol/L (50 -120); urine creatinine 3.6 mmol/L (7 - 16)
Osmolality 323 mmol/L (290 - 300); urine osmolality 305 mmol/L (50 - 1,250)

Which of his laboratory results indicate kidney failure?

10.1 9. Prostate, obstructive kidney failure indicated by urea, creatinine and osmolality.

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10.1 11. 36-year-old woman complains of a 2-day history of left sided loin pain, with macroscopic haematuria. The pain is continuous and dull. In her early twenties she had
similar pain on both sides, which got better over a few days. Her blood pressure is slightly elevated.

Laboratory results: 
Blood haemoglobin 153 g/L (117-157) 
Serum sodium 136 mmol/L (135-145) 
Serum potassium 4.7 mmol/L (3.5-5.0) 
Serum urea 11 mmol/L (2.6-6.7) 
Serum creatinine 176 umol/L (70-120) 
Serum albumin 45 g/L (35-50) 
Urinalysis: protein + (negative), blood +++ (negative) 
Urine microscopy: > 200 erythrocytes (0-2), 10 leukocytes/high-powered fields 
(0-5), and no organisms.

What is the most likely diagnosis of her disease?

10.1 11.Cystic kidney disease, clues are history, creatinine, urine blood and microscopy.

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10.2 1: 30-year-old marathon runner complains of pain of considerable severity and sudden onset in his left flank. Intermittently he had felt a burning sensation when
passing urine.

Laboratory tests:
Urinalysis showed large amounts of blood.
Blood chemistries were normal except for high normal sodium and chloride.

What is the diagnosis of the most likely disease?
Why is his plasma sodium and chloride increased?

10.2 1. Kidney stones from dehydration.

Note: stones can also increases BP

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10.2 2. 20 year-old man complains of headaches, pain in flank, anorexia and passing red coloured urine. Three weeks earlier he had tonsillitis, which was untreated.

Blood pressure 180/110 mmHg (120/80)

Laboratory tests: 
Serum sodium 150 mmol/L (136-145) 
Serum potassium 5.1 mmol/L (3.5-5.0) 
Serum creatinine 220 umol/L (80-120) 
Serum urea 16 mmol/L (3-7) 
Serum calcium1.8 mmol/L (2.2-2.5) 
Serum phosphate1.7 mmol/L (0.8-1.2) 
Serum protein 65 g/L (60-80) 
Serum albumin 40 g/L (35-55) 
Blood haemoglobin 90 g/L (140-175) 
White blood cells count 14 x 10 9 /L (5-10 x 10 9 /L)

What is the diagnosis of the most likely disease?

10.2 2. Acute glomerular nephritis probably from autoimmune response to an infection (post-streptococcal), data given is not diagnostic but there is significant history, serum creatinine, serum calcium and leukocyte count that supports this theory.

High BP and anorexia can be due to pain
Flank pain usually indicates stones
Low Hb = anemia
High WBC = inflammatory disease

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10.2 4. 20-year-old woman trying to get pregnant complains of severe lower abdominal pain with blood in a vaginal discharge.

Laboratory test:
Pregnancy test positive (negative)

What is the diagnosis of the most likely disease?
How can this disease be proven?

10.2 4. Ectopic pregnancy. Quantitative hCG two days apart. A normal healthy pregnancy doubles hCG every two days

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10.2 5. 35 year-old woman complains that she is short of breath. She was referred to a thoracic disease expert. Pulmonary function studies were made. Many fluffy infiltrates were seen. Her uterus enlarged.

Laboratory tests:
Quantitative pregnancy test was done. Very high levels of hCG were seen.

What disease is most likely?

10.2 5. Choriocarcinoma from lung X rays enlarged uterus and hCG in non pregnant women.

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10.2 6. 53 year-old woman, complains of a 6 months’ history of progressive vaginal discharge with a distinct smell and vaginal spotting after intercourse. She had
menopause three years before. She has smoked one pack of cigarettes a day for 20 years. She has back pain and right leg swelling.

What is the diagnosis of the most likely disease?

10.2 6. Cervical cancer metastasis from history. Leg swelling is from spreading to lymph nodes

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2 7. 21 year-old woman. She has never given birth. She is in a monogamous relationship. She has lower abdominal heaviness. Her uterus is normal size but is not tender. She has a 9 cm right adnexal mass that can be palpated. Her pregnancy test is
negative. Ultrasound showed enlarged and ovary.

Laboratory test:
Serum CA 125 (cancer antigen 125) is increased.
What is the diagnosis of the most likely disease?

10.2 7. Ovarian cancer from adnexal mass and serum CA 125.

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10.2 8. 28 year-old woman complains that she is hirsute with irregular menses. She is obese with acanthosis nigricans.

Laboratory tests:
Serum testosterone 1 nmol/L (0.5-2.5)
Serum free testosterone 50 pmol/L (4-30)
Serum luteinizing hormone LH 39 mIU/L (0-38)
Serum follicle stimulating hormone FSH 2 mIU/L (5-24)
Serum dehydroepiandrosterone DHEA 40 umol/L (0.8-20)
Serum 17-hydroxyprogesterone 1 nmol/L (0.6-8)
Plasma glucose 7.0 mmol/L (3.5-6.0)

What is the diagnosis of the most likely disease?

10.2 8. Anovulatory androgen excess or also called polycystic ovary disease from symptoms and laboratory results. Note increased plasma glucose, see 10.7.

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10.2 9. 29 year-old man complains of heaviness in his scrotal area for the last month. He denies trauma to the area. He has no significant medical history. He denies use of tobacco and excessive drinking. There is a 5 cm non-tender area in the right scrotum. There is no lymphadenopathy.

Laboratory tests:
Serum alpha fetoprotein (AFP) and beta human chorionic gonadotropin (hCG)
are increased.

What is the diagnosis of the most likely disease?

10.2 9. Testicular cancer from history, scrotal mass and serum AFP and hCG.

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10.3 1. 40-year-old man complains of diarrhoea, weight loss, vomiting and sometimes severe epigastric abdominal pain. These symptoms are episodic and
have been going for years. He has been told by his physician that he has duodenal ulcers. Antacids give him relief of symptoms. He is taking aspirin for pain relief.

Laboratory test results:
Faecal occult blood: positive (negative)
Excess of gastric acid (from a swallowed capsule, a qualitative test)
Serum gastrin: 120 pmol/L (< 48)

What is the most likely disease?

a) Helicobacter pylori infestation
b) Barret’s oesophagitis
c) Pancreatitis
d) Gastrinoma

10.3 1. D. Gastrinoma based on history, symptoms and gastrin level. Aspirin should not be taken.

gastrinoma due to Z. Ellison syndrome (high gastrin is a classic sign)***

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10.3 2. 40-year-old man complains of sharp, severe upper abdominal pain. He is pale, sweaty and ill, with shallow respiration. He is nauseous and has vomited. His abdomen is rigid to palpation. There was pain when this was pressed and increased pain when pressure was released (rebound). Temperature is 38 o C, blood pressure normal, pulse normal, respiration rate is normal. Recently he consumed large quantities of vodka.

Laboratory test results:
Haematocrit: 0.50 (0.39-0.49)
Leukocyte count: 10 x 10 9 /L (4-11 x 10 9 /L)
Serum creatinine: 115 umol/L (70-120)
Serum bilirubin: 45 umol/L (3-17)
Serum alanine amino transferase (ALT): 209 IU/L (3-35)
Serum alkaline phosphatase (ALP): 246 IU/L (<100)
Serum amylase (AMS): 2100 IU/L (30-130)
Serum lipase: 2000 IU/L (30-200)
Serum calcium: 2.0 mmol/L (2.2-2.5)
Serum bicarbonate: 22 mmol/L (22-30)

What is the most likely disease?

a) Cholecystitis
b) Hiatus hernia
c) Acute pancreatitis
d) Duodenal ulcers

10.3 2. C. Acute pancreatitis causing cholestasis. Note rebound pain, vodka use, AMS and lipase.

Cholestasis is defined as a decrease in bile flow due to impaired secretion by hepatocytes or to obstruction of bile flow through intra-or extrahepatic bile ducts. Therefore, the clinical definition of cholestasis is any condition in which substances normally excreted into bile are retained.

Amylase, Total, Serum - AMS

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10.3 3. 40-year-old man complains of watery diarrhoea, weight loss, progressively severe weakness and anaemia developing over three months at least.

Laboratory test results:
Blood haemoglobin: 90 g/L (135-175)
Mean corpuscular volume: 120 fL (80-100)
Platelet count: 50 x 10 9 /L (150-440 x 10 9 /L)
Serum folate: 7.5 nmol/L (16-45)
Serum vitamin B 12 : 27 pmol/L (110-660)

What is the most likely disease?

a) Coeliac disease
b) Vasointestinal polypeptide neoplasm (VIPoma)
c) Disaccharidase deficiency
d) Pernicious anaemia

What additional laboratory tests should be done to make the diagnosis?

a) Serum electrolytes
b) Challenge test with vitamin B 12 and intrinsic factor
c) Challenge test with glucose and galactose
d) Serum antiglutaminase antibody

10.3 3.

A. Coeliac disease giving anaemia, Vitamins B12 and folate deficiency.

D. antiglutaminase (AGT) antibody.

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10.3 4. 60-year-old woman complains of fatigue and that she has had bouts of diarrhoea since childhood. At age 33 she was noted to be anaemic and had
responded well to eating liver extract. She has taken iron supplements for the last year. She looks underweight.

Laboratory test results:
Her xylose excretion: 13 mmol (2 g) in urine (normal is >30 mmol (5g) 5
hours after a 154 mmol (25g) dose)
Faecal fat: 13 g/d (6)
Vitamin B 12 absorption: subnormal even with intrinsic factor added.
Blood haemoglobin: 130 g/L (110-155)
Haematocrit: 0.34 (0.35-0.47)
Prothrombin time: 16 seconds (11-14); PT improved with the addition of 10 mg of vitamin K.
Serum iron: 9 umol/L (9-30)
Serum albumin: 32 g/L (35-50)

What is the most likely disease?

a) Coeliac disease
b) Pernicious anaemia
c) Iron deficiency anaemia
d) Liver disease

How might you best prove it using the laboratory?

a) Serum antiglutaminase
b) Colon biopsy
c) Serum alanine amino transferase
d) Serum ferritin

10.3 4.

A another Coeliac with tests done for carbohydrate, fat, vitamin K and iron.

A. antiglutaminase antibody.

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10.3 5. 33-year-old woman, freelance journalist, complains of intermittent diarrhoea for the last year. This has never been bad enough for her to seek help
before. In the last week she has had episodes of bloody diarrhoea ten times a day. She has crampy abdominal pain, which lasts for 1-2 hours. Defecation eases
the pain. In the last few days she has become weak and her abdomen has become more painful and bloated. She has no problems with micturition or menstruation. She is married with two children. She traveled to Mexico on vacation with her family six months ago but has not been anywhere since. She smokes 10 cigarettes a day, to control her weight, she says. She drinks a glass of wine a day with the evening meal. For the diarrhoea she took amoxicillin for a few days, but it did nothing for her
disease. Her pulse is fast, blood pressure is normal and respiratory rate is normal. Her abdomen is distended and tender, especially around the right iliac fossa. Faint bowel sounds may be heard.

Laboratory test results:
Serum sodium: 141 mmol/L (135-145)
Serum potassium: 3.3 mmol/L (3.5-5.0)
Serum creatinine: 88 umol/L (70-120)
Serum urea: 7.6 mmol/L (3-7).
Blood haemoglobin: 100 g/L (117-157)
Mean corpuscular volume: 80 fL (81-99)
White cell counts: 10 x 10 9 /L (3.9-10.6 x 10 9 /L)
Platelets count: 250 x 10 9 /L (150-440 x 10 9 /L)
Erythrocyte sedimentation rate ESR: 74 mm in 1 hour (< 10)
Faecal occult (hidden) blood: positive (negative)

What is her most likely disease?

a) Ulcerative colitis
b) Crohn’s disease.
c) Inflammatory bowel disease
d) Infection of the gut

10.3 5.Ulcerative colitis but Crohn’s is possible though less likely based on the history. Scanning may make the diagnosis.

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3 6. A 50-year-old man complains of two years of severe intermittent abdominal pain radiating to the upper back. He passes bulky foul-smelling
faeces. He has been drinking at an alcoholic level for some years. He looks weary and thin. He has ankle oedema.

Laboratory test results:
Urinalysis by dipstick: glucose positive (negative)
Plasma bilirubin: 10 umol/L (2 - 17)
Serum alanine amino transferase (ALT): 30 IU/L (10 - 40)
Serum alkaline phosphatase (ALP): 200 IU/L (< 100)
Serum gamma glutamyl transferase (GGT): 65 IU/L (10 - 55)
Serum albumin: 30 g/L (35 - 50)
Serum amylase (AMS): 400 IU/L (50 - 250)
Fasting plasma glucose: 15 mmol/L (3 - 5.5)
Faecal fat output over 5 days: 10 g/d (< 5 g/d)

What is he most likely to be suffering from?

a) Diabetes mellitus
b) Alcoholic cirrhosis
c) Pancreatitis
d) Cholestasis

10.3 6.C. Pancreatitis probably caused by excessive alcohol intake.

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10.3 7. 50-year-old woman complains of low-level chronic diarrhoea for many years. A thorough history and testing fails to show any abnormality but when she is hospitalized the diarrhoea ceases then resumes when she goes home. Laboratory test results in hospital: All normal What is the most likely laboratory test to best explain why she is “sick” at home but healthy in hospital? a) Extract faeces with water and add alkali b) Culture faeces in hospital and at home to identify organisms involved c) Serum antigliadin antibodies at home and when she is in hospital d) Check water at home for pathogenic organisms

10.3 7. A. Extract and add alkali. A common laxative is also a pH indicator.

10.3 8. Athletes complain of black faeces after heavy exercise. Sometimes there is abdominal cramping and watery diarrhoea. For example, after setting the world marathon record in 1969 the athlete who achieved this passed black faeces for three days. What laboratory test is indicated to explain these symptoms? a) Plasma bilirubin b) Serum iron c) Faecal occult blood d) Serum electrolytes

10.3 8. C. Faecal occult blood. Black faeces means a serious gut bleed.

10.4 1. 15-year-old woman is suicidal. She swallowed pills from her parent’s bathroom medical cabinet two hours ago. Laboratory test results: Plasma bilirubin: 15 umol/L (2-17) Serum alanine amino transferase: 100 IU/L (< 35) Serum alkaline phosphatase: 100 IU/L (< 100) What should be done next? Why is bilirubin normal?

10.4 1. Tylenol overdose based on history and serum ALT. Measure Tylenol. Bilirubin is normal because the disease is early on.

10.4 2. 15-year-old boy from a boarding school came down with “influenza like” illness. There had been an outbreak of hepatitis at the school. He complains of pain in the right upper quadrant of his abdomen. Laboratory test results: Plasma bilirubin: 17 umol/L (< 17) Urine bilirubin: negative (negative) Serum alanine amino transferase: 325 IU/L (< 35) Serum alkaline phosphatase: 100 IU/L (< 100) Serum albumin 39 g/L (35 - 50) Serum protein 65 g/L (60 - 85) What are the clues from this data that he has hepatitis A? What other laboratory tests would confirm this?

10.4 2. Hepatitis A “flu” symptoms, environment, serum ALT make this most likely. Need immunoglobulin vs HAV IGM for diagnosis.

10.4 3. 40-year-old man, a fireman, recently returned from a vacation in southern Italy has had five days of increasing jaundice. Laboratory test results: Plasma bilirubin: 200 umol/L (<17) Urine bilirubin: positive (negative) Serum alanine amino transferase: 2,640 IU/L (< 35) Serum alkaline phosphatase: 500 IU/L (< 100) Serum albumin: 37 g/L (35-50) Serum protein: 66 g/L (60-80) What are the laboratory indicators for the severity of his disease? What additional work needs to be done to make the diagnosis and give prognosis?

10.4 3. Serum Bilirubin, ALT, ALP mean severe hepatitis and cholestasis secondarily, Immunoglobulins and markers for HBV and HDV. More severe than Hepatitis B alone.A focus of hepatitis D is in Italy.

10.4 4. 60-year-old man was visibly jaundiced. He had no pain, some weight loss, has pale stools, and is a moderate drinker He is not on any drugs. Laboratory test results: Plasma bilirubin: 250 umol/L (< 17) Serum alanine amino transferase: 90 IU/L (< 35) Serum alkaline phosphatase: 900 IU/L (< 100) What is the differential diagnosis? What additional laboratory tests will be needed to help this patient?

10.4 4. Cholestasis though the lack of pain is unusual. Differential diagnosis includes cirrhosis of some kind, hepatoma, carcinoma head of the pancreas. To sort this out need serum alpha foetoprotein, electrolytes, glucose, amylase, lipase, calcium, cholesterol and ferritin.

10.4 5. 35-year-old woman had hepatitis 9 months before. A possibility of chronic active hepatitis is being considered. Laboratory test results: Plasma bilirubin: 45 umol/L (< 17) Serum alanine amino transferase: 350 IU/L (< 35) Serum alkaline phosphatase: 400 IU/L (< 100) Serum albumin: 30 g/L (35 - 50) Serum protein: 115 g/L (60 - 85) What is the laboratory evidence for chronic active hepatitis? What additional laboratory work can help to make the diagnosis?

10.4 5 For chronic active hepatitis CAH see serum bilirubin, ALT, ALT, albumin. Hepatitis B and C serology and immunoglobulins may give cause.

10.4 6. 50-year-old labourer, vomited blood when lifting a beam. He has a history of alcohol abuse. Laboratory test results: Blood haemoglobin: 102 g/L (125-175) Haematocrit: 0.40 (0.40-0.52) Urine: tea coloured (clear), protein positive (negative) Faecal occult blood: positive (negative) Serum alanine amino transferase: 90 IU/L (0-35) Serum alkaline phosphatase: 200 IU/L (10-100) Serum protein: 50 g/L (50-80) Serum bilirubin: 85 umol/L (<17) Serum sodium: 152 mmol/L (135-147) Serum potassium: 3.1 mmol/L (3.5-5) Serum chloride: 91 mmol/L (95-108) Serum total bicarbonate: 29 mmol/L (22-30) Serum urea: 15 mmol/L (3-7) What is his disease? What additional laboratory tests should be done to assess or follow his disease?

10.4 6. Alcoholic cirrhosis. Follow with serum ALT. Kidney function should be checked as this is often abnormal. Blood glucose. Pancreatitis tests such as amylase.

10.4 7. 14-year-old boy complained of abdominal pain and diarrhoea for 4 days. He became jaundiced and was thought to have infective hepatitis. He died a few months later of liver failure. Laboratory test results: Viral serological tests: negative (negative). Post mortem liver copper: much increased from normal levels. What laboratory investigations should be carried out on this boy’s younger sister?

10.4 7. Wilson’s disease. Serum copper and/or caeruloplasmin.

10.4 8. 60-year-old woman has had breast carcinoma treated by mastectomy four years before. She now complains of general malaise and bone pain. Laboratory test work: Plasma bilirubin: 7 umol/L (<17) Serum alanine amino transferase: 40 IU/L (< 35) Serum alkaline phosphatase: 900 IU/L (< 100) Serum gamma glutamyl transferase: 40 IU/L (< 30) Where has the cancer spread to?

10.4 8. Metastasis from breast cancer. This has not spread to the liver, see serum bilirubin, ALT, GGT levels.

10.4 9. Daniel 42 year-old communications manager toured India. He developed diarrhoea and this was attributed to giardia and treated. After three weeks he became jaundiced. He had all the vaccines against the usual liver diseases before the trip to India. In Canada he tested negative for the viruses except for hepatitis E. It took 2 weeks to get the results. His liver biochemistry and clotting times were abnormal. He went into a confusion state and on to coma. He was prepared for liver transplant but at the last minute before transplant surgery he recovered. It took him 6 months for complete recovery. The official diagnosis was giardia and hepatitis E infections. From msn 2016 11 19.

No answer

10.5 1. Polly Dipsia, a 40-year-old woman has a history of extreme thirst and polyuria for the last three months. She urinates at least 4-5 times an hour. During the night she urinates at least 4 times. In the past she had endometriosis treated with hysterectomy. She looks healthy. Her height is 152 cm, weight is 50 kg, her blood pressure and pulse are within normal limits. ``` Laboratory test results included: Serum sodium 145 mmol/L (135-145) Serum urea 3 mmol/L (2.5-6.7) Serum creatinine 80 umol/L (70-120) Blood glucose 3.8 mmol/L (3.5-6.0) Urinalysis: glucose negative, specific gravity < 1.005 (1.001-1.035) Serum osmolality 293 mosmol/kg (270-290) Urine osmolality 266 mosmol/kg (50-1,200) ``` From this history what is the most likely disease? What other diseases are possible? How could you diagnose these using the laboratory?

10.5 1.Diabetes insipidus. Most likely cancer spread to hypothalamus from the uterus. Kidney tubule failure is in the differential diagnosis. Check this out with ADH inhibition test.

10.5 2. Fred O. Baggins: A 6 year old boy is much smaller than his classmates. He has normal body proportions. His bone age is said to be that of a three year old. His parents are normal sized. What tests should be used to investigate the causes of his problem? Consider also tests for non-hormonal diseases such as coeliac.

10.5 2. GH after stimulation with insulin or arginine, clonidine. Likely a pituitary dwarf For coeliac disease use serum antiglutaminase etc., liver disease use serum albumin etc., kidney disease serum creatinine, malnutrition tests for etc.

10.5 3. Princess Bride, a 46 year old woman complains of headaches that have been getting worse over the last three months. The headaches are worse in the morning and made worse by coughing. She complains that her eyesight has been getting worse recently. Her hands and forearms are painful at night. She cannot remove her wedding ring from her finger and she now needs a larger size in gloves and shoes. She has been told that her facial features have changed in the last few years. She takes Paracetamol (acetaminophen, Tylenol), for her headaches. Her pulse is normal and her blood pressure is 160 100 mm Hg (increased). Visual field examination shows some loss of the temporal field in each eye. Funduscopic shows optic atrophy. Her laboratory test results included: Blood haemoglobin 122 g/L (117-157) White cell count 6.7 x 10 9 /L (3.5-11.0 x 10 9 /L) Platelets count 248 x 10 9 /L (150-440 x 10 9 /L) Serum sodium 137 mmol/L (135-145) Serum potassium 3.8 mmol/L (3.5-5.0) Serum bicarbonate 27 mmol/L (24-30) Serum urea 5.2 mmol/L (2.5-6.7) Serum creatinine 98 umol/L (70-120) Fasting blood glucose 8.2 mmol/L (4.0-6.0) Urinalysis: no blood, no protein, glucose large (negative). What is the diagnosis? What additional tests are needed to prove this using the laboratory?

10.5 3. GH excess. Inhibition test – glucose tolerance test should turn it off if normal. This is likely to be a pituitary cancer.

10.5 4. A 15-year-old woman has had no menses for three months. She is not sexually active and is on no medication. She complains of some fatigue and mild cold intolerance. She looks normal with no hirsutism but there is bilateral galactorrhoea. She has a diffuse goitre twice the normal size. What laboratory tests are indicated?

10.5 4. Prolactin and, if that is normal, serum TSH. Thyroid disease seems most likely.

10.5 5. A. Trifecta, a 50 year-old man, a bookmaker, complained of impaired vision, which made driving difficult, in particular at night. His blood chemistries, complete blood count and serum electrolytes were within normal limits. He says that he is sometimes tired but denies decreased libido, polyuria or polydipsia. A triple bolus test was ordered. This is to give insulin, TRH and GnRH by IV infusion. The triple bolus test can be life threatening so must be done by a strict protocol. What is the diagnosis?

10.5 5. Prolactinoma. This was not on the Powerpoint slides. This is an exercise to give an idea of the wide scope of the test and why it is not used much.

10.5 6. Thea Royd, a 70-year-old woman, complains of fatigue. She has become increasingly lethargic and she sleeps every afternoon. She used to be energetic. She complains that she is constipated. Her hairdresser told her that her hair is thinning. Her pulse is 52 beats minute (slow) and blood pressure 138 90 mm Hg (high normal). Laboratory test results included: Blood haemoglobin 92 g/L (117-157) Mean corpuscular volume 105 fL (80-99) White cell count 4.2 x 10 9 /L (3.5-11.0 x 10 9 /L) Platelets count 154 x 10 9 /L (150-440 x 10 9 /L) Serum sodium 142 mmol/L (135-145) Serum potassium 4.4 mmol/L (3.5-5.0) Serum urea 5.2 mmol L (2.5-6.7) Serum creatinine 106 umol/L (70-120) Fasting blood glucose 4.9 mmol/L (4.0-6.0) Serum albumin 42 g/L (35-5.0) Serum thyroid stimulating hormone 54 mU/L (0.3 - 5.0) Serum thyroxine 23 nmol/L (55 - 155) Serum free thyroxine 2 pmol/L (9-22) Serum cholesterol 9.3 mmol/L (< 5.2) Serum creatine kinase 290 IU/L (0 - 100) Serum alanine amino transferase 35 IU/L (0 - 30) What do these results mean for the differential diagnosis of her disease? What else could be measured to find the cause of the disease?

10.5 6. Hypothyroid or, less likely old age, measure serum thyroid antimicrosomal antibodies

10.5 7. 50-year-old woman has weakness and lack of energy. The diagnosis was hypothyroidism. Thyroid hormone was replaced with some improvement. Now she has severe, constant headaches and decreased visual acuity. What laboratory tests are indicated now?

10.5 7. From her history and symptoms look at pituitary function. Measure serum TSH

10.5 8. Roberta Graves, a 28-year-old woman, a funeral home worker, complains of increased irritability and anxiety. She says that she feels constantly restless but has difficulty concentrating. She has lost 6 kg in weight recently though she has a good appetite. She has more frequent bowel movements. Her menstruation has become lighter and shorter. She feels tired, sweats profusely and cannot stand hot conditions. Her pulse is 104 beats minute (increased) and regular. Her blood pressure is 130 70 mm Hg (high normal). Present laboratory test results include: Blood haemoglobin 132 g/L (117-157) White cell count 4.7 x 10 9 /L (3.5-11.0 x 10 9 /L) Platelets count 262 x 10 9 /L (150-440 x 10 9 /L) Serum sodium 144 mmol/L (135-145) Serum potassium 4.8 mmol/L (3.5-5.0) Serum bicarbonate 22 mmol/L (24-30) Serum urea 6.2 mmol/L (2.5-6.7) Serum creatinine 88 umol/L (70-120) Fasting blood glucose 6.2 mmol/L (4.0-6.0) Urinalysis: no blood, no protein (negative). Serum thyroid stimulating hormone < 0.1 mU/L (0.3 - 5.0) Serum free T 4 25 pmol/L (10 - 27) Serum free T 3 9.5 pmol/L (3 - 9) What is the most likely disease? What laboratory tests could you use to find the cause of the disease?

10.5 8. Graves’ disease. Measure serum antibodies to TSH receptor.

10. 5 9. John Addison, a 30-year-old man, complains that he fainted at home. Over the past 6 months he has lost 10 kg in weight but his appetite is poor. In the last few days he has had abdominal pain with nausea and vomiting. He complains of muscle weakness for the last several weeks and he cannot concentrate at work. He looks pale and unwell. There were dark lines in the creases of his hands. His pulse is 120 beats/minute (high) and blood pressure 76 36 mm Hg (low). ``` Laboratory results included: Blood haemoglobin 172 g/L (133-177) Mean corpuscular volume 84 fL (80-99) White cell count 7.4 x 10 9 /L (3.9-10.6 x 10 9 /L) Platelets count 342 x 10 9 /L (150-440 x 10 9 /L) Serum sodium 125 mmol/L (135 - 147) Serum potassium 6.5 mmol/L (3.5 - 5.0) Serum chloride 95 mmol/L (96 - 108) Serum bicarbonate 20 mmol/L (22 - 30) Serum urea 20 mmol/L (3 - 7) Serum creatinine 200 umol/L (50 - 120) Serum albumin 48 g/L (35-50) Blood glucose 2.3 mmol/L (4.0-6.0) Urinalysis: no protein, blood or glucose (negative). ``` What is the diagnosis? What further tests will make this diagnosis more certain? What results would you expect to see?

10.5 9. Addison’s disease, note the glucose, Na and K results. Measure cortisol, this should be decreased. This is an Emergency.

10. 5 10. Dana Cushing, a 30-year-old woman was thought to have Cushing’s syndrome. She was obese, hypertensive and had wasting of the proximal limb muscles. Laboratory test results on admission: Diurnal variation of serum cortisol: 0800 hours 400 nmol/L 2200 hours 400 nmol/L. (This should halve by 2200 hours in a normal person) Insulin hypoglycemia test: Initially plasma glucose 4.5 mmol/L, decreased to 1.5 mmol/L (< 2.2). Initially serum cortisol 440 nmol/L, slight change to 480 nmol/L (> 150 increase) Dexamethasone test: low dose: initial serum cortisol 420 nmol/L, after 2 days 410 nmol/L. high dose after 2 days was 500 nmol/L (fall to < 50%) Plasma ACTH: at 0800 hours < 2 ng/L (7 – 51). What test best makes the diagnosis of her disease?

10.5 10. Cushing’s syndrome. Story is to give you an idea of what to expect.

10.5 11. A. Sadman, a 60-year-old man, complains that he is irritable, emotionally labile, has muscle weakness and fatigues easily. He finds it hard to get up from his armchair or to climb the stairs. He complains that his life is miserable. Sadman is depressed and is not sleeping well. His trunk is obese. He has gained 8 kg in weight in the last 6 months. His arms and legs are lean. He has a round face and purple stretch marks on his abdomen. He bruises easily. He smokes 30 cigarettes a day and drinks at least 2 beers a day. His pulse is normal and regular. His blood pressure is increased. He has peripheral oedema. Laboratory test results include: Blood haemoglobin 132 g/L (133-177) Mean corpuscular volume 87 fL (80-99) White cell count 5.2 x 10 9 /L (3.9-10.6 x 10 9 /L) Platelets count 237 x 10 9 /L (150-440 x 10 9 /L) Serum sodium 138 mmol/L (135-145) Serum potassium 3.3 mmol/L (3.5-5.0) Serum urea 6.2 mmol/L (2.5-6.7) Serum creatinine 113 umol/L (70-120) Serum albumin 38 g/L (35-50) Fasting blood glucose 8.3 mmol/L (4.0-6.0) Serum bilirubin 16 umol/L (3-17) Serum alanine aminotransferase 24 IU/L (5-35) Serum alkaline phosphatase 92 IU/L (30-300) Serum gamma glutamyl transferase 43 IU/L (11-51) Serum cortisol 550 nmol/L (80-440) Urinalysis no protein or blood (negative), glucose moderate amount (negative) What diseases seem likely? What else should be measured to make the diagnosis of the most likely diseases?

10.5 11. Cushing’s syndrome or disease or bronchogenic carcimoma. Need ACTH, lung scan, dexamethasone suppression tests.

10.5 12. Yolanda Balas, a 25-year-old woman, an immigrant from Eastern Europe, with incomplete medical records had elevated urinary 17 ketosteroids noted at birth. (This is an obsolete test now). In her country of origin she was suppressed with prednisone from 8 months of age until recently when she came to Canada. She has normal adult height, had menarche at age 13 years, has irregular menses since, her blood pressure is normal. She has facial hair in the sideburns area, upper lip and chin. She has no goitre and minimal breast development (her enlarged clitoris noted at her birth was later reduced by surgery.) Laboratory tests on serum included: 17 (OH) progesterone 30 nmol/L (0.4 - 2) Free testosterone 150 pmol/L (14 - 55) Androstenedione 30 nmol/L (3 - 10) Dehydroepiandrosterone sulfate DHEAS 11 nmol/L (4.5 - 34) What is the most likely diagnosis? Why was she given steroids soon after birth?

10.5 12. Congenital adrenal hyperplasia. The steroids were given to supress her own steroids. It is surprising that she went so long without side effects. See sex hormone case of Shirley Sheffield.

10.5 13. Constance Conan, a 50-year-old woman, has had high blood pressure for 15 years. She complains of frequent palpitations and sweating. Laboratory test results: Serum potassium 2.5 mmol/L (3.5-5.0). Hyperaldosteronism was suspected. How could you tell primary hyperaldosteronism from secondary hyperaldosteronism?

10.5 13. Conn’s syndrome. Primary disease has increased aldosterone and normal renin. This is the opposite of Addison’s disease. Note Na and K.

10.5 14. Cathy Colamin, a 28-year-old woman, complains that for the past nine months she has been suffering from episodes of severe pounding headaches, dizziness, shaking, sweating and palpitations with intense anxiety lasting for 20 minutes. These attacks have been increasing in frequency and now happen each day. Her pulse is normal and regular, her blood pressure is increased. ``` Laboratory test results included: Blood haemoglobin 143 g/L (117-157) Mean corpuscular volume 85 fL (80-99) White cell counts 8.2 x 10 9 /L (3.5-11.0 x 10 9 /L) Serum bicarbonate 27 mmol/L (24-30) Blood glucose 5.6 mmol/L (4.0 – 6.0) Serum creatinine 104 umol/L (60 - 120) Urinalysis: no protein, no blood (negative) ``` She was asked to collect urine during a period of dizziness. She was told to exclude vanilla containing products from her diet for three days before the test. (Why do you think this dietary restriction was made?) Laboratory results on urine: Metanephrines 3500 mmol/d (250 - 1700) Vanillyl mandelic acid 85 umol/d (1.5-39) During one of her attacks a blood pressure of 184 120 mm Hg (very high) was seen. What is the diagnosis of the most likely disease?

10.5 14. Pheochromocytoma. Scan and surgery. Tumour of the adrenal gland

10.6 1. Diana Kathy Adams, a 12-year-old girl, complained of not feeling well, thirst, tiredness and trouble focusing her eyes. In the last few weeks she has lost weight. She is not confused, and she demands soft drinks and candy. Laboratory test results: Plasma glucose 40 mmol/L (4.0-5.5) Serum sodium 133 mmol/L (135-147) Serum potassium 5.8 mmol/L (3.5-5.0) Serum urea 30 mmol/L (3-7) Blood pH 6.95 (7.35-7.40) pCO 2 22 mm Hg (35-45) Urine and plasma ketones, strongly positive (0) What is the most likely diagnosis? a) Diabetes mellitus type I. b) Diabetes mellitus type II. c) Maturity onset diabetes of youth. d) Non-insulin dependent diabetes of youth. What is the best test (fewest false positive results) to diagnose her disease? a) Plasma fructosamine. b) Serum antimicrosomal antibodies. c) Serum amylase d) Serum islet cell antibodies.

10.6 1. A. type I diabetes mellitus (in keto acidotic coma). A Type I; D. Islet cell antibodies.

10.6 2. Mr. Sweet, aged 56 years, has had type II diabetes mellitus for the last 10 years. He monitors his blood glucose twice daily with his own glucose monitor. During the last 2 weeks his fasting blood glucose values have been in the range 8.7-15.4 mmol/L, mean value 11 mmol/L (3.5-5.5). He is slightly overweight and his blood pressure 142/90 mm Hg (120/60). What is the best way to measure the long-term effects of abnormally increased blood glucose? a) Plasma glycosylated haemoglobin. b) Prothrombin time. c) Serum urea d) Serum cholesterol.

10.6 2. Monitoring of type II A. plasma HbA1c (glycosylated haemoglobin) Notes: LADA. Latent autoimmune disease of adulthood. Often diagnosed as type II but needs insulin. These may be “lean diabetics” and as such are often misdiagnosed. Metabolic syndrome is a common and complex disorder centred on insulin resistance, as seen in type II diabetes mellitus, and visceral obesity. Early atherosclerosis and polycystic ovarian disease are also believed to be part of this syndrome.

10.6 3. Bebe Grande, a 30-year-old pregnant woman has no prior medical problems. Laboratory test results: As part of routine obstetrical care at 24 weeks of pregnancy she was given a 50 g glucose drink. She is 160 cm tall and weight 100 kg. At 1 hour her blood glucose was 8.7 mmol/L (< 7.8). Because of this she was given a 2-hour glucose tolerance test with 100 g glucose drink. Fasting 6.2 mmol/L (3.5-5.5) 1 hour 10.2 (< 11.1) 2 hours 9.5 (< 7.8) 3 hours 8.2 (< 6.4) ``` What should you expect to be the effect of her condition on the blood glucose result in her child when it gets to be born? a) Hyperglycaemia. b) Hypoglycaemia. c) No effect. d) Ketosis. ```

10.6 3. Gestational (type IV) B. hypoglycaemia because of mother’s high insulin level and infant’s immature liver.

10.6 4. Lola Pop, a 56-year-old former entertainer, complains that for the last several months she has been feeling fatigued. She is especially tired just before she eats and then soon afterwards. Every two days or so she feels light headed and eating helps to relieve this. She is concerned because she is putting on too much weight to continue in her profession. Laboratory test results: Her family physician performed a 5-hour glucose tolerance test with a 100 g glucose drink. Fasting plasma glucose 5.7 mmol/L (3.5-5.5) 1 hour after glucose drink plasma glucose 4.8 mmol/L (< 11.1) 2 hours plasma glucose 4.9 mmol/L (< 7.8) 3 hours plasma glucose 2.2 mmol/L (< 6.4), serum insulin 55 IU/L (fasting 0-20) 4 hours plasma glucose 3.8 mmol/L (< 6.4) 5 hours plasma glucose 4.3 mmol/L (3.5-5.5) What is the most likely disease? a) Reactive hypoglycaemia. b) Glucagonoma. c) Gastrinoma. d) Hyperthyroidism.

10.6 4. A. Reactive hypoglycaemia, she gets hypoglycaemic depending on what she is doing and eating. Think of insulin as a drug to use in murder.

10.7 2. Modesty Blaise, a 16 year old girl, has never menstruated. She has normal growth and secondary sexual characteristics but no pubic or axillary hair. Modesty does well in school, is athletic and popular socially. Her hair is devoid of pigment except on her eyebrows and scalp. Her external genitals look normal. Her skin is soft and acne free. Laboratory test results: Plasma testosterone 12 nmol/L (0.5-2.4) Plasma luteinizing hormone 20 IU/L (0.5-15) Plasma follicle stimulating hormone 5 IU/L (0-9.2) What is the disease MOST LIKELY to be present? a) Testicular feminization (XY) b) Turner’s syndrome (XO) c) Delayed puberty d) Early polycystic ovarian disease.

10.7 2. A testicular feminization (XY seen to be XX). Note also Castor Semenya etc. T is converted into estrogen in the liver —> female appearance LH ad FSH results like this case may be seen in PCOS (but testosterone wouldn’t be high)

10.7 3. Shirley Sheffield, a 28-year-old elite pentathlete complains that for the last two years she has had an increase in face and body hair. She now shaves every day. She is balding and so has her hair cut short and wears a cap or hat. Her husband says that she has become aggressive, temperamental and much more sexually demanding. She looks muscular and has hair on her face, chest, arms, legs and back in a male distribution. She does not have a red face, ecchymoses or striae. Laboratory test results: Serum testosterone 16 nmol/L (0.5-2.4) Dehydroepiandrosterone (DHEA) 90 nmol/L (4.5-30) Androstenedione 26 nmol/L (3-9.6) Cortisol after dexamethasone (1 mg) stimulation 33 nmol/L (< 138) What organ is MOST LIKELY to be diseased? a) Thyroid. b) Adrenal. c) Ovaries d) Pituitary.

10.7 3. B. Adrenal. Congenital Adrenal hyperplasia or adrenal cancer.

10.7 5. A 40 year old woman is pregnant. She is concerned about the possibility of having a child with Down syndrome. At about 16 weeks of her pregnancy blood was taken for the measurement of relevant proteins and hormones. Laboratory test results: Serum alpha foetoprotein 55 mg/L (< 40) This means which of the following disorders are most likely to be present in the foetus? a) Spina bifida b) Trisomy 21 c) Down syndrome d) Hepatoma

10.7.5 A spina bifida based on serum AFP result and history.

10.8 1. 25-year-old woman with history of depression, suicide attempts. She has taken large amounts of aspirin. Now she is noted to have a rapid breathing rate. Laboratory test results: Blood pH 7.58 (7.35-7.45) pCO 2 26 mm Hg (35-45) bicarbonate 18 mmol/L (22-30) pO 2 115 mm Hg (80-100) What is the acid base diagnosis?

10.8 1. Respiratory alkalosis. Early on in salicylate overdose.

10.8 2. 70-year-old man has collapsed, is comatose and cyanosed with very low blood pressure. Laboratory test results: Blood gases pH 6.9 (7.35-7.45) pCO 2 60 mm Hg (35-45) pO 2 50 mm Hg (80- 100) bicarbonate 15 mmol/L (22-30) What is his acid base status?

10.8 2. Combined respiratory and metabolic acidosis.

10.8 3. 80 year old man with type II diabetes mellitus has chest pain, is breathless and cyanosed. Bicarbonate has been infused to correct his blood pH. Laboratory test results: Blood pH 7.6 (7.35-7.45) pCO 2 15 mm Hg (22-30) pO 2 50 mm Hg (60-100) What is his acid base status? When acid base measurement became common it became the clinical practice to infuse bicarbonate when the patient had a severe acidosis. This probably killed many patients. The body can correct a severe acidosis quite quickly, see 10.9, but alkalosis takes a long time, perhaps days, to compensate at the kidney.

10.8 3. Combined metabolic and respiratory alkalosis.

10.8.4. A 70-year-old woman, a heavy smoker, has chronic bronchitis. She is breathless and is put on oxygen by the nurse under her own initiative. (This may not have been a good idea as it may lead to confusion about the diagnosis or extent of disease). About an hour later a blood gas sample is drawn. Laboratory test results: Blood pH 7.0 (7.35-7.45) pCO 2 90 mm Hg (35-45) pO 2 120 mm Hg (80-100) bicarbonate 50 mmol/L (22-30) Make an acid base diagnosis.

10.8 4. Partially compensated respiratory acidosis.

10.8 5. A 20-year-old man is having an acute attack of asthma. He is given a nebulized bronchodilator immediately. Ten minutes after this is started an arterial sample is drawn for blood gases. (Perhaps the ABG should have been done before and after starting therapy). Laboratory test results: Blood pH 7.2 (7.35-7.45) pCO 2 45 mm Hg (35-45) pO 2 80 mm Hg (80-100) bicarbonate 27 mmol/L (22-30). Make an acid base diagnosis.

10.8 5. Respiratory acidosis. Not at the extreme because of the influence of the drug.

10.8 6. 50-year-old metal recycling worker is short of breath on exertion, he has clubbed fingers. He is a long time smoker and has coughed for years. He breeds budgerigars. He is not cyanosed. Make a differential diagnosis and suggest tests to sort this out.

10.8 6. Metal poisoning – take history, check for metal exposure. Check for sensitivity to birds – serum antibodies. Check for COPD – spirometry

10.8 7. 28-year-old offensive lineman, 6’7” (197.5 cm) tall and 350 lb (153 kg) weight, played for an XFL team had knee injury followed by surgery. He had chest pain after physical therapy and died soon after. Pulmonary embolus was found at autopsy. What are risk factors in this man? What tests should have been done?

10.8 7. Knee surgery. Blood gases, LD, D-dimer.

10.8 9. 80 year-old scientist has been in good health since his retirement but recently sleeps more than he used to and has no appetite. He is losing a significant amount of weight. He used to smoke fairly heavily from age 15 to age 50 years when he stopped because malignancies were found on his lip and in his colon. He has been spitting a little blood for two weeks now. Chest X ray showed his trachea deviated to the left and loss of volume in the left upper lobe. Wheeze is located to the left side of his chest. What is the most likely diagnosis? What laboratory work is indicated?

10.8 9. Lung cancer. Probably no tests are useful at this stage. There may be test done to look for the effects of the paraneoplastic syndrome. Hormone blockers may help if this is present.

10.8 10. Laboratory test results from a pleural aspirate: Straw coloured (clear) Protein 35 g/L (<20 g/L) Cells are predominantly lymphocytes (no cells). Glucose 0.5 mmol/L (2.5-4.0) Culture: no growth. Cytology: no malignant cells seen. Interpretation is what? What further investigations seem appropriate?

10.8 10. Exudate. Look for inflammatory disease markers: serum CRP, ESR, Rh etc.

10.8 8. 30-year-old woman, a smoker, on oral contraceptives, went to a clinic in Scarborough for abdominal liposuction. She felt unwell after the operation. She was sent home but hours later had intense chest pain. Shortness of breath (SOB) developed rapidly with tachycardia, 180 bpm. She was admitted to hospital. ``` Laboratory test results included: Blood pH 7.50 (7.35-7.45) pO 2 65 mm Hg (60-90) pCO 2 30 mm Hg (35-45) bicarbonate 23 mmol/L (22-30) Plasma sodium 143 mmol/L (135-147) Plasma potassium 4.1 mmol/L (3.5-5.0) Serum urea 3.6 mmol/L (3-7) ``` What are the risk factors for this woman? What tests should be done? What treatment do you expect to be given to this patient?

10.8 8. Smoking, OC, obesity. LD, D-dimer. “Clot Busting” anticoagulants..

10.9 1. 36-year-old healthy woman in for an insurance check up was noted to have serum cholesterol of 6 mmol/L (<5.2). How can you use the laboratory to tell if this result is of concern? What else do you need to know about her to explain the result?

10.9 1. HDL. Use of OC, is she a jogger or distance running athlete. She may well be “normal”.

10.9 2 45-year-old executive is concerned about his chances for having atherosclerotic heart disease. How could you use the laboratory to address his concerns?

10.9 2. Serum LDL cholesterol or apo B 100, hs CRP or hs troponin.

10.9 3. A sample of blood from a patient appeared pink. The sample was allowed to stand at room temperature for a few hours. His blood plasma was very turbid and a layer, like cream, formed at the top of the plasma. What could be his problem? How can you use the laboratory to make the diagnosis?

10.9 3. Hypertriglyceridaemia. Measure serum TG.

10.9 4. 50-year-old man, a non-smoker with high blood pressure. ``` Laboratory test results: Serum cholesterol 7 mmol/L (<6) Serum triglyceride 7 mmol/L (<1.8) Serum glucose 10 mmol/L (3-5.5) Serum gamma glutamyl transferase 150 IU/L (0-30) ``` What is his disease? What further testing should be done?

10.9 4. Diabetes mellitus. Perhaps hepatitis.

10.9 5. 49 year-old bus driver, obese, smoker, low exercise, adopted, blood pressure 165 96 mm Hg (increased) Laboratory test results: Serum cholesterol 7.4 mmol/L (<5.2). Repeat serum cholesterol 7.6 mmol/L Serum triglyceride 4.7 mmol/L Serum HDL cholesterol 0.7 mmol/L (< 2.0) Serum LDL cholesterol 4.5 mmol/L (<3.4) What do these results mean for diagnosis and prognosis?

10.9 5. Serum HDL and LDL mean heart disease possible. Lipids - possibility of inherited disease or acquired by life style. Prognosis is poor.

10.9 6. 80 year-old man complains of chest pain. He has low blood pressure. ``` Laboratory test results: Serum cholesterol, HDL cholesterol, LDL cholesterol and TG are normal Serum homocysteine is increased Serum folate decreased Serum vitamin B 12 is normal Serum vitamin B 6 is decreased. ``` Explain his disease?

10.9 6. Starvation.

10.9 7. 49-year-old male has crushing chest pain radiating down his left arm after an argument with his teenage son. An ambulance was called. In the Emergency Department he was noted to be sweatingprofusely, in pain and breathing rapidly. A heart attack, myocardial infarction, MI, was suspected. It is important to be sure that it is an MI and to start aggressive antithrombolytic therapy (usually with streptokinase, an enzyme that dissolves blood clots) as soon as possible. However this treatment is not without risk and a definite diagnosis should be made before treatment is started. What laboratory tests should be done and at what time after possible infarction to make the diagnosis?

10.9 7. Serum or urine Myoglobin 2-4 hours. Serum Troponin and CK 3 -12 hours. If MI should be evident at 6 hours.

10.9 8. 70-year-old man has experienced chest pain on exertion for some months. In the afternoon of the day prior to admission he had a particularly severe episode of the pain lasting for about an hour. On admission the following morning he was pale and there were no other abnormalities. His ECG was normal. His plasma enzymes at that time were: Creatine kinase 150 IU/L (normal is 30 - 200) Alanine aminotransferase (ALT) 40 U/L (10 - 40) Lactate dehydrogenase 2,500 U/L (230 - 460) Do these results indicate an MI? What other diseases might be possible?

10.9 8. Not MI. Pulmonary embolism.

10.9 9. Finland has one of the highest heart attack rates in the world. Why do you think this is so? How could you test for your theory using the laboratory?

10.9 9. Not known. It may be genetic, the shut in nature of winter living, seasonal depression and that the Finns seem to be binge drinkers. This is the worst way to imbibe from a health point of view. Measure serum GGT and hs troponin.

10.9 10. At Dala in Sweden 7 elite orienteers died suddenly. At autopsy on a few of them there seems to have been inflammation in the heart muscles. The official cause of death was given as consequent to Taiwan acute respiratory (TWAR) infections, now called Chlamydial pneumonia. (Dala is a small resort town in central Sweden. Not public knowledge is that the actual number of sudden cardiac death in the orienteers was more than 20. The athletes were aged 20-30. Of the seven deaths in the public domain one was a woman). What else might the cause of death be?

10.9 10. EPO, based on epidemiology and lack of similar problem in other similar sports in Sweden but cocaine, anabolic steroids, Lyme disease should be considered.

10.9 11. A 45-year-old man complains of shortness of breath that has lasted for a week. He reports that he had a viral infection about three weeks ago. After this he developed ankle oedema, a 7 kg weight gain, dyspnoea on exertion and having to sleep sitting up so as to be able to breath. (This is typical of right sided heart failure or severe left sided heart failure). His heart rate is 140 beats/minute and irregularly irregular. His blood pressure is 90/60 mm Hg (low normal) and his respiratory rate is 22 /minute. His jugular venous pressure is 12-14 mm H 2 O (abnormal increase). Lung examination shows bibasilar dullness with rales extending one fourth of the way up from the basal lung fields on each side. Cardiac examination shows S1 and S2 of variable intensity with a prominent S3 gallop over the displaced cardiac apex. The ECG shows atrial fibrillation with nonspecific ST-T wave changes with an occasional ventricular premature beat. ``` Laboratory test results: Arterial blood gases are pH 7.46 (7.35-7.45) pCO 2 32 mm Hg (35-45) pO 2 52 mm Hg (80-100) Bicarbonate 26 mmol/L (22-30) ``` What kind of heart failure does he have? What kidney function test results should you expect? Rheumatic heart disease may, in later life, give congestive heart failure

10.9 11. Congestive heart failure. Increasing serum creatinine, urea because of poor output from heart.

10.9 12. 50-year-old woman complains of fatigue, worsening dyspnoea and palpitations. As a child once she had fever, joint pains with difficulty moving. Then she recovered fully in a few weeks. Her chest X ray now shows an enlarged left atrium. Laboratory test results: Serum anti deoxyribonuclease-B titre, (DNase B) and antistreptolysin O titre (ASO) positive (negative). What is the cause of her congestive heart failure?

10.9 12. Rheumatic heart disease. ASO.

10.10 1. 22-year-old football player was hit in the back during a practice without padding. He complains of severe headaches and blood pressure 200 140 mm Hg (<120 80). What laboratory tests are indicated to make the diagnosis?

10.10 1. Kidney Artery Stenosis. Measure plasma renin, aldosterone.

10.10 2. 10-year-old girl complains of headaches, flank pain, discomfort and feeling unwell. She was well until 2 weeks before this when she had sore throat and painful swallowing. Her temperature then was 39.5 C. She had swollen tonsils. Her cervical lymph nodes were enlarged. Now she has a body temperature of 38 o C, blood pressure 140 100 mm Hg (100 60), pulse 100 beats/minute. Her face is puffy, and she has ankle and sacral oedema. Urine is tea colored (pale yellow). Laboratory test results: ``` Urine protein 1 g/L (0) Urine blood large amount (0) Blood Haemoglobin 120 g/L (120 - 155) Leukocytes count 10 x 10 9 /L (4.5 - 11 x 10 9 /L) Serum creatinine 285 umol/L (50 - 110) Serum albumin 35 g/L (35- 50) ``` What disease does she have?

10.10 2. Nephrotic syndrome. History and urine protein, creatinine, albumin.

10.10 3. 22-year-old female student complains of occiput (back part of the head) headache, fuzziness of vision for 5 days. She takes oral contraceptives. Blood pressure 220 130 mm Hg (120 60) Pulse 68 beats/minute. Funduscopic examination showed bilateral haemorrhages and exudates into the eye. Laboratory test results: Serum potassium 2.8 mmol/L ((3.5 - 5.0) - anabolism, vomiting. Serum creatinine 110 umol/L (50 –120). Urine protein 1 g/L (0). What else should be measured? What other commonly used drugs may cause hypertension?

10.10 3. Pregnancy test. Serum albumin, D-dimer, fasting blood glucose.

10.10 4. 60-year-old man complains of feeling unwell. Blood pressure 190 120 mm Hg (130 100). Laboratory test results: Serum potassium 2.0 mmol/L (3.5 - 5). Serum bicarbonate 32 mmol/L (22-30). Diuretic therapy is the commonest cause of such laboratory results. What other laboratory tests should be done?

10.10 4. Serum sodium.

10.10 5. 40-year-old commercial airline pilot grounded because of hypertension. He and his Trade Union protest this. He says that he is very fit and should not lose his job. What laboratory testing should be done?

10.10 5. Aldosterone. (from licorice addiction when under stress)

10.10 6. 36-year-old woman complains of fatigue for the last 2 years. She has muscle weakness, irritability, depression, mood swings and she is emotionally labile. In the last 2 years she has gained 17.5 kg in weight. She has had menstrual irregularity for the last 2 years. She bruises easily. She has a round red face, with facial hair and acne. She has purple striae on her abdomen. Her legs and arms are thin. She has proximal muscle weakness. She has fat pads at her shoulder and mid back. Weight 88 kg, height 167 cm, pulse 86 beats/minute and blood pressure 165 100 mm Hg (<120 80) Laboratory test results: Serum alanine aminotransferase 25 IU/L (<35) Serum alkaline phosphatase 90 IU/L (<100) Serum cortisol at 8 am 1,049 nmol/L (138-635) Serum cortisol after 1 mg of dexamethasone 883 nmol/L Urine free cortisol 2,414 nmol/d (55-245) What is her disease? Fasting blood glucose 9 mmol/L (3.5-6.0) Serum bicarbonate 34 mmol/L (22-30)

10.10 6. Cushing’s. Cortisol etc.

10.10 7. 40-year-old woman complains of headaches for the last 6 months. Her muscles ache. She has chronic low back and joint pain for the last 6 months. Her hands are large soft and sweaty. Her teeth are widely spaced. Her blood pressure is 150 100 mm Hg (< 120 80), pulse 60 beats/minute. Laboratory test result: Fasting blood glucose 8.5 mmol/L (3.5-5.5) What is her disease?

10.10 7. Acromegaly. Growth hormone etc.

10.10 8. 35-year-old man complains of headaches, palpitations, sweating and irritability. His blood pressure was 200 120 mm Hg. Diuretics had no effect but when he was put on beta blockers he almost died. Laboratory test results: Urine drug screen negative Urine catecholamines 900 nmol/L (< 109) Urine vanillyl mandelic acid VMA 110 umol/d (11-38) What is his disease?

10.10 8. Pheochromocytoma.- tumour of the adrenal gland

10.10 9. 21-year-old woman, 31 weeks pregnant. At 12 weeks her blood pressure was 100 70 mm Hg, now it is 180 110 mm Hg. She complains of headache and feeling swollen. Laboratory test results: Urate 700 umol/L (132-393) [This is the waste product from DNA, RNA etc. turnover. Very many activities, diseases and drugs increase this.] Urine protein 5 g/L (< 150 mg/d). What further laboratory testing should be done? This disease is thought to be due to placental ischaemia.

10.10 9. Kidney function tests. Serum albumin and magnesium as this condition is usually treated with magnesium salts. Mg is a tranquilizer. Liver function tests, complete

MC stone in North America is...

CALCIUM PHOSPHATE

MC cause of acute liver failure

acetaminophen overdose; next is hepatitis types

ketosis is common, insulins decreased, HLA associated (islet antibodies) present

DM 1

in stress, insulin present, HLA associated (islet antibodies) absent

DM 2

glycated Hb (HbA1c) - every 2-4 months test for...

DM 2

"Muscle damage, after 6 | hours or so"

Troponin I or T; and CK

B natriuretic peptide

CHF

MC hepatitis found in SE Asia (mild)

Hep E

Serum creatinine, serum and urine sodium, osmolality.

Acute kidney failure

Urine protein, serum creatinine, calcium, phosphate, osmolality.

Chronic kidney failure

Serum gamma glutamyl transferase (GGT)

alcohol

Low hygiene, 2-4 weeks, ALT, bilirubin, Mild. IgG anti HAV prior infection. IgM anti HAV current

hep A

contact with carrier, 2-6 months, ALT, bilirubin, AFP for cancer; Possible arthritis, rash. Carrier state. Anti HBV, HBsAg etc. Maylead to cirrhosis, cancer

hep B

blood products, 7 weeks, ALT, bilirubin, Anti-HCV; carrier state, may lead to cirrhosis, cancer

hep C

Already has hepatitis B, 1-2 months, ALT bilirubin. Possibly severe disease. Anti HDV

hep D

Low hygiene, 6 weeks, ALT, bilirubin, found in SE Asia, Usually mild

hep E

antiglutaminase (AGT) antibody.

Celiac disease

Afro-Carribean, skin keloids, uveal tract, hilar/mediastinal lymph nodes; lung, spleen, liver, bone marrow disease

Sarcoidosis

" Metabolism low, goitre, cold intolerance, bradycardia, lethargic, weight gain, skin cool dry scaly, hair thin."

Hypothyroidism

"Metabolism high, often goitre, heat intolerance, tachycardia, anxious, insomnia, protruding eyes, flushed, warm skin, fine hair."

Hyperthyroidism

LH, FSH | TSH

pituitary dysfunction, pituitary cancer or ovaries/testes failure "Alpha 1 antitrypsin"

"Alpha 1 antitrypsin"

"Lung disease, juvenile cirrhosis."

"Copper, caeruloplasmin " "Mental changes, cirrhosis."

Wilson's

"Carcinoembryonic antigen CEA (alpha foetoprotein AFP)" "Weight loss, faecal blood, anaemia, abdominal pain, change in bowel habit"

"Colon cancer etc, | (AFP, GGT for spread to liver)."

Increased fecal fat test or butterfat test

malabsorption

Increased Breath tests (H 2 , CH 4 )

Increased = Bacterial overgrowth

Estradiol and/or androgens = low LH, FS are increased What type of failure is this & what other test needs to be done?

Organ failure - stimulation test

LH and FHS are increased with low estrogens/androgens | What type of failure is this?

Control failure

Module 10 Exam Flashcards

(115 cards)