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Chem Path Flashcards

1
Q

How to work out Osmolarity?

A

2 (Na+ + K+) + Urea + Glucose

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2
Q

Normal range for serum osmolarity?

A

275 - 295 mmol/kg

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3
Q

Normal sodium range?

A

135- 145 mmol/L

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4
Q

Symptoms of hyponatraemia

A

less than 136 - nausea and vomiting
less than 130 - confusion
less than 125 - seizures and pulmonary oedema
less than 120 - coma/death

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5
Q

True hyponatraemia

A

Low osmolality

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6
Q

What is important to check when it comes to working out cause of true hyponatraemia?

A

Hydration status - are they hypervolemic, euvolemic or hypovalemic. Check urinary Na+ as well:

Hypervolemic - cardiac failure, cirrohosis, nephrotic syndrome. >20 - renal and less than 20 = non-renal

Euvolemic - SIADH, hypothyroidism, adrenal insufficiency

Hypovolemic - salt losing nephropathy, D+V, diuretics. > 20 = renal and less than 20 = non-renal

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7
Q

Major risk of rapidly correcting hyponatraemia?

A

Central pontine myelinolysis so to avoid increase Na+ by 1mmol/l

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8
Q

What is the urine osmolality like in SIADH?

A

Inapproriately high but patient is euvolemic. Increased renal secretion of Na+ (>20)

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9
Q

What are the causes of SIADH?

A
  • Drugs : opiates, SSRIs and carbamazepine
  • CNS : haemorrhage, abscess and meningoencephalitis
  • Lungs : TB, pneumonia, abscess
  • Cancer: Small cell lung cancer, pancreas, prostate and lymphoma (ectopic)
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10
Q

Risk of rapid correction of hypernatraemia?

A

Cerebral oedema

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11
Q

What types of hypernatraemia are there?

A

Hypovolemia - D + V, burns, excessive sweating, renal (loop diuretics or disease)
Euvolemia - diabetes
Hypervolemia - Conn’s syndrome, hypertonic saline (our fault)

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12
Q

Path of diabetes insipidus?

A

lack or no ADH

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13
Q

Symptoms + signs of diabetes insipidus?

A

polydipsia, polyuria, hypernatremia (thirst, lethargy, confusion), plasma osmolality > 2 (v.conc), urine dilute. Patient is euvolemic

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14
Q

Types of DI?

A

Cranial - makes no ADH (tumour, trauma, surgery)

Nephrogenic - doesnt respond to ADH (lithium, inhertied or chronic renal failure)

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15
Q

How to diagnose DI?

A

8hr fluid deprivation test

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16
Q

Diagnose - low plasma sodium, low plasma osmolality, normal/high urine osmolality, low urine sodium. Fluid status - hypovolemic

A

This patient could have D+V as they are losing the salt somewhere else. They could also have excessive sweating or severe burns leading to dehydration

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17
Q

Diagnose - low plasma sodium, low plasma osmolality, normal/high urine osmolality, low urine sodium. Fluid status - euvolemic

A

Patient most likely has SIADH

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18
Q

Diagnose - low plasma sodium, low plasma osmolality, normal/high urine osmolality, low urine sodium. Fluid status - hypervolemic/overloaded

A

Patient probably has either cardiac failure, cirrohosis, nephrotic syndrome

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19
Q

Diagnose - low plasma sodium, normal/high plasma osmolality.

A

Pseudohyponatraemia - caused by hyperlipidemia, hyperglycemia, multiple myeloma. Investigate further

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20
Q

Diagnose - low plasma sodium, normal/high plasma osmolality.

A

Pseudohyponatraemia - caused by hyperlipidemia, hyperglycemia, multiple myeloma. Investigate further

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21
Q

Results of fluid deprivation test?

A

Primary polydipsia - urine concentration goes back to normal
Cranial polydipsia - urine concentrates when desmopressin is given
Nephrogenic polydipsia - urine does not concentrate so urine osmolality is still low (?)

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22
Q

What is normal range of potassium?

A

3.5 - 5.5 mmol/l

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23
Q

Where is K+ reabsorbed in the nephron?

A

PCT and thick ascending limb

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24
Q

Which cells secrete K+ into the urine from the kidney?

A

Principle cells

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25
What does aldosterone do?
Na+ reabsorption and K+ secretion
26
What drugs cause hypokalaemia?
Loop diuretics and thiazides diuretics
27
Which loses more K+? Vomiting or Diarrhoea
Vomiting - minimal but causes metabolic alkolosis which causes hypoK due to low H+. Diarrhoea causes more K_ loss so Diarrhoea (seen in laxative abuse)
28
Symptoms of hypokalaemia?
Skeletal muscle - cramps, weakness, flaccid paralysis Smooth muscle - constipation Cardiac - arrythmias, cardiac arrest (Damn dramatic) Resp - resp depression
29
Causes of hypokalemia?
GI losses - V + D Renal - loop + thiazides diuretics, hyperaldosterism, cushings Metabolic alkalosis, insulin, beta-agonists. Poor intake - fasting, anorexia nervosa Renal tubular acidosis?
30
What do you see on an ECG in hyperkalaemia?
Peaked T-waves, short QT interval, ST segment depression SEVERE - prolonged PR/absent P wave and widened QRS segment
31
Tx of hyperkalaemia?
- Calcium, insulin, glucose, beta-adrengic agonists and sodium bicarbonate - Potassium wasting diuretics - Dialysis
32
Causes of hyperkalaemia?
- Excessive intake: iatrogenic or oral. - Cellular: acidosis, insulin deficiency (prediagnosed diabetes), tissue damage (burns, rhabdomylosis) - Decreased excretion: K+ sparing diuretics, beta-blockers, ACE-I, addison's acute and chronic renal failure
33
What is normal pH?
7.35 - 7.45
34
What is CO2 range?
4.7 - 6 kPa
35
What is bicarbonate range?
22 - 30 mmol/L
36
What is O2 range?
10-13 kPa
37
What does a high base excess suggest?
A high base excess (> +2mmol/L) indicates that there is a higher than normal amount of HCO3- in the blood, which may be due to a primary metabolic alkalosis or a compensated respiratory acidosis.
38
What does a low base excess suggest?
A low base excess (< -2mmol/L) indicates that there is a lower than normal amount of HCO3- in the blood, suggesting either a primary metabolic acidosis or a compensated respiratory alkalosis.
39
Anion gap?
(Na+ + K+) - (Cl- + HCO3-)
40
Normal range for anion gap?
14- 18 mmol/l
41
Mneumonic/causes of elevated anion gap?
MUDPILES: ``` Methanol/Metformin Uraemia Dka Paraldehyde Iron Lactate Ethanol Salicylates ```
42
Causes of decreased anion gap?
A decreased anion gap indicates decreased acid excretion or loss of HCO3–−: GI loss of HCO3— diarrhoea, ileostomy, proximal colostomy Renal tubular acidosis (retaining H+) Addison’s disease (retaining H+)
43
Liver Function tests - markers of liver cell damage
``` ALT AST ALK Phos GGT Bilirubin ```
44
Liver function tests - markers of synthetic function
Albumin Clotting (INR) Glucose
45
What would AST:ALT = 2:1 suggest?
Alcoholic liver disease
46
What would AST:ALT where AST is slightly higher than ALT suggest?
Viral liver disease
47
Normal range of ALP?
30 - 150 IU/L
48
Normal range of GGT
8 - 60 IU/L
49
When would GGT be raised?
Chronic alcohol use. It is used to confirm a hepatic cause of raised ALP. Also raised in bile duct disease and metastates
50
When would ALP be raised?
Bone disease Pregnancy Cholestasis
51
Normal range for AST?
3- 30
52
Normal range for ALT?
3 - 40
53
Normal range for bilirubin?
3- 17
54
Normal range for albumin
35 - 50
55
Comparing ALT and ALP?
A greater than 10-fold increase in ALT and a less than 3-fold increase in ALP suggests a predominantly hepatocellular injury A less than 10-fold increase in ALT and a more than 3-fold increase in ALP suggests cholestasis It is possible to have a mixed picture involving hepatocellular injury and cholestasis (e.g. ALT < 10-fold increase and ALP > 3-fold increase)
56
What if ALT > AST ?
ALT > AST is seen in chronic liver disease | AST > ALT is seen in cirrhosis and acute alcoholic hepatitis
57
When can you not do the combined pituitary function test?
Ischaemic heart disease, epilepsy and untreated hypothyroidism (impairs GH and cortisol response?)
58
How big is a microadenoma?
<10 mm (benign)
59
How big is a macroadenoma?
>10 mm (malignant)
60
When would you have excess ADH (SIADH)?
``` Ectopic production (SCLC) Drugs - SSRIs, carbamazepine, amtryliptine Brain - meningitis, traumatic brain injury ```
61
Reference range for TSH?
0.33 - 4.5
62
Reference range for free T4?
10.2 - 22.0
63
Reference range for free T3?
3.2 - 6.5
64
Types of hyperthyroidism
High Uptake - Grave's disease, toxic nodular, toxic adenoma Low uptake - Postpartum thyroiditis, viral thyroiditis
65
Types of hypothyroidism
``` Hashimotos Iodine deficiency Post-thyroidectomy Drug induced - Lithium, amiodarone Primary atrophic hypothyroidism ```
66
Treatment of hyperthyroidism?
NSAIDs - viral thyroiditis High uptake - carbimazole/propylthiouracil (risk of aplastic anaemia) Surgery
67
Treatment of hypothyroidism?
Thyroid replacement therapy
68
Types of thyroid cancers
Most common ---> least common - Papillary - Follicular - Medullary - Lymphoma (MALT) - Anaplastic
69
Role of calcitonin?
Lowers Ca2+ levels by inhibiting osteoclasts and inhibiting renal tubular resorption of Ca2+
70
Where is calcitonin produced?
Thyroid (parafollicular/ c-cells)
71
How is addison's diagnosed?
SynACTHen test
72
Electrolyte imbalance seen in addison's?
high K+ and low Na+ and low glucose
73
Role of aldosterone in terms of H+?
Excretes H+ into urine and keeps HCO3-
74
What is conn's syndrome
Adrenal tumour secreting too much aldosterone
75
What electrolyte imbalance would you see with conn's?
V. high Na+ and v. low K+. Hypertension
76
How to investigate conn's?
Aldosterone:renin ratio
77
How to investigate PHAEO
Plasma and 24 hr urinary VMA and catecholamines
78
What would you see in phenytoin toxicity?
Ataxia and nystagmus
79
What would you see in digoxin poisoning?
Arrythmias, heart block, confusion and seeing yellow
80
What would you see in lithium toxicity?
Tremor, seziures, renal failure, arrhythmia
81
What would you see in gentamicin toxicity?
Tinnitus, deafness, nystagmus, renal failure
82
Calcium range?
2.2-2.6 mmol/l
83
Hormones involved in calcium metabolism
PTH (increases Ca2+) and calcitriol (1,25 (OH)2D) - increases Ca2+ too
84
Tell me about PTH
Increases Ca2+ Gets rid of phosphate Increased tubular 1alpha hydroxylation of Vit D 25 (OH) D Kidney tings
85
How does Calcitriol work?
increases both Ca2+ and phosphate absorption from the gut
86
Main cause of primary hyperparathyroidism?
increase in PTH due to parathyroid adenoma (80%)
87
What else would you see in primary hyperparathyroidism?
High Ca2+, low phosphate, normal/high alk phosphate, vit D - normal
88
Main cause of secondary hyperparathyroidism?
Renal osteodystrophy
89
What else would you see in secondary hyperparathyroidism?
low Ca2+, high phosphate, high PTH, alk phosph high,
90
Main cause of tertiary hyperparathyroidism?
Post renal transplant
91
Cause of hypoparathyroidism?
Primary - DiGeorge Syndrome | Secondary - Post-thyroid surgery
92
What do you check in a patient with hypercalcaemia (next step)?
Albumin: High - if high urea as well = dehydration Low/Normal - check the phosphate. High phosphate - check the ALP.
93
Causes of hypercalcaemia
Dehydration (high albumin) ALP (high) - bone metastasis, thyrotoxicosis, sarcodosis ALP (normal) - too much vit D, myeloma, milk alkali syndrome
94
Symptoms of hypercalcaemia
Moans, bones, groans, stones and pyschiatric overtones
95
Treatment of hypercalcaemia
Correct dehyration, bisphonates and treat underlying cause
96
Causes of hypocalcaemia
``` Parathyroid - autoimmune destruction, diGeorge (22) or surgical removal Renal - poor reabsorption due to renal failure Vit D deficiency Burns and rhambdomylsis Pancreatitis Magnesium deficiency Resp alkalosis Osteomalacia ```
97
Symptoms of hypocalcaemia
Trousseaus and Chvostek sign, perioral tingling, seizures
98
Treatment of hypocalcaemia
- mild : give calcium - renal cause - ALFACALCIDOL - severe: IV calcium gluconate
99
Which kind of kidney stone is likely to form in alkaline urine?
Calcium phosphate
100
Which kind of kidney stone is likely to form in acidic urine?
Calcium oxalate
101
Staghorn kidney stone?
Seen in infection related kidney stone (struvite)
102
Risk factors for kidney stone
Dehydration UTI Diet high in purines or oxlate rich foods Abnormal urine pH (renal tubular acidosis, red meat), Anatomical abnormalities
103
Management of kidney stones
- Keep hydrated - Reduce oxlate intake (spinach, beer, rhubarb) - Thiazides - Citrate (alkalises urine)
104
Types of kidney stones
``` Calcium oxlate Calcium phophate Struvite (staghorn) Uric acid Cysteine Xanthine ```
105
Which kidney stone is not radioopaque (most are - hint)
Cysteine and Xanthine
106
How would you investigate a patient with suspected kidney stones?
Serum: Cr, bicarbonate, Ca, phosphate, urate, PTH Stone analysis Spot urine : pH, MCS, amino acids, albumin 24 hour urine XRAY
107
When would serum amylase be high? (x10)
Acute pancreatitis
108
Different types of CK
CK-MM : skeletal muscle | CK-MB : cardiac muscle
109
When would you see high CK
``` Normal in black people MI Duchenne muscular dystrophy Statin related myopathy Rhambdomyolysis ```
110
When do you measure Troponin?
6 and 12 hours post chest pain
111
Diagnostic criteria for MI
``` Typical rise and gradual fall of troponin Rapid rise and fall of CK-MB With: - Ischaemia - Pathological Q waves - Coronary artery intervation - Pathological exam and history findings ```
112
What happens when you don't have enough vit A? (SERUM)
Colour blindness
113
What happens when you have too much vit A? (SERUM)
Exfoliation Hepatitis Tetragenic
114
What happens when you don't have enough vit D? (SERUM)
Rickets | Osteomalacia
115
When happens when you have too much vit D? (SERUM)
Hypercalcaemia
116
What happens when you don't have enough Vit E?
Anaemia | Neuropathy
117
What happens when you don't have enough Vit K?
Shit clotting (haemorrhagic disease of the newborn)
118
What happens when you have enough Thiamin (B1)?
Beri-Beri Neuropathy Wernicke's syndrome
119
How do you test for thiamine deficiency?
RBC transketolase
120
What happens when you don't have enough Riboflavin (B2)?
Glossitis
121
What happens when you dont have enough Pyridoxine (B6)?
Dermatitis/Anaemia
122
What happens when you have too much pyridoxine (B6)?
Neuropathy
123
What happens when you dont have enough Vit b12
Pernicious anaemia
124
What happens when you dont have enough folate?
Neuro congential defects | Megaloblastic anaemia
125
What happens when you dont have enough Niacin (B3)
Pellagra - 3Ds: diarrhoea, dermatitis and dementia
126
Diagnositic criteria for diabetes mellitus
Fasting glucose > 7 Oral glucose tolerance test > 11.1 Random glucose >11.1
127
Diagnostic criteria for impaired glucose tolerance
Random/oral glucose tolerance test > 7.8 but less than 11.1
128
Hyperinsulinaemia hypoglycaemia
Insulin excess, sulphonyurea excess, insulinoma
129
Hypoinsulinaemia hypoglycaemia (+ve ketones_
Alcoholic binge with no food, addison's disease, pituitary insufficiency, liver failure, anorexia nervosa, fasting, strenuous excerise, critical illness
130
Hypoglycaemia in the neonate
Worry if there are no ketone bodies (inherited metabolic disorder) If ketones present - premature, IUGR etc
131
Hypernatraemia
risk of intraventricular haemorrhage. Give sodium bicarbonate when treating acidosis
132
Hyponatraemia
think congenital adrenal hyperplasia. Give caffeine when treating apnoea
133
Common problems with low birth weight
``` Respiratory distress syndrome Retinopathy of prematurity Intraventricular haemorrhage PDA NEC ```
134
When does a kid reach maturity of their GFR?
Two years
135
Why do you babies have issues concentrating their urine
short loop of henle and distal collecting duct
136
why do babies lose salt easily?
distal tubule is not that sensitive to aldosterone
137
Which one is always pathological? Unconjugated/Conjugated
Conjugated is always pathological
138
When do you start worry about jaundice?
Jaundice in the first 24 hrs of life More than 14 days in term More than 21 days in term

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