Chempath - hypoglycaemia + clin chem CPC

Question 1

Acute Mx of an alert and orientated hypoglycaemic patient

Answer 1

ORAL carbohydrates

Fast - juice/sweets
Long acting - sandwich

Consider IM glucagon 1mg

Question 2

2 e.g. of mx for an acutely drowsy (but intact swallow) + hypoglycaemic patient

Answer 2

Glucagel/hypostop

Question 3

2 options for IV treatment of hypoglycemia

Answer 3

100mL of 20% glucose

or

50mL of 50% glucose mini-jet

Question 4

What do you need to consider when assessing use of IM glucagon in a hypoglycaemic patient?

Answer 4

Glucagon takes 15-20 mins to work

Only works if there are enough glycogen stores present

Danger of rebound hypoglycemia

Question 5

2 forms of symptoms with hypoglycaemia?

Answer 5

Sympathetic - sweating, nausea, palpitations

Neuro - Confusion, seizures, incoordination

Question 6

Hormonal response to low glucose levels?

Answer 6

Increased cortisol, GH, ACTH, adrenaline

Question 7

Causes of hypoglycaemia in a non-diabetic individual

Answer 7

Fasting
Organ failure
Exercise
Insulinoma
Drugs - EtOH,beta blockers
Factitious

Question 8

Causes of hypoglycaemia in a diabetic individual

Answer 8

Missed meal
EtOH
Exercise
Impaired aAWARENESS

Question 9

Which 2 comorbidities are commonly associated with hypos in DM patients? Why?

Answer 9

Liver and renal failure - due to impaired clearance of DM drugs, therefore toxicity

Question 10

Useful tests for differentiating the cause of hypoglycemia

Answer 10

Insulin, C-peptide, FFAs, ketones, drug screen

Question 11

Hypoglycaemia due to excess injected insulin would result in a high or low C-peptide?

Answer 11

low

Question 12

Hypoglycaemia with low insulin and C-peptide. What are the causes?

Answer 12

appropriate response to hypoglycaemia!

Starvation
Exercise
Critical illness
Liver failure
Anorexia Nervosa

Question 13

What is 3-hydroxybutyrate?

Answer 13

Ketone body

Question 14

A neonate has hypoglycaemia. What are the potential causes?

Answer 14

High ketones - prematurity (no glycogen stores), IUGR, SGA

Low ketones: inborn metabolic defects

Question 15

If hypoglycaemia + high insulin levels, what are the potential causes?

Answer 15

Infant of GDM
Insulinoma
Excess DM drugs
Beckwith Weidemann syndrome
Nesidioblastosis

Question 16

how are beta cells stimulated to release insulin?

Answer 16

Glucose enters, is metabolised to generate ATP

ATP closes the K+channel, and depolarisation –> Ca2+ influx and insulin exocytosis

Question 17

MOA of sulfonylureas?

Answer 17

binds to Sur1 on K+ channel

Question 18

MOA of sulfonylureas?

Answer 18

binds to Sur1 on K+ channel

Question 19

Insulinoma - glucose, insulin and c-peptide level?

What syndrome is it associated with?

Answer 19

low glucose
high insulin + high c-peptid

Assoc with MEN1

Question 20

Low glucose
Low insulin + c-peptide
No ketones and FFAs

What is the cause?

Answer 20

Non-islet cell tumour hypoglycaemia

i.e. paraneoplastic. Big IGF2 release from tumour –> stimulation of insulin receptor

Question 21

how to confirm diagnosis of diabetes

Answer 21

HbA1c >6.5

Question 22

3 main groups of causes of metabolic alkalosis

Answer 22

Loss Of H+ (vomiting)
ingestion of bicarb
Hypokalemia

Question 23

NR of bicarbonate in an ABG?

Answer 23

8-14

Question 24

Osmolality = ?

Answer 24

2(Na+K)+ urea + glucose

Question 25

Causes of hypokalemia

Answer 25

GI: D+V, fistula
Insulin
Renal: Diuretics, excess aldosterone

Question 26

Effect of insulin on Potassium?

Answer 26

Insulin –> hypokalemia

Question 27

Which LFT is raised in acute MI?

Answer 27

Aspartate aminotransferase

Question 28

ALT stands for…?

Answer 28

alanine aminotransferase

Question 29

Why is there hypokalemia often seen in ectopic ACTH?

Answer 29

V high cortisol levels will eventually stimulate MC receptors –> increased aldosterone and K secretion

Question 30

NR of plasma osmolality

Answer 30

275-295

Question 31

What Ix is done to differentiate between acute and chronic renal failure

Answer 31

renal biopsy

Question 32

Mx of acute tubular necrosis?

Answer 32

Dialysis

Question 33

Top Sx in Paget’s disease of the skull

Answer 33

Deafness

Question 34

Once a blood test showing sky high ALP is done, what is a useful investigation to confirm Paget’s disease of the bone?

Answer 34

Radio labelled Technetium scan

Question 35

Which measurements are raised in acute MI? state in order

Answer 35

1. Troponin
2. CK (MB)
3. AST
4. LDH

Question 36

CK (MM) is from..?

Answer 36

skeletal muscle

Question 37

which level (apart from phosphate) is low in primary hyperparathyroidism

Answer 37

Vitamin D

PTH stimulates 1alpha-hydroxylase, thus vitamin D is consumed

Question 38

sudden dehydration –> AKI. which one changes the most - creatinine or urea?

Answer 38

Urea rises the most.

If Creatinine is normal, then you know it is an acute problem

Question 39

Mx of hyperkalemia in worsened ESRF

Answer 39

1) Calcium gluconate
2) insulin + dextrose
3) acute dialysis

Question 40

2 indications for acute dialysis in CKD?

Answer 40

acidosis + hyperkalemia

Question 41

3 structures of the portal triad

Answer 41

HPV
hepatic artery
bile duct

Question 42

Why is giving bicarb BOLUS, v dangerous in DKA?

Answer 42

bicarb will raise the pH and will then cause a rise in Co2 by equilibrium.

The CO2 crosses the BBB and worsens acidosis –> brainstem death

• bicarb is useful if given by slow infusion

Question 43

Best marker of glucose control over last 3 weeks?

last 3 months?

Answer 43

3 weeks: fructosamine

3 months: HbA1c