Clinical chemistry

Question 1

Causes of raised ALP

Answer 1

Liver: cholestasis, hepatitis, fatty liver, neoplasia

Paget's
Osteomalacia (low calcium)
Bone mets (raised calcium)
Hyperparathyroidism (raised calcium)
Renal failure (low calcium)

Physiological: pregnancy, growing children, healing fractures

Question 2

Familial hypercholesterolaemia inheritance and mutation

Answer 2

Autosomal dominant

High LDL-cholesterol due to a mutation in the LDL receptor protein

Question 3

Familial hypercholesterolaemia diagnostic criteria

Answer 3

Simon Broome criteria

Adults with total cholesterol >7.5mmol/l and LDL-C >4.9mmol/l
Children TC >6.7mmol/L and LDL-C >4.0mmol/L
Tendon xanthoma in patients or 1st/2nd degree relatives, or DNA-based evidence of FH

Question 4

Management of familial hypercholesterolaemia

Answer 4

Specialist lipid clinic
High dose statins first line
Screening for first degree relatives, including children

Stop statins in women 3 months before conception

Question 5

Causes of hyperkalaemia

Answer 5

AKI
Metabolic acidosis
Addisons disease
Rhabdomyolysis
Massive blood transfusion
Drugs: K+ sparing diuretics, ACE-I, ARBs, ciclosporin, heparin, food (bananas, kiwi, tomatoes, spinach, etc)

Question 6

Management of hyperlipidaemia

Answer 6

Primary prevention of CVD: atorvastatin 20mg OD

Secondary prevention: atorvastatin 80mg OD

Question 7

Primary CVD prevention vs. secondary prevention

Answer 7

Patients >=40…

Primary: a QRISK2 cardiovascular risk of >=10% in people <=84 (>=85 years are at high risk because of their age), or most type 1 diabetics, or CKD if eGFR<60

Secondary: known ischaemic heart disease, or cerebrovascular disease, or peripheral arterial disease

Question 8

Criteria for offering statins to type 1 diabetics

Answer 8

Offer 20mg atorvastatin to type 1 diabetics who are:

• older than 40, or
• have had diabetes for more than 10 years, or
• have established nephropathy, or
• have other CVD risk factors

Question 9

Follow up for patients started on statins

Answer 9

Follow up patients at 3 months
repeat a full lipid profile
If the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Question 10

Lifestyle modifications for hyperlipidaemia

Answer 10

Cardioprotective diet: low sat fat, low cholesterol, low sugar, eat at least 5 portions of fruit and veg, at least 2 portions of fish per week, wholegrain

Physical activity: at least 150 minutes of moderate intensity aerobic activity, or 75 mins of high intensity activity per week

Alcohol intake: no more than 3-4 unites/day in males and 2-3 units/day in females

Stop smoking

Question 11

Secondary causes of hyperlipidaemia

Answer 11

Hypertriglyceridaemia: DM, obesity, alcohol, CKD, liver disease, drugs (thiazides, non-selective beta blockers, unopposed oestrogen)

Hypercholesterolaemia: nephrotic syndrome, cholestasis, hypothyroidism

Question 12

Causes of hypophosphataemia

Answer 12

Alcohol excess, acute liver failure, diabetic ketoacidosis, refeeding syndrome, primary hyperparathyroidism, osteomalacia

Question 13

Consequences of hypophosphataemia

Answer 13

RBC haemolysis, WBC and . platelet dysfunction, muscle weakness and rhabdomyolysis, CNS dysfunction

Question 14

Causes of SIADH

Answer 14

Malignancy: SCLC, pancreas, prostate

Neurological: stroke, SAH, subdural haemorrhage, meningitis, encephalitis, abscess

Infections: TB, pneumonia

Drugs: sulfonylureas, SSRIs, TCAs, carbamazepine, vincristine, cyclophosphamide