Medical Act Flashcards
1
Q
How many doctors appointments are stress-related and how many adults experience adverse effects of stress?
A
75-90% of doctor’s appointments
> 40% of patients
2
Q
What is the vicious cycle of negative stress?
A
- Insufficient coping mechanisms
→ extreme stressor
→ very negative perceived stressor
→ multiple influencing factors - Homeostasis can not be preserved
→ Original stressor remains
→ Effects of stressor prevent coping with new stressors
→ New stressors and original ones accumulate
3
Q
What are the 3 stages of stress of the general adaptation syndrome by Hans Seyle?
A
Alarm Stage
Resistance Stage
Exhaustion Stage
4
Q
What happens in the alarm stage of the GAS model?
A
→ Activation of hypothalamus, adrenal glands and sympathetic nervous system
5
Q
What happens in the resistance stage of the GAS model?
A
→ Increased hormonal levels
→ Body systems operate at peak performance
6
Q
What happens in the exhaustion phase of the GAS model?
A
→ Body unable to respond further
→ Body damaged by increasing demands
7
Q
→ Increased HR and BP
→ Increased bronchodilation and ventilation
→ Increased blood glucose (cortisol)
→ Arousal of CNS and muscle activation (cortisol)
→ Decreased inflammatory and immune response (cortisol)
These are effects caused by?
A
Stress
8
Q
A stressor causes the secretion of which molecules?
A
→ Increased ACTH secretion (Adenocorticotropic Hormone)
→ Increased cortisol secretion
9
Q
What is the HPA stress reaction and is it fast or slow?
A
HPA (hypothalamus - pituitary gland - adrenal cortex) → slow stress reaction
- Hypothalamus releases CRH/CRF within 15sec
- After a few minutes pituitary gland releases ACTH
- Within 20min adrenal glands release glucocorticoids → e.g. cortisol
10
Q
How long does it take the adrenal glands to release cortisol?`
A
approx 20 minutes
11
Q
What is the SAM stress reaction and is it fast or slow?
A
SAM (Sympathetic Adreno Medullary) → fast stress reaction
- Hypothalamus stimulates adrenal medulla
- Adrenaline and noradrenaline are released
12
Q
“A state of imbalance within the body” what is meant here?
A
Stress
13
Q
What is allostasis?
A
process of bringing body back into a state of homeostasis
14
Q
How many of stages until burn out is reaches are there?
A
12
15
Q
- Must last for at least 2 weeks
- Can vary from mild to severe
- Feeling sad or having a depressed mood
- Loss of interest or pleasure in activities once enjoyed
- Changes in appetite → weight loss or gain unrelated to diet
- Trouble sleeping or sleeping too much
- Loss of energy or increased fatigue
- Increase in purposeless physical activity
- Slowed movements and speech
- Feeling worthless or guilty
- Difficulty thinking, concentrating or making decisions
- Thoughts of death and suicide
These are typical symptoms of which pathology?
A
Depression
16
Q
What are typical stress related somatic disorders?
A
- Herpes simplex
- Crohn disease (autoimmune disease of the bowel)
- Arrhythmias (fibrillation)
- Psoriarsis
- Obesity
- High BP
- Cardiovascular diseases
17
Q
What are typical conditions treated by an internist?
A
→ Cancer
→ Arteriosclerosis
→ High BP
→ Diabetes
18
Q
Latin term musculoskeletal system?
A
tractus locomotorius
19
Q
Latin term neurological system?
A
tractus neurologicus
20
Q
Latin term nerve system?
A
tractus cerebrospinalis
21
Q
Latin term cardiovascular system?
A
tractus circulatorius
22
Q
Latin term pulmonary system?
A
tractus respiratorius
23
Q
Latin term gastro-intestinal system?
A
tractus digestivus
24
Q
Latin term Genito-urinary system
A
tractus urogenitalis
25
Latin term endocrine system?
tractus hormonalis
26
Latin term skin system?
tractus integumentaris
27
What is palpitation?
Herzrasen
28
What is the cardiac control centre of the body?
The medulla
29
Where are baroreceptors and what is their function?
→ In wall of aorta and carotid arteries
→ Detect changes in blood pressure
Result: Change in rate and force of cardiac contraction
30
How does sympathetic activity influence the heart beat?
→ Tachycardia → Increase in heart rate and contractility
31
How does parasympathetic activity influence the heart beat?
→ Bradycardia → Decrease in heart rate and contractility
32
What is a normal heart beat?
60-100bpm
33
What is the average stroke volume?
70ml per contraction (by one ventricle)
34
What is peripheral resistance?
- Force opposing the blood flow
- Amount of friction between vessel walls and blood
35
Decreased sympathetic stimulation causes what type of vessel movement?
→ Systemic vasodilation
(THERE IS NO PARASYMPATHETIC NERVE INNERVATION IN BLOOD VESSELS)
36
Increased sympathetic stimulation causes what type of vessel movement?
→ Systemic vasoconstriction
37
How can the BP be calculated?
Blood pressure = cardiac output x peripheral resistance
38
How much blood does the human body carry on average?
Approx. 5L
39
How much of the blood made of plasma and what does it contain?
55% plasma
→ Proteins
→ Water
→ Amino acids, fats, carbs, vitamins, enzymes, electrolytes, waste products
40
How much of the blood made of cells and what types are there?
45% cells
→ Leukocytes
→ Erythrocytes
→ Thrombocytes
41
What is hemostasis?
prevention of blood loss by coagulants
42
What are characteristics of restrictive lung diseases?
- Decrease in total volume of air that the lungs are able to hold
- Often due to decrease in elasticity or problem related to expansion of the chest wall during inhalation
43
What are typical restrictive lung diseases?
- Lung cancer
- Interstitial lung disease
- Paralysis of diaphragm
- Spinal injury
- Kypho-scoliosis
- Obesity
- Morbus Bechterew
44
What are characteristics of obstructive lung diseases?
Airflow blockage and breathing related problems
45
What are typical obstructive lung diseases?
- Asthma
- COPD
- (Acute) brochi(oli)tis
- Bronchiectasis
- Cystic fibrosis
46
What are the 4 domains of disease burden in pulmonary diseases?
→ Complaints and limitations (CCQ ≤ 2) and dyspnea (mMRC ≤ 3)
→ Frequency of exacerbations (lung attacks) → ≥ 2 attacks/year treated with oral corticosteroids
→ Nutritional status (weight, BMI)
→ Degree of airway obstruction (FEV1)
47
In case of pulmonary disease indication what does the GP want to rule out?
heart failure
48
When is an increased disease burden in pulmonary diseases given?
If one of the subdomains is abnormal
49
What is a normal arterial oxygen pressure (PaO2)?
75-100 mmHg
50
At what level is hypoxemia present?
marked decrease in arterial oxygen pressure PaO2 < 60mmHg (< 8kPa)
51
At what level is hypercapnia present?
increase in PaCO2 (> 45mmHg or > 6kPa) → increase in ventilation
52
How does an increased PaCO2/hypercapnia lead to an increase in ventilation?
Increase in PaCO2 (> 6kPa) → gas diffusion to cerebrospinal fluid → decrease in PH → stimulation of respiratory centre → increase of ventilation
53
What are normal oxygen levels in arterial blood?
Approx. 20ml of oxygen per 100ml of blood in arteries
54
What are normal oxygen levels in venous blood?
Approx. 15ml of oxygen per 100ml of blood in veins
55
What can hypersensitivity to a drug lead to?
may lead to mild reaction or anaphylaxis
56
What are idiosyncratic/paradoxical effects of a drug?
unexpected or unusual reactions
57
What are iatrogenic effects of a drug?
negative effects due to medication error, overdose or unusual response
58
What are teratogenic/harmful effects of a drug?
developmental disorders in foetus
59
What is the result of a synergy of drugs?
combination of drugs causes an increase in effect
60
What is the result of antagonism of drugs?
combination of drugs causes a decrease in effect
61
What is the result of potentiation of drugs?
drug A enhances the effect of drug B
62
An optimal dose of drugs depends on?
→ Absorption
→ Transport in blood
→ Half-life
→ Biotransformation
63
By what is a dose expressed?
weight or measure and time factor
64
What are the two goals of medication-receptor interaction?
→ Stimulation
→ Inhibition
65
Which drugs lower blood pressure?
→ Angiotensin converting enzyme inhibitors (ACE inhibitors)
→ Beta blockers
→ Calcium channel blockers
→ Diuretics
→ Adrenergic blocking drugs
66
- Nitroglycerin
- Long-acting isosorbide
What kind of medication is this?
Vasodilators
67
What are vasodilators used for?
To treat angina attacks and prophylactic
68
How do vasodilators work and what are side effects?
**Action:**
→ Reduce peripheral resistance
→ Reduce workload of heart
→ Coronary arteries dilate
→ Better balance of oxygen supply and demand in heart muscle
→ Drop in BP
**Side effects:**
→ Dizziness
→ Red face
69
Enalapril
What kind of medication is this?
ACE-Inhibitor
70
What are ACE-Inhibitors used for?
- Decrease BP
- Tackle congestive heart failure
71
How do ACE-inhibitors work and what are side effects?
**Action:**
→ Block conversion of angiotensin I to angiotensin II
→ Reduce peripheral resistance (vasoconstriction)
→ Decrease angiotensin II release (aldosterone release) which leads to decrease in sodium and water retention
→ Action stimulated by renin release in kidneys (RAS)
**Side effects:**
→ Headache
→ Dizziness
→ Hypotension
72
→ Metoprolol
→ Atenolol
What kind of medication is this?
Beta Blockers
73
What are beta blockers used for?
- Reduce high BP and arrhythmias
- Reduce angina attacks
74
How do beta blockers work and what are side effects?
**Action:**
→ Blockage of beta1-adrenergic receptors in heart
→ Decrease in force of heart contraction
→ Reduce HR
**Side effects:**
→ Dizziness/fainting
→ Fatigue
→ Hypoglycemia
75
What is important when it comes to training intensity in patients that use beta blockers?
→ Heart rate doesn’t increase further → no acceleration or deepening in breathing
→ HR is not reliable to monitor fatigue
→ Use BORG score
76
What kind of medication is Nifedipine?
Calcium Channel Blocker
77
What are calcium channel blockers used for?
- Block movements of calcium ions in cardia muscle tissue
- Vasodilator
78
How do calcium channel blockers work and what are side effects?
**Action:**
→ Reduce cardiac contractility
→ Prophylactic mechanism for angina pectoris
**Side effects:**
→ Dizziness
→ Fainting
→ Headache
79
→ Hydrochlorothiazide
→ Furosemide
What type of medication are these?
Diuretics
80
What are diuretics used for?
- Treat high BP
- Treat congestive heart failure
- Reduce retention
81
How do diuretics work and what are side effects?
**Action:**
→ Removal of excessive sodium and water from body through kidneys
→ Blocking reabsorption
→ Increase urination
→ Decrease blood volume
→ Decrease oedema
**Side effects:**
→ Nausea
→ Diarrhoea
→ Dizziness
82
How do adrenergic blocking drugs work?
- Act directly on sympathetic nervous system in the brain
→ Blockage of peripheral alpha1-adrenergic receptors
→ Direct vasodilation
83
→ Aspirin
→ Warfarin
What type of medication are these?
Blood Thinners
84
What are blood thinners used for?
- Treat high BP
- Tackle congestive heart failure
85
How do blood thinners work and what are side effects?
**Action:**
→ Risk reduction of blood clots forming in coronary arteries or damaged heart valves
→ Prophylaxis for thromboembolism
**Side effects:**
→ Aspirin: stomach irritation, allergy
→ Warfarine: heavy bleeding (can be controlled by vitamin K)
86
Simvastatin
What type of drug is this?
Cholesterol lowering drug
87
When are cholesterol lowering drugs used?
In case exercise and diet can’t lower cholesterol
88
How do cholesterol lowering drugs work and what are side effects?
**Action:**
→ Reduction of cholesterol (LDL) by blocking synthesis in liver
**Side effects:**
→ Digestive problems
89
How does digoxin work and what are side effects?
**Action:**
→ Reduce pulse conduction through AV-node
→ Reduce HR
→ Increase heart contraction force → efficiency improvement
**Side effects:**
- Nausea
- Fatigue
- Headache
- Weakness
90
What is digoxin used for?
→ Cardiac glycosides
- Treat congestive heart failure
- Treat atrial arrhythmias
91
What should patients who use digoxin be checked for regularly?
Signs of toxicity
92
Salbutamol (Ventolin) is an example of what type of medication?
SABA short-acting beta-2 agonist
Short acting bronchodilator
93
Ipratropium (Atrovent) is an example of what type of medication?
SAMA short-acting muscarinic antagonist
Short acting bronchodilator
94
How do short-acting bronchodilators work and what are side effects?
**Action**:
→ Relaxation of bronchial smooth muscle tissue
→ Opening airways for easier breathing
→ Symptomatic treatment of exacerbations
**Side-effects**:
- Dry mouth
- Headache
- Cough
- Tremor
- Nervousness
- Tachycardia
95
What does SABA stand for?
short-acting beta-2 agonist
96
What does SAMA stand for?
short-acting muscarinic antagonist
97
Formoterol, Salmeterol
What types of medication are these?
LABA long-acting beta2-agonist
Long acting bronchodilators
98
Tiotropium
What type of medication is this?
LAMA longe-acting muscarinic antagonist
Long acting bronchodilator
99
What does LABA stand for?
long-acting beta2-agonist
100
What does LAMA stand for?
long-acting muscarinic antagonist
101
How do long-acting bronchodilators work and what are side effects?
**Action:**
→ Relaxation of bronchial smooth muscle tissue
→ Opening the airways for easier breathing
→ Symptomatic treatment of exacerbations
**Side effects:**
- Dry mouth
- Dizziness
- Tremor
- Running nose
- Irritated throat
- Upset stomach
102
→ Flucticasonpropionaat
→ Prednisone
What type of medication are these?
Corticosteroids for pulmonary patients
103
What are corticosteroids used for in lung patients?
For inflamed, swollen, irritated airways
104
How do corticosteroids in lung patients work and what are side effects?
**Action:**
→ Reduce inflammation and make breathing easier
**Side effects:**
- Irritation and dryness of nasal mucosa
- Slight nose bleed
- Headache
- Prednisone: weakness, upset stomach, weight gain
105
When should oxygen supplementation be initiated?
- When hypoxemia is suspected
- With peripheral oxygen saturation ≤ 92%
- With oxygen saturation during exercise below 90%
106
Which part of a normal cell carries all the organelles for metabolism?
Cytoplasm
107
Which part of a normal cell carries the DNA?
Nucleus
108
What is the normal process of cell reproduction and growth called?
Mitosis
109
How is mitosis regulated?
- Regulated by:
→ Growth factors like cytokines that signal proliferation
→ Inhibitors that prevent overgrowth
- DNA controls growth and reproduction
110
What does an accumulation of cell mutations lead to?
cancer
111
What is apoptosis ?
Programmed cell death
112
What are characteristics of neoplasms?
- Cell growth does not respond to bodily control systems anymore
- Tumor
- Continuous reproduction and cells have unique appearance
- Cells are not functioning and take up lots of space
- Lots of nutrient supply required
113
- Age
- Hormones
- Heredity
- Viruses
- Comorbidity
- Smoking
- Alcohol
- Chemicals
- Radiation
- Food
These are risk factors for the development of which pathology?
Cancer
114
What is the root of the term for a tumour in fatty tissue?
Lip-
115
What is the root of the term for a tumour in gland tissue?
Adeno-
116
What is the root of the term for a tumour in fibrous tissue?
Fibro-
117
What is the suffix for a benign tumour?
-oma
118
What is the suffix for a malignant epithelial tissue tumour?
-carcinoma
119
What is the suffix for a malignant connective tissue tumour?
-sarcoma
120
Slowly growing expanding
Surrounded by capsule
Relatively normal cells
What type of tumour is this?
Benign
121
Rapid growth
Irregular shape and surface
Tissue and blood vessel invasion
Necrosis
Abnormal cells
What type of tumour is this?
Malignant
122
What is a different term for primary tumour in malignant tumours?
Mother tumour
123
What is meant by invasion of a malignant tumour?
- Local distribution
- Tumour growth into adjacent region
- Release of lytic enzymes to break down tissue
124
What is meant by metastasis of a malignant tumour?
- Distribution to more distant areas
- Erosion → transport through blood/lymph vessels
- Often also in lungs or liver
- Creates new locations of cancer tumours
125
What is meant by seeding of a malignant tumour?
- Spread through tissue fluids or membranes
126
What is meant by "in situ" in cancer cells?
neoplastic cells in pre-invasive stage of cancer that can easily be diagnosed and treated
develop very slowly over years
127
What is the most accurate way to diagnose cancer?
Biopsy of tumour cells and combining diagnostic tests like markers and imaging are most accurate
128
What is examined when tumour markers are checked?
Substances produced by neoplastic cells are examined
129
What is the TNM-system and what does TNM stand for?
- Classified during diagnostics
- Basis for treatment and prognosis
- Identifies extend of illness
- Often a subgroup for cancer type
**TNM-System:**
- **T** - Size of the tumour
- **N** - Extend of regional lymph node involvement
- **M** - Spread of tumour → Invasion, Metastasis
130
- Single therapy or combination
- Causes mutations or changes in DNA
- Mitosis is stopped and cell death occurs
- Cutting off blood supply to tumour
- Also normal cells are damaged
This occurs in which cancer treatment?
Radiotherapy
131
→ Bone marrow suppression
→ Epithelial cell damage
→ Genital damage
→ Non-specific fatigue
→ Depending on dose and penetration
These are short or long term effects of which cancer treatment?
Short term effects of Radiotherapy
132
→ Fibrosis
→ Skin discolouration
→ Fatigue
→ Organ damage
→ Depending on dose and penetration
These are short or long term effects of which cancer treatment?
Long term effects of Radiotherapy
133
- Single therapy or combination
- Most effective in small tumour masses
- Usually 6 weeks after surgery to enable wound healing
- Usually combination of 2-4 drugs
- Inference with DNA duplication and protein synthesis
What type of cancer treatment is this?
Chemotherapy
134
→ Bone marrow suppression
→ Nausea, vomiting
→ Epithelial cell damage
→ Unique damaging effects (fibrosis of lungs)
→ Depending on type of treatment
These are short or long term effects of which cancer treatment?
Short term effects of Chemotherapy
135
→ (Chronic) fatigue
→ Polyneuropathy
→ Heart failure
→ Infertility
→ Depending on type of treatment
These are short or long term effects of which cancer treatment?
Long term effects of chemotherapy
136
When is a patient "cured" of cancer?
After 5 years without recurrence
137
What are typical parameters for exercise therapy with cancer patients?
- 50-80% of VO2max
- Borg score 12-14 (6-20 scale)
- Resistance Training: 2-4sets, 6-12 reps, 50-85% of 1RM
138
What do the alpha cells in the islets of Langerhans produce and for how much of the molecules in the islets do they make up for?
Production of glucagon
approx. 20% of cells
139
What do the beta cells in the islets of Langerhans produce and for how much of the molecules in the islets do they make up for?
Production of insulin
Approx. 80% of cells
140
Which cells produce somatotastin?
d-cells
141
What does insulin have NO effect on?
- Transport of glucose to brain cells
- Glucose absorption in intestines
- Skeletal muscle during normal exercise
142
What does insulin have an effect on?
- Skeletal muscle with excessive exercise
→ Blood glucose depletion leads to hypoglycaemia
143
Metformin
What is this medication used for?
DMT2
144
How does metformin work?
- Reduction of insulin resistance
- Reduction of glucose production
- Increase of insulin demands in muscles
→ better absorption of glucose and decrease of blood glucose
- Reduction of diabetic symptoms
145
What are side effects of metformin?
- Nausea
- Vomiting
- Dry mouth
146
With which drugs does metformin interact?
- ACE inhibitors → can further lower blood glucose
- Diuretics → can adversely effect kidney function
147
Gliclazide / Repaglinide
What are these drugs used for?
DMT2
148
How does Gliclazide / Repaglinide work?
- Increase of insulin secretion in pancreas
- Lowers blood glucose
149
What are side effects of Gliclazide / Repaglinide?
- Weight gain
- Hypoglycaemia
- Blurred vision
- Gastrointestinal complaints
150
With which drugs can Gliclazide / Repaglinide interact?
- Can be enhanced by ACE inhibitors
- Can reduce beta2 agonist function
- Can interact with beta blockers who mask hypoglycaemia
151
- Insulin replacements
- Insulin pen
- Insulin pump
- Biosynthetic form of insulin
When are these used as treatment?
DMT1
152
What are the 3 types of insulin used in DMT1 patients?
- Fast acting insulin (injection in abdomen)
- Intermediate insulin
- Long acting insulin (injection in leg)
153
- Humiline NHP
- Insulatard
- Insuman Basal
These are examples of what?
Insulin manufacturers
154
With which drugs can insulin supplements interact?
- Can be enhanced by ACE inhibitors
- Reduced effect by diuretics
- Can interact with beta blockers who mask hypoglycaemia
155
What is diabetic ketoacidosis and what type of diabetes is affected?
- Common in DMT1
- Insufficient insulin supply → blood glucose too high
- Develops over several days and often initiated by:
→ Infection, stress, dosage error, overeating or alcohol
156
- Dehydration
- Deep and rapid breathing
- Acetone breath (fruity odor)
- Metabolic acidosis (can lead to loss of consciousness)
- Electrolyte imbalance (can lead to cramps, nausea etc.)
These are signs and symptoms of?
Diabetic Ketoacidosis
157
What is Hyperosmolar Hyperglycaemic Non-Ketonic Coma and which diabetes type is mainly affected?
- Common in DMT2
- Often elderly with infection
- Often over-intake of carbs → more insulin required than expected
- Relative insuline deficiency
- Hyperglycaemia
158
What does Hyperosmolar Hyperglycaemic Non-Ketonic Coma lead to?
Leads to dehydration which leads to:
→ Neurological deficits
→ Muscle weakness
→ Difficult speech
→ Abnormal reflexes
159
What is Microangiopathy?
- Thick and hard basement membrane
- Obstruction and/or tearing of capillaries and small arteries
- Tissue necrosis
- Can lead to nefropathy or retinopathy
CHRONIC COMPLICATION OF DM
160
What can macroangiopathy lead to?
- Atherosclerosis
- Wounds
- Amputation
CHRONIC COMPLICATION OF DM
161
Where is Adrenocorticotropic hormone (ACTH) released and what is its function?
- Origin: Adenohypophysis
- Function: Stimulates adrenal cortex to primarily secrete cortisol
162
Where is Antidiuretic hormone (ADH, or vasopressin) released and what is its function?
- Origin: Pituitary gland (posterior lobe/neurohypophysis)
- Function: Increases reabsorption of water in kidneys
163
Where is Insulin released and what is its function?
- Origin: beta cells of pancreas
- Function: Transport of glucose and other substances into cells; lowering of blood glucose
164
Where is Glucagon released and what is its function?
- Origin: alpha cells of pancreas
- Function: Glycogenolysis in liver; increasing blood glucose level
165
Where is Aldosterone released and what is its function?
- Origin: Adrenal cortex
- Function: Increases sodium and water reabsorption in the kidneys
166
Where is Cortisol released and what is its function?
- Origin: Adrenal cortex
- Function: Anti-inflammatory and decreases immune response; catabolic effect on tissues; stress response
167
Where is Norepinephrine released and what is its function?
- Origin: Adrenal medulla
- Function: General vasoconstriction
168
Where is Epinephrine released and what is its function?
- Origin: Adrenal medulla
- Function: Stress response; visceral and cutaneous vasoconstriction; vasodilation skeletal muscle; increase of HR and contraction force; bronchodilation
169
What are the categories of mental disorders concerning depression?
Endogenous and exogenous
170
What are characteristics of a unipolar endogenous mental disorder?
- Diagnosis based on biological factors and personal characteristics
- Etiological factors involved:
- Genetics
- Development
- Psychosocial stressors
171
What are charactersitics of a unipolar exogenous mental disorder?
- Response to a life event
- Secondary to systemic conditions
172
What are characteristics of a bipolar depression disorder?
Alternating periods of depression and mania
173
What is the pathophysiology of a depression?
Decreased activity of excitatory neurotransmitters
→ Like norepinephrine and serotonin
174
What are components of non-medicinal treatment of depressions?
- Psychological treatment
- Psychotherapy
- Cognitive behavioural therapy (CBT)
- Interpersonal therapy (IPT)
175
What does the medicinal treatment of depressions consist of?
- Antidepressants
→ Increase norepinephrine activity
→ Good calculation of doses and keeping in mind interactions with other drugs very important
176
What is the factor for calculating the mg/dL value if you have the mmol/L value and vice versa for blood glucose levels?
to calculate mg/dL x18,016
to calculate mmol/L :18,016
177
What is the factor for calculating the mg/dL value if you have the mmol/L value and vice versa for cholesterol levels?
to calculate mg/dL :0,0259
to calculate mmol/L x0,0259
