Module 10 Exam Flashcards
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.
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
- 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)
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.
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.
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.
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..
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.
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.
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.
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
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
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
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.
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
- 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.
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.
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.
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)***
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
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.
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.
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.
- 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.
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.
- 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.
- 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.
