W21 - Diabetes CPC

Question 1

Which one is increased in a patient with Paget’s disease of the bone?

Answer 1

C) Alkaline phosphatase (ALP)

Question 2

Which one is increased in a patient with osteomalacia?

Answer 2

C) Alkaline phosphatase

(osteomalacia => lack of vitamin D => rise in PTH (2ndary hyperPTH) due to low calcium => increase bone formation and hence turnover => high ALP)

Question 3

Which one is increased in a patient following an acute MI?

Answer 3

D) AST

Heart muscle releases firstly troponins, CK (MB), then AST, then LDH (in order of highest [] to lowest [])

Question 4

Which one is raised in Addison’s disease?

Answer 4

Potassium

Question 5

Which one of the above is most increased in a patient with jaundice caused by a gallstone?

Answer 5

C) Alkaline phosphatase (OBSTRUCTIVE JAUNDICE)

• AST and ALT might also be raised, but ALP will be v high!

Question 10

What does this CXR show?

Answer 10

huge hilar lymph nodes on both sides = Bilateral hilar lymphadenopathy

Question 11

What does this CXR show?

Answer 11

Bilateral hilar lymphadenopathy

Question 13

Which one is most increased in a patient with jaundice caused by viral hepatitis?

Answer 13

ViraL = ALT (B)

ALT wins over AST in VIRAL hepatitis

Question 14

Which one is most increased in a patient with jaundice caused by chronic alcoholic cirrhosis?

Answer 14

D) Aspartate amino transferase (AST)

In alcoholic cirrhosis, you’ve got high AST, ALT, GGT but the HIGHEST in a chronic alcoholic cirrhosis will be AST

Question 15

Which one is most increased in a patient with prostatic carcinoma?

Answer 15

A) Acid phosphatase (we’ve now changed the name to prostate specific antigen/PSA)

Question 16

45 year old Afro-Carribean man presents with dyspnoea. Which is the most helpful investigation?

A) FBC

B) U&E

C) CXR

D) ECG

E) Echocardiogram

Answer 16

C) CXR

although all are useful, a CXR can pick up or exclude many possible diagnoses

if pt was orthopnoiec, E) echo would’ve been more useful to investigate HF

Question 19

45 year old Afro-Carribean man presents with dyspnoea. His calcium is 2.82 (2.20-2.60).

• What do you think he has?
• What result do you expect from his PTH?
• What is his treatment plan?

Answer 19

• What do you think he has? sarcoidosis
• What result do you expect from his PTH? suppressed to undetectable levels
• What is his treatment plan? steroids (which will normalise both the calcium and treat the lung problem)

Question 20

How does sarcoidosis cause hypercalcaemia?

Answer 20

Sarcoidosis is a systemic disease where macrophages express 1 alpha hydroxylase

Question 21

48 year old female unconscious.

• Acutely unwell a few days, Vomiting, Polyuria and polydipsia, Breathless, Dehydrated.
• Examination: obese, very dehydrated
• BP 80 / 40
• Urine dipstick: 4+ glycosuria

ABG: pH 7.65, PCO2 = 6.1 kPa (N 4.7-6.0), PO2 = 15 kPa

Describe what the ABG shows

Answer 21

pH high

pCO2 high

metabolic alkalosis

Question 22

Name 3 causes of metabolic alkalosis

Answer 22

1. H+ loss (e.g. vomiting)
2. Hypokalaemia
3. Ingestion of Bicarbonate

Question 23

As part of compensation, what happens to ventilation in metbolic alkalosis and why?

Answer 23

metabolic alkalosis inhibits ventilation => CO2 increases => H+ increases (compensation)

Question 24

• Na: 145, K: 2.5, U 40, pH 7.65, Glucose 46.
• Bicarb 55 mM

What is the osmolality ?

Answer 24

•Osmolality = 2(Na+K) + U + G

= 2 (145 + 2.5) + 40 + 46 = 381 mosm/kg

Question 25

What does this renal biopsy show?

Answer 25

Normal, healthy glomerulus!

Question 26

What does this renal biopsy show?

Answer 26

there is damage but you can still see the glomerulus = must be ATN

Question 27

Na: 145, K: 2.5, U 40, pH 7.65, Glucose 46, Bicarb 55 mM

What other information do you need to work out the anion gap ?

A. Creatinine

B. Bilirubin

C. Chloride

D. Magnesium

E. Calcium

F. Phosphate

Answer 27

Anion gap = Na + K + Cl - bicarb

C. Chloride

Question 28

3 causes of longstanding hypokalaemia?

Answer 28

1. GI loss (D&V, fistula)
2. Renal loss (hyperaldosteronism, mineralocorticoid/cortisol excess, diuretics, renal tubular disease)
3. Redistribution (insulin, alkalosis, beta-agonists)

Question 29

• Longstanding hypertension and diabetes
• Previous fractured hip
• Slowly worsening obesity.
• Wound on shin that did not heal

What is the diagnosis ?

A. Cystic fibrosis

B. SLE

C. Cushing’s syndrome

D. Sjogren’s

E. Osteoporosis

Answer 29

C. Cushing’s syndrome

Question 30

• ACTH 250 (very high)
• Cortisol 3120 nM (very high)
• Dexamethasone failed to suppress
• Low dose dex: cortisol = 3100 nM
• High dose dex: cortisol = 2990 nM

(totally failed to suppress).

What is the cause?

A. Pituitary Cushing’s

B. Ectopic ACTH

C. Adrenal tumour

Answer 30

B. Ectopic ACTH

Not C because ACTH is high

not A because it would suppress with high dose dexamethasone

Question 31

With an ectopic ACTH release, why would there be severe hypokalaemia?

Answer 31

•Because VERY high levels of cortisol bind to the aldosterone receptor (MR)

Question 32

Sources of ectopic ACTH (2)

Answer 32

1. Lung cancer
2. Other cancers

NB: therefore resp exam warranted

Question 33

Respiratory examination results in someone with suspected ectopic ACTH mass:

• Examination reduced on RIGHT
• Percussion: dull on RIGHT
• Vocal resonance: increased on RIGHT

Diagnosis?

A) pleural effusion

B) pneumothorax

C) collapse and consolidation

D) COPD

E) bronchiectasis

Answer 33

C. Collapse and consolidation

Question 36

• New onset difficulty walking.
• Tone increased on right
• Power reduced on right
• Brisk reflexes on right

Diagnosis ?

A. Right Upper Motor Neurone Signs

B. Right Lower Motor Neurone Signs

Answer 36

right UMN signs