THE ROYAL COLLEGE OF PATHOLOGISTS: Part 1 Examination in Clinical Biochemistry Practical Examination: Part 4, Spring 2008 Paper 2: Data Interpretation and Calculations Thursday 11° May 2006 9.30- 11.00 am. © Allten questions should be attempted Each question carries the same maximum number of m: Candidates are reminded that examiners attach great importance to the clear, legible and logical presentation of answers Reference to books and notes is not allowed, but simple calculators may be used You should assume that all analytical results have been correctly recorded : Use separate answer books for the case history (1-6) and calculation (7-10) questions Figures in the final column of tables in the case histories are reference intervals ls eco 1. Routine biochemical monitoring of a 75-year old woman, who has type 2 diabetes and mild chronic obstructive pulmonary disease, on the orthopaedic ward following a hip replacement produced the following results: ‘Sodium, 419 | mmol, Potassium 4.1 [mmol Urea 12.5 | mmol/l Creatinine 402 | umow ‘The duty orthopaedic Senior Hoilse Officer, who had recently attended a teaching session on electrolytes and therefore wished to pursue possibis diagnosis of syndrome of inappropriate antidiuretic hormone secretion, requested measurement of osmolality on this specimen and cn a urine sample: ‘Serum osmolality 261 | mOsmikg Urine osmolality 305 [mOsm/kg | a) In the context of the clinical details provided and the serum biochemistry, state three possible contributory factors to her hyponatraemia b) Give an approximate estimate of her serum glucose concentration — is this likely to be responsible for the degree of hyponatraemia observed? ©) What other test would you perform on her urine, and haw would this assist in reaching a diagnosis? d) ts the urine osmolality consistent with a diagnosis of SIADH? © The Royal College of Pathologists2. 90-year old woman who had previously been in good health, had gone off her lags and developed confusion during the last three weeks. Little further history was available although she said she had been constipated but had perhaps been passing urine more frequently than usual. She was on no regular medication. There were no significant findings on examination. Sodium 743 [mmol._[ Calcium 3.70 | mmo Potassium 2.2 | mmol/L | Albumin 30, Urea 10.7 | mmol/L__| Phosphate 0.81 | mmol/L. Creatinine 84 | umol. | Magnesium 0.52 | mmol. Glucose 8.7 | mmol/L. | Alkaline phosphatase 92 | UAL 45 - 180 Alanine aminotransferase_| 33 Uf. [8-40 ‘a) Comment on her calcium and phosphate results in relation to the other biochemical data provided. b) State the two most likely causes for her hypercalcaemia - ‘ 2 Ws logos rrr Ry tbe sented wr typeepnesaeria fuses —_—_ 4d) Describe the mechanism whereby hypokalaemia is directly associated with ‘hypercalcaemia and state one alternative cause of hypokalaemia that should be con: in this case. 3. A28-year-old woman presented with acute abdominal pain. She was obese and had recently been diagnosed with type 2 diabetes. The blood sample obtained on admission was noted to be lipaemic. A clinical diagnosis of acute pancreatitis is being considered. ‘Sodium 123 [mmol Potassium 3.8 | mmol/L. Urea 2.4 | mmol Creatinine * pmol ‘Glucose 17.2 | mmol Amylase = Tun 36-140 * assays not available due to lipaemia a) State three ways in which a biochemical diagnosis of acute pancreatitis could be achieved b) State two contributory causes of the hyponatraemia, state which you think is likely to be - more significant, and indicate one further fest you would perform on the sample to test this hypothesis, ¢) What pattern of dyslipidaemia would you expect to find? State its Friederickson classification, and suggest two investigations that would help to confirm this4, A2t-year-old woman was referred to a gynaecologist for investigation of amenohoea. He found that she was very hirsute and obese (BMI 34 kg/m*), and sent a request for the following tests to the laboratory: [Follicle stimulating hormone 6.1 (UML Luteinising hormone 41.9 [10M estradiol 434 | pmol. Prolactin 428 | mlUA._|_<700 Testosterone 3.0 [nmol | <2.6 a) What is the most likely diagnosis in this case b) Comment on her likely free testosterone level, and state one further biochemistry test ‘that would help to elucidate this, c) The gynaecologist asks you whether her hyperandrogenism could be due to an adrenal tumour. State why this is unlikely on the basis of the available results, and suggest one further biochemical test that could be performed to rule this out. d) What other metabolic abnormality is commonly present in this condition? 5, An eight month old baby girl was taken to the focal Emergency Department with a short history of being drowsy and floppy. She was sweating excessively and was unresponsive to painful stimuli. Sodium 744 | mmol | Bilirubin oT amor Potassium 4.3 | mmolL_| Alkaline phosphatase wre tua, | 175-775 ‘Urea 3.1 mmol. | Alanine aminotransferase_| 35 | UL 10-40 ‘Creatinine ‘37 | umol._| Albumin, 39 [gi ‘Glucose 05| mmol | Free fatty acids 42 {mmor | <0.6 Bhydroxybutyrate: 0.5 [mmol | <0.4 CSF giucose 7.0 [mmol CSF protein B00 [mgit. | 200-700 a) Describe blood results in relation to the clinical presentation b) Describe her CSF biochemistry x. ) Was she ketotic? Describe and interpret her B-hydroxybutyrate and free fatty acid results d) What is the most likely diagnosis? 2) What two further tests would you do to confirm this diagfiosis?