MBBS

spotting- cases
 A 37yr Male came to OPD with
complaints of frequent urination and
excessive feeling of thirst.
 Biochemical investigations:
1.Fasting blood glucose: 8mmoles/L [ 3.5-
7mmoles/L]
2.Post prandial glucose:12mmoles/L [3.5 -
7.8mmoles/L]
3.Sodium: 137 mEq/L (135-145)
4.Potassium: 4.6 mEq/L (3.5-5.0)
5.Urea : 5.8 mmol/L (3.3-7.7)
6.Creatinine:115 µmol/L(60-135)
7.HbA1C: 7.5 % ( < 6.3)
What is the possible diagnosis?
DIABETES MELLITUS
Biochemical basis:
Fasting sugar> 7mmoles/L
Post prandial sugar > 11.1 mmoles/L
HbA1c >6.4 %
 A 20 yrs male was brought in
emergency with headache, nausea
and vomiting .

•
His biochemical finding are as follows:
• Sodium: 130 mmol/L (135-145)
• Potassium: 5.9 mmol/L (3.5=5.0)
• Urea : 5.8mmol/L (2.5-7.5)
• Creatinine:115 umol/L (60-120)
• Glucose: 25mmol/L (F:3.5-6.5)
• Bicarbonate:12 mmol/L (21-28mmoles/L)
• pH= 7.1 (7.3-7.45)
• PCO2=3.1 kPa (4.6-6.0)
• PO2=10.1 kpa (9.3-13.3)
DIABETIC KETOACIDOSIS
• A 35 years old women attending regular
Antenatal checkup at 2nd trimester had done
Glucose challenge test as a screening
investigation showed following result.

• Serum glucose: 13mmoles/L [<7.8]

What is your interpretation if there is no

documentation of prior diabetes in this case?
Biochenical reason> GCT is more than 7.8 mmoles/L[140mg/dl]

GESTATIONAL DIABETES
 A 50 year old business executive
fainted in the middle of a meeting. He
was rushed to emergency room of
hospital in a semiconscious state. On
examination he was found to be
sweating profusely and BP was found
to be 90/50 mmHg
 Biochemical investigations
• Sugar Random - 2.2
2.2 mmol/L
mmol/L( 3.3 -7.8)
• Serum Urea- 4.5mmol/L (3.3-6.7)
• Serum creatinine- 89µmol/L (60-135)
• CK-MB- 12U/L
• Troponin-negative
HYPOGLYCEMIA

Biochemical reason:
blood glucose < 2.22mmoles/L [40mg/dl] is
symptomatic hypoglycemia
• During the period of a total textile mill strike
one of the employee was brought to the
hospital in an unconscious state. Following
were the laboratory findings.
• Blood sugar : 2.7 mmole/L
• Blood pH : 7.25
• Serum HCO3- : 15mmoles/L [21-28mmoles/L]
• Rothera’s test with urine : +ve
Biochemical reason:
1. Low blood glucose
2. Ketone bodies positive indicated by rothera’s
test
3. Blood pH acidotic
4. Serum bicarbonate low
STARVATION KETOACIDOSIS
A 25 yr/ M came to OPD complaining
of excessive moistness on his skin and
heat intolerance. He has lost his
weight inspite of normal appetite.
• His biochemical findings:
• Glucose (F) : 6.0mmol/L ( 4.5- 5.9)
• TSH: < 0.1mIU/L ( 0.6- 4.5)
• fT3: 6.0 pg/mL (1.2-4.2)
• fT4: 25.4 pg/mL (7.2-17.2)
• What is the probable diagnosis?
Biochemical reason:
High concentration of thyroid hormones and low TSH
High level of thyroid hormones supress the TSH secretion

THYROTOXICOSIS/
HYPERTHYROIDISM
A 23 yr girl came to Medical OPD
with complain of Irregular
Menstrual cycle, constipation, cold
intolerance , dry skin, and gain of
some weight.
 on investigations
• Glucose (F) : 5.4 mmol/L (4.5- 5.9)
• TSH: >55.0mIU/L ( 0.6- 4.5)
• fT3: 0.4 pg/mL (1.2-4.2)
• fT4: 3.5 pg/mL (7.2-17.2)
• What is the probable diagnosis?
HYPOTHYROIDISM
 On the suspected case of endocrine
disorder, the thyroid function test
showed following result.
• TSH: <0.1mIU/L ( 0.6- 4.5)
• fT3: 2.2 pg/mL (1.2-4.2)
• fT4: 2.5 pg/mL (7.2-17.2)
• What might be the probable diagnosis on the
basis of this findings ?
SECONDARY HYPOTHYROIDISM
A 10 year old boy was admitted to hospital with
generalized oedema, frothy urine.
In the lab after centrifugation of blood, Serum
was found to be milky white.
 Biochemical report was as the
followings
• Serum glucose: 5.0 mmol/L (F:4.5 -5.9)
• Potassium: 4.0 mEq/L(3.5-5.2)
• Sodium: 135 mEq/L(135-146)
• Urea -4.0 mmol/L (3.3-6.7)
• Creatinine -100 micromol/L (60-135)
• Total protein- 45gm/l ( 60-80)
• Serum albumin- 20gm/l (35-50)
• Serum cholesterol = 14.5 mmole/ L (< 5.1)
• 24hrs urinary protein = 4.0 gm/day.
 Biochemical reasoning:
Hypoproteinemia in blood
Proteinuria more than 4G/L
Hypercholesterolemia
hypertrigyceridemia

Write the possible diagnosis?

NEPHROTIC SYNDROME
 A 35 year old male came to emergency
with complaints of passage of 10-12
episodes of loose stool within the last 24
hours along with history of vomiting, and
decreased urine output.
Investigation
• Sugar (R)-5mmol/L (3.3 - 7.8)
• Sodium-140mEq/L (135-146)
• Potassium-4.2mEq/L (3.5-4.6)
• Urea-25 mmol/L 3.3-6.8)
• Creatinine-140 µmol/L (60-125)
• What is the possible diagnosis?
ACUTE RENAL FAILURE
A 65 year old female came on OPD
with complaints of malaise,
tiredness and wt. loss over the
previous 6 months and decrease
urine output.
 investigations
• Sodium- 130mEq/L (135-146)
• Potassium- 5.2mEq/L (3.5-5.2)
• Urea- 26 mmol/L (3.3-6.7)
• Creatinine- 650µmol/L ( 60-125)
• Sugar (R)- 6.0 mmol/L (3.3-7.8)
• Calcium-1.6mmol/L (2.1-2.6)
• Phosphorous- 5.6 mg/dL (2.5-4.8)
• Total protein-62gm/L (60-80)
• Serum Albumin-33gm/L (35-50)
What is the possible diagnosis?

CHRONIC RENAL FAILURE

A 40yrs male came to medical OPD
with complaint of abdominal pain,
fever,nausea and yellow
discoloration of skin.
 Biochemical investigations
• Serum Biliburin:
T-50µmol/L ( 3-21)
Direct-12 µmol/L (upto5)
• Total protein-65gm/L (60-80)
• Albumin-42gm/L (35-50)
• ALT-1560U/L (<45)
• AST-1320U/L (<35)
• Alp-300U/L (<306)
• Gamma GT- 80U/L (< 80)

What may be the possible diagnosis ?

ACUTE HEPATITIS
 A 57-yr male was brought to
Emergency Department with the acute
chest pain and pain radiating to the
left upper arm

His investigations show the following features.

• CPK total: 240 U/L (<170 U/L)
• CPK-MB: 76 U/L (<25U/L)
• AST: 176 U/L (<40 U/L)
• Troponin I: Positive
What is the probable diagnosis?

MYOCARDIAL INFARCTION
 A 35 years old female came to
OPD of TUTH because of skin
pigmentation, obesity, moon face,
hypertension and muscle weakness

Her biochemical findings are as follows:

 investigations
• Sodium: 144 mmol/L(135-145)
• Potassium: 2.9 mmol/L(3.5-5.2)
• Urea : 5.8mmol/L (2.5-7.5)
• Creatinine:115 umol/L(60-120)
• Glucose: 12.5mmol/L(F:3.5-6.5)
• 09.00 hr cortisol: 969 nmol/L(180-720)
• 24 hr urine free cortisol:1700nmol/L(100-350)
CUSHING SYNDROME
 A 19 yr/ F from Kavre district
presented to the OPD with
complaints of headache, weakness
and amenorrhea. Her routine
investigation of blood sugar, kidney
and liver function were normal
Other biochemical findings are as follows
 Hormone assaty

LH: 0.46mU/L (1-25)

FSH: 0.87mU/L (1-15)
09.00 hrs cortisol: 56nmol/L (180-720)
Prolactin: 30 mU/L (50-400)
TSH: 0.6µIU/mL (0.6-4.5.0)
Free T4: 12.4pgm/mL (12-25)
Free T3: 3.4pgm/mL (1.2 – 4.2)
What will be probable diagnosis?
PANHYPOPITUITARISM
A 60 yrs male came to the emergency
with an acute abdomen, severe
epigastric pain and nausea .On
examination ,he was found to be
hypertensive and showing abdominal
guarding. Some of his laboratory
finding are as follows:
 Investigations
• Sodium: 135 mmol/L(135-146)
• Potassium: 5.0 mmol/L(3.5-5.2)
• Urea : 7.0 mmol/L(3.3-6.8)
• Creatinine:125 umol/L(60-135)
• Glucose: 6.0 mmol/L (F: 3.5-6.5)
• Calcium: 2.0 mmol/L(2.1-2.55)
• Triglyceride: 1.3mmol/L (<2.3)
• Amylase: 2800 U/L(<200)
• What would be possible cause of the above
findings?
ACUTE PANCREATITIS
A 24 year female developed Mild
jaundice after fasting of 2 days
when celebrating the traditional
festival.
 investigations
• Serum bilirubin-60µmol/L (3-21)
• ALP-74U/L (<306)
• AST-34U/L (<40)
• Hb-normal
• Reticulocytes - normal
• Urine Bilirubin – negative
• What may be the possible diagnosis?
GILBERT SYNDROME
A 36 year old male had the history
of yellowish discoloration of sclera
and skin since 2 weeks.
 investigations
• Serum Biliburin:T-150 µmol/L ( 3-21) D-
78µmole/L (upto 5)
• Total protein-51gm/L (60-80)
• Albumin-24gm/L (35-50)
• ALT-56U/L (< 45 U/L)
• AST-74U/L (< 40 U/L)
• ALP- 410U/L (< 306 U/L)
• Gamma GT-88U/L (< 60 U/L)
• What is the possible diagnosis?
LIVER CIRRHOSIS
 A 45 year male ,known case of
HTN, came to OPD with
complaints of muscle weakness
and frequent urination at night.
 Investigations
• Serum glucose (F): 4.5mmol/L(3.5-6.5)
• Potassium: 3.0 mmol/L(3.5-5.2)
• Sodium: 146 mmol/L(135-146)
• Serum calcium -1.8mmol/L (2.1-2.6)
• Serum Aldosterone level- 2.5nmol/L (0.1-0.9)

• What is the possible diagnosis.

CONNS DISEASE
 A 54 year old male presented to
Medical OPD with joints pain and
mild fever since last 3 months,the
joint pain is most prominent in first
metatarsophyreangel joint
 investigations

• Urea -5.6 mmol/L (3.3-6.8)

• Creatinine-100µmol/L (60-135)
• Serum Uric Acid -570 µmol/L (220-450)
•
• What is your provisional diagnosis?
GOUT
 A 26yrs female came to medical
OPD with complaint of easy fatigue
and tiredness.There was a history
of menorrhagia.She lookes slightly
pale on examination.

• Her investigations were as follows

• Hb:10G/dl
• Iron: 35 mcg/dl [ 37-147mcg/dl]
• TIBC: 525 mcg/dl [200-400 mcg/dl]
• Ferritin: 20ng/ml [14-203 ng/ml]
IRON DEFICIENCY ANEMIA
A 28 years old man with multiple injuries in road
accident had the following biochemical findings:
• Sugar: 3.3mmole/L
• Urea: 7.9mmole/L
• Creatinine: 120μmole/L
• Sodium : 147meq/L
• Potassium: 5.3meq/L
• CPK: 1410U/L
• LDH: 495U/L
What is the diagnosis?
MUSCLE
INJURY[RHABDOMYOLYSIS]
State the acid-base status of the patient from
given data in following cases.
• Blood pH : 7.55
• pCO2 : 20mm of Hg ( 35 – 45 mm Hg)
• HCO3 : 27 mmoles/L (21-28mmoles/L)
RESPIRATORY ALKALOSIS
A 34years male with chest injury in road
accident showed the arterial blood gas
analysis as follows:
• pH:7.18
• pCO2: 62mm Hg ( 35 – 45 mm Hg)
• HCO3: 26mmoles/L (21-28 mmoles/L)
What is the diagnosis?
RESPIRATORY ACIDOSIS
A 40 yrs male suspected of meningitis had lumber
puncture done. His CSF findings showed following
results. What is your opinion? What will happen
to CSF protein and sugar in case of meningitis?

• Appearance : clear
• Cells: 3 Lymphocytes/mm3 [ 0-5 Lymphocytes]
• CSF protein: 4G/dL [1.5 -4 G/dL]
• CSF Glucose : 3mmoles/L [2.2 -3.3 mmoles/L]
NORMAL CSF
A patient was admitted with acute abdominal
pain.
• Serum amylase = 1500IU/L (150 – 340 U/L)
• Serum lipase = 1000 U/L (<60U/L)
• Urine lipase = ↑
ACUTE PANCREATITIS
A 24 years male had a history of eating out in
local restaurants.Now he came with pain right
upper quadrant and having nausea and
vomiting.diagnose the case from the following
findings.
• Total bilirubin:34micromoles/L
• Direct bilirubin: 17micromoles/L
• SGPT:1000U/L [<40]
• SGOT:1000U/L [<40]
• ALP: 235U/L [<460]
• Gamma GT: 12 U/L [<30]
HEPATITIS
A newly born infant had the biochemical
investigations as below.What is your probable
diagnosis.
• Total bilirubin:40micromoles/L
• Direct bilirubin: 7micromoles/L
• SGPT:25U/L [<40]
• SGOT:25U/L [<40]
• ALP: 435U/L [<460]
PHYSIOLOGICAL JAUNDICE
A 34 years female had a history of pain right upper
quadrant and having nausea and vomiting. On
examination showed jaundice .USG abdomen
showed stones in gall bladder.diagnose the case
from the following findings.
• Total bilirubin:40micromoles/L
• Direct bilirubin: 30micromoles/L
• SGPT:60U/L [<40]
• SGOT: 50U/L [<40]
• ALP: 935U/L [<460]
• Gamma GT: 35 U/L [<30]
OBSTRUCTIVE JAUNDICE
A 32years old women is willing for 2nd child since
last year; she had her first baby 4 years back
and was taking OCP in between. She
complained of inability to conceive. Her lab
investigation are as follows: intercept.

• Prolactin: 92 μg/ml (3.3-24.5μg/ml)

• FSH: 0.7μU/ml ( 3.2-10 5μg/ml – proliferative
phase)
• LH : 1.1 μU/ml ( 1.2 – 12.575μg/ml –
proliferative phase)
INFERTILITY SECONDARY TO
HYPERPROLACTINEMIA
A 47 year old male presented with
history of Persistent localized low
back pain, fatigue , weight loss.
There is the past history of
fractures of verterbrae.
• Sugar(R): 5.8 mmol/L ( upto 7.8)
• Urea: 4.5 mmol/L ( 3.3-6.8)
• Creatinine: 100 µmol/L (60-135)
• Total Protein: 98 gm/L (60-80)
• Albumin: 48gm/L (35-50)
• Serum calcium- 2.80 mmol/L (2.1-2.6)
• Serum Electrophoresis: Monoclonal band seen
• Urine: Bence Jones Proteins present
electropherograms
MULTIPLE MYELOMA
Electrophoretic Strip following Staining:

Sample H2
(urine)

Control sample
(serum)

Sample H1
(serum)
Nephrotic syndrome:
 Nephrotic Syndrome
Decreased albumin
Increased 2-macroglobulin
Decreased gamma globulins

Albumin 1 2  
A 40 yrs female with high grade fever and vomiting
was admitted in medical ward for
evaluation.There was neck rigidity in CNS
examination.Her CSF findings showed following
result. Give your provisional diagnosis with
biochemical reasoning.

• Appearance : turbid
• Cells: 300 polymorphonuclear cells /mm3 [ 0-5
Lymphocytes]
• CSF protein: 20G/dL [1.5 -4 G/dL]
• CSF Glucose : 2 mmoles/L [2.2 -3.3 mmoles/L]
Bacterial meningitis

BACTERIAL MENINGITIS
• Gullian Barre syndrome
• 8.A 24 year female in the end of 2nd trimester
presented with peripheral and perioral tingling
sensations, muscle spasms, carpopedal spasm.
The following are the biochemical parameter.
• Serum blood sugar (R)-4.5mmol/L ( up to7.8)
• Serum Calcium-1.8mmol/L ( 2.1-2.6)
• Serum Potassium -3.8 mEq/L (3.5-5.2)
• Serum Sodium-137 mEq/L (135-146)
• Serum Albumin -40gm/L (35-50)
• What is the probable diagnosis?
• Hypocalcemia, because of increased demand
in pregnancy
• A 22-year-old male, admitted in the surgical ward for
evaluation of acute pain abdomen without vomiting and
abdominal distention and referred for status epilepticus.
• the urine sample collected last night turned red in the
morning.
• Liver function tests were normal.
• Initial blood and urine cultures were sterile .
• However Urine was positive for porphobilinogen but
coproporphyrinogen was negative.
• What is your diagnosis?
• Which enzyme is deficit in this case?
Enzyme deficit: uroporphyrinogen I synthase

ACUTE INTERMITTENT PORPHYRIA

• transudate
• A 64 years chronic smoker came with
shortness of breath for 3 days. He was
suspected of respiratory failure.ABG was sent
which showed the following results. Interpret
the case with biochemical reasoning.
• pH:7.2, PCO2: 80mmHg, HCO3:34mmoles/L,
O2 saturation: 75 %
Repiratory acidosis
• 2.A 50yrs male admitted in medical ward with
decreased urine output.Today he complained of
weakness and feeling of syncope.On examination
Pulse was normal but rhythm was irregular.Bedside
ECG showed arrhythmia of heart differing from his
previous ECG report.His file showed following
biochemical report.Interpret the case with
biochemical reasoning.
• Urea:10mmoles/L,Creatinine:400micromoles/L,Calciu
m:1.4mmoles/L,Phosphorus:10mg/dl,
• Sodium:135mmoles/L, potassium:8mmoles/L
• hyperkalemia
ORAL GLUCOSE TOLERANCE TEST
• malignancy
• osteomalacia
 Instruments:

• Centrifuge
• PH electrode
• Weighing balance
• Dispenser
• Pipet
• Colorimeter filter
 reagents
• Biuret reagent
• Mixed acid reagent
• Mixed color reagent
• Bromocresol green dye
• Starch buffer
• Iodine solution