Laboratory diagnosis of carbohydrate metabolism

1
Laboratory diagnosis of carbohydrate metabolism

• Erika Seres MD.
• Department of Clinical Chemistry
• University of Szeged

2
Case 1An elderly unconscious man

• Mr H L, a 72 year old man in a coma, is brought
  to the Accident and Emergency department by
  ambulance. He is seen by the duty doctor who
  takes a history from his son and request some
  investigations.

3
Summary of admission notes

• The patient is a 72 year old West Indian man, Mr
  H L, who has not been seen for 2 days. He had
  been found unconscious on the kitchen floor by
  his son.
• Past medical history
• Hypertension diagnosed recently
• Transurethral resection of prostate with recent
  recurrence of prostatic symptoms
• Drug history
• Bendrofluazide 2.5 mg daily. Long acting
  propranolol 160 mg daily

4

• Family history
• Both parents died in their seventies from strokes
• Younger brother recently developed diabetes
• Social history
• The history was elicited from the son who said
  that his father was a life-long smoker (about 20
  cigarettes per day). The son was concerned about
  his fatherss alcohol consumption which had been
  about cans of strong beer per day but which had
  increased since Mr H Ls wife had died one year
  ago.

5
Examination

• The patient is unconscious with Glasgow Coma
  Scale (GCS) 4/15, dehydrated and pyrexial (37.7
  oC)
• Central nervous system
• No signs of meningism. Loss of muscle tone in the
  right leg and arm, brisk reflexes and an extensor
  plantar reflex on the same side indicating a
  stroke.
• Cardiovascular system
• Blood pressure is 114/60, pulse 108 beats per
  minute. (normal lt100 b.p.m.)

6
Glasgow Coma Scale (GCS)

• Extensive study of the outcomes of patients
  following head injury has allowed the development
  of the GCS, in which the main predictors of
  ultimate outcome are assessed. These parameters
  are eye opening, verbal output and the best motor
  response.
• Eye opening
• 1. Nil 2. To pain 3. To loud voice 4.
  Spontaneous
• Best motor response
• Nil 2. Extension posturing 3. Abnormal flexion
  posturing 4. Withdraws
• 5. Localises 6. Obeys command
• Verbal response
• Nil 2. Incomprehensible sounds 3. Inappropriate
  words
• 4. Confused, disoriented 5. Oriented

7
Examination

• Respiratory system
• No obvious abnormality. Examination difficult in
  a comatose patient but no obvious sign of
  infection.
• Abdomen
• Soft and non-tender with no palpable masses or
  organomegaly.
• There appears to be no evidence of trauma.

8
The duty doctor considers the following
differential diagnosis

• Stroke (cerebrovascular accident)
• Diabetes mellitus
• Poisoning
• Dehydration

9
The AE nurse measures blood glucose

• The nurse, using a glucose meter, measures the
  capillary blood glucose and gets a result of gt 33
  mmol/L

10
Does this single measurement of capillary blood
glucose confirm the diagnosis of diabetes
mellitus?

• Yes
• No
• (Select the correct answer)
• Each correct answer scores one point.
• Each incorrect answer scores -1 point.

11
Preliminary investigations

• The capillary blood glucose result suggest that
  the patient has diabetes mellitus and the duty
  doctor organises the following preliminary
  investigations for confirmation and to act as a
  baseline.
• Plasma urea, creatinine and electrolytes
• Plasma glucose
• Arterial blood gases
• Plasma osmolality
• Blood and urine samples are saved for toxicology
  screen
• Full blood count (FBC)
• Electrocardiogram (ECG)
• Chest X-ray

An intravenous infusion of normal saline is
commenced because of the patients dehydration.
12
Assessment by admitting medical team

• The patient is assessed by a junior member of the
  professorial medical team.
• She confirms the findings of the duty AE doctor
  and notes some additional abnormalities
• Fundoscopy tortuous vessels, silver wiring,
  arterio-venous nipping, flame haemorrhages,
  widespread microaneurysm

13
Assessment by admitting medical team

• The chest X-ray appears normal
• The ECG shows sinus rhythm, rate 116 per minute
  with marked left ventricular hypertrophy
  consistent with long standing hypertension.

14
Look at the laboratory report

• Sodium 159 mmol/L (135-145)
• Potassium 6.4 mmol/L (3.6-5.0)
• Urea 38.0 mmol/L (3.3-5.0)
• Creatinine 267 umol/L (55-120)
• Glucose 69.8 mmol/L (2.8-6.0)
• Osmolality 441 mmol/L (282-295)
• H 53 nmol/L (pH 7,27) (36-44) (pH 7.36-7.44)
• PCO2 4.68 kPa (35 mmHg) (4.5-6) (35-46 mmHg)
• PO2 13.8 kPa (104 mmHg) (11.0-13.9) (85-105
  mmHg)
• Bicarbonate 6.4 mmol/L (22-30)
• Haemoglobin 168 g/L (135-175)
• Haematocrit 56 (40-52)
• WBC 15.6 x 109/L (4-11.0)
• Platelets 550 x 109/L (150-400)

15
What type of acid-base disturbance is present?

• Metabolic acidosis
• Metabolic alkalosis
• Respiratory alkalosis
• Respiratory acidosis
• (Select the correct answer)

16
Which of these calculations of plasma osmolality
approximates best to measured values?

• 2(Na K) creatinine umol/L glucose
  mmol/L
• (Na K) - (Cl- HCO3-)
• 2(Na K) urea mmol/L glucose
  mmol/L
• 2(Na Cl-) urea mmol/L glucose
  mmol/L
• (Select the correct answer)
• The calculated osmolality is 439 mmol/kg which
  compares well with the measured value of 441
  mmol/kg.

17
The admitting teams junior doctor orders further
investigations

• In view of the patients history of alcohol
  consumption, she adds liver function tests to
  admission sample.

18
Summary

• An elderly man who lives alone was admitted
  unconscious
• He is a widower, has been depressed and his
  alcohol consumption has recently increased
• He has hypertension but no previous history of DM
• The differential diagnosis includes stroke,
  diabetes and poisoning
• The initial finding of a raised blood glucose
  suggests the patient has diabetes
• He also has a mild metabolic acidosis

19
Clinical investigations and further findings

• Following the consideration of the initial
  investigations, intercurrent infection and renal
  impairment were added to the initial list of
  differential diagnoses (dehydration, stroke,
  diabetes, poisoning) and a diagnosis of diabetes
  with hyperosmolar non-ketotic coma (HONK) was
  considered the most likely.

20
Overwiew of HONK

• This condition is a complication of type 2
  diabetes it may be presenting feature of
  condition or develop in previously diagnosed
  patients.
• It is characterised by
• -hyperglycaemia (blood glucose may exceed 50
  mmol/L) causing greatly increased plasma
  osmolality and viscosity
• -severe dehydration
• -abscence of ketonaemia
• -abscence of or only mild non-respiratory
  acidosis
• The clinical features include
• -polyuria and polydipsia (though decreased renal
  perfusion secondary to dehydration may lead to
  oliguria in severe cases)
• -dehydration
• -weight loss
• -altered consciousness (from drowsiness to, in
  severe cases, coma)
• Vomiting is not usually a feature of HONK because
  patients are not ketotic.

21
Pathogenesis of HONK

• Hyperosmolar, non-ketotic hyperglycaemia is a
  result of insulin deficiency and/or resistance to
  the action of insulin on adipose tissue appears
  to be reatined in type 2 diabetes such that
  lipolysis and ketogenesis are not stimulated.

22
Diagnosis of HONK

• This is usually straightforward.
• The level of consciousness may be decreased and
  patients are sometimes frankly comatose.
• Dehydration is often severe and is reflected by
  the plasma urea concentration often being
  disproportionately high in relation to
  creatinine.
• Blood glucose concentration is very high, but
  there is no little ketosis or acidosis.
• Hypernatraemia is often present at diagnosis.
  This reflects renal sodium reabsorbtion
  stimulated by severe hypovolaemia, coupled with
  water loss as a result of osmotic diuresis.

23
Management

• Rehydration to prevent cerebral oedema as it is
  important that plasma osmolality does not fall
  too quickly. Even though patients are often
  hypernatraemic, replacement should be with
  physiological saline initially which should be
  given rapidly (unless there is evidence of
  cardiac failure). Blood glucose concentration
  often falls relatively rapidly and plasma sodium
  concentration may increase. This may suggest that
  fluid replacement should be changed to 0,45
  (half-normal saline). However, this may cause
  plasma osmolality to fall too rapidly plasma
  osmolality may be a better guide to the choice of
  replacement fluid than plasma sodium
  concentration.

24
Management

• Constant intravenous soluble insulin infusion.
  Patients with HONK tend to be more sensitive to
  the effects of insulin than patients with DKA,
  but a similar infusion rate (5-10 units/h) can be
  used initially, reduced when necessary, to
  prevent the blood glucose concentration falling
  by more than 5 mmol/L/h.
• Potassium should be replaced as indicated by
  measurement of plasma concentarion. Patients with
  HONK usually require less potassium than patients
  with DKA.
• The use of heparin as an anticoagulant is often
  recommended because of the risk of thrombosis due
  to the very high plasma osmolality.
• Once blood glucose reaches approximately 15
  mmol/L, the infusion fluid is changed to 5
  dextrose to prevent hypoglycaemia. The infusion
  of insulin is reduced and intravenous fluid and
  insulin are maintained until the patient is able
  to drink normally, when carbohydrate can be given
  by mouth.

25
Why was non-ketotic (HONK) coma considered?

• The high plasma glucose
• The abnormal acid base status
• The results of plasma electrolytes
• (Select the correct answer)

26
Why are plasma ketones not significantly raised
in hyperosmolar non-ketotic (HONK) coma?

• Continuing residual insulin secretion
• Urinary ketone loss
• (Select the correct answer)

27
The patient is catheterised and a sample of urine
collected for dipstick and laboratory analysis. A
fluid balance chart is started with hourly
measurements of urine volume. Blood cultures are
taken and treatment is commenced.

• Which of the following treatments would you wish
  the patient to receive?
• Intravenous or subcutaneous heparin
• Intravenous antibiotics
• Intravenous insulin infusion
• Intravenous fluid replacement
• (Select the correct answer)

28
The patient has already received nearly one litre
of normal saline and a further one litre is
prepared for use. Treatment with intravenous
insulin is required.

• Which one of the following insulin preparations
  could you use for this intravenous infusion?
• Human Mixtard 30 (biphasic isophane insulin,
  human)
• Porcine Insulatard (isophane insulin, porcine,
  highly purified)
• Human Actrapid (soluble insulin, human)
• (Select the correct answer)

29
Monitoring of treatment

• Following a bolus injection of 10 units of human
  Actrapid, an infusion is started at a rate of 6
  units/hour. He is then admitted to the medical
  ward.
• An hour later, a more senior member of the
  professorial medical team reviews the patients
  care and decides that a further analysis of
  electrolytes, urea, creatinine and glucose is
  required.

30
Sodium 165 mmol/L (135-145)Potassium 6.3
mmol/L (3.6-5.0)Urea 33.0 mmol/
(3.3-5.0)Creatinine 250umol/L
(55-120)Glucose 62.0 mmol/L (2.8-6.0)
Preliminary investigations

• Sodium 159 mmol/L (135-145)
• Potassium 6.4 mmol/L (3.6-5.0)
• Urea 38.0 mmol/L (3.3-5.0)
• Creatinine 267umol/L (55-120)
• Glucose 69.8 mmol/L (2.8-6.0)

31
On the basis of the biochemical results the
physician decided to change the intravenous fluid
regimen.

• Whivh one of these types of intravenous fluid
  would you consider the best therapy in view of
  the available results?
• Hypotonic saline (NaCl 75 mmol/L) with added
  potassium ( KCl 20 mmol/L)
• Isotonic saline (NaCl 150 mmol/L) with added
  potassium ( KCl 20 mmol/L)
• Hypotonic saline (NaCl 75 mmol/L)
• (Select the correct answer)

32
Further management

• One litre hypotonic saline (75 mmol/L) without
  potassium was given over one hour.
• The results of urinanalysis were
• Urine was noted to be cloudy and red-brown in
  colour
• Ward dipstick analysis glucose , ketones
  trace, protein , blood
• Microscopy gt100 WBC/mm3, No RBCs, Organism
  large numbers

33
On the basis of the urinanalysis results and the
information you already have, which of the
following diagnoses would you consider possible?

• Urinary tract infection
• Diabetic ketoacidosis
• Pre-renal failure due to dehydration
• (Select the correct answer)

34
Further treatment and investigations

• A central venous catheter is inserted to monitor
  central venous pressure in order to guide fluid
  replacement. An urinary tract infection is
  diagnosed and broad-spectrum antibiotics are
  commenced.
• Three hours later the patients condition has
  improved. He now responds to pain and in part to
  verbal commands (Glasgow Coma Scale 8/15) and
  there is some slight improvement in muscular tone
  of his right arm.
• Temperature has fallen to 37.1 oC
• Blood pressure is 160/90 mmHg, pulse 96/min
• Urine output is 110 mL/h

35
Which of the following investigations would you
now request to assist in the management of the
patient?

• Arterial blood gas analysis
• Plasma electrolytes, urea, creatinine
• Plasma glucose
• Plasma CRP (C-reactive protein)
• Plasma osmolality
• Plasma amylase
• Computerised tomogram (CT) of brain
• (Select the correct answer)

36
The patient is reviewed and the following
investigations are requested

• Repeat urea, creatinine and electrolytes
• Plasma glucose
• Computerised tomogram (CT) of brain
• Blood pressure request frequent monitoring

37
Laboratory report

• Sodium 153 mmol/L (135-145)
• Potassium 3.1 mmol/L (3.6-5.0)
• Urea 29.0 mmolL (3.3-5.0)
• Creatinine 296 umol/L (55-120)
• Glucose 56.4 mmol/L (2.8-6.1)
• H 43 nmol/L (pH 7.36) (36-44)
  (7.36-7.44)
• PCO2 3.6 kPa (27 mmHg) (4.5-6) (35-46)
• PO2 16.8 kPa (126 mmHg) (11.0-13.9) (80-105)
• Bicarbonate 15 mmol/L (22-30)

38
Which type of acid disturbance is now present?

• Combined metabolic alkalosis and respiratory
  acidosis
• Compensated metabolic alkalosis
• Compensated metabolic acidosis
• (Select the correct answer)

39
Professorial ward round

• The patient is seen by the professor. He examines
  the patient and explains to the team that on the
  basis of fundoscopic findings his diabetes must
  have been present for severel years.

40
Which of the following fundoscopic features would
have suggested that diabetes had been present for
several years?

• Tortuous vessels
• Arterio-venous nipping
• Flame haemorrhages
• Microaneurysms
• (Select the correct answer)

41
Professorial ward round (continued)

• The professor reviews the results of all
  investigations obtained so far. On the basis of
  his examination and the results of the
  investigations he confirms the diagnoses made by
  his team.
• Type 2 DM complicated by hyperosmolar non-ketotic
  coma (HONK)
• Hypertension
• Renal impairment
• Urinary tract infection
• Thrombotic stroke

42
The professor explains that HONK can be
precipitated by a number of factors, occuring
either alone or in combination. In this patients
case there are several potential factors.

• Which precipitating factor(s) do you think were
  most important in this case?
• Anti-hypertensive drug therapy
• Renal failure
• Thrombotic stroke
• Urinary tract infection
• (Select the correct answer)

43
Further treatment

• The professor asks his team about the type of
  intravenous fluid which should be used. He
  suggests that isotonic saline is continued until
  the patients plasma glucose concentration has
  fallen to 15 mmol/L and then is changed to 5
  dextrose. Potassium should also be added to the
  infusion as the patients plasma potassium
  concentration has fallen from 6.3 to 3.1 mmol/L.
  The medical student on the team asks how the
  potassium concentration can fall so quickly.

44
Which of the following explanations did the
professor give to account for the rapid fall in
plasma potassium concentration?

• The fall in blood glucose concentration following
  insulin therapy
• The rise in arterial H following rehydration
• A promt diuresis following rehydration
• (Select the correct answer)

45
Patient update

• The insulin infusion is continued and potassium
  chloride (20 mmol/L) is added to saline infusion.
  The professor emphasises the importance of
  appropriate potassium replacement in such
  patients and close monitoring of plasma potassium
  concentrations.

46
One day later

• Twenty-two hours after admission the patient is
  conscious, lucid and taking fluid by mouth. The
  CT brain scan requested earlier is reported as
  showing no abnormalities.
• Further investigations are requested and later in
  the morning the results are available together
  with those of liver function requested earlier.

47
Look at the laboratory report

• Sodium 143 mmol/L (135-145)
• Potassium 4.7 mmol/L (3.6-5.0)
• Urea 20.5 mmol/L (3.3-5.0)
• Creatinine 320 umol/L (55-120)
• Glucose 21.3 mmol/L (2.8-6.0)
• Bicarbonate 16 mmol/L (22-30)
• Bilirubin 35 umol/L (3-20)
• Alkaline phosphatase 185 U/L (30-90)
• AST 2120 U/L (lt35)
• Total protein 60 g/L (60-80)
• Albumin 30 G/L (35-50)

48
What did the measurement of chloride allow the
clinical biochemist to calculate?

• Plasma osmolality
• The anion gap
• The osmolar gap
• (Select the correct answer)

(Na K) - (Cl- HCO3-) (143 4,7)
(116 16) 15,7 The reference interval 14-18
mmol/L.
49
Which of the following are associated with
hyperchloraemic (normal anion gap) acidoses?

• Chronic renal failure
• Diarrhoea
• Poisoning with ethylene glycol
• The recovery phase of diabetic ketoacidosis
• Treatment with acetazolamide
• (Select the correct answer)

50
Continuing treatment

• Intravenous isotonic saline with potassium
  chloride (20 mmol/L) is continued until the
  patients blood glucose concentration falls to 15
  mmol/L and is then changed to 5 dextrose with
  potassium chloride (20 mmol/L). The insulin
  infusion is altered according to his blood
  concentration measured at the bedside by the
  nursing staff, who refer to a sliding scale
  provided.
• The urine is still discoloured with a red-brown
  tinge, but not as dark as that previosly.

51
The afternoon ward round

• The professor sees the patient. He notes the
  colour of the patients urine and reviews the
  result of laboratory investigations.
• He quizzes his team as to the possible causes of
  the deranged biochemical results. He then asks
  the laboratory for some futher investigations.

52
Which of the following do you think is
responsible for the patients deranged
biochemical results?

• A cardiac cause
• A muscular cause
• A hepatic cause
• (Select the correct answer)

53
Which of the following statements relating to
cardiac markers are true?

• In the troponin/tropomyosin complex, troponin I
  binds calcium and regulates contraction
• Measurement of serum cardiac troponin T is of
  prognostic value in patients with unstable angina
• Measurement of serum cardiac troponin I alone can
  be used to exclude a diagnosis of rhabdomyolysis
• Successful reperfusion after thrombolytic therapy
  can be assessed sensitively and specifically by
  measuring cardiac markers
• The release of cardiac troponin T exhibits a
  characteristic biphasic response following a
  myocardial infarction
• (Select the correct answer)

54
Which of the following statements relating to
creatine kinase are correct

• Following brain damage, plasma enzyme activity
  often increases to more than five times the upper
  limit of the reference interval
• In health, the enzyme found in plasma is mainly
  derived from skeletal muscle
• The active enzyme is tetrameric
• The plasma enzyme forms can contain one or both
  of two distinct monomers
• Thyroid and brain tissue contain the same
  isoenzyme
• (Select the correct answer)

55
Which of the following statements are true
regarding markers of mycardial infarction?

• Plasma aspartate transaminase activity peaks at
  about 48 hours
• Plasma myoglobin is a sensitive and specific
  marker of myocardial damage
• Serial plasma enzyme changes may detect further
  infarction in the absence of ECG changes
• The maximum increase in plasma creatine kinase
  activity occurs after about 24 hours
• Total plasma creatine kinase activity rises
  before a rise in the cardiac isoenzyme is
  detectable
• (Select the correct answer)

56
Which of the following statements are true
regarding myocardial infarction?

• Plasma AST is a good marker of myocardial
  infarction as is plasma CKMB
• Currently available markers can guide the use of
  thrombolytic therapy
• Troponin T release indicates myofibrillar damage
• Troponins T and I are sensitive and specific
  markers of myocardial infarction
• Troponins T and I may still be elevated 1 week
  after myocardial infarction
• (Select the correct answer)

57
The reasons why you may have chosen a cardiac
cause are

• The high AST activity may have lead you to
  believe that the patient had suffered a
  myocardial infarction
• Myocardial infarction is a common precipitating
  factor in diabetic decompensation
• A myocardial infarction could also account for
  the patient being found unconscious

58
Which of the following do you think is
responsible for the patients deranged
biochemical results?

• A cardiac cause
• A muscular cause
• A hepatic cause
• (Select the correct answer)

59
Which of the following are recognised causes of
rhabdomyolysis?

• Carnitine palmityl transferase deficiency
• Hemlock poisining
• Hyperosmolar non-ketotic coma
• Hyperphosphataemia
• Hyponatraemia
• (Select the correct answer)

60
Which of the following are recognised clinical
features of rhabdomyolysis?

• Disseminated intravascular coagulation
• Muscle pain or tenderness
• Passage of red/brown urine
• Shock
• Swelling of muscle bed or limb
• (Select the correct answer)

61
Which of the following are recognised biochemical
features of rhabdomyolysis?

• Hyperglycaemia
• Hypocalcaemia
• Hypokalaemia
• Raised serum CK-MB concentration
• Raised serumtroponin I concentration
• (Select the correct answer)

62
Which of the following are recognised causes for
creatine kinase activity to be elevated to
greater than five times the upper limit of the
reference interval?

• Grand mal epileptic convulsions
• Hypothyroidism
• Malignant hyperpyrexia
• Rhabdomyolysis
• Severe exercise
• (Select the correct answer)

63
The reasons why you may have chosen a muscular
cause are

• The source of the high serum AST activity in this
  patient is likely to be skeletal muscle
• There is no indication that the source is cardiac
  because of the normal ECG on admission (no T
  wave, ST segment abnormalities or Q waves)
• The liver is unlikely to be the source of the AST
  since the other liver function parameters are not
  severely deranged

64
Which of the following do you think is
responsible for the patients deranged
biochemical results?

• A cardiac cause
• A muscular cause
• A hepatic cause
• (Select the correct answer)

65
Which of the following are recognised causes of
acute hepatitis?

• Carbon tetrachloride poisoning
• Cytomegalovirus infection
• Consumption of large amounts of ethanol
• Gallstones
• Persistent infection with hepatitis B
• (Select the correct answer)

66
Which of the following is usually present in
patients with acute hepatitis?

• Hypoalbuminaemia
• Hypoglycaemia
• Increased plasma AST activity
• Increased plasma CK activity
• Increased plasma immunoglobulin concentrations
• (Select the correct answer)

67
Which of the following are recognised features of
acute hepatic failure?

• Decreased plasma urea concentration
• Hyperglycaemia
• Increased plasma sodium concentration
• Lactic acidosis
• Respiratory alkalosis
• (Select the correct answer)

68
The reasons why you may have chosen a hepatic
cause are

• The high serum AST activity could indicate a
  serious liver disorder
• You may belive delibrate ingestion of drugs is
  responsible e.g. paracetamol
• The history of alcohol abuse could be consistent
  with a serous liver disorder

69
The professor had taken into account the

• Presentation of the patient
• Red-brown urine
• High serum AST activity
• Impaired renal function
• Hyperchloraemic acidosis
• Total CK results were
• Admission 157,0 IU/L (lt200)
• Current 103,0 IU/L

70
Summary

• The patient experienced an episode of
  rhabdomyolysis - a very rare complication of HONK
• This may have been due to the metabolic
  abnormalities associated with HONK and/or muscle
  damage the patient may have been unconscious,
  lying on the floor, for up to two days
• The diagnosis was confirmed by the very high
  plasma CK activity in the retrospective analysis
  of the sample taken on admission
• The normal troponin I ruled out a cardiac cause.

71
Update

• The professor was worried that major renal damage
  might occur. He was heartened, however, by the
  observations that
• Despite being very high, the CK activity was
  falling from its admission value
• Urine output remained stable
• The colour of the urine was becoming lighter
• He wanted the patient to maintain good urine
  output and encouraged oral fluid intake with
  careful monitoring of fluid balance.

72

• After a comfortable night, Mr H L continues to
  recover. His urine output remains good and the
  colour has returned to normal. His neurological
  abnormalities have also resolved.

73
Which of the following would most likely account
the complete resolution of the patients
neurological signs?

• Dispersal of clot within the middle cerebral
  artery with rehydration
• A change in blood viscosity with rehydration and
  control of hyperglycaemia
• (Select the correct answer)

74
The patient is questioned further

• On questioning, mr H L gives a history of thirst
  and nocturia for the previous 5 or 6 months,
  which he had attributed to his prostatic problem.
  At this point the patient is asked about
  additional symptoms.

75
Which symptoms suggest diabetes rather than
prostatism?

• Thirst
• Weight loss
• Getting up at night to pass urine (nocturia)
• Getting up at night to drink
• Increased frequency of micturition passing large
  volumes of urine (polyuria)
• (Select the correct answer)

76
On day 3 the patient is now much improved. He is
eating and drinking normally and beginning to
walk around the ward. His temperature is now
normal but his blood pressure has risen and
remained high at about 190/100 mmHg.

• What level of blood pressure in this patient with
  type 2 diabetes would you consider acceptable?
• 160/90
• 140/85
• 160/100
• (Select the correct answer)

77
Update

• The following changes are made to Mr H Ls
  treatment
• Oral antibiotics are substitued for iv.
  antibiotics and iv. fluids are stopped
• A calcium-channel blocker is given to control his
  blood pressure
• One hour after his iv. insulin is stopped he
  receives his first subcutaneous injection of
  fast-acting soluble insulin

78
Update

• A diabetes specialist nurse teaches the patient
  to use a pen injector device for insulin and
  shows him how to measure and record his own
  capillary blood glucose concentrations using a
  portable blood glucose meter.
• The patient also receives information about
  hypoglycaemia, what to do in case of intercurrent
  illness and a contact telephone number for use in
  an emergency or if advice is needed.
• The patient is discharged home and given an
  appointment for outpatient review in six weeks
  time.

79
Outpatients 6 weeks later

• Mr H L is seen in the Diabetic clinic. He appears
  healthy and is coping very well with his
  diabetes. He says he has never felt better!
• Since going home, repeated minor hypoglycaemic
  episodes have required a reduction in his dose of
  insulin from 20 units morning, 12 units evening,
  to 8 units morning and 4 units evening. He
  continues with the calcium-channel blocker for
  his hypertension.

80
Which of the following possible causes of
hypoglycaemia is most likely to account for this
patients changing insulin requirements?

• Altered renal function
• An improvement in pancreatic insulin secretion
• Alcohol excess
• Concomitant endocrine disease
• (Select the correct answer)

81
Which of the following investigations would you
routinely request for monitoring a patients with
diabetes?

• Fructosamine
• Plasma creatinine
• Thyroid function tests
• Liver function tests
• Glycated haemoglobin
• Lipid profile
• Urine ketones
• Urine albumin/creatinine ratio
• (Select the correct answer)

82
A series of investigations is performed in the
outpatient clinic

• Glycated haemoglobin
• Plasma creatinine
• Thyroid function tests
• Random lipid profile
• Urine albumin/creatinine ratio
• Doppler ultrasound of lower limb arteries

83
Look at the laboratory report

• Hba1c 9.2 (lt6 )
• Creatinine 98 umol/L (55-120)
• TSH 9.8 mU/L (0.5-6.0)
• Free T4 12 pmol/L (10-24)
• Cholesterol 6.8 mmol/L (lt5.2)
• HDL 0.76 mmol/L (gt1,0)
• Triglycerides 3.4 mmol/L (lt1.5)
• Albumincreatinine ratio 9.8 mg/ mmol/L (lt2.5)

84
In treating his lipidaemia what target
lipoprotein levels would you aim for?

• LDL colesterol lt 3,0 mmol/L
• HDL cholesterol gt1,0 mmol/L
• Triglycerides lt2,5 mmol/L
• (Select the correct answer)

85
Treatment with a statin drug is suggested and Mr
H L is advised to transfer from insulin to oral
hypoglycaemic therapy. He readily agrees to do so.

• Which one of the following drugs would you
  prescribe for Mr H Ls diabetes?
• Metformin
• Acarbose
• A thiazoladinedione
• Gliclazide
• (Select the correct answer)

86
The albumincreatinine ratio was elevated on a
random urine sample and further investigations
are required. Which of the following tests would
you wish to carry out?

• Mid-stream urine for microscopy and culture
• Measurement of glomerular filtration rate
• Overnight timed urine collections for albumine
  excretion
• (Select the correct answer)

87
Which of the following anti-hypertensive agents
would you consider first-line treatment for a
diabetic patient with microalbuminuria?

• Calcium-channel blocker
• Angiotensin-converting enzyme (ACE) inhibitor
• Thiazide diuretic
• Beta-blocker
• (Select the correct answer)

88

• Mr H L is commenced on treatment with gliclazide
  40 mg twice daily and advised to contact the
  diabetes specialist nurse if his control
  deteriorates. Arrangements are made for a further
  follow up appointment in 6 months time to assess
  the response to lipid lowering therapy and change
  in medication. He is asked to provide further
  urine samples to further investigate the
  increased albumincreatinine ratio.

Total score may be achived 76