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Case 1:
19-year-old woman was brought by a friend to the emergency room because she felt "at death's
door." Two days ago she began to have a great thirst, began to urinate more frequently and more,
she felt unusually tired and slow. This morning she woke up with dyspnea, lightheadedness and she
had nausea and vomited several times.
Physical examination: oriented, temperature 36.5, blood pressure 98/60, pulse 110, respiratory rate
24 with, deep breaths. Lips were dry.
Laboratory: Ketone bodies in urine.
Na
K
Cl
Urea
Creatinine
Glucose
HTC
pH
HCO3paCO2
paO2
On admission
145
5,5
107
14,29
132,6
33,3
42
7,20
13
(26) 3.1
(95) 13,7
1. Explain the symptoms.
Standard
135 -145 mmol/l
3,5-5 mmol/l
95-105 mmol/l
2,0 – 7,5 mmol/l
35 – 100 umol/l (woman)
3,3 – 6,1 mmol/l
35-42% (woman)
7,40 ±0,04
22 – 26 mmol/l
(40 torr) 4,8 – 5, 9
(100 torr) 9,9 – 14,4
mmol/l
mmol/l
2. Why is the patient tired and weak and has lightheadedness?
3. How would you assess the patient's ABB?
4. Why the patient is dyspnoic and has a higher heart rate?
5. Why are ketone bodies in urine and when can it generally increase?
6. Evaluate the patient's ions. Why has the patient hyperpotassemia?
7. Why has she higher urea and creatinine in plasma?
8. How might the state of this patient develop without treatment?
Case 2:
A 23-year old male was saved after 25 days in the ruins of a house following earth quake. There
was no food but sufficient water. At the arrival to the hospital the patient was unconscious with
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frequent, deep respiration, and the expired air smelled of acetone. The cardiac rate was 85/min, and
the arterial blood pressure was 11,3/7,3 kPa (85/55 mmHg).
The blood glucose was 2,2 mmol/l, and the plasma free fatty acids were increased. The serum
concentrations of proteins and essential amino acids were reduced. There was moderate diuresis
with ketonuria with signs of water retention and a high nitrogen loss in the urine.
The patient was treated with parenteral administration of glucose, amino acids and electrolytes.
Following the glucose intake, the blood glucose was increased to 10 mmol/l, and glucosuria
occurred. A glucose tolerance test was performed and resulted in a high blood glucose level that had
not reached the normal level within 2 hours.
1.
Describe the energetic events leading to survival.
2.
Why did the patient smell of acetone?
3.
Explain the signs and symptoms of the patient.
4.
Explain the laboratory findings.
5.
Explain the high nitrogen loss in the urine.
6.
What happened with the metabolism of sugars after infusion?
7.
How might the state of this patient develop without treatment?
Case3:
28 year old patient complains of muscle weakness and fatigue. Against the last visit by a doctor (7
months ago) she has lost 15 kg. She has no other complains.
Physical examination: the patient is skinny and looks very tired. Blood pressure is 100/76, pulse
88, respiratory rate 16/min. The patient is afebrile, has a red throat and mouth mucous membrane
excoriations and defects on the back of the teeth. Otherwise there are no significant findings.
Plazma:
Na+
K+
ClBUN
Creatinine
Glukose
Bikarbonate
Blood pH
pCO2
pO2
Urine pH
136
2,8
85
20
1,0
80
36
7,48
48
80
6,0
Norma:
136-146 mmol/l
3.5-5.3 mmol/l
98-108 mmol/l
7-22 mg/dl
0.7-1.5 mg/dl
70-110 mg/dl
23-27 mmol/L
7,42 ± 0,02
40 mmHg
100 mmHg
1. What is the primary ABR defect of this patient and how did this happen? Calculate the anion
gap. Is it important in this case?
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2. What might be the cause of reduced levels of chlorine?
3. Why does the patient have hypokalaemia (describe all mechanisms).
4. Why is the patient tired?
5. Why is the blood pressure low in this patient?
6. How the body compensates this patient's metabolic disorder?
7. What other signs should the patient expect?
8. What might be the cause of this condition? What else do you need to know to make a
diagnosis?
9. Could the patient die from the disease? What would be the cause of death?
Case 4:
A 48-year-old man complaining of erectile dysfunction sought medical attention. Further
questioning revealed that he was also shaving less frequently. The patient’s shoe size had increased
from a 9-C to 11-E over past five years, and his dental plate had to be altered three times in 6 years.
Recently, his friends have remarked on changes in appearance. The patient also admitted to tingling
of his fingers and joint pains.
Physical examination: The patient has coarse facial features with a bulbose nose, enlarged tongue,
and teeth were wide spaced.testing on visual fields showed a loss of both lateral (temporal) fields.
The hands and feets are enlarged with spade like fingers. The liver was enlarged.
Laboratory findings: The patient had afasting blood glucose 7.2 mmol/l and higher concentrations
of growth hormone, which did not decrease after glucose load. Magnetic resonance revealed a large
pituitary mass protruded upward from sella turcica.
1. Why did the physician measure the GH level?
2. What caused the changes in the patient's appearance?
3. Why is fasting blood glucose increased? Which changes are you awaiting in insulin levels?
4. What is a normal consequence of increased glucose on secretion of growth hormone, and
why it had not changed in this patient?
5. Why has the patient the visual field loss?
6. Why the patient had erectile dysfunction?
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Case 5:
A 48-year-old woman came to the local emergency because of an abrupt onset of lower back
pain. X-ray examination showed a compression fracture of the L2 vertebra and revealed severe
osteoporosis in the spine. The doctor had further discovered that the woman gained 25kg in 3 years,
muscle weakness and a tendency to easy bruising. The patient also complained of increasing
emotional lability and sleep disturbances.
Physical examination: Obese woman with excess adipose tissue largely in the face, above
the clavicles and about the trunk. The extremities were thin and exhibited muscle atrophy. Skin was
thin with bruises and large purple marks over the abdomen. Excess hair growth was present on the
upper lip and skin. Blood pressure was164/102, pulse 76/min.
Laboratory findings: Glucose 7,5 mmol/l, slightly increased bicarbonate and decreased
potassium concentration.
1. How would you explain the symptoms and signs?
2. What is the most likely hormonal disorder in this patient and why?
3. Why has the patient increased blood glucose?
4. Why has the patient hypertension? How do you explain hypokalemia?
5. Has the patient ABB disorder? Why do you think so and how it originated?
6. What other hormones have altered secretion?
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