vis dis exam 4 BCP

BCP

a group of select tests that can screen for certain conditions - patterns of abnormal values provide data for arriving at a diagnosis - CMP is like the same thing

glucose

primary energy source - blood glucose levels are held within a fairly constant range by regulatory hormones and metabolic activity - disorders of glucose metabolism result in hypoglycemia and hyperglycemia - insulin decreases blood glucose concentrations - levels controlled by feedback mechanism

what things increase blood glucose levels

glucagon (secreted in the fasting state), epinephrine, growth hormone, ACTH, and cortisol

insulin

secreted to drive glucose into the cells to be metabolized to glycogen. amino acids, and fatty acids = reduces glucose

reasons for hyperglycemia

diabetes mellitus, acute stress response, cushing’s syndrome, pheochromocytoma, renal failure, acromegaly, pancreatitis

reasons for hypoglycemia

insulin overdose, pancreatic islet cell tumor, starvation, liver disease, addison’s disease, hypothyroidism

diabetes symptoms

polydipsia (thirsty), polyuria, polyphagia, fatigue, weight loss, blurred vision, slow healing, dizziness, nausea

ranges for fasting blood glucose

normal is under 100 mg/dl (really between 70-99), pre-diabetes is ≥100 mg/dl to <126 mg/dl, diabetes is ≥126 mg/dl

symptoms of hypoglycemia

sweating, hunger, trembling, anxiety, confusion, blurred vision

glucose tolerance test (OGTT)

used if diabetes is suspected - usually a 2hr OGTT (most commonly used) - patient fasts, then a FBS is taken and then is given an oral glucose load (75 g of glucose in 300 ml water) - tested 30 min, 1hr, 2hr, 3hr, and sometimes 4hr - normally there is a rapid insulin increase in response to the glucose load and peaks within the first hour and returns to normal in about 3 hours - 2hr mark should be less than 140

results of OGTT

patient with an appropriate insulin response are able to tolerate the glucose load and glucose does not spill into the urine - patient’s with diabetes will not tolerate the load and serum levels will be greatly elevated from 1 to 5 hours and glucose spills out in the urine

ranges for OGTT

normal is under 140 mg/dl, pre-diabetes is ≥140 mg/dl and <200 mg/dl, diabetes is ≥200 mg/dl

hemoglobin A1c test (HbA1c)

blood test used to determine how well a patient’s diabetes/blood sugar levels are being controlled - provides an average of your blood sugar control over a 6-12 seek period - normal range is 4-6% for those without diabetes - goal for patients with diabetes should be less than 7% (low A1c level means a significantly lower likelihood of experiencing complications from diabetes

what test is being recommended to becoming the new gold standard for diagnosing diabetes?

A1c assay

A1c ranges

normal is <5.6%, pre-diabetes is ≥5.7% to <6.5%, diabetes is ≥6.5%

diabetes mellitus diagnosis

diagnosis is <200 mg/dl or a FBS >126 or a ≥200 mg/dl on OGTT or ≥6.5 A1c - glycosuria is present when glucose levels exceed the renal threshold values (RTV may rise in some diabetics)

diabetes

patients often present with musculoskeletal and neurological complaints - only half of patients are aware of their disorder - the leading cause of kidney failure, lower-limb amputations, and adult-onset blindness

type 1 diabetes mellitus

insulin dependent - polyuria, polydipsia, hyperglycemia - most commonly seen in juveniles, circulating insulin is absent and plasma glucagon is elevated - autoimmune destruction of pancreatic islet beta cells, although the etiology is unknown - dependent on exogenous insulin to sustain life

type 2 diabetes mellitus

most common type, most patients are over 40 and obese with a family history - polyuria, polydipsia, hyperglycemia = circulating insulin is present but inadequate in times of increased need - insulin resistance or decreased amounts - may be controlled by diet, lifestyle, exercise, maybe oral hypoglycemic agents

gestational diabetes mellitus

occurs during pregnancy and disappears after delivery - tested between 24th-28th week - imbalance occurs between the mother’s ability to secrete insulin ad the diabetogenic hormones of pregnancy (estrogen and progesterone) which results in insulin resistance and glucose levels ride (hyperglycemia) - extra blood glucose goes through the placenta, giving the baby high blood glucose levels, which causes baby’s pancreas to make extra insulin to get rid of the blood glucose - since baby is getting more energy than it needs to grow and develop, the extra energy is stored as fat

what percent chance do people who had gestational diabetes have of developing diabetes in the next 10-20 years?

35-60%

diabetes mellitus complications

diabetic catarcts, diabetic retinopathy, glaucoma, diabetic nephropathy, diabetic neuropathy, vascular disease, skin lesions, foot gangrene, diabetic coma

diabetic coma/DKA - diabetic ketoacidosis

from a shortage of insulin - glycosuria, ketonuria, hyperglycemia, polyuria, polydipsia, fatigue, vomiting, mental stupor and can progress to coma, rapid breathing, fruity breath odor

hypoglycemia

blood glucose levels below 70 mg/dl - more common in a diabetic patient - anxiety, sweating, palpitations, tremor, hunger - if it persists, CNS glucose deprivation occurs and they may exhibit lethargy, headaches, confusion, visual disturbances convulsions, and coma - symptoms of reactive and fasting hypoglycemia are similar to diabetes-related hypoglycemia

reactive hypoglycemia

occurs within 4 hours after meals - under 70 mg/dl - also called postprandial hypoglycemia - relief of symptoms when glucose returns to normal (eat small meals and snacks about every 3 hours) - high blood sugar can result in excessive insulin secretion and results in lowered glucose levels - exercise regularly

fasting hypoglycemia

often related to underlying disease, various medications, excess insulin or carbohydrate deprivation, tumors like insulinoma, insulin overdose in diabetic, hormonal deficiencies, hepatic or renal disease - under 50 mg/dl - also called postabsorptive hypoglycemia - may need a 5 or 6 hour glucose tolerance test with measurements hourly

whipple’s triad

symptoms known or likely to be caused by hypoglycemia - a low plasma glucose measured at the time of symptoms - relief of symptoms when the glucose is raised

blood urea nitrogen BUN

measures the amount of urea nitrogen in the blood - urea is formed in the liver as an end product of protein metabolism and transported to the kidneys for excretion - this test is related to the metabolic function of the liver and excretory function of the kidneys - nearly all renal disease will elevate this - high protein diet may also elevate and severe liver disease and overhydration will decrease levels

azotemia

elevated blood levels of BUN

what 2 tests are the renal function tests

BUN and creatinine

creatinine

measures the amount of creatinine in the blood - catabolic product of creatine phosphate which is used in muscle contraction - only renal disorders can elevate this (so better indicator of renal disease than BUN) - levels tend to rise later and indicate chronicity

uric acid

nitrogenous compound that is a product of purine catabolism excreted by the kidney and a little by the intestinal tract - hyperuricemia (elevated levels) is associated with gout - may also be elevated in renal disease, metastasis, multiple myeloma, alcoholism, leukemias

radiographic findings of gout

soft tissue swelling, decreased joint space, nonmarginal erosions (overhang sign)

gout of the big toe is called what?

podagra

proteins

constituents of muscle, enzymes, hormones, hemoglobin, etc. - most significant factor for osmotic pressure, keeping fluids within the vascular space - increased in multiple myeloma, dehydration, chronic infections, and malignancies - decreased in liver disease, kidney disease, and malabsorption diseases

what 2 proteins constitute most of the protein in the body and are measured as the total protein?

albumin and globulin

albumin

formed in the liver and makes up 60% of the total protein and helps regulate colloidal osmotic pressure and transports important blood constituents - measure of liver function - levels are decreased in liver disease, malnutrition, overhydration, inflammatory diseases - increased levels with dehydration

globulins

the key building block of antibodies and some are used in transport of various proteins

example patients who would have decreased levels of total proteins

malnourished, burn, and protein losing uropathy patients

albumin/globulin ratio

if albumin is low and globulins are high, then the total proteins may be normal - normally the ratio exceeds 1.0 - diseases that reduce albumin reduce the ratio - diseases that increase total proteins particularly the globulins (MM, malignancy, inflammatory diseases) can reverse the ratio

what are some symptoms of hypercalcemia?

nausea, confusion, constipation, polyuria, and fatigue

biomarkers for multiple myeloma

hypercalcemia, hypercelciuria, elevated ESR, elevated protein in blood and urine, M spike on PEP, rouleaux formation, normocytic normochromic anemia, reversed A/G ratio, phosphorus is normal, alkaline phosphatase usually is normal or low, increased BUN and creatinine (kidney dysfunction), uric acid may be increased

biomarker stats for lytic metastasis

urine calcium often increased, serum calcium and phosphate usually normal or increased, serum ALP normal or increased, normocytic normochromic anemia

biomarkers for blastic metastasis

serum calcium usually normal, urine calcium is low, ALP is increased, acid phosphatase increased (prostate - PSA), serum phosphorus variable, normocytic normochromic anemia

bilirubin

measures excretory function of the liver - metabolism for this begins with the breakdown of RBC in the RES, hemoglobin released from RBCs is broken down into heme and iron, heme is transformed into bilirubin (unconjugated) in the liver it is converted to conjugated bilirubin - increased levels may be due to unconjugated or conjugated bilirubin - total serum bilirubin is the sum of both types

elevated bilirubin

causes jaundice and need to determine if conjugated or not - hepatocellular dysfunction results in elevated unconjugated bilirubin as does increased RBC hemolysis - liver disease and extrahepatic obstruction such as gallstones, tumor blocking bile ducts, results in elevated conjugated bilirubin

urobilinogen parameters

increased in liver/biliary disease, absent with biliary obstruction, increased in hemolytic anemia - these findings are from the urine

bilirubin parameters

positive with liver/biliary disease, positive with biliary obstruction, negative/absent in hemolytic anemia

primarily unconjugated hyperbilirubinemia

increased production (from hemolysis, intravascular or extravascular, ineffective erythropoiesis, hematoma, or pulmonary embolus), decreased hepatic uptake, decreased glucuronidation

primarily conjugated hyperbilirubinemia

decreased liver excretion (intrahepatic), extrahepatic biliary obstruction, external compression - increased in conjugated bilirubin are highly specific for disease of the liver or bile ducts

alkaline phosphatase ALP

found in many tissues, the highest concentrations are found in the liver, bone, biliary tract epithelium, placenta, and intestinal mucosa - detection of this enzyme is important in detecting liver and bone disorders (particularly blastic problems)

when is ALP elevated?

in intrahepatic and extrahepatic obstructions, biliary disease, and cirrhosis, tumors, hepatitis, liver metastasis

what is the most important site for extrahepatic ALP?

bone - new bone growth is associated with elevated ALP (osteoblastic activity) - high in adolescents, pathological new bone growth like blastic mets, Paget’s, bone disease, healing fractures, and hyperparathyroidism - decreased in hypothyroidism and pernicious anemia

what should you do if there is elevated ALP?

a liver function test (GGTP) - is normal LFT, then non-liver problem - if abnormal LFT, then liver/biliary tract problem

osteopoikilosis

multiple bone islands

chondrocalcinosis etiologies

cartilage degeneration = DJD

crystal deposition = primary is CPPD, then gout

cation disease = hemochromatosis Fe++, hyperparathyroidism HPT Ca++, wilson’s disease Cu++

acid phosphates - prostatic acid phosphatase PAP

this is found in many tissues but highest levels are found in the prostate gland - levels primarily used to diagnose, stage, and monitor treatment of metastatic cancer of the prostate

when are PAP levels elevated

with prostatic cancer that has metastasized beyond the prostate capsule to other parts of the body, especially to bone - may also be seen in MM and benign prostatic hypertrophy or a recent prostate exam - PAP is normal in a confined tumor with enlargement

prostate specific antigen

glycoprotein found in the cytoplasm of prostate epithelial cells - can be detected in all males - elevated levels are seen with prostate cancer, the higher the levels, the greater the tumor burden - a sensitive test to monitor treatment, more sensitive and specific than other tumor markers like PAP - may be elevated in benign prostatic hypertrophy and prostatitis

PSA level parameters

between 4-10 ng/mL is considered suspicious - levels >10 ng/mL has high probability of being cancer

PSA velocity

change in PSA level over time - a sharp rise raises the suspicion of cancer

signs indicating prostate cancer metastasis to bone

markedly elevated PAP and PSA with elevated ALP

age dependent ranges

slide 189 - ask if he’ll provide normal ranges

lactate dehydrogenase

catalyzes lactate to pyruvate - is found in many tissues - total LDH is not a specific indicator of any one disease - disease affects cells that contain LDH, the cell lyses and releases LDH

gamma-glutamyl transpeptidase GGTP

an enzyme that participates in transfer of amino acids and peptides across cell membranes - highest concentrations are found in the liver and biliary tract - lesser concentrations are found in the kidneys, spleen, and heart - test is used to detect liver cell dysfunction (sensitive to liver disease) - sensitive to chronic alcohol ingestion and is the most sensitive test for alcohol induced liver disease

when is GGTP not elevated?

on bone disease - if ALP is elevated with GGTP, it would imply skeletal disease

elevated GGTP and ALP implies what?

hepatobiliary disease

aspartate aminotransferase AST

enzyme which removes the amino group from aspartate - when diseased cells lyse, they release AST - AST/SGOT is one of the cardiac enzymes - widely used for suspected coronary occlusive heart disease or suspected hepatocellular disease - found in heart, liver, and skeletal muscles - rises uickly and returns to normal in 3-4 days

is AST/SGOT or ALT/SGPT more sensitive for the liver?

ALT/SGPT

is AST/SGOT or ALT/SGPT more sensitive for the heart?

AST/SGOT

alanine aminotransferase ALT

found predominantly in the liver and in lesser quantities the heart, kidneys, and skeletal muscles - injury or disease of the liver will release this enzyme - generally elevated with liver disease

components of liver panel

AST (heart), ALT (liver), ALP, LDH, GGTP, protein (especially albumin), bilirubin - a UA would also be helpful

electrolytes

substances whose molecules dissociate into ions when in solution - total cations equal total anions to maintain electroneutrality - major functions are to maintain osmotic pressure, water distribution, proper pH, regulation of proper heart and muscle function - profile includes sodium, potassium, chloride, and bicarbonate

sodium

major extracellular cation and is important for water distribution and osmotic pressure in plasma

potassium

major intracellular cation and is important to cellular metabolism and normal neuromuscular function, particularly of the heart

chloride

major extracellular anion and is important in maintaining cellular integrity through water balance and osmotic pressure

bicarbonate

major component of carbon dioxide in plasma, helps regulate acid-base balance

minerals

calcium: 99% in bone and involved with neurotransmission and muscular contraction

phosphorus: 80-85% in bone

magnesium: 50-60% in bone, cofactor for enzymes, activator for some enzymes, neurotransmission and muscular contraction

calcium

can evaluate parathyroid function - hypercalcemia typically associated with muscle weakness and disorientation seen with skeletal metastasis, HPT, MM, hyperthyroidism, renal transplant - hypocalcemia typically associated with tetany and seen with hypoalbuminemia (alcoholics), renal failure, vitmain D deficiecny, hypoparathyroidism

2 most common causes of hypercalcemia

primary hyperparathyroidism, then malignancy - make up >90% of cases

hyperparathyroidism

overactivity of the parathyroid gland - PTH is a strong osteoclastic hormone - primary cause is adenoma - secondary is chronic renal disease (hemodialysis - renal osteodystrophy (secondary and tertiary HPT))

primary HPT

most common type and cause of hypercalcemia in ambulatory patients - parathyroid adenoma in 90% of cases - elevated PTH, hypercalcemia, hypophosphatemia

sestamibi parathyroid scan

procedure of nuclear medicine performed to identify hyperparathyroidism

secondary HPT

complication of chronic renal disease - persistent loss of calcium and phosphorus - stimulates PTH release (high PTH and low to normal calcium) - hyperphosphatemia (kidney’s can’t excrete it as well)

tertiary HPT

seen in dialysis patients, parathyroid gland acts independent of serum calcium levels (high PTH and calcium)

demographics for HPT

30-40 women more than men - bone pain, fractures, weakness, lethargy, polydipsia, polyuria, may have renal stones, pancreatitis, elevated ALP and PTH - hypercalcemia in primary, normal to low in secondary, elevated in tertiary

parathormone physiology

maintains the circulating level of calcium ion - stimulates osteoclasts to resorb bone and release calcium and phosphorus ion into the blood stream = increased calcium absorption through small intestine —> renal tubular phosphate excretion and calcium absorption which upsets homeostasis - in secondary HPT, calcium loss and abnormal vit D formation leads to hypocalcemia and release of PTH

HPT radiography

osteopenia, subperiosteal resorption, distal tuft resorption (acro-osteolysis), accentuated trabeculation, brown tumors (cystic accumulations of fibrous tissue), loss of cortical definition, soft tissue calcification (metastatic calcification - vascular calcification), salt and pepper skull

subperiosteal resorption

most definitive radiographic sign of HPT (pathognomonic) - seen especially at the radial margins of middle and proximal phalanges of the 2nd and 3rd digits - outer cortical erosion may appear frayed or lace life - widened joint spaces and osteolysis especially of AC and SI joints

what kind of relationship do phosphorus and calcium have?

inverse one

hyperphosphatemia

seen with renal failure, hypoparathyroidism, excess vit D, bone metastasis, myeloma, and cell destruction

hypophosphatemia

seen with decreased intestinal absorption, increased renal excretion, HPT

hypermagnesemia

seen with dehydration, renal insufficiency, uncontrolled diabetes

hypomagnesemia

seen with malabsorption, malnutrition, alcoholism, cirrhosis typically accompanied by tetany, muscle weakness, and cardiac arrhythmias

a decrease in magnesium results in what?

calcium being released from bone and increased deposition in aorta and kidney

chamberlain’s line

odontoid can go no further than 3mm above this line

mcgregor’s line

odontoid can go no further than 4.5mm above this line

what does a bone panel consist of?

calcium, phosphorus, alkaline phosphatase, acid phosphatase (male), PSA (male), uric acid, total proteins, A/G ratio, serology, CBC/ESR/CRP

amylase

most specific for pancreatitis (upper quadrant, epigastric severe pain, mid back pain) - normally secreted by pancreas and aids in catabolism of carbohydrates - damage to pancreatic cells (pancreatitis and tumor) cause outpouring of this enzyme - rises quickly and returns to normal rapidly unless it’s a persistent condition

lipase

most common cause of elevated levels if acute pancreatitis - secreted by pancreas into duodenum to break down triglycerides into fatty acids - increased levels are released with damage to pancreatic cells - elevates a littler later and lasts a little longer than amylase