mohammed karim
Badges: 3
Rep:
?
#1
Report Thread starter 1 year ago
#1
A 58-year-old woman is admitted with a humeral fracture following minimal trauma. Biochemical investigations included a bone profile, including plasma phosphate and magnesium, the results of which are shown below. X-ray of her humerus reveals osteolytic lesions in addition to the fracture.

Total Calcium

3.28 mmol/L

(2.20-2.60)

Phosphate

0.42 mmol/L

(0.7-1.4)

Albumin

42 g/L

(35-50)

Alkaline Phos

532 U/L

(30-130)

Magnesium

0.73 mmol/L

(0.7-1.0)



Suggest a differential diagnosis for this clinical presentation. What further investigations would be appropriate?


A 57-year-old man presents to his doctor with intense generalized itch and yellow skin. He has unintentionally lost an unspecified amount of weight. On questioning, he denies any pain, but admits that his stools are pale. He is on no medications. On examination, he is deeply jaundiced. Results of liver function tests are as follows:

Bilirubin

275 μmol/L

(3-22)

ALT

42 U/L

(3-55)

AlkPhos

980U/L

(30-130)

Albumin

36 g/L

(35-50)

What is the probable type of jaundice? Why is stool color important? How would you follow up to aid in diagnosis?

A 16-year-old male attends his general practitioner (GP) with a history of excessive fatigue and respiratory symptoms; a lower respiratory tract infection is diagnosed and antibiotics prescribed. At his initial visit, the GP orders investigations, including liver function tests, the results of which are shown below.

Bilirubin

34 μmol/L

(3-22)

Conjugated

Normal


Unconjugated

Increased


ALT

20 U/L

(3-55)

AlkPhos

350U/L

(30-130)

Albumin

47 g/L

(35-50)

What is the possible diagnosis? How would you confirm? What is the prognosis in this condition?
0
reply
usycool1
  • Study Helper
Badges: 19
#2
Report 1 year ago
#2
Well, what are your thoughts on them/what do you know? You’ll learn best if you go through it first and then we can guide you from there.
0
reply
Jpw1097
Badges: 15
Rep:
?
#3
Report 1 year ago
#3
(Original post by mohammed karim)
A 58-year-old woman is admitted with a humeral fracture following minimal trauma. Biochemical investigations included a bone profile, including plasma phosphate and magnesium, the results of which are shown below. X-ray of her humerus reveals osteolytic lesions in addition to the fracture.

Total Calcium

3.28 mmol/L

(2.20-2.60)

Phosphate

0.42 mmol/L

(0.7-1.4)

Albumin

42 g/L

(35-50)

Alkaline Phos

532 U/L

(30-130)

Magnesium

0.73 mmol/L

(0.7-1.0)



Suggest a differential diagnosis for this clinical presentation. What further investigations would be appropriate?


A 57-year-old man presents to his doctor with intense generalized itch and yellow skin. He has unintentionally lost an unspecified amount of weight. On questioning, he denies any pain, but admits that his stools are pale. He is on no medications. On examination, he is deeply jaundiced. Results of liver function tests are as follows:

Bilirubin

275 μmol/L

(3-22)

ALT

42 U/L

(3-55)

AlkPhos

980U/L

(30-130)

Albumin

36 g/L

(35-50)

What is the probable type of jaundice? Why is stool color important? How would you follow up to aid in diagnosis?

A 16-year-old male attends his general practitioner (GP) with a history of excessive fatigue and respiratory symptoms; a lower respiratory tract infection is diagnosed and antibiotics prescribed. At his initial visit, the GP orders investigations, including liver function tests, the results of which are shown below.

Bilirubin

34 μmol/L

(3-22)

Conjugated

Normal


Unconjugated

Increased


ALT

20 U/L

(3-55)

AlkPhos

350U/L

(30-130)

Albumin

47 g/L

(35-50)

What is the possible diagnosis? How would you confirm? What is the prognosis in this condition?
Case 1 - the patient has a high calcium, high ALP, low phosphate and a humerus fracture after minimal injury. This to me suggests that the patient has primary hyperparathyroidism. This occurs when there is excessive production of PTH (parathyroid hormone) from a parathyroid adenoma (benign neoplasm) or rarely a parathyroid carcinoma (malignant). PTH stimulates bone resorption by osteoclasts - decreasing mineral bone density - as well as reabsorption of calcium and excretion of phosphate in the kidney. Osteolytic lesions also make you think of multiple myeloma, however, myeloma tends to affect the central/axial skeleton and phosphate would be high. You would need to look at the PTH levels, which will be high in primary hyperparathyroidism. You could also do a calcium infusion and then measure PTH after; normally PTH should be low (due negative feedback) but in primary hyperparathyroidism, PTH will still be high.

Case 2 - the patient has painless jaundice, with pale stools, unintended weight loss and pruritus (itching). His LFTs show a normal ALT, extremely high bilirubin and a high ALP - this gives us a cholestatic (obstructive) picture of jaundice. Obstructive causes of jaundice include gallstones, ascending cholangitis, pancreatic cancer, cholangiocarcinoma, primary biliary cirrhosis, primary sclerosing cholangitis, etc. Due to the history of weight loss and the lack of pain, malignancy seems more likely - so pancreatic cancer, cholangiocarcinoma or even a primary liver tumour. I think it would be good to get a CT scan of the abdomen to look for any tumours.

Case 3 - the patient has an unconjugated hyperbilirubinaemia, normal ALT, high ALP and a lower resp tract infection. My first thought was that this is probably Gilbert's syndrome - a reduced activity of glucuronyltransferase enzyme that conjugates bilirubin, and this can lead to episodes of jaundice, typically due to infection and other stressors. However, I'm not sure how this explains the elevated ALP and I'm too tired to look further into it.

Hope that helps.
Last edited by Jpw1097; 1 year ago
0
reply
X

Quick Reply

Attached files
Write a reply...
Reply
new posts
Back
to top
Latest
My Feed

See more of what you like on
The Student Room

You can personalise what you see on TSR. Tell us a little about yourself to get started.

Personalise

Are you worried that a cap in student numbers would affect your place at uni?

Yes (130)
59.09%
No (48)
21.82%
Not sure (42)
19.09%

Watched Threads

View All
Latest
My Feed