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Diabetes Clinical cases CID please…

Diabetes Clinical cases CID please…. Chemical Pathology: Y5 Karim Meeran. -. +. pH [H +]. H + HCO 3 = CO 2 + H 2 O. 6.92 7.0 7.1 7.22 7.40 7.52 7.70 7.80. Metabolic acidosis. respiratory acidosis. Draw this on your IPAD. Metabolic alkalosis. respiratory alkalosis.

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Diabetes Clinical cases CID please…

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  1. Diabetes Clinical cases CID please… Chemical Pathology: Y5 Karim Meeran

  2. - + pH [H+] H + HCO3 = CO2 + H2O 6.92 7.0 7.1 7.22 7.40 7.52 7.70 7.80 Metabolic acidosis respiratory acidosis Draw this on your IPAD Metabolic alkalosis respiratory alkalosis pCO2

  3. Case 1: • 16 year old unconscious. • Acutely unwell a few days. • Vomiting • Breathless.

  4. Case 1: data • pH 6.85 • PCO2 = 2.3 kPa (N 4-5) • PO2 = 15 kPa

  5. pH 6.85 PCO2 = 2.3 kPa (N 4-5) PO2 = 15 kPa What is the acid/base abnormality? • Respiratory acidosis • Metabolic acidosis • Respiratory alkalosis • Metabolic alkalosis

  6. What is the acid/base abnormality? • Low pH = acidosis • ie: excess H+ ions • HCO3- + H+ = CO2 + H20 • Low CO2 = low bicarbonate

  7. What is the acid/base abnormality? • Draw the following graph, which will always tell you the answer:

  8. Type in your CID now - + pH [H+] H + HCO3 = CO2 + H2O 6.92 7.0 7.1 7.22 7.40 7.52 7.70 7.80 Metabolic acidosis respiratory acidosis Metabolic alkalosis respiratory alkalosis pCO2

  9. What is the acid/base abnormality? • Low pH = acidosis • Low CO2 = low bicarbonate • Metabolic acidosis

  10. Na: 145, K: 5.0, U 10, pH 6.85, Glucose 25. • Why is he unconscious ? • What is the osmolality ? Case 1: more data.

  11. Na: 145, K: 5.0, U 10, pH 6.85, Glucose 25. • Why is he unconscious ? Because brain enzymes cannot function at a very acid pH • What is the osmolality ? Case 1: more data.

  12. Na: 145, K: 5.0, U 10, pH 6.85, Glucose 25. • Osmolality = charged molecules + uncharged =cations + anions + urea + glucose • (Na, K) (Cl, HCO3) • Since cations = anions, this can be reduced to: • Osmolality = 2(Na+K) + U + G Case 1: osmolality : derivation* Also PO4, SO4, etc

  13. Na: 145, K: 5.0, U 10, pH 6.85, Glucose 25. • Osmolality = charged molecules + uncharged =cations + anions + urea + glucose • (Na, K) (Cl, HCO3) • Since cations = anions, this can be reduced to: • Osmolality = 2(Na+K) + U + G • What is the osmolality? Case 1: osmolality : derivation* Also PO4, SO4, etc

  14. Na: 145, K: 5.0, U 10, Glucose 25. Case 1: osmolality

  15. Cations (Na/K) = Anions (Cl, Bicarb, others) • “Others” known as “anion gap”. • Anion gap = Na + K – Cl – bicarb Case 1: anion gap*

  16. Cations (Na/K) = Anions (Cl, Bicarb, others) • “Others” known as “anion gap”. • Anion gap = Na + K – Cl – bicarb Case 1: anion gap*

  17. Cations (Na/K) = Anions (Cl, Bicarb, others) • “Others” known as “anion gap”. • Anion gap = Na + K – Cl – bicarb • Normal AG =140+4.0 – 102 – 24 = 18 mM Case 1: anion gap*

  18. Anion gap = Na + K – Cl – bicarb • Normal AG =140+4.0 – 102 – 24 = 18 mM • In this patient: Case 1: anion gap*

  19. Anion gap = Na + K – Cl – bicarb • Normal AG =140+4.0 – 102 – 24 = 18 mM • In this patient calculate the anion gap now: • 145 + 5.0 – 96 – 4.0 Case 1: anion gap*

  20. Anion gap = Na + K – Cl – bicarb • Normal AG =140+4.0 – 102 – 24 = 18 mM • In this patient: • 145 + 5.0 – 96 - 4 • = (high) • Suggests extra anions (Ketones) Case 1: anion gap*

  21. A 19 year old known to have type 1 diabetes for several years presents unconscious. • Results: pH 7.65 • PCO2 = 2.8 kPa • Bicarb = 24 mM (normal) • PO2 = 15 kPa What is the acid-base abnormality ? Case 2:

  22. pH 7.65 PCO2 = 2.8 kPa Bicarb = 24 mM (normal) PO2 = 15 kPa Case 2: What is the acid/base abnormality? • Respiratory acidosis • Metabolic acidosis • Respiratory alkalosis • Metabolic alkalosis

  23. What is the acid/base abnormality? • High pH = alkalosis • Low CO2 = respiratory

  24. - + pH [H+] H + HCO3 = CO2 + H2O 6.92 7.0 7.1 7.22 7.40 7.52 7.70 7.80 Metabolic acidosis respiratory acidosis Slows down spontaneously Primary hyperventilation Metabolic alkalosis respiratory alkalosis pCO2

  25. What is the acid/base abnormality? • High pH = alkalosis • Respiratory alkalosis

  26. Further results: • Na = 140, K=4.0, bicarb=24, Cl=100 • Glucose 1.3 mM • What is the anion gap? • What is the diagnosis ?

  27. Further results: • Na = 140, K=4.0, bicarb=24, Cl=100 • Glucose 1.3 mM • What is the anion gap? (normal) • What is the diagnosis ?

  28. Further results: • Na = 140, K=4.0, bicarb=24, Cl=100 • Glucose 1.3 mM • What is the anion gap? (normal) • What is the diagnosis ? Anxiety caused by hypoglycaemia.

  29. 60 year old man presents unconscious to casualty, with a history of polyuria and polydipsia. Investigations reveal: • Na: 160, K: 6.0, U 50, pH 7.30, Glucose 60. • What is the osmolality ? • Why is he unconscious ? Case 3.

  30. 60 year old man presents unconscious to casualty, with a history of polyuria and polydipsia. Investigations reveal: • Na: 160, K: 6.0, U 50, pH 7.30, Glucose 60. • What is the osmolality : mosm/kg • Why is he unconscious ? Case 3.

  31. 60 year old man presents unconscious to casualty, with a history of polyuria and polydipsia. Investigations reveal: • Na: 160, K: 6.0, U 50, pH 7.30, Glucose 60. • What is the osmolality : mosm/kg • Why is he unconscious : because the brain is VERY dehydrated. Case 3.

  32. 59 year old man known to have type 2 diabetes, on a good diet and metformin presents to casualty unconscious: • Urine is negative for ketones. • Na: 140, K: 4.0, U 4.0, pH 7.10, Glucose 4.0 • PCO2=1.3 kPa. Cl = 90. Bicarb = 4.0 mM • What is the osmolality : • What is the anion gap: • What is the acid-base disturbance • Why is he unconscious : Case 4.

  33. 59 year old man known to have type 2 diabetes, on a good diet and metformin presents to casualty unconscious: • Urine is negative for ketones. • Na: 140, K: 4.0, U 4.0, pH 7.10, Glucose 4.0 • PCO2=1.3 kPa. Cl = 90. Bicarb = 4.0 mM • What is the osmolality : • What is the anion gap: • What is the acid-base disturbance • Why is he unconscious : Case 4.

  34. What is the osmolality : • Na: 140, K: 4.0, U 4.0, pH 7.10, Glucose 4.0 • PCO2=1.3 kPa. Cl = 90. Bicarb = 4.0 mM • Osmo=2(Na+K) + U + G Case 4.

  35. What is the anion gap: • Na: 140, K: 4.0, U 4, pH 7.10, Glucose 4.0 • PCO2=1.3 kPa. Cl = 90. Bicarb = 4.0 mM • Urine is negative for ketones. • Anion Gap = (Na+K) - bic - chloride Case 4.

  36. What is the anion gap: • Na: 140, K: 4.0, U 4, pH 7.10, Glucose 4.0 • PCO2=1.3 kPa. Cl = 90. Bicarb = 4.0 mM • Urine is negative for ketones. • Anion Gap = (Na+K) - bic - chloride Case 4.

  37. What is the anion gap: • Na: 140, K: 4.0, U 4, pH 7.10, Glucose 4.0 • PCO2=1.3 kPa. Cl = 90. Bicarb = 4.0 mM • Urine is negative for ketones. • Anion Gap = (Na+K) - bic - chloride • ie: there are an excess of anions Case 4.

  38. pH 7.10 PCO2 = 1.3 kPa (N 4-5) PO2 = 15 kPa What is the acid/base abnormality? • Respiratory acidosis • Metabolic acidosis • Respiratory alkalosis • Metabolic alkalosis

  39. What is the acid-base disturbance? • pH 7.10 (acidosis) • pCO2 = 1.3 kPa (very low) Case 4.

  40. What is the acid-base disturbance? • pH 7.10 (acidosis) • pCO2 = 1.3 kPa (very low) • Metabolic acidosis Case 4.

  41. ie: there are an excess of anions • Not ketones • What else ? • Methanol, ethanol, lactate • Metformin in overdose can cause a lactic acidosis • Lactate = 10 mM (N<2.0) Case 4.

  42. Glucose (muscle) Lactate • Glucose Lactate The Cori cycle: circulation Inhibited by metformin liver

  43. Why is he unconscious? • pH 7.10 (acidosis) • The brain cannot function in such an acidic pH. Case 4.

  44. Definition (type 2 diabetes) • Fasting glucose > 7.0 mM • Glucose tolerance test (75 grams glucose given at time 0) • Plasma glucose > 11.1 mM at 2 hours • (2h value 7.8 – 11.1 = impaired glucose tolerance).

  45. Acid base graph: CID

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