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  1. Biochemistry Problem Set Jack Blazyk 3/9/04

  2. Case #1 Lamont

  3. Presenting Complaint “I’ve felt so weak lately. Sometimes, I can hardly stand up, and when I do, I feel like I’ll fall,” muttered Lamont.

  4. History of Chief Complaint Lamont, a 15-year-old boy, presents in the emergency department with general weakness that has increased progressively over the past three weeks. He states that he thinks he has had the flu. He admits nausea, fever, and abdominal pain as part of his flu symptoms. He also states that although he often feels hungry, he has had trouble eating. He has had some diarrhea and flatus. He denies any vomiting. He denies any history of head injury . Mom says she’s noticed that Lamont is making frequent trips to the bathroom to urinate.

  5. Medication Lamont takes no prescription or over-the-counter medication on a regular basis, except for an occasional Advil for sports-related aches and pains.

  6. Habits Lamont denies recreational drug use. He does not use tobacco or alcohol. He had been exercising regularly in high school athletics until about 3 months ago, when he began to feel worn out and decided to take a break.

  7. Social History Lamont lives at home with his parents and younger brother and attends high school. Until recently, he was active in wrestling and track.

  8. Past Medical History Lamont has had no major medical problems in the past, except for a case of pneumonia when he was six years old.

  9. Family Medical History Lamont’s father, 45 years old, has hypertension as does his paternal grandfather. The father, a local landscaper, says that his only sibling, a brother, had “a wasting type sickness” as a young boy and that he died at age 10. Except for fibrocystic breast disease, the mother is in good health. Her parents died in a plane crash in 1969. There is no family history of heart disease, high blood pressure, stroke, renal disease, tuberculosis, cancer, psychiatric or neurological disorders, migraine headaches, blood diseases, rheumatic disease or gout.

  10. Systems Review • Respiratory • Lamont’s mother states that he had pneumonia when he was 6 years old and that he has had a fever off and on for the last couple of weeks, but she doesn't know how high. • Gastrointestinal • Lamont complains of some abdominal pain and has had nausea and diarrhea with his “flu.”

  11. Systems Review • Endocrine • Lamont admits to frequent trips to the bathroom during the day and having to get up during the night as many as five or six times to urinate. He states that he has been drinking quite a bit of water for the past few months now, and that he has lost about 25 pounds in the last 6 months, which he attributed to not eating right and loss of appetite.

  12. Physical Exam • General Appearance • Height: 71 inches • Weight: 132 pounds • Alert, but disoriented and unbalanced • Thin with poor skin turgor, skin is very dry

  13. Physical Exam • Vital Signs • Temperature: 101.2°F • Pulse: 115/min supine, 140/min upright • Respirations: 32/min • Blood Pressure: 106/76 supine, 88/60 upright

  14. Physical Exam • Head / Neck • Mucous membranes red and very dry • Slight superficial cervical and paratracheal lymphadenopathy • Abdomen • Bowel sounds are hyperactive in all quadrants

  15. Physical Exam • Neurological • Lethargic, disoriented, and weak, but able to verbalize and communicate • Muscles are very weak

  16. Lab Tests Acetone Positive Arterial Blood Gases P O2 100 mm Hg P CO2 25 mm Hg pH 7.18 HCO3- 9 meq/L

  17. Lab Tests Electrolytes Na+ 148 meq/L K+ 5.4 meq/L Cl- 103 meq/L HCO3- 9 meq/L Anion gap 41 meq/L

  18. Lab Tests Glucose Random 625 mg/dL HbA1c 18%

  19. Lab Tests Lipid Profile Total Cholesterol 190 mg/dL HDL Cholesterol 40 mg/dL LDL Cholesterol 135 mg/dL Triglycerides 150 mg/dL

  20. Lab Tests Liver Profile SGOT (AST) 25 U/L SGPT (ALT) 39 U/L Bilirubin 0.8 mg/dL

  21. Lab Tests Urinalysis Acetone Positive Glucose Positive

  22. Questions • What is Lamont’s acid-base situation? How did this arise? • What is happening in adipose cells? How is this regulated? • Since glucose can enter liver cells by facilitated diffusion, why is the liver NOT capable of reducing the blood glucose concentration? • What is happening in skeletal muscle? Why? • What is HbA1c and what is its significance? Is hemoglobin the only protein that can react with glucose?

  23. HyperglycemicConditions

  24. Glycogenesis Hyperglycemic Liver Glycolysis Cholesterol Synthesis Pentose Shunt Triglyceride Synthesis Fatty Acid Synthesis

  25. Hyperglycemic Adipose Pentose Shunt Glycolysis Cholesterol Synthesis Triglyceride Synthesis Fatty Acid Synthesis

  26. Hyperglycemic Muscle Glycogenesis

  27. Insulin-deficientConditions

  28. Glycogenolysis Liver Gluconeogenesis Ketone Body Synthesis Fatty Acid Oxidation

  29. No Uptake Adipose Triglyceride Breakdown Fatty Acid Oxidation

  30. No Uptake Muscle Ketone Body Utilization Fatty Acid Oxidation

  31. Case #2 Mazie

  32. Presenting Complaint Mazie visits her family practitioner complaining of another yeast infection.

  33. History of Chief Complaint Over the years, Mazie, a 58-year-old female, has experienced recurring yeast infections. This is her fourth this year. She states she has been thirsty lately and urinates frequently. She says that she is hungry all the time. Recently, she has noticed that she gets dizzy when she stands up quickly.

  34. Medication Mazie takes no prescription or over-the-counter medication on a regular basis.

  35. Habits Mazie has smoked two packs of cigarettes a day for over 30 years. She admits to an occasional beer. Her lifestyle is totally sedentary.

  36. Social History Mazie is a housewife with six children, ages 28 to 42. She lives in Nelsonville with her husband, who is unemployed. She has never been outside of Athens County in her life, and has only been to Athens twice. She worries whether Medicaid will cover her doctor bills.

  37. Past Medical History Mazie had gall bladder problems 23 years ago.

  38. Past Surgical History Mazie had her gall bladder removed at age 35.

  39. Family Medical History Mazie’s maternal grandmother had “sugar” and died at age 64. Her mother, age 73, also has “sugar” and has had two heart attacks, the most recent last year. Her father died in an accident at the coal mine when she was 2. Her only sibling, a 57-year-old sister, has sugar and kidney problems.

  40. Systems Review • Cardiovascular • Mazie admits dyspnea on exertion, but denies any recurrent chest discomfort, palpitations, orthopnea, paroxysmal nocturnal dyspnea, hypertension, edema, cyanosis, cardiac murmurs, phlebitis, varicosities or claudication.

  41. Systems Review • Respiratory • Mazie often has “coughing spells” upon waking in the morning, but denies any history of pain in or unusual drainage from the ears, nose or throat. She does not suffer frequent nosebleeds. She denies recurrent chest pain, wheezing, hemoptysis, pneumonia, tuberculosis, fever or night sweats.

  42. Systems Review • Gastrointestinal • Mazie admits to increased appetite recently. She denies any history of recurrent abdominal pain, chronic indigestion, pyrosis, food dyscrasias, anorexia, recurrent nausea, vomiting, diarrhea, constipation, hematemesis, abnormal stools, jaundice, hemorrhoids or recent change in bowel habits.

  43. Systems Review • Urinary • Mazie admits to a burning sensation on the “outside” while urinating. She admits to polyuria, and has to get up three or four times at night to urinate. She denies any problems with urinary urgency, dysuria, hematuria, facial edema, oliguria, recurrent kidney or bladder infections, difficulty starting urinary stream, change in size or force of urinary stream, kidney stones, incontinence or urinary retention.

  44. Systems Review • Genital / Reproductive • Mazie has experienced repeated yeast infections accompanied by cheesy white discharge. • Endocrine • Mazie admits to dry skin and increased thirst and urination recently. Over the past two years, she has gained about 20 pounds.

  45. Physical Exam • General Appearance • Height: 64 inches • Weight: 180 pounds • Alert • Oriented to time, person and place

  46. BMI

  47. Physical Exam • Vital Signs • Temperature: 98.6°F • Pulse: 80/min supine, 95/min upright • Respirations: 15/min • Blood Pressure: 120/80 supine, 100/60 upright

  48. Physical Exam • Head / Neck • Mucous membranes dry and pink • Dentition is poor, with numerous caries noted • Gingiva are inflamed • Genitals • White cheesy discharge (KOH positive) noted

  49. Lab Tests Acetone Moderate Arterial Blood Gases P O2 100 mm Hg P CO2 32 mm Hg pH 7.34 HCO3- 17 meq/L

  50. Lab Tests Electrolytes Na+ 140 meq/L K+ 4.2 meq/L Cl- 100 meq/L HCO3- 14 meq/L Anion gap 30 meq/L